HIV in Pregnancy – High Yield
1. Maternal-Fetal Transmission
Transmission risk without intervention: 15–45%
Routes of transmission:
In utero (transplacental)
Intrapartum (most common, via blood & secretions)
Breastfeeding (postnatal)
Risk factors increasing transmission:
High maternal viral load
Low maternal CD4 count
Vaginal delivery (esp. prolonged rupture of membranes >4 hrs)
Chorioamnionitis
Breastfeeding
Invasive procedures (fetal scalp electrodes, forceps, vacuum, amniocentesis)
2. Antiretroviral Therapy (ART)
All HIV-positive pregnant women should receive ART, regardless of CD4 count or viral
load.
Goal: Undetectable viral load before delivery
Preferred regimen: Combination ART (HAART)
2 NRTIs + 1 INSTI or NNRTI or PI
Example: Tenofovir + Lamivudine (or Emtricitabine) + Dolutegravir
Continue ART throughout pregnancy, delivery, and postpartum.
3. Mode of Delivery
Viral load < 1000 copies/mL at 36 weeks → Vaginal delivery safe
Viral load > 1000 copies/mL or unknown → Elective C-section at 38 weeks
Avoid:
Prolonged rupture of membranes
Episiotomy
Instrumental delivery
Fetal scalp electrodes
4. Intrapartum Management
Continue maternal ART
IV Zidovudine during labor if viral load > 1000 or unknown
Avoid breastfeeding if safe alternative feeding is available
5. Neonatal Management
Neonatal prophylaxis depends on maternal viral load:
If maternal VL < 1000: baby gets Zidovudine for 4 weeks
If maternal VL > 1000 or mother untreated: baby gets Combination prophylaxis
(Zidovudine + Nevirapine or 3-drug regimen) for 6 weeks
PCR testing for HIV at:
14–21 days
1–2 months
4–6 months
Start cotrimoxazole prophylaxis at 6 weeks until HIV is excluded.
6. Breastfeeding
High-income settings: Avoid breastfeeding (use formula)
Low-resource settings (where formula is unsafe/unavailable): Exclusive breastfeeding
with maternal ART is recommended
✅ Exam Pearls
C-section reduces transmission risk by ~50% if viral load high.
Zidovudine (AZT) is the cornerstone drug historically tested.
ART should never be stopped during pregnancy.
Transmission risk with optimal ART & management: <1%.
HIV in Pregnancy – Flashcards
Q1. What is the risk of vertical HIV transmission without intervention?
A1. 15–45%
Q2. What is the most common route of mother-to-child HIV transmission?
A2. Intrapartum (during labor and delivery)
Q3. List 4 risk factors that increase HIV transmission during pregnancy/delivery.
A3.
High maternal viral load
Low CD4 count
Prolonged rupture of membranes (>4 hrs)
Chorioamnionitis / breastfeeding / invasive procedures
Q4. Should all HIV-positive pregnant women receive ART?
A4. Yes, regardless of CD4 or viral load
Q5. What is the preferred ART regimen in pregnancy?
A5. 2 NRTIs + 1 INSTI (or NNRTI/PI) → Example: Tenofovir + Lamivudine + Dolutegravir
Q6. At what viral load is vaginal delivery considered safe?
A6. < 1000 copies/mL at 36 weeks
Q7. What is the recommended delivery if viral load > 1000 copies/mL or unknown?
A7. Elective C-section at 38 weeks
Q8. What intrapartum drug is given if viral load > 1000 or unknown?
A8. IV Zidovudine
Q9. Which procedures should be avoided during labor in HIV mothers?
A9. Prolonged ROM, episiotomy, forceps/vacuum, fetal scalp electrodes
Q10. Neonatal prophylaxis if maternal VL < 1000?
A10. Zidovudine for 4 weeks
Q11. Neonatal prophylaxis if maternal VL > 1000 or untreated?
A11. Combination prophylaxis (Zidovudine + Nevirapine or 3-drug regimen) for 6
weeks
Q12. When is infant PCR testing for HIV performed?
A12. 14–21 days, 1–2 months, 4–6 months
Q13. When should cotrimoxazole prophylaxis be started in HIV-exposed infants?
A13. At 6 weeks, continued until HIV is excluded
Q14. Breastfeeding recommendation in high-income countries?
A14. Avoid breastfeeding → use formula
Q15. Breastfeeding recommendation in low-resource settings?
A15. Exclusive breastfeeding with maternal ART
Q16. With optimal ART and management, what is the transmission risk?
A16. <1%
