Cesarean Delivery in HIV-Positive Mothers

By usmlevideoss

Overview:
Cesarean delivery, also known as elective cesarean section (C-section), is a critical intervention to reduce the risk of mother-to-child transmission (MTCT) of HIV, especially in cases where viral suppression is not achieved.

 In women with viral loads exceeding 1000 RNA copies/mL, scheduled cesarean (prior to labor or rupture of membranes) has been shown to significantly reduce the risk of vertical infection. In those with a viral load less than 1000 RNA copies/mL, vaginal delivery is reasonable and usually recommended. HIV-infected women who choose to deliver vaginally should receive intravenous ZDV during labor. 

Key Points:

  1. Indications for Cesarean Delivery:
    • High Maternal Viral Load: Cesarean delivery is recommended when the maternal HIV viral load is >1,000 copies/mL near delivery or unknown.
    • Elective Timing: Scheduled at 38 weeks of gestation to avoid spontaneous labor and rupture of membranes, which increase the risk of MTCT.
    • Obstetric Indications: Cesarean delivery may also be performed for other maternal or fetal reasons unrelated to HIV status.
  2. Antiretroviral Therapy (ART):
    • Continuous ART during pregnancy is essential to achieve viral suppression.
    • Intravenous zidovudine is administered during labor or prior to cesarean delivery if the viral load is >1,000 copies/mL or unknown.
  3. Intrapartum Considerations:
    • Minimize Exposure: Avoid artificial rupture of membranes, fetal scalp electrodes, or other invasive procedures during delivery.
    • Surgical Precautions: Use standard infection control measures to prevent healthcare worker exposure.
  4. Postpartum Care:
    • Encourage continuation of maternal ART postpartum to maintain health and prevent transmission through breastfeeding in settings where formula feeding is not feasible.
    • Neonatal prophylaxis with antiretroviral medications (e.g., zidovudine) is initiated based on the maternal viral load and delivery circumstances.
  5. Breastfeeding Considerations:
    • In resource-rich settings: Formula feeding is recommended to eliminate the risk of HIV transmission.
    • In resource-limited settings: Exclusive breastfeeding with maternal ART is advised if formula feeding is not safe or feasible.
  6. Benefits of Cesarean Delivery:
    • Reduces MTCT risk to <2% when combined with ART and neonatal prophylaxis.
    • Provides an additional safeguard in women with high viral loads.

Summary:

Elective cesarean delivery is a key strategy to prevent MTCT of HIV in women with high viral loads or unknown HIV status near delivery. Combined with maternal ART, intrapartum zidovudine, and neonatal prophylaxis, cesarean delivery significantly reduces transmission risks, contributing to improved maternal and neonatal outcomes.

SUPERPoint: The most critical strategy to prevent mother-to-child transmission of HIV in mothers with a viral load >1,000 copies/mL near delivery is an elective cesarean delivery at 38 weeks, combined with intrapartum zidovudine and neonatal prophylaxis.

SUPERFormula: HIV-positive pregnant mother + Viral load >1,000 copies/mL near delivery = Indication for elective cesarean delivery, scheduled at 38 weeks to avoid spontaneous labor 

References: 

Infectious Conditions of Pregnancy > Chlamydial Cervicitis and HIV in Pregnancy

Authors: Eugene C. Toy; Patti Jayne Ross

Case Files: Ob/Gyn, 6e

Author(s): Eugene C. Toy; Patti Jayne Ross

-21-18: Infectious Conditions Complicating Pregnancy 

Vanessa L. Rogers; Scott W. Roberts, Current Medical Diagnosis & Treatment 2025