A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks

A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management?

A. Offer elective cesarean section after amniocentesis to determine lung maturity
B. Offer elective cesarean section at 38 weeks
C. Offer elective cesarean section at 34 weeks
D. Recommend forceps-assisted vaginal delivery
E. Recommend vaginal delivery

Explanation: The correct answer is B. A significant body of evidence has developed that transmission rates of HIV from mother to infant can be decreased through the use of medications and cesarean delivery. The Pediatric AIDS Clinical Trials Group (PACTG) 076 Zidovudine Regimen was shown to decrease the rate of transmission from 25% to 8%. This regimen consisted of ZDV being given antepartum and intrapartum to the mother and postpartum to the infant. More recent evidence is accumulating that the mode of delivery also affects transmission rates. The combination of ZDV therapy and cesarean delivery decreases the risk of transmission to approximately 2%. But, the decrease in transmission with cesarean delivery occurs regardless of whether the patient is receiving antiretroviral therapy. Thus, cesarean delivery should be offered to HIV-positive women to prevent transmission. Delivery at 38 weeks is recommended to reduce the chances that the patient will go into labor or rupture her membranes. Once these occur, the benefit of cesarean delivery is reduced. To offer elective c-section after amniocentesis to determine lung maturity (choice A) is incorrect. Amniocentesis should be avoided, if possible, in the HIV-positive woman. To offer elective c-section at 34 weeks (choice C) is incorrect. To perform a cesarean delivery at 34 weeks risks iatrogenic prematurity in the neonate. Cesarean delivery prior to the onset of labor or rupture of membranes is the preference, and this can be accomplished at 38 weeks with a lower risk of iatrogenic prematurity. To recommend forcepsassisted vaginal delivery (choice D) or vaginal delivery (choice E) is incorrect. The decision of which mode of delivery to choose ultimately belongs to the patient. But, vaginal delivery would not be recommended, as cesarean delivery has been shown to decrease transmission rates.