the original landmark study , pactg 076 reported a 
 decrease in the vertical transmission of human immunodeficiency virus ( hiv ) 
 infection from mother to child from 25% to 8% with the use of zidovudine in the 
 antenatal , intrapartum , and neonatal periods . more recently , 
 cesarean section has been recommended in women with viral load above 1000 copies / ml 
 to further prevent vertical transmission of hiv .   while there are many 
 studies supporting the benefits of the combination of cesarean delivery and 
 antiretroviral medications in preventing vertical transmission of hiv disease 
 from mother to child [ 38 ] , there are also reports on the morbidities that hiv - infected women 
 incurred from surgical procedures [ 911 ] . previous reports on the morbidities of 
 cesarean deliveries implied that even healthy , nonimmunodeficient women could 
 sustain significant complications [ 12 , 13 ] . thus , it would appear that 
 hiv - infected women may have even more post - operative complications , especially 
 the infectious morbidities , due to their immunodeficient status when they 
 underwent cesarean delivery in an attempt to decrease vertical transmission of 
 the hiv disease . current available data reported 
 conflicting results with regard to the post - operative morbidities experienced 
 by hiv - infected women [ 4 , 911 , 14 , 15 ] , therefore , we undertook this 
 study to further examine and compare the infectious complication rate from 
 cesarean delivery of hiv - infected women with those of hiv negative women . a retrospective analysis was 
 performed on data obtained from women who presented at two teaching medical 
 institutions , the medical center of louisiana at new orleans - university campus and tulane 
 health sciences center , and who subsequently underwent a cesarean section . identification of the 
 study patients ( hiv - infected women ) was obtained by reviewing the labor and 
 delivery log . control subjects were 
 hiv - seronegative women who delivered by cesarean section during the same time 
 period and whose medical records were available for review . medical records were reviewed and 
 data was collected on maternal demographics , number of previous cesarean 
 deliveries , estimated gestational age at time of delivery , classification of 
 cesarean delivery as elective or emergent , pre - operative hematocrit values on 
 the day of delivery , membrane status , application of internal monitoring 
 device , type of anesthesia , skin incision , uterine incision , operative time , 
 estimated blood loss , post - operative morbidities ,   hiv status , cd4 lymphocyte count , and viral 
 load . for this study , elective cesarean delivery was defined as 
 a planned operation without signs of labor prior to surgery . emergent cesarean delivery was defined as 
 surgery performed after the presence of regular uterine contractions with or 
 without rupture of membranes and for maternal and/or fetal indications , such as 
 nonreassuring fetal heart rate status , arrest disorders , and third trimester 
 bleeding . post - operative infectious morbidities that were evaluated 
 in this study included endometritis 
 ( defined as temperature elevation above 38c with uterine 
 tenderness and requiring antibiotics treatment in the absence of other etiology 
 for the fever ) , urinary tract infection , septic pelvic thrombophlebitis , 
 pneumonia , and superficial or deep wound breakdown at the time of discharge 
 from the hospital . at the 
 above teaching institutions , the management of the patients was conducted by 
 resident physicians under the supervision of maternal - fetal medicine specialist 
 or general obstetrician with consultation from maternal - fetal medicine 
 specialist as indicated . data was 
 analyzed using spss-11 software ( spss inc . , chicago , ill . ) . chi - square analysis with fischer exact when 
 necessary , student 's t - test , and multiple logistic regression analysis were 
 performed when appropriate . over the study period , from july 1998 to december 2004 , 
 119 hiv infected women delivered by cesarean section at the above two teaching 
 institutions . data was collected on 264 
 hiv - negative women who delivered by cesarean section during this time and served 
 as the controls . overall , the majority of the patients 
 were african american ( 92.1% of hiv - infected group and 84.3% of hiv - negative 
 group , p < .05 ) . both groups 
 demonstrated a high body mass index ( 32.7  7.8 kg / m in 
 hiv - infected group versus 33.6  8.2 kg / m in hiv - negative group , 
 p > .05 ) . the cd4 lymphocyte 
 count and viral load near time of delivery of the hiv - infected group were 
 evaluated ; 78.8% of the hiv - infected women had a cd4 lymphocyte 
 count of   200 and 19.2% had undetectable viral load ( table 1 ) . there was no significant difference between 
 the hiv - infected group and the hiv - negative group in terms of gravidity , 
 parity , number of previous cesarean sections , estimated gestational age at time 
 of delivery , and rate of chorioamnionitis . hiv - infected women were significantly more likely to have a lower 
 preoperative hematocrit than the hiv - negative women ( 31.9  3.8% versus 33.6  3.8% , 
 resp . , p < .01 ) . hiv - negative 
 women were significantly more likely than hiv - infected patients to deliver by 
 emergent cesarean section ( 78.0% versus 51.3% , resp . , p < .01 ) , to labor 
 prior to delivery ( 69.4% versus 48.3% , resp . , p < .01 ) , to have ruptured membranes 
 prior to delivery ( 63.5% versus 34.8% , resp . , p < .01 ) , and to have 
 application of internal monitoring devices during labor ( 31.5% versus 6.0% , 
 resp . , p < .01 ) . the surgical characteristics of cesarean delivery in both 
 hiv - infected and hiv - negative women are presented in table 3 . pfannenstiel skin incision were more often 
 performed in hiv - infected women than their controls ( 94.5% versus 82.7% , 
 resp . .   there was no 
 statistical difference in the other characteristics reviewed which included the 
 type of anesthesia , the type of uterine incision , the estimated blood loss 
 during surgery , or the operative time . there was no significant difference in the 
 infectious morbidities between the hiv infected women and the control group . the 
 most common infectious morbidity after cesarean delivery for our study 
 population is postpartum endometritis . furthermore , there 
 was no statistical significant difference between the mean  sd cd4 lymphocyte count between the hiv - infected women with infectious morbidity and 
 those without infectious morbidity ( 413.2  257.9 cells / mm and 465.4  283.7 cells / mm , resp . , p > .05 ) , and between the mean 
  sd viral load of those with infectious morbidity and those without infectious 
 morbidity ( 26,967.1  79,491.6 copies / ml and 43,7242.9  123,389.8 copies / ml , 
 resp . , p > .05 ) . postoperative infectious morbidity in both groups was analyzed 
 according to whether the cesarean section was an elective or emergent 
 delivery .   both groups of women were 
 statistically more likely to experience postpartum endometritis when being 
 delivered by emergent cesarean section than by elective cesarean section , ( 21.3% 
 versus 3.4% , resp . , p < .05 in hiv - infected women and 14.6% versus 3.5% , 
 resp . , p < .05 in hiv - negative women ) . postpartum endometritis composed the majority of the 
 post - operative infectious morbidity , and hiv - negative women in our study had 
 significantly more obstetrics risk factors for postpartum endometritis than the 
 hiv - infected women . those risk factors were : delivery by emergent cesarean 
 section , rupture of membranes and labor prior to delivery , and insertion of 
 internal monitoring . because of that , we further performed logistic regression 
 analysis , controlling for these risk factors to determine whether hiv infection 
 play a significant role in postpartum endometritis . to identify risk factors 
 influencing the risk of postpartum endometritis hiv infectious 
 status , emergent cesarean delivery , ruptured membranes prior to delivery , 
 application of internal monitoring devices during labor , chorioamnionitis , and 
 preoperative hematocrit were included in the model - building . hiv infectious status , rupture of membranes 
 prior to cesarean delivery , application of internal monitoring devices during 
 labor , and preoperative hematocrit were not found to be significant predictors 
 of endometritis ( p > .05 ) . however , 
 the odds of having endometritis were almost 4 times higher in emergent cesarean 
 delivery ( odds ratio ( or ) 4.1 , 95% confidence interval ( ci ) 1.411.91 , p = .009 ) and 3 times higher in those 
 with chorioamnionitis during labor ( or 3.02 , 95% ci 1.138.03 , p = .027 ) . it should be noted that because colinearity 
 was present between labor prior to delivery by emergent cesarean section and 
 emergent cesarean delivery , we only included emergent cesarean delivery in the 
 multivariate stepwise logistic regression model ( table 5 ) . according to our study , there was not a 
 significant difference in infectious postoperative morbidity in hiv infected 
 women who delivered by cesarean section when compared to their cohorts of 
 hiv - negative women . however , logistic regression analysis highlighted the 
 increased risk of postpartum endometritis in women who delivered by emergent 
 cesarean section and who had chorioamnionitis during labor , controlling for covariates 
 including hiv infectious status . the hiv 
 infected women in this study were significantly less likely than the control 
 subjects to deliver by emergent cesarean delivery ( 51.3% versus 78.0% , resp . , 
 p < .01 ) and should , therefore , have had a lower rate of postpartum 
 endometritis .   since 
 we observed similar rates of postpartum endometritis in the two groups , despite 
 the fact that hiv - infected women had less risk factors for postpartum 
 endometritis , we can speculate that hiv infection may be a risk factor for 
 postpartum endometritis after cesarean section . however , because of the small 
 sample size , we do not find statistical evidence that hiv infection resulted in 
 higher infectious morbidity after cesarean delivery as reported in some previous 
 studies [ 811 , 1621 ] . a 
 possible explanation for our result is that we reported on a population of 
 hiv - infected women who were reasonably immunocompetent . the mean  sd cd4 lymphocyte 
 count of our study population was 455.0  277.9 and 78.8% had a cd4 lymphocyte count of at least 200 or greater . most studies reported the increased risk of 
 postoperative infectious morbidities to be associated with the severe degree of 
 immune suppression [ 9 , 17 ] . stratified analysis by whether 
 cesarean delivery was emergent or elective in hiv infected women demonstrated 
 that emergent cesarean delivery increased postoperative endometritis over 
 elective cesarean delivery . this is 
 consistent with previous studies which have also demonstrated the highest risk 
 of postoperative morbidity occurring in hiv - infected women who deliver by 
 emergent cesarean section [ 11 , 20 , 21 ] . therefore 
 as an hiv - infected woman considers elective cesarean delivery or attempt at 
 vaginal delivery , our counseling should include the increased risk of 
 developing postoperative endometritis should her attempt at vaginal delivery 
 fail and emergent cesarean delivery become necessary . we agreed with marcollet 's recommendation 
 that women with a low probability of having a successful vaginal delivery 
 should consider scheduled cesarean delivery . current acog guidelines on recommending 
 elective cesarean delivery for hiv infected women to reduce vertical 
 transmission emphasize the importance of performing the surgery prior to the 
 onset of labor or rupture of membranes . 
 cesarean delivery performed after the onset of labor or rupture of 
 membranes ( i.e. , emergent cesarean delivery ) is of unclear benefit with regard 
 to decreasing the vertical transmission risk . thus , it is important to adhere to the acog 
 recommendation on elective cesarean delivery for hiv - infected women as a mean 
 to further reduce vertical transmission rate , as the benefits of cesarean 
 delivery performed after labor or rupture of membranes is unknown and based on 
 current study and other reports [ 11 , 14 , 20 , 21 ] , maternal infectious morbidity 
 is greater at times of emergent cesarean delivery when compared to elective 
 cesarean delivery . limitations of this study include the small number of 
 study patients with severe hiv disease status as determined by cd4 lymphocyte 
 counts and viral   load quantifications . thus , we were not able to demonstrate 
 the association between post - operative morbidity among hiv - infected women and 
 the severity of their diseases . larger study populations are necessary to truly 
 examine the impact of disease status on postoperative morbidity in hiv - infected 
 patients . we also did not evaluate the 
 use of antiretroviral medications and are unable to comment on any possible 
 effects that these medications may have had on postoperative morbidity . this study was also limited due to its 
 retrospective approach to data collection . a large prospective study will 
 better evaluate the post - operative morbidities of cesarean delivery in 
 hiv - infected women .
objective . to compare the infectious complication rates from cesarean delivery of human immunodeficiency virus ( hiv)-infected women and hiv - negative women . 
 materials and methods . 
 a retrospective analysis was performed on data derived from hiv - infected women and hiv - negative women , who underwent cesarean delivery at two teaching hospitals . 
 main outcome measures were infectious postoperative morbidity . 
 descriptive , comparison analysis , and multiple logistic regression analysis were performed . 
 results . 
 one hundred and nineteen hiv - infected women and 264 hiv - negative women delivered by cesarean section and were compared . 
 the hiv - negative women were more likely than the hiv - infected women to deliver by emergent cesarean section ( 78.0% versus 51.3% , 
 resp . 
 , p < .05 ) , to labor prior to delivery ( 69.4% versus 48.3% , resp . , p < .01 ) , and to have ruptured membranes prior to delivery ( 63.5% versus 34.8% , resp 
 . , p < .05 ) . in bivariate analysis , hiv - infected and hiv - negative women had similar rates of post - operative infectious complications ( 16.8% versus 19.7% , resp . , p > .05 ) . 
 in a multivariate stepwise logistic analysis , 
 emergent cesarean delivery and chorioamnionitis but not hiv infection were associated with increased rate of post - operative endometritis ( odds ratio ( or ) 4.10 , 95% confidence interval ( 95% ci ) 1.4111.91 , p < .01 , and or 3.02 , 95% ci 
   1.138.03 , p < .05 , resp . ) . conclusion . in our facilities , 
 emergent cesarean delivery and chorioamnionitis but not hiv infection were identified as risk factors for post - operative endometritis .