This presentation discusses the management of a multiparous HIV positive patient who was admitted to Baylor University Medical Center's labor and delivery unit with premature rupture of membranes (PROM) at 28 weeks gestation. A multidisciplinary approach was taken to provide the best care to the maternal-fetal dyad.
This case involves a gravida 3, para 1 who presented to labor and delivery 28 5/7 weeks gestation with PROM. Her obstetric history included one spontaneous abortion and one 24-week preterm delivery of an infant who died at 8 days of life. Her medical history was complicated by positive HIV infection, bipolar depression, multifocal demyelination disorder, and advanced maternal age. Her HIV status was diagnosed during her current pregnancy, and she was placed on a combination antiretroviral regimen. Her last viral load prenatally was undetectable.
Upon presentation to labor and delivery, she stated she had been leaking fluid for 1½ hours. No signs of labor or vaginal bleeding were noted on admission. Rupture of membranes was confirmed. She was placed on latency antibiotics and given corticosteroids for fetal lung maturation. Following consultation with representatives from infectious disease, the neonatal intensive care unit (NICU), maternal fetal medicine, and neurology, it was decided to continue her prenatal antiviral drug regimen. Repeat CD4 count and viral load lab work were performed confirming undetectable viral load. The patient received a psychological consult for her depression and anxiety and an occupational therapy consult for her demyelination syndrome. She was counseled regarding contraceptive care and bottle feeding as the preferred method to reduce transmission.
At 29 5/7 weeks, she began experiencing cramping, vaginal bleeding, and signs of chorioamnionitis. She was transferred to labor and delivery, where the decision was made to proceed with a cesarean. Per guidelines of the Centers for Disease Control and Prevention, intravenous AZT was started and allowed to infuse for the recommended 3 hours prior to birth. The infant was born with 8/9 Apgar scores, was bathed and transferred to the NICU on room air. The infant was started on antivirals, with a plan to continue for the first 6 weeks of life.
When PROM occurs prior to 37 weeks, decisions about delivery should be based on gestational age, duration of rupture, HIV RNA level, current antiretroviral regimen, and evidence of acute infection. It is essential to provide ongoing training and the most current recommendations for management of HIV infection for the labor and delivery staff.