In women who have a detectable VL it may be possible to optimize their HAART regimen to reduce the risk of MTCT (See Recommendation 4.2.6). 7.3.5 The management of PPROMs 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 Gefitinib will require group B streptococcus prophylaxis in line with national guidelines. Grading: 1C 7.3.6 When PPROM occurs at <34 weeks:

Grading: 1C Intramuscular steroids should be administered in accordance with national guidelines. Virological control should be optimized. There should be multidisciplinary discussion about the timing of delivery. There are no data to inform the optimum management of preterm labour or early preterm pre-labour ROMs. Decisions regarding the optimum management of early preterm ROM require the assessment of a number of

factors, including the exact gestation, facilities available, maternal VL and presence of other co-morbidities such as infection and pre-eclampsia. Corticosteroids to improve fetal lung maturation should be given as per the Royal College of Obstetricians NU7441 manufacturer and Gynaecologists guidelines [49] and (if delivery is to be delayed) oral erythromycin [50]. Decisions regarding timing of delivery should be made in consultation with the full MDT, including the neonatal unit. There is no evidence that steroids for fetal lung maturation (with the associated 24-h delay in induction) are of overall benefit at 34–37 weeks’ gestation in women with ROMs, thus delay for the optimization of fetal lung maturity is not recommended. Thiamine-diphosphate kinase For this reason, and to minimize the risk of developing chorioamnionitis, induction is recommended from 34 weeks’ gestation in women with ROMs who are not in labour. If the maternal VL is not fully suppressed, consideration should be given to the options available to optimize therapy. An additional concern is that the early preterm infant

may be unable to tolerate oral therapy and therefore loading the infant through the transplacental route with maternal therapy is recommended (see Section 5: Use of antiretroviral therapy in pregnancy). There is most experience with maternal oral nevirapine 200 mg stat >2 h before delivery, but double-dose tenofovir and standard-dose raltegravir can also be considered. 7.4.1 Intrapartum intravenous zidovudine infusion is recommended in the following circumstances: For women with a VL > 10 000 HIV RNA copies/mL plasma who present in labour, or with ROMs or who are admitted for planned CS. Grading: 1C For untreated women presenting in labour or with ROMs in whom the current VL is not known. Grading: 1C In women on zidovudine monotherapy undergoing a PLCS intravenous zidovudine can be considered. Continued oral dosing is a reasonable alternative.