ARTICLE
Clinical and epidemiological profile and reproductive outcome in hiv-infected pregnant women assisted at a university hospital maternity in vitória, brazil

INTRODUCTION

Infection by human immunodeficiency virus (HIV) is a worldwide epidemic, with serious consequences in terms of maternal-fetal morbidity and mortality, demanding enormous efforts and resources to their confrontation¹. Women already represent half of people living with HIV in the world, with increasing incidence in many countries^1,2, attributed to biological², socioeconomic and behavioral factors^2,3,4.

The reproductive outcome in pregnant women infected with HIV has been studied, as well as strategies for reducing mother-to-child transmission (MTCT), due to frequent detection of the virus during the gestational period after the implementation of routine serological testing^5,6.

These studies were needed for the elaboration of more suitable care protocols to this population and the actions of information dissemination to the general population, especially women in reproductive period.

This study had as its main purpose to describe the characteristics of these women and the reproductive outcome because of the great relevance of knowing the clinical-epidemiological profile of these pregnant women, as well as the maternal and fetal consequences, in order to guide preventive intervention to reduce the impact of HIV infection on the health of the woman and the child.

OBJECTIVE

To describe the clinical and epidemiological profile of HIV infected pregnant women, as well as the reproductive outcome in them.

METHODS

A cross-sectional study was developed with HIV-infected pregnant women with parturition in the maternity ward of a university hospital, reference in the assistance of HIV infected pregnant women in the municipality of Vitória, Espírito Santo, between November 2001 and May of 2012.

Among the 250 births of HIV-infected pregnant women that occurred in this period, 109 non gemelar pregnancies, with data on gestational age (GA), HIV infection immune state (HIV and Aids) and concept data, were included in the study. It was considered preterm birth those occurred before the 37^th week of gestation. The variables of this study were the demographic, clinical, laboratory, obstetric and neonatal data. The data were extracted retrospectively from medical and public records, and tabulated in Excel spreadsheet (Microsoft Office 2010) for simple frequency calculation on each category. There was no patient approach for data collection. This study has been approved by the Institution's Research Ethics Committee.

RESULTS

It was observed a frequency of 1.2% (250) of HIV infected pregnant women out of 20,942 terminations in the analyzed period. In this casuistry, 109 cases whose gestational age was confirmed by ultrasound performed until 20 weeks were included. As for the age group, 50% of pregnant women were between 24 and 32 years and 97% were in the ideal reproductive age.

It was found that 76.1% were black and browns, 63.3% with up to 8 years of elementary education, 59.4% were housewives, 70.6% were married/in stable relationship, and 86.1% were residing within the metropolitan area in Vitória (Table 1).

Table 1:

Demographic characteristics of HIV/Aids gestations.

Ef #: Efective number; F: absolut frequency; f: relative frequency.

Smoking was reported by 25.2%, alcohol use by 8.4% and illicit drugs use by 8.5% of the pregnant women. Among the patients, 34.9% made less than 6 prenatal consultations, the same being considered inadequate (Table 2).

Table 2:

Gestation characteristics and current termination of 109 HIV/Aids pregnant women.

Ef#: Efective number; F: absolut frequency; f: relative frequency

Regarding obstetric history, 24.1% were nulliparous and 15.7% had 3 or more childbirths.

As for the moment of diagnosis, it was observed that 33% of pregnant women had diagnosis of HIV infection during pregnancy and 18.8% in previous pregnancies. Fifty-one (46.8%) became pregnant with Aids diagnosis prior. Fifty-eight cases (53.7%) presented Aids defining criteria during the study, 50 (46.3%) did not present it, and in only one case the stage of the disease was unknown. The laboratory findings relating to lymphocytes T CD4 count and viral load are shown in Table 3.

Table 3:

HIV Infection characteristics in 109 pregnacies.

Ef #: Efective number; F: absolut frequency; f: relative frequency.

Regarding parturition, in 17.4% of cases the birth was vaginal, 41.1% occurred in labor, being 33.3% spontaneous and 2.8% induced. There was spontaneous rupture of membranes in 21.7% of cases (Table 4). Gestational age ranged from 26 to 41 weeks, averaging 37.3±2.9 and 38 median, being 50% of the cases between 37 and 39 weeks. Preterm birth occurred in 17.4% (95%CI 10.3-24.5), and post-term delivery was not found in this study (Table 3).

Table 4:

Gestation characteristics and current terminations in 109 pregnant women.

Ef #: Efective number; F: absolut frequency; f: relative frequency.

In the group of patients with a diagnosis of Aids, we observed one case of puerperal infection and one case of maternal death by neurotoxoplasmosis.

It was observed 54.1% of female newborn in this series. The Apgar score of less than or equal to 7 in the first minute was observed in 3.8% (95%CI 0.1-7.5).

Among all the cases, the assistance in the Neonatal Intensive Care Unit (NICU) was needed in 22.3% (95%CI 14.3-30.3). Low birth weight occurred in 23.9%, and perinatal death in 4.6% of newborns (NB) (95%CI 0.7-8.5).

Zidovudine (AZT) intravenous in prepartum was used in 93.2% of women in labour. A follow-up of more than 18 months of postnatal life was observed in 85 cases of RN in pediatric infectious diseases services, and vertical transmission (TV) was verified in 3 cases (3.5%) (Table 5).

Table 5:

Fetal outcome characteristics in 109 gestations.

Ef #: Efective number; F: absolut frequency; f: relative frequency

DISCUSSION

The prevalence of HIV-infected pregnant women in this study (1.2%) was greater than the observed by Miranda and collaborators in a cohort of young pregnant women, with an average of 20.2 years, during labor in Brazilian public hospitals (0.7%)⁴.

Sociodemographic characteristics of pregnant women in the study (Table 1) make up a typical pregnant women profile seen in Brazilian public maternity hospitals, as reported in other regional studies (7.8) or Brazilians^9,10.

Knowing the sociodemographic and health profile and the prenatal monitoring of pregnant women infected with HIV is of great importance to improve welfare services and tailor strategies for prevention of adverse perinatal outcomes. Socioeconomic conditions can affect the perception of the risks of HIV contamination, which is the main reason to study this variable¹¹.

In a study of black women living with HIV/Aids in the State of São Paulo, it was observed the occurrence of social inequality of this population, which is seen by low schooling and inequity in accessing health services⁹, also observed in our study.

Although it has been found important prevalence of smoking (25%) in this series, it was not possible to compare it with other Brazilian studies due to lack of data on this variable. This limitation has also been found by other authors in order to evaluate prevalence of tobacco, alcohol and drugs use in HIV-infected pregnant women¹².

It is important to highlight that only 65% of the women made the 6 prenatal consultations, being 43.7% at the university hospital where the study was conducted (HUCAM/UFES), and that only 62.1% had good nutritional status assessed by body mass index (BMI) prior to pregnancy (leanness in 10.7%, 20.4% in obesity and overweight in 6.8%). In Brazil, the percentage of pregnant women during prenatal care that held 6 consultation and all basic examinations, including HIV, is around 4%¹³.

Taken altogether, these findings reveal several risk conditions of pregnant women infected with HIV and allow characterizing the material as a group vulnerable to bad reproductive outcome, such as prematurity and its consequences, without even considering the assault by HIV. Prenatal care is the moment to approaches for minimizing many of these risks, adopting prevention and care measures.

The considerable frequency of diagnosis of HIV infection during current pregnancy (33%) observed in this series is similar to that described in other studies in Brazil^{6,7,9,14,15,16} due to the practice of routine serological testing. In the study of Stefani¹⁷, it was observed that 70% of pregnant women had the diagnosis of HIV in pregnancy or childbirth.

This fact leads us to reflect on the importance of early diagnosis of HIV infection in women of childbearing age, since some studies show that many women just know their diagnosis during the prenatal period¹⁸.

The national policy for prevention of mother-to-child transmission of the HIV virus recommends systematic testing of pregnant women during prenatal care, as well as the antiretroviral treatment offered by the institution in cases in which the test is considered positive. Pregnant women should be notified, as well as exposed children⁶, about favor control and strategizing concerning mother-to-child transmission of HIV.

The proportion of cases of pregnant women with Aids in this study (53%) was greater than the reported by Miranda⁷ in the same region (28.8%) and by Lee⁹ in another Brazilian State. This finding could point to possible shortcomings of risk-oriented education, being thus recommended the pre and post-conception advice for HIV+ women to opt for getting pregnant or not.⁹

It is worth noting that the largest number of cases of pregnant women with Aids in this series could be justified by a selection bias due in the case of referral hospital for high risk obstetrics.

When assessing the immune status of pregnant women in this study through the lymphocytes T CD4 count less than 200 cells/mm³, it was observed frequency of 10.8%, less than the proportion of 14.3% reported by Melo et al.¹⁵; and viral load <1,000/mm³ was observed in 56.8% of cases, similar to the 60.4% found in the study of Melo et al.¹⁵. This result is of great importance because in pregnant women with viral load less than 1,000 copies/mL and with more than 34 weeks the mode of delivery can be an obstetric indication.

In the present study, the vaginal birth occurred in 17.4% of cases. Spontaneous rupture of membranes above 4 hours could not be evaluated in this study precisely, which is a recognized factor associated with mother-to-child transmission of HIV, as well as the high viral load and prematurity⁶.

The occurrence of preterm birth was higher than the reported in several studies of pregnant women infected with HIV^9,19,20, which is the Brazilian average occurrence²¹ and much higher than the 4.8% of the Live Birth Information System (SINASC) from Vitoria²², corresponding to a direct increase of 12.6% (Number Needed to Treat (NNT): 7.9, Simple ratio (SR): 3.6 and OR: 4.18 (95%CI 2.37-7.35)). These data indicate the need for preventive actions for the monitoring of pregnant women infected with HIV in order to reduce these events.

In previous studies, it was not found higher frequency of puerperal infection in pregnant women infected with HIV^23,24.

Few studies report higher incidence of birth of female fetuses^25,26, which constitutes a peculiar finding of the present study, maybe relevant because there are more reports of TV for female fetuses²⁷.

The Apgar score was similar to that observed in SINASC²² and lower than the 10.5% observed in 2002 Tuomala's study²⁸. The occurrence of fetal death was similar to that found in the study of Lee⁹ and lower than the observed by Isaacs²⁵, being greater than the proportion in the SINASC²². Several studies have reported lower prevalence of perinatal deaths than the observed in this study^15,28.

Regarding TV cases, it was observed they all occurred with some factor associated with increased transmission (syphilis, without prenatal and without art). This rate is similar to that found in another location study⁷ and in other Brazilian cities^10,15,29, however was fewer than the Brazilian rate in 2001 (7.1%) and less than the rate of TV in the Southeast (7.0 %)³⁰.

In Brazil, the rates of HIV mother-to-child transmission had decreased in the last decade due implementation of the measures of the STD/Aids program⁶. Knowing the clinical-epidemiological profile, the prenatal monitoring of pregnant women infected with HIV is of great importance to improve welfare services and tailor strategies for prevention of adverse perinatal outcomes.

CONCLUSION

The epidemiological profile of this series showed the occurrence of categories typical of a low socioeconomic level, such as low schooling and non-remunerated occupation in HIV-infected pregnant women.

Clinical and immunological profile found was of highest number of Aids cases in the HIV-infected pregnant women in this study. Regarding the reproductive outcome in children born to HIV-infected pregnant women, birth and perinatal preterm death were more common when compared with the general population.