‘Bloodless Cesarean Section’ to Reduce HIV Transmission
Bloodless Cesarean Section’ to Reduce HIV Transmission
Abstract & Commentary
Synopsis: In the absence of zidovudine use, neonatal exposure to maternal blood and bodily fluids at the time of birth is an important determinant of HIV transmission.
Source: Towers CV, et al. Am J Obstet Gynecol 1998; 179:708-714.
To reduce fetal exposure to blood or bodily fluids at the time of delivery in HIV-infected mothers, Towers and associates performed a "bloodless cesarean section" and compared neonatal outcomes in these infants to the infants of HIV-infected mothers delivered either vaginally or by routine cesarean section. Newborns were followed for a minimum of 15 months or until negative findings were confirmed. Of 53 infants delivered by "bloodless cesarean section," 5.7% (3/53) became infected compared with 20% (11/55) in control patients—a significant difference and a reduction in transmission of more than 70%. When patients who received antenatal or intrapartum zidovudine were excluded from the analysis, 6.3% (2/32) of infants delivered by "bloodless cesarean section" became infected vs. 23.7% (9/38) of neonates in the control group. The rate of neonatal HIV transmission in patients in the "bloodless cesarean section" group who did not receive zidovudine was similar to that of control patients who received this therapy (6.3% vs 7.9%, respectively). The study groups were comparable for important risk factors that may affect perinatal transmission of HIV, including antenatal zidovudine use, maternal AIDS cases, CD4 counts, and breast feeding. The control group was marked by a higher rate of fetal scalp electrode use, episiotomies or lacerations, and rupture of membranes. Patients delivered by emergency cesarean section were excluded from the study.
Towers et al conclude that, in the absence of zidovudine use, neonatal exposure to maternal blood and bodily fluids at the time of birth is an important determinant of HIV transmission. Surgical techniques designed to reduce this exposure may lower the rate of transmission.
Comment by Steven G. Gabbe, MD
Overall, approximately 25% of neonates whose mothers are HIV positive will become infected, most as a result of exposure during labor and delivery. The use of zidovudine during pregnancy and labor, followed by neonatal therapy, can decrease the risk of perinatal transmission by two-thirds. Now, Towers et al have demonstrated a lower rate of transmission associated with a "bloodless cesarean section." This method included meticulous attention to the control of bleeding in the abdominal incision, cleaning and draping the surgical field to cover any blood contamination, cleansing the surgeon’s gloves with a soap solution before entering the uterus, efforts to avoid rupture of the membranes, and use of a stapling device that provides hemostasis along the uterine incision as it cuts the uterus. The infants who benefitted most from this approach were those whose mothers had not received zidovudine. A recent report from the French Perinatal Cohort (Mandelbrot L, et al. JAMA 1998;280:55-60) emphasized the benefits of both elective cesarean delivery and zidovudine therapy. In 133 women who received zidovudine and were delivered by elective cesarean, only one child was infected. Transmission was reduced five-fold in association with elective cesarean section when compared to vaginal or emergent cesarean deliveries.
Should all women who are HIV-infected be delivered by elective cesarean section? Certainly, this approach will not be available in many developing countries, and we need more data before we can routinely recommend a procedure that places the mother and health care providers at greater risk. For the present time, we should make every effort to treat HIV-infected pregnant women with antiviral therapy and, if they are delivered by cesarean section, reduce exposure of their newborn to blood and other bodily fluids at the time of birth.
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