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Hindle S, Brien MÈ, Pelletier F, Giguère F, Trudel MJ, Dal Soglio D, Kakkar F, Soudeyns H, Girard S, Boucoiran I. Placenta analysis of Hofbauer cell profile according to the class of antiretroviral therapy used during pregnancy in people living with HIV. Placenta 2023; 139:120-126. [PMID: 37364521 DOI: 10.1016/j.placenta.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/16/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION The use of antiretroviral therapy drastically reduces vertical transmission of Human Immunodeficiency Virus. However, recent studies demonstrate associations between ART use during pregnancy and placental inflammation, particularly within protease inhibitor (PI)-based regimens. We sought to characterize placental macrophages, namely Hofbauer cells, according to the class of ART used during pregnancy. METHODS Using immunofluorescence and immunohistochemistry, placentas from 79 pregnant people living with HIV (PPLWH) and 29 HIV-uninfected people were analyzed to quantify the numbers and frequencies of leukocytes (CD45+) and Hofbauer cells (CD68+ and/or CD163+). PPLWH were stratified into three groups based on class of ART: non-nucleoside reverse transcriptase inhibitor (NNRTI)-based, integrase strand-transfer inhibitor (INSTI)-based, and PI-based regimens. RESULTS Placentas of PPLWH contained significantly more leukocytes and Hofbauer cells than controls. Multivariable analyses revealed that this increase in immune cells was associated with a predominantly CD163+ profile in all ART subgroups compared to the HIV-negative group. This was characterized by an increase in total CD163+ cells in the PI and INSTI subgroups, and a higher frequency of CD163+ cells and CD163+/CD68+ ratio in the NNRTI and PI subgroups. DISCUSSION Placentas of PPLWH treated with any ART regimen during their entire pregnancy displayed a selection for CD163+ cells compared to the HIV-negative group, regardless of class of ART, suggesting that class of ART does not intrinsically affect selection of CD163+ and CD68+ Hofbauer cells. Further investigations into the role of Hofbauer cells in ART-associated placental inflammation are warranted to identify the mechanisms behind their potential involvement in maternal-fetal tolerance maintenance.
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Affiliation(s)
- Stephanie Hindle
- Department of Pharmacology and Physiology, Université de Montréal, 2900 boul. Édouard-Montpetit, Montréal, QC, H3T 1J4, Canada; CHU Sainte-Justine Research Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada.
| | - Marie-Ève Brien
- CHU Sainte-Justine Research Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada.
| | - Florence Pelletier
- CHU Sainte-Justine Research Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada.
| | - Frédérique Giguère
- CHU Sainte-Justine Research Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada.
| | - Mei Juan Trudel
- CHU Sainte-Justine Research Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada.
| | - Dorothée Dal Soglio
- Department of Pathology, CHU Sainte-Justine, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada.
| | - Fatima Kakkar
- CHU Sainte-Justine Research Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada; Department of Pediatrics, Université de Montréal, 2900 boul. Édouard-Montpetit, Montréal, QC, H3T 1J4, Canada.
| | - Hugo Soudeyns
- CHU Sainte-Justine Research Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada; Department of Microbiology, Infectiology and Immunology, Université de Montréal, 2900 boul. Édouard-Montpetit, Montréal, QC, H3T 1J4, Canada.
| | - Sylvie Girard
- Department of Pharmacology and Physiology, Université de Montréal, 2900 boul. Édouard-Montpetit, Montréal, QC, H3T 1J4, Canada; CHU Sainte-Justine Research Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada; Department of Obstetrics and Gynecology, Université de Montréal, 2900 boul. Édouard-Montpetit, Montréal, QC, H3T 1J4, Canada; Department of Microbiology, Infectiology and Immunology, Université de Montréal, 2900 boul. Édouard-Montpetit, Montréal, QC, H3T 1J4, Canada; Department of Obstetrics and Gynecology, Department of Immunology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Isabelle Boucoiran
- CHU Sainte-Justine Research Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1S2, Canada; Department of Obstetrics and Gynecology, Université de Montréal, 2900 boul. Édouard-Montpetit, Montréal, QC, H3T 1J4, Canada.
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Mtintsilana A, Norris SA, Dlamini SN, Nyati LH, Aronoff DM, Koethe JR, Goldstein JA, Prioreschi A. The impact of HIV and ART exposure during pregnancy on fetal growth: a prospective study in a South African cohort. BMC Pregnancy Childbirth 2023; 23:415. [PMID: 37270499 DOI: 10.1186/s12884-023-05743-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 05/27/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND In utero exposure to human immunodeficiency virus (HIV) and antiretroviral (ART) is associated with adverse birth outcomes, which are often attributed to alterations in placental morphology. This study used structural equation models (SEMs) to examine the impact of HIV and ART exposure on fetal growth outcomes and whether these associations are mediated by placental morphology in urban-dwelling Black South African women. METHODS This prospective cohort study included pregnant women living with HIV (WLWH, n = 122) and not living with HIV (WNLWH, n = 250) that underwent repeated ultrasonography during pregnancy, and at delivery, to determine fetal growth parameters in Soweto, South Africa. The size and the velocity of fetal growth measures (i.e., head and abdominal circumference, biparietal diameter, and femur length) were calculated using the Superimposition by Translation and Rotation. Placenta digital photographs taken at delivery were used to estimate morphometric parameters and trimmed placental weight was measured. All WLWH were receiving ART for the prevention of vertical transmission of HIV. RESULTS A trend towards a lower placental weight and significantly shorter umbilical cord length was reported in WLWH compared to their counterparts. After sex stratification, umbilical cord length was significantly shorter in males born to WLWH than in male fetuses born to WNLWH (27.3 (21.6-32.8) vs. 31.4 (25.0-37.0) cm, p = 0.015). In contrast, female fetuses born to WLWH had lower placental weight, birth weight (2.9 (2.3-3.1) vs. 3.0 (2.7-3.2) kg), and head circumference (33 (32-34) vs. 34 (33-35) cm) than their counterparts (all p ≤ 0.05). The SEM models showed an inverse association between HIV and head circumference size and velocity in female fetuses. In contrast, HIV and ART exposure was positively associated with femur length growth (both size and velocity) and abdominal circumference velocity in male fetuses. None of these associations appeared to be mediated via placental morphology. CONCLUSION Our findings suggest that HIV and ART exposure directly affects head circumference growth in females and abdominal circumference velocity in male fetuses; but may improve femur length growth in male fetuses only.
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Affiliation(s)
- Asanda Mtintsilana
- SA MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Department of Paediatrics, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Private Bag X3, Johannesburg, 2050, South Africa.
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, Gauteng, South Africa.
| | - Shane A Norris
- SA MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Department of Paediatrics, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Private Bag X3, Johannesburg, 2050, South Africa
- School of Human Development and Health, University of Southampton, Southampton, UK
| | - Siphiwe N Dlamini
- SA MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Department of Paediatrics, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Private Bag X3, Johannesburg, 2050, South Africa
- School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lukhanyo H Nyati
- SA MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Department of Paediatrics, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Private Bag X3, Johannesburg, 2050, South Africa
- Faculty of Community and Health Sciences, University of the Western Cape, Blanckenberg Street, Bellville, Cape Town, 7535, South Africa
| | - David M Aronoff
- SA MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Department of Paediatrics, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Private Bag X3, Johannesburg, 2050, South Africa
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - John R Koethe
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Jeffrey A Goldstein
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alessandra Prioreschi
- SA MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Department of Paediatrics, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Private Bag X3, Johannesburg, 2050, South Africa
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Abstract
Prior to widespread availability of antiretroviral therapy (ART) in sub-Saharan Africa, children who were HIV-exposed but uninfected (HEU) had increased mortality, morbidity and undernutrition compared with children who were HIV-unexposed. Scale-up of ART has led to impressive declines in vertical HIV transmission, but over 15 million children are now HEU, 90% of whom live in sub-Saharan Africa. There are ongoing health disparities among children who are HEU, with higher mortality, morbidity and stunting and modest impairments in early child development, which collectively hamper health and human capital in high prevalence countries. The underlying causes are multifactorial and include exposure to HIV, co-infections and a skewed antenatal inflammatory milieu, particularly if mothers start ART once they have advanced disease, as well as socioeconomic risk factors, which may cluster in HIV-affected households. Improving maternal health through early and sustained ART, ensuring optimal breastfeeding, and implementing evidence-based priority interventions for all children in areas of high HIV prevalence, will likely improve outcomes. A more comprehensive intervention package based on the Nurturing Care Framework may have particular benefits for children who are HEU, to close health gaps and ensure that the next generation of HIV-free children survive and thrive, and lead healthy and productive lives.
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Ramphal S, Govender N, Singh S, Khaliq OP, Naicker T. Histopathological features in advanced abdominal pregnancies co-infected with SARS-CoV-2 and HIV-1 infections: A case evaluation. Eur J Obstet Gynecol Reprod Biol X 2022; 15:100153. [PMID: 35600136 PMCID: PMC9106399 DOI: 10.1016/j.eurox.2022.100153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/27/2022] [Accepted: 05/11/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives This study aims to provide a semi-qualitative histopathological report of the dual SARS-CoV-2 and HIV infected placentae in the third trimester of Advanced Abdominal Pregnancy (AAP). Study design Four AAP placentae in the third trimester of pregnancy (two positive for HIV-1 and two positives for SARS-CoV-2) were histologically examined. Results The SARS-CoV-2+ HIV+ placentae were dysmorphic in shape compared to the flattened disc-like shape noted in the SARS-CoV-2+HIV-, SARS-CoV-2-HIV+and SARS-CoV-2-HIV- placentae. Diffused syncytial knots and syncytial degeneration were observed in all placentae. Intermittent cytotrophoblast increase, perivillous and intravillous fibrin deposition, mononuclear inflammatory cells with widespread degeneration/necrosis of the syncytiotrophoblast and microcalcification were pronounced in the SARS-CoV-2+HIV+ compared to the SARS-CoV-2+HIV- placentae. Vascular pathological changes included thrombi, ectasis, mural hypertrophy and atherotic vessels. Conclusion Elevated syncytial trophoblast injury, villitis, microcalcifications and mineralisation of the syncytial basement membrane in the AAP placentae may be due to SARS-CoV-2 viral transgression instead of HIV infection alone. Vascular malperfusion is suggestive of a hypoxic insult arising from a compensatory response to meet the fetal oxygen and nutrient demands of an AAP. Placentae from HIV infected women on antiretroviral treatment were characterised by vascular malperfusion.
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Dunk CE, Serghides L. Protease inhibitor-based antiretroviral therapy in pregnancy: effects on hormones, placenta, and decidua. Lancet HIV 2022; 9:e120-e129. [PMID: 34863352 DOI: 10.1016/s2352-3018(21)00249-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 06/13/2023]
Abstract
The use of antiretroviral therapy (ART) in pregnancy is important for maternal health, and has been successful in reducing vertical transmission rates to almost zero in those taking effective ART regimens with good adherence. However, there are reports of higher rates of low birthweight and preterm births in women with HIV, which can be further exacerbated by ART usage in pregnancy. Protease inhibitors, and ritonavir-boosted lopinavir in particular, might directly contribute to placental and uteroplacental pathology in part by altering plasma concentrations of the essential steroid hormones of pregnancy, progesterone and oestradiol. In this Review, we collate the increasing evidence of dysregulated maternal endocrinology, reproductive physiology, and placental compromise associated with protease inhibitors. Based on findings of placental and decidual effects, we recommend that ritonavir-boosted lopinavir should be avoided in pregnancy, in line with US and European guidelines. Long-term follow-up of children exposed to protease inhibitors in utero is also recommended.
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Affiliation(s)
- Caroline E Dunk
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada; Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
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Viral Infections During Pregnancy: The Big Challenge Threatening Maternal and Fetal Health. MATERNAL-FETAL MEDICINE 2022; 4:72-86. [PMID: 35187500 PMCID: PMC8843053 DOI: 10.1097/fm9.0000000000000133] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/11/2021] [Indexed: 12/18/2022] Open
Abstract
Viral infections during pregnancy are associated with adverse pregnancy outcomes, including maternal and fetal mortality, pregnancy loss, premature labor, and congenital anomalies. Mammalian gestation encounters an immunological paradox wherein the placenta balances the tolerance of an allogeneic fetus with protection against pathogens. Viruses cannot easily transmit from mother to fetus due to physical and immunological barriers at the maternal-fetal interface posing a restricted threat to the fetus and newborns. Despite this, the unknown strategies utilized by certain viruses could weaken the placental barrier to trigger severe maternal and fetal health issues especially through vertical transmission, which was not fully understood until now. In this review, we summarize diverse aspects of the major viral infections relevant to pregnancy, including the characteristics of pathogenesis, related maternal-fetal complications, and the underlying molecular and cellular mechanisms of vertical transmission. We highlight the fundamental signatures of complex placental defense mechanisms, which will prepare us to fight the next emerging and re-emerging infectious disease in the pregnancy population.
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Maswime S, Pule C, Mtshali Z, Chawana R, Matjila M. HIV, Placental Lesions, and Adverse Perinatal Outcomes. J Infect Dis 2021; 224:S691-S693. [PMID: 34882204 DOI: 10.1093/infdis/jiab494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Africa has the highest number of pregnant women with human immunodeficiency virus (HIV). In some studies, HIV has been associated with adverse perinatal outcomes. However, the pathophysiological mechanism leading to adverse fetal outcomes is not known. Maternal vascular malformation, chorioamnionitis, and decreased placental weight have been described as placental features associated with HIV in some studies. The use of antiretroviral therapy has reduced perinatal transmission of HIV and adverse fetal outcomes. However, placental mechanisms associated with HIV and the fetal immune response to maternal HIV infection are poorly understood. Additional research is required to understand whether altered maternal immunity in women living with HIV can trigger fetal responses leading to stillbirth or preterm birth.
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Affiliation(s)
- Salome Maswime
- Global Surgery Division, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Caroline Pule
- Global Surgery Division, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Zama Mtshali
- Division of Anatomical Pathology, Department of Pathology, National Institutes of Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard Chawana
- Global Surgery Division, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Mushi Matjila
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
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Ikumi NM, Matjila M, Gray CM, Anumba D, Pillay K. Placental pathology in women with HIV. Placenta 2021; 115:27-36. [PMID: 34537469 DOI: 10.1016/j.placenta.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/03/2021] [Accepted: 09/09/2021] [Indexed: 01/24/2023]
Abstract
Recognizing the importance of placental features and their unique functions can provide insight into maternal health, the uterine environment during the course of pregnancy, birth outcomes and neonatal health. In the context of HIV and antiretroviral therapy (ART), there have been great strides in the prevention of mother to child transmission of HIV. However, there is still paucity of data on the impact of HIV/ART exposure on placental pathology and studies available only examine specific patterns of placental injury, further justifying the need for a more defined and comprehensive approach to the differential diagnoses of HIV/ART-exposed placentae. The purpose of this review is to consolidate findings from individual studies that have been reported on patterns of placental injury in the context of HIV/ART exposure. In both the pre- and post-ART eras HIV and/or ART has been associated with placental injury including maternal vascular malperfusion as well as acute and chronic inflammation. These patterns of injury are further associated with adverse birth outcomes including preterm birth and current evidence suggests an association between poor placental function and compromised fetal development. With the ever increasing number of pregnant women with HIV on ART, there is a compelling need for full incorporation of placental diagnoses into obstetric disease classification. It is also important to take into account key elements of maternal clinical history. Lastly, there is a need to standardize the reporting of placental pathology in order to glean additional insight into the elucidation of HIV/ART associated placental injury.
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Affiliation(s)
- Nadia M Ikumi
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Mushi Matjila
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Clive M Gray
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Division of Molecular Biology and Human Genetics, Stellenbosch University, Cape Town, South Africa
| | - Dilly Anumba
- Academic Unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Komala Pillay
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa; National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa.
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Abstract
IMPORTANCE Rates of maternal sepsis are increasing, and prior studies of maternal sepsis have focused on immediate maternal morbidity and mortality associated with sepsis during delivery admission. There are no data on pregnancy outcomes among individuals who recover from their infections prior to delivery. OBJECTIVE To describe perinatal outcomes among patients with antepartum sepsis who did not deliver during their infection hospitalization. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted using data from August 1, 2012, to August 1, 2018, at an academic referral center in San Francisco, California. Included patients were all individuals with nonanomalous, singleton pregnancies who delivered after 20 weeks' gestation during the study period. Data were analyzed from March 2020 through March 2021. EXPOSURES Antepartum admission for infection with clinical concern for sepsis and hospital discharge prior to delivery. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of perinatal outcomes associated with placental dysfunction and consisted of 1 or more of the following: fetal growth restriction, oligohydramnios, hypertensive disease of pregnancy, cesarean delivery for fetal indication, child who is small for gestational age, or stillbirth. RESULTS Among 14 565 patients with nonanomalous singleton pregnancies (mean [SD] age at delivery, 33.1 [5.2] years), 59 individuals (0.4%) were in the sepsis group and 14 506 individuals (99.6%) were in the nonsepsis group; 8533 individuals (59.0%) were nulliparous. Patients with sepsis, compared with patients in the reference group, were younger (mean [SD] age at delivery, 30.6 [5.7] years vs 33.1 [5.2] years; P < .001), were more likely to have pregestational diabetes (5 individuals [8.5%] vs 233 individuals [1.6%]; P = .003), and had higher mean (SD) pregestational body mass index scores (26.1 [6.1] vs 24.4 [5.9]; P = .03). In the sepsis group, the most common infections were urinary tract infections (24 patients [40.7%]) and pulmonary infections (22 patients [37.3%]). Among patients with sepsis, 5 individuals (8.5%) were admitted to the intensive care unit, the mean (SD) gestational age at infection was 24.6 (9.0) weeks, and the median (interquartile range) time from infection to delivery was 82 (42-147) days. Antepartum sepsis was associated with higher odds of placental dysfunction (21 patients [35.6%] vs 3450 patients [23.8%]; odds ratio, 1.77; 95% CI, 1.04-3.02; P = .04). On multivariable logistic regression analysis, antepartum sepsis was an independent factor associated with placental dysfunction (adjusted odds ratio, 1.88; 95% CI, 1.10-3.23; P = .02) after adjusting for possible confounders. CONCLUSIONS AND RELEVANCE This study found that pregnancies complicated by antepartum sepsis were associated with higher odds of placental dysfunction. These findings suggest that increased antenatal surveillance should be considered for these patients.
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Affiliation(s)
- Christine A. Blauvelt
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of California, San Francisco
| | - Kiana C. Nguyen
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of California, San Francisco
| | - Arianna G. Cassidy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of California, San Francisco
| | - Stephanie L. Gaw
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of California, San Francisco
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Smithmyer ME, Mabula-Bwalya CM, Mwape H, Chipili G, Spelke BM, Kasaro MP, De Paris K, Vwalika B, Sebastião YV, Stringer JSA, Price JT. Circulating angiogenic factors and HIV among pregnant women in Zambia: a nested case-control study. BMC Pregnancy Childbirth 2021; 21:534. [PMID: 34320947 PMCID: PMC8317322 DOI: 10.1186/s12884-021-03965-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 06/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal HIV increases the risk of adverse birth outcomes including preterm birth, fetal growth restriction, and stillbirth, but the biological mechanism(s) underlying this increased risk are not well understood. We hypothesized that maternal HIV may lead to adverse birth outcomes through an imbalance in angiogenic factors involved in the vascular endothelial growth factor (VEGF) signaling pathway. METHODS In a case-control study nested within an ongoing cohort in Zambia, our primary outcomes were serum concentrations of VEGF-A, soluble endoglin (sEng), placental growth factor (PlGF), and soluble fms-like tyrosine kinase-1 (sFLT-1). These were measured in 57 women with HIV (cases) and 57 women without HIV (controls) before 16 gestational weeks. We used the Wilcoxon rank-sum and linear regression controlling for maternal body mass index (BMI) and parity to assess the difference in biomarker concentrations between cases and controls. We also used logistic regression to test for associations between biomarker concentration and adverse pregnancy outcomes (preeclampsia, preterm birth, small for gestational age, stillbirth, and a composite of preterm birth or stillbirth). RESULTS Compared to controls, women with HIV had significantly lower median concentrations of PlGF (7.6 vs 10.2 pg/mL, p = 0.02) and sFLT-1 (1647.9 vs 2055.6 pg/mL, p = 0.04), but these findings were not confirmed in adjusted analysis. PlGF concentration was lower among women who delivered preterm compared to those who delivered at term (6.7 vs 9.6 pg/mL, p = 0.03) and among those who experienced the composite adverse birth outcome (6.2 vs 9.8 pg/mL, p = 0.02). Median sFLT-1 concentration was lower among participants with the composite outcome (1621.0 vs 1945.9 pg/mL, p = 0.04), but the association was not significant in adjusted analysis. sEng was not associated with either adverse birth outcomes or HIV. VEGF-A was undetectable by Luminex in all specimens. CONCLUSIONS We present preliminary findings that HIV is associated with a shift in the VEGF signaling pathway in early pregnancy, although adjusted analyses were inconclusive. We confirm an association between angiogenic biomarkers and adverse birth outcomes in our population. Larger studies are needed to further elucidate the role of HIV on placental angiogenesis and adverse birth outcomes.
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Affiliation(s)
- Megan E Smithmyer
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Humphrey Mwape
- University of North Carolina Global Projects Zambia, Lusaka, Zambia
| | - Gabriel Chipili
- University of North Carolina Global Projects Zambia, Lusaka, Zambia
| | - Bridget M Spelke
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Margaret P Kasaro
- University of North Carolina Global Projects Zambia, Lusaka, Zambia
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Kristina De Paris
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Yuri V Sebastião
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jeffrey S A Stringer
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- University of North Carolina Global Projects Zambia, Lusaka, Zambia
| | - Joan T Price
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- University of North Carolina Global Projects Zambia, Lusaka, Zambia
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
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Cerveny L, Murthi P, Staud F. HIV in pregnancy: Mother-to-child transmission, pharmacotherapy, and toxicity. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166206. [PMID: 34197912 DOI: 10.1016/j.bbadis.2021.166206] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/18/2021] [Accepted: 06/11/2021] [Indexed: 12/15/2022]
Abstract
An estimated 1.3 million pregnant women were living with HIV in 2018. HIV infection is associated with adverse pregnancy outcomes and all HIV-positive pregnant women, regardless of their clinical stage, should receive a combination of antiretroviral drugs to suppress maternal viral load and prevent vertical fetal infection. Although antiretroviral treatment in pregnant women has undoubtedly minimized mother-to-child transmission of HIV, several uncertainties remain. For example, while pregnancy is accompanied by changes in pharmacokinetic parameters, relevant data from clinical studies are lacking. Similarly, long-term adverse effects of exposure to antiretrovirals on fetuses have not been studied in detail. Here, we review current knowledge on HIV effects on the placenta and developing fetus, recommended antiretroviral regimens, and pharmacokinetic considerations with particular focus on placental transport. We also discuss recent advances in antiretroviral research and potential effects of antiretroviral treatment on placental/fetal development and programming.
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Affiliation(s)
- Lukas Cerveny
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Padma Murthi
- Department of Medicine, School of Clinical Sciences, and Department of Pharmacology, Monash Biomedicine Discovery Institute Monash University, Clayton, Victoria, Australia; Hudson Institute of Medical Research, The Ritchie Centre, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Frantisek Staud
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic.
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12
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Bruce-Brand C, Schubert PT, Wright CA. HIV, placental pathology and birth outcomes - a brief overview. J Infect Dis 2021; 224:S683-S690. [PMID: 33987644 DOI: 10.1093/infdis/jiab240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The spectrum of placental pathology in human immunodeficiency virus (HIV) is vast. Features observed are not only limited to the effects of the virus itself but may include that of coinfections such as tuberculosis and syphilis. The presence of other comorbidities and changes as a result of antiretroviral therapy may further confound the histologic findings. There is a paucity of unbiased information of the effects of maternal HIV on the placenta and how these changes relate to birth outcomes. Antiretroviral therapy, now in widespread use, has altered the course of maternal HIV disease and it is unknown whether this has altered the pathophysiology of HIV on the placenta. HIV-associated placental findings that have been most well described include acute chorioamnionitis, low placental weight and maternal vascular malperfusion, with a tendency towards lower rates of chronic villitis.
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Affiliation(s)
- Cassandra Bruce-Brand
- Division of Anatomical Pathology, Tygerberg Hospital, National Health Laboratory Service, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Pawel T Schubert
- Division of Anatomical Pathology, Tygerberg Hospital, National Health Laboratory Service, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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13
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Bebell LM, Parks K, Le MH, Ngonzi J, Adong J, Boatin AA, Bassett IV, Siedner MJ, Gernand AD, Roberts DJ. Placental decidual arteriopathy and vascular endothelial growth factor A (VEGF-A) expression among women with and without HIV. J Infect Dis 2021; 224:S694-S700. [PMID: 33880547 DOI: 10.1093/infdis/jiab201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Women with HIV (WHIV) are at higher risk of adverse birth outcomes. Proposed mechanisms for the increased risk include placental arteriopathy (vasculopathy) and maternal vascular malperfusion (MVM) due to antiretroviral therapy (ART) and medical comorbidities. However, these features and their underlying pathophysiologic mechanisms have not been well characterized in WHIV. METHODS We performed gross and histologic examination and immunohistochemistry staining for vascular endothelial growth factor A (VEGF-A), a key angiogenic factor, on placentas from women with one or more MVM risk factors including: weight <5 th percentile, histologic infarct or distal villous hypoplasia, nevirapine-based ART, hypertension, and pre-eclampsia/eclampsia during pregnancy. We compared pathologic characteristics by maternal HIV serostatus. RESULTS A total of 27/41 (66%) placentas assessed for VEGF-A were from WHIV. Mean maternal age was 27 years. Among WHIV, median CD4 T-cell count was 440 cells/mm 3 and HIV viral load was undetectable in 74%. Of VEGF-A stained placentas, both decidua and villous endothelium tissue layers were present in 36 (88%). VEGF-A was detected in 31/36 (86%) with decidua present, and 39/40 (98%) with villous endothelium present. There were no differences in VEGF-A presence in any tissue type by maternal HIV serostatus (P=0.28-1.0). MVM was more common in placentas selected for VEGF-A staining (51 versus 8%, P<0.001). CONCLUSIONS VEGF-A immunostaining was highly prevalent, and staining pattern did not differ by maternal HIV serostatus among those with MVM risk factors, indicating the role of VEGF-A in placental vasculopathy may not differ by maternal HIV serostatus.
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Affiliation(s)
- Lisa M Bebell
- Massachusetts General Hospital Division of Infectious Diseases, Boston, MA, USA.,MassGeneral Global Health, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center of Massachusetts General Hospital, Boston, MA, USA
| | - Kalynn Parks
- Department of Nutritional Sciences, Pennsylvania State University, University Park, PA, USA
| | - Mylinh H Le
- Medical Practice Evaluation Center of Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Ngonzi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Julian Adong
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adeline A Boatin
- MassGeneral Global Health, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Department of Obstetrics and Gynecology, Boston, MA, USA
| | - Ingrid V Bassett
- Massachusetts General Hospital Division of Infectious Diseases, Boston, MA, USA.,Medical Practice Evaluation Center of Massachusetts General Hospital, Boston, MA, USA
| | - Mark J Siedner
- Massachusetts General Hospital Division of Infectious Diseases, Boston, MA, USA.,MassGeneral Global Health, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center of Massachusetts General Hospital, Boston, MA, USA
| | - Alison D Gernand
- Department of Nutritional Sciences, Pennsylvania State University, University Park, PA, USA
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14
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Ikumi NM, Pillay K, Tilburgs T, Malaba TR, Dzanibe S, Enninga EAL, Chakraborty R, Lamorde M, Myer L, Khoo S, Jaspan HB, Gray CM. T cell Homeostatic Imbalance in Placentae from Women with HIV in the absence of Vertical Transmission. J Infect Dis 2021; 224:S670-S682. [PMID: 33880544 DOI: 10.1093/infdis/jiab192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Implementation of universal antiretroviral therapy (ART) has significantly lowered vertical transmission rates but has also increased numbers of HIV-exposed uninfected children (HEU), who remain vulnerable to morbidities. Here, we investigated whether T cell alterations in the placenta contribute to altered immune status in HEU. METHODS We analyzed T cells from term placentae decidua and villous tissue and paired cord blood from pregnant women with HIV (PWH) who initiated ART late in pregnancy (n=21) with pregnant women not living with HIV (PWNH) (n=9). RESULTS Placentae from PWH showed inverted CD4:CD8 ratios and higher proportions of tissue resident CD8+ T cells in villous tissue relative to control placentae. CD8+ T cells in the fetal capillaries, which were of fetal origin, positively correlated with maternal plasma viraemia prior to ART initiation, implying that imbalanced T cells persisted throughout pregnancy. Additionally, the expanded memory differentiation of CD8+ T cells was confined to the fetal placental compartment and cord blood but was not observed in the maternal decidua. CONCLUSIONS T cell homeostatic imbalance in the blood circulation of PWH is reflected in the placenta. The placenta may be a causal link between HIV-induced maternal immune changes during gestation and altered immunity in newborn infants in the absence of vertical transmission.
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Affiliation(s)
- Nadia M Ikumi
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Komala Pillay
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa.,Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Tamara Tilburgs
- Division of Immunobiology, Center for Inflammation and Tolerance, Cincinnati Children's Hospital, Cincinnati OH 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati OH 45229, USA
| | - Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Sonwabile Dzanibe
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | | | - Rana Chakraborty
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.,Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Minnesota, USA.,Department of Immunology, Mayo Clinic, Rochester, MN
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Saye Khoo
- Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.,Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Heather B Jaspan
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Clive M Gray
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa.,National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa.,Department of Pathology, University of Cape Town, Cape Town, South Africa
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15
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Davis J, Mire E. Maternal obesity and developmental programming of neuropsychiatric disorders: An inflammatory hypothesis. Brain Neurosci Adv 2021; 5:23982128211003484. [PMID: 33889757 PMCID: PMC8040564 DOI: 10.1177/23982128211003484] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/09/2021] [Indexed: 12/19/2022] Open
Abstract
Maternal obesity is associated with the development of a variety of neuropsychiatric disorders; however, the mechanisms behind this association are not fully understood. Comparison between maternal immune activation and maternal obesity reveals similarities in associated impairments and maternal cytokine profile. Here, we present a summary of recent evidence describing how inflammatory processes contribute towards the development of neuropsychiatric disorders in the offspring of obese mothers. This includes discussion on how maternal cytokine levels, fatty acids and placental inflammation may interact with foetal neurodevelopment through changes to microglial behaviour and epigenetic modification. We also propose an exosome-mediated mechanism for the disruption of brain development under maternal obesity and discuss potential intervention strategies.
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Affiliation(s)
- Jonathan Davis
- Hodge Centre for Neuropsychiatric Immunology, Neuroscience and Mental Health Research Institute, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Erik Mire
- Hodge Centre for Neuropsychiatric Immunology, Neuroscience and Mental Health Research Institute, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
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16
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IKUMI NM, MALABA TR, PILLAY K, COHEN MC, MADLALA HP, MATJILA M, ANUMBA D, MYER L, NEWELL ML, GRAY CM. Differential impact of antiretroviral therapy initiated before or during pregnancy on placenta pathology in HIV-positive women. AIDS 2021; 35:717-726. [PMID: 33724257 PMCID: PMC8630811 DOI: 10.1097/qad.0000000000002824] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the association between timing of antiretroviral treatment (ART) initiation in HIV-infected women and placental histopathology. DESIGN A nested substudy in a larger cohort of HIV-infected women which examined the association between ART status and birth outcomes. METHODS Placentas (n = 130) were examined for histopathology from two ART groups: stable (n = 53), who initiated ART before conception and initiating (n = 77), who started ART during pregnancy [median (interquartile range) 15 weeks gestation (11-18)]. Using binomial regression we quantified associations between ART initiation timing with placental histopathology and pregnancy outcomes. RESULTS One-third of all placentas were less than 10th percentile weight-for-gestation and there was no significant difference between ART groups. Placental diameter, thickness, cord insertion position and foetal-placental weight ratio were also similar by group. However, placentas from the stable group showed increased maternal vascular malperfusion (MVM) (39.6 vs. 19.4%), and decreased weight (392 vs. 422 g, P = 0.09). MVM risk was twice as high [risk ratios 2.03 (95% confidence interval: 1.16-3.57); P = 0.01] in the stable group; the increased risk remaining significant when adjusting for maternal age [risk ratios 2.04 (95% confidence interval: 1.12-3.72); P = 0.02]. Furthermore, MVM was significantly associated with preterm delivery and low birth weight (P = 0.002 and <0.0001, respectively). CONCLUSION Preconception initiation of ART was associated with an increased MVM risk, and may contribute to placental dysfunction. The association between MVM with preterm delivery and low birth weight suggests that a placenta-mediated mechanism likely links the putative association between long-term use of ART and adverse birth outcomes.
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Affiliation(s)
- Nadia M IKUMI
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Thokozile R MALABA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Komala PILLAY
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
| | - Marta C COHEN
- Department of Histopathology, Sheffield Children’s NHS Foundation Trust , Sheffield, UK
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK, Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town South Africa
| | - Hlengiwe P MADLALA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mushi MATJILA
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town South Africa
| | - Dilly ANUMBA
- Academic Unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Landon MYER
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Marie-Louise NEWELL
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Clive M GRAY
- Division of Immunology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
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17
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Rittenhouse KJ, Mwape H, Nelson JA, Mwale J, Chipili G, Price JT, Hudgens M, Stringer EM, De Paris K, Vwalika B, Stringer JS. Maternal HIV, antiretroviral timing, and spontaneous preterm birth in an urban Zambian cohort: the role of local and systemic inflammation. AIDS 2021; 35:555-565. [PMID: 33394679 PMCID: PMC7944942 DOI: 10.1097/qad.0000000000002808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess plasma and vaginal inflammation in three antenatal groups (HIV-uninfected women, HIV-infected women entering care on preconceptional ART, and HIV-infected women not on preconceptional ART) and whether these measures are associated with spontaneous preterm birth (sPTB). DESIGN Case--control study nested within a pregnancy cohort in Lusaka, Zambia. METHODS We analyzed 11 pro-inflammatory and two anti-inflammatory markers in 207 women with paired plasma and vaginal specimens collected between 16 and 20 gestational weeks. Among 51 HIV-infected women, we repeated the assays in 24-34-week samples. We used confirmatory factor analysis to create inflammation scores and compared them among the three groups. RESULTS At baseline, HIV-infected women not on ART had higher vaginal pro-inflammatory scores than HIV-uninfected women [mean 0.37 (95% CI -0.06 to 0.80) vs. -0.02 (-0.32 to 0.27), P = 0.02]. In repeat testing, women not on preconceptional ART had an increase in vaginal inflammation between the baseline and 24-34-week visits compared with those continuing preconceptional ART [mean 0.62 (95% CI -0.80 to 4.20) vs. -0.07 (-2.78 to 2.11), P = 0.04]. In multivariate analyses, baseline vaginal inflammation predicted sPTB (aOR 1.5; 95% CI 1.0-2.3; P = 0.02). Plasma inflammation did not differ by HIV or ART exposure and was not associated with sPTB. CONCLUSION Women not receiving ART at entry into pregnancy care had more vaginal inflammation than women entering on treatment. They also experienced an increase in vaginal inflammation between the two sampling timepoints, possibly as a consequence of ART initiation. Vaginal (but not systemic) inflammation was associated with sPTB and offers a potential mechanistic insight into this important adverse birth outcome.
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Affiliation(s)
- Katelyn J. Rittenhouse
- University of North Carolina at Chapel Hill, Chapel Hill, USA
- University of North Carolina Global Projects-Zambia, Lusaka, Zambia
| | - Humphrey Mwape
- University of North Carolina Global Projects-Zambia, Lusaka, Zambia
| | | | - John Mwale
- University of North Carolina Global Projects-Zambia, Lusaka, Zambia
| | - Gabriel Chipili
- University of North Carolina Global Projects-Zambia, Lusaka, Zambia
| | - Joan T. Price
- University of North Carolina at Chapel Hill, Chapel Hill, USA
- University of North Carolina Global Projects-Zambia, Lusaka, Zambia
| | - Michael Hudgens
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Elizabeth M. Stringer
- University of North Carolina at Chapel Hill, Chapel Hill, USA
- University of North Carolina Global Projects-Zambia, Lusaka, Zambia
| | | | | | - Jeffrey S.A. Stringer
- University of North Carolina at Chapel Hill, Chapel Hill, USA
- University of North Carolina Global Projects-Zambia, Lusaka, Zambia
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18
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Blanche S. Mini review: Prevention of mother-child transmission of HIV: 25 years of continuous progress toward the eradication of pediatric AIDS? Virulence 2021; 11:14-22. [PMID: 31885324 PMCID: PMC6961731 DOI: 10.1080/21505594.2019.1697136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Prevention of mother-to-child transmission with antiretrovirals is extraordinarily effective. When medically well followed, a mother living with human immunodeficiency virus can now expect to avoid transmitting the virus to her child. Despite the immense difficulties inherent in the global implementation of this treatment, the virtual disappearance of pediatric AIDS can be considered in the long term.
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Affiliation(s)
- Stéphane Blanche
- Pediatric Immunology-Hematology Unit, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP) and Faculté de Médecine Paris Descartes, Paris, France
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19
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Yampolsky M, Shlakhter O, Deng D, Kala S, Walmsley SL, Murphy KE, Yudin MH, MacGillivray J, Loutfy M, Dunk C, Serghides L. Exploring the impact of HIV infection and antiretroviral therapy on placenta morphology. Placenta 2020; 104:102-109. [PMID: 33310298 DOI: 10.1016/j.placenta.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/05/2020] [Accepted: 12/03/2020] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Women living with HIV experience more adverse birth outcomes; the mechanisms are not fully understood. We examined placenta morphology and associations with birth outcomes in a Canadian cohort of women living with HIV (HIV+) on antiretroviral therapy (ART) from conception and HIV-uninfected (HIV-) women. METHODS Term placentas from 94 women (40 HIV-, 54 HIV+) were studied. Trimmed placenta weight was collected. Placenta digital photos were used to compute morphometric parameters. Regression models investigated associations between log-transformed placenta parameters and birth outcomes. RESULTS We observed a trend towards lower placenta weight and smaller placenta area in the HIV+ group, both of which were significantly associated with small for gestational age births. HIV+ serostatus was associated with 6-fold (95%CI 2-20) greater odds of having placenta area in the lowest quartile (<236 cm2). Cord marginality (distance from the edge) was significantly lower in the HIV+ group (p = 0.004), with 35% of placenta having an abnormal (marginal or velamentous) cord insertion vs. 12.5% in the HIV- group (p = 0.01). Velamentous cord insertion was seen in 13% of placentas in the HIV+ vs. 0% in HIV- group (p = 0.02). A significant correlation between cord marginality and placenta thickness was observed in the HIV- group, with a more marginal cord being associated with a thicker placenta. This correlation was not observed in the HIV+ group. HIV+ placentas exposed to protease inhibitors were significantly less circular compared to the HIV- group (p = 0.03). CONCLUSION Our data suggest that HIV/ART exposure affects placenta morphology and is associated with higher rates of abnormal cord insertion.
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Affiliation(s)
| | | | - Dianna Deng
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Smriti Kala
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Sharon L Walmsley
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Kellie E Murphy
- Department of Obstetrics and Gynaecology, Sinai Health System, University of Toronto, Toronto, Canada
| | - Mark H Yudin
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Jay MacGillivray
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Canada; Ryerson University, Toronto, Canada
| | - Mona Loutfy
- Department of Medicine, University of Toronto, Toronto, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Caroline Dunk
- Research Centre for Women's and Infants' Health, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Sinai Health System, Toronto, Canada
| | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Canada; Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Canada.
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20
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Kala S, Dunk C, Acosta S, Serghides L. Periconceptional exposure to lopinavir, but not darunavir, impairs decidualization: a potential mechanism leading to poor birth outcomes in HIV-positive pregnancies. Hum Reprod 2020; 35:1781-1796. [PMID: 32712670 PMCID: PMC7398624 DOI: 10.1093/humrep/deaa151] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION Does HIV protease inhibitor (PI)-based combination antiretroviral therapy (cART) initiated at periconception affect key events in early pregnancy, i.e. decidualization and spiral artery remodeling? SUMMARY ANSWER Two PIs, lopinavir and darunavir, currently offered as cART options in HIV-positive pregnancies were evaluated, and we found that lopinavir-based cART, but not darunavir-based cART, impaired uterine decidualization and spiral artery remodeling in both human ex vivo and mouse in vivo experimental models. WHAT IS KNOWN ALREADY Early initiation of cART is recommended for pregnant women living with HIV. However, poor birth outcomes are frequently observed in HIV-positive pregnancies exposed to PI-based cART, especially when it is initiated prior to conception. The correlation between early initiation of PI-cART and adverse birth outcomes is poorly understood, due to lack of data on the specific effects of PI-cART on the early stages of pregnancy involving uterine decidualization and spiral artery remodeling. STUDY DESIGN, SIZE, DURATION Lopinavir and darunavir were evaluated in clinically relevant combinations using an ex vivo human first-trimester placenta-decidua explant model, an in vitro human primary decidual cell culture system, and an in vivo mouse pregnancy model. The first-trimester (gestational age, 6–8 weeks) human placenta-decidua tissue was obtained from 11 to 15 healthy women undergoing elective termination of pregnancy. C57Bl/6 female mice (four/treatment group) were administered either lopinavir-cART, darunavir-cART or water by oral gavage once daily starting on the day of plug detection until sacrifice. PARTICIPANTS/MATERIALS, SETTING, METHODS Human: Spiral artery remodeling was assessed by immunohistochemical analysis of first-trimester placenta-decidua explant co-culture system. Trophoblast migration was measured using a placental explant culture. A primary decidual cell culture was used to evaluate the viability of immune cell populations by flow cytometry. Soluble factors, including biomarkers of decidualization and angiogenesis, were quantified by ELISA and Luminex assay using decidua-conditioned media. Mouse: In the mouse pregnancy model, gestational day 6.5 or 9.5 implantation sites were used to assess decidualization, spiral artery remodeling and uterine natural killer (uNK) cell numbers by immunohistochemistry. Transcription factor STAT3 was assayed by immunohistochemistry in both human decidua and mouse implantation sites. MAIN RESULTS AND THE ROLE OF CHANCE Lopinavir-cART, but not darunavir-cART, impaired uterine decidualization and spiral artery remodeling in both experimental models. Lopinavir-cART treatment was also associated with selective depletion of uNK cells, reduced trophoblast migration and defective placentation. The lopinavir-associated decidualization defects were attributed to a decrease in expression of transcription factor STAT3, known to regulate decidualization. Our results suggest that periconceptional initiation of lopinavir-cART, but not darunavir-cART, causes defective maturation of the uterine endometrium, leading to impairments in spiral artery remodeling and placentation, thus contributing to the poor birth outcomes. LARGE SCALE DATA N/A LIMITATIONS, REASONS FOR CAUTION The human first-trimester placenta/decidua samples could only be obtained from healthy females undergoing elective termination of pregnancy. As biopsy is the only way to obtain first-trimester decidua from pregnant women living with HIV on PI-cART, ethics approval and participant consent are difficult to obtain. Furthermore, our animal model is limited to the study of cART and does not include HIV. HIV infection is also associated with immune dysregulation, inflammation, alterations in angiogenic factors and complement activation, all of which could influence decidual and placental vascular remodeling and modify any cART effects. WIDER IMPLICATIONS OF THE FINDINGS Our findings provide mechanistic insight with direct clinical implications, rationalizing why the highest adverse birth outcomes are reported in HIV-positive pregnancies exposed to lopinavir-cART from conception. We demonstrate that dysregulation of decidualization is the mechanism through which lopinavir-cART, but not darunavir-cART, use in early pregnancy leads to poor birth outcomes. Although lopinavir is no longer a first-line regimen in pregnancy, it remains an alternate regimen and is often the only PI available in low resource settings. Our results highlight the need for reconsidering current guidelines recommending lopinavir use in pregnancy and indicate that lopinavir should be avoided especially in the first trimester, whereas darunavir is safe to use and should be the preferred PI in pregnancy. Further, in current times of the COVID-19 pandemic, lopinavir is among the top drug candidates which are being repurposed for inclusion in clinical trials world-over, to assess their therapeutic potential against the dangerous respiratory disease. Current trials are also testing the efficacy of lopinavir given prophylactically to protect health care workers and people with potential exposures. Given the current extraordinary numbers, these might include women with early pregnancies, who may or may not be cognizant of their gestational status. This is a matter of concern as it could mean that women with early pregnancies might be exposed to this drug, which can cause decidualization defects. Our findings provide evidence of safety concerns surrounding lopinavir use in pregnancy, that women of reproductive age considering participation in such trials should be made aware of, so they can make a fully informed decision. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by funding from the Canadian Institutes of Health Research (CIHR) (PJT-148684 and MOP-130398 to L.S.). C.D. received support from CIHR Foundation (FDN143262 to Stephen Lye). S.K. received a TGHRI postdoctoral fellowship. The authors declare that there are no conflicts of interest. L.S. reports personal fees from ViiV Healthcare for participation in a Women and Transgender Think Tank.
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Affiliation(s)
- Smriti Kala
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Caroline Dunk
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Sebastian Acosta
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
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21
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dos Reis HLB, Boldrini NAT, Rangel AFR, Barros VF, Merçon de Vargas PR, Miranda AE. Placental growth disorders and perinatal adverse outcomes in Brazilian HIV-infected pregnant women. PLoS One 2020; 15:e0231938. [PMID: 32352999 PMCID: PMC7192492 DOI: 10.1371/journal.pone.0231938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 04/03/2020] [Indexed: 12/18/2022] Open
Abstract
Fetal and placental growth disorders are common in maternal human immunodeficiency virus (HIV) infection and can be attributed to both the infection and comorbidities not associated with HIV. We describe placental growth disorders and adverse reproductive outcomes in HIV-infected pregnant women whose delivery occurred between 2001-2014 in Vitoria, Brazil. Cases with gestational age (GA) ≥ than 22 weeks validated by ultrasonography, with placental and fetal weight dimensions at birth, were studied. Outcomes were summarized as proportions of small (SGA), appropriate (AGA), and large (LGA) for GA when the z-score values were below -1.28, between -1.28 and +1.28, or above +1.28, respectively. Of 187 fetal attachment requisitions, 122(65.2%) women and their newborns participated in the study. The median maternal age was 28 years and 81(66.4%) underwent ≥ 6 prenatal visits. A total of 81(66.4%) were diagnosed before current pregnancy; 68(55.7%) exhibited criteria for acquired immunodeficiency syndrome (AIDS); 64(52.4%) had detectable viral load; 25(20.5%) cases presented SGA placental weight and 6(4.9%) SGA placental thickness. SGA placental area was observed in 41(33.6%) cases, and among the SGA placental weight cases 12(48%) were also SGA fetal weight. Preterm birth (PTB) occurred in 15.6%(19/122) of cases; perinatal death in 4.1%(5/122) and HIV vertical transmission in 6 of 122 (4.9%). Women, ≥36 years old, were 5.7 times more likely to have PTB than those under 36. Also, patients with AIDS-defining criteria were 3.7 times more likely to have PTB. Prenatal care was inversely associated with PTB. Statistically significant associations were observed between AGA placental area and Protease Inhibitor usage and between SGA placental weight and SGA area. We found a prevalence of placental growth disorders in HIV-infected pregnant women and values higher than international reference values. The restriction of placental growth was a common disorder, possibly attributed to virus effects or a combination of antiretroviral regimens.
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Affiliation(s)
- Helena Lucia Barroso dos Reis
- Post-Graduate Program of Infectious Diseases, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
- * E-mail:
| | | | - Ana Fernanda Ribeiro Rangel
- Department of Pathology, Pathology Laboratory of Cassiano Antonio Moraes University Hospital, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
| | - Vinicius Felipe Barros
- Department of Pathology, Pathology Laboratory of Cassiano Antonio Moraes University Hospital, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
| | - Paulo Roberto Merçon de Vargas
- Department of Pathology, Pathology Laboratory of Cassiano Antonio Moraes University Hospital, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
| | - Angélica Espinosa Miranda
- Post-Graduate Program of Infectious Diseases, Federal University of Espírito Santo, Vitória, Espírito Santo State, Brazil
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22
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Freriksen JJM, Schalkwijk S, Colbers AP, Abduljalil K, Russel FGM, Burger DM, Greupink R. Assessment of Maternal and Fetal Dolutegravir Exposure by Integrating Ex Vivo Placental Perfusion Data and Physiologically-Based Pharmacokinetic Modeling. Clin Pharmacol Ther 2020; 107:1352-1361. [PMID: 31868223 PMCID: PMC7325314 DOI: 10.1002/cpt.1748] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/22/2019] [Indexed: 12/13/2022]
Abstract
Antiretroviral therapy during pregnancy reduces the risk of vertical HIV‐1 transmission. However, drug dosing is challenging as pharmacokinetics (PK) may be altered during pregnancy. We combined a pregnancy physiologically‐based pharmacokinetic (PBPK) modeling approach with data on placental drug transfer to simulate maternal and fetal exposure to dolutegravir (DTG). First, a PBPK model for DTG exposure in healthy volunteers was established based on physiological and DTG PK data. Next, the model was extended with a fetoplacental unit using transplacental kinetics obtained by performing ex vivo dual‐side human cotyledon perfusion experiments. Simulations of fetal exposure after maternal dosing in the third trimester were in accordance with clinically observed DTG cord blood data. Furthermore, the predicted fetal trough plasma concentration (Ctrough) following 50 mg q.d. dosing remained above the concentration that results in 90% of viral inhibition. Our integrated approach enables simulation of maternal and fetal DTG exposure, illustrating this to be a promising way to assess DTG PK during pregnancy.
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Affiliation(s)
- Jolien J M Freriksen
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stein Schalkwijk
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Angela P Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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23
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Tiam A, Kassaye SG, Machekano R, Tukei V, Gill MM, Mokone M, Letsie M, Tsietso M, Seipati I, Barasa J, Isavwa A, Tylleskär T, Guay L. Comparison of 6-week PMTCT outcomes for HIV-exposed and HIV-unexposed infants in the era of lifelong ART: Results from an observational prospective cohort study. PLoS One 2019; 14:e0226339. [PMID: 31877153 PMCID: PMC6932788 DOI: 10.1371/journal.pone.0226339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/25/2019] [Indexed: 01/04/2023] Open
Abstract
Background Lifelong antiretroviral therapy (ART) reduces mother-to-child HIV transmission (MTCT) and improves maternal health. Data on the outcomes of HIV-exposed infants (HEI) compared to their unexposed counterparts in the era of universal ART is limited. We compared birth and 6-week outcomes among infants born to HIV-positive and HIV-negative women in Lesotho. Methods 941 HIV-negative and 653 HIV-positive pregnant women were enrolled in an observational cohort to evaluate the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) program after implementation of universal maternal ART in 14 health facilities. Pregnancy, delivery, birth, and 6-week data were collected through participant interviews and medical record review. DNA PCR testing for HEI was conducted within 2 weeks of birth and at around 6 weeks of age. Data were analysed to estimate the distribution of birth outcomes, mortality, HIV transmission and HIV-free survival at 6 weeks. Results HIV-positive women were older (mean age of 28.7 vs. 24.4 years) and presented for antenatal care earlier (mean gestational age of 23.0 weeks vs 25.3 weeks) than HIV-negative women. Prematurity was more frequent among HEI, 7.8% vs. 3.6%. There was no difference in rates of congenital anomalies between HEI (1.0%) and HIV-unexposed infants (HUI) (0.6%). Cumulative HIV transmission was 0.9% (N = 4/431) (95% CI:0.25–2.36) at birth and 1.0% (N = 6/583) (95% CI:0.38–2.23) at 6 weeks. Overall mortality, including stillbirths, was 5.2% and 6.0% by 6 weeks for HUI and HEI respectively. Among liveborn infants, 6-week HIV-free survival for HEI was 95.6% (95% CI:93.7–97.1) compared to 96.8% (95% CI:95.4–97.9) survival for HUI. Conclusions Implementation of universal maternal ART lowers MTCT at 6 weeks of age with no differences in congenital anomalies or early mortality between HIV exposed Infants and HIV unexposed infants. However, HIV exposed infants continue to have high rates of prematurity despite improved maternal health on ART.
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Affiliation(s)
- Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
- Centre for International Health, University of Bergen, Bergen, Norway
- * E-mail:
| | - Seble G. Kassaye
- Department of Medicine Georgetown University School of Medicine, Washington D.C., United States of America
| | - Rhoderick Machekano
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
| | - Vincent Tukei
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
| | | | | | | | | | - Janety Barasa
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Anthony Isavwa
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | | | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation, Washington D.C., United States of America
- Department of Epidemiology and Biostatistics, George Washington University Milken Institute School of Public Health, Washington D.C., United States of America
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24
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Placental Structure in Preterm Birth Among HIV-Positive Versus HIV-Negative Women in Kenya. J Acquir Immune Defic Syndr 2019; 80:94-102. [PMID: 30272633 PMCID: PMC6289800 DOI: 10.1097/qai.0000000000001871] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Preterm birth (PTB) is a major cause of infant morbidity and mortality in developing countries. Recent data suggest that in addition to Human Immunodeficiency Virus (HIV) infection, use of antiretroviral therapy (ART) increases the risk of PTB. As the mechanisms remain unexplored, we conducted this study to determine whether HIV and ART were associated with placental changes that could contribute to PTB. Setting: We collected and evaluated placentas from 38 HIV-positive women on ART and 43 HIV-negative women who had preterm deliveries in Nairobi, Kenya. Methods: Anatomical features of the placentas were examined at gross and microscopic levels. Cases were matched for gestational age and compared by the investigators who were blinded to maternal HIV serostatus. Results: Among preterm placentas, HIV infection was significantly associated with thrombosis (P = 0.001), infarction (P = 0.032), anomalies in cord insertion (P = 0.02), gross evidence of membrane infection (P = 0.043), and reduced placental thickness (P = 0.010). Overall, preterm placentas in both groups were associated with immature villi, syncytial knotting, villitis, and deciduitis. Features of HIV-positive versus HIV-negative placentas included significant fibrinoid deposition with villus degeneration, syncytiotrophoblast delamination, red blood cell adhesion, hypervascularity, and reduction in both surface area and perimeter of the terminal villi. Conclusions: These results imply that HIV infection and/or ART are associated with morphological changes in preterm placentas that contribute to delivery before 37 weeks. Hypervascularity suggests that the observed pathologies may be attributable, in part, to hypoxia. Further research to explore potential mechanisms will help elucidate the pathways that are involved perhaps pointing to interventions for decreasing the risk of prematurity among HIV-positive women.
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25
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Weckman AM, Ngai M, Wright J, McDonald CR, Kain KC. The Impact of Infection in Pregnancy on Placental Vascular Development and Adverse Birth Outcomes. Front Microbiol 2019; 10:1924. [PMID: 31507551 PMCID: PMC6713994 DOI: 10.3389/fmicb.2019.01924] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/05/2019] [Indexed: 12/16/2022] Open
Abstract
Healthy fetal development is dependent on nutrient and oxygen transfer via the placenta. Optimal growth and function of placental vasculature is therefore essential to support in utero development. Vasculogenesis, the de novo formation of blood vessels, and angiogenesis, the branching and remodeling of existing vasculature, mediate the development and maturation of placental villi, which form the materno-fetal interface. Several lines of evidence indicate that systemic maternal infection and consequent inflammation can disrupt placental vasculogenesis and angiogenesis. The resulting alterations in placental hemodynamics impact fetal growth and contribute to poor birth outcomes including preterm delivery, small-for-gestational age (SGA), stillbirth, and low birth weight (LBW). Furthermore, pathways involved in maternal immune activation and placental vascularization parallel those involved in normal fetal development, notably neurovascular development. Therefore, immune-mediated disruption of angiogenic pathways at the materno-fetal interface may also have long-term neurological consequences for offspring. Here, we review current literature evaluating the influence of maternal infection and immune activation at the materno-fetal interface and the subsequent impact on placental vascular function and birth outcome. Immunomodulatory pathways, including chemokines and cytokines released in response to maternal infection, interact closely with the principal pathways regulating placental vascular development, including the angiopoietin-Tie-2, vascular endothelial growth factor (VEGF), and placental growth factor (PlGF) pathways. A detailed mechanistic understanding of how maternal infections impact placental and fetal development is critical to the design of effective interventions to promote placental growth and function and thereby reduce adverse birth outcomes.
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Affiliation(s)
- Andrea M Weckman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Michelle Ngai
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Julie Wright
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Chloe R McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Kevin C Kain
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
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26
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Springer PE, Slogrove AL, Kidd M, Kalk E, Bettinger JA, Esser MM, Cotton MF, Zunza M, Molteno CD, Kruger M. Neurodevelopmental and behavioural outcomes of HIV-exposed uninfected and HIV-unexposed children at 2-3 years of age in Cape Town, South Africa. AIDS Care 2019; 32:411-419. [PMID: 31280587 DOI: 10.1080/09540121.2019.1637506] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Successful vertical HIV transmission prevention programmes (VTP) have resulted in an expanding population of HIV-exposed uninfected (HEU) infants whose growth, health and neurodevelopmental outcomes could have consequences for future resource allocation. We compared neurodevelopmental and behavioural outcomes in a prospective cohort of 2-3 year old HEU and HIV-unexposed uninfected (HU) children.Women living with and without HIV and their infants were enrolled within three days of birth from a low-risk midwife obstetric unit in Cape Town, South Africa during 2012 and 2013, under WHO Option A VTP guidelines. HIV-uninfected children aged 30-42 months were assessed using the Bayley scales of Infant Development-Third edition (BSID) and Strengths and Difficulties questionnaire (SDQ).Thirty-two HEU and 27 HU children (mean birth weight 3048g vs 3096g) were assessed. HEU children performed as well as HU children on BSID cognitive, language and motor domains. Mean scores fell within the low average range. Mothers of HEU children reported fewer conduct problems but stunting was associated with increased total difficulties on the SDQ.HEU and HU children's performance on the BSID was similar. In this low-risk cohort, HIV exposure did not confer additional risk. Stunting was associated with increased behavioural problems irrespective of HIV exposure.
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Affiliation(s)
- P E Springer
- Department of Paediatrics and Child Health and Tygerberg Hospital, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A L Slogrove
- Department of Paediatrics and Child Health and Tygerberg Hospital, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Ukwanda Centre for Rural Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - M Kidd
- Centre for Statistical Consultation, Stellenbosch University, Stellenbosch, South Africa
| | - E Kalk
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - J A Bettinger
- Vaccine Evaluation Center, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - M M Esser
- Immunology Unit, Medical Microbiology, National Health Laboratory Service Tygerberg, Department of Pathology, Stellenbosch University, Cape Town, South Africa
| | - M F Cotton
- Department of Paediatrics and Child Health and Tygerberg Hospital, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Family Clinical Research Unit, Tygerberg Hospital and Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa
| | - M Zunza
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - C D Molteno
- Department of Psychiatry, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - M Kruger
- Department of Paediatrics and Child Health and Tygerberg Hospital, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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27
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Ogunlola M, Reddy P, Sibiya MN, O'Connor L, Borg D, Haffejee F, Ghuman S, Ngxongo T, Govender N. Circulating soluble fms-like tyrosine kinase-1, soluble endoglin and placental growth factor during pregnancy in normotensive women in KwaZulu-Natal, South Africa. Afr Health Sci 2019; 19:1821-1832. [PMID: 31656464 PMCID: PMC6794537 DOI: 10.4314/ahs.v19i2.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Based on the increased pre-eclampsia and HIV antenatal incidence in South Africa, we determined the angiogenic profiles due to its mechanistic link in preeclampsia development, throughout uncomplicated pregnancies in HIV positive and negative women. OBJECTIVE To determine the angiogenic profiles throughout uncomplicated pregnancies in HIV positive and HIV negative women. We explored possible correlations between angiogenic serum levels and selected maternal characteristics (HIV status, gestational age, maternal factors, and pregnancy outcomes). METHOD This study was conducted at a primary health care facility in Durban, South Africa. Forty-six pregnant women aged 18-45 years, were enrolled at 10-20, 22-30 and 32-38 weeks' gestation, respectively through convenient sampling. Serum samples were collected and quantitatively evaluated using ELISAs. Clinical and epidemiological data were analysed using STATA (version 14). A probability level of p < 0.05 was considered statistically significant. RESULTS Of those enrolled, 28.3% were nulliparous, 82% were HIV positive and none developed pre-eclampsia. Systolic and diastolic blood pressure increased slightly throughout pregnancy. Fluctuating angiogenic and anti-angiogenic levels were demonstrated during pregnancy. CONCLUSION This study contributes to the current angiogenic knowledge in normotensive pregnancies, and may assist as a reference range against which these factors may be compared in HIV complicated pregnancies.
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Affiliation(s)
- Muhammed Ogunlola
- Department of Community Health Studies, Faculty of Health Sciences, Durban University of Technology
| | - Poovendhree Reddy
- Department of Community Health Studies, Faculty of Health Sciences, Durban University of Technology
| | - Maureen N Sibiya
- Faculty of Health Sciences, Durban University of Technology, Durban, South Africa
| | - Laura O'Connor
- Department of Chiropractic and Somatology, Faculty of Health Sciences, Durban University of Technology, SA
| | - Dorinda Borg
- Department of Chiropractic and Somatology, Faculty of Health Sciences, Durban University of Technology, SA
| | - Firoza Haffejee
- Department of Basic Medical Sciences, Durban University of Technology, Durban, South Africa
| | - Shanaz Ghuman
- Department of Community Health Studies, Faculty of Health Sciences, Durban University of Technology
| | - Thembelihle Ngxongo
- Department of Nursing, Faculty of Health Sciences, Durban University of Technology, SA
| | - Nalini Govender
- Department of Basic Medical Sciences, Durban University of Technology, Durban, South Africa
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28
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Price JT, Vwalika B, Winston J, Kumwenda A, Lubeya MK, Rittenhouse KJ, Stringer E, Kasaro MP, Stringer JSA. HIV serostatus, viral load, and midtrimester cervical length in a Zambian prenatal cohort. Int J Gynaecol Obstet 2019; 146:206-211. [PMID: 30973655 DOI: 10.1002/ijgo.12823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 11/12/2018] [Accepted: 04/10/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate whether maternal HIV serostatus and plasma viral load (VL) are associated with midtrimester cervical length (CL). METHODS The Zambian Preterm Birth Prevention Study (ZAPPS) is an ongoing prospective cohort that began enrolling in Lusaka in August 2015. Pregnant women undergo ultrasound to determine gestational age and return for CL measurement at 16-28 weeks. We evaluated crude and adjusted associations between dichotomous indicators and short cervix (≤2.5 cm) via logistic regression, and between VL and CL as a continuous variable via linear regression. RESULTS This analysis includes 1171 women enrolled between August 2015 and September 2017. Of 294 (25.1%) HIV-positive women, 275 (93.5%) had viral load performed close to CL measurement; of these, 148 (53.8%) had undetectable virus. Median CL was 3.6 cm (IQR 3.5-4.0) and was similar in HIV-infected (3.7 cm, IQR 3.5-4.0) versus uninfected (3.6 cm, IQR 3.5-4.0) participants (P=0.273). The odds of short CL were similar by HIV serostatus (OR 0.64; P=0.298) and detectable VL among those infected (OR 2.37, P=0.323). We observed no association between log VL and CL via linear regression (-0.12 cm; P=0.732). CONCLUSION We found no evidence of association between HIV infection and short CL.
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Affiliation(s)
- Joan T Price
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,University of North Carolina Global Projects Zambia, Lusaka, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Jennifer Winston
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew Kumwenda
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Mwansa K Lubeya
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Elizabeth Stringer
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jeffrey S A Stringer
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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29
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Ernst LM. Maternal vascular malperfusion of the placental bed. APMIS 2018; 126:551-560. [DOI: 10.1111/apm.12833] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/28/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Linda M. Ernst
- Department of Pathology and Laboratory Medicine; NorthShore University HealthSystem; Evanston Hospital; Evanston IL USA
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30
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HIV antiretroviral exposure in pregnancy induces detrimental placenta vascular changes that are rescued by progesterone supplementation. Sci Rep 2018; 8:6552. [PMID: 29700323 PMCID: PMC5919912 DOI: 10.1038/s41598-018-24680-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/03/2018] [Indexed: 11/09/2022] Open
Abstract
Adverse birth outcomes are common in HIV-positive pregnant women receiving combination antiretroviral therapy (cART), especially when cART is initiated in early pregnancy. The mechanisms remain poorly understood. Using a mouse model we demonstrate that protease inhibitor based-cART exposure beginning on day 1 of pregnancy was associated with a pro-angiogenic/pro-branching shift in the placenta driven by lower Flt-1 levels and higher Gcm-1 expression. Micro-CT imaging revealed an increase in the number of arterioles in cART-treated placentas, which correlated with fetal growth restriction. Delaying initiation of cART, or supplementing cART-treated mice with progesterone, prevented the pro-angiogenic/pro-branching shift and the associated placenta vascular changes. In agreement with our mouse findings, we observed an increase in the number of terminal-villi capillaries in placentas from HIV-positive cART-exposed women compared to HIV-negative controls. Capillary number was inversely correlated to maternal progesterone levels. Our study provides evidence that cART exposure during pregnancy influences placenta vascular formation that may in turn contribute to fetal growth restriction. Our findings highlight the need for closer investigation of the placenta in HIV-positive pregnancies, particularly for pregnancies exposed to cART from conception, and suggest that progesterone supplementation could be investigated as a possible intervention to improve placenta function in HIV-positive pregnant women.
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31
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Rabelo K, de Souza Campos Fernandes RC, de Souza LJ, Louvain de Souza T, Dos Santos FB, Guerra Nunes PC, de Azeredo EL, Salomão NG, Trindade GF, Basílio-de-Oliveira CA, de Carvalho JJ, Medina-Acosta E, Paes MV. Placental Histopathology and Clinical Presentation of Severe Congenital Zika Syndrome in a Human Immunodeficiency Virus-Exposed Uninfected Infant. Front Immunol 2017; 8:1704. [PMID: 29270171 PMCID: PMC5725436 DOI: 10.3389/fimmu.2017.01704] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 11/20/2017] [Indexed: 11/25/2022] Open
Abstract
In the large Zika virus (ZIKV) epidemic that occurred in Brazil in 2015, the intrauterine fetal exposure to ZIKV was associated with a significant risk of developing microcephaly and neurological disorders in the infected infants. ZIKV-associated disease has since been reported in 24 countries in the Americas. At present, definitive evidence is lacking regarding the intrauterine co-exposure to ZIKV and other viral infections and whether the coinfection impacts the risk of acquiring either infection or disease severity. Here, we provide evidence of intrauterine exposure to both ZIKV and human immunodeficiency virus (HIV) infections, causing congenital Zika syndrome in an HIV-exposed uninfected infant. Clinical, imaging and laboratory examinations of the pregnant woman and the newborn were performed. Histopathology, ZIKV/HIV-specific immunoassays, and ultrastructural evaluation of the placenta were performed. The Zika-asymptomatic, HIV-positive pregnant woman underwent ultrasounds revealing fetal cerebral ventriculomegaly, microcephaly, and brain atrophy. Her baby girl was born small for gestational age and with the neurological sequelae of congenital Zika syndrome. The evaluation of the abnormally large term placenta revealed severe damage to the maternal decidua and chorionic villi, cells positive for ZIKV-specific antigens but not for HIV antigens, and intracellular membranous clusters of virus-like particles approximately 25 nm in diameter. The rapid progression and severity of the congenital Zika syndrome may be related to the uncontrolled HIV disease in the mother. The poor inflammatory response observed in the placenta may have reduced the inherent risk of mother-to-child transmission of HIV.
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Affiliation(s)
- Kíssila Rabelo
- Laboratório de Ultraestrutura e Biologia Tecidual, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Regina Célia de Souza Campos Fernandes
- Faculdade de Medicina de Campos, Campos dos Goytacazes, Brazil.,Laboratório de Biotecnologia, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, Brazil
| | | | - Thais Louvain de Souza
- Faculdade de Medicina de Campos, Campos dos Goytacazes, Brazil.,Laboratório de Biotecnologia, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, Brazil
| | | | | | | | - Natália Gedeão Salomão
- Laboratório Interdisciplinar de Pesquisas Médicas, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | - Jorge José de Carvalho
- Laboratório de Ultraestrutura e Biologia Tecidual, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Enrique Medina-Acosta
- Laboratório de Biotecnologia, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, Brazil
| | - Marciano Viana Paes
- Laboratório Interdisciplinar de Pesquisas Médicas, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
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Altered angiogenesis as a common mechanism underlying preterm birth, small for gestational age, and stillbirth in women living with HIV. Am J Obstet Gynecol 2017; 217:684.e1-684.e17. [PMID: 29031892 PMCID: PMC5723571 DOI: 10.1016/j.ajog.2017.10.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/22/2017] [Accepted: 10/01/2017] [Indexed: 12/17/2022]
Abstract
Background Angiogenic processes in the placenta are critical regulators of fetal growth and impact birth outcomes, but there are limited data documenting these processes in HIV-infected women or women from low-resource settings. Objective We sought to determine whether angiogenic factors are associated with adverse birth outcomes in HIV-infected pregnant women started on antiretroviral therapy. Study Design This is a secondary analysis of samples collected as part of a clinical trial randomizing pregnant women and adolescents infected with HIV to lopinavir/ritonavir-based (n = 166) or efavirenz-based (n = 160) antiretroviral therapy in Tororo, Uganda. Pregnant women living with HIV were enrolled between 12-28 weeks of gestation. Plasma samples were evaluated for angiogenic biomarkers (angiopoietin-1, angiopoietin-2, vascular endothelial growth factor, soluble fms-like tyrosine kinase-1, placental growth factor, and soluble endoglin) by enzyme-linked immunosorbent assay between: 16-<20, 20-<24, 24-<28, 28-<32, 32-<36, 36-<37 weeks of gestation. The primary outcome was preterm birth. Results In all, 1115 plasma samples from 326 pregnant women and adolescents were evaluated. There were no differences in angiogenic factors according to antiretroviral therapy group (P > .05 for all). The incidence of adverse birth outcomes was 16.9% for spontaneous preterm births, 25.6% for small-for-gestational-age births, and 2.8% for stillbirth. We used linear mixed effect modelling to evaluate longitudinal changes in angiogenic factor concentrations between birth outcome groups adjusting for gestational age at venipuncture, maternal age, body mass index, gravidity, and the interaction between treatment arm and gestational age. Two angiogenic factors–soluble endoglin and placental growth factor–were associated with adverse birth outcomes. Significantly higher concentrations of soluble endoglin throughout gestation were found in study participants destined to deliver preterm [likelihood ratio test, χ2(1) = 12.28, P < .0005] and in those destined to have stillbirths [χ2(1) = 5.67, P < .02]. By contrast, significantly lower concentrations of placental growth factor throughout gestation were found in those destined to have small-for-gestational-age births [χ2(1) = 7.89, P < .005] and in those destined to have stillbirths [χ2(1) = 21.59, P < .0001]. Conclusion An antiangiogenic state in the second or third trimester is associated with adverse birth outcomes, including stillbirth in women and adolescents living with HIV and receiving antiretroviral therapy.
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