Helaine Milanez

Antiretroviral therapy (ART) use in pregnancy presents unquestionable benefits in preventing mother-to-child transmission (MTCT) of HIV although it is associated with maternal adverse effects. The aim of this study was to evaluate the adverse effects of antiretroviral therapy in pregnant women infected with HIV. Cohort study of pregnant women infected with HIV followed at the CAISM/UNICAMP Obstetric Clinic from 2000 to 2015. The following maternal adverse effects were observed: anemia, thrombocytopenia, allergy, liver function test abnormalities, dyslipidemia and diabetes. Data collected from patients’ files was added to a specific database. Descriptive analysis was shown in terms of absolute (n) and relative (%) frequencies and mean, median and standard deviation calculations. Chi-square or Fisher exact test (n < 5) and relative risk (RR) with its respective p values were used for categorical variables and Student t-test (parametric data) or Mann-Whitney (non-parametric data) for the quantitative ones. A 95% confidence interval (CI) and a significant level of 0.05 were used. A multivariate Cox Logistic Regression was also done. Data analysis was conducted using SAS version 9.4. Data from 793 pregnancies were included. MTCT rate was 2.3%, with 0.8% in the last 5 years. Maternal adverse effects were: dyslipidemia (82%), anemia (56%), liver function test abnormalities (54.5%), including hyperbilirubinemia (11.6%), fasting glycemia alteration (19.2%), thrombocytopenia (14.1%), and allergic reaction (2.7%). The majority of adverse effects deemed related to ART in this study were mild according to DAIDS scale. In the multivariate analysis, co-infections and starting ART during pregnancy were risk factors for maternal anemia, while CD4 count higher than 200 cells/mm3 was protective. Nevirapine, nelfinavir and atazanavir regimens increased the risk for liver function tests abnormalities. Lopinavir use during pregnancy increased the risk for fasting glycemia alteration. The evolution of the national guidelines of antiretroviral therapy for pregnant women improved adherence to the treatment and resulted in a significant reduction of MTCT. Despite the high frequency of maternal adverse effects, they are mostly of low severity. Newer ART medications with improved efficacy and significantly more favorable tolerability profiles should reduce the incidence of ART-related adverse effects.

Antiretroviral therapy (ART) in pregnancy was associated with a drastic reduction in HIV mother-to-child transmission (MTCT), although it was associated with neonatal adverse effects. The aim of this study was to evaluate the neonatal effects to maternal ART. This study was a cohort of newborns from HIV pregnant women followed at the CAISM/UNICAMP Obstetric Clinic from 2000 to 2015. The following adverse effects were evaluated: anemia, thrombocytopenia, liver function tests abnormalities, preterm birth, low birth weight and congenital malformation. Data collected from patients’ files was added to a specific database. Descriptive analysis was shown in terms of absolute (n) and relative (%) frequencies and mean, median and standard deviation calculations. The association between variables was tested through Chi-square or Fisher exact test (n < 5) and relative risk (RR) with its respective p values for the categorical ones and t-Student (parametric data) or Mann-Whitney (non-parametric data) for the quantitative ones. The significant level used was 0.05. A multivariate Cox Logistic Regression was done. Statistical analysis was performed using SAS version 9.4. Data from 787 newborns was analyzed. MTCT rate was 2.3%, with 0.8% in the last 5 years. Observed neonatal adverse effects were: liver function tests abnormalities (36%), anemia (25.7%), low birth weight (22.5%), preterm birth (21.7%), children small for gestational age (SGA) (18%), birth defects (10%) and thrombocytopenia (3.6%). In the multivariate analysis, peripartum CD4 higher than 200 cells/mm3 was protective for low birth weight and preterm birth, and C-section was associated with low birth weight, but not with preterm birth. Neonatal anemia was associated with preterm birth and exposure to maternal AZT. Liver function tests abnormalities were associated with detectable peripartum maternal viral load and exposure to nevirapine. No association was found between different ART regimens or timing of exposure with preterm birth, low birth weight or congenital malformation. Highly active antiretroviral treatment in pregnant women and viral load control were the main factors associated with MTCT reduction. Antiretroviral use is associated with a high frequency but mainly low severity adverse effects in newborns.

The increased occurrence of syphilis during pregnancy, and its severe repercussions to the fetal environment, has been a cause for concern among health care professionals. It is hard to comprehend why congenital syphilis has not yet been controlled, since its agent, the spirochaete Treponema pallidum, is well known and is highly susceptible to penicillin, a low cost and easily available drug. When we compare the control of mother-to-child transmission (MTCT) of HIV with that of syphilis, it is even harder to understand why we have such success with the first one and disastrous results with the second![1] When we evaluate the epidemiology of syphilis in pregnancy and in the general adult population, we notice that there were great expectations to eradicate this disease after WWII, when penicillin was discovered, and its high efficacy in controlling Treponema confirmed. There was actually a reduction in the number of cases in the mid-1950s. Nevertheless, there was a significant increase starting in the 1960s, due probably to sexual liberation and the growing use of illicit drugs. A new reduction in the number of cases occurred again in the 1970s, due to public health campaigns. In the 1980s, a new growth in the number of cases was detected, strongly associated with the HIV epidemic around the world, sexual promiscuity and the sexual practices of men who have sex with men (MSM). At that time, increasing rates were also observed in heterosexual individuals who were associated with promiscuity, unprotected sexual practices and prostitution. Until today, despite many initiatives to reduce the number of cases, the infection rate in adults is alarming, particularly among pregnant women and newborns.[2] [3] Many public health campaigns launched in Brazil in the last decades, specifically targeting pregnant women, tried to control the disease and prevent the infection in newborns. By the end of the 1980s, a new campaign was launched to “eradicate congenital syphilis by the year 2000”. This campaign focused on educating pregnant women about the importance of being tested and treated during prenatal care. Unfortunately, we arrived to the year 2000 with a higher occurrence of congenital syphilis. At this point, a new campaign was created trying to control congenital syphilis by 2012, since eradicating the disease seemed unrealistic. Again, the campaign failed to reach its goals and a higher number of infections was observed.[3] [4] [5] Why is it so hard to face the congenital syphilis problem in our country? Because syphilis can be easily diagnosed and efficient treatment is available at low cost, potential barriers for the control of the disease have been studied. The role of health care workers is one of them. The new campaign from the Ministry of Health in Brazil is focusing on evaluating the health professional's role in caring for pregnant women and preventing congenital syphilis in newborns.[4] [5] Recent data on syphilis during pregnancy and congenital syphilis in our country are alarming. A significant proportion of women and newborns are infected. Among pregnant women, there was an increase of 1047% between 2005 and 2013. During this same period, an increase of 135% in congenital syphilis notifications was observed. These numbers might mean that the notification has improved, which in fact has happened. Nevertheless, this is not enough to explain the epidemic number of cases in pregnant women and newborns.[5] Data about syphilis cases around the world show that more than 12 million cases a year, registered by the World Health Organization (WHO), happen in the countries with less financial and social resources. They were associated with 90,000 neonatal deaths and to 65,000 premature or low birth weight newborns. The global rates for adverse events varied from 58 to more than 80%.[6] It is estimated that, in 2008, there were 1,360,485 cases of syphilis in pregnancy around the world. Of these, 39% were in Africa, 8% in the Americas, 44% in Asia and 1.6% in Europe, and 1,085.637 had prenatal care. Untreated maternal syphilis resulted in 304,000 fetal and perinatal deaths, and more than 216,000 infected children at risk for early death. The majority (87%) of these adverse events occurred in women who had prenatal care. In 2000, the WHO launched a campaign to eliminate syphilis MTCT with the intention to test and treat more than 90% of the pregnant women by 2015. Unfortunately, this has not happened yet.[3] [6] The repercussions in the infected children's health can be severe. Syphilis occurrence during pregnancy can result in bad adverse effects for the concept , ranging from abortions, fetal or perinatal deaths, to newborns with diverse disease sequels that can be manifested up to 2 years of age. It is important to emphasize that 70% of the infected children have no symptoms at birth. Therefore, it is extremely important to screen and treat women during pregnancy.[2] [4] [7] National guidelines determine screening for the infection twice during prenatal care: early in the pregnancy and at the beginning of the third trimester. Women should be tested again at admission to delivery (or to abortion). This strategy would identify women who had untreated infections prior to becoming pregnant and the ones who were infected during pregnancy, labor or delivery. The adequate identification would lead to the correct treatment, preventing fetal or neonatal infection.[4] The great majority of the infected pregnant women are in the latent stage of the disease, when no disease symptoms are manifested yet. Hence, the importance of screening for the infection through laboratory exams, serological tests and rapid test.[2] [4] Identifying primary chancre of syphilis in pregnant women is not frequent since most of these lesions happen in the vagina or cervix and are not usually noticed by the patient. We must always consider the possibility of the presence of syphilis in any pregnant woman who...

To evaluate mother-to-child transmission (MTCT) rates and related factors in HIV-infected pregnant women from a tertiary hospital between 2000 and 2009. cohort of 452 HIV-infected pregnant women and their newborns. Data was collected from recorded files and undiagnosed children were enrolled for investigation. qui-square test, Fisher exact test, Student t test, Mann-Whitney test, ANOVA, risk ratio and confidence intervals. MTCT occurred in 3.74%. The study population displayed a mean age of 27 years; 86.5% were found to have acquired HIV through sexual contact; 55% were aware of the diagnosis prior to the pregnancy; 62% were not using HAART. Mean CD4 cell-count was 474 cells/ml and 70.3% had undetectable viral loads in the third trimester. HAART included nevirapine in 35% of cases and protease inhibitors in 55%; Zidovudine monotherapy was used in 7.3%. Mean gestational age at delivery was 37.2 weeks and in 92% by caesarian section; 97.2% received intravenous zidovudine. Use of AZT to newborn occurred in 100% of them. Factors identified as associated to MTCT were: low CD4 cell counts, elevated viral loads, maternal AIDS, shorter periods receiving HAART, other conditions (anemia, IUGR (intra uterine growth restriction), oligohydramnium), coinfecctions (CMV and toxoplasmosis) and the occurrence of labor. Use of HAART for longer periods, caesarian and oral zidovudine for the newborns were associated with a decreased risk. Poor adhesion to treatment was present in 13 of the 15 cases of transmission; in 7, coinfecctions were diagnosed (CMV and toxoplasmosis). Use of HAART and caesarian delivery are protective factors for mother-to-child transmission of HIV. Maternal coinfecctions and other conditions were risk factors for MTCT.

Pregnancy is a good time to develop healthy lifestyle habits including regular exercise and good nutrition. Programs of physical exercise for pregnant women have been recommended; however, there are few references on this subject in the literature. The objective of this study was to evaluate the knowledge, attitude and practice of pregnant women with respect to appropriate physical exercise during pregnancy, and also to investigate why some women do not exercise during pregnancy.

Background: Children born to HIV+ mothers are exposed intra-utero to several drugs and cytokines that can modify the developing immune system, and influence the newborn's immune response to infections and vaccines. We analyzed the relation between the distribution of cord blood lymphocyte subsets and cytokine profile in term newborns of HIV+ mothers using HAART during pregnancy and compared them to normal newborns.Methods: In a prospective, controlled study, 36 mother-child pairs from HIV+ mothers and 15 HIV-uninfected mothers were studied. Hematological features and cytokine profiles of mothers at 35 weeks of pregnancy were examined. Maternal and cord lymphocyte subsets as well as B-cell maturation in cord blood were analyzed by flow cytometry. The non-stimulated, as well as BCG- and PHA-stimulated production of IL2, IL4, IL7, IL10, IL12, IFN-γ and TNF-alpha in mononuclear cell cultures from mothers and infants were quantified using ELISA.Results: After one year follow-up none of the exposed infants became seropositive for HIV. An increase in B lymphocytes, especially the CD19/CD5+ ones, was observed in cord blood of HIV-exposed newborns. Children of HIV+ hard drug using mothers had also an increase of immature B-cells. Cord blood mononuclear cells of HIV-exposed newborns produced less IL-4 and IL-7 and more IL-10 and IFN-γ in culture than those of uninfected mothers. Cytokine values in supernatants were similar in infants and their mothers except for IFN-γ and TNF-alpha that were higher in HIV+ mothers, especially in drug abusing ones. Cord blood CD19/CD5+ lymphocytes showed a positive correlation with cord IL-7 and IL-10. A higher maternal age and smoking was associated with a decrease of cord blood CD4+ cells.Conclusions: in uninfected infants born to HIV+ women, several immunological abnormalities were found, related to the residual maternal immune changes induced by the HIV infection and those associated with antiretroviral treatment. Maternal smoking was associated to changes in cord CD3/CD4 lymphocytes and maternal hard drug abuse was associated with more pronounced changes in the cord B cell line.

Objective: to compare the distribution of caesarean rates in the Robson's 10 groups classification in order to see if any change occurred after the implementation of an audit and feedback intervention.Design:cross sectional, before and after an audit and feedback study.Setting: a university hospital in Brazil.Methods: clinical records of all births during two three months-periods were evaluated. Each case of CS was classified into one of ten mutually exclusive categories according to obstetric characteristics. The proportion of CS in each group was compared in both periods.Results: total number of deliveries and the high rate of CS were similar in both periods. Group 3 (multiparous excluding previous CS, single, cephalic, ≥ 37 weeks, spontaneous labour) accounted for the largest proportion of deliveries, 28.5 and 26.8% in both periods. Group 1 (nulliparous, single, cephalic, ≥ 37 weeks, spontaneous labour) was the second largest one, while Group 5 (previous caesarean section, single, cephalic, and ≥ 37 weeks) was the third but the largest contributor to CS, accounting for 16.6 and 14.9% among all deliveries in both periods. Groups 2 (nulliparous, single, cephalic, ≥ 37 weeks, induction or CS before labour) and 4 (multiparous excluding previous CS, single, cephalic, ≥ 37 weeks, induction or CS before labour) were less prevalent, however had higher rates of CS. Only in Group 10 (All single, cephalic, ≤ 36 weeks, including previous CS), there was a significant decrease of CS rate from 70.5 to 42.6% between periods.Conclusion: Robson's classification did not identify any significant change in the pattern of CS rates with the audit and feedback process, but showed to be useful for comparing trends among similar obstetric populations.