Effect of antiretroviral therapy on hemostasis in Brazilian pregnant women with HIV infection

Abstract

Clinical observation shows pregnant women under antiretroviral therapy present bleeding episodes at delivery, although this therapy promotes a decrease in fibrinolysis in nonpregnant patients, suggesting a prothrombotic state in the former. Since these drugs provoke hepatic disorders, they can cause bleeding disturbances. We investigated effects of antiretroviral therapy on hemostasis in pregnant women. Two groups were studied: pregnant women with HIV (n = 11), and (control) pregnant women without HIV (n = 7). Four blood samples were collected from each individual in both groups: one at the beginning of pregnancy before treatment, two during pregnancy and therapy, and one 6 weeks after delivery. Treatment was performed according to recommendations of the Brazilian Health Department for the evaluation of the prothrombin time, activated partial thromboplastin time, factors VII, X, and XII, fibrinogen concentration, protein C, protein S, tissue-type plasminogen activator (t-PA) antigen, plasminogen activator inhibitor-1, and fibrin degradation products (FbDPs). Statistical analysis demonstrated pregnancy caused increased factor VII (P = 0.0313), factor X (P = 0.0156) and factor XII (P = 0.0156) activity, fibrinogen concentration (P = 0.0156), t-PA (P = 0.0313), plasminogen activator inhibitor-1 (P = 0.0156) and FbDP levels (P = 0.0313). HIV infection caused increased factor XII (P = 0.0114), t-PA (P = 0.0346) and FbDPs (P = 0.0003), and decreased protein S levels (P = 0.0441). Antiretroviral therapy reduced the activated partial thromboplastin time (P = 0.0114) and protein S (P = 0.0012), and increased t-PA (P = 0. 0204) and FbDP levels (P = 0.0154). The results suggest a prothrombic state developing during pregnancy, maintenance of hemostatic equilibrium in HIV infection and occurrence of hyperfibrinolysis, not due to hepatotoxicity, during antiretroviral therapy, causing the clinically observed bleeding episodes.

Coagulation in the HIV-positive pregnant patient : a thromboelastography study

“…23 A further study found that HIV patients on ART had increased levels of tissue plasminogen activator antigen and plasminogen activator inhibitor type 1, which suggests increased fibrinolysis. 9 Our study found no between-group difference in fibrinolysis as assessed by the LY-30, despite the fact that our patients were receiving ARV therapy. 12 The findings of our study, comparing the coagulation status using TEG of HIV-positive and -negative patients, suggests that in asymptomatic HIV-positive patients, routine laboratory or point of care coagulation studies are not indicated before regional anaesthesia.…”

“…13,14 Pregnancy is associated with an increase in pro-coagulant factors (II, VII, VIII, X and XI) and a decrease in anti-coagulant factors (Protein C and S, and Antithrombin III). 4,9 Fibrinogen levels rise from 28 weeks gestation, and D-dimer levels are raised throughout pregnancy. These haematological occurrences are thought to be a physiological adaptation to minimise blood loss during childbirth.…”

“…There are limited studies examining the effect of HIV infection and anti-retroviral medication on coagulation in pregnancy. 6,9 We therefore performed a cross-sectional study comparing the coagulation profile (as assessed by TEG) of HIV-positive versus -negative patients at term. Secondary outcomes included a comparison of TEG variables in patients in whom anti-retroviral therapy (ART) had been commenced before or during pregnancy.…”

Basic Coagulation Parameters among Human Immunodeficiency Virus-Infected Adults in Gondar, Northwest Ethiopia: A Comparative Cross-Sectional Study

“…HAART treatment reduces the production of lupus anticoagulant, and thus HIV-infected individuals who were taking HAART have lower lupus anticoagulant than HAART-naïve subjects [43]. In this study, APTT value of HAART-naïve study subjects was higher than that of HAART groups, though the difference was not statistically significant ( P = 0.074).…”

An anesthesiologist’s view of problems in HIV-positive patients

“…Зміни гемостазу у ВІЛінфікованих вагітних на тлі АРВТ і хіміопрофілактики, згідно з літературними дани [2]. Згідно з дослідженнями de Andrade C. M. et al [3] у вагітних жінок, які отримували антиретровірусні препа рати, при пологах відзначалися епізоди кровотеч за ра хунок активації фібринолізу, що пояснюється токсичною дією препаратів на функцію печінки. Токсичне ураження печінки зазвичай розвивається протягом перших тижнів від початку хіміопрофілактики.…”