THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                                              april  2010 The rate of HIV infection in pregnancy is high.1-7 There is evidence that HIV infection in pregnant women is as- sociated with adverse maternal and fetal outcomes.2,5,6 The effects of HIV infection include severe anaemia, in- fectious morbidities and vertical transmission.2,5,8-14 In a Malawian study, AIDS and anaemia were the leading causes of maternal mortality,15 and in Zaire maternal mortality rates in HIV-infected women were 10 times those of HIV-negative women.16 A personal commu- nication revealed that in a recent unpublished report from a Nigerian Teaching Hospital, HIV/AIDS accounted for 20.2% of maternal deaths. However, the effect of pregnancy on HIV disease pro- gression remains contentious. Evidence from developed countries suggests that pregnancy does not accelerate the progression of HIV disease,17-21 while reports from low-resource settings imply otherwise, indicating that pregnancy may influence the rate of disease progres- sion.2 It has been suggested that other factors, includ- ing genetics, nutritional status and intercurrent infec- tions, may be responsible for the rate of HIV disease progression in low-resource settings.2,22,23 John and colleagues report an association between CCR5 pro- motor polymorphism and increased maternal mortality in a Kenyan cohort.23 The objectives of the present study were to determine the association between pregnancy and biochemical and haematological changes in HIV-infected Nigerian women as a possible indicator of disease severity. IS PREGNANCY ASSOCIATED WITH BIOCHEMICAL AND HAEMATOLOGICAL CHANGES IN HIV-INFECTED NIGERIAN WOMEN? o r i g i n a l a r t i c l e L O Omo-Aghoja1, MB BS, FWACS, FMCOG, FICS E Abe2, MB BS, FWACS V W Omo-Aghoja3, BDS, FMCDS A Onowhakpor1, MB BS, FWACS P Feyi-Waboso4, MB BS, FWACS 1Department of Obstetrics and Gynaecology, College of Health Sciences, Delta State University, Abraka, Nigeria 2Department of Obstetrics and Gynaecology, Central Hospital, Benin City, Nigeria 3Department of Oral and Maxillofacial Surgery, Central Hospital, Sapele, Nigeria 4Department of Obstetrics and Gynaecology, Abia State University Teaching Hospital, Aba, Nigeria 8 45 Background. While there is evidence that HIV affects the course and outcome of pregnancy, reports on the effects of pregnancy on HIV infection remain conflicting, especially in low-resource settings. Methodology. A prospective study of two demographically similar cohorts of HIV-seropositive women, 154 pregnant and 151 non-pregnant, was conducted in a hospital setting in Nigeria. Results. Cases and controls were matched for age, but parity in controls was significantly higher than in cases (p<0.0001). The time between diagnosis and treatment commencement was greater in controls compared with cases (p<0.0001). Electrolyte, urea and creatinine levels were within normal limits, with mean serum urea and potassium higher in controls compared with cases (p=0.002 and p=0.023). Aspartate aminotransferase (AAT)/ serum glutamic oxaloacetic acid transaminase (SGOT), alanine aminotransferase (ALT)/serum glutamic-pyruvic transaminase (SGPT) and amylase levels were higher in controls compared with cases (p=0.001, p=0.0001 and p=0.05), but the mean CD4 count was higher in cases compared with controls (p=0.001). The haematological parameters were within normal limits and comparable in cases and controls. A comparison of CD4 count, total white blood cell count and packed cell volume across the three trimesters in the cases did not reveal any statisti- cally significant differences in these parameters. Conclusion. Pregnancy did not affect biochemical and haematological parameters in HIV-infected Nigerian women. april  2010                                                                THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                                   METHODOLOGY This study was conducted in Central Hospital, Benin City, Nigeria, which provides tertiary care to patients in Benin City and its environs. It was a prospective study of two demographically similar cohorts of HIV-sero- positive women, 154 pregnant and 151 non-pregnant. The cases were pregnant women attending the ante- natal clinics of the hospital from October 2005 to October 2007. Once a pregnant case was identified, the next non-pregnant HIV-seropositive patient pre- senting to the HIV treatment, control and prevention programme unit of the hospital and matched for so- cial class (patient’s educational status and husband’s occupation,24 location of residence, size of apartment, average weekly income, number and types of cars if any, types of electronic and electrical gadgets at home) was selected as a control. Any patient who experienced repeated attacks of malaria or other intercurrent infec- tions was excluded from the study. Upon recruitment, both pregnant and non-pregnant women had a data sheet completed that elicited infor- mation on socio-demographic variables, time since di- agnosis of seropositive status, duration of antiretroviral therapy, and biochemical and haematological param- eters. Specifically, the following biochemical measure- ments were done: serum electrolyte, urea and creatinine levels, serum fasting blood sugar (FBS), serum aspar- tate aminotransferase (AAT)/ glutamic oxaloacetic acid transaminase (SGOT), alanine aminotransferase (ALT)/ serum glutamic-pyruvic transaminase (SGPT), total bi- lirubin, serum amylase, serum cholesterol, very low-den- sity lipoprotein (VLDL) and lactate dehydrogenase (LH). In addition, a full blood count (FBC - packed cell volume (PCV), white blood cell (WBC) count, platelet count and differentials) and CD4 cell count were performed. The study was approved by the hospital’s Human Ethics Committee and was carefully explained to the patients, and only those who gave informed written consent were recruited into the study. The Statistical Package for Social Sciences (SPSS) ver- sion 13 was used for the data management and statis- tical analysis, with Fisher’s exact test, the chi-square test or Student’s t-test (as appropriate) being used for comparison of the mean absolute values and standard deviations (SDs). The level of significance was 0.05. RESULTS The socio-demographic profile and time since diagno- sis and commencement of treatment are set out in Ta- ble I. The pregnant women had had their HIV diagnosis for periods ranging from 1 to 30 months (median 10 months) and had been on treatment for periods rang- ing from 1 to 30 months (median 8 months), while the non-pregnant women had had their HIV diagnosis for periods ranging from 14 to 29 months (median 17 months) and had been on treatment for periods rang- ing from 2 to 29 months (median 16 months). The median age of the pregnant women was 29.4 years, with a range of 18 - 36 years (mean 28.6, SD 4.6) and the median age of the non-pregnant women 30.2 years, with a range of 16 - 42 years (mean 29.2, SD 3.9). The median parity in the pregnant women was 1.00, with a range of 0 - 7 (mean 1.25, SD 1.59), and that for the non-pregnant women 2.00, with a range of 0 - 13 (mean 2.10, SD 2.29). This difference was sta- tistically significant (p<0.0001). The median estimated gestational age at booking was 26 weeks, with a range of 2 - 42 weeks (mean 25.8, SD 8.13). In the pregnant 46 Parameters N Mean (SD) Median p-value Age (yrs) Cases 154 28.6 (4.2) 29.4 Controls 151 28.9 (4.1) 30.2 0.239 Parity Cases 154 1.25 (1.59) 1.00 Controls 151 2.10 (2.29) 2.00 <0.0001 EGA at booking (wks) Cases 154 25.8 (8.13) 26.00 Controls 151 N/A N/A Time since diagnosis (mo.) Cases 154 10.27 (6.12) 10.00 Controls 151 16.86 (1.69) 17.00 <0.0001 Duration of treatment (mo.) Cases 154 8.86 (5.99) 8.00 Controls 151 15.02 (3.82) 16.00 <0.0001 SD = standard deviation; EGA = estimated gestational age. taBle i. coMPariSon oF tHe SUMMarY StatiSticS oF tHe Socio-DeMograPHic ProFile, DUration oF DiagnoSiS anD treatMent oF caSeS v. controlS THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                                              april  2010 47 Parameter N Mean (SD) p-value Sodium (mmol/l) Cases 154 139.36 (17.21) 0.260 Controls 151 142.00 (19.99) Potassium (mmol/l) Cases 154 4.15 (0.65) 0.023 Controls 151 4.48 (0.96) Urea (mmol/l) Cases 154 6.67 (9.81) 0.002 Controls 151 11.70 (14.70) Creatinine (mmol/l) Cases 154 1.16 (1.44) 0.629 Controls 151 1.24 (1.26) taBle ii. coMPariSon oF MeanS oF SerUM electrolYte, Urea anD creatinine levelS oF caSeS v. coHortS Parameters N Mean (SD) p-value FBS (mg/dl) Cases 154 79.67 (8.41) 0.808 Controls 151 91.00 (13.92) AAT/SGOT (U/l) Cases 154 35.66 (35.28) 0.001 Controls 151 57.91 (68.17) ALT/SGPT (U/l) Cases 154 17.29 (16.27) <0.0001 Controls 151 27.68 (24.89) Amylase (U/l) Cases 154 69.3 (37.86) 0.05 Controls 151 83.17 (45.36) VLDL (mg/dl) Cases 154 67.79 (162.75) 0.045 Controls 151 31.58 (53.28) taBle iii. coMPariSon oF MeanS oF otHer BiocHeMical ParaMeterS oF caSeS v. controlS Parameter N Mean (SD) p-value CD4 count (cells/µl) Cases 154 378.16 (272.57) 0.001 Controls 151 279.74 (230.74) Total WBC (×109 /l) Cases 154 5.64 (1.77) 0.304 Controls 151 5.35 (2.81) Lymphocytes (×109 /l) Cases 154 2.15 (2.04 ) 0.920 Controls 151 2.17 (1.96) taBle iv. coMPariSon oF MeanS oF HaeMatological ParaMeterS oF caSeS v. controlS group a median of 10 months had elapsed since the diagnosis of HIV, with a range of 1 - 30 months (mean 10.27, SD 6.12), and in the non-pregnant group a me- dian of 17 months had elapsed, with a range of 14 - 29 months (mean 16.86, SD 1.69). This difference was statistically significant (p<0.0001). Serum electrolyte, urea and creatinine levels in cases versus controls are set out in Table II. The mean se- rum urea and potassium levels, though within normal limits, were higher in non-pregnant than pregnant women, as were the mean serum aspartate amino- transferase (AAT)/ serum glutamic oxaloacetic acid transaminase (SGOT), alanine aminotransferase (ALT)/ serum glutamic-pyruvic transaminase (SGPT) and se- rum amylase (Table III). However, the CD4 cell count was higher in the pregnant women than in the controls (p=0.001), while the haematological parameters were within normal limits and comparable between cases and controls (Table IV). Comparison of the mean CD4 april  2010                                                                THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                                   count, total WBC count and PCV in the three trimesters of pregnancy did not reveal any statistically significant differences in the respective values. DISCUSSION A systematic review and meta-analysis of seven cohort studies from 1983 to 1996 suggested that there is an association between adverse maternal outcomes and pregnancy in HIV-infected women. The summary odds ratios for the risk of an adverse maternal outcome re- lated to HIV infection and pregnancy were 1.8 (85% confidence interval (CI) 0.99 - 3.3) for death, 1.41 (95% CI 0.85 - 2.33) for HIV disease progression, and 1.63 (95% CI 1.00 - 2.67) for progression to an AIDS-defin- ing illness. This association appeared to be stronger in the one study in this group conducted in a resource- poor setting.2 The objective of the present study was to describe any biochemical and haematological differences in the plas- ma of pregnant and non-pregnant HIV-infected Nige- rian women. In all women, the parameters assessed were within normal limits. The CD4 count was significantly higher in the pregnant compared with the non-pregnant controls, despite the fact that the non-pregnant women had been on antiretroviral drugs for longer. Nutritional factors and intercurrent infections have been shown to play a role in disease progression in low- resource settings. These factors were controlled for in this study, as the two groups were matched for social class and women with intercurrent infections were ex- cluded from the study. The prognosis for HIV disease in pregnancy is worse for patients with intercurrent in- fections such as malaria, urinary tract infections, sexu- ally transmitted infections and parasitic infestation.2,24 Malnutrition, infections and infestations are generally widespread in low resource-settings. In conclusion, this study failed to show any independ- ent association between pregnancy and abnormal blood parameters that may suggest disease severity in HIV-infected Nigerian women. It is reasonable to suppose that any increased morbidity and mortality of pregnancy may be modulated through the combined effects of nutritional factors, intercurrent infections and genetic factors. Efforts to address these are likely to contribute to reducing the burden of HIV morbidity in infected pregnant Nigerian women. Conflict of interest. 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