Efficacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1

 

Abstract

Background

Cesarean section before labor and before ruptured membranes ("elective cesarean section", or ECS) has been introduced as an intervention for the prevention of mother-to-child transmission (MTCT) of HIV-1. The role of mode of delivery in the management of HIV-1-infected women should be assessed in light of risks as well as benefits, since HIV-1-infected pregnant women must be provided with available information with which to make informed decisions regarding cesarean section and other options to prevent transmission of infection to their children.

Objectives

Our objectives were to assess the efficacy (for prevention of MTCT of HIV-1) and the safety of ECS among HIV-1-infected women.

Search methods

Electronic searches were undertaken using MEDLINE and other databases. Hand searches of reference lists of pertinent reviews and studies, as well as abstracts from relevant conferences, were also conducted. Experts in the field were contacted to locate any other studies. The search strategy was iterative.

Selection criteria

Randomized clinical trials assessing the efficacy and safety of ECS for prevention of MTCT of HIV-1 were included in the analysis, as were observational studies with relevant data.

Data collection and analysis

Data regarding HIV-1 infection status of infants born to HIV-1-infected women according to mode of delivery were extracted from the reports of the studies. Similarly, data regarding postpartum morbidity (PPM) (including minor (e.g., febrile morbidity, urinary tract infection) and major (e.g., endometritis, thromboembolism) morbidity) of the HIV-1-infected women, and infant morbidity, according to mode of delivery were extracted.

Main results

One randomized clinical trial of the efficacy of ECS for prevention of MTCT of HIV-1 was identified. No data regarding infant morbidity according to the HIV-1-infected mother's mode of delivery were available. Data regarding PPM according to mode of delivery were available from this clinical trial as well as from five observational studies. Among HIV-1-infected women not taking antiretrovirals (ARVs) during pregnancy or taking only zidovudine, ECS was found to be efficacious for prevention of MTCT of HIV-1. PPM is generally higher among HIV-1-infected women who undergo cesarean as compared to vaginal delivery, with the risk with ECS being intermediate between that of vaginal delivery and NECS (including emergency procedures). Other factors associated with the risk of PPM among HIV-1-infected women include HIV-1 disease stage (more advanced disease, as manifested by lower CD4 counts and higher viral loads, being associated with a greater risk of PPM) and co-morbid conditions (e.g., diabetes).

Authors' conclusions

ECS is an efficacious intervention for the prevention of MTCT among HIV-1-infected women not taking ARVs or taking only zidovudine. The risk of PPM with ECS is higher than that associated with vaginal delivery, yet lower than with NECS. Among HIV-1-infected women, more advanced maternal HIV-1 disease stage and concomitant medical conditions (e.g., diabetes) are independent risk factors for PPM. The risk of MTCT of HIV-1 according to mode of delivery among HIV-1-infected women with low viral loads (low either because the woman's HIV-1 disease is not advanced, or because her HIV-1 disease is well-controlled with ARVs) is unclear. Therefore, an important issue to be addressed in one or more large studies (individual studies or an individual patient data meta-analysis combining data from more than one study) is assessment of the effectiveness of ECS for prevention of MTCT of HIV-1 among HIV-1-infected women with undetectable viral loads (with or without receipt of highly active ARV therapy (HAART)).

 

Plain language summary

Mother-to-child transmission (MTCT) of HIV is the primary way that children become infected with HIV. More than 2000 children worldwide are infected in this way every day.

Cesarean section before labor and before ruptured membranes (also called "elective cesarean section," or ECS) has been introduced as an intervention for the prevention of MTCT of HIV. The objectives of this review were to assess the efficacy (for prevention of MTCT of HIV) and the safety of ECS among HIV-infected women.

The authors found that ECS is a good intervention for the prevention of MTCT among HIV-infected women not taking antiretrovirals (ARV), or taking only zidovudine. The risk of MTCT of HIV according to mode of delivery among HIV-infected women with low HIV viral loads (low either because the woman's HIV disease is not advanced, or because her HIV disease is well-controlled with ARVs) is unclear. Therefore, an important issue to be addressed in one or more large studies is an assessment of the effectiveness of ECS for prevention of MTCT of HIV among HIV-infected women with undetectable viral loads, whether or not they are receiving highly active ARV therapy (HAART).

 

摘要

背景

剖腹產對於預防母子垂直感染HIV1的功效及安全性

在分娩前或是羊水膜破裂前剖腹(選擇性剖腹產，以下簡稱 ECS)已被推薦為可介入預防母子垂直感染(MTCT)HIV1的方法. 既然應提供被HIV1感染的懷孕婦女足夠的資訊,而這些資訊可讓這些婦女對剖腹產及其他能防止垂直傳染給孩子的其他方法中在知情後做出決定,對於HIV1感染的女性其生產的方式應同時評估其風險及益處。

目標

我們的目的就是評估對於已被HIV1感染的女性做分娩前或是羊水膜破裂前剖腹(選擇性剖腹產，ECS)的安全性及效能。

搜尋策略

電子資源搜尋使用MEDLINE及其他資料庫。手動搜尋則包含切題的回顧文章中所引用的參考文獻及相關會議的摘要。我們也接觸這領域的專家以指出有無其他的研究。搜尋資料的策略是反覆綿密的。

選擇標準

評估分娩前或是羊水膜破裂前剖腹(ECS)的安全性及效能包含了隨機臨床研究以及有相關資料的觀察研究。

資料收集與分析

從這些研究報告中擷取關於HIV1感染婦女以不同生產方式所生下嬰兒的HIV1感染狀態的資料。同樣地，也從中擷取不同生產方式的產後併發症(postpartum morbidity, PPM, 包括輕微的併發症如發燒及泌尿道感染，和嚴重的如子宮內膜炎和血栓栓塞)的資料。

主要結論

搜尋結果找到ㄧ個關於ECS預防HIV1母子垂直感染的隨機臨床試驗，但是並沒有關於HIV1婦女的不同生產方式所造成嬰兒併發症的資料。這個隨機臨床試驗及其他五個觀察性研究則均有關於不同生產方式後PPM的資料。在懷孕期間沒有接受抗病毒藥物或只有服用zidovudine的HIV1感染婦女，發現ECS能有效地預防HIV1母子垂直感染。 普遍而言，HIV1感染婦女剖腹產相較於陰道產其PPM較高，而ECS的風險則介於陰道產及非ECS(含緊急手術)之間。其他PPM的危險因子包括HIV1疾病程度(較嚴重的疾病，指表現出較低的CD4數量及較高的病毒量者，其PPM較高)和其他並存的疾病(如糖尿病)。

作者結論

選擇性剖腹產對HIV1感染婦人沒有接受抗病毒藥物或只有服用zidovudine者來預防母子垂直感染(MTCT)HIV1為一種有效的方式。選擇性剖腹產在產後發病率(PPM)的危險上高於陰道產但低於非選擇性剖腹產。在被HIV1感染婦人,更嚴重的母體HIV1疾病狀態及伴隨的疾病情況(如糖尿病)都是分娩前或是羊水膜破裂前剖腹的獨立危險因子。在被HIV1感染且低病毒量的婦人(可能因為HIV1並不嚴重或接受抗病毒藥的控制良好)中,依據生產的模式不同而垂直(MTCT)感染HIV1的危險仍不清楚。因此在一個或多個更大型的研究(單一研究或一個個別病人資料的整合分析合併其他研究的資料)有一重要的議題需要提出: 即評估選擇性剖腹產對HIV1感染且病毒量低到無法偵測(不論有無接受高效能抗病毒藥物治療HAART)的婦人來預防母子垂直感染HIV1的效果。

翻譯人

本摘要由臺北榮民總醫院易宏濤翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

母子垂直感染HIV1是孩童感染HIV最主要的途徑,全世界每天有超過2000個孩童以此途徑感染HIV。 分娩前或是羊水膜破裂前剖腹(選擇性剖腹產)已被推薦為可介入預防母子垂直感染HIV1(MTCT)的方法。 本評論文章的目標即評估選擇性剖腹產預防母子垂直感染HIV1的安全性及效能。 作者發現選擇性剖腹產為一對被HIV1感染婦人沒有接受抗病毒藥物或只有服用zidovudine可介入預防母子垂直感染HIV1(MTCT)的方法. 被HIV1感染且低病毒量的婦人(HIV1並未進展或接受抗病毒藥的控制良好)中母子垂直依據生產的方式感染HIV1(MTCT)的危險仍不清楚。 因此在一個或多個更大型的研究(單一研究或一個個別病人資料的整合分析合併其他研究的資料)有一重要的議題需要提出: 即評估選擇性剖腹產對HIV1感染且病毒量低到無法偵測(不論有無接受高效能抗病毒藥物治療HAART)的婦人來預防母子垂直感染HIV1的效果。