Viral Infections in the Neonate

Richard J. Martin MBBS, FRACP, in Fanaroff and Martin's Neonatal-Perinatal Medicine, 2020
Maternal Antepartum/Intrapartum Care
1.
All pregnant, HIV-infected women should receive combination ARV drugs ante partum, starting as early as possible
during pregnancyregardless of their HIV RNA levels and CD4 T lymphocyte counts. A French cohort study, which
looked at factors associated with mother-to-child transmission of HIV despite low viral load at the time of delivery,
showed that women who transmitted the virus to their offspring were less likely to have had viral loads less than 500
copies/mL and were also less likely to have received ART at the time of becoming pregnant and early in the
pregnancy.261 It is also known that mother-to-child transmission is possible even with low RNA levels and in mothers
on ART. There have been reports of discordance between the viral loads in blood and those in the genital tract;
women with undetectable levels in blood have been found to shed the virus in the genital tract. 197,275
2.
Resistance testing is indicated in women whose RNA levels are above the resistance testing threshold (>500-1000
copies/mL) before starting or modifying ARV drug regimens in patients with known HIV infection and those diagnosed
early in pregnancy. However, if HIV infection is diagnosed late in pregnancy, therapy should be started even if the
results of resistance testing are not available. In all pregnant patients on ARV, the importance of strict adherence to
the ARV regimen should be strongly emphasized.
3.
IV zidovudine continuous infusion (2 mg/kg IV over 1 hour followed by continuous infusion of 1 mg/kg until delivery)
isrecommended for HIV-infected mothers withviral loads greater than 1000 copies/mL near delivery, those in
whom viral loads are unavailable near the time of delivery, or in women who did not receive any antepartum ART
regardless of the antepartum regimen or mode of delivery.
Women who are on ART and have well-controlledviral loads less than 50 copies/mL consistently during late
pregnancy and near delivery and in whom compliance has not been a problem,do not need IV zidovudine and should
continue their drug regimen orally on schedule as much as possible during labor and even before a
scheduled cesarean section. This can be accomplished by taking the medication with small sips of water.

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For women withviral loads between 50-999 copies/mL, the current available data are not sufficient to determine
whether IV zidovudine offers additional protection to the infant. Some studies have shown lower maternal-to-fetal
transmission in women with viral loads below 50 copies/mL as compared with those with 50-1000 copies/mL; 0.25
versus 2%.181 Experts, therefore, recommend that IV zidovudine beconsidered in this group of patients, but this is left
to the clinical judgment of the provider.
In women who are scheduled for a cesarean section and require IV zidovudine, it should be started 3 hours before
the surgery (1-hour loading dose and 2-hour continuous infusion). For emergency cesarean section, the aim is to try
to complete the 1-hour loading dose before proceeding with the cesarean section.
4.
Expedited testing for HIV should be performed in all mothers without documentation of their HIV status unless they
“opt out.” Women who are considered to be at increased risk for acquiring HIV (partner with HIV infection, multiple
sexual partners during pregnancy, illicit drug use, exchange of sex for money, or living in an area with high incidence
of HIV infection in childbearing age) should also be tested at the time of labor, even if testing earlier in pregnancy
yielded negative results. Testing shou
ld be done with HIV-1 and HIV-2 antigen/antibody combination immunoassay and an HIV RNA assay. These testing
modalities should be available in institutions that offer maternity and neonatal intensive care and nursery services.
For women who test positive, IV zidovudine should be started immediately.