Amniocentesis in pregnant HIV-infected patients
Absence of mother-to-child viral transmission in a
series of selected patients
Dieudonne ´ Ekoukoua, Marie-Aude Khuong-Jossesb, Nelly Ghibaudoa,
Denis Mechalib, Daniel Rottena,*
aDepartment of obstetrics and gynecology, Ho ˆpital Delafontaine, 2 rue du docteur Pierre-Delafontaine, 93205 Saint-Denis, France
bDepartment of infectious and tropical diseases, Ho ˆpital Delafontaine, 2 rue du docteur Pierre-Delafontaine, 93205 Saint-Denis, France
Received 21 February 2007; received in revised form 23 January 2008; accepted 7 April 2008
Objectives: To assess the risk of vertical transmission in HIV-infected pregnantwomen undergoing diagnostic amniocentesis, and to identify
possible predictive factors.
Study design: This was a single center retrospective study. The records of 330 HIV-infected pregnant women booked in our antenatal clinic
from 31 January 2001 to 31 January 2006 were analyzed. Women who actually underwent diagnostic amniocentesis (‘‘amniocentesis
performed’’ group) were compared to those eligible for amniocentesis but who did not undergo the procedure (‘‘amniocentesis withheld’’
Results: During the time period, 318 liveborn babies were delivered (9 HIV infected (2.8%)). Thirty-four women (35 fetuses) were eligible
for diagnostic amniocentesis. Amniocentesis was performed in 11 (32.4%) of these women (12 fetuses, none infected among the 9 liveborns)
and withheld in 23 (67.6%) women. Among the 19 liveborn babies in this latter group, 1 (5.3%) was infected. There was no statistical
difference in vertical transmission rate between the whole cohort of HIV-infected pregnant women and the group of women eligible for
amniocentesis; or between the women who actually had or did not have an amniocentesis.
Thewomen who did undergo amniocentesis all received highly active antiretroviral combination therapy with three drugs; all but two had
an undetectable HIV viral load, only one had immunosuppression and none had HCV co-infection.
pregnant women. In the presence of high genetic risk during pregnancy, amniocentesis can be considered after proper patient counselling.
# 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: HIV-infected pregnant women; HIV vertical transmission; Genetic amniocentesis
Invasive procedures such as amniocentesis are usually
contra-indicated in pregnant women infected with human
deficiency virus. Puncture of the uterine wall or of an
anterior placenta may lead to a blood leak into the
amniotic cavity  and increase the infant’s exposure to
maternal blood. Thus, the procedure may lead to an
increased mother-to-child transmission [2–4]. However,
when facing a high risk of genetic or karyotypic anomaly
for the fetus, some HIV-infected mothers nevertheless
wish to be tested and should be provided with pertinent
Data evaluating vertical transmission rates after amnio-
centesis is scant and inconsistent. Early studies reported an
increased transmission after late  or mid-trimester 
procedures. As a result, amniocentesis was not offered to
HIV-infected patients in most centers prior to 2003 even
European Journal of Obstetrics & Gynecology and
Reproductive Biology 140 (2008) 212–217
* Corresponding author. Tel.: +33 1 42 35 61 40x6894;
fax: +33 1 42 35 42 31.
E-mail address: firstname.lastname@example.org (D. Rotten).
0301-2115/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved.
when a medical indication existed [7,8]. From 2003 on, the
reported risk of mother-to-fetus transmission fell dramati-
cally [9–11]. Many centers, including our institution, started
offering mid-trimester amniocentesis to selected HIV-
infected patients when indicated for genetic/karyotypic
indications. In parallel, the wider use of anti-retroviral
chemotherapy during pregnancy has reduced the overall
vertical transmission rate of HIV [2–4,12], prompting
necessary a reappraisal of the actual risk of amniocentesis in
this clinical setting.
The aim of this retrospective study was to assess if
diagnostic amniocentesis was associated with an increased
vertical transmission rate of HIV. A secondary objectivewas
to assess the influence of factors presumed associated with
an increased mother-to-fetus transmission rate, such as HIV
viral load [6,12–14], degree of immunosuppression  and
co-infection with hepatitis C virus (HCV) .
2. Patients and methods
All HIV-infected patients who had a medical indication
for amniocentesis and who were booked in the antenatal
clinic at any time during pregnancy from 31 January 2001 to
31 January 2006 were included in the study. Their medical
records were retrospectively reviewed. During the study
period, 18,191 deliveries took place in our ward, and 1168
amniocenteses were performed. Three hundred and thirty
An accepted indication for diagnosis amniocentesis
existed in 34 (10.3%) HIV-infected pregnant mothers (35
fetuses). Amniocentesis was performed in 11 of these HIV-
infected mothers (12 fetuses) and not performed in 23
patients. The ‘‘amniocentesis withheld’’ group included
was not offered according to our policy at that time. Eleven
patients declined the proposed procedure, either because
they would not interrupt pregnancy in the case of an
abnormal result (usually for religious reasons) or because of
the perceived risk associated with the procedure. In four
cases, the decision to withhold amniocentesis resulted from
an agreement between the patient and the antenatal team. It
was felt that the risks associated with the procedure
outweighed the benefits, specifically in patients presenting
with factors presumed to be associated with an increase in
theverticaltransmission rate, suchaspositiveHIVviral load
due to treatment resistance, late onset of antiviral therapy or
co-infection with HCV.
All patients were counselled about the benefits and the
possible risks of the test, including premature rupture of
membranes, abortion or premature labor, and increased risk
of HIV transmission. When a mother chose to undergo the
procedure, written consent was obtained, specifying the
possibility of an increased risk of HIV transmission to the
All patients followed up regularly during their pregnancy
received one of the standardized recommended anti-retro-
viral treatments during the pregnancy and intra-partum
period [2–4,12]. All the liveborn children received oral anti-
Amniocentesis was performed using a 20-gauge needle
under sonographic guidance.
For each patient, the following parameters were recorded:
maternal age, parity, HIV viral load, CD4+ T-cell count and
fluid study. When amniocentesis was performed, we also
the description of the procedure. If amniocentesis was
withheld, the reason was recorded. Immunosuppression was
In all cases, the HIV status of the newborn was recorded. A
baby was defined as HIV-free when two consecutive HIV-
PCR tests were negative after anti-retroviral therapy.
The x2-test and Mann–Whitney U-test were used as
Demographic details for the 34 patients (35 fetuses) who
had an indication for genetic amniocentesis are shown in
Table 1. In all cases but one, these were midtrimester
procedures indicated to search for genetic or karyotypic
anomalies. Some patients had more than one indication. In
one case, amniocentesis was indicated because of third
trimester occurrence of polyhydramnios associated with
intra-uterine growth retardation (IUGR) and abnormal
umbilical Doppler measurements.
Amniocentesis was performed in 11 (32.4%) women (12
fetuses) and withheld in 23 (67.6%). Demographic profiles
and indications for amniocentesis for both groups of patients
were similar (Table 1).
Details about the 12 amniocenteses performed are shown
in Table 2. The placenta was anterior in nine cases.
Amniocentesis demonstrated one trisomy 21, one sickle-cell
anemiaand no anomalyin 10 fetuses.In the two cases where
an anomaly was diagnosed, the mother opted for medical
termination of pregnancy. In one additional case, fetal death
was discovered at 26 gestational weeks (GW) in one twin of
a pair. Severe pre-eclampsia was present in the mother. The
babies were delivered by cesarean section at 32 GW. IUGR
below the 3rd centile in the liveborn baby and partial
placental necrosis were found at birth. Nine babies were
liveborn.In the ‘‘amniocentesis withheld’’ group, therewere
three cases of severe pre-eclampsia associated with IUGR
and abruptio placentae, causing fetal death (at 26, 32 and 33
GW). One baby had multiple congenital anomalies and died
immediately after birth. At neonatal examination, none of
the 19 live born babies of this group had clinical evidence of
any genetic or karyotypic abnormality.
D. Ekoukou et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 140 (2008) 212–217213
All patients in the ‘‘amniocentesis performed’’ group
received highly active anti-retroviral combination therapy
(HAART) with three drugs (Table 3). Immunosuppression
occurred in one patient, and all but two had an
undetectable HIV viral load. Median CD4+ T-cell count,
CD4+ T-cell % and viral load are shown in Table 3. In the
‘‘amniocentesis withheld’’ group, 20 patients received
HAART, 18 with triple therapy and 2 patients received
four drugs. One patient received zidovudine monotherapy
and two patients received no treatment. Immunosuppres-
sion was present in four patients, and three had an
undetectable HIV viral load.
Five patients in the ‘‘amniocentesis performed’’ group
delivered vaginally and five had a cesarean section for
obstetric reasons. None had scheduled cesarean delivery for
prevention of vertical transmission of HIV infection. Ten
patients in the ‘‘amniocentesis withheld’’ group delivered
vaginally and three had a cesarean section for obstetric
reasons. In 10 patients, scheduled cesarean delivery was
indicated for viral reasons (detectable viral load and/or
absence of HAART).
No HIV testing was attempted in the seven stillborn
babies. The nine liveborn babies in the ‘‘amniocentesis
performed’’ group tested negative for HIV. Among the 19
liveborn babies in the ‘‘amniocentesis withheld’’ group, one
was positive for HIV. In this case, amniocentesis had been
indicated because of abnormal biochemical testing, but was
declined by the mother. The baby had fetal growth
retardation (10th centile).
Mother-to-fetus transmission rates were not different
between the babies liveborn to HIV-infected pregnant
women when an amniocentesis was indicated versus those
with no indication for amniocentesis (1/28 (3.6%) versus 8/
290 (2.8%); p = 0.8047, x2-test).
D. Ekoukou et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 140 (2008) 212–217214
Clinical characteristics, ‘‘amniocentesis performed’’ group
Gestational age at
at delivery (weeks)
46, XY sickle-cell
46, XX, +21
aMTOP, medical termination of pregnancy.
bIUFD, second twin to case number 10, intra-uterine fetal death at 26 weeks.
Demographic characteristics of patients who had an indication for amniocentesis
ParametersAll patients‘‘Amniocentesis performed’’‘‘Amniocentesis withheld’’
Number of patients (amniocenteses)
Patient age [mean (range)]
Parity [mean (range)])
Patient place of birth&
Indications for amniocentesisa,$
Maternal age >38 years
Elevated serum markers
Anomaly found at morphologic sonography
Polyhydramnios + IUGR
Sickle cell carrier
aMore than one indication could exist in one patient.
&p = 0.7240 (x2-test).
$p = 0.5288.(x2-test).
There was no difference in transmission rate between
patients who had an amniocentesis versus those in whom an
amniocentesis was considered but withheld (0/9 versus 1/19
(5.3%); p = 0.4833 (x2-test). There was no difference in the
CD4+ T-cell count between the ‘‘amniocentesis performed’’
and the ‘‘amniocentesis withheld’’ groups (mean rank 18.9
versus 17.5; p = 0.7022, Mann–Whitney U-test). The HIV
viral load was significantly higher in the latter group (mean
rank 22.9 versus 8.7; p = 0.0001, Mann–Whitney U-test).
All three patients who tested positive for HCV belonged to
the ‘‘amniocentesis withheld’’ group.
The mother with a HIV-infected baby had a viral load
above the90thpercentile ofthe distributionof thepatientsin
whom an amniocentesis was indicated (52,293 copies/mL).
The CD4+ T-cell count and the CD4+ T-cell % approxi-
mated the 50th percentile (326 (20.4%)). She tested negative
for HCV. The baby was born by cesarean delivery for viral
In total, fetal demise due to severe pre-eclampsia
associated with IUGR occurred in four cases (one in the
‘‘amniocentesis performed’’ group and three in the
‘‘amniocentesis withheld group’’). This occurrence rate
was significantly higher than observed in the HIV-infected
women who had no indication for amniocentesis, where pre-
eclampsia occurred in five cases (25–37 GW) (4/32 (12.5%)
versus 5/288 (1.7%); p = 0.0005, x2-test). None of the
mothers who had fetal demise had amniocentesis indicated
for abnormal biochemical tests.
Invasive procedures have long been thought contra-
indicated in HIV-infected pregnant women for fear of an
increased vertical transmission rate, as reported in early
studies (Table 4). For instance, in the French Perinatal
Cohorts study, thevertical transmission ratewas 35.9% after
an invasive procedure compared to 19% in the control group
. Only 5.5% of the women in these cohorts received HIV-
specific treatment, which was zidovudine monotherapy, and
these data referred to third trimester procedures (amniocent-
esis and amnioscopy). Similarly, after third trimester
amniocentesis, Tess et al. reported an increased vertical
transmission, with 6 infected newborns from 15 procedures
(OR = 4.1, 95%, IC = 1.2–13.5 compared with the control
group) . Maiques et al. reported 10 mid-trimester
amniocenteses performed during the 1984–1996period. The
vertical transmission rate was 30% (3/10), as compared to
16.2% (40/247) in the control group. In this study, two
women in the amniocentesis group received zidovudine
monotherapy, and one of the two had an infected newborn
D. Ekoukou et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 140 (2008) 212–217215
Immunologic and viral characteristics
ParametersAll patients ‘‘Amniocentesis performed’’‘‘Amniocentesis withheld’’
CD4+ T-cell count [median (range)]
CD4+ T-cell % [median (range)]
Viral load, HIV1-RNA copies/mL [median (range)]
Child HIV status according to anti-retroviral therapy (literature review)a
Type of treatmentNone Zidovudine only HAART
Child HIV statusInfectedNot infectedInfectedNot infectedInfectedNot infected
aThe data refer to midtrimester genetic amniocentesis unless otherwise stated.
bThird trimester amniocentesis, n = 13 and amnioscopy, n = 26 (all third trimester).
cThird trimester amniocentesis.
dAmniocentesis, n = 56, choriocentesis, n = 3, cordocentesis, n = 4 (all third trimester).
ep = 0.0001 (x2-test).
The generalization of zidovudine monotherapy has been
accompanied by a dramatic decline in the vertical
transmission rate in HIV-infected pregnancies . In
parallel with this decline, a decrease in the transmission rate
after invasive procedures has also been observed. Bucceri
et al. reported no infected newborns in a series of 10
amniocenteses . One woman was untreated and nine
received zidovudine monotherapy. Altogether (Table 4),
among 24 women treated with zidovudine monotherapy and
who had an invasive procedure, only two newborns were
a further reduction of vertical HIV transmission after
invasive procedures. Maiques et al. reported 18 late (pre-
delivery) amniocenteses performed during the 1997–2000
period . All patients were receiving HAART. None of the
newborn babies was infected in the amniocentesis group (0/
18), compared with 3.7% (3/81) in women who had no
In a multicenter study, Somigliana et al. also showed no
difference in transmission rate between mothers who had an
invasive procedure (midtrimester amniocentesis, chorio-
centesis and/or cordocentesis) and the control group (2/60
(3.3%) versus 12/712 (1.7%)) . In this cohort, HAART
of the two infected infants in the invasive procedure group
was born from a mother untreated at time of amniocentesis
(this mother had been unaware of her HIV positive status).
Themother ofthe secondinfected newbornbabywas treated
with zidovudine monotherapy only, and had had a high HIV
viral load at time of the procedure (10 000 copies/mL).
Coll et al. showed no (0/6) infected newborns after mid-
trimester amniocentesis. A zero transmission rate was also
observed in the control patients (0/109) .
In all, the data collected in published studies (Table 4)
show that the implementation of anti-retroviral therapy with
zidovudine monotherapy first, and with HAART later, has
been accompanied with a dramatic decline in the vertical
transmission rate of HIV (p = 0.0001, x2-test).
This observation prompted a change in policy in many
centers caring for pregnant HIV-infected women. In
particular, from 2003 on, our center began offering
diagnostic amniocentesis to HIV-infected high-risk mothers.
In the present series, none of the nine HIV-infected
mothers who underwent amniocentesis gave birth to a
liveborn baby infected with HIV. It must be emphasized that
in the group of 34 women eligible for amniocentesis, the 11
highly selected. When factors associated with an increase in
vertical transmission were present, i.e. high HIV viral load
[6,12–14], immunosuppression  or HCV co-infection
, the procedure was withheld as a result of agreement
between the patient and the antenatal team. Actually, high
HIV viral load (four cases), immunosuppression (one case)
and HCV co-infection (one case) contra-indicated amnio-
centesis. All patients who actually underwent amniocentesis
received HAART with three drugs, and all but one had a
negative HIV viral load, none had immunosuppression, and
none had a HCV co-infection. Importantly, an anterior
placenta was punctured in six patients with no maternal-to-
fetus viral transmission.
Together with results obtained by other investigators
(Table 4), our data suggest that when indicated, diagnostic
amniocentesis should not be systematically withheld on the
basis of HIVinfection. Indeed, all available noninvasive risk
assessment tests, such as first trimester search for nuchal
translucency, assessment of biochemichal markers and
sonographic genetic scanning, should be performed prior
to considering amniocentesis, in order to decrease the risk
under the level indicating amniocentesis . But in the
presence of a risk above the threshold level or when no other
test exists, amniocentesis should be considered, and
carefully discussed with the patient. This applies in
particular in the absence of factors associated with an
increased transmission risk.
of the antenatal clinic, a delay may be necessary before
performing the procedure, in order to obtain a negative HIV
viral load. This may influence the gestational age at which
amniocentesis is performed; 17–22.5 weeks in our series
(one was done at 35 weeks, because of third trimester
discovery of polyhydramnios, IUGR and pathological
Doppler of the umbilical arteries).
In our study, we note a high incidence of pre-eclampsia in
HIV-infected women receiving HAART. Abnormal serum
biochemical markers in the absence of aneuploidy are
associated with various adverse outcomes, such as
hypertensive disorders of pregnancy, abruptio placentae,
IUGR and fetal death [20–22]. However, in the present
series, none of the mothers who had intra-uterine fetal death
had abnormal serum biochemical markers. Thus the
observation of a high rate of fetal demise in the group of
patients who had an indication for amniocentesis remains
unexplained. In our study we note, however, the known
increased risk of pre-eclampsia and fetal death rate in HIV-
infected pregnant women receiving highly active anti-
retroviral therapy .
The data obtained in the present study do not allow
definitive conclusions about the safety of amniocentesis in
HIV-infected pregnant patients, even in the absence of
known risk factors. Such data are unlikely to be obtained in
the future, as the demonstration of a 25% increase in the
transmission rate above the 2.8% transmission rate in our
population, would necessitate the study of a group of more
than 24,000 HIV-infected pregnant women, assuming a 10%
In conclusion, we present a series of 12 amniocenteses in
330 HIV-infected pregnant women (midtrimester, n = 11;
third trimester, n = 1). The observed vertical transmission
rates were similar in the ‘‘amniocentesis performed’’ group
(0/9) and the ‘‘amniocentesis considered but withheld’’
group (1/19). This data accords with other published series.
D. Ekoukou et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 140 (2008) 212–217216
Our patients were highly selected however, based on the Download full-text
following criteria: administration of highly active anti-
retroviral combination therapy, negative HIV viral load, no
immunosuppression and no HCV co-infection.
This study was supported in part by grants from Agence
Nationale de lutte contre le SIDA (ANRS) and Association
Maternite ´-Pe ´rinatalite ´-Enseignement.
We gratefully acknowledge the help of David S.
Celermajer, MD, for English language improvement.
 Giorlandino C, Gambuzza G, D’Alessio P, Santoro ML, Gentili P,
Vizzone A. Blood contamination of amniotic fluid after amniocentesis
in relation to placental location. Prenat Diag 1996;16:180–2.
 Delfraissy JF (under the direction of). Therapeutic management of
human immunodeficiency virus-infected subjects (recommendations
of the group of experts), Report to the Minister of Health, 2002 [http://
 Delfraissy JF (under the direction of). Therapeutic management of
human immunodeficiency virus-infected subjects (recommendations
of the group of experts), Report to the Minister of Health, 2004
 RoyalCollegeofObstetricians andGynaecologists (RCOG).Manage-
ment of HIV in pregnancy. London (UK): Royal College of Obste-
tricians and Gynaecologists (RCOG); April 2004 (Guideline; no. 39).
 Mandelbrot L, Mayaux MJ, Bongain A, et al. Obstetric factors and
mother-to-child transmission of human immunodeficiency virus type
1: the French perinatal cohorts. SEROGEST French Pediatric HIV
Infection Study Group. Am J Obstet Gynecol 1996;175:661–7.
 Shapiro DE, Sperling RS, Mandelbrot L, Britto P, Cunningham BE.
in patients receiving zidovudine prophylaxis. Pediatric AIDS Clinical
 Coll O, Fiore S, Floridia M, et al. Pregnancy and HIV infection: a
European consensus on management. AIDS 2002;16(Suppl 2):S1–8.
 Royal College of Obstetricians and Gynaecologists. Amniocentesis
and chorionic villus sampling. RCOG Guideline no. 8; 2005, 1–11.
 Maiques V, Garcia-Tejedor A, Perales A, Cordoba J, Esteban RJ. HIV
detection in amniotic fluid samples: amniocentesis can be performed
in HIV pregnant women? Eur J Obstet Gynecol Reprod Biol
 Somigliana E, Bucceri AM, Tibaldi C, et al. Italian Collaborative
Study on HIV infection in pregnancy. Early invasive diagnostic
techniques in pregnant women who are infected with the HIV: a
multicenter case series. Am J Obstet Gynecol 2005;437–42.
 Coll O, Suy A, Hernandez S, et al. Prenatal diagnosis in human
immunodeficiency virus-infected women: a new screening program
for chromosomal anomalies. Am J Obstet Gynecol 2006;194:192–8.
 Perinatal HIV Guidelines Working Group. Public Health Service Task
Force recommendations for use of antiretroviral drugs in pregnant
perinatal HIV-1 transmission in the United States. Rockville (MD):
U.S. Public Health Service; July 6, 2006.
 Sperling RS, Shapiro DE, Coombs RW, et al. Maternal viral load,
zidovudine treatment, and the risk of transmission of human immu-
nodeficiency virus type 1 from mother to infant. Pediatric AIDS
Clinical Trials Group Protocol 076 Study Group. N Engl J Med
 Mayaux MJ, Dussaix E, Isopet J, et al. Maternal virus load during
pregnancy and mother-to-child transmission of human immunodefi-
ciency virus type 1: the French perinatal cohort studies. SEROGEST
Cohort Group. J Infect Dis 1997;175:172–5.
Treat Issues 1997;11:25–31.
 Pappalardo BL. Influence of maternal human immunodeficiency virus
(HIV) co-infection on vertical transmission of hepatitis C virus
(HCV): a meta-analysis. Int J Epidemiol 2003;32:727–34.
 Tess BH, Rodrigues LC, Newell ML, Dunn DT, Lago TD. Breastfeed-
ing,genetic, obstetricand other risk factorsassociatedwith mother-to-
child transmission of HIV-1 in Sao Paulo State, Brazil. Sao Paulo
Collaborative Study for Vertical Transmission of HIV-1. AIDS
 Bucceri AM, Somigliana E, Vignali M. Early invasive diagnostic
techniques during pregnancy in HIV-infected women. Acta Obstet
Gynecol Scand 2001;80:82–3.
 Davies G, Wilson RD, Desilets V, et al. Society of obstetricians and
gynaecologists of Canada. Amniocentesis and women with hepatitis
B, hepatitis C, or human immunodeficiency virus. J Obstet Gynaecol
 Wald NJ, Morris JK, Ibison J, Wu T, George LM. Screening in early
pregnancy for pre-eclampsia using down syndrome quadruple test
markers. Prenat Diagn 2006;26:559–64.
 YaronY,CherryM,KramerRL, etal.Second-trimestermaternal serum
marker screening: maternal serum alpha-protein, beta-human chorionic
gonadotropin, estriol, and their various combinations as predictors of
pregnancy outcome. Am J Obstet Gynecol 1999;181:968–74.
 Spencer K, Cowans NJ, Avgidou K, Nicolaides KH. First-trimester
ultrasound and biochemical markers of aneuploidy and the prediction
 Suy A, Martinez E, Coll O, et al. Increased risk of pre-eclampsia and
fetal death in HIV-infected pregnant women receiving highly active
antiretroviral therapy. AIDS 2006;20:59–66.
D. Ekoukou et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 140 (2008) 212–217 217