What is the role of cesarean delivery in the management of pregnant women with HIV?

Updated: Apr 02, 2019
  • Author: Ashley T Peterson, MD; Chief Editor: Ronald M Ramus, MD  more...
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Answer

Cesarean delivery must be discussed and the patient counseled regarding the possibility of an unnecessary surgical procedure should the final HIV result be negative. [18] Care should be individualized according to clinical scenario.

Early studies regarding cesarean delivery and transmission risk showed conflicting results. Cesarean delivery before the onset of labor may prevent microtransfusion that occurs with uterine contractions, and avoiding vaginal delivery eliminates exposure to virus in the cervicovaginal secretions and blood at time of delivery.

In the late 1990s, prospective cohort studies noted a decrease in mother-to-child transmission in women on zidovudine (ZDV) who underwent elective cesarean delivery compared with women who did not take ZDV prophylaxis. [34, 35] In 1999, results from a large meta-analysis of individual patient data from 15 prospective cohort studies demonstrated a 50% reduction of vertical transmission with the use of elective cesarean delivery for women with HIV, after adjusting for antiretroviral therapy, maternal stage of disease, and infant birth weight.

Of note, vertical transmission risk did not change when the study group was limited to those women who had rupture of membranes shortly before surgery. The transmission risk was decreased by about 80% for women who had both an elective cesarean delivery and were taking antiretroviral medication. [36]

In the same year, ACOG issued an opinion that elective cesarean delivery should be discussed and offered to all pregnant women who were HIV positive at 38 weeks’ gestation to avoid the potential risk of spontaneous labor and rupture of membranes. [31]

These studies did not adjust for viral load and were performed before HAART came into use. In patients on HAART with an undetectable viral load (< 1000 copies), the risk of transmission is very low, and whether cesarean delivery offers any further benefit remains unknown.

This led to an updated ACOG statement in 2000, stating that women infected with HIV whose viral loads are greater than 1,000 copies/mL should be counseled regarding the potential benefit of scheduled cesarean delivery to further reduce the risk of vertical transmission of HIV beyond that achieved with antiretroviral therapy alone. [31] However, data are insufficient to demonstrate a benefit for neonates of women with viral loads less than 1,000 copies/mL.

Longer duration of ruptured membranes may be associated with a higher rate of mother-to-child transmission. The International Perinatal HIV group meta-analysis found that the risk of vertical transmission increased by 2% for every increase of 1 hour in the duration of ruptured membranes. If cesarean delivery is performed after the onset of labor or rupture of membranes, the benefit of surgery is likely lost as available data indicate no reduction in the transmission rate if cesarean delivery is performed after the onset of labor or rupture of membranes.  In this scenario, a decision regarding the route of delivery should be individualized. [31, 36]

Operative risk may outweigh the potential benefit of further reducing HIV transmission. In a study by Louis et al that compared the outcome of cesarean section in 378 women infected with HIV and in more than 54,000 uninfected women, HIV-infected women had a higher rate of intraoperative need for blood transfusion as well as increased incidence of postpartum endometritis, sepsis, pneumonia, admission to the intensive care unit, and maternal death. [37]

In the HIV-infected group, morbidity and mortality were associated with infection and related to immune function, with the greatest risk being for women with a CD4 count less than 200 cells/mL. [37]

Because morbidity is increased in women infected with HIV who undergo cesarean delivery, prophylactic antibiotics should be administered. Scheduled cesarean delivery should be discussed and recommended for women with viral loads greater than 1000 copies/mL, whether or not they are taking antiretroviral therapy.

Discussion of the recommendation of scheduled cesarean delivery in women with high viral loads should begin as early as possible in pregnancy with every pregnant woman infected with HIV, to give her an adequate opportunity to consider the recommendations and plan for the procedure. The risks, which appear to be greater for the mother, must be balanced with the benefits expected for the neonate. The patient's autonomy must be respected when making the decision to perform a cesarean delivery, because the potential for maternal morbidity is significant.

Consultation and follow-up with specialists in infectious disease and maternal-fetal medicine is recommended.


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