In this section we provide a brief overview of evidence based guidelines on best obstetric practice. Viral load measurement plays a key part in deciding the mode of delivery. The overall aim is to increase women's choice in relation to vaginal delivery or planned caesarean section (CS) and reduce the need for emergency CS.

 

Here Penny Hill (Consultant obstetrician) talks about maternity care in the context of HIV: the role of the multidiscipinary team, minimising the risk of transmission, normalising the experience and choices for delivery...

 

 

Mode of delivery

• Vaginal delivery is recommended for women on HAART with an undetectable HIV viral load at 36 weeks
  • Review viral load at 36 weeks: If undetectable at 36wk and no other contraindication, Normal Vaginal Delivery (NVD) is indicated and labour may be managed as in any other pregnant woman
  • Obstetric management should follow the same principles as that for any pregnant woman
  • It is unlikely that use of fetal scalp electrodes or fetal blood sampling confers increased risk of transmission in a woman with an undetectable viral load
• Vaginal birth after Ceasarean section (VBAC) may also be offered to women with an undetectable viral load 
• Delivery by Planned Caesarean Section (PLCS)  is recommended for women on monotherapy irrespective of viral load and for women with a viral load >400cpm regardless of ART 
• Where the indication for PLCS is the prevention of mother to child transmission, PLCS should be undertaken at 38-39 weeks gestation to avoid the onset of labour 
• Where PLCS is indicated for obstetric reasons and viral load is undetectable the usual obstetric considerations apply and timing may be later

Spontaneous Rupture of Membranes (SROM)

• Delivery should be expedited in all cases of preterm SROM

Preterm Premature Rupture of Membranes (PPROM) <34 weeks:

• Intramuscular steroids should be administered as per policy/guidelines 
• Virological control should be optimised 
• When PPROM occurs at <34 weeks the HIV Multi Disciplinary Team (MDT) should be consulted about the choice of antibiotics and timing of delivery

SROM > 34 weeks

• Women on ARVs and last viral load is undetectable (within 4 weeks)
  • Assess for other factors that may increase risk of MTCT (Amnionitis, concurrent sexually transmitted infections, non adherence to ARV since last result of viral load)
  • If no other risk, manage delivery as per any pregnant woman
  • Delivery should be expedited by augmentation of labour
  • If any other risk factors consult with HIV MDT and consider pathway for women not on ARV….
• Women not on ARV, on monotherapy or if VL >50cpm
  • Aim to deliver <6 hours from rupture of membranes by Caesarean section
  • Avoid vaginal delivery where possible
  • Prescribe and administer ARV STAT
  • If a normal vaginal delivery is unavoidable avoid fetal scalp monitoring and fetal blood sampling, forceps are preferable to ventouse if an instrumental delivery is required
  • Contact/liaise with Obstetric HIV consultant, GUM consultant and Neonatal team

Invasive prenatal diagnostic testing

• HIV status should be known before invasive prenatal diagnostic testing 
• Invasive prenatal diagnostic testing should  ideally be deferred until viral suppression is achieved

External Cephalic Version (ECV)

• ECV may be offered to women with an undetectable viral load and breech presentation at >36 weeks gestation in the absence of obstetric contraindications

 

Links to guidelines

British HIV Association guidelines for the management of HIV infection in pregnant women (2018)

Guidelines for the management of HIV positive pregnant women in Northern Ireland (Public Health Agency, 2013)

National Institute for health and Clinical Excellence, Caesarean section NICE Clinical guideline 132 (2011) 

Royal College of Obstetricians and Gynaecologists. Green top Guideline No 39. Management of HIV in pregnancy (2010)

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