Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States
Intrapartum Care
Other Intrapartum Management Considerations
(Last updated:9/14/2011)
Panel’s Recommendations:
- Generally avoid artificial rupture of membranes unless there are clear obstetric indications because of a potential increased risk of transmission (BIII).
- Routine use of fetal scalp electrodes for fetal monitoring should be avoided in the setting of maternal HIV infection unless there are clear obstetric indications (BIII).
- Operative delivery with forceps or a vacuum extractor and/or episiotomy should be performed only if there are clear obstetric indications (BIII).
- The antiretroviral drug (ARV) regimen a woman is receiving should be taken into consideration when treating excessive postpartum bleeding resulting from uterine atony:
- In women who are receiving a cytochrome P (CYP) 3A4 enzyme inhibitor such as a protease inhibitor (PI), methergine should only be used if no alternative treatments for postpartum hemorrhage are available and the need for pharmacologic treatment outweighs the risks. If methergine is used, it should be administered in the lowest effective dose for the shortest possible duration (BIII).
- In women who are receiving a CYP3A4 enzyme inducer such as nevirapine or efavirenz, additional uterotonic agents may be needed because of the potential for decreased methergine levels and inadequate treatment effect. (BIII)
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If spontaneous rupture of membranes occurs before or early during the course of labor, interventions to decrease the interval to delivery, such as administration of oxytocin, may be considered in women without indications for cesarean delivery.
Artificial rupture of membranes should be avoided and used only for a clear obstetric indication in women with intact membranes and detectable viral load who present in labor and proceed to vaginal delivery. Data are limited on artificial rupture of membranes in women with undetectable viral load and planned vaginal delivery. In general, the procedure should be performed only for clear obstetrical indications because of the potential, albeit small, increased risk of HIV transmission.
Obstetric procedures that increase the risk of fetal exposure to maternal blood, such as invasive fetal monitoring, have been implicated in increasing vertical transmission rates by some, but not all, investigators, primarily in studies performed in the pre-combination antiretroviral therapy (ART) era [1-4]. Data are limited on routine use of fetal scalp electrodes in labor in women receiving suppressive ARV regimens and undetectable viral load; routine use of fetal scalp electrodes for fetal monitoring should be avoided in the setting of maternal HIV infection unless there are clear obstetric indications.
Similarly, data are limited to the pre-combination ART era regarding the potential risk of perinatal transmission of HIV associated with operative vaginal delivery with forceps or the vacuum extractor and/or use of episiotomy [2, 4]. These procedures should be performed only if there are clear obstetric indications. Delayed cord clamping has been associated with improved iron status and benefits such as decreased risk of intraventricular hemorrhage in preterm births to HIV-uninfected mothers [5-7]. Even though HIV-specific data on the practice are lacking, there is no reason to modify it in HIV-infected mothers.
Postpartum Hemorrhage, Antiretroviral Drugs, and Methergine Use
Oral or parenteral methergine or other ergot alkaloids are often used as first-line treatment for postpartum hemorrhage resulting from uterine atony. However, methergine should not be coadministered with drugs that are potent CYP3A4 enzyme inhibitors, including PIs. Concomitant use of ergotamines and PIs has been associated with exaggerated vasoconstrictive responses. When uterine atony results in excessive postpartum bleeding in women receiving PIs as a component of an ARV regimen, methergine should be used in women with excessive postpartum bleeding who are receiving PIs as a component of ART only if alternative treatments such as prostaglandin F 2 alpha, misoprostol, or oxytocin are unavailable. If no alternative medications are available and the need for pharmacologic treatment outweighs the risks, methergine should be used in as low a dosage and for as short a period as possible. In contrast, additional utertonic agents may be needed when other ARV drugs that are CYP3A4 inducers, such as nevirapine and efavirenz, are used because of the potential for decreased methergine levels and inadequate treatment effect.
References
1. Boyer PJ, Dillon M, Navaie M, et al. Factors predictive of maternal-fetal transmission of HIV-1. Preliminary analysis of zidovudine given during pregnancy and/or delivery. JAMA. 1994 Jun 22-29;271(24):1925-1930.
2. Mandelbrot L, Mayaux MJ, Bongain A, et al. Obstetric factors and mother-to-child transmission of human immunodeficiency virus type 1: the French perinatal cohorts. SEROGEST French Pediatric HIV Infection Study Group. Am J Obstet Gynecol. 1996 Sep;175(3 Pt 1):661-667.
3. Mofenson LM, Lambert JS, Stiehm ER, et al. Risk factors for perinatal transmission of human immunodeficiency virus type 1 in women treated with zidovudine. Pediatric AIDS Clinical Trials Group Study 185 Team. N Engl J Med. 1999 Aug 5;341(6):385-393.
4. Shapiro DE, Sperling RS, Mandelbrot L, Britto P, Cunningham BE. Risk factors for perinatal human immunodeficiency virus transmission in patients receiving zidovudine prophylaxis. Pediatric AIDS Clinical Trials Group protocol 076 Study Group. Obstet Gynecol. 1999 Dec;94(6):897-908.
5. Oh W, Fanaroff AA, Carlo WA, Donovan EF, McDonald SA, Poole WK. Effects of delayed cord clamping in very-low-birth-weight infants. J Perinatol. 2011 Apr;31 Suppl 1:S68-71.
6. Rabe H, Reynolds G, Diaz-Rossello J. A systematic review and meta-analysis of a brief delay in clamping the umbilical cord of preterm infants. Neonatology. 2008;93(2):138-144.
7. Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics. 2006 Apr;117(4):1235-1242.