Complications may outweigh benefits of Caesarian delivery

The trend toward routine use of elective C-section delivery for HIV positive mothers in Europe and the US, as a strategy to reduce mother to child transmission, irrespective of their antiretroviral use remains controversial.

This is largely due to the increased maternal morbidity and mortality associated with this procedure. A letter to the Lancet in 1999 concerning the causes of death in this country, related to delivery, reported a six-fold increase in mortality rate among Caesarean rather than vaginal deliveries. (This finding included both emergency and elected caesarean deliveries). These risks are higher in HIV positive women and higher in many developing countries.

A French report from Cochin Hospital published in the April edition of the American Journal of Obstetrics and Gynecology assessed the impact of elective Caesarean section on postpartum morbidity in a review of deliveries by HIV positive women between June 1989 and June 1999. The authors defined elective Caesarean as that carried out before the onset of labour and ruptured membranes, and emergency caesarean as during labour or with ruptured membranes.

Of the 401 women studied, 109 had elective Caesarean deliveries and 92 emergency compared to a group of 200 women who delivered vaginally. The main indication for elective Caesarean section in this group was reduction of mother to child transmission in 70 cases, and the main indications for emergency Caesarean section was failure to progress in 45 cases and anomalous foetal heart rate tracings in 22 cases.

One or more serious complications occurred after 12% of emergency Caesarean deliveries, after 6.4% of elective Caesarian deliveries and after 4% of vaginal deliveries. Findings from a multivariate analysis, which was adjusted for maternal CD4 count and antepartum haemorrhage the relative risk of any postpartum complication (serious or minor) was increased by 1.85 after elective Caesarian delivery and 4.17 after emergency caesarian delivery, compared to vaginal delivery (p=0.0001).

The investigators comment: “With combination antiretroviral therapies the transmission risk is decreased, thus the risk of postoperative complications may outweigh the residual benefit of caesarean delivery.”

Comment

C-section is very much standard of care in the UK to the point that women often don’t realise that they have a choice. This is worrying on all sorts of counts not least that women are likely to have more than one child and thus future complications, this population may return to Africa and then have more children.

Data to demonstrate benefit of c-section within the setting of combination therapy has not been generated.