**5.6. What to do with HIV(+) pregnant women with threat of premature delivery?**

involving defects of neural tube closure. Nevertheless, there are no categorical studies supporting such recommendation (Level 3 evidence). Likewise, the use of the ddl/d4T

The genotyping study should be performed on pregnant women undergoing ART with VL >1,000 copies/ml, particularly in pregnancies that have not achieved such goal at 34 weeks of gestation. Moreover, the addition of a single dose of nevirapine at the moment of delivery is

Several clinical guidelines propose such management based on expert recommendations

**5.3. What to do with HIV(+) pregnant women who reach 32 weeks of gestation without ART?** In pregnant women reaching the 32nd week of gestation or more without ART, it is recom‐ mended to assess CD4 T-cell levels and VL and to initiate immediately ART with AZT/3TC coformulated, together with a protease inhibitor (PI). Nevirapine (NVP) can be used instead

There is wide experience on the use of NVP during pregnancy. The drug has a risk of severe

clinical guidelines propose such management based on expert recommendations. When NVP is used during delivery, AZT/3TC needs to be used subsequently to prevent drug resistance

**5.4. What to do with HIV(+) pregnant women close to delivery date without prior ART?**

**•** Use AZT/3TC for 1 week, add PI, until evaluating the best regimen to continue therapy

Several clinical guidelines propose such management based on expert recommendations

Because of the potential teratogenesis of ribavirin, its preconception withdrawal for at least 4 months in women and at least for 7 months in case the couple had received such drug should be counseled. In case of an eventual use during pregnancy, it should be immediately with‐

**5.5. What to do with HIV(+) pregnant women who have been treated with ribavirin?**

drawn, and a consultation visit should be arranged to assess maternal liver function.

(Grade D recommen‐

, especially in coinfection with HBV and HCV. Several

of a reinforced PI when CD4 T-cell counts are lower than 250 cells/mm3

combination should be terminated [15-21].

64 Trends in Basic and Therapeutic Options in HIV Infection - Towards a Functional Cure

suggested (Grade D recommendation).

hepatotoxicity with CD4 >250 cells/mm3

The following are to be observed:

**•** Single dose of nevirapine.

(Level 4 evidence) [15-21].

(Grade D recommendation).

**•** Ideally assess CD4 T cells and VL.

**•** Intravenous zidovudine as per regimen.

**•** Resolution of delivery through cesarean section.

induced by NVP (Level 4 evidence) [15-21].

(Level 4 evidence) [15-21].

dation).

The administration of IV AZT 2 mg/kg/h, together with tocolytic therapy, during the first hour followed by 1 mg/kg/h until dynamics ease up, according to ART administration policy during delivery, is recommended in the presence of regular uterine dynamics, despite cervical modifications being scarce. If unable to slow down the situation and if delivery is triggered and/or rupture of membranes ensues, a cesarean section shall be performed sufficiently in advance (Grade C recommendation).

Premature delivery constitutes a risk factor for perinatal transmission of the virus: a maternal viral load (VL) of <400 c/ml in a delivery occurring before 34 weeks was related to an 8-fold increase in the risk of transmission as compared to term delivery (Level 2+ evidence) [58].

## **5.7. What to do with HIV(+) pregnant women with premature rupture of membranes?**

All patients should receive ART and undergo the usual control and therapeutic measures such as the administration of prophylactic antibiotics, steroids, and eventually the use of magnesi‐ um sulfate as neuroprotector. In case of a suspected infection or loss of fetal well-being, pregnancy interruption must be carried out. The recommended delivery route is cesarean section. The management of each case depends on the gestational age (Grade D recommen‐ dation).

In pregnancies of less than 26 weeks, a conservative therapy is recommended in view of the risk of severe sequels as a result of prematurity and high neonatal mortality (Grade D recom‐ mendation). Between weeks 26 and 30, each case shall be evaluated according to maternal and fetal status, the virological status of the mother, if she has been administered a therapy or not, and the neonatal outcomes of the center (Grade D recommendation). Between 30 and 34 weeks, the general behavior that is recommended is to terminate pregnancy. In view of the higher tendency to an increase of reported VT in premature deliveries with PROM even while receiving ART, the preferred route for delivery shall be cesarean section (Grade D recommen‐ dation)

There is a clear difference in the risk of severe sequels between gestational ages (61.5% at week 23 and 10% at week 28). In view of the higher risk of VT in preterms, a cesarean section shall be considered (Level 2+ evidence) [21, 56, 58].

Before the use of ART during pregnancy, several studies found a relationship between the duration of the rupture of membranes and the VT, particularly if such duration was greater than 4 h. In women with less than 24 h since the rupture of membranes, for every hour that elapses after the rupture, the risk of vertical transmission rises in 2%. Because the risk of fetal infection in patients with PROM and very low plasmatic viral load and/or under ART is unknown, treatment of PROM has not been fully clarified. Several clinical guidelines propose such management based on expert recommendations (Level 4 evidence) [15-21].
