Perioperative cesarean delivery morbidity among HIV-infected women under highly active antiretroviral treatment: a case-control study

Risk factors during pregnancy and birth-related complications in HIV-positive versus HIV-negative women in Denmark, 2002-2014

OBJECTIVES

We aimed to compare risk factors for adverse pregnancy outcomes in women living with HIV (WLWH) with those in women of the general population (WGP) in Denmark. Further, we estimated risk of pregnancy- or birth-related complications.

METHODS

A retrospective cohort study including all WLWH who delivered a live-born child from 2002 to 2014 and WGP, matched by origin, age, year and parity, was carried out. We compared risk factors during pregnancy and estimated risk of pregnancy- and birth-related complications using multivariate logistic regression.

RESULTS

A total of 2334 pregnancies in 304 WLWH and 1945 WGP were included in the study. WLWH had more risk factors present than WGP during pregnancy: previous caesarean section (CS) (24.7% versus 16.3%, respectively; P = 0.0001), smoking (14.2% versus 7.5%, respectively; P = 0.0001) and previous perinatal/neonatal death (2.3% versus 0.9%, respectively; P = 0.03). We found no difference between groups regarding gestational diabetes, hypertensive disorders, low birth weights or premature delivery. More children of WLWH had intrauterine growth retardation (IUGR) [adjusted odds ratio (aOR) 1.9; 95% confidence interval (CI) 1.1-3.2; P = 0.02]. Median gestational age and birth weight were lower in children born to WLWH. WLWH had a higher risk of emergency CS (EmCS) (aOR 1.6; 95% CI 1.2-2.1; P = 0.0005) and postpartum haemorrhage (aOR 1.4; 95% CI 1.0-1.9; P = 0.02) but not infection, amniotomy, failure to progress, low activity-pulse-grimace-appearance-respiration (APGAR) score or signs of asphyxia.

CONCLUSIONS

WLWH had more risk factors present during pregnancy, similar risks of most pregnancy- and birth-related complications but a higher risk of postpartum haemorrhage and EmCS compared with WGP. Children born to WLWH had lower median birth weights and gestational ages and were at higher risk of IUGR.

Complications and Route of Delivery in a Large Cohort Study of HIV-1-Infected Women-IMPAACT P1025

OBJECTIVE

To investigate complications of cesarean section in a cohort of HIV-infected pregnant women.

METHODS

IMPAACT P1025 is a prospective cohort study of HIV-1-infected women and infants, enrolled 2002-2013, at clinical sites in the United States and Puerto Rico. Demographic, medical, and obstetric data were collected and analyzed including cesarean indications. The delivery route was categorized as elective cesarean (ECS) (before labor and <5 minutes before membrane rupture), nonelective cesarean (NECS) (all other cesareans) or vaginal delivery. Logistic regression models evaluated associations between delivery route and maternal intrapartum/postpartum morbidities. Composite morbidity of vaginal delivery was compared with ECS and NECS.

RESULTS

This study included 2297 women. Of note, 99% used antiretroviral medication and 89% were on a combination antiretroviral therapy regimen; 84% had a HIV-1 viral load ≤400 copies per milliliter before delivery; 46% (1055) delivered vaginally, 35% (798) by ECS, and 19% (444) by NECS. Although interruption of HIV-1 infection was the second most frequent indication for cesarean after repeat cesarean, it decreased as an indication over time. There were no delivery-related maternal mortalities. Overall, 19% of women had ≥1 complication(s)-primarily wound complications (14%) or other infections (11%). Vaginal delivery had the lowest complication rate (13%), followed by ECS (23%), and highest NECS (28%) with an overall P < 0.001. HIV-1 mother-to-child transmission rates were low and did not differ by delivery mode group.

CONCLUSIONS

HIV interruption as cesarean indicator declined during the study. Morbidity was more common in HIV-infected women delivering by NECS than ECS and lowest with vaginal delivery.

CLINICAL TRIAL REGISTRATION

Prenatal and Postnatal Studies of Interventions for Prevention of Mother-To-Child Transmission https://clinicaltrials.gov/ct2/show/NCT00028145?term=impaact+1025&rank=2 NCT00028145.

Assessment of mode of delivery and predictors of emergency caesarean section among women living with HIV in a matched-pair setting with women from the general population in Denmark, 2002-2014

OBJECTIVES

We aimed to assess mode of delivery and predictors of emergency caesarean section (EmCS) in women living with HIV (WLWH) in a matched-pair setting with women from the general population (WGP) in Denmark. Further, we analysed birth plan in WLWH.

METHODS

All WLWH giving birth to live-born children from 2002 to 2014 were included in the study. Data were retrieved from medical records and national registries. WLWH were matched 1:5 by age, birth year, parity and ethnicity to WGP. Multivariate logistic regression was used to estimate predictors.

RESULTS

We included 389 WLWH and 1945 WGP in the study. At delivery, all WLWH were on antiretroviral therapy and 85.6% had HIV RNA <40 HIV-1 RNA copies/mL. Mean age was 32.7 years [95% confidence interval (CI) 32.1-33.2 years]. Mode of delivery differed significantly between WLWH and WGP [vaginal delivery, 33.4% versus 73.3%, respectively; elective caesarean section (ECS), 40.6% versus 9.7%, respectively; EmCS, 26% versus 17%, respectively; P < 0.0001]. Age > 40 years [adjusted odds ratio (aOR) 2.3; 95% CI 1.5-3.5], asphyxia (aOR 3.2; 95% CI 2.4-4.1), delivery during the evening and at night [aOR 2.3 (95% CI 1.7-3.0) and aOR 2.0 (95% CI 1.5-2.7), respectively], preterm delivery (aOR 3.8; 95% CI 2.6-5.6) and premature rupture of membranes (aOR 3.0; 95% CI 2.1-4.4) predicted EmCS. WLWH had a higher risk of EmCS compared with WGP [2002-2006, aOR 2.0 (95% CI 1.2-3.3); 2007-2008, aOR 2.9 (95% CI 1.4-5.9); 2009-2014, aOR 2.6 (95% CI 1.7-3.9)]. After 2007, more than half of WLWH planned to deliver vaginally. Prior caesarean section was associated with ECS (aOR 11.0; 95% CI 4.5-26.8). No mother-to-child transmission occurred.

CONCLUSIONS

Increasing numbers of WLWH deliver vaginally. Despite virological suppression, more WLWH plan and deliver by ECS than WGP. WLWH had a twofold higher risk of EmCS compared with WGP.

Postpartum Maternal and Neonatal Hospitalizations Among Women with HIV: A Population-Based Study

Postpartum maternal and neonatal readmissions in the period shortly following birth are indicators of serious morbidity. We compared the risk of postpartum maternal and neonatal hospitalizations in women living with and without HIV in Ontario, Canada. We conducted a population-based study of pregnancies in Ontario between April 1, 2002 and March 31, 2011 using Ontario's administrative health care databases. Generalized estimating equations were used to derive adjusted odds ratios (aORs) and 95% confidence intervals (CI) for the association of HIV infection with postpartum maternal hospitalizations within 30 days of hospital discharge and neonatal hospitalizations within 30 and 60 days of hospital discharge. Between 2002/2003 and 2010/2011, 1,133,505 pregnancies were available for analysis, of which 634 (0.06%) were to women living with HIV. The proportion of postpartum maternal hospitalizations (2.8% versus 1.1%; odds ratio 2.53; 95% CI 1.57 to 4.07) was higher among women with HIV. The multivariable adjusted odds ratio was 1.54 (95% CI 0.93 to 2.55). The proportions of neonates hospitalized within 30 (2.6% versus 3.7%; aOR 0.68, 95% CI 0.42 to 1.10) and 60 days (4.9% versus 4.9%; aOR 0.86, 95% CI 0.60 to 1.24) of discharge were similar among infants born to women with and without HIV. Women living with HIV are at a higher risk of postpartum maternal hospitalizations than women not living with HIV. The effect of HIV infection was attenuated by multivariable adjustment, suggesting that sociodemographic or health care factors are responsible for much of the difference in outcomes.

Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators

IMPORTANCE

Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized.

OBJECTIVE

To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level.

MAIN OUTCOMES AND MEASURES

All-cause 30-day postoperative mortality.

RESULTS

The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%), and coronary artery bypass grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/μL or more, 16.3% with 50/μL to 199/μL, and 3.7% with less than 50/μL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41-3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/μL: IRR, 1.92; 95% CI, 1.02-3.60; P = .04; 200-499/μL: IRR, 1.89; 95% CI, 1.20-2.98; P = .01; 50-199/μL: IRR, 2.66; 95% CI, 1.29-5.47; P = .01; and <50/μL: IRR, 6.21; 95% CI, 3.55-10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78-6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23-1.76; P < .001) were also strongly associated with mortality.

CONCLUSIONS AND RELEVANCE

Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.

Complications of cesarean deliveries among HIV-infected women in the United States

OBJECTIVE

To compare rates of complications associated with cesarean delivery in HIV-infected and HIV-uninfected women in the United States and to investigate trends in such complications across four study cycles spanning the implementation of HAART in the United States (1995-1996, 2000-2001, 2005-2006, 2010-2011).

DESIGN

The Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project is the largest all-payer hospital inpatient care database in the United States; when weighted to account for the complex sampling design, nationally representative estimates are derived. After restricting the study sample to women aged 15-49 years, our study sample consisted of approximately 1 090 000 cesarean delivery hospitalizations annually.

METHODS

Complications associated with cesarean deliveries were categorized as infection, hemorrhage, or surgical trauma, based on groups of specific International Classification of Diseases 9th revision codes. Length of hospitalization, hospital charges, and in-hospital deaths were also examined.

RESULTS

The rate of complications significantly decreased during the study periods for HIV-infected and HIV-uninfected women. However, rates of infectious complications and surgical trauma associated with cesarean deliveries remained higher among HIV-infected, compared with HIV-uninfected women in 2010-2011, as did prolonged hospital stay and in-hospital deaths. Length of hospitalization decreased over time for cesarean deliveries of HIV-infected women to a greater extent compared with HIV-uninfected women.

CONCLUSION

In the United States, rates of cesarean delivery complications decreased from 1995 to 2011. However, rates of infection, surgical trauma, hospital deaths, and prolonged hospitalization are still higher among HIV-infected women. Clinicians should remain alert to this persistently increased risk of cesarean delivery complications among HIV-infected women.

HIV and the risk of direct obstetric complications: a systematic review and meta-analysis

Background

Women of reproductive age in parts of sub-Saharan Africa are faced both with high levels of HIV and the threat of dying from the direct complications of pregnancy. Clinicians practicing in such settings have reported a high incidence of direct obstetric complications among HIV-infected women, but the evidence supporting this is unclear. The aim of this systematic review is to establish whether HIV-infected women are at increased risk of direct obstetric complications.

Methods and findings

Studies comparing the frequency of obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia and intrauterine infections in HIV-infected and uninfected women were identified. Summary estimates of the odds ratio (OR) for the association between HIV and each obstetric complication were calculated through meta-analyses. In total, 44 studies were included providing 66 data sets; 17 on haemorrhage, 19 on hypertensive disorders, five on dystocia and 25 on intrauterine infections. Meta-analysis of the OR from studies including vaginal deliveries indicated that HIV-infected women had over three times the risk of a puerperal sepsis compared with HIV-uninfected women [pooled OR: 3.43, 95% confidence interval (CI): 2.00–5.85]; this figure increased to nearly six amongst studies only including women who delivered by caesarean (pooled OR: 5.81, 95% CI: 2.42–13.97). For other obstetric complications the evidence was weak and inconsistent.

Conclusions

The higher risk of intrauterine infections in HIV-infected pregnant and postpartum women may require targeted strategies involving the prophylactic use of antibiotics during labour. However, as the huge excess of pregnancy-related mortality in HIV-infected women is unlikely to be due to a higher risk of direct obstetric complications, reducing this mortality will require non obstetric interventions involving access to ART in both pregnant and non-pregnant women.

Cesarean section for HIV-infected women in the combination antiretroviral therapies era, 2000-2010

OBJECTIVE

Elective cesarean section (CS) is a proven method to prevent mother-to-child transmission (MTCT), but is no longer recommended for women with antiretroviral therapy resulting in a low viral load (VL): <400 copies/mL in French and <1000 copies/mL in US guidelines. We sought to describe mode of delivery practices in human immunodeficiency virus (HIV)-infected women and their association with MTCT and postpartum complications.

STUDY DESIGN

All deliveries from HIV-1-infected women in the French Perinatal Cohort (Agence Nationale de Recherches sur le Sida/Enquête Périnatale Française) 2000 through 2010 (N = 8977) were analyzed, with additional details for 2005 through 2010 (n = 4717).

RESULTS

Vaginal deliveries increased from 25% in 2000 to 53% in 2010. Over 2005 through 2010, 4300 women had VL before delivery <400 copies/mL; among them only 49.3% delivered vaginally, 22.0% had nonelective CS, and 28.7% had elective CS. Elective CS were performed for scarred uterus in 45.4%, other obstetrical indications in 37.1%, and solely because of HIV in 15.7%. Of the 417 women with VL ≥400 copies/mL, 48.9% had elective CS as recommended, 25.9% had nonelective CS, and 25.2% had vaginal delivery. The MTCT rate did not differ according to the mode of delivery in term deliveries (≥37 gestational weeks) in 2000 through 2010: 0.3% after both vaginal delivery and elective CS with VL <50 copies/mL, 4.0% vs 5.3%, respectively, with VL ≥10,000 copies/mL. In case of preterm delivery, MTCT rates tended to be higher with vaginal delivery. Postpartum complications were more frequent following CS than vaginal deliveries (6.5% vs 2.9, P < .01).

CONCLUSION

Our findings suggest that HIV-infected women on antiretroviral therapy with low VL can safely opt for vaginal delivery in the absence of obstetrical risk factors.

Factors predictive of 30-day postoperative mortality in HIV/AIDS patients in the era of highly active antiretroviral therapy

BACKGROUND

Factors that predict HIV (human immunodeficiency virus)/AIDS patient postoperative mortality have remained poorly defined.

OBJECTIVES

The primary objective of this study was to identify factors predictive of short-term, postoperative mortality in HIV/AIDS patients. The secondary objective of this study was to develop a scoring system that would predict short-term postoperative mortality in HIV/AIDS patients.

METHODS

We retrospectively reviewed all HIV/AIDS patients who underwent surgical procedures in British Columbia, Canada, between April 1995 and March 2002. The primary outcome evaluated was 30-day postoperative mortality. Demographic, clinical, and hospitalization-related data were obtained and utilized to predict outcomes using a logistic regression model.

RESULTS

A total of 2305 procedures were carried out on 1322 patients during the study period. Admissions were classified as urgent/emergent for 1311 procedures (57%) and the overall 30-day postoperative mortality was 9.5% (126 deaths). Urgent/emergent admission, older age, prior surgery, a CD4 cell count of ≤ 50 cells/mm, a hemoglobin level ≤ 120 g/L, and a white blood cell count >11 g/L within 90 days before the surgical procedure was predictive of an increased 30-day postoperative mortality in a multivariate model. Using these variables, we formulated the HIV Surgical Mortality Score (HSMS) to obtain the median-estimated probability of postoperative death.

CONCLUSIONS

For accurate preoperative mortality risk stratification for HIV/AIDS patients, we have found that several clinical and laboratory variables must be evaluated. If appropriately validated, our proposed HSMS could be utilized to estimate the probability of short-term postoperative death among HIV/AIDS patients.