Intrapartum management and infant prophylaxis for pregnant women with HIV in resource-rich settings

Treatment and VL status of the mother	Received antepartum ART with no adherence concerns			No antepartum ART* ART adherence concerns Unknown HIV RNA HIV diagnosis made in labor Acute/primary HIV during pregnancy^¶
Treatment and VL status of the mother	Undetectable VL (<50 copies/mL) within 4 weeks of delivery	Detectable (≥50 copies/mL) but ≤1000 copies/mL within 4 weeks of delivery	>1000 copies/mL within 4 weeks of delivery
Risk for HIV transmission	Low risk	High risk	High risk	High risk
Preferred delivery mode	Determined by obstetric indications	Determined by obstetric indications	Scheduled cesarean delivery at 38 weeks	Individualized based on HIV viral level (if known) and presentation^Δ
Intrapartum antiretrovirals	Continue baseline ART regimen	Continue baseline ART regimen Consider intrapartum intravenous zidovudine^◊	Continue baseline ART regimen Intrapartum intravenous zidovudine^◊	Continue baseline ART regimen if receiving ART Intrapartum intravenous zidovudine^§
Other intrapartum interventions	Avoid fetal scalp electrodes	Avoid artificial rupture of membranes Avoid operative delivery with forceps or vacuum extractor Avoid fetal scalp electrodes	Avoid fetal scalp electrodes	Avoid artificial rupture of membranes (if not undergoing cesarean) Avoid operative delivery with forceps or vacuum extractor (if not undergoing cesarean) Avoid fetal scalp electrodes
Infant antiretroviral prophylaxis^¥	2 to 4 weeks of zidovudine	Presumptive HIV therapy	Presumptive HIV therapy	Presumptive HIV therapy

This table reflects the general principles of intrapartum management and infant antiretroviral prophylaxis for pregnant women with HIV.

ART: antiretroviral therapy; VL: viral load.

* Women who present in labor with unknown HIV status (or a prior negative test with subsequent risk factors for HIV infection) should undergo rapid combination antibody/antigen HIV testing. If this test is positive, the woman and her infant should be managed as high risk for HIV transmission (having had no antepartum ART) while awaiting confirmatory testing.

¶ Primary HIV infection refers to the first 6 months of infection.

Δ In the United States, clinicians can consult with the National Perinatal HIV/AIDS Clinical Consultation Center at 1-888-448-8765 to help rapidly develop an individualized plan for individuals who present in labor or with ruptured membranes.

◊ Clinicians may reasonably add intrapartum zidovudine for such patients, particularly if there were concerns about adherence to ART during pregnancy. We typically use intrapartum zidovudine at this VL range.

§ Intrapartum zidovudine is administered intravenously with a 2 mg/kg dose followed by a continuous infusion of 1 mg/kg/hour until delivery. For women undergoing scheduled cesarean delivery, zidovudine is initiated 3 hours before the procedure. For women who present in labor and have not received antepartum ART, intravenous zidovudine should be administered immediately.

¥ Refer to other UpToDate content for specifics on regimens and dosing for infant antiretroviral prophylaxis.

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Intrapartum management and infant prophylaxis for pregnant women with HIV in resource-rich settings