ABSTRACT
Introduction: In a context of high HIV prevalence, poor pregnancy follow-up, frequent poverty, preeclampsia, and preterm delivery, we aimed to describe the characteristics and outcomes of pregnancies among women living with HIV in French Guiana. Methods: A retrospective cohort study was conducted on HIV-infected pregnancies enrolled between January 1st 1992 to 31st July 2022. Overall, there were 1,774 pregnancies in 881 women living with HIV. Results: For 75.1% of pregnancies, the HIV diagnosis was already known before pregnancy and in 67.6% of women, HIV follow-up predated pregnancy. Nearly half of women, 49.6%, only had one pregnancy since having been diagnosed with HIV. Although most women received antiretroviral therapy during pregnancy, for those with the available information we found only 48.5% had an undetectable viral load at delivery. Overall, 15.3% of pregnancies ended with an abortion. There were a total of 110 newborns infected with HIV representing an overall transmission rate of 6.2% (110/1,771). Between 1993 and 2002, the transmission rate was 34%, between 2003 and 2012 it was 1.3%, and between 2013 and 2022 it was 0.7%. Overall, in Cayenne, since 2008, 106 of 581 HIV-infected pregnancies (18.2%) with available information were premature before 37 weeks of pregnancy; of these, 33 (5.7%) were very preterm deliveries and 73 (13.3%) were late preterm deliveries. Over time, in Cayenne, preterm delivery declined significantly. Conclusions: The present study emphasizes that, despite spectacular progress in reducing mother to child transmission, pregnancy outcomes among women living with HIV are still preoccupying with high incidence of preterm delivery and low birth weight. Teasing out what fraction is linked to HIV and what fraction is linked to social precariousness and poor follow-up was not possible in this study. Despite the high incidence of very preterm delivery recent progress suggests that coordination efforts to improve follow-up may also have improved obstetrical outcomes.
ABSTRACT
OBJECTIVE: This study aimed to evaluate if manual rotation, undertaken during labor, of fetuses in occiput posterior or occiput transverse position led to an increased rate of spontaneous vaginal delivery. DATA SOURCES: Searches were performed in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials with the use of a combination of keywords and text words related to "occiput posterior," "occiput transverse," and "manual rotation" from inception of the databases to July 2021. STUDY ELIGIBILITY CRITERIA: We included all randomized controlled trials evaluating manual rotation of fetuses in the occiput posterior or occiput transverse position during labor. METHODS: The primary outcome was the rate of spontaneous vaginal delivery. Meta-analyses were performed using the random effects model of DerSimonian and Laird to determine the relative risks or mean differences with 95% confidence intervals. RESULTS: A total of 643 records were screened with inclusion of 6 articles and 1002 randomized patients. All included studies compared manual rotation of fetuses in occiput posterior or occiput transverse position, all confirmed using ultrasound examinations, after complete cervical dilation with either no rotation or a sham rotation procedure. There was no difference in the rate of spontaneous vaginal delivery with manual rotation (relative risk, 1.07; 95% confidence interval, 0.95-1.20) nor was there any difference in any other maternal or fetal outcomes. In a subgroup analysis of occiput posterior fetuses, there was a 12.80-minute decrease in the length of the second stage of labor in the manual rotation group (mean difference, -12.80; 95% confidence interval, -22.61 to -2.99). There were no significant differences in any other maternal or fetal outcomes in the occiput posterior subgroup and no differences in the occiput transverse subgroup. CONCLUSION: Prophylactic manual rotation of fetuses in occiput posterior or occiput transverse position, confirmed using ultrasound examination, did not increase the rate of spontaneous vaginal delivery compared with no manual rotation. Manual rotation of the occiput posterior fetal head early during the second stage of labor was associated with a significant 12.8-minute decrease in the length of the second stage of labor with no changes in any other maternal or fetal outcomes. There were no differences demonstrated for fetuses rotated from occiput transverse position or for the combination of occiput posterior and occiput transverse fetuses. Because there is some evidence of benefit, prophylactic manual rotation can be offered to patients during the second stage of labor presenting with occiput posterior position of the fetal head documented during ultrasound examination.