4 be associated with the degree of immune suppression. Sem- prini et al in a study of 156 HIV-infected women under- going cesarean delivery and controlling for potential con- founding variables demonstrated that profound immunode- ﬁciency (deﬁned as a CD4 count below 200 cells/µL) was the predominant risk factor for postpartum morbidity [8]. Sim- ilarly, Maiques-Montesinos et al in a case control study of HIV-infected women undergoing cesarean section demon- strated that the lowest risk of morbidity was among HIV- infected women with a CD4 count > 500 cells/µL compared to more immunosuppressed patients [9]. The obvious incon- sistencies in the ﬁndings among the diﬀerent studies cited may be related to diﬀerences in sample size and patient pop- ulation. In our study, we found an increased use of imaging in the evaluation of febrile morbidity among women with AIDS and a resultant delay in initiation of antibiotics. There was no diﬀerence in the overall use of IV antibiotics. The manage- ment of febrile morbidity among these immunosuppressed women is a question that has yet to be answered. In the uninfected population, prophylactic antibiotics have been demonstrated to decrease perioperative morbidity associated with cesarean delivery [2, 10]. Longer duration of antimicro- bial therapy has not been advocated. However, those studies did not include the evaluation of HIV-infected women. Our data indicate that interventions for decreasing postcesarean infectious morbidity in women with AIDS warrant investi- gation. In our cohort, the predominant indication for elective ce- sarean delivery was a high viral load (data not shown). In a randomized trial, the European Mode of Delivery Collabora- tive demonstrated a 50% reduction of vertical transmission with the use of scheduled cesarean section [11]. This ﬁnd- ing was conﬁrmed by a large meta-analysis [12]. The ﬁnd- ings of these studies resulted in the release of a committee opinion by the American College of Obstetricians and Gy- necologists, which indicated that patients with a viral load > 1000 copies/ml should be counseled and oﬀered an elec- tive cesarean section at 38 weeks of gestation to decrease the risk of vertical transmission [13]. Since that time, the use of cesarean section as a tool in the prevention of maternal-to- child transmission has increased [14]. While this has been an eﬀective part of the management to decrease perinatal trans- mission, it does so at a maternal cost. Among high-risk pa- tients who may present late for prenatal care, prompt diag- nosis and initiation of highly active retroviral treatment play a crucial role. In particular, women with advanced HIV in- fection may have a higher baseline viral load or therapeu- tic resistance requiring therapy manipulation [15]. Eﬀective therapy may decrease the number of women requiring a ce- sarean delivery thus decreasing the associated perioperative morbidity. This study is limited in that it is a retrospective review at a single institution. The patient population was partic- ularly in high risk with regards to entry to care and sub- stance abuse. Providers were not blinded in regards to im- mune status. As such, that information may have impacted their management decisions. Additionally, the small-sample Infectious Diseases in Obstetrics and Gynecology sizes may preclude us from detecting an association that may truly exist. Regardless, this study illustrates that women with AIDS face additional risks with cesarean delivery. These ﬁnd- ings would confer an additional duty for the perinatal care provider to include more information about these risks in the extensive counseling given to women with AIDS when planning for mode of delivery prior to initiation of labor. These ﬁndings emphasize further the importance of early ini- tiation of prenatal care to allow time for viral load suppres- sion and place HIV care providers for women of childbearing age at the leading edge of this most important care initia- tive. REFERENCES [1] CDC. HIV/AIDS Surveillance Report. US Department of Health and Human Services C, ed. Atlanta, 2003 (vol. 15). [2] Nielsen TF, Hokegard KH. Postoperative cesarean section morbidity: a prospective study. American Journal of Obstetrics and Gynecology. 1983;146(8):911–916. [3] Yonkers M. Risk factors for postcesarean endomyometritis. The American Journal of Medicine. 1985;78(6):177–187. [4] Panburana P, Phaupradit W, Tantisirin O, Sriintravanit N, Buamuenvai J. Maternal complications after caesarean section in HIV-infected pregnant women. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2003;43(2):160–163. [5] Bartlett JG, Gallant JE. Medical Management of HIV Infection. 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