Morbidity and Mortality High in HIV-Infected Women After Cesarean Section

By Martha Kerr

NEW YORK (Reuters Health) Aug 14 - The overall complication rate is 60% higher among HIV-infected women undergoing cesarean section compared with their uninfected counterparts, according to findings from a National Institutes of Health study.

Principal investigator Dr. Judette Louis of Case Western Reserve University in Cleveland, Ohio, and colleagues with the National Institutes of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network, compared C-section outcomes in 378 HIV-infected women and 54,281 uninfected women.

"Patients infected with HIV were more likely to have postpartum endometritis (11.6% compared with 5.8%), require a postpartum blood transfusion (4.0% compared with 2.0%), develop maternal sepsis (1.1% compared with 0.2%), be treated for pneumonia (1.3% compared with 0.3%), and to have a maternal death (0.8% compared with 0.1%)," Dr. Louis and colleagues report in the August issue of Obstetrics and Gynecology.

Even after controlling for potential confounders, including type of anesthesia, number of previous cesarean deliveries, and duration of rupture of membranes, "patients with HIV infection were more likely to have one or more postpartum morbidities," with an odds ratio of 1.6, the researchers say.

"While we also found an increased risk of death, it is likely related to their disease and not the cesarean delivery itself," Dr. Louis commented to Reuters Health.

The size of the cohort and the multi-center design are study strengths, but "the lack of data regarding antiretroviral therapy and immune status among the HIV-infected women is a weakness that may limit generalizability of our results," Dr. Louis and associates caution.

"Nonetheless," they say, "our findings are significant and consistent with studies published in other countries that indicate an increase in maternal mortality and perioperative risk associated with cesarean delivery in HIV-infected patients."

The investigators note that morbidity and mortality risks can be minimized with interventions such as "avoidance of cesarean delivery in patients with an undetectable viral load, more extensive prophylactic antibiotic therapies, or selective identification and prophylaxis of individuals at increased risk for infectious morbidities."

The most effective precaution, Dr. Louis said, "may be optimal viral suppression during pregnancy with an appropriate antiretroviral regimen. This would prevent the need for a cesarean delivery solely on the basis of a high viral load."

"An additional measure is ensuring that the patient receives a prophylactic dose of antibiotics at the time of cesarean delivery. That is one measure that has proven over time to decrease the risk of infectious morbidity."

Obstet Gynecol 2007;110:385-390.