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HAART & Fetal death/Pre-eclampsia
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What is Preeclampsia?
Preeclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn baby. Affecting at least 5-8% of all pregnancies, it is a rapidly progressive condition characterized by high blood pressure and the presence of protein in the urine. Swelling, sudden weight gain, headaches and changes in vision are important symptoms; however, some women with rapidly advancing disease report few symptoms.
Typically, preeclampsia occurs after 20 weeks gestation (in the late 2nd or 3rd trimesters or middle to late pregnancy), though it can occur earlier. Proper prenatal care is essential to diagnose and manage preeclampsia. Preeclampsia, Pregnancy Induced Hypertension (PIH) and toxemia are closely related conditions. HELLP Syndrome and eclampsia are other manifestations of the same syndrome. It is important to note that research shows that more women die from preeclampsia than eclampsia and one is not necessarily more serious than the other.
Preeclampsia and other hypertensive disorders of pregnancy are a leading global cause of maternal and infant illness and death. By conservative estimates, these disorders are responsible for 76,000 deaths each year.
Increased risk of pre-pclampsia and fetal death in HIV-infected pregnant women receiving highly active antiretroviral therapy
This abstract was submitted for The XV International AIDS Conference, 2004 (Oral Abstract session)
Abstract no. ThOrB1359
A Suy, O Coll, E Martinez, M Lonca, E de Lazzari, S Pisa, M Larrouse, A Milinkovic, S Hernandez, J L Blanco, J Mallolas, F Garcia, J M Miro, V Cararach, J A Vanrell, J M Gatell
Hospital Clinic, Barcelona, Spain
Background: We have recently detected an increasing number of pre-eclampsia (PE) and fetal death (FD) in HIV-infected pregnant women receiving highly active antiretroviral therapy (HAART). We aimed to study the incidence and the risk for PE and FD in HIV-infected women.
Methods: All pregnant women with available data delivering (at least 22 weeks of gestation) in our institution were included. Factors related to demographics, pregnancy, HIV infection, and antiretroviral therapy were assessed to detect any potential association with PE and FD, defined as bad outcome. Multivariate analyses for bad outcome considering all pregnant women, and all HIV-infected women were done.
Results:
From 1/01 to 8/03, 8295 women delivered and 82 (0.9%) were HIV-infected. There were 237 (2.9%) PE and 40 (0.5%) FD.
In that period, the rates of PE (9 HIV-infected, 11.0% vs 242 non-HIV-infected, 2.8%; RR 4.3 95%CI 1.9-9.0) and FD (6 HIV-infected, 6.1% vs 41 non-HIV-infected, 0.5%; RR 13.7 95%CI 5.3-35.6) were significantly higher in HIV-infected women (p<0.01).
Multiple gestation (adjusted OR 3.0, 95% CI 1.9-4.7), HIV infection (adjusted OR 4.6, 95% CI 2.3-9.1), multiparity (adjusted OR 0.70, 95% CI 0.54-0.90) and tobacco (adjusted OR 0.71, 95% CI 0.52-0.96) were independent factors for bad outcome in all pregnant women.
From 11/85 to 8/03, data from 472 HIV-infected pregnant women were available: 258 from 1985 to 1994 (no antiretroviral therapy period), 74 from 1994 to 1998 (mono/double therapy period), and 140 from 1998 to 2003 (HAART period).
Vertical transmission in these 3 periods was 12%, 4%, and 0%, respectively.
Cases of PE and FD were: 0 (0%) and 2 (0.8%), 0 (0%) and 0 (0%), and 9 (6.4%), and 6 (4.2%), respectively.
HAART before pregnancy (adjusted OR 5.6, 95% CI 1.7-17.9) and tobacco (adjusted OR 0.18, 95% CI 0.05-0.62) were independent factors for bad outcome in HIV-infected women.
Conclusion: An unexpected increasing rate of PE and FD has been identified in HIV-infected pregnant women on HAART. Longer HAART prior to pregnancy was associated with a higher risk.
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HIV InSite's Coverage of the XV International AIDS Conference
Laurence Peiperl, MD, University of California San Francisco
Published July 2004
HIV in Pregnancy: Increased Risk of Pre-Eclampsia and Fetal Death in HIV-Infected Pregnant Women Receiving Highly Active Antiretroviral Therapy
Background
Pre-eclampsia is a complication of the later months of pregnancy characterized by hypertension, proteinuria, and, in serious cases, progression to seizures. Pre-eclampsia is thought to involve an inappropriate immune response, and has been considered rare in women with HIV infection.
Results
This study of pregnant women in Barcelona who delivered (after at least 22 weeks' gestation) between 2001 and 2003, after effective combination antiretroviral therapy (ART) became available, reports an increased risk of pre-eclampsia (RR 4.9; p < .001) and of fetal death (RR 13.7; p < 0.01) in women with HIV (n = 82) compared with HIV-uninfected controls.(1) HIV-infected women who delivered in 1998-2003 (n = 140), following the availability of effective combination ART, showed a marked increase in the incidence of pre-eclampsia (6.4%) and of fetal death (4.2%) compared with HIV-positive pregnant women delivering between 1985 and 1994 (no ART; 0% pre-eclampsia and 0.8% fetal death) and between 1994 and 1998 (single- or 2-drug ART; no cases of pre-eclampsia or fetal death observed). Use of 3-drug ART before pregnancy was found to be an independent risk factor for pre-eclampsia or fetal death in HIV-infected pregnant women (OR 5.6; 95% confidence interval [CI]: 1.7-17.9), and risk increased with duration of ART prior to pregnancy. Viral load was well controlled in almost all cases of pre-eclampsia, and mother-to-child transmission of HIV did not occur in this cohort after 1998.
Discussion
Although, prior to the availability of effective ART, HIV-infected women were at low risk of pre-eclampsia, the risks of pre-eclampsia and of fetal death appear to be increased in women with HIV on combination ART. This increase appears to be due to ART, perhaps as a consequence of improved immune function. Although the benefits of ART outweigh the risks in pregnant women with advanced HIV infection, heightened vigilance for early signs of pre-eclampsia is indicated in HIV-infected pregnant women.
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