A 38-year-old woman, gravida 3 para 2, at 37 weeks gestation comes to the labor and delivery unit for contractions. Her contractions started this morning and now are painful and occur every 5 minutes. The patient has had no leakage of fluid or vaginal bleeding. Fetal movement is normal. Previous pregnancies ended in uncomplicated term vaginal deliveries. The patient was diagnosed with HIV at her first prenatal visit during this pregnancy, and her viral load one week ago was 12,300 copies/mL. She does not always take her combination antiretroviral therapy but takes a daily prenatal vitamin. Blood pressure is 132/86 mm Hg and pulse is 98/min. The patient is tolerating labor well, and the uterus is soft and nontender between contractions. The fetal heart rate tracing is shown in the exhibit. The cervix is 4 cm dilated and 100% effaced and the fetal vertex is at 0 station. The amniotic sac is tense and palpable. In addition to starting zidovudine, which of the following is the best next step in management of this patient?

Question

A 38-year-old woman, gravida 3 para 2, at 37 weeks gestation comes to the labor and delivery unit for contractions.  Her contractions started this morning and now are painful and occur every 5 minutes.  The patient has had no leakage of fluid or vaginal bleeding.  Fetal movement is normal.  Previous pregnancies ended in uncomplicated term vaginal deliveries.  The patient was diagnosed with HIV at her first prenatal visit during this pregnancy, and her viral load one week ago was 12,300 copies/mL.  She does not always take her combination antiretroviral therapy but takes a daily prenatal vitamin.  Blood pressure is 132/86 mm Hg and pulse is 98/min.  The patient is tolerating labor well, and the uterus is soft and nontender between contractions.  The fetal heart rate tracing is shown in the exhibit.  The cervix is 4 cm dilated and 100% effaced and the fetal vertex is at 0 station.  The amniotic sac is tense and palpable.  In addition to starting zidovudine, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da3d_7382_bc81_3796df61dd26_MD0003_00 This patient at 37 weeks gestation with regular contractions, cervical dilation, and a category I fetal heart tracing is in early normal labor, which is typically managed expectantly (Choice C). However, labor management (including mode of delivery) in patients with HIV differs based on maternal viral load at delivery, which determines the risk of vertical transmission to the neonate. Patients with a viral load ?1,000 copies/mL deliver vaginally because the risk of vertical transmission is low. These patients do not require additional intrapartum antiretroviral therapy (ie, zidovudine) but do continue their daily antiretroviral regimen. In contrast, patients with a viral load >1,000 copies/mL are at high risk of vertical transmission during vaginal delivery because the fetus is exposed to infected maternal body fluids during passage through the vaginal canal and is at greater risk of skin barrier compromise. Cesarean delivery reduces perinatal HIV transmission by 50% when maternal viral load is >1,000 copies/mL. Therefore, the best next step in this patient's management is cesarean delivery, as well as administration of intrapartum zidovudine (which additionally helps reduce vertical transmission rates) and continuation of her daily antiretroviral regimen. (Choice A) Amniotomy, fetal scalp electrode placement, and operative vaginal delivery are contraindicated in women with HIV, hepatitis B, and hepatitis C. These procedures can break the protective fetal skin barrier, increasing the risk of vertical transmission. Amniotomy (Choices D and E) Misoprostol (used for labor induction) and oxytocin (used for labor augmentation) are not indicated in patients in normal labor (eg, regular contractions, cervical dilation). In addition, these medications are contraindicated in this patient because they promote vaginal delivery, which is associated with higher rates of neonatal HIV infection when maternal viral load is >1,000 copies/mL at delivery. Educational objective: Pregnant women with HIV and a viral load >1,000 copies/mL at delivery are at high risk for vertical transmission. These patients require cesarean delivery and intrapartum zidovudine, both of which help decrease neonatal HIV infection risk. In contrast, patients with a viral load ?1,000 copies/mL are candidates for vaginal delivery and do not require intrapartum zidovudine. 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 38-Year-Old Woman, Gravida 3 Para 2, at 37 Weeks