Last reviewed: September 2018
Last updated: June  2018

US guidance now recommends consideration of intrapartum zidovudine in women with detectable viral loads <1000 copies/mL

Updated guidelines on the use of antiretroviral drugs in pregnant women with HIV infection have been published by the US Department of Health and Human Services.

The panel now recommends considering intrapartum intravenous zidovudine for women with HIV RNA levels between 50 and 999 copies/mL. Previously, intrapartum zidovudine was only recommended in women with HIV RNA levels >1000 copies/mL or unknown viral load near delivery.

There are inadequate data to determine whether reducing this threshold provides additional protection against perinatal transmission; however, some experts administer zidovudine in this setting as the perinatal transmission risk is slightly higher in these patients compared with women with HIV RNA levels <50 copies/mL.

Intravenous zidovudine is not recommended in women with HIV RNA levels <50 copies/mL.

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Original source of update

US and EU drug regulators warn of possible increased risk of neural tube defects in babies born to women taking dolutegravir

The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have both issued alerts after preliminary results from an ongoing study reported an increased risk of serious neural tube defects in women who became pregnant while taking dolutegravir-based regimens. The risk appears to be highest in women taking the drug at the time of becoming pregnant or early in the first trimester.

It is recommended that women of childbearing age with HIV currently taking dolutegravir are counseled about this new potential risk. Pregnant women currently taking dolutegravir should not stop their treatment but should discuss the possible risks with their healthcare provider.

Women of childbearing age with HIV who are trying to become pregnant should discuss alternative antiretroviral therapy regimens with their healthcare provider. Women of childbearing age with HIV who are not planning to become pregnant may be on dolutegravir-based regimens provided their pregnancy test before starting therapy is negative and they consistently use a reliable method of contraception during treatment.

Both the FDA and the EMA said they would continue to monitor results from the ongoing study and would issue further advice as additional data become available.

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Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • increased risk of maternal HIV infection
  • increased risk of perinatal HIV transmission

Other diagnostic factors

  • oral candidiasis
  • increasing dyspnea
  • weight loss
  • fever
  • malaise
  • lymphadenopathy
  • maculopapular blanching rash

Risk factors

  • needle-sharing with injection drug use
  • receptive penile-vaginal intercourse
  • unprotected receptive anal intercourse
  • percutaneous needle stick
  • sexually transmitted infections (STIs) and bacterial vaginosis
  • high maternal viral load (perinatal transmission)
  • absence of prenatal maternal antiretroviral therapy (perinatal transmission)
  • breast-feeding (perinatal transmission)
  • violence against women and girls
  • receptive oral intercourse
  • insertive oral intercourse
  • multiple sexual partners
  • low maternal CD4 count (perinatal transmission)

Diagnostic investigations

1st investigations to order

  • maternal HIV-1/HIV-2 antigen/antibody enzyme-linked immunosorbent assay (ELISA)
  • maternal HIV-1/HIV-2 antibody differentiation immunoassay
  • neonatal HIV DNA or RNA polymerase chain reaction (PCR)
Full details

Investigations to consider

  • HIV-1 western blot
  • HIV-1 indirect immunofluorescence assay (IFA)
  • HIV-1 nucleic acid test (NAT)
  • CD4 count
  • plasma viral load
  • renal function tests
  • liver function tests
  • tests for coinfections
  • drug resistance test (genotyping)
  • CBC
  • fetal ultrasound
Full details

Treatment algorithm

Contributors

Authors VIEW ALL

Assistant Professor of Obstetrics and Gynecology

Georgetown University School of Medicine

Scientific Director of Women’s Health Research

MedStar Health Research Institute

Director

MedStar WHC Women's Center for Positive Living

MedStar Washington Hospital Center Department of Women’s and Infants’ Services

Washington

DC

Disclosures

RKS declares that she has no competing interests.

Dr Rachel K. Scott would like to gratefully acknowledge Dr Isaac Delke, Dr Christina Bailey, and Dr Mettassebia Kano, the previous contributors to this monograph. ID, CB, and MK declare that they have no competing interests.

Peer reviewers VIEW ALL

Assistant Professor of Medicine

Associate Residency Program Director

University of Chicago

Chicago

IL

Disclosures

AS declares that she has no competing interests.

Reader in Communicable Diseases

Faculty of Medicine

Imperial College

London

UK

Disclosures

GPT has been reimbursed by various pharmaceutical companies for attending conferences, lecturing, and consulting, and has been chief investigator of investigator-initiated industry-funded research on HIV and pregnancy.

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