Mode of Delivery and Postpartum Morbidity among HIV-Infected Women: The Women and Infants Transmission Study

Important note: Information in this article was accurate in 2001. The state of the art may have changed since the publication date.

Mode of Delivery and Postpartum Morbidity among HIV-Infected Women: The Women and Infants Transmission Study

Journal of Acquired Immune Deficiency Syndromes (03.00.01) Vol. 26 - Tuesday, April 10, 2001
Jennifer S Reed, et al, and the Women and Infants Transmission Study Group

Cesarean delivery before the onset of labor and rupture of membranes (scheduled cesarean delivery) has been associated with a decrease in the likelihood of mother-to-child transmission of the human immunodeficiency virus type 1 (HIV). However, the benefits of scheduled cesarean delivery with regard to transmission must be weighed against the possible postpartum effects of surgical delivery on women who have HIV. Although there have been European studies of the mode of delivery for women with HIV that looked at postpartum morbidity rates, those studies compared delivery types between HIV-positive women and women who were uninfected by the virus.

The goal of this study was to describe postpartum morbidity among HIV-infected women in North America enrolled in the Women and Infants Transmission Study (WITS)-an ongoing, multi-center cohort study of HIV-infected women and their children sponsored by the National Institutes of Health and other federal agencies. The primary hypothesis of the study was that scheduled cesarean delivery is associated with a higher risk of postpartum morbidity and longer hospitalization time than vaginal delivery.

The study covered women whose deliveries resulted in a singleton, live birth before March 1, 1998, with analyses performed to assess trends in the delivery of antiretroviral therapy during pregnancy. These trends fell into three categories, i.e., none: 1990-February 1994; zidovudine prophylaxis: February 1994 until August 1996; combination antiretroviral therapy: August 1996 until 1998.

Of the 1,249 deliveries, 1,225 represented singleton births. Postpartum morbidity data were available for 97 percent (1,186) of these deliveries. Of these, 890 deliveries (75 percent) were vaginal, 248 (21 percent) were cesarean, and 48 (4 percent) were of unknown type. Of vaginal deliveries, 816 were spontaneous, 57 were operative and 17 were of unknown type. Of cesarean deliveries, 56 were scheduled, 147 were nonscheduled and 45 were of unknown type. The median length of hospitalization was two days.

Of the 1,186 deliveries, 178 (15 percent) were complicated by "any postpartum morbidity" defined as any fever without infection. Mortality during the 8-week period following delivery was (0.2 percent) with two deliveries: one vaginal, the other cesarean. Both deaths were due to Pneumocystis carinii pneumonia. The most common reported postpartum morbidity events were fever without infection, hemorrhage or severe anemia, endometritis, urinary tract infection and cesarean wound complications.

In a lengthy discussion section, the authors point to changes in therapy over the period of the study and to the great improvements in surgical and obstetrical care, especially post- operative care and the use of antimicrobial treatments. However, they point to the potential for postpartum morbidity, "and specifically postpartum fever without infection" as an increased risk of scheduled cesarean delivery. They conclude that "Counseling of HIV-infected pregnant women regarding scheduled cesarean delivery as a possible intervention to decrease maternal-infant transmission of HIV should include discussion of these results, as well as new data as they become available, regarding the incidence of severity of postpartum morbidity events among HIV-infected women."
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