Indications for Cesarean Section Delivery
Among the options provided, HELLP Syndrome, active genital herpes, and HIV infection with high viral load (>1,000 copies/mL) at term are valid indications for cesarean section delivery.
HELLP Syndrome
- HELLP syndrome is a severe complication of pregnancy characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets, often requiring expedited delivery 1
- Cesarean section is associated with improved maternal and perinatal outcomes in women with severe pregnancy-related liver complications like HELLP syndrome 1, 2
- The condition can rapidly deteriorate, leading to maternal and fetal mortality if not managed promptly with delivery 1
Active Genital Herpes
- A cesarean delivery is strongly recommended if a first episode of genital herpes is suspected or confirmed at the onset of labor 3
- The risk of neonatal herpes is estimated at between 25% and 44% if a primary first genital herpes episode is ongoing at delivery 3
- Cesarean section significantly reduces the risk of vertical transmission by preventing direct contact between the fetus and active genital lesions 3
- Even with recurrent genital herpes that is active during labor, cesarean delivery should be considered, especially when membranes are intact 3
HIV Infection with High Viral Load
- Scheduled cesarean delivery is recommended for women with HIV-1 RNA >1,000 copies/mL near the time of delivery, regardless of the type of antiretroviral therapy the woman is receiving 1
- This recommendation is supported by multiple guidelines, including those from the U.S. Public Health Service Task Force and the American College of Obstetricians and Gynecologists 1
- Elective cesarean section has been shown to significantly lower the risk of mother-to-child transmission of HIV-1 infection without significantly increased risk of complications for the mother 4
- The procedure should be performed at 38 completed weeks of gestation, based on the best clinical estimate of gestational age 1
Hepatitis B Surface Antigen Positive Status
- Hepatitis B surface antigen positive status alone is not an indication for cesarean section 5, 6
- Current guidelines do not recommend cesarean delivery solely based on maternal hepatitis B infection 5
- Appropriate neonatal prophylaxis with hepatitis B immunoglobulin and vaccination is the standard of care for preventing vertical transmission 5
Severely Displaced Pelvic Fracture
- While not specifically mentioned in the provided guidelines, severely displaced pelvic fractures may be considered an indication for cesarean section if they cause cephalopelvic disproportion or obstruction of the birth canal 2
- However, the decision should be based on individual assessment of the specific fracture pattern, degree of displacement, and potential obstruction to vaginal delivery 2
Common Pitfalls to Avoid
- Performing unnecessary cesarean sections increases maternal risks including postpartum infections, which are five to seven times more common after cesarean section compared with vaginal delivery 1
- Cesarean section carries long-term risks including chronic wound pain, increased risk of placenta previa and accreta in subsequent pregnancies, and venous thromboembolism 6
- For HIV-infected women with viral loads <400 copies/mL on antiretroviral therapy, vaginal delivery can be safely considered as the MTCT rate does not differ significantly from elective cesarean section (0.3% for both) 7
- Postpartum complications are more frequent following cesarean sections than vaginal deliveries (6.5% vs 2.9%) 7
Special Considerations
- For women with HIV, intravenous zidovudine should be started at least 3 hours before the cesarean operation 1
- The woman's prenatal antiretroviral regimen should not be interrupted around the time of delivery 1
- Prophylactic antibiotics should be administered to reduce the risk of postpartum infection in women undergoing cesarean section 1