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Mother-to-Child HIV Prevention: Is Elective C-section Necessary?

Project Inform Perspectives 28 - September, 1999

Studies suggest that the majority of mother-to-child HIV transmission (vertical transmission) occurs during labor and delivery, thereby fueling a debate about the safest route of child birth. This debate centers around the risks and benefits of Cesarean-section (abdominal surgical delivery) performed before the onset of labor (called elective C-section) versus natural, vaginal delivery.

Results from three recent studies suggest that elective C-section and the use of anti-HIV drug AZT (Retrovir®) may further reduce the risk of vertical transmission compared to what has been achieved by using AZT alone.* Results also suggest that elective C-section reduces the risk of vertical transmission independent of the effects of AZT. This procedure protects the baby from direct contact with the mother's HIV-containing genital tract secretions and blood. One study showed that elective C-section was associated with a lower vertical transmission rate compared to natural vaginal delivery among women receiving AZT (O.8% versus 6.6%, respectively)

While these studies appear to make a strong case for recommending elective C-section for HIV-positive women, none have looked at anti-HIV regimens other than the AZT regimen. These studies also did not measure HIV levels.

Studies in progress are testing whether combination therapy reduces vertical transmission rates more than the widely used AZT regimen. The same benefits offered by elective C-section and AZT therapy are likely reached with combination therapy, a regimen that results in more complete suppression of the mother's viral load. In this context, surgical delivery may be unnecessary.

Moreover, the risk of vertical transmission must be weighed against the dangers surgical delivery poses for the mother. Compared to vaginal delivery, elective C-sections have much higher rates of complications, including increased risk of hemorrhage (uncontrolled bleeding), infection and death. One study found HIV-positive women have post-operative complications three times as often as HIV-negative women. In immune compromised women, these complications are particularly dangerous.

At this time, it is unclear which route of delivery is best for both mother and baby. More studies are needed to determine the effect of triple-drug therapy on reducing vertical transmission; if viral load predicts the benefit of elective C-section; and if postoperative complications are associated with HIV infection. In the meantime, the decision to deliver vaginally or via C-section remains a matter of carefully considered medical opinion and personal choice.

*Note: In one major study, vertical transmission rates were 25% among women who did not receive anti-HIV treatment compared to 8% among women who received AZT. The study provided AZT (or placebo) to the mother after week 14 of pregnancy; to the mother through intravenous (in the vein) injection during labor; and finally to the newborn for six weeks after birth.

Prevention of Fungal Infections
During Pregnancy

The revised Guidelines for the Prevention of Opportunistic Infections include new recommendations regarding the use of antifungal drugs during pregnancy. In short, the Guidelines recommend that the oral "azole" antifungals [including fluconazole (Diflucan®), itraconazole (Sporanox®) and ketoconazole (Nizoral®)] not be started during pregnancy. The Guidelines further state that these drugs be discontinued in HIV-positive women who become pregnant and that women receiving these drugs take effective birth control.

In animal studies, use of itraconazole and/or ketoconazole during pregnancy caused birth defects. In addition, there have been four reported cases of infants born with severe skeletal abnormalities to women who used fluconazole for an extended period of time while pregnant. It is presumed that these same potential risks apply to other oral azole antifungals.

For the treatment or prevention of oral or vaginal candidiasis, topical antifungal therapies such as nystatin (Mycostatin®, Pedi-Dri®) may be preferable for pregnant women. For the treatment or prevention of other fungal infections, such as cryptococcosis or histoplasmosis, the Guidelines suggest amphotericin B (Fungizone®), especially in the first trimester. Amphotericin B is also approved for the treatment of oral candida. Although no formal studies have been performed, amphotericin B has been used by pregnant women without apparent harm to their unborn children. While amphotericin B may be preferable to azole therapy in pregnant women, it is not without potentially severe side effects, including kidney toxicity and anemia. In addition, the intravenous (in the vein) suspension of the drug may not be feasible for some women.

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