As both acute and chronic chorioamnionitis have been associated with perinatal transmission

[40, 267-269], albeit from studies largely performed in the pre-cART era, it is recommended that labour should be expedited for all women with ROM at term. Hence women with ROM at term with a viral load of < 50 HIV RNA copies/mL should have immediate induction with a low threshold for the treatment of intrapartum pyrexia. The NICE induction of labour guidelines Doramapimod datasheet [270] and the NICE intrapartum guidelines [251] should be followed with regard to use of antibiotics and mode of induction. NSHPC data for the effect of ROM greater or less than 4 hours for women with a viral load of > 50 HIV RNA copies/mL are more difficult to interpret as the numbers are currently small. In women with VL 50–999 HIV RNA copies/mL there were two transmissions with ROM > 4 hours (2/51) and none in the women with ROM ≤ 4 hours (0/43). The two transmissions occurred in women who had emergency Caesarean sections but the timing of this is not known. KU-57788 mw Although not statistically significant (P = 0.19), these limited unpublished data suggest a possible trend towards greater transmission risk with ruptured membranes

> 4 hours for those with viral loads ≥ 50 HIV RNA copies/mL, and until further data are available, it is the recommendation of the Writing Group that Caesarean section should be considered for women with a viral load of 50–999 HIV RNA copies/mL at term. Again, if Caesarean section is not undertaken, delivery should be expedited, as above. Data from the NSHPC for women with a viral load of > 1000 HIV RNA copies/mL are sparse at present, with 1/14 (7.1%) transmitting with

ROM ≤ 4hours compared to 3/15 (20%) with ROM > 4 hours. A single-centre study from Miami of 707 women on ART showed ROM > 4 hours to be associated with an increased risk of MTCT if the VL was > 1000 HIV RNA copies/mL. There was no association at < 1000 HIV RNA copies/mL but it is not possible to determine the number of women with a viral load Sclareol greater than 50 and less than 1000 HIV RNA copies/mL in this group. Until further data are available, an urgent (category 2) Caesarean section is recommended where the viral load is > 1000 HIV RNA copies/mL regardless of treatment [271]. In women who have a detectable viral load it may be possible to optimize their cART regimen to reduce the risk of MTCT (See Recommendation 4.2.6). 7.3.5 The management of prolonged premature rupture of membranes (PPROM) at ≥ 34 weeks is the same as term ROM (see Section 7.3 Management of spontaneous rupture of membranes) except women who are 34–37 weeks’ gestation will require group B streptococcus prophylaxis in line with national guidelines. Grading: 1C 7.3.