Scenario A

HIV-infected women presenting in late pregnancy (after about 36 weeks of gestation), known to be HIV-infected but not receiving antiretroviral therapy, and who have HIV RNA level and lymphocyte subsets pending but unlikely to be available before delivery.

Therapy options should be discussed in detail. The woman should be started on antiretroviral therapy including at least the PACTG 076 ZDV regimen. The woman should be counseled that scheduled cesarean section is likely to reduce the risk of transmission to her infant. She should also be informed of the increased risks to her of cesarean section, including increased rates of postoperative infection, anesthesia risks, and other surgical risks.

If cesarean section is chosen, the procedure should be scheduled at 38 weeks of gestation based on the best available clinical information. When scheduled cesarean section is performed, the woman should receive continuous intravenous ZDV infusion beginning three hours before surgery and her infant should receive six weeks of ZDV therapy after birth. Options for continuing or initiating combination antiretroviral therapy after delivery should be discussed with the woman as soon as her viral load and lymphocyte subset results are available.

Scenario B

HIV-infected women who initiated prenatal care early in the third trimester, are receiving highly active combination antiretroviral therapy, and have an initial virologic response, but have HIV RNA levels that remain substantially over 1,000 copies/mL at 36 weeks of gestation.

The current combination antiretroviral regimen should be continued as the HIV RNA level is dropping appropriately. The woman should be counseled that although she is responding to the antiretroviral therapy, it is unlikely that her HIV RNA level will fall below 1,000 copies/mL before delivery. Therefore, scheduled cesarean section may provide additional benefit in preventing intrapartum transmission of HIV. She should also be informed of the increased risks to her of cesarean section, including increased rates of postoperative infection, anesthesia risks, and surgical risks.

If she chooses scheduled cesarean section, it should be performed at 38 weeks' gestation according to the best available dating parameters, and intravenous ZDV should be begun at least three hours before surgery. Other antiretroviral medications should be continued on schedule as much as possible before and after surgery. The infant should receive oral ZDV for six weeks after birth. The importance of adhering to therapy after delivery for her own health should be emphasized.

Scenario C

HIV-infected women on highly active combination antiretroviral therapy with an undetectable HIV RNA level at 36 weeks of gestation.

Scenario D

HIV-infected women who have elected scheduled cesarean section but present in early labor or shortly after rupture of membranes..

Intravenous ZDV should be started immediately since the woman is in labor or has ruptured membranes.

If labor is progressing rapidly, the woman should be allowed to deliver vaginally. If cervical dilatation is minimal and a long period of labor is anticipated, some clinicians may choose to administer the loading dose of intravenous ZDV and proceed with cesarean section to minimize the duration of membrane rupture and avoid vaginal delivery. Others might begin pitocin augmentation to enhance contractions and potentially expedite delivery.

If the woman is allowed to labor, scalp electrodes and other invasive monitoring and operative delivery should be avoided if possible. The infant should be treated with six weeks of ZDV therapy after birth

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