Intrapartum management for prevention of mother-to-child transmission of HIV in resource-limited settings: a review of the literature.

Prevention of mother-to-child transmission (PMTCT) of HIV guidelines in resource-limited settings focus on antenatal and postnatal management. In this review of the literature, we present findings from select studies, highlight best practices, and present evidence-based guidelines for intrapartum PMTCT management that are applicable to resource-limited settings. We discuss the roles of intrapartum HIV testing, intrapartum antiretroviral medications, mode of delivery in settings with and without HIV RNA testing, other delivery practices, and infant care in the immediate postnatal period. With the advent of Option B+, which recommends all HIV-infected pregnant women commence lifelong combination antiretroviral therapy (ART), the potential impact for intrapartum interventions will be greatest for those women who recently have seroconverted and those with unknown HIV status. Research on intrapartum PMTCT interventions should focus on these populations.

Maternal and newborn outcomes at a tertiary care hospital in Lusaka, Zambia, 2008-2012.

OBJECTIVE: To measure key obstetric and neonatal outcomes recorded at a tertiary hospital in Zambia over a 5-year period. METHODS: A retrospective analysis was conducted among women who had delivered at the University Teaching Hospital in Lusaka, between January 1, 2008, and December 31, 2012. Data were extracted from electronic medical records. The main outcomes were maternal mortality, cesarean delivery, prenatal or intrapartum hemorrhage, stillbirth, a 5-minute Apgar score of less than 7, and admission to the neonatal intensive care unit. RESULTS: A total of 62 470 deliveries were recorded. Rates of maternal mortality, cesarean delivery, and hemorrhage during pregnancy all declined over time. Decreased admissions to the neonatal intensive care unit were observed; however, the rate spiked temporarily in late 2011 and early 2012 before returning to previous levels. The proportion of stillbirths remained stable over time but reports of a 5-minute Apgar score of less than 7 rose. CONCLUSION: Routinely collected obstetric and neonatal data could aid ongoing program monitoring and should be used to guide quality improvement activities.

Pregnancy outcomes and birth defects from an antiretroviral drug safety study of women in South Africa and Zambia.

OBJECTIVE: To evaluate the safety of combination antiretroviral therapy (ART) in conception and pregnancy in different health systems. DESIGN: A pilot ART registry to measure the prevalence of birth defects and adverse pregnancy outcomes in South Africa and Zambia. METHODS: HIV-infected pregnant women on ART prior to conception were enrolled until delivery, and their infants were followed until 1 year old. RESULTS: Between October 2010 and April 2011, 600 women were enrolled. The median CD4 cell count at study enrollment was lower in South Africa than Zambia (320 vs. 430 cells/µl; P < 0.01). The most common antiretroviral drugs at the time of conception included stavudine, lamivudine, and nevirapine. There were 16 abortions (2.7%), one ectopic pregnancy (0.2%), 12 (2.0%) stillbirths, and 571 (95.2%) live infants. Deliveries were more often preterm (29.7 vs. 18.4%; P = 0.01) and the infants had lower birth weights (2900 vs. 2995 g; P = 0.11) in Zambia compared to South Africa. Thirty-six infants had birth defects: 13 major and 23 minor. There were more major anomalies detected in South Africa and more minor ones in Zambia. No neonatal deaths were attributed to congenital birth defects. CONCLUSIONS: An Africa-specific, multi-site antiretroviral drug safety registry for pregnant women is feasible. Different prevalence for preterm delivery, delivery mode, and birth defect types between women on preconception ART in South Africa and Zambia highlight the potential impact of health systems on pregnancy outcomes. As countries establish ART drug safety registries, documenting health facility limitations may be as essential as the specific ART details.