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Anaesthetic Management of HIV-Positive Pregnant Female for Caesarean Section

1. Preoperative Assessment

Multidisciplinary Team Coordination

• Notify consultant anaesthetist, obstetrician, neonatologist/paediatrician, infection control, and ICU
• Involve HIV/ID specialist; maintain strict patient confidentiality
• Birth plan should document HIV status explicitly for theatre/ward staff

History & Examination

• Disease stage: CD4+ count, viral load (most recent, ideally at 36 weeks)
• Full antiretroviral therapy (ART) history - drug names, doses, duration, adherence
• Side effects/toxicities of ARVs (hepatotoxicity, nephrotoxicity, peripheral neuropathy, lipodystrophy)
• Opportunistic infections - TB, PCP, CMV, cryptococcal meningitis
• Comorbidities: cardiovascular disease, diabetes (protease inhibitor side effect), renal/hepatic impairment
• Airway assessment (standard obstetric)

Investigations

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2. Mode of Delivery & Timing

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3. ART Perioperative Management

• Continue ART throughout perioperative period - do not interrupt; minimise interruptions to reduce drug resistance
• Oral medications can be taken preoperatively with small sips of water
• IV Zidovudine (ZDV): Indicated when viral load is >1000 copies/mL at or near delivery
  • Loading dose: 2 mg/kg IV over 1 hour (ideally 3 hours before delivery)
  • Maintenance: 1 mg/kg/hr IV as continuous infusion until delivery
  • Goal: achieve adequate maternal and fetal ZDV levels

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4. Choice of Anaesthesia

Regional Anaesthesia - Preferred Choice

• Spinal anaesthesia: Preferred for planned LSCS - faster onset, dense block, lower LA dose
• Combined spinal-epidural (CSE): Option if prolonged surgery anticipated or conversion to GA possible
• Contraindications to neuraxial block - must exclude:
  • Active CNS infection (meningitis, encephalitis, space-occupying lesion)
  • Thrombocytopenia (platelet count < 70-80 x10⁹/L - use clinical judgement)
  • Coagulopathy (INR >1.5, APTT >40 sec)
  • Active local infection at puncture site
  • Patient refusal
• Check for peripheral neuropathy - document pre-existing neurological deficits before block
• Strict aseptic technique is paramount given immunocompromised state

General Anaesthesia

• Rapid Sequence Induction (RSI) - standard obstetric protocol (preoxygenation, cricoid pressure, suxamethonium or rocuronium)
• Avoid propofol infusions (TIVA) in patients on NRTIs - both can promote mitochondrial toxicity and lactic acidosis
• Halothane and methoxyflurane should be avoided due to hepatic/renal toxicity (interaction risk with hepatotoxic ARVs)

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5. Drug Interactions with ARVs

Resource for real-time interaction checking: HIV Drug Interactions (Liverpool database)

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6. Infection Control and Universal Precautions

• Double gloves for all theatre staff performing/assisting the caesarean (NICE recommendation 1.4.26)
• Follow all safe surgical and sharps practices; minimise sharp instrument passes
• Eye protection and impermeable gowns
• Strict aseptic technique for all invasive procedures
• If needlestick/blood exposure occurs: initiate post-exposure prophylaxis (PEP) within 1-2 hours ideally
• If TB suspected: healthcare worker should wear N95/HEPA-grade mask
• Decontaminate anaesthetic breathing circuit and equipment after use

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7. Intraoperative Management

• Standard ASA/AAGBI monitoring (SpO₂, NIBP, ECG, ETCO₂ if GA, temperature)
• Left uterine displacement (15°) until delivery
• IV access: at least one large-bore IV
• Antibiotic prophylaxis: cephalosporin or appropriate agent before incision (same as general obstetric population)
• Fluid management - avoid overload; titrate vasopressors (phenylephrine preferred) for spinal hypotension
• Blood products should be on standby - HIV patients may have thrombocytopenia
• Oxytocin after delivery: standard protocol; note ergometrine is relatively contraindicated with PIs (vasoconstriction risk)

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8. Postoperative Management

• Continue ART without interruption postoperatively
• Multimodal analgesia: paracetamol, NSAIDs (if not contraindicated), intrathecal morphine (if spinal used), wound infiltration
• Avoid intramuscular injections where possible (immunosuppression, bruising risk)
• Deep vein thrombosis prophylaxis: LMWH + mechanical (HIV is an independent risk factor for thromboembolism)
• Monitor for postoperative infections diligently - fever threshold for investigation may be lower given immunosuppression
• Breastfeeding: context-dependent; in high-resource settings, formula feeding is recommended to prevent postnatal transmission

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9. Neonatal Considerations

• Alert neonatologist/paediatrician to be present at delivery
• Neonate receives prophylactic ARVs (usually AZT/nevirapine) per protocol
• Cord blood sampling as per institutional protocol
• Defer all non-urgent neonatal procedures

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Summary Checklist

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• WFSA Update in Anaesthesia - HIV and Anaesthesia
• BHIVA Guidelines on Management of HIV in Pregnancy (2024 public consultation)
• ACOG Committee Opinion - Labor and Delivery Management of Women with HIV (reaffirmed 2024)
• NICE Guideline NG192 - Caesarean Birth (amended 2024)