Update on vertical HIV transmission

OBJECTIVE

To describe the factors that contribute to vertical transmission of human immunodeficiency virus (HIV) and review means of decreasing the risk of transmission.

STUDY DESIGN

Medline search of the international English-language literature pertaining to HIV in pregnancy from 1989 to the present. Special emphasis was placed on articles published in the last three years related to vertical transmission as well as to antepartum, intrapartum and postpartum management to reduce transmission.

RESULTS

High levels of maternal viral load and more advanced maternal disease are associated with a greater risk of vertical transmission of HIV. Antepartum and intrapartum maternal treatment with zidovudine and postpartum neonatal zidovudine treatment decreases the risk of transmission by two-thirds, at least in patients with earlier stages of the disease. Breast-feeding is a source of postpartum HIV transmission and may double the total transmission rate.

CONCLUSION

Zidovudine should be used in pregnancy to decrease the viral load and reduce transmission of HIV to the fetus. Other antiviral agents should be used during pregnancy if indicated, although current information is lacking about their effects on the fetus and any potential benefits in decreasing vertical transmission of HIV. Breast-feeding should be avoided.

Predictors of neonatal resuscitation, low Apgar scores, and umbilical artery pH among growth-restricted neonates

OBJECTIVE

To identify risk factors associated with poorer immediate neonatal outcomes among growth-restricted neonates.

METHODS

Records of all 530 growth-restricted neonates born between January 1989 and February 1995 were reviewed. Outcomes included resuscitation measures, Apgar scores, and umbilical blood gas values. Neonates were assigned to one of six anesthetic groups, and outcomes were compared. Predictors of poorer outcomes were examined using logistic and linear regression.

RESULTS

Neonates exposed to general anesthesia were more likely to be intubated (37.9% versus 4.1%, P < .001, Pearson chi2) and had lower mean 1- (4.0 versus 7.0) and 5-minute (6.5 versus 8.4) Apgar scores (P < .01, Scheffé) than those in all other anesthetic groups. They also had significantly lower umbilical artery (UA) pH values than neonates who received nalbuphine, epidural, or no anesthesia (7.21 versus 7.28, 7.26, 7.29, respectively; P < .01, Scheffé). Factors that significantly and independently predicted intubation among all neonates included exposure to general anesthesia (odds ratio [OR] 4.1; 95% confidence interval [CI] 1.9, 8.9) and lower infant weight (OR 10.1 per kg decrease; CI 5.1, 20). Factors predicting UA pH at most 7.15 included preeclampsia (OR 3.0; CI 1.5, 5.9) and older maternal age (OR 1.3 per 5 years; CI 1.02, 1.64); vertex delivery (OR 0.5; CI 0.2, 0.9) was protective. Factors predicting a 5-minute Apgar less than 7 were meconium (OR 1.5 per category going from none to terminal to light to heavy; CI 1.04, 2.3), general anesthesia (OR 6.9; CI 2.6, 18.2), lower infant weight (OR 16.5 per kg decrease; CI 7.8, 34.5), and vaginal breech delivery (OR 7.0; CI 1.8, 28.6); cesarean delivery (OR 0.2; CI 0.08, 0.66) was protective. Spontaneous vertex delivery raised the UA pH, and preeclampsia, amnioinfusion, breech delivery, and general anesthesia significantly and independently lowered the UA pH among all neonates. For infants delivered by cesarean, "fetal distress," preeclampsia, previous spontaneous abortion, failed forceps use, and nalbuphine significantly and independently predicted lower UA pH.

CONCLUSION

Risk factors for poorer immediate neonatal outcomes among growth-restricted neonates include preeclampsia, fetal distress, breech delivery, forceps use, nalbuphine during labor, lower infant weight, and general anesthesia.

Court-ordered cesarean section: an analysis of ethical concerns in compelling cases

Two previously unreported cases are presented in which court-ordered cesarean sections were considered appropriate by physicians. An analysis of the factors that compel physicians to deem court-ordered intervention appropriate is presented. When the significance of a third-trimester fetal death or a lifetime physical or mental disability is balanced against the demand to uphold maternal autonomy at all costs, the recognized ethical principles of beneficence, nonmaleficence, justice, obstetric contract keeping, and acting in the patients' best interests combine, in rare situations, to override concerns for individual maternal autonomy and justify court-ordered intervention.

Fetal skull fracture and brain injury after a maternal automobile accident. A case report

A woman in labor and not wearing a seat belt sustained multiple fractures of the pelvis and femur while in an automobile accident. The fetus suffered fractures of the parietal and occipital bones. To minimize maternal pelvic and fetal injury, delivery by cesarean section was performed. The infant had generalized cerebral edema and intraventricular and subarachnoid hemorrhage, diagnosed shortly after birth. Motor abnormalities and residual injury to the periventricular white matter were evident at age 4 months. Use of seat belts may significantly diminish or prevent such injuries.