Excess Intrauterine Fetal Demise Associated with Maternal Human Immunodeficiency Virus

Infection
Author(s): Claire Langston, Dorothy E. Lewis, Hunter A. Hammill, Edwina J. Popek, Claudia
A. Kozinetz, Mark W. Kline, I. Celine Hanson and William T. Shearer
Source: The Journal of Infectious Diseases, Vol. 172, No. 6 (Dec., 1995), pp. 1451-1460
Published by: Oxford University Press
Stable URL: http://www.jstor.org/stable/30134654
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 1451

Excess Intrauterine Fetal Demise Associated with Maternal Human

Immunodeficiency Virus Infection
Claire Langston, Dorothy E. Lewis, Hunter A. Hammill, Departments of Pathology, Microbiology and Immunolog
Edwina J. Popek, Claudia A. Kozinetz, Mark W. Kline, Obstetrics and Pediatrics, Baylor College of Medicine and
I. Celine Hanson, and William T. Shearer Children's Hospital, Houston

A prospective study of transplacental transmission of human immunodeficiency virus (HIV)

showed an increased rate of spontaneous fetal demise in HIV-seropositive mothers: 14 losses in 124
pregnancies. HIV was detected in placental and fetal tissues in 7 of 14 by in situ hybridization. The
proportion of fetal infection far exceeded the transmission rate of 13% in liveborn babies. No
association was seen between fetal transmission and a maternal history of drug abuse or coinfections;
mothers with AIDS more often had fetal loss associated with HIV transmission than did asymptom-
atic mothers. In affected fetuses, HIV was detected in many tissues and was associated with thymic
pathology. This suggests that maternal HIV infection increases the risk for pregnancy loss associated
with HIV transmission. The possibility that HIV may be fetotoxic, that thymic dysfunction may
interfere with pregnancy progression, or that the intrauterine milieu in HIV-seropositive pregnancies
may be unfavorable (or a combination of factors) should be considered.

in HIV-seropositive women have shown an increase in fetal

Vertical transmission of human immunodeficiency virus
loss [10-13], and there is emerging evidence of onset of dis-
(HIV) from mother to infant can occur in utero, intrapartum,
ease in utero in infected liveborn neonates. The increased fetal
and postnatally in association with breast-feeding [1-3]. There
loss identified in previous studies has been variously ascribed
is considerable controversy concerning the relative proportion
to such
of infants infected in each and in the timing of infection in factors as an unexplained less-than-expected fetal loss
utero and postpartum in association with breast milk [2, in
4-6].
a control group [11] or an assumed high rate of fetal loss
in socially and medically deprived populations. No study has
Although there is a case definition for intrauterine transmission
[7], it is an empiric definition only and must be validated by
attempted to investigate the role of HIV in excess fetal loss. The
studies
further testing and observation. Most transmission of HIV to that document early fetal infection do so anecdotally in
undefined populations and often with material obtained from
the fetus is now assumed to take place late in utero or intrapar-
tum. There is increasing evidence to support this conclusion,
therapeutic pregnancy terminations [9].
as the majority of studied cases appear to fulfill the working
definition for late rather than early transmission [4, 8]. Studies
Subjects and Methods
have identified infected fetuses as early as 8 weeks of gestation
[9], and there is surely a component of early transmission,
The subjects were from an HIV-seropositive maternal study
although its exact contribution remains unknown. The timing
population that included HIV-seropositive pregnant women fol-
of fetal transmission is of some concern, as attempts to interrupt
lowed in the Special Mothers Clinic of the Harris County Hospital
transmission must occur prior to the establishment of the virus
District (Texas) and women identified during their pregnancy as
in fetal tissues. If most transmission is late in gestation or
being HIV-seropositive and referred for care who subsequently
intrapartum, therapeutic options are more easily applied. delivered at one of three hospitals in proximity to the processing
Although it is widely assumed that in utero transmission of
laboratory. During January 1990 through March 1994, 15 of 124
HIV has little effect on the fetus and that HIV-related disease
pregnancies in this population terminated in fetal demise; there
is a postnatal phenomenon, some studies of pregnancy outcomewere 2 therapeutic and 13 spontaneous fetal losses, including 1 of
a set of twins (the cotwin survived 1 h). This early neonatal loss
is also included in our study, as the twins were monochorionic
diamniotic and therefore monozygotic. One of the mothers in our
Received 27 March 1995; revised 6 July 1995. study population had 3 consecutive fetal losses, so only 11 women
Presented in part: First National Conference on Human Retroviruses and were affected. The remaining 109 pregnancies produced 110 live-
Related Infections, Washington, DC, December 1993 (abstract 29).
born children (including a set of dichorionic twins).
Human experimentation guidelines of the US Department of Health and
Human Services and of Baylor College of Medicine were followed in the Initial processing. After delivery, the placenta was brought to
conduct of this research. All mothers gave permission for examination of their the laboratory, generally within 1 h, for preliminary examination
fetuses.
and sampling. That examination included measurements of placen-
Grant support: National Institutes of Health (AI-32466).
tal size and weight and cord length, as well as notation of the
Reprints and correspondence: Dr. Claire Langston, Dept. of Pathology,
character of the placental disk and membranes. The placenta was
Texas Children's Hospital, 6621 Fannin St., Houston, TX 77030.
then sampled for HIV in situ hybridization. A full-thickness section
The Journal of Infectious Diseases 1995; 172:1451-60
0 1995 by The University of Chicago. All rights reserved. from the placental disk at a central location was time-fixed in 4%
0022-1899/95/7206-0005$01.00 RNase-free paraformaldehyde and processed through RNase-free

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 1452 Langston et al. JID 1995; 172 (December)

graded alcohols before being embedded

HIV-seropositive in paraffin.
women, and about Th
one-fourth of all HIV-
of the placenta, membranes, and
seropositive cord
pregnancies were
in Harris Countyfixed in
over the study pe-10
buffered formalin and sectioned later.
riod. HIV-seropositive women who did or did not enter the
When a fetus or curettage samples of products of conception
study population did so on the basis of their selection of clinic
were received, they too were examined immediately, and any le- site from those available for their care. Those who selected
sions or malformations were noted. Samples of fetal tissues, gener-
care sites staffed by Baylor College of Medicine physicians
ally to include thymus, brain, and liver, were similarly processed
in RNase-free reagents. The rest of the fetal tissues were fixed in
and who delivered at sites served by those physicians entered
10% neutral-buffered formalin and examined histologically. Tis- the study.
sues were placed in 4% RNase-free paraformaldehyde for 5-6 h, The numbers of births in the county in the study period by
washed in RNase-free PBS, and passed through graded RNase- year were 57,853 (1990), 57,750 (1991), and 57,050 (1992).
free alcohols. They were held in 80% RNase-free alcohol and The numbers of placentas received into the study from deliver-
processed the next day into paraffin. ies that produced living children were 16 (1990), 10 (1991),
In situ hybridization. The paraffin blocks of RNase-free fixed and 29 (1992); 43 placentas were received in 1993, and 11 in
the first quarter of 1994. In addition to the 109 pregnancies
tissue were cut as
dried overnight. 3-.m
Four sections
serial onto
sections silane-treated
were slides
cut from each and
block.
that produced living children, there were 15 with 16 fetal losses
These slides were hybridized with a 35S-labeled HIV riboprobe
(one set of twins). Of these fetal losses, 2 were therapeutically
(Oncor Laboratories; Gaithersburg, MD) according to a defined
induced in ill mothers, and 14 were spontaneous. This repre-
protocol [14-16]. HIV sense riboprobe was used as a negative
control, and an actin probe was used to confirm RNA preservation.
sents an 11% spontaneous intrauterine fetal loss rate in the
Known HIV-positive and -negative placental or fetal tissues were study population. The rate of spontaneous fetal loss in the
tested as controls along with each batch of samples. Sections were similar but HIV-seronegative pregnant population remains dif-
developed for 2-3 days and read by confocal microscopy. ficult to estimate, as statistics are available only for those who
Positive reactions were confirmed and localized by other observ- reach midgestation.
ers using light microscopy. For a reaction to be positive, it was Maternal findings. Pregnancy losses (both induced and
required to occur in duplicate samples and be confirmed by at least spontaneous) in the study occurred at 8-32 weeks of gestation
2 observers. All determinations of placental positivity were made (median, 18); half the losses occurred before 20 weeks of gesta-
without knowledge of maternal disease state or fetal outcome; all
tion (table 1). The mothers, all HIV-seropositive, were aged
determinations of fetal positivity were made without knowledge
16-32 years (median, 20). As noted previously, 1 mother had
of the HIV status of the placenta. The advantage of in situ hybrid-
ization is that the infected cells are visualized and can be character- 3 spontaneous fetal losses, and there was a set of twins in the
fetal loss group. Of the 11 mothers, 2 had a history of intrave-
ized in the tissues studied. This avoids the problem of contamina-
tion by infected maternal cells in the placental studies; for placental nous drug (IVDU) and cocaine use, and 1 had a history of
tissues to be considered positive, the hybridization reaction had to alcohol abuse. These 3 and the other 8, without a drug or
occur within cells of the placental villi, not within the intervillous alcohol abuse history, were also considered to be at risk for
space or decidua. heterosexual transmission, as they had either known HIV-in-
Histologic examination. Sections of placenta, umbilical cord, fected or high-risk sex partners.
membranes, and samples of fetal tissues fixed in 10% neutral- Two mothers were Hispanic, 1 was white, and 8 were black,
buffered formalin were processed and paraffin-embedded. Sections reflecting the racial composition of identified HIV infection in
were cut at 3 ,um and stained with hematoxylin-eosin. Placental
Harris County (15% Hispanic, 14% white, 70% black, and 4%
sections were also examined by immunohistochemistry with an
other). Two mothers had AIDS; the rest were asymptomatic
antibody to cytomegalovirus (Dako, Carpinteria, CA) and by in
from HIV infection. Both mothers with AIDS had a history of
situ hybridization for Epstein-Barr virus (Enzo Diagnostics, Far-
Pneumocystis carinii pneumonia (PCP), and 1 of them had
mingdale, NY) according to standard methodology [17-20]. Sec-
tions were examined without knowledge of maternal disease state. PCP during the pregnancy in which fetal loss was sustained.
Data collection. A standard data collection form was com- In pregnancies resulting in livebom children, 12% of mothers
pleted as fully as possible for each pregnant woman. Data were
itemssymptomatic and 5% had a diagnosis of AIDS compared
included demographics, immunology, HIV symptoms, HIVwith 2 (18%) of 11 mothers with AIDS in those with fetal loss.
treat-
ment or prophylaxis, and coinfections. Data were entered into
One the
of the asymptomatic mothers had a prior positive serologic
study data base file and linked with infant data from the Pediatric
test for syphilis and had been treated before pregnancy. One
HIV Registry maintained in the Department of Pediatrics. mother was a participant in a trial of zidovudine for prevention
of HIV transmission; however, she received placebo. No
mother with fetal loss received antiretroviral therapy during
Results
pregnancy.
Fetal loss rate. Statistics from the Texas Department of HIV transmission. Seven of the 14 conceptions (13 preg-
Health Survey of Childbearing Women (a blinded seropreva- nancies, 1 set of twins) were positive for HIV by in situ hybrid-
ization (table 2). Three of the early pregnancy losses (cases 1-
lence study) and from the maternal and pediatric HIV registries
maintained at Baylor College of Medicine suggest that our3) did not have fetal tissue identified but did have placental
study population comprises ~50% of pregnancies of known villi, endometrium, and decidual tissue available for study. In

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JID 1995; 172 (December) Fetal Loss in HIV Infection 1453

Table 1. Status of HIV-seropositive women with fetal loss.

G-P Time of loss

Case (age, years) Race status Behavior HIV status (week of gestation)

1 (32) H G3P2 Heterosexual +, asymptomatic, CD4 = 429 8

2* (17) B G2PO IVDU/cocaine, heterosexual AIDS 10
3 (20) B G4P1Ab2 Heterosexual +, asymptomatic CD4 = 212 10-14
4 (20) W G4PO Heterosexual +, asymptomatic, CD4 = 510 12
5* (17) B G3PO IVDU/cocaine, heterosexual AIDS 15
6 (19) B G2P0Ab1 Heterosexual +, asymptomatic 16
7 (24) B GiPO Heterosexual +, asymptomatic 18
8 (18) B G2P1 Heterosexual +, asymptomatic CD4 = 467 21 (twins)
9 (22) B G4P2 IVDU/cocaine, alcohol abuse, +, asymptomatic 23
heterosexual

10 (22) B G2P1 Heterosexual AIDS 23

11 (17) H GIPO Heterosexual +, asymptomatic 27
12* (16) B GlPO IVDU/cocaine, heterosexual, AIDS, PCP 27
076 participant (placebo)
13 (19) B GIPO Heterosexual +, asymptomatic 32

NOTE. G, gravidity; P, parity; Ab, abortion; H, Hispanic; B, bla

seropositive; CD4, CD4 cell count/mm3.
* These are same mother with 3 consecutive spontaneous intraut

each of these cases, the implantation site was Fetal

twins) were negative. identit
anchoring trophoblasts and other
tion fortrophoblastic
HIV (table 2) tissues
includ
plantation site was into 2B), liver (figure
endometrium, 2C), kid
with a notable vir
(figure lA) that was particularly heavy The
rarely positive. in 2 thymu
cases
Anchoring villi in 1 of these (case cells
positive 1) also
of showed
all fetalposi
tiss
tions by in situ a 60%
hybridization for transmission ratewas
HIV, and this case in
in those in which fetal
transmission loss (10
occurred. pregnancies
Of the other 2,w
villi were identified in case 3, andshowed
evaluable case 2 had unsat
6 transm
preparations for in situ Fetal and placentalfinding
hybridization, as villi were no
the tissue submitted in also evaluated.
RNase-free One, a 12-w
paraformaldehyde
the later-submitted gravida (G)
formalin-fixed 2, para
tissue). (P)
This is 1 wh
the
unsatisfactory preparationofin IVDU and cocaine
the study. Neitheruse,
case a
included in those with transmission.
was positive for HIV by in s
Fetal/placental pairs were
andconcordant for HIV
placental villi, stat
decidua,
situ hybridization in 8 of week-gestation
10 pregnancies for
loss which
to a 32b
and placental tissues were available
AIDS, (table
active PCP,2);
a 6 of 10
histor
were positive but only 4 CD4
of the associated
cell count of 6 placent
87/mm3
villus positivity. The 5 HIV-negative
hybridization fetuses (inclu
of thymus an
twins) all had HIV-negative placental examinations.
also negative.
conceptuses that were demonstrated
Early spontaneous losses (cases 1-3;to
table 2)be
showedHIV-posi
promi-
HIV identified in placental syncytiotrophoblast,
nent inflammatory changes, both acute and chronic, in the asso- in ce
villous stroma (most ciated decidualized
likely Hofbauer endometrium. Ascells),
noted above, noor
fetal both
negative conceptus had positive placental
tissues were identified tissue.
in these early pregnancy losses. Other Deci
tivity alone was not sufficient to
losses before midgestation score
in which a identified
fetal tissues were placenta
positive. Endometrium was positive
showed nonspecific in
findings and changes allwith
associated cases
intra- in
was tested, whether or not
uterine placental villi
fetal demise in the placental tissues in or fetal
the 3 with HIV tiss
positive. Those with endometrium
transmission to the fetus (casesavailable
5-7) as defined by HIV forposi- tes
all in the younger gestational
tivity by in situ age group.
hybridization Positive
in fetal tissues. The single fetus st
anchoring villi was also noted inwithout
in this gestation period 1 other, case
evidence of fetal transmission 6 (fi
Of the 13 spontaneous (case
losses (14
4) had evidence conceptuses
of placental abruption, accounting for beca
the fetal loss.
the twins), 7 of the conceptuses were positive for H
situ hybridization (includingOf the 6case
pregnancy1 with
losses in the last placental
half of gestation (table pos
the absence of identifiable fetal
2), 3 fetuses showed tissue) and 7 and
evidence of HIV transmission (includ
4 (in-

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 1454 Langston et al. JID 1995; 172 (December)

Table 2. Fetal and placental findings and transmission in sp

Weights (g) HIV status

of placenta/
Case Age*/sex fetus Placenta Fetus Transmission Placental; fetal pathology

1 8/NF 21/- +V, +D, +E - Yes Acute and chronic deciduitis, endometritis
2t 10/NF 76/- NR V, +D, +E No Necrotizing villitis and deciduitis
3 10-14/NF 15/- -V, +D, +E - No Acute and chronic deciduitis
4 12/M 40/14 -V, D and E nt -: kidney, adrenal, lung, No Abruptio placenta >50%; nonspecific
thymus, liver fetal changes related to IUFD
5t 15/F 74/50 -V, D and E nt +: liver; -: spleen, Yes Retroplacental hematoma and infarct 40%
brain, thymus
6 16/M 46/77 +V, +D +: kidney, brain, testis; Yes Chronic deciduitis, placental changes
-: adrenal, bowel IUFD, PROM; morcellated fetus
7 18/F 87/176 +V, +D, +E +: thymus, liver, kidney Yes Placental changes, IUFD; fetal maceration
8

Twin a 21/F 235/400 -V, +D -: thymus, liver, brain, No MCDA twin, funisitis, chorioamnionitis;
spleen GBS pneumonia, IVH
Twin b 21/F 235/540 -V, +D -: thymus, liver, brain, No MCDA twin, mild subchorionic acute
spleen inflammation; GBS, IVH
9 22/F 249/480 -V, -D -: thymus, brain No Placental abruption 20%
10 23/F 95/670 +V, D nt +: thymus, lung Yes Small placenta, 10% infarct, hemorrhagic
endovasculosis, meconium-stained
membranes, placental insufficiency;
fetal maceration

11 27/M 600/710 -V, D nt -: liver, spleen, adrenal No Large edematous placenta, parvovirus;
macerated hydropic fetus, parvovirus
infection

12t 27/M 266/1380 +V, D nt +: thymus, liver Yes Placental edema and hemorrhage; fetal
cardiovascular lymphoid infiltrates
13 32/F 172/1320 +V, +D +: thymus, lung, skeletal Yes Placental ischemic changes, multiple
muscle infarcts 15%, hematoma; SGA
coarctation, bicuspid aortic
tubular hypoplasia aorta, gl

NOTE. NF, no fetal tissue identified; V, villus tissue; D, decidual tissue; E, endometrium;
hybridization; nt, not tested; IUFD, intrauterine fetal demise; PROM, premature ruptur
streptococcus; IVH, germinal matrix/intraventricular hemorrhage; SGA, small for gestational
* Gestational age (weeks).
t Fetal losses to same mother (see table 1).

dependent
cluding the twins) did not. Other infections on gestational
were implicated age
in and incre
3 of the 4 intrauterine demises ofto 1:4 at 28 weeks
HIV-negative to 1:7
fetuses; at term).
the
The most
twins (case 8) were both septic, with positive mature
cultures forfetus
groupin our stud
fetus with
B streptococcus and with Gram-positive cocci evidence of placental isch
and Fusobacte-
infarcts
rium species identified in the placental constituting
membranes; both 'had
15% of the p
fetus
germinal matrix hemorrhages as well. was theHIV-negative
Another only one with signific
formations,
fetus (case 11) had evidence of parvovirus including
fetopathy a bicuspid aor
with fetal
coarctation,
hydrops, a large edematous placenta, tubular hypoplasia
and characteristic inclu- of the
paranasal
sions of parvovirus in nucleated red blood skin
cells in tag,
both theand a single umbi
fetus
alsowithout
and placenta. The HIV-negative fetus had thea most extensive HIV pos
documented
of any case
infectious etiology for death had a placental examined:
abruption 3 of 4 tissues
involv-
positive
ing 20% of the maternal surface of the by in
placenta; situ were
there hybridization
no and
fetal abnormalities. tive cells were identified.
Two of the 3 HIV-positive fetuses in
The this
other gestational
HIV-positive age
fetus (case 12) was well developed
class were growth-retarded. Both had small for
and appropriate placentas;
gestational age;that of
however, lymphocytic in-
the 670-g 23-week-gestation fetus filtrates
(case were
10)identified
weighed in the 95
epicardium
g, andof the heart and in
that of the 1320-g 32-week-gestation fetus
the adventitia (case
of the 13) artery
left carotid weighed
near its origin from the
aorta.placental-to-fetal
172 g. These are strikingly abnormal In situ hybridization for HIVratios
was not done on these
cardiac
of 1:7.0 at 23 weeks and 1:7.7 at 32 weekstissues. (normal ratios are

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 JID 1995; 172 (December) Fetal Loss in HIV Infection 1455

Figure 1. Case 1. Spontaneous pregnancy loss at 8 weeks of gestation. A

within curettage specimen shows heavy virus burden by HIV in situ hybr
strated by granular black silver positivity, which is extensive through
implantation site, positive reactions by in situ hybridization are seen in
head) and adjacent anchoring villus (arrow). Autoradiographs countersta

toxylin; original magnifications = x50 (A) and X25 (B); bars = 20 Mm

(B).

In all HIV-positive fetuses in which the thymus was available logic or chromosomal (or both) abnormalities of the fetus [22-
for examination, there were abnormalities (table 3, figure 3). 24]. Pregnancy loss is much less common in the fetal period
These were evident even in the most immature, a 15-week- and is said to occur in <3% of pregnancies once the fetus has
gestation fetus in which the thymus was not HIV-positive by in attained a gestational age of 10 weeks [25]. According to thes
situ hybridization but did show abnormal features. The thymic estimates from the general population, it is clear that the HIV-
changes included lymphocyte depletion from the organ (with seropositive women in our study had an increased incidence
consequent blurring or loss of corticomedullary demarcation) of fetal loss. Of the 13 spontaneously aborted pregnancies
and paucity or absence of Hassall's corpuscles in all specimens none were in the preembryonic period and 3 were in the embry-
and additional changes of fatty infiltration, acute thymitis, and onic period; there were 11 fetal losses in the 10 pregnancies
the angiomatoid pattern associated with marked lymphocyte spontaneously lost between 12 and 32 weeks of gestation. Thus
depletion in some. the 9% rate of fetal loss (11/119), excluding the 3 embryonic
losses in which only placental and no fetal tissue was identified
was elevated in this population of HIV-seropositive women.
Discussion
As 3 of the fetal losses, 2 with HIV transmission, were to
the same mother, it initially might appear that this introduces
To assess the impact of any factor, including HIV infection,
bias into the study. Although a number of early studies sug
on pregnancy loss, it is useful to assign losses to functional
periods of pregnancy rather than the more conventional gested
but that a history of previous transmission influenced th
outcome of subsequent pregnancies, they were not designed to
arbitrary trimesters. These functional periods are the preembry-
directly
onic, from 3 to 5 weeks of gestation; the embryonic, from 6 address this issue. A single study [26] designed to
assess the risk of vertical transmission of HIV in twin and
to 10 weeks of gestation; and the fetal, constituting the remain-
der of gestation. While the overall rate for pregnancysecond
loss pregnancies showed that in neither situation was there
is 10%-15% of all recognized pregnancies, this rate varies
increased risk of transmission. The results of that study support
markedly across gestation [21]. In the preembryonic period,
the inclusion of these 3 pregnancies and the twin pregnancy
in our analysis.
there are a large number of losses, often without clinical recog-
nition of pregnancy. The majority of pregnancy losses occur
Although most studies of pregnancy outcome in HIV-sero-
positive women have addressed the consequences to liveborn
in the embryonic period and are often associated with morpho-

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1456 Langston et al. JID 1995; 172 (December)

Figure 2. Fetal tissues positive for HIV by in situ hybr

from case 10 (23-week-gestation spontaneous fetal loss
Hassall's corpuscles (inset). Autoradiograph counterstain
= 10 /tm. B, Brain from case 6 (16-week-gestation feta
Autoradiograph counterstained with hematoxylin; or
spontaneous fetal loss) shows positive reaction in both

hematoxylin; original magnification = X50; bar = 20

children, the issue of fetal losses

pregnancy inin
loss early or ev
HIV-infec
has also been addressed in a number
these studies.of studies
Data fromin
H
and less developed
societies [10,partners
tive sex 12, 13, 27-33].
of men A w
neous
of these studies suggest, as oursfetal
does,losses as seron
that there is a
rate of fetal loss in pregnancies of HIV-seroposit
of these occurred in the fir
[10, 12, 13, 31-33]. These Studies from
findings havedeveloped
been large c
occasionally even by come
those in have
who HIV-seropositive c
collected the
it is generally thought have
that usually
maternal comprised
HIV infectionp
no effect on pregnancy 32]. Relatively
outcome. few women
The largest numb
positive pregnant women asin in whom the African outcome studies,has be g
not identified.
are in studies of African women Three of these studies did
[12, 13,show an29,
increased30].

a higher rate of fetal rate of

loss in fetalseropositive
loss [10, 31, 32] that did not always
than reach statistical
in se
women. While those significance.
studies In one that controlledlarge
examined for drug usepopula
[31], it was
provide no information not shown
on to be a significant contributing
gestational age factor
or to
HIVfetal loss.
st
fetal losses; most refer In anotherto
only study stillborn
with a similarly high rate of IVDU inAs
rates. seroposi-
pr
may not begin early in tive and seronegative
these pregnant women [10], the
populations, it only
isstatisti-
un

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 JID 1995; 172 (December) Fetal Loss in HIV Infection 1457

Table 3. Thymic features in HIV-positive andabortion

obtained after therapeutic -negative fetuses
and were reported anecdot- of
HIV-seropositive women. ally. For most such studies, it is not possible to estimate the
rate of fetal transmission by gestational age.
Thymic weight
Case HIV* Aget (g) Histologic findings One study examined 100 fetal thymuses by polymerase chain
reaction (PCR) for HIV [42]. None was from a gestation of
4 - 12 Not seen Early cortex and medulla with early <15 weeks, the gestational age at which we too have been
condensation of epithelial cells to
able to reliably identify thymic tissue in fetuses, and only a few
form HC
(10) were beyond 28 weeks of gestation. The overwhelming
5 + 15 0.1 Lymphocyte depletion with
majority of the fetuses were the product of therapeutic abortion;
indistinct CMJ, rare thymic
epithelial cell, no HC there were only 8 spontaneous losses or intrauterine deaths in
6 + 16 0.3 Early cortical involution with their study population. Although only 2 of the thymuses were
"starry sky," blurred CMJ, few
positive for HIV by PCR, both were from the smaller group
early HC
of spontaneous losses and had intrauterine courses similar to
7 + 18 NA Mild autolysis, no HC
8 those of our affected fetuses. That study does suggest that the
Twin a - 21 0.85 Acute stress with "starry sky," rate of transmission in early gestation is low [42] and supports
plentiful HC our suggestion that HIV transmission in utero may have pro-
Twin b - 21 1.1 Normal-appearing thymus, distinct found deleterious effects on pregnancy outcome. Our data sug-
CMJ, many HC
gest that HIV, like other viruses that can infect the fetus, may
9 - 22 0.4 Distinct CMJ, abundant HC
be associated with fetal loss when viral transmission occurs
10 + 23 0.4 Moderate autolysis, lymphocyte-
depleted poor CMJ, few HC earlier in gestation and with an affected but liveborn infant
11 - 27 0.5 Macerated but normal-appearing when it occurs later or intrapartum. While there are suggestive
thymus data from studies of HIV transmission in liveborn children
121 + 27 0.4 Lymphocyte depletion with "starry
of HIV-seropositive mothers [4, 8] that a majority of viral
sky," blurred CMJ, apparent
decreased HC, thymitis with transmission occurs in late gestation and intrapartum, these
microabscesses, fatty infiltration estimates of the time of transmission are flawed by the failure
septa to evaluate the impact of HIV transmission on fetal loss to
13 + 32 0.8 Marked lymphocyte depletion,
this population. Our data suggest that there is a higher-than-
prominent vasoformative pattern,
recognized rate of transmission earlier in gestation and that
HC, fat infiltrating septa
many of these affected fetuses are lost. Experimental models
NOTE. HC, Hassall's corpuscles; CMJ, corticomedullary junction;
of HIV NA,
infection are supportive. A study of the simian immuno-
not available.
deficiency virus (SIV) model showed that infection of pregnant
* Positive or negative by in situ hybridization.
t Gestational age in weeks. rhesus monkeys resulted in a 20% (2/10) spontaneous abortion
w Fetal losses to same mother. rate, although fetal tissues were not examined for SIV expres-
sion [43].
Transmission in utero is thought to be transplacental and
cally significant difference in pregnancy outcome was theinitiated either (1) by cell-to-cell spread of HIV from infected
higher number of fetal losses in the HIV-seropositive group.maternal mononuclear cells within the intervillous space to the
The authors of most such studies suggest that IVDU is a con-trophoblastic epithelium covering placental villi, then to the
tributory factor in poor pregnancy outcome; however, a studyvillous stroma, fetal blood vessels in the placental villi, and
of the reproductive history of IVDU women did not show anyvia the fetal blood stream to the fetus itself or (2) by infected
impairment in fertility and did show a distribution of pregnancymaternal mononuclear cells gaining direct access to the fetal
outcomes similar to those of similar ethnic and racial back- circulation [44]. CD4 is present on fetal-derived placental tissue
ground in the general population [28]. (syncytiotrophoblast, fetal vascular endothelium, and Hofbauer
Not only does our study suggest that fetal loss is substantiallycells), and this tissue is capable of infection by HIV [45]. As it
increased in HIV-seropositive women, but unlike other such is believed that maternal blood cells do not enter the intervillous
studies, we have documented the HIV status of the fetal lossesspace before 12 weeks of gestation [46], placental and fetal
by in situ hybridization and show that 60% of the spontaneousinfection that occurs before then must do so by direct contact
fetal losses were associated with transmission of HIV to the with infected maternal cells in the decidualized endometrium.
fetus. There are numerous reports [4, 34-41] of in utero trans- In our study population, the HIV burden was heavy in decid-
mission of HIV detected by immunohistochemistry, in situ ualized endometrium in a high proportion of cases in which
hybridization, culture, and electron microscopy in fetal tissues such tissue was available for examination. Endometrial or de-
at various gestational ages; also HIV has been detected in fetal cidual infection was found in 7 of the 8 spontaneous losses
hematopoietic cells by in situ hybridization and immunohisto- that had such tissues available for testing but in only 1 of 10
chemistry as early as 8 weeks of gestation [9]. Many fetal term placentas with decidualized endometrium available for
tissues that have been studied for the presence of HIV were study [47]. The HIV burden appeared to be heavier in such

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 1458 Langston et al. JID 1995; 172 (December)

Figure 3. Comparis
HIV-positive and -nega
case 4 (12-week-ges
shows early architect
ning condensation of
gregate of epithelial ce
early Hassall's corpusc
nal magnification = x
bar = 10 Mm. B, Thy
gestation HIV-negativ
thymic architecture
medullary region cont
puscles (multiple betw
sin; original magnif
C, Thymus from cas
positive fetus) shows
cytes with no evident
and no Hassall's cor
original magnificat
Thymus from case 12
tive fetus) shows som
blurring of corticome
tively few Hassall's
microcystic change.
magnification = x25

tissues from the be more

earlier specific for HIV infection.
gestations. These include
The precocious
female
tissues are involution, dynamic,
immunologically associated with severe lymphoid
replete depletion of both
with
senting cells and other cortex
immuneand medulla, and epithelialpopulations
cell injury manifested by micro- c
sponding to antigenic cystic change, calcification,
stimulation with or virtual absence of Hassall's
cytokine cor-
and
duction that may eitherpuscles, sometimes with or
facilitate associated severe thymitis.
hinder repro In our
[48]. The degree of study, fetal losses thatvirus
endometrial were associated with fetal HIV infection
burden in e
suggests a potentiation were
of characterized
virus by very similar
burden thymic abnormalities
with early as p
may be a result of the early as 15 weeks
normal of gestation,
events of the T
earliest
cellinfected thymus
infilt
invasion intermediateavailable
by for study.
trophoblasts altering uteri
and hormonal or cytokineIt is difficult to define a mechanism for fetal loss in HIV-
influences.
It has been generally positive fetuses. In contrast,
assumed that the HIV-negative
fetalfetuses all showed
infectio
has little if any effect on
either fetal
placental well-being
or fetal lesions that could account for fetaland
loss.
Early reports of HIV Many of these placentas[49]
fetopathy showed thehave
effects of maternal
been decidual
ref
most studies in liveborn vascular
childrenevents (abruption,
showinfarction)little
or infection (other
if than
any
the rate of HIV) considered
malformation or significant
growth enough to abnormality
result in fetal demise. The
fected and noninfected HIV-positive
offspring fetuses generallyof
did notHIV-seroposi
show such significant pla-
The notable exception cental
to changes, and
this isin only
the 2 (cases 10 and 13) was there associ-
observations o
that have been made in fetuses and neonates born to HIV- ated fetal growth retardation. The role of HIV in these fetal losses
seropositive mothers [39, 51]. Reported thymic abnormalities
remains unknown; however, it may be that the effects of thymic
include changes in both the lymphoid and epithelial cell compo-
injury with altered cytokine production results in an unfavorable
uterine, endometrial, or decidual (or a combination) environment
nents of the thymus and are similar to those reported in pediatric
AIDS patients [52-54]. The changes seen at biopsy [54] rather
for the continuation of pregnancy or in some as-yet-unrecognized
than autopsy [52, 53] are easier to interpret and appearfetal
to effect leading to fetal death.

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 JID 1995; 172 (December) Fetal Loss in HIV Infection 1459

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