Monitoring
In addition to routine antenatal care, the following should be monitored during pregnancy.[7]
HIV RNA: recommended at the initial antenatal visit, 2-4 weeks after initiating (or modifying) antiretroviral therapy (ART), monthly until HIV RNA levels are undetectable, and then at least every 3 months during pregnancy. Assess at 36 weeks' gestation to inform decisions about mode of delivery. Regular viral load monitoring is required in pregnancy to detect lack of viral suppression. More frequent monitoring may be required when using regimens associated with lower drug levels in the third trimester, or drugs with limited pharmacokinetic data in pregnancy available.
CD4 cell count: recommended at the initial antenatal visit and then every 3 months during pregnancy in patients who have been on ART <2 years, patients with CD4 counts <300 cells/microlitre, and patients with inconsistent adherence and/or detectable viral loads. Other patients do not need their CD4 counts monitored after the initial antenatal visit.
Resistance testing: recommended in women with virological failure and HIV RNA levels >200 copies/mL before initiating or modifying ART in select patients.
Standard gestational diabetes screening recommended. Some experts may perform glucose screening earlier in pregnancy for patients who are on protease inhibitors and who may be at high risk for gestational diabetes.
Liver function tests: recommended at initiation or modification of ART (ideally within 2-4 weeks), and every 3 months during pregnancy, with additional testing as clinically indicated.
Fetal genetic screening: as amniocentesis should only be performed after initiation of effective ART and ideally when HIV RNA levels are undetectable, non-invasive genetic screening is encouraged. Consider a consultation with an expert if a pregnant woman with detectable HIV RNA levels requires amniocentesis.
Laboratory testing to monitor complications of specific ART regimens: should be based on what is known about the adverse effects of the drugs an individual is receiving.
If lack of viral suppression is identified, evaluation of contributing factors is required (e.g., adherence, drug resistance, pharmacokinetic changes in pregnancy leading to insufficient drug levels, drug-drug and drug-food interactions). Viral load testing should be repeated within 2-4 weeks of addressing these factors. Regimens should be modified in consultation with a specialist. Adding a single drug to a regimen that has resulted in virological failure is not generally recommended due to the risk of developing resistance to one or more drugs in the regimen. Interrupting or discontinuing ART is also not recommended as this may lead to a rapid increase in HIV RNA and a decrease in CD4 cell count resulting in clinical progression or perinatal HIV transmission.[7]
Healing of wound sites, uterine involution, and appropriate cessation of postnatal bleeding should be assessed. Because of the potential for an increase in post-ceasarean section wound infection, assessment of wound healing should be carried out between the time of hospital discharge and the routine postnatal visit.
Women should have contact with their obstetric care provider within the first 3 weeks of the postnatal period, and their HIV practitioner within the first 2-4 weeks after discharge.
As women with HIV have higher rates of mental illness and depression, they appear to be at risk for postnatal depression. Given the increased prevalence for behavioural health comorbidities, screening for disorders such as post-traumatic stress disorder, anxiety, and depression is recommended, as well as indications for behavioural health care, such as smoking cessation, substance abuse treatment, or mental health services.[7]
The Antiretroviral Pregnancy Registry is a collaborative effort between pharmaceutical companies, the US Centers for Disease Control and Prevention, the US National Institutes of Health, and obstetric and paediatric practitioners, to collect observational information on antiretroviral exposure during pregnancy to assess potential fetal/infant anomalies. Patient names are not used and information is confidential. All cases of ART drug exposure during pregnancy should be reported to the registry.[7] Antiretroviral Pregnancy Registry Opens in new window
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