Madhva Prasad*, Sumit Chamariya*, Rashmi Khadkikar**, A. R. Chauhan***
(* Third Year Resident, ** Assistant Professor, *** Additional Professor. Department of Obstetrics & Gynecology, Seth GS
College & KEM Hospital, Parel, .) Mumbai, India
Maternal HIV infection leads to immunocompromised state and adverse maternal and perinatal outcomes. With institution of ART and a multi-disciplinary approach, improved outcomes are possible even with severe immune compromise. Successful pregnancy outcome in a patient with CD4 count of only four is highlighted here.
HIV infection is a major global health problem; an estimated 35.3 million people were living with HIV in 2012 but deaths due to HIV/ AIDS have decreased to 1.6 million people. To “eliminate HIV infection among children and reduce maternal deaths” is a key element described by WHO. This is possible by good anti-retroviral therapy (ART) coverage, which has reached 62% in 2012.1 In this context of improved survival among mothers with HIV/AIDS, a successful pregnancy outcome in a severely immunocompromised case is presented here.
A 25 year old primigravida, separated from husband, urban resident in
India, middle socio-economic status, with 19 weeks’ gestation was
referred for severe anemia. Patient had complaints of decreased appetite, fever
and breathlessness. Though detected to be HIV positive six months earlier and
advised ART, she had defaulted and was not on any treatment. She had been
transfused one unit blood prior to referral.
She was conscious, severely pale, and afebrile, with mild tachycardia (pulse 104 beats / minute). She was cachexic, with a BMI of 15.3. On general examination, she had palpable cervical lymph nodes and extensive bilateral crepitations on respiratory system auscultation. Abdominal examination revealed a relaxed uterus of 18 weeks’ with positive external ballotment and regular fetal heart sounds; non-tender hepato-splenomegaly and minimal ascites. She had candidasis and an erythematous rash on speculum examination; cervical os was closed. There was no other evidence of opportunistic infections.
Investigations revealed severe anemia (hemoglobin 5.6 gm/ dl), total WBC count of 5600/ mm3, thrombocytopenia of 40000/ mm3. CD4 count was only 4. The normal value of CD4+ T helper cells ranges between 410 and 1590/ µL. The AIDS surveillance and case definition system utilizes this CD4 count: any count < 200 is sufficient to label the patient as having AIDS.2 Ultrasonography showed a single live fetus of 19 weeks’gestation with oligohydramnios and fetal hydrocephalus. Rest of the fetal anatomical survey was normal. Abdominal scan showed multiple lymph nodes, hepato-splenomegaly and altered liver echotexture suggestive of abdominal tuberculosis. Chest X- ray was normal. Sputum for acid fast bacilli was negative. Other viral markers were negative.
Correction of severe anemia was initiated with two units of blood transfusion. ART was instituted in consultation with the physician; patient was started on HAART (Highly Active Anti-Retroviral Therapy) with daily tablets of tenofovir/ lamivudine and efavirenz. In view of extremely low CD4 count, she was also empirically started on weekly tablets of secnidazole and azithromycin. Candidiasis was treated with cotrimoxazole vaginal pessary. Category 1 anti-tuberculous therapy was started in view of abdominal tuberculosis as per the recommended standard regimen; patient was discharged and asked to follow-up on outpatient basis.
However, her follow- up was irregular and she next presented at 32 weeks gestation with threatened preterm labor. Examination revealed a relaxed uterus of 30 weeks’ with regular fetal heart sounds and closed internal os. Ultrasonography revealed a single live fetus of 30 weeks 2 days with moderate oligohydramnios and estimated weight of 1.2 kg; Doppler flows were suggestive of fetoplacental insufficiency. Corticosteroids were given for fetal lung maturity. Doppler two days later was suggestive of fetoplacental and uteroplacental insufficiency with severe oligohydramnios and incidentally detected bilobulated psoas abscess of 60 ml volume in maternal pelvis. No active intervention was done for this abscess as patient remained asymptomatic. In view of abnormal Doppler and oligohydramnios, labor was induced with prostaglandin E2 gel. Patient delivered a male child of 1.425 kg with Apgar score of 9/10. The mother opted to top- feed. The baby was admitted to neonatal intensive care, was tested to be HIV negative. Zidovudine prophylaxis for 6 weeks was started as per standard recommendations. Detailed ultrasonography ruled out any major neurological problem. Once appropriate weight gain was achieved, mother and baby were discharged on day 11 on life.
A comprehensive approach to manage anemia, including micronutrient supplementation and infectious disease control is warranted in HIV-infected women in resource-limited settings, as seen in our patient, who received blood transfusion in early pregnancy.
CD4 count during pregnancy is dependent on gestational age, micronutrient status and seasonal influences. However, these do not appear to influence clinical practices. Though our patient had alarmingly low CD4 count of 4, she never required ICU care; intensive care admission itself is an adverse outcome predictor in HIV positive patients. Institution of ART is the most important step to improving maternal outcomes in these patients. However, use of HAART regimen itself is associated with low birth weight and other poor obstetric outcomes; this has been confirmed in a study from a similar geographic location. Studies have found an association between maternal HIV and adverse pregnancy outcomes including spontaneous abortions, preterm delivery, low birth weight and perinatal loss. Low CD4 count and opportunistic infections increase the propensity of the same.[9-13] Pregnancy-related mortality in HIV infected women is unlikely to be due to a higher risk of direct obstetric complications and reducing this mortality will require non- obstetric interventions involving access to ART in pregnant women.
Our patient progressed from a symptomatically ill 20 weeks’ pregnant patient to a stable, compliant patient with successful maternal and neonatal outcome despite advanced maternal HIV disease. The cornerstone of the management included institution of ART and a multi-disciplinary approach. With the advent of ART, health care providers can expect increasing numbers of mothers with advanced maternal HIV disease and can expect a consistent improvement in outcomes.
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Prasad M, Chamariya S, Khadkikar K,
Pregnancy Outcome In Severely Immunocompromised Patient. JPGO 2014.
Volume 1 Number 10. Available from: http://www.jpgo.org/2014/10/successful-pregnancy-outcome-in.html Chauhan AR.