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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 9, Num. 1, 2005, pp. 14-15
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Untitled Document
African Journal of Reproductive Health, Vol. 9, No. 1, April, 2005 pp.
14-15
Commentary
Management of Breech Presentation in Areas with High Prevalence
of HIV Infection
Jos van Roosmalen3
3Jos van Roosmalen, Department of Obstetrics, Leiden University Medical Centre,
The Netherlands.
E-mail j.j.m.van-roosmalen@lumc.nl
Code Number: rh05003
Holmes and Hofmeyr1 stated that in settings where
caesarean section (CS) is safe and available, HIV positive women, or those
who might be at risk of HIV with a fetus with a term breech presentation should
be offered elective CS to reduce the risks of both vaginal breech delivery
and mother to child HIV transmission. In settings where CS is unsafe or unavailable,
or when women prefer vaginal delivery, they recommend external cephalic version
(ECV) at term instead. The evidence for these recommendations, however, is
not very convincing, as there is no evidence that ECV increases the risk of
mother to child HIV transmission. ECV is an evidence-based intervention to
reduce the number
of breech births.2 ECV should thus be recommended to all women with
a term breech presentation, whether or not they are HIV positive and whether
or not CS is safe and available.
Secondly, there is no evidence that a policy of planned CS
is better for neonatal outcome than a policy of planned vaginal delivery in
breech presentation at term. Although the Hannah term breech trial3 suggested
this in 2000, the long-term follow-up of a majority of the trial's infants
at two years of age showed no difference between the two study arms.4
Although Hannah et al suggested that the policy is safe for
the mother, the trial did not
have enough power to reach such a
conclusion. From the confidential enquiries into
maternal deaths in the UK and The Netherlands the hysterectomy and even maternal
death.7 Also, post-caesarean sepsis may lead to serious complications
needing re-laparotomy, multi-organ failure and even maternal death. Late complications
are infertility, extra-uterine pregnancy, repeat need for caesarean section,
uterine scar rupture in a subsequent labour, as well as placenta praevia and
accreta.8-9 This last condition may lead to uncontrollable haemorrhage
and hysterectomy. Especially in settings where women still prefer more children,
this danger
will increase exponentially with the number of previous operations.
In addition to this, the evidence that CS reduces the risk
of mother to child HIV transmission stems for the period that only one antiretroviral
agent was used during pregnancy.10 At present, however, highly active
antiretroviral therapy (HAART) is used and it includes three different drugs.
Both The Netherlands and Canada nowadays have the policy of accepting vaginal
birth when the viral load is not detectable in the blood of the woman.11-12
This calls for every effort to make HAART available to all
HIV positive pregnant women in this world, and not like now only to those few
who live in those parts of the world where
HIV is much less prevalent. Moodley rightly argued against routine caesarean
section for HIV positive women, but with HAART available for such women it
is also not indicated in the
more privileged parts of the world.13
References
- Holmes WR and Hofmeyr GJ. Management of breech presentation
in areas with high prevalence of HIV infection. Int J Gynecol Obstet 2004;
87: 272-276.
- Hofmeyr GJ and Gyte G. Interventions to help external cephalic
version for breech presentation at term. The Cochrane Library 2004;
Issue 4.
- Hannah Hannah ME, Hannah WJ, Hewson SA, et al. Planned
caesarean section versus planned vaginal birth for breech presentation
at term: a randomised multicentre trial. Lancet 2000; 356: 1375-83.
- Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah
K, Cheng M, Gafni A, Guselle P, Helewa M, Holnett ED, Hutton E, Kung R,
McKay D, Ross S, Willan A and the Term Breech Trial Collaborative Group.
Outcomes
of children at 2 years after planned cesarean birth versus planned vaginal
birth for breech presentation at term: the International Randomized Term
Breech Trial. Am J Obstet Gynecol 2004; 191: 864-871.
- Lewis G and Drife J. Why mothers die 2000-2002. The sixth
report of the Confidential Enquiries into Maternal Death in the United
Kingdom. RCOG Press 2004, London.
- Schutte JM, Steegers EAP, Santema JG, Schuitemaker NEW
and van Roosmalen J. Maternal deaths after elective caesarean section for
breech presentation in The Netherlands. Submitted
- Häger RME, Daltveit AK, Hofoss D, et al. Complications
of cesarean deliveries: rates and risk factors. Am J Obstet Gynecol 2004;
190: 428-434.
- Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal
outcomes associated with a trial of labor after prior cesarean delivery. N
Engl J Med 2004; 351: 2581-89.
- Gilliam M, Rosenberg D and Davis F. The likelihood of placenta
previa with greater number of cesarean deliveries and higher parity. Obstet
Gynecol 2002; 99: 976-80.
- The European Mode of Delivery Collaboration. Elective
caesarean section versus vaginal delivery in prevention of vertical HIV-1
transmission: a randomised clinical trial. Lancet 1999; 353: 1035-59.
- Van der Ende ME, Boer K, Lotgering FK and Geelen SPM.
Treatment during pregnancy. In: Antiretroviral treatment. Guideline Kwaliteitsinstituut
voor de gezondheidszorg CBO, Utrecht, 2000: 62-9 (www.cbo.nl).
- Burdge DR, Money DM, Forbes JC, et al. Canadian consensus
guidelines for the management of pregnant HIV-positive women and their
offspring. CMAJ 2003;
168: 1683-88.
- Moodley D and, Moodley J. HIV-1 infection: an indication
for caesarean section? Int J Obstet Anesth 2000; 9: 221-224.
© Women's Health and Action Research Centre 2005
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