C-Sections and the Prevention of Newborn HIV
Frederick R. Jelovsek MD
If a woman gets infected with the human immunodeficiency virus (HIV) and becomes pregnant, then the primary medical goal is to prevent the baby from becoming infected. Recent studies have helped clarify whether a planned Cesarean section can prevent what is called vertical transmission. In other words, some exposure of the baby to HIV virus does not occur until mother undergoes labor and delivery. At that time the virus must cross over from mother's blood to
baby's blood. The question has been asked for quite a while as to whether C-section could prevent any instances of transmission. Before treatment with the antiviral drug zidovudine (ZDV), it did not seem that C-section had much effect. However ZDV has been shown to reduce the transmission rate itself and most women are now on ZDV therapy during pregnancy.
A recent publication from the American College of Obstetricians and Gynecologists, Scheduled Cesarean delivery and the prevention of vertical transmission of HIV infection. ACOG Committee Opinion. 1999;219:1-3, has given us information about HIV and pregnancy.
How likely is the baby to get infected with HIV?
Without any ZDV treatment or C-section, about 25% of babies become infected with the HIV virus. When ZDV therapy is given to a woman during pregnancy, the incidence of infection is reduced to about 5-8%. When C-section is performed and ZDV is given during labor, the infection rate is further reduced to about 2%. It is on this basis that current recommendations are to perform scheduled C-Section after 39 weeks in order to minimize the chance of newborn infection.
Won't a Cesarean section result in many more complications for a woman with HIV than a vaginal delivery?
Women who have low CD4 cell counts seem to have the most postpartum complications. This makes sense because those women have the most active disease with probably the greatest viral loads. Women with very low viral load counts of less than 1000 viral copies per ml of plasma (presumably due to effective ZDV therapy) actually have very low rates of the baby being infected. In these cases, C-section does not actually improve the newborn infection rate.
What if a woman with HIV doesn't want to have a C-section?
Women always have autonomy in whether or not to have surgery regardless of the effect on the baby. Courts have long upheld that a woman can refuse surgery even though that refusal may result in the baby dying or being significantly harmed directly due to that refusal.Informed consent for this scheduled delivery is necessary and whatever a woman decides should be honored.
What kind of drug treatment should be given around the time of delivery?
Women with HIV should receive during pregnancy whatever antiviral chemotherapy is recommended according to current adult guidelines. Then in addition, they should receive intravenous therapy with an antiviral like ZDV starting about 3 hours before and then during the Cesarean delivery. The baby will then receive oral ZDV syrup for the first 6 weeks of life. Right now this is the best therapy for minimizing HIV infection in the newborn.
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