Higher rates of post-partum complications in HIV-infected than in uninfected women irrespective of mode of delivery

Accouchement des patientes enceintes infectées par le VIH : étude rétrospective de 358 grossesses suivies entre 2000 et 2004

OBJECTIVE

Evaluate the mode of delivery of HIV-infected women and the risk of mother-to-child transmission.

PATIENTS AND METHODS

A retrospective study conducted on HIV-infected women who delivered at the maternity ward of Bichat Hospital in Paris between 1st January 2000 and 31(st) December 2004. Pregnancy care, antiretroviral therapy, decision of the mode of delivery and neonate treatment were conformable to the French recommendations.

RESULTS

The analysis was performed on 332 cases out of 358 pregnancies followed during this period. 75% received a Highly Active Anti Retroviral Therapy (HAART), 24% an AZT monotherapy and 1% did not receive any antiretroviral treatment. Plasmatic HIV viral load was under the level of detectability (50 copies/ml) for 64,6% of women under HAART and 28,7% of women under AZT monotherapy. Only 31,7% of women under HAART delivered vaginally. 44,7% of women under HAART with undetectable viral load at the moment of delivery delivered vaginally. 59,5% of women who were allowed to deliver vaginally had finally a vaginal delivery. 332 women gave birth to 341 babies with 9 twin pregnancies and one still-birth at 22 WA. Out of these 340 babies, 3 babies whose mother received HAART were HIV infected (2 in utero and 1 per-partum).

DISCUSSION AND CONCLUSION

The reasons why only one third of HIV-infected women could deliver vaginally in this study are primarily the persistence of a detectable HIV viral load under HAART. Women's choice of the mode of delivery comes next, which depends on the quality of the counselling about the benefits and risks of the cesarean section in the context of HIV infection. The third reason is obstetrical contra indications to vaginal delivery in the context of HIV infection. In the future, it is possible to reduce the incidence of cesarean section in HIV-infected women by elevating the level of HIV plasmatic viral load which allowed vaginal delivery (1000 copies/ml), by improving the observance to antiretroviral treatment, by adaptating antiretroviral medications posology using determination of serum protease inhibitors concentration and by modifying obstetrical management with less restrictive contra indications to vaginal delivery. However the impact of prophylactic cesarean section when plasmatic HIV viral load is undetectable must still be evaluated.

HIV in pregnancy

PURPOSE OF REVIEW

This review discusses recent articles on various aspects of the prevention of mother-to-child transmission during pregnancy and delivery.

RECENT FINDINGS

Rapid human immunodeficiency virus (HIV) testing of women in labour whose status is not known allows the prompt treatment of mother and baby to reduce transmission risk. The feared clinical resistance in the mother after treatment with a single dose of nevirapine has been confirmed. Strategies are required to minimize this resistance and allow the use of nevirapine for treatment of the mother. There are new findings of mitochondrial toxicity in babies who have been exposed to anti-retroviral medicines during pregnancy or delivery, but the clinical implications are not clear. Long-term follow-up of exposed children is required. Resource-poor countries are starting to use multiple drugs to further reduce transmission to the infant. These efforts are reducing the rates of transmission to the level found in affluent countries.

SUMMARY

Improvements in treatment continue to reduce the risk of HIV transmission from mother to child in resource-poor countries, but subsequent maternal resistance continues to be a problem since treatment for the mother's health is now possible. The long-term effects on the infant are still not understood.

Pregnancy outcome among HIV-infected women in the Helsinki metropolitan area

BACKGROUND

Antiretroviral medication and good obstetric practice have greatly reduced the rate of vertical transmission of human immunodeficiency virus (HIV) infection. The incidence of HIV infection has remained low in Finland. Universal antenatal screening has been offered to all pregnant women since 1998.

METHODS

We analyzed the outcomes of 52 pregnancies among 45 HIV-infected mothers delivering at our department during 1993-2003. A multidisciplinary team planned the management strategy individually and supported the mother's adherence to treatment.

RESULTS

The incidence of HIV infection among women delivering in our hospital district increased from 0.6/10,000 (95% CI 0-1.6) to 4.8/10,000 (95% CI 1.4-8.2) between 1993 and 2002. HIV infection was diagnosed during pregnancy in 40% (18/45) of the mothers. Antiretroviral medication was used prior to pregnancy in 17 (33%) cases; in 34 (66%) cases of the pregnancies, medication was started during the pregnancy. A good virological response (i.e. HIV RNA load <1000/ml during the last trimester) to antiretroviral medication was achieved in 90% (36/40) of the patients; in 60% (24/40) of cases, the HIV RNA load was below the assay detection limit. One mother with advanced HIV infection succumbed to pneumonia shortly after delivery. Of the infants, 92% were born at term, and their mean (+/-SD) birth weight was 3350 +/- 395 g. The Caesarean section (CS) rate was 25% (13/52). All newborns were in good condition, and their mean umbilical pH was 7.23. All newborns received antiretroviral medication. One infant was infected with HIV, the mother was found HIV-positive postpartum. None of the infants born to mothers known to be HIV positive were infected.

CONCLUSIONS

A combination of universal antenatal screening and multidisciplinary management allows individualized treatment and prevents vertical transmission of HIV infection.

Efficacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1

BACKGROUND

Cesarean section before labor and before ruptured membranes ("elective cesarean section", or ECS) has been introduced as an intervention for the prevention of mother-to-child transmission (MTCT) of HIV-1. The role of mode of delivery in the management of HIV-1-infected women should be assessed in light of risks as well as benefits, since HIV-1-infected pregnant women must be provided with available information with which to make informed decisions regarding cesarean section and other options to prevent transmission of infection to their children.

OBJECTIVES

Our objectives were to assess the efficacy (for prevention of MTCT of HIV-1) and the safety of ECS among HIV-1-infected women.

SEARCH STRATEGY

Electronic searches were undertaken using MEDLINE and other databases. Hand searches of reference lists of pertinent reviews and studies, as well as abstracts from relevant conferences, were also conducted. Experts in the field were contacted to locate any other studies. The search strategy was iterative.

SELECTION CRITERIA

Randomized clinical trials assessing the efficacy and safety of ECS for prevention of MTCT of HIV-1 were included in the analysis, as were observational studies with relevant data.

DATA COLLECTION AND ANALYSIS

Data regarding HIV-1 infection status of infants born to HIV-1-infected women according to mode of delivery were extracted from the reports of the studies. Similarly, data regarding postpartum morbidity (PPM) (including minor (e.g., febrile morbidity, urinary tract infection) and major (e.g., endometritis, thromboembolism) morbidity) of the HIV-1-infected women, and infant morbidity, according to mode of delivery were extracted.

MAIN RESULTS

One randomized clinical trial of the efficacy of ECS for prevention of MTCT of HIV-1 was identified. No data regarding infant morbidity according to the HIV-1-infected mother's mode of delivery were available. Data regarding PPM according to mode of delivery were available from this clinical trial as well as from five observational studies. Among HIV-1-infected women not taking antiretrovirals (ARVs) during pregnancy or taking only zidovudine, ECS was found to be efficacious for prevention of MTCT of HIV-1. PPM is generally higher among HIV-1-infected women who undergo cesarean as compared to vaginal delivery, with the risk with ECS being intermediate between that of vaginal delivery and NECS (including emergency procedures). Other factors associated with the risk of PPM among HIV-1-infected women include HIV-1 disease stage (more advanced disease, as manifested by lower CD4 counts and higher viral loads, being associated with a greater risk of PPM) and co-morbid conditions (e.g., diabetes).

AUTHORS' CONCLUSIONS

ECS is an efficacious intervention for the prevention of MTCT among HIV-1-infected women not taking ARVs or taking only zidovudine. The risk of PPM with ECS is higher than that associated with vaginal delivery, yet lower than with NECS. Among HIV-1-infected women, more advanced maternal HIV-1 disease stage and concomitant medical conditions (e.g., diabetes) are independent risk factors for PPM. The risk of MTCT of HIV-1 according to mode of delivery among HIV-1-infected women with low viral loads (low either because the woman's HIV-1 disease is not advanced, or because her HIV-1 disease is well-controlled with ARVs) is unclear. Therefore, an important issue to be addressed in one or more large studies (individual studies or an individual patient data meta-analysis combining data from more than one study) is assessment of the effectiveness of ECS for prevention of MTCT of HIV-1 among HIV-1-infected women with undetectable viral loads (with or without receipt of highly active ARV therapy (HAART)).

Incidence of postcesarean infections in relation to HIV status in a setting with limited resources

BACKGROUND

The aim of the present study was to assess the incidence of postcesarean infections in relation to HIV status in a setting where resources are limited, HIV infection is common, and antiretroviral treatment is not generally available.

METHODS

The setting was a tertiary African obstetric unit with 27,000 deliveries annually. The study design was prospective and the sample consisted of 1600 of cesarean sections. All women requiring cesarean section were eligible for inclusion. HIV status was registered from the antenatal card only. For the analysis, the participants were divided into two categories: those with negative or unknown HIV status and those with positive HIV status. The main outcome measures are endometritis, wound infection, and mobilization parameters. RESULTS. A total of 1526 cases, of which 1492 were emergency cesarean sections, were included in the analysis. HIV status was negative or unknown in 1430 cases and positive in 96. In the HIV-negative/unknown group, the incidence of endometritis was 8.5% (121/1430), wound infection 5.0% (71/1430), and endometritis and/or wound infection 10.8% (154/1430). In the HIV-positive group, the corresponding incidences were 51.0% (49/96), 29.2% (28/96), and 65.5% (63/96), respectively. The indication for cesarean section was dystocia in 79% (134/170) of the women who developed endometritis.

CONCLUSIONS

The results indicate that women with untreated HIV infection are at very high risk of postcesarean infection in low-resourced settings.

Sperm washing, use of HAART and role of elective Caesarean section

PURPOSE OF REVIEW

Today, 50% of people living with HIV are women and most have been sexually infected. Highly active antiretroviral therapy (HAART) reduces the rates of both sexual and vertical infection, but maximum protection is achieved with sperm washing and elective Caesarean section.

RECENT FINDINGS

Men taking HAART have lower seminal concentration of HIV, and sexual transmission may be reduced. However, a certain percentage of aviraemic men retain viral presence in semen, and unprotected intercourse to achieve fertilization must be discouraged as it carries the risk of sexual transmission of the virus. HIV-discordant couples should be informed that sperm washing can remove HIV from semen, allowing conception without the risk of infection for the seronegative female and eventually the child. In HIV-positive women, perinatal transmission of HIV can be curtailed to less than 2% by using HAART to decrease maternal viral load and offering prenatal preexposure prophylaxis of the fetus, and elective Caesarean section. Each intervention carries specific risks and benefits. The contribution of each preventive arm in achieving fetal protection can only be crudely measured and optimal obstetric management must involve discussion with the pregnant woman of the pros and cons of each strategy.

SUMMARY

In HIV-positive men taking HAART, seminal viral load is decreased but not eliminated and fertilization should be achieved through sperm washing to offer maximum protection for the uninfected female. Pregnant HIV-positive women on antiretroviral medication have a reduced risk of transmitting the virus, but should still be counselled about the possibility to further limit the chances of infecting their infant through elective Caesarean section.

Mother-to-Child Transmission of HIV Infection in the Era of Highly Active Antiretroviral Therapy

BACKGROUND

Very low rates of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) are achievable with use of highly active antiretroviral therapy (HAART). We examine risk factors for MTCT in the HAART era and describe infants who were vertically infected, despite exposure to prophylactic MTCT interventions.

METHODS

Of the 4525 mother-child pairs in this prospective cohort study, 1983 were enrolled during the period of January 1997 through May 2004. Factors examined included use of antiretroviral therapy during pregnancy, maternal CD4 cell count and HIV RNA level, mode of delivery, and gestational age in logistic regression analysis.

RESULTS

Receipt of antenatal antiretroviral therapy increased from 5% at the start of the HAART era to 92% in 2001-2003. The overall MTCT rate in this period was 2.87% (95% confidence interval [CI], 2.11%-3.81%), but it was 0.99% (95% CI, 0.32%-2.30%) during 2001-2003. In logistic regression analysis that included 885 mother-child pairs, MTCT risk was associated with high maternal viral load (adjusted odds ratio [AOR], 12.1; P=.003) and elective Caesarean section (AOR, 0.33; P=.04). Detection of maternal HIV RNA was significantly associated with antenatal use of antiretroviral therapy, CD4 cell count, and mode of delivery. Among 560 women with undetectable HIV RNA levels, elective Caesarean section was associated with a 90% reduction in MTCT risk (odds ratio, 0.10; 95% CI, 0.03-0.33), compared with vaginal delivery or emergency Caesarean section.

CONCLUSIONS

Our results suggest that offering an elective Caesarean section delivery to all HIV-infected women, even in areas where HAART is available, is appropriate clinical management, especially for persons with detectable viral loads. Our results also suggest that previously identified risk factors remain important.

HIV and pregnancy: is the outlook for mother and baby transformed?

PURPOSE OF REVIEW

Advances in antiretroviral regimens and specific obstetrical procedures have enabled HIV-positive women to have children, with a very low risk of transmitting the infection to the infant and with improved chances of seeing their children reach adulthood. New studies have given providers of care better information on how to assist women with HIV who want to have a child in the safest possible way.

RECENT FINDINGS

Highly active antiretroviral therapy can effectively control viral replication and reduce the risk of vertical transmission. The benefit of treatment for the mother and the infant must be balanced against any negative effects on pregnancy, the embryo and the fetus. Potential long-term consequences of prenatal exposure to potent compounds should also be considered and monitored. The evidence suggests that even in women with undetectable viral load, Caesarean section reduces vertical transmission to the same degree as documented previously for all women. Although the absolute risk reduction is very low, no study can show whether or not this is statistically significant and therefore women should be helped to make their individual choice. Mothers with HIV should not breastfeed in countries where formula milk is easily available, however highly active antiretroviral therapy administered to mothers or infants may reduce the risk of postnatal HIV transmission.

SUMMARY

Counselling and assistance to conceive, modification of the therapeutic regimens and options about delivery have changed dramatically since the beginning of the HIV epidemic. Nowadays, women with HIV, similarly to uninfected women, can discuss with their doctors which therapeutic and treatment options would best fit their expectations of care.