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The management of HIV positive women during pregnancy is multifaceted, combining medical and obstetrical management with counselling and social support. The woman's social and psychological concerns may be as important as her need for medical care. Ideally, a team approach with health workers, counsellors and support groups should be used^{358,359,360,361,362}.

In all cases, the management in pregnancy, including antiretroviral treatment, should be seen as only a part of the continuum of care for the mother and child^{360,363,364,290}. Ongoing care may be undertaken at home, within the primary health care services, at hospitals, or at specialist clinics, depending upon the individual needs and available facilities³⁶⁵. The following discussion highlights some of the management issues for HIV positive pregnant women, and does not provide detailed guidelines. Diagnostic procedures and medical management will be dependent upon the available resources and each country should develop appropriate recommendations for their own situation.

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Most HIV positive women will be asymptomatic and have no major obstetrical problems during their pregnancies^{99,366,367,368,369}. They should receive similar obstetric antenatal care to that given to HIV-negative women, unless indicated by the need to provide specific HIV-related treatment. There is no evidence that there is a need to increase the number of antenatal visits, provided there are no complications of the HIV infection, although additional counselling time may be required. The care of the HIV positive woman during pregnancy should include ongoing counselling and support as an integral part of the management. Advice on the possible risks of unprotected intercourse during pregnancy should be provided.

Obstetrical management

Antenatal care of the HIV positive pregnant woman will depend on the woman's risk of experiencing an adverse perinatal outcome. To an extent this will be mediated by other obstetric risk factors and antenatal care will need to be tailored to the individual woman. Consideration can be given to the assessment of fetal growth, whether by regular uterine fundal height measurements or, where available, by serial ultrasound assessments.

Invasive diagnostic procedures, such as chorion villus sampling, amniocentesis or cordocentesis should be avoided where possible, due to a possible risk of infection of the fetus³⁰². External cephalic version of a breech fetus may be associated with potential maternal-fetal circulation leaks and the advantages and disadvantages of the procedure should be very carefully considered.

Examination and investigations

HIV positive women should have a full physical examination at the first visit. Particular attention should be paid to any signs of HIV-related infections [particularly tuberculosis], oral or vaginal thrush, or lymphadenopathy. Herpes zoster [shingles] in a young woman is often an early sign of HIV infection and current herpes lesions or the scars from previous infection may be found. Other co-existent sexually transmitted infections, especially syphilis, are common in HIV positive women^{96,97,370,371} and may increase the risk of transmission and the level of virus in vaginal and cervical secretions. Clinical diagnosis and treatment of vaginal or cervical inflammation, abnormal discharge or STI should be a priority. The pregnant woman should be monitored for any signs of HIV-related opportunistic infections and for any other intercurrent infections, such as urinary or respiratory infection. Maternal weight should be monitored and nutritional supplementation advised where necessary. The oro-pharynx should be examined at each visit, for the presence of thrush.

Laboratory investigations will depend upon the available resources of the health service. Syphilis testing should be undertaken, and repeat testing in late pregnancy may be advisable⁴⁰. A haemoglobin estimation is mandatory and a complete blood count should be performed and T cell subset investigations undertaken where possible. Anaemia is more common in HIV-infected women and repeated haemoglobin tests may be helpful. Viral load estimation may provide a valuable prognostic indicator, where available. A cervical smear should be performed if this has not been undertaken within the recent past. Colposcopy should be reserved for women who have an abnormal cervical smear result.

Medical treatment during pregnancy

The medical care of HIV positive women should be tailored to the individual needs of the woman. In general, pregnancy is not a contraindication for the most appropriate antiretroviral therapy for a woman or for most of the medical management of HIV-related conditions, but the risk to the fetus should always be considered, and treatment modified if necessary²⁹⁰.

The value of vitamin A supplementation in reducing transmission has not been proven, but multivitamins may provide cost effective nutritional support^372,373,374. Mebendazole should be given at the first visit in areas of high hookworm prevalence.

Malaria in pregnancy causes high maternal and infant morbidity and mortality, and may be associated with increased risk of mother-to-child transmission of HIV^216.217. Current recommendations are that intermittent treatment with an effective, preferably one-dose antimalarial drug should be made available to all primigravidae and secundigravidae in highly endemic areas. This should be started from the second trimester and given at intervals of not more than one month apart.

Prophylaxis for opportunistic infections should be given in pregnancy, as indicated by the clinical stage of the HIV infection, and according to local policy. Prophylaxis and treatment for tuberculosis should be given where indicated, although streptomycin and pyrazinamide are not recommended during pregnancy. Pneumocystis carinii pneumonia (PCP) prophylaxis should continue through pregnancy: sulfamethoxazole/trimethoprim (Bactrim/Septran) or pentamidine can be used. The risk to the fetus of maternal sulphonamide administration in the third trimester is outweighed by the risk to maternal health of PCP and kernicterus has not been reported where the drug was not also used in the neonatal period⁵. Consideration should be given to pneumococcal and Hepatitis B vaccination.

Treatment for opportunistic infections during pregnancy depends on the clinical stage of the patient. Treatment regimens should follow local policy guidelines. Where a variety of treatment options are available, those with the lowest risk to the fetus should be used. Dermatological conditions are common in HIV positive women and men, and treatment may be required for prolonged periods. Acyclovir can be used safely after the first trimester. Topical imidazole antifungals or topical gentian violet can be used throughout pregnancy and oral fluconazole can be used after the first trimester, if required.

Antiretroviral therapy

The use of antiretroviral drugs in pregnancy should be considered for two indications: the health of the mother and prevention of transmission^364,290,291. Pregnancy should not be a contra-indication for antiretroviral therapy in the mother, if indicated. The use of ZDV in the prevention of transmission to the fetus has been discussed above^375,376,377. Current recommendations for adult antiretroviral therapy are that monotherapy with ZDV is sub-optimal treatment and that two antiretrovirals with the possible addition of a protease inhibitor is preferable^{288,289,378,379}. Although there is a theoretical risk to the fetus from combination therapy, there is limited experience with the use of other antiretrovirals such as lamivudine, stavudine, and protease inhibitors in pregnancy. Some have recommended stopping these therapies during the first trimester and restarting the combinations, but this also carries a risk of developing resistance. Detailed recommendations have been released in the USA on combination therapy in pregnancy²⁹¹. As many of the newer compounds do not have long-term safety data following use in pregnancy, this should be discussed with the patients. The use of any antiretroviral drugs should be accompanied by an explanation of the available knowledge to the women and advice that there should be long-term follow-up of the child²⁷².

Care during labour and delivery

Care during labour for HIV positive women should follow routine practice in most respects. Prolonged rupture of membranes should be avoided, as mother-to-child transmission is increased where membranes are ruptured for more than four hours¹¹⁹. Artificial rupture of membranes should not be undertaken if progress of labour is adequate. Given these advantages, this may be introduced as a routine part of the management of labour for all women in high prevalence areas.

There are conflicting reports of the importance of obstetric interventions in the facilitation of transmission^111,113. As a general rule, any procedure which breaks the baby's skin or increases the baby's contact with the mother's blood - such as scalp electrodes or scalp blood sampling - should be avoided unless absolutely necessary, due to the unconfirmed magnitude of the risk of these for HIV transmission. Universal precautions should be applied in managing labouring women in all cases. Episiotomy should not be performed routinely, but reserved for those cases with an obstetrical indication.

If an assisted delivery is required, forceps may be preferable to vacuum extraction, given the risk of micro-lacerations of the scalp from the vacuum cup. There is increasing evidence that elective Caesarean section may help prevent transmission of HIV to the baby²²⁵. The operation carries risks of maternal complications and is associated with higher post operative morbidity in HIV positive women¹¹⁰. The decision on Caesarean section delivery should be made on an individual basis, taking into account the available facilities, and will not be possible in most developing countries with high HIV prevalence. Prophylactic antibiotics should be given for both elective and emergency Caesarean sections.

Postpartum care

The postpartum care of HIV positive women should be similar to that for uninfected patients. They do not require separate nursing facilities. Women may, however, require private facilities to lessen the social stigma associated with not breastfeeding if this is the choice they make in a culture which is likely to condemn such behaviour.

HIV positive women are more prone to postpartum infectious complications – including urinary tract, chest, episiotomy and Caesarean section wound infections. Health workers should be aware of this and observe for signs of infection. Mothers should be given information on the early symptoms of infection at the time of discharge, especially where the postpartum hospital stay is short. All mothers should be given instructions on perineal care and the safe handling of lochia and blood stained sanitary pads or materials.

Mothers should be given information on how to care for their babies without the risk of exposure to infection, and full discussion on the risks and benefits of infant feeding choices. If, after counselling, the mother chooses not to breastfeed, she should receive full information on adequate replacement feeding up to two years of age, and guidance on breast care, until lactation stops. Mothers who choose to breastfeed should be advised of the possible increased transmission risk in the presence of cracked nipples, mastitis, breast abscess or of oral lesions in the child and should be taught how to prevent such problems through adequate breastfeeding techniques. Reduced duration of breastfeeding and early cessation may be encouraged to reduce the risk of transmission where this can be achieved safely. The mother should be counselled on the need for follow-up care for her and her child, and the available options for testing of the child. She should be given information about and referred to local HIV support groups. Contraceptive advice should be given and early arrangements made to start with an appropriate method. Contraceptive advice is particularly important when a mother does not breastfeed because of the loss of the contraceptive properties of breastfeeding^380,381.

Care of neonates

Babies of HIV positive mothers should be handled with gloves until maternal blood and secretions are washed off, after which time they can be handled safely by mothers and health workers. Anaemia has been the most common complication seen in the neonate with the long-course treatment of six weeks ZDV to the child. Haemoglobin should be measured at baseline and after six weeks and 12 weeks if this regimen is used. The anaemia risk is much less with the short-regimen. Infants receiving long-course antiretrovirals may experience a transient elevation of hepatic transaminases.

There is less experience with the use of combination therapy in the pregnant mother and the risk of toxicity to these infants, and more intensive haematological monitoring would be advised.

Mothers should decide on infant feeding practice before delivery and be supported in their choice. Children should be referred for long-term follow-up and for repeat testing for diagnosis of HIV infection, either by early PCR if available, or by ELISA at 15 to 18 months.