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OBSTETRICS
Pregnancy outcomes in young women with perinatally
acquired human immunodeficiency virus-1
Shauna F. Williams, MD; Megan H. Keane-Tarchichi, MD;
Linda Bettica, RN; Arry Dieudonne, MD; Arlene D. Bardeguez, MD, MPH
OBJECTIVE: The objective of the study was to review pregnancy and ted infections (STIs) (80%). Initial median CD4 and viral load were 317
neonatal outcomes among perinatally infected pregnant patients at our cells/mm3 and 8780 copies/mL, respectively. The median gestational
institution. age at delivery was 38 weeks. The most common obstetrical complica-
tions were preeclampsia (23%) and premature rupture of membranes/
STUDY DESIGN: A retrospective review of maternal and neonatal
preterm delivery (31%). The cesarean delivery (CD) rate was 62%, with
records for all 10 perinatally infected adolescents between 1997 and
HIV as the indication in 75%. All infants were born alive; 1 was HIV
2007 was performed. Demographics, CD4 and viral load, antiretroviral
infected.
treatment, medical comorbidities, pregnancy outcomes, and neonatal
human immunodeficiency virus (HIV) status were abstracted. CONCLUSION: Despite high rates of STIs, CD, preterm delivery, and
hypertensive disorders, perinatal outcomes were favorable.
RESULTS: The median age at first pregnancy was 18.5 years and 70%
were African American. The most common comorbidities were hema- Key words: adolescent pregnancy, human immunodeficiency virus,
tologic abnormalities (70%) and cervical dysplasia/sexually transmit- perinatal infection
Cite this article as: Williams SF, Keane-Tarchichi MH, Bettica L, et al. Pregnancy outcomes in young women with perinatally acquired human immunodeficiency
virus-1. Am J Obstet Gynecol 2009;200:149.e1-149.e5.
ually transmitted infection rates up to age. If all tests were negative, the infant Hematologic 7
..................................................................................................
12% and abnormal cervical cytology in was deemed HIV negative. If HIV DNA Anemia a
5
..................................................................................................
47.5% of tested adolescents.14 PCR was positive at any point, a confir- Thrombocytopenia b
3
Therefore, given the significant uncer- matory test was repeated as soon as pos- ...........................................................................................................
AIDS-related illnesses 4
tainties regarding pregnancy outcomes sible. An infant was considered to have in ..................................................................................................
objective was to describe the medical and tive HIV DNA PCR tests within 2 weeks Wasting syndrome 3
..................................................................................................
obstetric complications of this group of birth. Neonatal status was docu- Lymphoid interstitial pneumonitis 1
over the past decade at our institution. mented in pediatric charts of the FXB ...........................................................................................................
Sexually transmitted infections 8
This can provide information to be uti- clinic and reviewed by 2 of the authors ..................................................................................................
Obstetrics
wasting syndrome,
candidiasis
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9 36 197 400 48,042 82 Anemia None PPROM, low birthweight/ CD: HIV Negative
small for gestational age
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
400
Research
10 40 317 15,200 100 Asthma, anemia, Hospitalized for None NSVD Negative
neuropathy neuropathy
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
NSVD, normal spontaneous vaginal delivery; CMV, cytomegalovirus; GDM, gestational diabetes; HSV, herpes simplex virus; LIP, lymphoid interstitial pneumonitis; PPROM, preterm premature rupture of membranes; RAD, reactive airway disease.
a
Percent of visits with documentation of self-reported adherence to antiretroviral regimen.
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
149.e3
Williams. Pregnancy outcomes in young women with perinatally acquired HIV-1. Am J Obstet Gynecol 2009.
Research Obstetrics www.AJOG.org
TABLE 3
Demographic characteristics and medication regimens
Year of Age at Number of past
Case Year of birth pregnancy delivery ARVs Regimen during pregnancy
1 1980 1997 16 2 ZDV, DDI, indinavira
................................................................................................................................................................................................................................................................................................................................................................................
b
2a 1979 1999 20 2 None
................................................................................................................................................................................................................................................................................................................................................................................
2b 1979 2006 27 10 Lamivudine, abacavir, lopinavir/ritonavir
................................................................................................................................................................................................................................................................................................................................................................................
3 1983 2001 17 3 ZDV, DDI, indinavir/ritonavir
................................................................................................................................................................................................................................................................................................................................................................................
4a 1985 2002 16 6 Abacavir/lamivudine/ZDV
................................................................................................................................................................................................................................................................................................................................................................................
4b 1985 2006 21 7 Abacavir/lamivudine/ZDV
................................................................................................................................................................................................................................................................................................................................................................................
5 1984 2003 19 5 ZDV, DDI, lopinavir/ritonavir
................................................................................................................................................................................................................................................................................................................................................................................
6 1986 2004 18 6 ZDV, lamivudine, nelfinavir
................................................................................................................................................................................................................................................................................................................................................................................
7a 1982 2004 21 3 ZDV, lamivudine, nelfinavir
................................................................................................................................................................................................................................................................................................................................................................................
7b 1982 2007 24 3 ZDV, lamivudine, nelfinavir
................................................................................................................................................................................................................................................................................................................................................................................
a
8 1983 2005 21 6 ZDV, DDI, nelfinavir
................................................................................................................................................................................................................................................................................................................................................................................
a
9 1988 2006 18 4 Tenofovir, DDI, lopinavir/ritonavir
................................................................................................................................................................................................................................................................................................................................................................................
10 1987 2007 19 7 Lamivudine, tenofovir, lopinavir/ritonavir
................................................................................................................................................................................................................................................................................................................................................................................
ARV, antiretroviral medication; DDI, didanosine; ZDV, zidovudine.
a
Regimen changed during pregnancy; b Patient refused antiretroviral therapy.
................................................................................................................................................................................................................................................................................................................................................................................
Williams. Pregnancy outcomes in young women with perinatally acquired HIV-1. Am J Obstet Gynecol 2009.
this cohort, medical comorbidities were use of highly active antiretroviral therapy 6. HIV/AIDS surveillance in adolescents and
seen in the majority of patients, particu- has lead to reduced mortality and mor- young adults. Available at: http://www.CDC.
gov./hiv/topics/surveillance/resources/slides/
larly anemia, but did not lead to adverse bidity of perinatally infected adolescents
adolescents/slides/7. Accessed September
maternal or fetal outcomes. Indeed, and young adults. Nonetheless, our cur- 24, 2008.
these observations appear to be consis- rent challenges include how and when to 7. New Jersey Department of Health and Senior
tent with expected complications previ- address reproductive health issues such Services. New Jersey HIV/AIDS report. New
ously reported by other authors in non as safe-sex practices counseling, contra- Jersey Department of Health and Senior Ser-
HIV-infected adolescents.2,4 ception, and STI prevention including vices; 2006. Available at: http://www.state.
There was a high rate of CD (62%) in early access to human papilloma virus nj.us/health/aids/documents/qtr0606.pdf. Ac-
cessed June 1, 2007.
this group of patients compared with our immunization to prevent premalignant
8. Abrams EJ, Weedon J, Bertolli J, et al. Aging
institutional rate of 32.8%. HIV-indi- and malignant genital lesions. cohort of perinatally human immunodeficiency
cated cesarean deliveries accounted for It is also imperative that we support virus-infected children in New York City. Pediatr
75% of these, highlighting the likelihood treatment adherence to achieve and Infect Dis J 2001;20:511-7.
of CD secondary to inadequate viral sup- maintain viral suppression to avert oper- 9. Grubman S, Gross E, Lerner-Weiss N, et al.
pression. Inadequate viral suppression ative deliveries for an HIV indication, Older children and adolescents living with peri-
frequently seen in HIV-infected adoles- which can compromise future reproduc- natally acquired human immunodeficiency virus
infection. Pediatrics 1995;95:657-63.
cent cohorts reinforces the need for close tive health. As we decrease HIV MTCT
10. The European Collaborative Study. Fluctu-
surveillance and counseling on treat- globally, we must monitor and address ations in symptoms in human immunodefi-
ment adherence to decrease operative the reproductive health issues experi- ciency virus-infected children: the first 10 years
deliveries.15 Complications following enced by this population of perinatally of life. Pediatrics 2001;108:116-22.
CD in our cohort were rare, but prior infected adolescents in both high- and 11. Gortmaker SL, Hughes M, Cervia J, et al.
studies have shown increased morbidity low-income countries to improve peri- Effect of combination therapy including pro-
rates in HIV-positive patients after natal outcomes and long-term maternal tease inhibitors on mortality among children and
adolescents infected with HIV-1. N Engl J Med
CD.16 Prior CD is the most common in- health. f
2001;345:1522-8.
dication for repeat cesarean section; 12. Crane S, Sullivan M, Feingold M, Kaufman
thus, this group of patients is likely to GE. Successful pregnancy in an adolescent
ACKNOWLEDGMENTS
experience repeat abdominal deliveries with perinatally acquired human immunodefi-
We thank Drs James Oleske, Joseph Apuzzio,
in future pregnancies with its associated and Barry Dashefsky, Jocelyn Grandchamp,
ciency virus. Obstet Gynecol 1998;92:711.
morbidities.17 RN, and Charmaine Calilap-Bernardo, RN, for 13. Zorrilla C, Febo I, Ortiz I, et al. Pregnancy in
High-risk sexual behavior is also of their care of this population and input in the perinatally HIV-infected adolescents and young
preparation of this manuscript as well as to the adultsPuerto Rico, 2002. MMWR Morb Mor-
concern in this group of patients. Abnor-
clinic staff at University Obstetric Associates tal Wkly Rep 2003;52:149-51.
mal cervical cytology and STIs affected 14. Brogly SB, Watts DH, Ylitalo N, et al. Repro-
and University Hospital (Newark, NJ) for their
80% of the patients in our cohort, and 7 excellent support and assistance in the care of ductive health of adolescent girls perinatally in-
patients (70%) were diagnosed with an these patients. fected with HIV. Am J Public Health 2007;97:
STI during pregnancy. High rates of 1047-52.
STIs, specifically chlamydia and gonor- 15. Perinatal HIV guidelines working group.
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