[Frequency and practice of prescribing prenatal HIV tests during pregnancy]. / Frequenza e modalità di prescrizione del test anti-HIV "per gravidanza" nelle puerpere.

BACKGROUND: To assess frequency and practices of antenatal HIV testing. METHODS: Cross-sectional study. Site: obstetric units of San Paolo Hospital, Milan (teaching, public, 60 beds, 1500 deliveries/years, reference centre for HIV and pregnancy) and of Sandro Pertini Hospital, Rome (public, urban, 36 beds, 1500 deliveries/year). PARTICIPANTS: parturients consecutively admitted for delivery, in the last three months of 1997. INTERVENTION: interview by a structured questionnaire. Out-comes: frequency and practices of antenatal HIV testing. RESULTS: About 79% of the 500 parturients admitted at the San Paolo Hospital and 57% of the 300 at the Pertini Hospital had been tested for HIV during the current pregnancy (p < 0.001). Overall, in 91% of cases (507/555) the test has been requested by the woman's gynecologist with other antenatal tests. Discussion on HIV testing, infection and pregnancy lasted less than 5 minutes in 92% of San Paolo parturients, and in almost all (99.4%) of the Pertini women. Women in the San Paolo hospital had HIV information available by leaflets in 47% of cases in comparison to 35% of those at the Pertini hospital. CONCLUSIONS: In Italy, HIV testing seems to be routinely included in the management of pregnancy, although the uptake and practices of offering the test seem not always appropriate. The higher uptake and the better practice seem to correlate with the higher involvement of San Paolo hospital in the fields of HIV infection in pregnancy. However, the reported overall 71% of tested parturients suggests that in Italy we are still far away from a universal antenatal HIV testing. Specific guidelines should be issued in order to implement and to uniform universal antenatal HIV testing, and to optimize the management of infected women.

[Testing for HIV infection in pregnant women at the obstetric centers in Italy]. / Accertamenti per l'infezione da HIV nelle donne in gravidanza nei centri ostetrici italiani.

BACKGROUND: To assess antenatal HIV testing policy implemented in Italian obstetric centres. METHODS: Cross-sectional study, Site and Participants: Italian obstetric centres. INTERVENTION: structured postal questionnaire. Out-comes: policies and practices of antenatal HIV testing in Italian obstetric centres. RESULTS: A total of 213 centres, accounting for a total of 167.927 deliveries/year (30% of the Italian number of deliveries) filed out the questionnaire. Of these, 45% reported having a policy on HIV antenatal testing. Having a policy on antenatal testing is associated to the number of observed HIV-positive women. HIV testing is offered to all women in 89% of centres, included in routine antenatal tests in 67%, with an opt out (57.5%) or on opt in (10.5%) on request. HIV testing is performed at the initial clinic visit in 78% of centres; it is offered routinely to male partners in 7.5% of centres. Amongst centres which observed HIV-positive pregnant women, 47% reported zidovudine is not available as a measure of HIV vertical transmission prevention. CONCLUSIONS: In Italy, HIV testing seems to be routinely included in management of pregnancy, although the practices of offering the test seem not always appropriate and the availability of measures for reducing the risk of vertical transmission not adequate. Specific guidelines should be issued in order to implement and to uniform universal antenatal HIV testing, and to optimize the management of infected women.

Short-term therapy for recurrent abortion using intravenous immunoglobulins: results of a double-blind placebo-controlled Italian study.

It is still unclear whether i.v. immunoglobulins (Ig) can facilitate the reproductive prognosis of women who have suffered recurrent pregnancy loss. We report the results of a multicentre placebo-controlled study on the effect of Ig administration on pregnancy outcome in 46 women who had suffered at least three recurrent miscarriages. All were screened to exclude chromosomal or Müllerian abnormalities, the presence of antinuclear antibodies, lupus anticoagulant (LA) or elevated titres of anticardiolipin antibodies which may have revealed an underlying autoimmune problem. To avoid a selection bias towards ongoing pregnancies, i.v. Ig or placebo were administered between weeks 5 and 7 of gestation for 2 consecutive days as soon as each woman knew she was pregnant and before embryonic heart activity could be detected. A further infusion was administered at week 8 when ultrasonography confirmed an ongoing embryonic development. In all, 68% of the women who received Ig went to term versus 79% of those who received a placebo (not significant), with no significant differences in the pregnancy course or the perinatal outcome. These results suggest either that women with recurrent miscarriages who have no recognized cause of pregnancy loss have a good reproductive prognosis without any treatment or that the emotional care associated with the administration of a placebo can indirectly facilitate the progression of pregnancy.

Perinatal outcome in HIV-infected pregnant women.

We have observed 74 HIV-seropositive and 48 HIV-seronegative drug-addicted women and 22 HIV-seropositive nondrug-addicted pregnant women during pregnancy and we report their perinatal outcome. 8 out of 96 HIV-seropositive patients had hematological signs of immunodeficiency and 2 of these patients were symptomatic belonging to CDC class III. We recorded 2 early and 3 late spontaneous abortions, no intrauterine fetal death and 3 neonatal deaths. Seropositive patients had 3 malformed babies, seronegative patients had 1. All these women had a high incidence of premature delivery and intrauterine fetal growth retardation: seropositive patients had a higher incidence of fetuses small for gestational age and a lower incidence of preterm delivery compared to seronegative patients, but the difference was not statistically significant. The incidence of malformation was comparable to the general population: 3 malformed babies were born to HIV-positive drug-addicted mothers, and 1 to a seronegative drug-addicted mother. These findings do not support the hypothesis of a direct detrimental effect of HIV on perinatal outcome. Consequences of fetal exposure to maternal HIV infection involve mostly postnatal life and development of acquired immunodeficiency.

[Prenatal diagnosis of congenital toxoplasmosis]. / Diagnosi prenatale di toxoplasmosi congenita.

Primary Toxoplasmosis is devoid of any consequences in the mother in most cases, while the fetus can suffer serious damages following transplacental passage of the parasite. This is probably due to its limited immunocompetence. 440 women have been seen for suspected primary infection during pregnancy: clinical and serological parameters excluded infection in 62% of the cases. In 168 cases primary infection was likely and they underwent therapy with Spiramycin 3 grams per day to prevent placental and fetal colonization: 53 cases were elected for invasive prenatal diagnosis. Amniotic fluid was obtained by amniocentesis and fetal blood by ultrasound guided cordocentesis and by fetoscopy: the samples were analyzed for specific anti Toxoplasma IgM and sent for isolation of the parasite. Diagnosis of fetal infection was made in 4 cases: 3 cases had specific IgM in cord blood, 1 case showed intracranial calcifications by ultrasound screening. Fetal infection rate is thus below 10% and prenatal diagnosis avoids unjustified interruption of pregnancies complicated by maternal toxoplasmic infection.

Effect of prednisone and heparin treatment in 14 patients with poor reproductive efficiency related to lupus anticoagulant.

In women with a previous intrauterine fetal death related to lupus anticoagulant (LAC), we studied the effect of prednisone and calcieparine treatment to enable longer intrauterine life, increased fetal growth and increased survival rate. LAC was determined by the kaolin clotting time and was associated with elevated levels of antinuclear and anticardiolipin antibody in 42% and 21% of the cases, respectively. 14 women entered the study; they had a past history of 27 pregnancies, with only 1 small-for-gestational age (SGA) liveborn. The mean gestational age at the time of fetal death was 30 +/- 4 weeks. During index pregnancies, we observed 2 miscarriage, 9 liveborns (6 of appropriated gestational weight, 3 SGA) and a mean gestational age of 35 +/- 3 weeks. The mean decrease in fetal weight from the 50th percentile in previous pregnancies was 44%, and with treatment this was reduced to 12%. All these differences were statistically significant. We conclude that prednisone and heparin treatment can improve reproductive prognosis in fertile patients with LAC.

HIV infection and AIDS in newborn babies of mothers positive for HIV antibody.

PIP: 2/3 of the reported cases of the acquired immune deficiency syndrome (AIDS) in children have no risk factor except a mother belonging to a group with an increased prevalence of infection with human immunodeficiency virus (HIV). There is evidence of transplacental passage of the virus during early and late gestation, but the incidence of fetal and neonatal infection in newborn babies of seropositive mothers has not yet been determined. This article presents the clinical and serological outcome of 24 babies aged 6 months born to mothers who were drug addicts and positive for HIV antibodies. At 6 months 12 babies were seropositive and 12 seronegative. 1 seropositive baby died of Pneumocystis carinii pneumonia at 4 months, and another was diagnosed as suffering from AIDS related complex at the age of 3 months. All the other babies thrived, the results of their follow up being entirely normal. These 2 cases indicate that early morbidity and mortality are a severe problem, but their incidence seems to be restricted to about 10% of the offspring. Unfortunately, nothing can yet be said about long term morbidity and mortality. Cesarean section does not seem to protect the fetus from infection. These data may be helpful in counselling seropositive women before or in early gestation, as they suggest that the risk of fetal infection and severe postnatal morbidity is high. Unfavorable perinatal outcome, usually associated with drug addiction, was similar in seropositive and seronegative women: a detrimental effect of the virus in this regard was not evident.^ieng