Cesarean section delivery to prevent vertical transmission of human immunodeficiency virus type 1. Associated risks and other considerations.

Abstract

Delivery by elective cesarean section (ECS), cesarean section prior to labor and rupture of membranes, is associated with a lower rate of vertical transmission of HIV compared with other modes of delivery. The efficacy of ECS among women receiving combination antiretroviral therapy or among women with low viral loads is unknown. In assessing the possible utility of ECS as an intervention to decrease vertical transmission in the United States and other countries, the potential risks associated with operative delivery as well as other considerations should also be addressed. Although cesarean section delivery is associated with an increased rate of postpartum morbidity compared with vaginal delivery in the general population, operative delivery performed emergently carries a higher risk of complications than scheduled or elective procedures. Analyses of the risk of postpartum morbidity according to mode of delivery among HIV-infected women have been performed in the Women and Infants Transmission Study (WITS), the largest database in North America with relevant data, as well as other, smaller databases. These analyses suggest a similar pattern to that observed in the general population. In addition to quantifying the incidence of postpartum morbidity events, it is also important to distinguish between minor and major morbidity. Neonatal morbidity related to ECS is generally due to iatrogenic preterm birth, that is, situations where the gestational age is not accurately assessed prior to delivery. Occupationally acquired HIV infection related to obstetric procedures is a possibility, although risk related to mode of delivery is unknown. The results of economic analyses of ECS compared to vaginal delivery in the US indicate that ECS is a cost-effective intervention in preventing vertical transmission of HIV among women who refrain from breastfeeding. However, more precise estimates of the risk of vertical transmission among women receiving combination antiretroviral therapy and of the potential risks of maternal and pediatric adverse events related to receipt of such therapy are needed. In summary, the benefit of ECS must be weighed against potential risks, and issues such as cost-effectiveness also should be taken into consideration.