Elective Cesarean Delivery Reduces Vertical Transmission of HIV
Abstract & Commentary
To determine the effect of elective cesarean delivery on the transmission of HIV-1 from an infected mother to her baby, the International Perinatal HIV Group performed a meta-analysis on more than 8000 mother-child pairs from 15 prospective cohort studies, five performed in Europe and 10 in North America. An elective cesarean section was defined as a procedure performed before the onset of labor and rupture of the membranes.
Using a logistic-regression model to adjust for antiretroviral therapy, the presence or absence of AIDS in the mother, and low infant birthweight, the likelihood of vertical transmission of HIV-1 was reduced by approximately 50% with elective cesarean delivery. Elective cesarean delivery decreased the risk even in patients whose membranes were ruptured for less than one hour (odds ratio, 0.55) and less than four hours (odds ratio, 0.53). In women who received antiretroviral treatment during the prenatal and intrapartum periods and whose neonates were treated as well, elective cesarean delivery reduced the rate of transmission by nearly 90%. In these cases, the rate of transmission was only 2%, compared with a rate of 7.3% in cases receiving appropriate antiretroviral treatment but delivered vaginally.
These investigators conclude that elective cesarean delivery reduces mother-to-child transmission of HIV-1 and, along with antiretroviral prophylaxis and avoidance of breast feeding, should be presented as a therapeutic option to infected women (N Engl J Med 1999;340:977-987).
COMMENT BY STEVEN G. GABBE, MD
This important study provides information about the mechanism of transmission of HIV-1 from mother to fetus and supports elective cesarean delivery to further reduce the risk. More than two-thirds of the cases of vertical transmission of HIV-1 occur during labor and delivery. Because HIV-1 infected women who underwent a cesarean delivery within hours of rupture of membranes were still more likely to deliver an infected infant, it appears that the transmission of HIV-1 can occur not only when the newborn is exposed to infected blood or secretions at delivery, but may be due to leakage of infected blood across the placenta during labor. A limitation of this study is the lack of information about maternal viral load, which has been correlated with the risk of vertical transmission of HIV. It is unclear whether cesarean delivery will reduce neonatal infection in women who have an undetectable viral load as a result of aggressive antiretroviral therapy.
Elective cesarean delivery does increase the risks for morbidity and mortality for an HIV-1 infected mother. Therefore, it is an option we must discuss with pregnant patients who are infected with HIV-1, just as we review with them the reduction in the rate of vertical transmission associated with antiretroviral therapy and the increased risk of neonatal infection with breast feeding.
Based on the data provided by the International Perinatal HIV Group, which of the following methods of delivery is likely to be associated with the lowest risk of vertical transmission?
a. Spontaneous assisted vaginal delivery
b. Vacuum-assisted vaginal delivery
c. Elective cesarean delivery
d. Elective cesarean delivery after the onset of labor
e. Elective cesarean delivery within one hour of rupture of membranes
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