HIV Clinical Trial
Official title:
Duration of Rupture of Membranes and Risk of Fetal Transmission of HIV in Optimally Managed HIV Positive Mothers
In optimally managed HIV+ women with undetectable viral loads, who are on HAART and also receiving intrapartum IV ZDV, the risk of vertical transmission of HIV is independent of the length of time of rupture of membranes.
In developed countries, HIV infection is now considered a chronic disease and thus the life
expectancy of people infected with HIV is approaching that of the general population.
Therefore many HIV positive women are choosing to pursue pregnancies. An important concern
for antenatal and intrapartum management is decreasing the risk of vertical transmission.
With the use of highly active antiretroviral therapy (HAART) and intrapartum IV zidovudine
(ZDV) the risk of transmission is decreased significantly, however there is some debate
surrounding optimal mode of delivery. Possible mechanisms leading to perinatal transmission
include transfusion of the mother's blood to the fetus during labour contractions, infection
after rupture of membranes and direct contact of the fetus with infected secretions or blood
from the maternal genital tract.
When maternal viral load is detectable, The Society of Obstetricians and Gynaecologists of
Canada (SOGC) and other governing bodies recommend that elective cesarean section be
performed for delivery as there is a 12-fold increased risk of perinatal transmission.
However, the evidence suggests that for women at very low risk of transmission, such as those
with an undetectable viral load and on HAART, the benefit of transmission reduction provided
by cesarean section may be negligible.
The question of length of time of rupture of membranes prior to delivery and transmission
risk has been a source of controversy, especially in the context of women on suppressive
therapy (HAART) with an undetectable viral load. Traditional thinking has stated that the
length of time of rupture of membranes should not be longer than 4 hours, as the benefit of
cesarean section is lost after this time. However, this thinking is based on data where
maternal viral loads were not known and only intrapartum IV ZDV was used. Many practitioners
believe that in women with undetectable viral loads, virally suppressed on HAART, the safest
route of delivery is vaginal, irrespective of length of time of rupture of membranes.
This is a retrospective cohort study which plans to examine the mode of delivery and median
length of time of rupture of membranes for HIV positive women in two downtown academic
institutions in Toronto.
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