Complications and Route of Delivery in a Large Cohort Study of HIV-1–Infected Women—IMPAACT P1025

Abstract

Objective Investigate complications of cesarean section in a cohort of HIV-infected pregnant women. Methods IMPAACT P1025 is a prospective cohort study of HIV-1-infected women and infants, enrolled 2002 to 2013, at clinical sites in the United States and Puerto Rico. Demographic, medical, and obstetric data were collected and analyzed including cesareans indications. Delivery route was categorized as elective cesarean (ECS, before labor and <5 minutes before membrane rupture), non-elective cesarean (NECS, all other cesareans) or vaginal delivery. Logistic regression models evaluated associations between delivery route and maternal intrapartum/postpartum morbidities. Composite morbidity of vaginal delivery was compared to ECS and NECS. Results This study included 2297 women. 99% used antiretroviral medication and 89% were on a combination antiretroviral therapy regimen. 84% had a HIV-1 viral load ≤400 copies/mL before delivery. 46% (1055) delivered vaginally, 35% (798) by ECS, and 19% (444) by NECS. While interruption of HIV-1 infection was the second most frequent indication for cesarean after repeat cesarean, it decreased as an indication over time. There were no delivery-related maternal mortalities. Overall 19% of women had ≥1 complication(s) - primarily wound complications (14%) or other infections (11%). Vaginal delivery had the lowest complication rate (13%), followed by ECS (23%), and highest NECS (28%) with an overall p<0.001. HIV-1 mother-to-child transmission rates were low and did not differ by delivery mode group. Conclusions HIV interruption as cesarean indicator declined during the study. Morbidity was more common in HIV-infected women delivering by NECS than ECS and lowest with vaginal delivery.

Assessment of mode of delivery and predictors of emergency caesarean section among women living withHIVin a matched‐pair setting with women from the general population in Denmark, 2002−2014

“…A recent American study found that 61% of WLWH planned a vaginal delivery and 27% of these ended up having a CS. A total of 24% of WLWH planning an ECS went in to labour prior to the scheduled ECS and had an EmCS performed , which corresponds to findings from our cohort, where 20.4% of WLWH planning an ECS and 32% of WLWH planning a vaginal delivery ended up having an EmCS.…”

“…Consistent with the decreasing rate of ECS, Livingston et al . reported only 39% of American WLWH planning an ECS . The primary indications of CS were prior CS (33%) and PMTCT (26%).…”

Most women living with HIV can deliver vaginally—National data from Finland 1993–2013

“…The proportion of women fulfilling the virological criteria for vaginal delivery in Finland is comparable to that reported from France, Denmark and the US [ 13 , 17 , 20 ]. However, whilst over 75% of women fulfilling these criteria in Finland deliver vaginally, only half of them in France or the US do so [ 13 , 17 ]. This rate was not reported in the Danish study [ 20 ].…”

“…The transition from CS to vaginal delivery in clinical practice has been slow; 40–66% of women living with HIV (WLWH) in Europe, Canada and the US still deliver by CS and 22–51% by elective CS despite excellent virological treatment results [ 4 , 12 – 17 ].…”

Surveillance monitoring for safety of in utero antiretroviral therapy exposures: current strategies and challenges

“…The study collected detailed information during pregnancy, allowing careful control for potential confounders. However, the study followed infants only for 1 year and reduced infant follow-up to 6 months in 2007; as a result, this study has primarily focused on adverse birth and early neonatal outcomes [56]. The Pediatric AIDS Clinical Trials Group (PACTG) 219/219C study followed 3552 infected children (90% perinatally-acquired) and 2342 HEU youth for long-term outcomes, including neurodevelopment and neurological functioning, congenital anomalies, growth, cancer and mitochondrial dysfunction [57–60].…”