Profile of antiphospholipid antibodies in HIV-infected and HIV-uninfected women with a history of thrombosis.

INTRODUCTION: Increased antiphospholipid antibodies (aPL) have been described in human immunodeficiency virus (HIV) infection. However, the association between aPL and the increased risk of thrombosis in HIV requires further clarification. METHODS: We reviewed the medical records of 215 consecutive women with a history of thrombosis and/or obstetric complications (158 HIV-uninfected and 57 HIV-infected) between July 2017 and March 2021. Participants (n = 215) without clinical criteria manifestations for antiphospholipid syndrome were included as matched controls. Testing for lupus anticoagulant (LAC), anticardiolipin (aCL) and anti-beta2-glycoprotein1 (aß2GP1) IgM and IgG was performed. RESULTS: Thirty-two (10.1%) HIV-uninfected and 15 (13.2%) HIV-infected participants were positive at baseline for one of the five criteria aPL, with no statistically significant difference. The profile of the HIV-infected participants with thrombosis (n = 11) included LAC in 15.8%, aCL IgG in 3.5% and aß2GP1 IgG in 1.8%. In contrast, the HIV-infected controls (n = 4), included aCL IgM in 1.8% and aß2GP1 IgM in 5.3%. Only LAC was significantly associated with thrombosis (p < 0.003). On repeat testing, in a HIV-infected sub-population, 2/7 with thrombosis were positive, while 3/3 controls tested negative. CONCLUSION: In contrast to earlier reports, the prevalence and expression of aPL in HIV-infected women with a history of thrombosis in the present study, in the era of antiretroviral therapy, were similar to HIV-uninfected women. Baseline LAC positivity was associated with a significantly increased risk for thrombosis in HIV. Future studies are recommended to explore additional coagulation abnormalities in HIV.

Warfarin Anticoagulation and Fetal Central Nervous System Abnormalities: a Case Report.

BACKGROUND: Anticoagulation of pregnant woman with mechanical prosthetic heart valves is associated with significant maternal and fetal risks. METHODS: We describe a case of dorsal midline dysplasia in a fetus at 11 weeks' gestation. The mother was receiving warfarin therapy at a dose of 7.5 mg daily following a mechanical mitral valve replacement for rheumatic heart disease. RESULTS: Histological assessment revealed a meningocele with hemorrhage. No cerebellar or cerebral tissue was present in the skull confirming anencephaly. CONCLUSIONS: A multidisciplinary approach in pregnant women with mechanical prosthetic heart valves is essential in order to improve fetal outcomes.

Pregnancy in women with cardiac disease: a one-year retrospective review of management and maternal and neonatal outcomes in a tertiary hospital in Johannesburg, South Africa.

INTRODUCTION: In South Africa, cardiac disease continues to be the most important non-obstetric cause of maternal death. METHODS: A record review of 74 pregnant women with cardiac disease was performed to determine the prevalence and outcomes of cardiac disease at Charlotte Maxeke Johannesburg Academic Hospital between January and December 2017. RESULTS: Rheumatic heart disease was the most common cardiac diagnosis (n = 21, 28.4%), followed by pulmonary hypertension (n = 13, 17.6%) and congenital heart disease (n = 12, 16.2%). There were one (1.4%) maternal and two (2.7%) perinatal deaths. Neonatal complications included pre-term delivery (n = 20, 32.3%) and small-for-gestational-age infants (n = 10, 16.1%). Cardiac complications (n = 30, 40.5%) included heart failure (n = 15, 20.3%), pulmonary hypertension (n = 11, 14.9%) and blood transfusions (n = 8, 10.8%). CONCLUSIONS: Cardiac disease in pregnancy was associated with a high risk of maternal and neonatal complications. Pre-conceptual counselling and managing pregnant women at a dedicated centre by a multidisciplinary team could, however, improve outcomes.

Pregnancy-related venous thromboembolism and HIV infection.

OBJECTIVE: To assess risk factors for venous thromboembolism (VTE) in African women in order to guide thromboprophylaxis. METHODS: A case-control study was performed at a specialist obstetric unit in South Africa from July 1, 2017 to June 30, 2020. We identified 128 cases with VTE and 640 controls, matched for gestation. RESULTS: Prepartum risk factors associated with VTE included; medical comorbidities (odds ratios [OR] 5.32, 95% confidence intervals [CI] 1.82-15.56), human immunodeficiency virus (HIV) (OR 2.84, 95% CI 1.50-5.41), and hospital admission or immobility (OR 5.33, 95% CI 1.17-24.22). Postpartum, the following were identified as significant risk factors; medical comorbidities (OR 23.72, 95% CI 8.75-64.27), hospital admission or immobility (OR 13.18, 95% CI 5.04-34.49), systemic infection (OR 4.48, 95% CI 1.28-15.68), HIV (OR 3.20, 95% CI 1.49-6.87), pre-eclampsia and fetal growth restriction (OR 2.74, 95% CI 1.18-6.36), and postpartum hemorrhage (OR 4.38, 95% CI 1.75-10.97). Antiretroviral therapy, opportunistic infections, and viral load >50 copies/ml, however, were not associated with VTE risk among HIV-infected participants. CONCLUSION: HIV was a significant risk factor for pregnancy-related thrombosis. This was independent of traditional HIV risk factors. As such, future studies are recommended to explore the mechanisms of thrombosis associated with HIV infection.

A Rare Prothrombin Gene Mutation C20209T in a South African Patient with Pulmonary Embolism in Pregnancy: a Case Study and Systematic Review.

BACKGROUND: The G202010A prothrombin gene mutation is a documented prothrombotic risk factor in Caucasian patients. Several other mutations have been described within the prothrombin gene, predominantly in non-Caucasians, including the C20209T mutation. The clinical significance of this mutation is uncertain, but it has been associated with thrombotic events and pregnancy complications. METHODS: We describe a 28-year-old black South African woman who presented with pulmonary embolism during pregnancy. She was investigated for underlying prothrombotic biomarkers. RESULTS: Genetic screening for the prothrombin G202010A mutation by real-time polymerase chain reaction and melting curve analysis demonstrated an atypical mutant peak. Sequencing confirmed a variant C20209T prothrombin mutation. CONCLUSIONS: This is the first report of the C20209T mutation in the Southern African population. It remains uncertain whether genetic testing should be offered routinely to non-Caucasian patients in a resource-limited setting.

A prospective trial showing the safety of adjusted-dose enoxaparin for thromboprophylaxis of pregnant women with mechanical prosthetic heart valves.

OBJECTIVE: To determine whether dosage adjustment of enoxaparin during pregnancy, to maintain a peak anti-Xa of 1.0 to 1.2 U/mL, is safe for women with mechanical prosthetic heart valves (MPHV). DESIGN: A prospective observational study. SETTING: This study was performed at Charlotte Maxeke Johannesburg Academic Hospital from 2007 to 2009. POPULATION: Fifteen women with MPHVs. METHODS: Women were treated with enoxaparin with dosage adjustment to achieve a peak anti-Xa of 1.0 to 1.2 U/ mL. MAIN OUTCOME MEASURES: Main outcomes measured were prosthetic valve thrombosis, bleeding, and maternal mortality. RESULTS: There was no maternal mortality. None of the women developed valvular thrombosis during pregnancy. In all, 2 women developed epistaxis and another developed spotting per vaginum. CONCLUSION: Our data show that enoxaparin may be administered safely during pregnancy to pregnant women with MPHV when there is dosage adjustment throughout pregnancy to maintain an anti-Xa of 1.0 to 1.2 U/mL.