Mode of delivery and postpartum morbidity among HIV-infected women: The Women and Infants Transmission Study

Cesarean delivery before onset of labor and rupture of membranes (i.e., sch eduled cesarean delivery) is associated with a lower risk of vertical trans mission of HIV. The following a priori hypotheses were tested: among HIV-in fected women, scheduled cesarean delivery is associated with a higher risk of postpartum morbidity, longer hospitalization, and a higher risk of rehos pitalization than spontaneous vaginal delivery. Postpartum morbidity occurr ed following 178 of 1,186 (15%) of deliveries during 1990 to 1998 in The Wo men and Infants Transmission Study. The most commonly reported postpartum m orbidity events were: fever without infection, hemorrhage or severe anemia, endometritis, urinary tract infection, and cesarean wound complications. S everal time trends were observed: the median duration of ruptured membranes decreased (p < .001), intrapartum antibiotic use increased (p < .001), the median antepartum plasma HIV RNA concentration decreased (p < .001). and t he incidence of any postpartum morbidity decreased (p = .02). With spontane ous vaginal delivery as the reference category, both scheduled (odds ratio [OR] = 4.69: 95% confidence interval [95% CI], 2.03-10.84), and nonschedule d (OR, 2.50; 95% CI, 1.24-5.04) cesarean deliveries were associated with fe ver without infection; with urinary tract infection (OR, 3.79; 95% CI 1.04- 13.85; OR, 3.86; 95% CI, 1.55-9.60, respectively), and with any postpartum morbidity (OR, 3.19: 95% CI 1.69-6.00; OR, 4.10; 95% CI, 2.71-6.19, respect ively). Nonscheduled cesarean deliveries were more likely to be complicated by endometritis (OR, 6.98: 95% CI, 3.53-13.78). Adjusted ORs relating mode of delivery and each of the outcomes (fever without infection, urinary tra ct infection, endometritis, and any postpartum morbidity) were similar to u nadjusted ORs. Results of this analysis indicate scheduled cesarean deliver y is associated with an increased risk of any postpartum morbidity and, spe cifically, postpartum fever without infection. The potential for postpartum morbidity with scheduled cesarean delivery should be considered in light o f possible adverse events associated with other interventions to decrease t he risk of vertical transmission of HIV. Counseling of HIV-infected pregnan t 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 and severity of postpartum morbidity events among HIV-infected wo men according to mode of delivery.