Thompson Dana R, Momplaisir Florence M, Adams Joëlla W, Yehia Baligh R, Anderson Emily A, Alleyne Gregg, Brady Kathleen A
Center for Women's and Children's Health Research, Christiana Care Health Systems, Newark, Delaware, United States of America.
Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States of America.
PLoS One. 2015 Dec 14;10(12):e0144592. doi: 10.1371/journal.pone.0144592. eCollection 2015.
Current guidelines call for HIV-infected women to deliver via scheduled Caesarean when the maternal HIV viral load (VL) is >1,000 copies/ml. We describe the mode of delivery among HIV-infected women and evaluate adherence to relevant recommendations.
We performed a population-based surveillance analysis of HIV-infected pregnant women in Philadelphia from 2005 to 2013, comparing mode of delivery (vaginal, scheduled Caesarean, or emergent Caesarean) by VL during pregnancy, closest to the time of delivery (≤1,000 copies/ml versus an unknown VL or VL >1,000 copies/ml) and associated factors in multivariable analysis.
Our cohort included 824 deliveries from 648 HIV-infected women, of whom 69.4% had a VL ≤1,000 copies/ml and 30.6% lacked a VL or had a VL >1,000 copies/ml during pregnancy, closest to the time of delivery. Mode of delivery varied by VL: 56.6% of births were vaginal, 30.1% scheduled Caesarean, and 13.3% emergent Caesarean when the VL was ≤1,000 copies/ml; when the VL was unknown or >1,000 copies/ml, 32.9% of births were vaginal, 49.9% scheduled Caesarean and 17.5% emergent Caesarean. In multivariable analyses, Hispanic women (adjusted odds ratio (AOR) 0.17, 95% Confidence Interval (CI) 0.04-0.76) and non-Hispanic black women (AOR 0.27, 95% CI 0.10-0.77) were less to likely to deliver via scheduled Caesarean compared to non-Hispanic white women. Women who delivered prior to 38 weeks' gestation (AOR 0.37, 95% CI 0.18-0.76) were also less likely to deliver via scheduled Caesarean compared to women who delivered after 38 weeks' gestation. An interaction term for race and gestational age at delivery was significant in multivariable analysis. Non-Hispanic black (AOR 0.06, 95% CI 0.01-0.36) and Hispanic women (AOR 0.03, 95% CI 0.00-0.59) were more likely to deliver prematurely and less likely to deliver via scheduled C-section compared to non-Hispanic white women. Having a previous Caesarean (AOR 27.77, 95% CI 8.94-86.18) increased the odds of scheduled Caesarean delivery.
Only half of deliveries for women with an unknown VL or VL >1,000 copies/ml occurred via scheduled Caesarean. Delivery prior to 38 weeks, particularly among minority women, resulted in a missed opportunity to receive a scheduled Caesarean. However, even when delivering at or after 38 weeks' gestation, a significant proportion of women did not get a scheduled Caesarean when indicated, suggesting a need for focused public health interventions to increase the proportion of women achieving viral suppression during pregnancy and delivering via scheduled Caesarean when indicated.
当前指南要求，当感染人类免疫缺陷病毒（HIV）的孕妇孕期HIV病毒载量（VL）>1000拷贝/毫升时，应通过计划性剖宫产分娩。我们描述了感染HIV的孕妇的分娩方式，并评估了对相关建议的遵循情况。
我们对2005年至2013年在费城感染HIV的孕妇进行了基于人群的监测分析，比较了孕期（最接近分娩时间）的病毒载量（≤1000拷贝/毫升与病毒载量未知或>1000拷贝/毫升）对应的分娩方式（阴道分娩、计划性剖宫产或急诊剖宫产），并在多变量分析中分析了相关因素。
我们的队列包括648名感染HIV的妇女的824次分娩，其中69.4%的孕妇在孕期（最接近分娩时间）病毒载量≤1000拷贝/毫升，30.6%的孕妇病毒载量未知或>1000拷贝/毫升。分娩方式因病毒载量而异：当病毒载量≤1000拷贝/毫升时，56.6%的分娩为阴道分娩，30.1%为计划性剖宫产，13.3%为急诊剖宫产；当病毒载量未知或>1000拷贝/毫升时，32.9%的分娩为阴道分娩，49.9%为计划性剖宫产，17.5%为急诊剖宫产。在多变量分析中，与非西班牙裔白人妇女相比，西班牙裔妇女（调整比值比[AOR]0.17，95%置信区间[CI]0.04 - 0.76）和非西班牙裔黑人妇女（AOR 0.27，95%CI 0.10 - 0.77）通过计划性剖宫产分娩的可能性较小。与妊娠38周后分娩的妇女相比，妊娠38周前分娩的妇女（AOR 0.37，95%CI 0.18 - 0.76）通过计划性剖宫产分娩的可能性也较小。在多变量分析中，分娩时的种族和孕周的交互项具有显著性。与非西班牙裔白人妇女相比，非西班牙裔黑人妇女（AOR 0.06，95%CI 0.01 - 0.36）和西班牙裔妇女（AOR 0.03，95%CI [0.00 - 0.59]）早产的可能性更大，通过计划性剖宫产分娩的可能性更小。既往有剖宫产史（AOR 2,777，95%CI 8.94 -
病毒载量未知或>1000拷贝/毫升的妇女中，只有一半通过计划性剖宫产分娩。妊娠38周前分娩，尤其是少数族裔妇女，导致错失接受计划性剖宫产的机会。然而，即使在妊娠38周及以后分娩，仍有相当比例的妇女在指征明确时未接受计划性剖宫产，这表明需要有针对性的公共卫生干预措施，以提高孕期实现病毒抑制并在指征明确时通过计划性剖宫产分娩的妇女比例。 86.18）增加了计划性剖宫产分娩的几率。
