Prophylactic Intrapartum Antibiotics and Immunological Markers for Postpartum Morbidity in HIV Positive Women

INTRODUCTION The World Health Organisation (WHO) estimates that 582 000 women die world-wide each year due to pregnancy related conditions that could be prevented. Most of these deaths occur in developing countries1. Some of the underlying causes of increased maternal morbidity and mortality are HIV-related. In South Africa the antenatal HIV seroprevalence surveys report an infection rate of 32%, the highest among the Sub-Saharan countries2. According to the Saving Mothers Report (NCCEMD) pregnancy-related sepsis was the fourth commonest cause of maternal mortality, while AIDS was the second leading cause3. Of the 67 women who died of HIV/AIDS in 1998, 41 died from puerperal sepsis of which 54% had a vaginal delivery and 46% had a caesarean section. It is not clear from the report to what extent HIV infection had contributed to the severity of sepsis.

The clinical impression is that women with HIV infection have a higher incidence of post delivery morbidity than HIV-negative women. Proposed contributory factors include, low CD4 count and associated impaired immunological function, other obstetric complications and sexually transmitted infections3.

The puerperal sepsis rate is about 2-6 % in most studies. It is however much higher in women with bacterial vaginosis (14%)2 and those who deliver out of health institutions (18%)3. Women with HIV infection are more likely to harbour BV and other sexually transmitted infections. For this and other reasons it is generally accepted that HIV-positive women are at increased risk of puerperal infectious morbidity and mortality independent of the mode of delivery and antiretroviral therapy.

Di Lieto et al4 reported a 33.8 % incidence of infectious morbidity following emergency caesarean delivery. The incidence of infectious morbidity has been reported to be higher in HIV positive women compared to HIV negative women (Semprini et al. 1995)5.

The role of prophylactic antibiotics in obstetric complications has been previously investigated especially in women with preterm labour, prelabour rupture of membranes, cardiac disease and women delivered by caesarean section. There is good evidence that prophylactic antibiotics significantly reduce postpartum morbidity. In these studies prophylactic antibiotics were largely administered intra-operatively. The question that remains is whether prophylactic antibiotics need to be given to only women identified as at risk or to all women with HIV infection.