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7 mo pregnant,HIV+ and worried about delivery
Feb 7, 2001

I have a few questions regarding delivery of my child and prevention of transmission. I am HIV+, T4=700 & viral load was 3,000 at beginning of pregnancy but is currently nondetectable. I am scheduled for a c-section but am at risk for premature labor/delivery. Should I deliver vaginally is there anything else that should/should not be done to prevent transmission other then intravenous AZT (i.e. should I try to push more so baby is delivered quicker?)? Should a different procedure, then usual, be followed when cutting the cord so that my blood isn't pushed/forced into the baby? Is there a special solution that the baby should be cleaned with immediately following deliver so any/all of my infected fluids can be removed from the baby's skin (i believe babies are usually only wiped off with a blanket/towel following delivery)? Should the baby be taken and cleaned off ASAP rather then me holding the baby immediately following delivery? Would my baby be put on intravenous AZT or oral AZT immediately following delivery and is there any added benefit to either? How old will the baby be when we know whether he has been infected? Should a baby still take AZT for 6 weeks even if initial PCR indicates they are not infected? I just want to make sure that every possible precaution/ measure is taken in decreasing my baby's exposure to HIV

Response from Dr. Luzuriaga

The risk of transmission when the mother's HIV-1 RNA is undetectable (<400 copies/ml) is very low (<1%). Available data suggest that caesarean section will add little to preventing mother-to-child transmission in women with RNA < 400. In fact, the most recent treatment guidelines (November, 2000; available on this site's treatment guidelines page or at http://hivatis.org/guidelines/perinatal/Nov_00/text/index.html) recommend c-section for women with plasma RNA > 1000.

You don't mention what antivirals you have taken in the past and what you are currently taking. In general, AZT treatment of mom (200 mg po three times a day or 300 mg po twice a day) during pregnancy, intravenous treatment of mom during delivery, and 6 weeks of oral AZT treatment for the baby are recommended (along with whatever other antivirals are recommended by the mom's medical provider), unless the mother is intolerant of AZT or has resistant virus. Whether to add other antivirals depends on individual circumstances. Several potential antiviral scenarios are discussed in the November, 2000 treatment guidelines referenced above -- you and your care provider might find these useful.

You ask about measures in the baby. The cord is usually double clamped before being cut, which will prevent mom's blood from getting to the baby. While the other measures that you outline are reasonable to consider, we do not have data to prove or disprove their utility (particularly when mom's viral load is undetectable).

You ask whether a baby should take AZT for 6 weeks even if the testing at birth suggests that the baby is uninfected. The answer is definitely yes. A negative test at birth indicates that the baby was not infected during pregnancy. however, most babies are infected at the time of delivery and this is why we intensify efforts to prevent transmission around the time of delivery and after birth.

KL


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