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Anaesthetic Management: HIV-Positive Parturient for Elective LSCS

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1. Preoperative Assessment

Clinical History

• HIV disease staging: CD4 count, viral load (HIV RNA copies/mL), duration of infection
• Antiretroviral therapy (ART): current regimen, adherence, duration, last dose
• Opportunistic infections: tuberculosis, PCP pneumonia, CMV, toxoplasmosis, fungal infections
• Systemic organ involvement: cardiac (cardiomyopathy), pulmonary (PCP, lymphoid interstitial pneumonitis), renal (HIV nephropathy), hepatic (hepatitis B/C co-infection, HAART hepatotoxicity), neurological (peripheral neuropathy, CNS involvement), haematological
• Obstetric history: gestational age, placental position, amniotic fluid, fetal well-being
• Substance abuse: intravenous drug use (increases perioperative risk)

Indications for Elective LSCS in HIV

• Viral load >1,000 copies/mL near term - elective caesarean at 38 weeks is recommended regardless of ART status
• Co-infection with hepatitis C (to reduce dual vertical transmission)
• When viral load is suppressed (<1,000 copies/mL), delivery timing follows standard obstetric guidelines

Investigations

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2. ART Management Perioperatively

• Continue ART throughout the perioperative period - interruption even for <24 hours can lead to viral rebound and drug resistance
• Oral medications can be taken preoperatively with sips of water
• Drugs requiring food for absorption (e.g., some protease inhibitors) can be taken with liquid dietary supplements - consult the anaesthesiologist
• IV Zidovudine (ZDV): For viral load >1,000 copies/mL or unknown - begin IV ZDV at least 3 hours before surgery:
  • Loading dose: 2 mg/kg IV over 1 hour
  • Maintenance: 1 mg/kg/hr continuous infusion until delivery
• If all ART must be briefly interrupted, all drugs should be stopped simultaneously (to prevent resistance) and restarted together as soon as feasible

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3. Choice of Anaesthesia

Regional Anaesthesia: PREFERRED

• Does not interfere with the immune system (unlike general anaesthesia, which causes immunosuppression)
• No interaction with antiretroviral drugs
• Avoids airway manipulation (reduced exposure of staff to secretions)
• Reduced maternal morbidity and mortality
• Studies confirm low complication rates with spinal anaesthesia for CS in HIV-positive women on ART (Avidan et al., Anesthesiology 2002)
• Not associated with increased perioperative complications, changes in immune function, or viral load

• Sepsis / bacteraemia
• Significant thrombocytopaenia (platelets <80,000/mm³)
• Coagulopathy
• Patient refusal
• Local infection at the site

• Peripheral neuropathy (common in HIV) does not contraindicate regional anaesthesia, but document pre-existing neurological deficits carefully before the block
• Post-dural puncture headache (PDPH): If it occurs, epidural blood patch is not contraindicated in HIV-positive patients - studies show no increased CNS complications or changes in viral load
• Concern about introducing HIV into a "virus-free" CSF compartment is theoretical and not supported by evidence (CNS involvement occurs early in HIV infection)

• Heavy bupivacaine 0.5%: 1.8-2.2 mL (10-12.5 mg) + fentanyl 15-25 mcg ± morphine 100-150 mcg intrathecally
• Left lateral uterine displacement
• Aggressive prophylaxis and treatment of hypotension (IV fluids, vasopressors - phenylephrine or ephedrine)

General Anaesthesia: Use Only if Regional is Contraindicated

• Coagulopathy / severe thrombocytopaenia
• Active sepsis
• Severe haemodynamic instability
• Patient refusal of regional
• Technical failure of regional block
• Urgency not allowing time for regional

• Immunosuppression - volatile agents and opioids suppress immune function, worsening already compromised immunity
• Drug interactions (see below)
• Higher risk of difficult/failed intubation (consider potential for lymphadenopathy, pharyngeal masses)
• Higher aspiration risk (standard obstetric precautions apply)
• Neonatal respiratory depression from induction agents

• Rapid sequence induction (RSI): preoxygenation, thiopentone 4-5 mg/kg (or propofol 2-2.5 mg/kg) + suxamethonium 1.5 mg/kg
• Note: succinylcholine pseudocholinesterase activity may be reduced with some ARVs (e.g., abacavir) - watch for prolonged neuromuscular block
• Maintenance: volatile agent (isoflurane/sevoflurane) + 50% O2/N2O or air
• Avoid prolonged N2O (reduces methionine synthase, worsens haematological effects of ZDV)
• Muscle relaxants: rocuronium can be used; avoid repeat doses of suxamethonium if pseudocholinesterase levels uncertain

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4. Key Drug Interactions: ART and Anaesthetic Agents

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5. Intraoperative Management

• Universal precautions / standard infection control: double gloves (NICE guidelines 1.4.26), eye protection, gown - for ALL staff
• Avoid needlestick injuries: use needle-safe devices, announce before passing sharps
• Position: left lateral tilt of 15 degrees to prevent aortocaval compression
• Prophylactic antibiotics: mandatory (cefazolin 2g IV) - HIV-positive patients have higher rates of infectious complications post-LSCS
• Oxytocin is the uterotonic of choice (ergometrine avoided due to drug interactions with protease inhibitors causing severe hypertension/vasospasm)
• Maintain normothermia (immunocompromised patients more susceptible to hypothermia-related complications)
• Careful fluid management; avoid excessive crystalloid
• Monitor blood glucose (protease inhibitors cause hyperglycaemia)
• Thromboprophylaxis: HIV patients are in a prothrombotic state; LMWH post-operatively as per protocol

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6. Postoperative Management

• Continue ART without interruption
• Analgesia: multimodal - paracetamol + NSAIDs (if not contraindicated) + intrathecal morphine (if given) + wound infiltration
• Avoid IM opioids where possible; use oral/IV PCA if needed
• Watch for enhanced opioid effects in patients on PIs (especially fentanyl/alfentanil)
• Antibiotic cover: continue post-operative antibiotics as indicated
• Venous thromboembolism prophylaxis: early mobilisation + LMWH
• Immune monitoring: CD4 count and viral load post-operatively if clinically indicated
• Breastfeeding: in resource-rich settings, HIV-positive mothers are advised against breastfeeding (risk of postnatal transmission); country-specific guidelines apply

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7. Neonatal Considerations

• Paediatric team must be present at delivery
• Neonatal antiretroviral prophylaxis should be initiated within 6-12 hours of delivery
• Avoid foetal scalp electrodes and operative vaginal delivery where possible (increase transmission risk)

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8. Universal Precautions Summary

• Double gloves for surgeon, assistant, and scrub nurse
• Eye protection/face shield
• Safe sharps handling
• Appropriate disposal of all biohazardous material
• Post-exposure protocol must be in place and known to all staff

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Quick Summary

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• Toledano RD, Pope R, Pian-Smith M. Peripartum management of HIV-positive patients. BJA Education 2023 (PMID: 37720556)
• Anaesthetic Considerations for the HIV Positive Parturient. PMC4111002
• NIH/DHHS Perinatal HIV Guidelines - Intrapartum Care
• ACOG Committee Opinion - Labor and Delivery Management of Women With HIV
• NICE Guideline NG192 - Caesarean Birth (2021)