A 24-year-old primigravid woman comes to the office for her first prenatal visit. The patient's last menstrual period was 2 months ago, and she has had no vaginal bleeding or cramping. She has a history of intravenous heroin use but stopped when she was diagnosed with HIV infection last year. The patient has completed a methadone program and currently does not use tobacco, alcohol, or illicit drugs. She started combination antiretroviral therapy last year but stopped taking her medications 2 weeks ago when she found out she was pregnant. Vital signs are normal. Serum laboratory results are as follows: Urine β-hCG is positive and toxicology screen is negative. Ultrasound confirms a 6-week intrauterine pregnancy. Which of the following is the best next step in management of this patient?

Question

A 24-year-old primigravid woman comes to the office for her first prenatal visit.  The patient's last menstrual period was 2 months ago, and she has had no vaginal bleeding or cramping.  She has a history of intravenous heroin use but stopped when she was diagnosed with HIV infection last year.  The patient has completed a methadone program and currently does not use tobacco, alcohol, or illicit drugs.  She started combination antiretroviral therapy last year but stopped taking her medications 2 weeks ago when she found out she was pregnant.  Vital signs are normal.  Serum laboratory results are as follows:  Urine β-hCG is positive and toxicology screen is negative.  Ultrasound confirms a 6-week intrauterine pregnancy.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da03_9f6b_bc81_01839c763ac2_MD0003_00 Current guidelines recommend that all pregnant women with HIV begin taking combination antiretroviral therapy (ART) as soon as possible, regardless of HIV RNA viral load or CD4 count, to minimize maternal risks of HIV infection and reduce perinatal transmission (Choices C and D). Drug-resistance testing is performed prior to treatment initiation; however, ART is begun immediately and modified according to results. Combination drug therapy throughout pregnancy is more effective than single-drug therapy and should include a nucleoside reverse transcriptase inhibitor and either a protease or an integrase inhibitor. Early initiation of multidrug ART allows for optimal viral load reduction by the time of delivery because viral load dictates the mode of delivery: Patients with viral load ≤1,000 copies/mL may deliver vaginally without intrapartum zidovudine (AZT). Patients with viral load >1,000 copies/mL receive intrapartum AZT + cesarean delivery. Infants receive postexposure prophylaxis after delivery to further reduce their risk of viral infection. Therapy and dosing vary based on the maternal viral load and specific infant risk factors. Mothers with HIV who live in areas where formula is readily available (eg, the United States) should not breastfeed because HIV can be transmitted through breast milk. However, mothers with HIV living in developing countries should continue ART and breastfeed for 6 months to minimize infant morbidity and mortality from other infectious diseases. (Choices B and E) Using single-drug therapy at delivery only or delaying combination ART until the third trimester may not adequately reduce viral load at the time of delivery, which significantly increases the risk of vertical transmission. Educational objective: Pregnant women with HIV should start combination antiretroviral therapy (ART) as soon as possible, independent of HIV RNA viral load or CD4 count. Early initiation of ART-in addition to intrapartum zidovudine (AZT) administration, cesarean delivery, and postexposure ART prophylaxis for the infant-can decrease the risk of neonatal HIV infection. Women who achieve optimal viral load reduction (≤1,000 copies/mL) may deliver vaginally without AZT. References: Achievement in public health. Reduction in perinatal transmission of HIV infection - United States, 1985-2005. (http://www.ncbi.nlm.nih.gov/pubmed/16741495) Cesarean section for HIV-infected women in the combination antiretroviral therapies era, 2000-2010. (http://www.ncbi.nlm.nih.gov/pubmed/23791563)

A 24-Year-Old Primigravid Woman Comes to the Office for Her