Perioperative morbidity and mortality among human immunodeficiency virus infected women undergoing cesarean delivery

Pregnancy rates and clinical outcomes among women living with HIV enrolled in HPTN 052

HPTN 052 was a multi-country clinical trial of cART for preventing heterosexual HIV-1 transmission. The study allowed participation of pregnant women and provided access to cART and contraceptives. We explored associations between pregnancy and clinical measures of HIV disease stage and progression. Of 869 women followed for 5.70 (SD = 1.62) years, 94.7% were married/cohabitating, 96% initiated cART, and 76.3% had >2 past pregnancies. Of 337 women who experienced pregnancy, 89.3% were from countries with lower contraceptive coverage, 56.1% first started cART with PI-based regimens and 57.6% were 25-34 years old. Mean cART duration and condom use were similar among pregnant and nonpregnant individuals. Adjusting for confounders, viral load suppression (VLS) was not (aHR(CI) = 0.82(0.61, 1.08)) and CD4 was slightly associated with decreased rates of first pregnancy over time (aHR(CI) = 0.9(0.84, 0.95)); baseline VLS was associated with increased (aRR(CI) = 2.48(1.71, 3.59)) and baseline CD4 was slightly associated with decreased number of pregnancies (aRR(CI) = 0.9(0.85,0.96)) over study duration. Partner seroconversion was univariably associated with higher rates of first pregnancy (HR(CI) = 2.02(1.32,3.07)). Despite a background of higher maternal morbidity and mortality rates, our findings suggest that becoming pregnant does not pose a threat to maternal health in women with HIV when there is access to medical care and antiretroviral treatment.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Changes in Immune Activation During Pregnancy and the Postpartum Period in Treated HIV Infection

Background

Pregnant women with HIV (PWWH) have high postpartum morbidity and mortality from infections like tuberculosis. Immunologic changes during pregnancy and postpartum periods may contribute to these risks, particularly the immunoregulatory kynurenine pathway of tryptophan catabolism, which contributes to both HIV and tuberculosis pathogenesis and increases in the early postpartum period.

Methods

Women with HIV initiating antiretroviral therapy (ART) in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort who were pregnant at enrollment or became pregnant during observation were studied (n = 54). Plasma kynurenine/tryptophan (KT) ratio, soluble CD14 (sCD14), sCD163, sCD27, interferon-inducible protein 10 (IP-10), D-dimer, interleukin-6, and intestinal fatty-acid binding protein levels were assessed through the first year of ART and at 3-month intervals throughout pregnancy and 1 year postpartum. Biomarker changes were assessed with linear mixed models adjusted for ART duration. Hemoglobin concentration changes were used to estimate pregnancy-related changes in plasma volume.

Results

The median pre-ART CD4 count was 134. D-dimer increased through the third trimester before returning to baseline postpartum, while most other biomarkers declined significantly during pregnancy, beyond what would be expected from pregnancy-associated plasma volume expansion. IP-10 and sCD14 remained suppressed for at least 12 months postpartum. KT ratio was the only biomarker that increased above prepregnancy baseline postpartum (mean + 30%; P < .001) and remained higher than baseline for ≥9 months (P ≤ .045 for all time points).

Conclusions

Several immune activation markers decline during pregnancy and remain suppressed postpartum, but the kynurenine pathway of tryptophan catabolism increases above baseline for ≥9 months postpartum. The mechanisms underlying postpartum kynurenine pathway activity are incompletely understood but may contribute to increased tuberculosis risk in this setting.

HIV Infection and risk of postpartum infection, complications and mortality in rural Uganda

HIV infection may increase risk of postpartum infection and infection-related mortality. We hypothesized that postpartum infection incidence and attributable mortality in Mbarara, Uganda would be higher in HIV-infected than HIV-uninfected women. We performed a prospective cohort study of 4231 women presenting to a regional referral hospital in 2015 for delivery or postpartum care. All febrile or hypothermic women, and a subset of randomly selected normothermic women were followed during hospitalization and with 6-week postpartum phone interviews. The primary outcome was in-hospital postpartum infection. Secondary outcomes included in-hospital complications (mortality, re-operation, intensive care unit transfer, need for imaging or blood transfusion) and 6-week mortality. We performed multivariable regression analyses to estimate adjusted differences in each outcome by HIV serostatus. Mean age was 25.2 years and 481 participants (11%) were HIV-infected. Median CD4+ count was 487 (IQR 325, 696) cells/mm³, and 90% of HIV-infected women (193/215 selected for in-depth survey) were on antiretroviral therapy. Overall, 5% (205/4231) of women developed fever or hypothermia. Cumulative in-hospital postpartum infection incidence was 2.0% and did not differ by HIV status (aOR 1.4, 95% CI 0.6-3.3, P = 0.49). However, more HIV-infected women developed postpartum complications (4.4% vs. 1.2%, P = 0.001). In-hospital mortality was rare (2/1768, 0.1%), and remained so at 6 weeks (4/1526, 0.3%), without differences by HIV serostatus (P = 1.0 and 0.31, respectively). For women in rural Uganda with high rates of antiretroviral therapy coverage, HIV infection did not predict postpartum infection or mortality, but was associated with increased risk of postpartum complications.

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

OBJECTIVE

To 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 2002-2013, at clinical sites in the United States and Puerto Rico. Demographic, medical, and obstetric data were collected and analyzed including cesarean indications. The delivery route was categorized as elective cesarean (ECS) (before labor and <5 minutes before membrane rupture), nonelective 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 with ECS and NECS.

RESULTS

This study included 2297 women. Of note, 99% used antiretroviral medication and 89% were on a combination antiretroviral therapy regimen; 84% had a HIV-1 viral load ≤400 copies per milliliter before delivery; 46% (1055) delivered vaginally, 35% (798) by ECS, and 19% (444) by NECS. Although 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.

CLINICAL TRIAL REGISTRATION

Prenatal and Postnatal Studies of Interventions for Prevention of Mother-To-Child Transmission https://clinicaltrials.gov/ct2/show/NCT00028145?term=impaact+1025&rank=2 NCT00028145.

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

OBJECTIVES

We aimed to assess mode of delivery and predictors of emergency caesarean section (EmCS) in women living with HIV (WLWH) in a matched-pair setting with women from the general population (WGP) in Denmark. Further, we analysed birth plan in WLWH.

METHODS

All WLWH giving birth to live-born children from 2002 to 2014 were included in the study. Data were retrieved from medical records and national registries. WLWH were matched 1:5 by age, birth year, parity and ethnicity to WGP. Multivariate logistic regression was used to estimate predictors.

RESULTS

We included 389 WLWH and 1945 WGP in the study. At delivery, all WLWH were on antiretroviral therapy and 85.6% had HIV RNA <40 HIV-1 RNA copies/mL. Mean age was 32.7 years [95% confidence interval (CI) 32.1-33.2 years]. Mode of delivery differed significantly between WLWH and WGP [vaginal delivery, 33.4% versus 73.3%, respectively; elective caesarean section (ECS), 40.6% versus 9.7%, respectively; EmCS, 26% versus 17%, respectively; P < 0.0001]. Age > 40 years [adjusted odds ratio (aOR) 2.3; 95% CI 1.5-3.5], asphyxia (aOR 3.2; 95% CI 2.4-4.1), delivery during the evening and at night [aOR 2.3 (95% CI 1.7-3.0) and aOR 2.0 (95% CI 1.5-2.7), respectively], preterm delivery (aOR 3.8; 95% CI 2.6-5.6) and premature rupture of membranes (aOR 3.0; 95% CI 2.1-4.4) predicted EmCS. WLWH had a higher risk of EmCS compared with WGP [2002-2006, aOR 2.0 (95% CI 1.2-3.3); 2007-2008, aOR 2.9 (95% CI 1.4-5.9); 2009-2014, aOR 2.6 (95% CI 1.7-3.9)]. After 2007, more than half of WLWH planned to deliver vaginally. Prior caesarean section was associated with ECS (aOR 11.0; 95% CI 4.5-26.8). No mother-to-child transmission occurred.

CONCLUSIONS

Increasing numbers of WLWH deliver vaginally. Despite virological suppression, more WLWH plan and deliver by ECS than WGP. WLWH had a twofold higher risk of EmCS compared with WGP.

Complications of cesarean deliveries among HIV-infected women in the United States

OBJECTIVE

To compare rates of complications associated with cesarean delivery in HIV-infected and HIV-uninfected women in the United States and to investigate trends in such complications across four study cycles spanning the implementation of HAART in the United States (1995-1996, 2000-2001, 2005-2006, 2010-2011).

DESIGN

The Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project is the largest all-payer hospital inpatient care database in the United States; when weighted to account for the complex sampling design, nationally representative estimates are derived. After restricting the study sample to women aged 15-49 years, our study sample consisted of approximately 1 090 000 cesarean delivery hospitalizations annually.

METHODS

Complications associated with cesarean deliveries were categorized as infection, hemorrhage, or surgical trauma, based on groups of specific International Classification of Diseases 9th revision codes. Length of hospitalization, hospital charges, and in-hospital deaths were also examined.

RESULTS

The rate of complications significantly decreased during the study periods for HIV-infected and HIV-uninfected women. However, rates of infectious complications and surgical trauma associated with cesarean deliveries remained higher among HIV-infected, compared with HIV-uninfected women in 2010-2011, as did prolonged hospital stay and in-hospital deaths. Length of hospitalization decreased over time for cesarean deliveries of HIV-infected women to a greater extent compared with HIV-uninfected women.

CONCLUSION

In the United States, rates of cesarean delivery complications decreased from 1995 to 2011. However, rates of infection, surgical trauma, hospital deaths, and prolonged hospitalization are still higher among HIV-infected women. Clinicians should remain alert to this persistently increased risk of cesarean delivery complications among HIV-infected women.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

METHODS

We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

FINDINGS

292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland.

INTERPRETATION

Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

FUNDING

Bill & Melinda Gates Foundation.

HIV and maternal mortality

The majority of the 17 million women globally that are estimated to be infected with HIV live in Sub-Saharan Africa. Worldwide, HIV-related causes contributed to 19 000-56 000 maternal deaths in 2011 (6%-20% of maternal deaths). HIV-infected pregnant women have two to 10 times the risk of dying during pregnancy and the postpartum period compared with uninfected pregnant women. Many of these deaths can be prevented with the implementation of high-quality obstetric care, prevention and treatment of common co-infections, and treatment of HIV with ART. The paper summarizes what is known about HIV disease progression in pregnancy, specific causes of HIV-related maternal deaths, and the potential impact of treatment with antiretroviral therapy on maternal mortality. Recommendations are proposed for improving maternal health and decreasing maternal mortality among HIV-infected women based on existing evidence.

[Consensus statement on monitoring of HIV: pregnancy, birth, and prevention of mother-to-child transmission]

OBJECTIVE

The main objective in the management of HIV-infected pregnant women is prevention of mother-to-child transmission; therefore, it is essential to provide universal antiretroviral treatment, regardless of CD4 count. All pregnant women must receive adequate information and undergo HIV serology testing at the first visit.

METHODS

We assembled a panel of experts appointed by the Secretariat of the National AIDS Plan (SPNS) and the other participating Scientific Societies, which included internal medicine physicians with expertise in the field of HIV infection, gynecologists, pediatricians and psychologists. Four panel members acted as coordinators. Scientific information was reviewed in publications and conference reports up to November 2012. In keeping with the criteria of the Infectious Diseases Society of America, 2levels of evidence were applied to support the proposed recommendations: the strength of the recommendation according to expert opinion (A, B, C), and the level of empirical evidence (I, II, III). This approach has already been used in previous documents from SPNS.

RESULTS AND CONCLUSIONS

The aim of this paper was to review current scientific knowledge, and, accordingly, develop a set of recommendations regarding antiretroviral therapy (ART), regarding the health of the mother, and from the perspective of minimizing mother-to-child transmission (MTCT), also taking into account the rest of the health care of pregnant women with HIV infection. We also discuss and evaluate other strategies to reduce the MTCT (elective Cesarean, child's treatment…), and different aspects of the topic (ARV regimens, their toxicity, monitoring during pregnancy and postpartum, etc.).

HIV and the risk of direct obstetric complications: a systematic review and meta-analysis

Background

Women of reproductive age in parts of sub-Saharan Africa are faced both with high levels of HIV and the threat of dying from the direct complications of pregnancy. Clinicians practicing in such settings have reported a high incidence of direct obstetric complications among HIV-infected women, but the evidence supporting this is unclear. The aim of this systematic review is to establish whether HIV-infected women are at increased risk of direct obstetric complications.

Methods and findings

Studies comparing the frequency of obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia and intrauterine infections in HIV-infected and uninfected women were identified. Summary estimates of the odds ratio (OR) for the association between HIV and each obstetric complication were calculated through meta-analyses. In total, 44 studies were included providing 66 data sets; 17 on haemorrhage, 19 on hypertensive disorders, five on dystocia and 25 on intrauterine infections. Meta-analysis of the OR from studies including vaginal deliveries indicated that HIV-infected women had over three times the risk of a puerperal sepsis compared with HIV-uninfected women [pooled OR: 3.43, 95% confidence interval (CI): 2.00–5.85]; this figure increased to nearly six amongst studies only including women who delivered by caesarean (pooled OR: 5.81, 95% CI: 2.42–13.97). For other obstetric complications the evidence was weak and inconsistent.

Conclusions

The higher risk of intrauterine infections in HIV-infected pregnant and postpartum women may require targeted strategies involving the prophylactic use of antibiotics during labour. However, as the huge excess of pregnancy-related mortality in HIV-infected women is unlikely to be due to a higher risk of direct obstetric complications, reducing this mortality will require non obstetric interventions involving access to ART in both pregnant and non-pregnant women.

Cesarean section for HIV-infected women in the combination antiretroviral therapies era, 2000-2010

OBJECTIVE

Elective cesarean section (CS) is a proven method to prevent mother-to-child transmission (MTCT), but is no longer recommended for women with antiretroviral therapy resulting in a low viral load (VL): <400 copies/mL in French and <1000 copies/mL in US guidelines. We sought to describe mode of delivery practices in human immunodeficiency virus (HIV)-infected women and their association with MTCT and postpartum complications.

STUDY DESIGN

All deliveries from HIV-1-infected women in the French Perinatal Cohort (Agence Nationale de Recherches sur le Sida/Enquête Périnatale Française) 2000 through 2010 (N = 8977) were analyzed, with additional details for 2005 through 2010 (n = 4717).

RESULTS

Vaginal deliveries increased from 25% in 2000 to 53% in 2010. Over 2005 through 2010, 4300 women had VL before delivery <400 copies/mL; among them only 49.3% delivered vaginally, 22.0% had nonelective CS, and 28.7% had elective CS. Elective CS were performed for scarred uterus in 45.4%, other obstetrical indications in 37.1%, and solely because of HIV in 15.7%. Of the 417 women with VL ≥400 copies/mL, 48.9% had elective CS as recommended, 25.9% had nonelective CS, and 25.2% had vaginal delivery. The MTCT rate did not differ according to the mode of delivery in term deliveries (≥37 gestational weeks) in 2000 through 2010: 0.3% after both vaginal delivery and elective CS with VL <50 copies/mL, 4.0% vs 5.3%, respectively, with VL ≥10,000 copies/mL. In case of preterm delivery, MTCT rates tended to be higher with vaginal delivery. Postpartum complications were more frequent following CS than vaginal deliveries (6.5% vs 2.9, P < .01).

CONCLUSION

Our findings suggest that HIV-infected women on antiretroviral therapy with low VL can safely opt for vaginal delivery in the absence of obstetrical risk factors.

Reduction of maternal mortality with highly active antiretroviral therapy in a large cohort of HIV-infected pregnant women in Malawi and Mozambique

Background

HIV infection is a major contributor to maternal mortality in resource-limited settings. The Drug Resource Enhancement Against AIDS and Malnutrition Programme has been promoting HAART use during pregnancy and postpartum for Prevention-of-mother-to-child-HIV transmission (PMTCT) irrespective of maternal CD4 cell counts since 2002.

Methods

Records for all HIV+ pregnancies followed in Mozambique and Malawi from 6/2002 to 6/2010 were reviewed. The cohort was comprised by pregnancies where women were referred for PMTCT and started HAART during prenatal care (n = 8172, group 1) and pregnancies where women were referred on established HAART (n = 1978, group 2).

Results

10,150 pregnancies were followed. Median (IQR) baseline values were age 26 years (IQR:23–30), CD4 count 392 cells/mm³ (IQR:258–563), Viral Load log₁₀ 3.9 (IQR:3.2–4.4), BMI 23.4 (IQR:21.5–25.7), Hemoglobin 10.0 (IQR: 9.0–11.0). 101 maternal deaths (0.99%) occurred during pregnancy to 6 weeks postpartum: 87 (1.1%) in group 1 and 14 (0.7%) in group 2. Mortality was 1.3% in women with <than 350 CD4 cells/mm³ and 0.7% in women with greater than 350 CD4s cells/mm³ [OR = 1.9 (CL 1.3–2.9) p = 0.001]. Mortality was higher in patients with shorter antenatal HAART: 22/991 (2.2%) if less than 30 days and 79/9159 (0.9%) if 31 days or greater [OR = 2.6 (CL 1.6–4.2) p<0.001]. By multivariate analysis, shorter antenatal HAART (p<0.001), baseline values for CD4 cell count (p = 0.012), hemoglobin (p = 0.02), and BMI (p<0.001) were associated with mortality. Four years later, survival was 92% for women with shorter antenatal HAART and 98% for women on established therapy prior to pregnancy, p = 0.001.

Conclusions

Antiretrovirals for PMTCT purposes have significant impact on maternal mortality as do CD4 counts and nutritional status. In resource-limited settings, PMTCT programs should provide universal HAART to all HIV+ pregnant women given its impact in prevention of maternal death.

The contribution of HIV to pregnancy-related mortality: a systematic review and meta-analysis

OBJECTIVES

Although much is known about the contribution of HIV to adult mortality, remarkably little is known about the mortality attributable to HIV during pregnancy. In this article we estimate the proportion of pregnancy-related deaths attributable to HIV based on empirical data from a systematic review of the strength of association between HIV and pregnancy-related mortality.

METHODS

Studies comparing mortality during pregnancy and the postpartum in HIV-infected and HIV-uninfected women were included. Summary estimates of the relative and attributable risks for the association between HIV and pregnancy-related mortality were calculated through meta-analyses. Varying estimates of HIV prevalence were used to predict the impact of the HIV epidemic on pregnancy-related mortality at the population level.

RESULTS

Twenty-three studies were included (17 from sub-Saharan Africa). Meta-analysis of the risk ratios indicated that HIV-infected women had eight times the risk of a pregnancy-related death compared with HIV-uninfected women [pooled risk ratio 7.74, 95% confidence interval (95% CI) 5.37-11.16]. The excess mortality attributable to HIV among HIV-infected pregnant and postpartum women was 994 per 100,000 pregnant women. We predict that 12% of all deaths during pregnancy and up to 1-year postpartum are attributable to HIV/AIDS in regions with a prevalence of HIV among pregnant women of 2%. This figure rises to 50% in regions with a prevalence of 15%.

CONCLUSION

The substantial excess of pregnancy-related mortality associated with HIV highlights the importance of integrating HIV and reproductive health services in areas of high HIV prevalence and pregnancy-related mortality.

Management of HIV in the pregnant woman

The treatment of human immunodeficiency virus (HIV)-infected pregnant women is one of the most effective HIV-prevention interventions known. With prenatal testing, antiviral therapy, scheduled cesarean section when indicated, and formula feeding when feasible, rates of neonatal and perinatal HIV infection can diminish significantly. Although significant prevention is achievable, new cases of HIV in neonates continue to occur both worldwide and locally due to limited resources, delayed diagnosis, lack of linkage to care, and lack of timely effective therapy. Where those resources are available, the management of HIV infection in the pregnant woman requires a multidisciplinary expert approach to achieve optimal outcomes for both mother and child.

The impact of HIV on maternal morbidity in the Pre-HAART era in Uganda

Objective. To compare maternal morbidity in HIV-infected and uninfected pregnant women. Methods. Major maternal morbidity (severe febrile illness, illnesses requiring hospital admissions, surgical revisions, or illnesses resulting in death) was measured prospectively in a cohort of HIV-infected and uninfected women followed from 36 weeks of pregnancy to 6 weeks after delivery. Odds ratios of major morbidity and associated factors were examined using logistic regression. Results. Major morbidity was observed in 46/129 (36%) and 104/390 (27%) of the HIV-infected and HIV-uninfected women, respectively, who remained in followup. In the multivariable analysis, major morbidity was independently associated with HIV infection, adjusted odds ratio (AOR) 1.7 (1.1 to 2.7), nulliparity (AOR 2.0 (1.3 to 3.0)), and lack of, or minimal, formal education (AOR 2.1 (1.1 to 3.8)). Conclusions. HIV was associated with a 70% increase in the odds of major maternal morbidity in these Ugandan mothers.

Women facing HIV. Key question on women with HIV infection: Italian consensus workshop

A panel of leading Italian specialists in infectious diseases, obstetrics and gynaecology met in a national consensus workshop on women facing HIV to review critical aspects and discuss recommendations for selected key questions on four issues: (1) women and highly active antiretroviral therapy (HAART): access to care and adherence to therapy, side effects and drug-drug interaction; (2) HIV-infected pregnant women: prevention of mother to child transmission; (3) desire for children among women living with HIV: assisted reproduction; (4) sexually transmitted diseases and genital disturbances. The method of a nominal group meeting was used, and recommendations were graded for their strength and quality of evidence using a system based on the one adopted by the Infectious Diseases Society of America. Main conclusions are summarized and critically discussed, and some of the most recent data supporting recommendations are provided.

Pregnancy outcomes in young women with perinatally acquired human immunodeficiency virus-1

OBJECTIVE

The objective of the study was to review pregnancy and neonatal outcomes among perinatally infected pregnant patients at our institution.

STUDY DESIGN

A retrospective review of maternal and neonatal records for all 10 perinatally infected adolescents between 1997 and 2007 was performed. Demographics, CD4 and viral load, antiretroviral treatment, medical comorbidities, pregnancy outcomes, and neonatal human immunodeficiency virus (HIV) status were abstracted.

RESULTS

The median age at first pregnancy was 18.5 years and 70% were African American. The most common comorbidities were hematologic abnormalities (70%) and cervical dysplasia/sexually transmitted infections (STIs) (80%). Initial median CD4 and viral load were 317 cells/mm(3) and 8780 copies/mL, respectively. The median gestational age at delivery was 38 weeks. The most common obstetrical complications were preeclampsia (23%) and premature rupture of membranes/preterm delivery (31%). The cesarean delivery (CD) rate was 62%, with HIV as the indication in 75%. All infants were born alive; 1 was HIV infected.

CONCLUSION

Despite high rates of STIs, CD, preterm delivery, and hypertensive disorders, perinatal outcomes were favorable.

Infections related to pregnancy

Infections in pregnancy and in the postpartum period represent an important knowledge base that emergency physicians should have. Being able to understand the risk that pregnancy-related infections have on maternal and fetal health in addition to the initiation of appropriate treatment for these infections is crucial. In the postpartum period, most infections (94%) are likely to manifest after hospital discharge; therefore, patients frequently present to the emergency department.

The impact of cesarean delivery on transmission of infectious agents to the neonate

The rate of cesarean deliveries has increased dramatically over the past decade. Studies to date have highlighted a number of factors on the part of the treating physician and the expectant mother contributing to this increase. Maternal infections are not a major cause of this increase. There are a limited number of infections in a pregnant woman that warrant cesarean delivery to prevent perinatal transmission. This article outlines those infections known to be transmitted perinatally through the infected birth canal and details the current recommendations for cesarean delivery. Pregnant women with active genital herpes lesions or with known herpes simplex virus infection and a prodromal illness consistent with recurrence at the time of presentation in labor should undergo cesarean delivery. Pregnant women who are HIV infected and have detectable viremia (>1000 copies/mL) should be counseled regarding the potential benefits of cesarean delivery as an adjunct to antiretroviral therapy. Hepatitis C virus (HCV) can be transmitted intrapartum, but prevention of HCV transmission by cesarean delivery has not been proved effective and is not generally indicated. A limited number of other infectious agents can be transmitted through the birth canal but do not constitute an indication for cesarean delivery.