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High prevalence of hypertension and placental insufficiency, but no in utero HIV transmission, among women on HAART with stillbirths in Botswana.

Shapiro RL, Souda S, Parekh N, Binda K, Kayembe M, Lockman S, Svab P, Babitseng O, Powis K, Jimbo W, Creek T, Makhema J, Essex M, Roberts DJ - PLoS ONE (2012)

Bottom Line: Verbal autopsies; maternal HIV, CD4 and HIV RNA testing; stillbirth HIV PCR testing; and placental pathology (blinded to HIV and treatment status) were performed.Placental insufficiency associated with hypertension accounted for most stillbirths.Hypertension and placental insufficiency were associated with most stillbirths in this tertiary care setting.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America. rshapiro@hsph.harvard.edu

ABSTRACT

Background: Increased stillbirth rates occur among HIV-infected women, but no studies have evaluated the pathological basis for this increase, or whether highly active antiretroviral therapy (HAART) influences the etiology of stillbirths. It is also unknown whether HIV infection of the fetus is associated with stillbirth.

Methods: HIV-infected women and a comparator group of HIV-uninfected women who delivered stillbirths were enrolled at the largest referral hospital in Botswana between January and November 2010. Obstetrical records, including antiretroviral use in pregnancy, were extracted at enrollment. Verbal autopsies; maternal HIV, CD4 and HIV RNA testing; stillbirth HIV PCR testing; and placental pathology (blinded to HIV and treatment status) were performed.

Results: Ninety-nine stillbirths were evaluated, including 62 from HIV-infected women (34% on HAART from conception, 8% on HAART started in pregnancy, 23% on zidovudine started in pregnancy, and 35% on no antiretrovirals) and 37 from a comparator group of HIV-uninfected women. Only 2 (3.7%) of 53 tested stillbirths from HIV-infected women were HIV PCR positive, and both were born to women not receiving HAART. Placental insufficiency associated with hypertension accounted for most stillbirths. Placental findings consistent with chronic hypertension were common among HIV-infected women who received HAART and among HIV-uninfected women (65% vs. 54%, p = 0.37), but less common among HIV-infected women not receiving HAART (28%, p = 0.003 vs. women on HAART).

Conclusions: In utero HIV infection was rarely associated with stillbirths, and did not occur among women receiving HAART. Hypertension and placental insufficiency were associated with most stillbirths in this tertiary care setting.

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Figure 1a and Figure 1b.Figure 1a. H&E stains of placentas with typical characteristics of hypertension, Botswana. A. Distal villous hyperplasia – small round and elongate villi with large syncytial trophoblastic knots and abundant intervillous space. B. Severe decidual vasculopathy with atherosis. C.Chronic abruption. Figure 1b. H&E stains of placentas with infection and other non-hypertensive findings: A,B, and C are examples of findings that support and infectious cause of death: A. Necrotizing Funisitis – umbilical vein with transmural inflammation and necrotic neutrophil debri as a halo in Wharton's jelly. B. Acute villitis/microscopic abcess. C. Acute chorioamnionitis with multiple bacterial cocci present. D and E are other non-infectious findings: D. Villous maturational arrest (a term placenta with immature villi and centralized vessels) E. Hydrops placentalis – this placenta weighed >900 grams and showed diffuse acute villous edema.
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pone-0031580-g001: Figure 1a and Figure 1b.Figure 1a. H&E stains of placentas with typical characteristics of hypertension, Botswana. A. Distal villous hyperplasia – small round and elongate villi with large syncytial trophoblastic knots and abundant intervillous space. B. Severe decidual vasculopathy with atherosis. C.Chronic abruption. Figure 1b. H&E stains of placentas with infection and other non-hypertensive findings: A,B, and C are examples of findings that support and infectious cause of death: A. Necrotizing Funisitis – umbilical vein with transmural inflammation and necrotic neutrophil debri as a halo in Wharton's jelly. B. Acute villitis/microscopic abcess. C. Acute chorioamnionitis with multiple bacterial cocci present. D and E are other non-infectious findings: D. Villous maturational arrest (a term placenta with immature villi and centralized vessels) E. Hydrops placentalis – this placenta weighed >900 grams and showed diffuse acute villous edema.

Mentions: Placental pathology results are shown in Table 3, by maternal HIV status and antiretroviral exposure status. Placental insufficiency, with features strongly suggestive of chronic placental hypertensive damage, accounted for more than half of all stillbirths in both HIV infected and HIV-uninfected women. Among women with these pathologic findings, 11 were acute, 43 were chronic, and 4 were both acute and chronic. Figure 1a demonstrates a placenta with the typical features of acute and chronic hypertension. Of women with evidence of placental insufficiency, 71% had evidence of peripheral hypertension prior to delivery, as indicated by a blood pressure measurement ≥140 mm Hg systolic or ≥90 mm Hg diastolic, or by a recorded diagnosis of hypertension during pregnancy. Of these, 73% were noted to have started an antihypertensive agent prior to delivery. Only 2 women with placental insufficiency had no recorded blood pressure or hypertension diagnosis in pregnancy. Preeclampsia (with documented proteinuria and edema) was reported in 18% of women, and eclampsia in 3%, and these did not differ by HIV status. Compared with all other women, those with placental insufficiency were more likely to report headache in pregnancy (45% vs. 17%, p = 0.003), to report puffy face in pregnancy (30% vs. 8%, p = 0.008), to require an induction of labor for intrauterine fetal demise (57% vs. 21%, p = 0.0005), and to report smaller than normal size of the stillborn (80% vs. 60%, p = 0.03).


High prevalence of hypertension and placental insufficiency, but no in utero HIV transmission, among women on HAART with stillbirths in Botswana.

Shapiro RL, Souda S, Parekh N, Binda K, Kayembe M, Lockman S, Svab P, Babitseng O, Powis K, Jimbo W, Creek T, Makhema J, Essex M, Roberts DJ - PLoS ONE (2012)

Figure 1a and Figure 1b.Figure 1a. H&E stains of placentas with typical characteristics of hypertension, Botswana. A. Distal villous hyperplasia – small round and elongate villi with large syncytial trophoblastic knots and abundant intervillous space. B. Severe decidual vasculopathy with atherosis. C.Chronic abruption. Figure 1b. H&E stains of placentas with infection and other non-hypertensive findings: A,B, and C are examples of findings that support and infectious cause of death: A. Necrotizing Funisitis – umbilical vein with transmural inflammation and necrotic neutrophil debri as a halo in Wharton's jelly. B. Acute villitis/microscopic abcess. C. Acute chorioamnionitis with multiple bacterial cocci present. D and E are other non-infectious findings: D. Villous maturational arrest (a term placenta with immature villi and centralized vessels) E. Hydrops placentalis – this placenta weighed >900 grams and showed diffuse acute villous edema.
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Related In: Results  -  Collection

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getmorefigures.php?uid=PMC3285159&req=5

pone-0031580-g001: Figure 1a and Figure 1b.Figure 1a. H&E stains of placentas with typical characteristics of hypertension, Botswana. A. Distal villous hyperplasia – small round and elongate villi with large syncytial trophoblastic knots and abundant intervillous space. B. Severe decidual vasculopathy with atherosis. C.Chronic abruption. Figure 1b. H&E stains of placentas with infection and other non-hypertensive findings: A,B, and C are examples of findings that support and infectious cause of death: A. Necrotizing Funisitis – umbilical vein with transmural inflammation and necrotic neutrophil debri as a halo in Wharton's jelly. B. Acute villitis/microscopic abcess. C. Acute chorioamnionitis with multiple bacterial cocci present. D and E are other non-infectious findings: D. Villous maturational arrest (a term placenta with immature villi and centralized vessels) E. Hydrops placentalis – this placenta weighed >900 grams and showed diffuse acute villous edema.
Mentions: Placental pathology results are shown in Table 3, by maternal HIV status and antiretroviral exposure status. Placental insufficiency, with features strongly suggestive of chronic placental hypertensive damage, accounted for more than half of all stillbirths in both HIV infected and HIV-uninfected women. Among women with these pathologic findings, 11 were acute, 43 were chronic, and 4 were both acute and chronic. Figure 1a demonstrates a placenta with the typical features of acute and chronic hypertension. Of women with evidence of placental insufficiency, 71% had evidence of peripheral hypertension prior to delivery, as indicated by a blood pressure measurement ≥140 mm Hg systolic or ≥90 mm Hg diastolic, or by a recorded diagnosis of hypertension during pregnancy. Of these, 73% were noted to have started an antihypertensive agent prior to delivery. Only 2 women with placental insufficiency had no recorded blood pressure or hypertension diagnosis in pregnancy. Preeclampsia (with documented proteinuria and edema) was reported in 18% of women, and eclampsia in 3%, and these did not differ by HIV status. Compared with all other women, those with placental insufficiency were more likely to report headache in pregnancy (45% vs. 17%, p = 0.003), to report puffy face in pregnancy (30% vs. 8%, p = 0.008), to require an induction of labor for intrauterine fetal demise (57% vs. 21%, p = 0.0005), and to report smaller than normal size of the stillborn (80% vs. 60%, p = 0.03).

Bottom Line: Verbal autopsies; maternal HIV, CD4 and HIV RNA testing; stillbirth HIV PCR testing; and placental pathology (blinded to HIV and treatment status) were performed.Placental insufficiency associated with hypertension accounted for most stillbirths.Hypertension and placental insufficiency were associated with most stillbirths in this tertiary care setting.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America. rshapiro@hsph.harvard.edu

ABSTRACT

Background: Increased stillbirth rates occur among HIV-infected women, but no studies have evaluated the pathological basis for this increase, or whether highly active antiretroviral therapy (HAART) influences the etiology of stillbirths. It is also unknown whether HIV infection of the fetus is associated with stillbirth.

Methods: HIV-infected women and a comparator group of HIV-uninfected women who delivered stillbirths were enrolled at the largest referral hospital in Botswana between January and November 2010. Obstetrical records, including antiretroviral use in pregnancy, were extracted at enrollment. Verbal autopsies; maternal HIV, CD4 and HIV RNA testing; stillbirth HIV PCR testing; and placental pathology (blinded to HIV and treatment status) were performed.

Results: Ninety-nine stillbirths were evaluated, including 62 from HIV-infected women (34% on HAART from conception, 8% on HAART started in pregnancy, 23% on zidovudine started in pregnancy, and 35% on no antiretrovirals) and 37 from a comparator group of HIV-uninfected women. Only 2 (3.7%) of 53 tested stillbirths from HIV-infected women were HIV PCR positive, and both were born to women not receiving HAART. Placental insufficiency associated with hypertension accounted for most stillbirths. Placental findings consistent with chronic hypertension were common among HIV-infected women who received HAART and among HIV-uninfected women (65% vs. 54%, p = 0.37), but less common among HIV-infected women not receiving HAART (28%, p = 0.003 vs. women on HAART).

Conclusions: In utero HIV infection was rarely associated with stillbirths, and did not occur among women receiving HAART. Hypertension and placental insufficiency were associated with most stillbirths in this tertiary care setting.

Show MeSH
Related in: MedlinePlus