HIV and pregnancy: risks of transmission and therapeutic possibilities

In Europe, transmission of HIV-1 during pregnancy occurs in 14% of children born to HIV-infected women. Risk factors for transmission are (1) virus load measured by p-24 antigenemia and HIV RNA level, (2) low CD4+ lymphocyte counts (below 600/microliter, (3) placental membrane inflammation and (4) time interval between membrane rupture and delivery. Breast feeding and vaginal delivery increase the risk of transmission of HIV infection. Antiretroviral therapy with zidovudine (Retrovir) at a dose of 500 mg/day reduces the transmission of HIV infection by two thirds. No malformation of the newborn due to zidovudine has been reported so far, but the possibility of unknown long-term adverse effects on children exposed to zidovudine must be weighed against the benefit of a considerable decrease in HIV transmission. Pregnancy is not associated with a higher rate of progression to AIDS, and HIV infection has no adverse effect on the pregnancy outcome in asymptomatic women.     

Need for systematic HIV serological study during pregnancy

BACKGROUND: To evaluate human immunodeficiency virus (HIV) screening usefulness in pregnancy and to know the prevalence of this infection in an urban area of Spain. PATIENTS AND METHOD: Routine prenatal screening for antibodies to HIV was offered to pregnant women from Fuenlabrada-Leganés Health Care Area (Madrid) from 1992 to 1995. Unlinked anonymous screening of HIV was done with the sera from women refusing the assay or if it had not been offered. RESULTS: HIV prevalence was 0.28% (CI: 95%; 0.19 to 0.40) in the 11.021 pregnant women group studied. 87.1% pregnant seropositive women were detected by consented screening. 55.6% of them recognized risk behavior (73.33% by intravenous drug use) and 44.4% did not do it. With a second anamnesis in this group 75% admitted risk conducts and 25% confirmed their ignorance about them. CONCLUSIONS: HIV seropositive screening in pregnant women selected only by risk behavior may be unsuccessful. For that reason, it is more convenient the perform a routine test for detection of HIV antibodies after informed consent in high prevalence areas of HIV infection.     

Incidence and consequences of pregnancy in women with known duration of HIV infection. Italian Seroconversion Study Group

BACKGROUND: The increasing incidence of human immunodeficiency virus (HIV) infection in women of childbearing age led us to evaluate whether pregnancy affects the natural history of this disease. OBJECTIVES: To conduct a prospective study of women with known dates of HIV seroconversion to describe the incidence and outcome of pregnancy and to assess differences according to age and exposure group. To compare the rate of disease progression between pregnant and nonpregnant women. PATIENTS: All participants, recruited from 14 clinical centers in Italy, had documented HIV-seronegative test results followed by confirmed positive test results within 2 years. RESULTS: A total of 331 women, who had seroconversion between 1981 and 1994, were followed up for a median of 5.5 years from seroconversion; 94 developed HIV-related diseases, 47 developed acquired immunodeficiency syndrome, and 53 had at least 1 CD4 cell count lower than 0.10 x 10(9)/L (< 100 cells/mm3). Thirty-eight women (11.5%) were pregnant at the time of HIV seroconversion and 31 (9.4%) became pregnant after HIV seroconversion (cumulative incidence of pregnancy within 8 years of seroconversion, 28.9%; 95% confidence interval, 21.6%-36.2%). Forty-five (65.2%) of the 69 pregnancies were carried to term. There were no discernible differences in these findings by age or exposure group. Pregnant women did not experience a more rapid rate of progression of disease, even when adjusting for age, exposure group, CD4 cell count, or use of treatment (adjusted relative hazards: HIV-related diseases, 0.72; acquired immunodeficiency syndrome, 0.69; CD4 cell count <0.10 x 10(9)/L, 1.24). CONCLUSION: Women infected with HIV continue to become pregnant after seroconversion, yet pregnancy does not appear to influence the rate of progression of HIV disease.     

Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unitended pregnancy.

This study assessed the applicability of the transtheoretical model of behavior change (J. O. Prochaska & C. C. DiClemente, 1983, 1984) to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess use of oral contraceptives and hormonal implants but that measurement of condom use required separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. Consistent with research on other health behaviors, SE scores rose significantly across stages, from precontemplation to maintenance, and a shift in decisional balance was observed for 2 of 3 behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Endothelin--possible significance in pregnancy and hypertensive pregnancy

Endothelin (ET) is the most potent endogenous vasoconstrictory substance known. There are three structurally and pharmacologically separate endothelial isopeptides in humans; Endothelin-1 is exclusively produced in the vascular endothelium. It seems likely that ET acts as a local paracrine signal rather than a circulating hormone. The synthesis and release of ET is stimulated among others by hypoxia, thrombin and endotoxin. Its effects are mediated by specific, membrane-bound receptors, which are detectable in high concentrations in the fetoplacental tissue. ET-1 causes an initial transient fall in blood pressure, followed by a strong, long-lasting increase in peripheral resistance and blood pressure. Plasma ET-1 levels are increased in preeclampsia as compared to those of normal pregnancies, and do not correlate with mean arterial blood pressure and degree of proteinuria. In umbilical cord blood ET-1 concentrations are 2.5-10-fold higher than those of maternal plasma. Determination of plasma ET is unlikely to be of value in the prediction of the disease. ET-1 induces an increased synthesis of vasodilatory prostaglandins (PGI2, PGE2) and an increased production of endothelial-derived relaxing factor (EDRF); thromboxane concentrations in blood are elevated by thrombin-induced activation of platelets. In animal models ET-1 causes an activation of plasmatic coagulation with consecutive hypercoagulability. In preeclampsia ET may play an important role in the regulation of the endothelial balance. Future therapeutic approaches may include the development of effective ET-antibodies or of inhibitors of the endothelin-converting enzyme.     

The effect of pregnancy on survival in women infected with HIV: a systematic review of the literature and meta-analysis

OBJECTIVE: To investigate the effect of pregnancy on disease progression and survival in women infected with HIV by a systematic review of the literature and meta-analysis. METHODS: Appropriate publications were identified using electronic and hand searching of relevant journals from 1983 to 1996. Studies were included in the review if they were cohort studies, either prospective or retrospective, or case-control studies which investigated disease progression of pregnant women infected with HIV and included a control group of non-pregnant women infected with HIV for comparison. Methodological quality was assessed for each study. Data were extracted for predetermined outcome measures. Sensitivity analyses were performed to explore the association between pregnancy and disease progression for the following study characteristics: clinical setting (developed or developing countries), methodological quality (high or poor) and whether studies had controlled for potential confounding. RESULTS: Seven studies, all prospective cohorts, were eligible to be included in the review. The summary odds ratio for the risk of an adverse maternal outcome related to HIV infection and pregnancy were as follows: death 1.8 (85% CI 0.99-3.3); HIV disease progression 1.41 (95% CI 0.85-2.33); progression to an AIDS-defining illness 1.63 (95% CI 1.00-2.67) and fall of CD4 cell count to below 200 x 10(6)/L 0.73 (95% CI 0.17-3.06). Sensitivity analyses showed that HIV progression in pregnancy was significantly more common in a developing country setting (odds ratio 3.71, 95% CI 1.82-7.75) than in developed countries (odds ratio 0.55, 95% 0.27-1.11) and also significantly more common in high quality studies when compared to low quality ones, odds ratios 3.71 (95% CI 1.82-7.57) and 0.55 (95% CI 0.27-1.11), respectively. However, there appears to be less progression of HIV disease and progression to AIDS when studies attempted to control for confounding by matching or restriction techniques, although this was not statistically significant in either case. CONCLUSIONS: The findings of this review have implications for women infected with HIV who are pregnant or are considering a pregnancy. There does appear to be an association between adverse maternal outcomes and pregnancy in women infected with HIV, although this association is not strong. The relation may be due to the result of bias including residual confounding. Further large scale observational studies with long term follow up are required before this issue can be fully resolved.     

Breastfeeding and HIV

An assessment was done during 1991 to evaluate the quality of care with regard to mouth hygiene rendered to patients in a teaching hospital in Namibia. The sample was drawn from nine wards. By means of a type of quota sampling, the patients were categorised as dependent, interdependent or independent. The nursing process was used as a framework for the study. From the assessment it became evident that no policies existed with regard to oral hygiene. Planning was not in every case based on assessment, and it seemed that when planning(s) were done, it was not always implemented. Record keeping was the aspect most poorly attended to.     

Sperm and HIV

Screening and prevention are two major weapons in the fight against AIDS. Procreation of couples where the spouse is seropositive poses a serious ethical social and epidemiological problem. We have consequently established a list of the current biological data concerning HIV in the sperm at the level of non germinal cells, seminal plasma and spermatozoa and of the clinical data on the transmission of the virus during sexual intercourse and insemination. Finally, we have presented the results of the research on predictable factors of the infectiousness of sperm. After this analysis, we consider the possibilities open to the medical corps: dissuasion, ovulation monitoring, insemination with the husband sperm, IVF and insemination with hope to be able to participate in the debate which must lead to a clear concerted and coherent position on the part of the medical corps, at least on a national level.     

Migraine and pregnancy

Migraine and tension-type headache are primary headache disorders that occur during pregnancy. Migraine sometimes occurs for the first time with pregnancy. Most migraineurs improve while pregnant; however, migraine often recurs postpartum. Some disorders that produce headache, such as stroke, cerebral venous thrombosis, eclampsia, and SAH, occur more frequently during pregnancy. Diagnostic testing serves to exclude organic causes of headache, to confirm the diagnosis, and to establish a baseline before treatment. If neurodiagnostic testing is indicated, the study that provides the most information with the least fetal risk is the study of choice. Although drugs are used commonly during pregnancy, there is insufficient knowledge about their effects on the growing fetus. Most drugs are not teratogenic. Adverse effects, such as spontaneous abortion, development defects, and various postnatal effects, depend on the dose and route of administration and the timing of the exposure relative to the period of fetal development. Although medication use should be limited, it is not absolutely contraindicated in pregnancy. In migraine, the risk of status migrainosus may be greater than the potential risk of the medication use to treat the pregnant patient. Nonpharmacologic treatment is the ideal solution; however, analgesics, such as acetaminophen and narcotics, can be used on a limited basis. Preventive therapy is a last resort.     

Scleroderma and pregnancy

Pregnancy in systemic sclerosis may be uneventful, with both good maternal and fetal outcomes. Because scleroderma is a multisystem disease and complications do occur, however, careful antenatal evaluations, discussion of potential problems, and participation in a high-risk obstetric monitoring program is very important to optimize the best outcome. Because women with diffuse scleroderma are at greater risk for developing serious cardiopulmonary and renal problems early in the disease, they should be encouraged to delay pregnancy until the disease stabilizes. All patients who become pregnant during this high-risk time should be monitored extremely carefully. Although there are some suggestions that there are increases in infertility and miscarriages before disease onset, recent studies show that these issues probably do not have major impact for women with established scleroderma who plan to become pregnant. The high risk of premature and small infants may be minimized with specialized obstetric and neonatal care, however. Renal crisis in scleroderma is the only truly unique aspect of these pregnant, which, unlike blood pressure elevation in nonscleroderma pregnancies, must be treated aggressively with ACE inhibitors. Other pregnancy problems may not be unique to scleroderma, but because it is a chronic illness, any complication carries higher risks for both mother and child. Careful planning, close monitoring, and aggressive management should allow women with scleroderma to have a high likelihood of a successful pregnancy.     

Asthma and pregnancy

Pregnancy is accompanied by physiological hyperventilation that may be perceived as shortness of breath; causes are a reduced residual capacity and a reduced expiratory reserve volume due to the swelling uterus, and a larger tidal volume due to increase of the progesterone concentration and of the chemosensitivity to CO2 and O2. Fatigue, lowered exercise tolerance and orthopnoea also may occur, as do basal crepitations at auscultation. In pregnant asthma patients the symptoms may either improve greatly or become aggravated. During an asthma attack the foetus is exposed to hypoxaemia, which may be worsened by a decreased uteroplacental blood circulation in case of maternal alkalosis. Poorly controlled asthma has a stronger adverse effect on the unborn child than the judicious use of anti-asthma drugs. Safe drugs against asthma during pregnancy, around parturition and during breast feeding, are cromoglycic acid and ipratropium; relatively safe drugs are short-acting beta-sympathicomimetics, inhalation corticosteroids and systemic corticosteroids, as well as theophylline from the second trimester; use of long-acting beta-sympathicomimetics is advised against.