Pregnant, Substance-Using Women
Treatment Improvement Protocol (TIP) Series 2

Obstetrical Care Guidelines for HIV-Infected Women ²³

1 Complete an initial workup. The initial workup should include a complete medical history, complete review of symptoms, comprehensive physical examination, and additional laboratory screening.

a) Complete medical history, with special attention to

• Sexual practices (sexual partners and their HIV status, practice of anal and oral sex, exchange of sex for money and drugs)
• Alcohol and other drug abuse (injection drug use, use of shared needles, drugs of choice, and sexual or drug partners' history of alcohol and other drug abuse)
• Blood transfusions, including dates and locations
• Tuberculosis (TB) exposure, past PPDs, and TB prophylaxis
• Sexually transmitted diseases (STDs), including herpes simplex genitalis/labialis, syphilis, genital warts, and chancroid
• Vaginal candidiasis
• Cervical dysplasia

b) Complete review of symptoms that includes

• Rashes, bruising, bleeding
• Fever, chills, night sweats
• Fatigue, exercise intolerance, dyspnea, cough
• Anorexia, nausea, vomiting, odynophagia, diarrhea
• Vaginal discharge, dysuria, abdominal pain
• Headache, visual changes, memory loss, depression, paresthesia, weakness
• Weight loss and/or poor weight gain prior to and during pregnancy

c) Comprehensive physical examination that includes:

• Vital signs: Temperature, weight, blood pressure, respiration
• Skin: Seborrheic dermatitis, folliculitis, track marks, purple lesions (Kaposi's sarcoma [KS] -- rare in women)
• HEENT: Fundi: cotton wool spots, retinitis (CMV), hemorrhages; and Mouth: ulcers (herpes, syphilis), hairy leukoplakia, thrush (candida), purple lesions (KS)
• Nodes: Lymphadenopathy
• Chest: Dullness, rales, rubs (PCP, TB, CMV), murmurs, gallops
• Abdomen: Hepatomegaly, splenomegaly
• Genital (include full pelvic and rectal exam): Ulcers (herpes, chancroid, syphilis), chancroid, condylomata (HPV, syphilis), discharge (candida, STDs), Pap smear (dysplasia)
• Neurological: Cognitive deficits, cranial nerve defects, sensory or motor changes, weakness (HIV, toxoplasma, cryptococcus)

d) Additional laboratory screening that includes

• HIV culture and antigen assay where available
• CBC, differential, platelets
• Immunological status assessment, e.g., CD- or T-cell counts
• Serological tests for syphilis, GC, chlamydia-repeat screening as indicated
• PPD with antigen panel
• Possible freezing of serum sample for later testing of titers for toxoplasma, CMV, and cryptococcus

2 Provide medical treatment for HIV-related conditions. Medical treatment should be provided in consultation with HIV specialists and consistent with current recommendations. Women with CD4 counts of less than 200mm³ should be placed on an antiviral agent and given appropriate prophylaxis.²⁴

• Aggressively evaluate and promptly treat any conditions diagnosed.
• If laboratory studies indicate significant immuno-suppression, consider prophylactic treatment against opportunistic infections.
• Consider the use of an anti-viral agent (zidovudine [AZT]).
• Consider other experimental treatment guidelines and refer the patient as indicated.

3 Provide obstetric management. Obstetric management should include all of the usual obstetric practices, with special attention to the following:
 
a) Antepartum care

• Provide close prenatal followup.
• Obtain interim history and conduct a physical examination to include HIV-related elements.
• Repeat serological tests for syphilis, GC, chlamydia, and other laboratory tests as clinically indicated.
• Assess immunological status every trimester, or more often if the patient develops an illness or if a declining trend is noted.
• Perform a fetal assessment if clinically indicated. To prevent possible HIV transmission and nosocomial infection, avoid invasive procedures if possible, but not at the expense of accepted standards of care (e.g., genetic amniocentesis).
• Discuss with the patient the need to share pertinent medical information with her other direct care providers and those of her infant.
• Ensure primary care and specialized pediatric followup.
• Ensure involvement in an alcohol and other drug treatment program.
• Reinforce the need to practice safer sex.
• Recommend involvement in an HIV/AIDS support group.

• Follow universal precautions for blood and body fluids and OSHA standards that include
  • Gowns, masks, eye protection, and double gloves for deliveries
  • Gloves for invasive procedures, changing soiled linens or dressings, handling the placenta and cord, and handling the neonate prior to the first bath
  • Mechanical or bulb aspiration of the newborn: Avoid mouth-operated aspiration traps
• Utilize fetal monitoring as indicated.
• There is no specific indication for Caesarean delivery.

c) Postpartum care

• Breastfeeding is not recommended; otherwise, encourage mother-infant bonding.
• Ensure comprehensive medical followup for the woman, infant, and family members as indicated.
• Educate the woman to care for the infant's special needs.
• Ensure followup in an alcohol and other drug treatment program.
• Encourage use of an appropriate family planning method.