Amniocentesis and chorionic villus sampling in HIV-infected pregnant women: a multicentre case series

Human Immunodeficiency Virus in Pregnancy

Approximately 5000 people living with human immunodeficiency virus (HIV) give birth each year. Perinatal transmission of HIV will occur in about 15% to 45% of pregnancies without treatment. With appropriate antiretroviral therapy for pregnant people as well as appropriate intrapartum and postpartum interventions, the rate of perinatal transmission can be reduced to less than 1%. Antiretroviral therapy will also reduce health risks for pregnant patients living with HIV. All pregnant people should be offered the opportunity to learn their HIV status and access treatment as needed.

Prevention of the Vertical Transmission of HIV; A Recap of the Journey so Far

In 1989, one in four (25%) infants born to women living with HIV were infected; by the age of 2 years, there was 25% mortality among them due to HIV. These and other pieces of data prompted the development of interventions to offset vertical transmission, including the landmark Pediatric AIDS Clinical Trial Group Study (PACTG 076) in 1994. This study reported a 67.5% reduction in perinatal HIV transmission with prophylactic antenatal, intrapartum, and postnatal zidovudine. Numerous studies since then have provided compelling evidence to further optimize interventions, such that annual transmission rates of 0% are now reported by many health departments in the US and elimination has been validated in several countries around the world. Despite this success, the elimination of HIV's vertical transmission on the global scale remains a work in progress, limited by socioeconomic factors such as the prohibitive cost of antiretrovirals. Here, we review some of the key trials underpinning the development of guidelines in the US as well as globally, and discuss the evidence through a historic lens.

Toxoplasma gondii infection in HIV-infected pregnant women: epidemiology and risks of mother-to-child transmission

Toxoplasma gondii (T. gondii) infects approximately one third of the world's population. Globally there are an estimated 13.1 million cases of T. gondii co-infection in HIV-infected people with 87.1% of these individuals living in sub-Saharan Africa. The risk of T. gondii infection in HIV-infected women rises significantly with lower CD4+ T cell counts (particularly under 100 cells/μl). Mother-to-child transmission (MTCT) occurs in approximately 30% of cases of maternal T. gondii infection during pregnancy. The global prevalence of latent toxoplasmosis in HIV-infected pregnant women is 47.5% but the overall risk in HIV-infected mothers of MTCT of T. gondii is however, estimated to be low at < 5%. MTCT in HIV-infected mothers not only occurs due to T. gondii primary infection in pregnancy but also due to reactivation. Infants with congenital toxoplasmosis born to HIV-infected mother may have a more rapid onset and greater dissemination of disease thus having potentially devastating effects. This article discusses the key risks for MTCT of T. gondii infection in HIV-infected mothers as well highlighting the many knowledge gaps for which further study is required.

Neurofibromatosis and HIV infection in a pregnant woman

Although pregnant neurofibromatosis or HIV patient established a high-risk group, this report demonstrated that a careful planning and widespread valuations should be associated with a favorable prognosis for both mother and newborn.

Effect of COVID-19 pandemic process on prenatal diagnostic procedures

OBJECTIVE

To evaluate the accessibility of pregnant women to prenatal screening and diagnostic tests during the COVID-19 pandemic process and analyze the effect of the pandemic process on acceptance-rejection rates of fetal diagnostic procedures for high risk pregnancies.

MATERIALS AND METHODS

As part of this cross-sectional study, during the pandemic, between the dates of 11 March 2020-30 June 2020 at Karadeniz Technical University Faculty of Medicine Perinatology Clinic, fetal structural anomaly detected by ultrasonography or with increased risk in screening test in the first and second trimester of high risk pregnancies, who were therefore recommended a prenatal diagnosis test, were defined as the control group and retrospectively compared with high risk pregnancies of the same periods (11 March 2019-30 June 2019) in the previous year.

RESULTS

A total of 267 cases were evaluated within the scope of the study. The rate of pregnant women undergoing the first and second trimester screening tests was 83% in the control group and 56% for pregnant women in the study group. When the total number of prenatal diagnostic procedures and the year each of the procedures performed are compared, a statistically significant difference was found between the study and control groups (p: .041 and p < .001, respectively). When evaluating the rates of performed prenatal diagnostic procedures during the first patient visit in comparison to years, a statistically significant difference was observed in the A/S group and in the total number of cases (p = .023, p < .001, respectively). Similarly, the rate of performed prenatal diagnostic procedure during the first patient visit and the patient's city of residence was similarly statistically significant from year to year (p < .05).

CONCLUSIONS

The decrease in number of prenatal diagnosis and screening tests during the COVID-19 pandemic draws attention. Prenatal care services are a serious issue that cannot be overcome by any deficiencies in both maternal and fetal care.

An Ethical Framework for Research in Maternal-Fetal Intervention in the Presence of Maternal Human Immunodeficiency Virus or Hepatitis B and C Infection

Maternal-fetal interventions continue to be a groundbreaking and rapidly expanding area. In this article, we examine whether it is ethically permissible to conduct investigation into the expansion of inclusion criteria for existing maternal-fetal interventions to include pregnant patients with human immunodeficiency virus (HIV) and hepatitis B or C infection with low or undetectable viral loads. We addressed this ethical question by appealing to ethical principle of respect for the autonomy of the pregnant patient; the patient status of the fetus; the balance of overall benefits and risks of the procedure(s) to pregnant, fetal, and neonatal patients; and to the ethical principle of justice. The ethical framework we have provided supports the conclusion that research on maternal-fetal interventions with pregnant women with HIV and hepatitis B and C infection with low or undetectable viral loads is ethically permissible. To accumulate sufficient numbers, such research should be multicenter.

Risk factors during pregnancy and birth-related complications in HIV-positive versus HIV-negative women in Denmark, 2002-2014

OBJECTIVES

We aimed to compare risk factors for adverse pregnancy outcomes in women living with HIV (WLWH) with those in women of the general population (WGP) in Denmark. Further, we estimated risk of pregnancy- or birth-related complications.

METHODS

A retrospective cohort study including all WLWH who delivered a live-born child from 2002 to 2014 and WGP, matched by origin, age, year and parity, was carried out. We compared risk factors during pregnancy and estimated risk of pregnancy- and birth-related complications using multivariate logistic regression.

RESULTS

A total of 2334 pregnancies in 304 WLWH and 1945 WGP were included in the study. WLWH had more risk factors present than WGP during pregnancy: previous caesarean section (CS) (24.7% versus 16.3%, respectively; P = 0.0001), smoking (14.2% versus 7.5%, respectively; P = 0.0001) and previous perinatal/neonatal death (2.3% versus 0.9%, respectively; P = 0.03). We found no difference between groups regarding gestational diabetes, hypertensive disorders, low birth weights or premature delivery. More children of WLWH had intrauterine growth retardation (IUGR) [adjusted odds ratio (aOR) 1.9; 95% confidence interval (CI) 1.1-3.2; P = 0.02]. Median gestational age and birth weight were lower in children born to WLWH. WLWH had a higher risk of emergency CS (EmCS) (aOR 1.6; 95% CI 1.2-2.1; P = 0.0005) and postpartum haemorrhage (aOR 1.4; 95% CI 1.0-1.9; P = 0.02) but not infection, amniotomy, failure to progress, low activity-pulse-grimace-appearance-respiration (APGAR) score or signs of asphyxia.

CONCLUSIONS

WLWH had more risk factors present during pregnancy, similar risks of most pregnancy- and birth-related complications but a higher risk of postpartum haemorrhage and EmCS compared with WGP. Children born to WLWH had lower median birth weights and gestational ages and were at higher risk of IUGR.

Operative vaginal delivery and invasive procedures in pregnancy among women living with HIV

OBJECTIVES

To describe the use and outcomes of operative delivery and invasive procedures in pregnancy amongst women living with HIV.

STUDY DESIGN

The National Study of HIV in Pregnancy and Childhood (NSHPC) is a comprehensive population-based surveillance study in the UK and Ireland. The NSHPC has collected data on operative delivery since 2008, and invasive procedures in pregnancy (amniocentesis, cordocentesis, chorionic villus sampling) from 2012. Descriptive analyses were conducted on 278 pregnancies expected to deliver from 1 January 2008 with outcome reported to the NSHPC by 31 March 2016.

RESULTS

Among 9372 pregnancies in 2008-2016, there were 9072 livebirths with 251 operative deliveries and 27 invasive procedures in pregnancy reported. Information was available for 3023/3490 vaginal deliveries, and use of forceps or vacuum reported in 251deliveries (8.2%), increasing over calendar time to almost 10% by 2014-16. Forceps were used twice as often as vacuum delivery, and forceps use increased over time. One infant delivered operatively is known to have acquired HIV. From 2012 there were 4063 pregnancies resulting in 3952 livebirths, 83 terminations and 28 stillbirths. 2163/4063 had information on use (or not) of invasive procedures in pregnancy. Amniocentesis was reported in 25/2163 pregnancies, there was one report of chorionic villus sampling and one of cordocentesis. There were no reported transmissions following invasive procedures in pregnancy.

CONCLUSIONS

This is the largest study to date to report on operative delivery in women living with HIV on combined antiretroviral therapy (cART), and provides an up-to-date picture of invasive procedures during pregnancy in this group. Findings from this comprehensive national study are reassuring but numbers are currently low; on-going monitoring is crucial as obstetric care of women with HIV becomes normalised.