Adnexal masses during pregnancy: diagnosis, treatment, and prognosis

Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. Although most adnexal masses in pregnancy can be safely observed and approximately 70% spontaneously resolve, a minority of cases warrant surgical intervention because of symptoms, risk of torsion, or suspicion of malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy because of accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis Simple Rules, and International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adneXa scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant vs surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible because of consistently demonstrated shorter hospital length of stay and less postoperative pain and some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, preterm birth, and low birthweight. The best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester of pregnancy, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12 to 15 mm Hg, intraoperative maternal capnography, pre- and postoperative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxes. Although planning surgery for the second trimester of pregnancy generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed because of gestational age. When performed at a facility with appropriate obstetrical, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for pregnant patients and fetuses.

Attitudes toward COVID-19 vaccination of pregnant and lactating women in Hungary

OBJECTIVES

This study has three purposes. First, we explore the percentage of the population that is vaccinated and the factors that contribute to whether or not an individual takes up COVID-19 vaccination. Second, we also look at how pregnant and lactating women (PLW) take up vaccination. Third, we reveal what the public think about PLW receiving vaccines.

METHODS

Questionnaire data collection was carried out online using the quota method among Hungarians aged 18-65 with Internet access. The survey was carried out between 29th November and 11th December 2021. A total of 1,000 participants completed the questionnaire.

RESULTS

A total of 66.4% of the respondents aged 18-65 received vaccination. There were significant differences across sociodemographic variables in vaccination: men and individuals with more education, better perceived financial status, and personal experience with COVID-19 were more likely to be vaccinated. PLW were less likely to be vaccinated, partly due to their fear of vaccines' side-effects. More than one third of the participants do not agree with PLW having COVID-19 vaccination. In general, attitudes toward vaccination of PLW differed significantly by social group. Men and individuals with tertiary education and better financial situation, who knew somebody who had died of COVID-19 infection, and who had been vaccinated were more likely to accept vaccination for both pregnant women and lactating mothers.

CONCLUSIONS

Acceptance of receiving COVID-19 vaccination depends on social status; thus, targeted campaigns are required. In addition, PLW are afraid of vaccines' side effects, so they should be provided information, just as there is a need to increase public information on this topic.

A systematic review and meta-analysis of the prevalence of human cytomegalovirus shedding in seropositive pregnant women

The detection of human cytomegalovirus (HCMV) in an individual's bodily fluid by culture techniques or through HCMV DNA detection by polymerase chain reaction, is known as HCMV shedding. Human cytomegalovirus shedding has the potential to transmit HCMV infection, where an individual can become infected with HCMV through contact with the bodily fluid of another individual containing HCMV. Human cytomegalovirus shedding can occur in primary infection and in non-primary infection for individuals with prior infection (HCMV seropositive). Human cytomegalovirus infection causes few or no symptoms in a pregnant woman, but can cause significant harm to her foetus if congenital CMV (cCMV) infection occurs. The association between HCMV shedding in HCMV seropositive pregnant women and the vertical transmission of HCMV to result in cCMV infection is poorly investigated, challenged by a limited understanding of the distribution of HCMV shedding in HCMV seropositive pregnant women. We systematically reviewed the published literature to describe the prevalence of HCMV shedding in HCMV seropositive women during pregnancy up to delivery. This analysis identified nine studies that met our eligibility criteria. In these studies, the prevalence of HCMV shedding in any bodily fluid of HCMV seropositive women during pregnancy and at delivery ranged from 0% to 42.5%. A meta-analysis, performed on six of the nine studies with suitable sample sizes, estimated a pooled prevalence of 21.5% [95% CI 12.7%,30.3%]. To our knowledge, this is the first review to systematically search the literature to summarise the prevalence of HCMV shedding in HCMV seropositive pregnant women. These estimates can help in the development of disease burden models and therapeutic or preventative strategies against cCMV infection in the context of non-primary maternal HCMV infection.

Intracranial Tuberculoma in a Pregnant Lady: A Hitherto Unknown Case and a Successful Outcome

Central nervous system tuberculosis (CNS-TB) is rarely suspected in pregnancy because its clinical presentation may masquerade other common conditions in pregnancy, such as eclampsia. In high tuberculosis endemic areas, CNS-TB should be suspected with a high degree of suspicion among unimmunized and immunocompromised individuals. We hereby report a case of a 32-year-old pregnant woman conceived by in vitro fertilization due to tubal blockage causing infertility, probably due to chronic infection, who presented with a history of multiple seizure episodes without a history of similar complaints outside this pregnancy. Obstetric examination revealed a gravid uterus larger than the corresponding gestational age, and an antenatal scan confirmed dichorionic diamniotic twins with the first twin in the breech and the second twin in the cephalic presentation. Magnetic resonance imaging of the brain revealed multiple nodular lesions of varying sizes that were isointense on T1-weighted imaging and hypointense on T2-weighted imaging in multiple regions of the brain, which suggest tuberculomas. A preterm cesarean section was performed at 31 weeks gestational age due to preterm rupture of membranes. We report this case to enlighten the physicians in diagnosing seizures causing intracranial tuberculoma in pregnant women and utilizing the role of imaging in diagnosis.

Multi-decade national cohort identifies adverse pregnancy and birth outcomes associated with acute respiratory illness hospitalisations during the influenza season

BACKGROUND

Despite the World Health Organization (WHO) recommendation that pregnant women be prioritised for seasonal influenza vaccination, coverage in the Western Pacific Region remains low. Our goal was to provide additional data for the Western Pacific Region about the value of maternal influenza vaccination to pregnant women and their families.

METHODS

We conducted a 16-year retrospective cohort to evaluate risks associated with influenza-associated maternal acute respiratory infection (ARI) in New Zealand. ARI hospitalisations during the May to September influenza season were identified using select ICD-10-AM primary and secondary discharge codes from chapter J00-J99 (diseases of the respiratory system). Cox proportional hazards models were used to calculate crude and adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

We identified 822,391 pregnancies among New Zealand residents between 2003 and 2018; 5095 (0.6%) had ≥1 associated ARI hospitalisation during the influenza season; these pregnancies were at greater risk of preterm birth (aHR 1.50, 95% CI 1.39-1.61) and low birthweight (aHR 1.64, 95% CI 1.51-1.79) than pregnancies without such hospitalisations. We did not find an association between maternal ARI hospitalisation and fetal death (aHR 0.96, 95% CI 0.69-1.34) during the influenza season. Maternal influenza vaccination was associated with reduced risk of preterm birth (aHR 0.79, 95% CI 0.77-0.82), low birthweight (aHR 0.87, 95% CI 0.83-0.90) and fetal death (aHR 0.50%, 95% CI 0.44-0.57).

CONCLUSION

In this population-based cohort, being hospitalised for an ARI during the influenza season while pregnant was a risk factor for delivering a preterm or a low birthweight infant and vaccination reduced this risk.

Wildfire Smoke Exposure during Pregnancy: A Review of Potential Mechanisms of Placental Toxicity, Impact on Obstetric Outcomes, and Strategies to Reduce Exposure

Climate change is accelerating the intensity and frequency of wildfires globally. Understanding how wildfire smoke (WS) may lead to adverse pregnancy outcomes and alterations in placental function via biological mechanisms is critical to mitigate the harms of exposure. We aim to review the literature surrounding WS, placental biology, biological mechanisms underlying adverse pregnancy outcomes as well as interventions and strategies to avoid WS exposure in pregnancy. This review includes epidemiologic and experimental laboratory-based studies of WS, air pollution, particulate matter (PM), and other chemicals related to combustion in relation to obstetric outcomes and placental biology. We summarized the available clinical, animal, and placental studies with WS and other combustion products such as tobacco, diesel, and wood smoke. Additionally, we reviewed current recommendations for prevention of WS exposure. We found that there is limited data specific to WS; however, studies on air pollution and other combustion sources suggest a link to inflammation, oxidative stress, endocrine disruption, DNA damage, telomere shortening, epigenetic changes, as well as metabolic, vascular, and endothelial dysregulation in the maternal-fetal unit. These alterations in placental biology contribute to adverse obstetric outcomes that disproportionally affect the most vulnerable. Limiting time outdoors, wearing N95 respirator face masks and using high quality indoor air filters during wildfire events reduces exposure to related environmental exposures and may mitigate morbidities attributable to WS.

Gestational diabetes is associated with alteration on pelvic floor muscle activation pattern during pregnancy and postpartum: Prospective cohort using electromyography assessment

Background and objective

Gestational diabetes mellitus (GDM) is a comorbidity which may cause acute and lifelong disorders to mother and child. Alterations in muscular and connective tissues have been associated with GDM in translation studies, characterizing gestational diabetic myopathy. Pregnancy-specific urinary incontinence and sexual disabilities, disorders that depend on the pelvic floor muscle (PFM) integrity, are also associated with GDM both during and after pregnancy. The aim was to compare PFM activation patterns between GDM and non-GDM women from 24-30 gestational weeks to 18-24 months postpartum during a standard clinical test during gestation and postpartum.

Methods

We conducted a prospective three-time-point cohort study from gestation (24-30 weeks-T1, and 36-38 weeks-T2) to 18-24 months postpartum (T3). PFM electromyography was recorded in primigravida or primiparous women with one previous elective c-section with or without the diagnosis of GDM according to the American Diabetes Association criteria. A careful explanation of the muscle anatomy and functionality of the PFM was given to participants before EMG assessment. The outcome measures were PFM activation patterns assessed during pregnancy and postpartum, comparing intra and between groups. PFM activation patterns were assessed by normalized electromyography signal at rest and during 1-second (sec) phasic, 10-sec hold, and 60-sec sustained contractions.

Results

Demographic and obstetric data showed homogeneity between groups. The GDM group achieved peak PFM EMG amplitudes similarly to the non-GDM group, but they took longer to return to baseline levels during the ~1-sec contraction (flicks). During 10-sec hold contractions, the GDM group sustained lower levels of PFM activation than the non-GDM group at both 36-38 weeks of gestation and 18-24 months postpartum when compared to the non-GDM group.

Conclusion

The results suggest that GDM impaired PFM control mainly on 1-sec flicks and 10-sec hold contraction, which appears to develop during late pregnancy and extends long-term postpartum. This motor behavior may play a role on pelvic floor dysfunctions.

Association of Pregnancy With Coronavirus Cytokine Storm: Systematic Review and Meta-analysis

BACKGROUND

COVID-19 was first identified in Wuhan, China, in December 2019, spreading to the rest of the globe, becoming a pandemic. Some studies have shown an association between pregnancy status and severe COVID-19 with a cytokine storm, whereas others have shown contrasting results.

OBJECTIVE

The aim of this study was to examine the relationship between pregnancy status and the clinical COVID-19 severity characterized by the cytokine storm through a systematic review and meta-analysis.

METHODS

We searched the Google Scholar, PubMed, Scopus, Web of Science, and Embase databases to identify clinical studies suitable for inclusion in this meta-analysis. Studies reporting pregnancy status and comparing the COVID-19 severity cytokine storm outcome were included. COVID-19 severity characterized by a cytokine storm was described using parameters such as intensive care unit admission, invasive mechanical ventilation, mechanical ventilation, hospital admission, pro- and anti-inflammatory cytokine levels, consolidation on chest computed tomography scan, pulmonary infiltration, extreme fevers as characteristic of a cytokine storm, syndromic severity, higher neutrophil count indicative of a cytokine storm, and severe COVID-19 presentation.

RESULTS

A total of 17 articles including data for 840,332 women with COVID-19 were included. This meta-analysis revealed a correlation between positive pregnancy status and severe COVID-19 with a cytokine storm (random-effects model odds ratio [OR] 2.47, 95% CI 1.63-3.73; P<.001), with a cumulative incidence of 6432 (14.1%) and 24,352 (3.1%) among pregnant and nonpregnant women with COVID-19, respectively. The fixed-effects model also showed a correlation between pregnancy status and severe COVID-19 with a cytokine storm (OR 7.41, 95% CI 7.02-7.83; P<.001). Considerable heterogeneity was found among all pooled studies (I²=98%, P<.001). Furthermore, the updated analysis showed substantially low heterogeneity (I²=29 %, P=.19), and the funnel plot revealed no publication bias. The subanalysis between single-center and multicenter studies demonstrated similar heterogeneity (I²=72% and 98%, respectively). Sensitivity analysis on each subgroup revealed that pregnancy was significantly related to severe COVID-19 with a cytokine storm from single-center studies (fixed-effects model OR 3.97, 95% CI 2.26-6.95; P<.001) with very low heterogeneity (I²=2%, P=.42).

CONCLUSIONS

Being pregnant is clearly associated with experiencing a severe course of COVID-19 characterized by a cytokine storm. The COVID-19 pandemic should serve as an impetus for further research on pregnant women diagnosed with COVID-19 to map out the salient risk factors associated with its severity.

TRIAL REGISTRATION

PROSPERO CRD42021242011; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242011.

Characteristics and outcomes of parturients with COVID-19, admitted to a critical care unit: A single-center retrospective observational study

Background

Data on outcomes of coronavirus disease 2019 (COVID-19) in pregnancy are scarce, although they represent a unique physiological state affecting both the mother and child. We present collated data from a tertiary care center in North India, encompassing the outcome, clinical characteristics, and management of these patients.

Materials and Methods

Parturients ≥ 18 years old, with COVID-19 reverse transcriptase polymerase chain reaction positive for severe acute respiratory syndrome coronavirus 2, requiring intensive care unit (ICU) admission at a tertiary care hospital were included. Data were retrospectively collected from April 2020 to November 2021.

Results

In all, 26 parturients were admitted to ICU with COVID-19. Five patients were admitted during the first wave, and all were asymptomatic. Twenty-one patients presented during the second wave (March 2021 onward), among which four were asymptomatic and 17 symptomatic (all with severe pneumonia). Three patients presented in the second trimester, all with critical disease, out of which one did not survive. Two patients had twin gestation, and others were singleton pregnancies. Seven patients (27%) were primigravida, and five patients (19.2%) had more than third pregnancy. Twenty critically ill women (77%) delivered during the hospital stay. Six patients died during the second wave, and four deaths (66.7%) were because of COVID-19 acute respiratory distress syndrome (ARDS).

Conclusions

The number of admissions and mortality related to COVID-19 ARDS was higher in the second wave than in the first. We report the safe use of remdesivir and tocilizumab in our patients.

Doppler ultrasound findings in symptomatic pregnant women diagnosed with COVID-19

The primary aim of this study was to investigate the potential impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on maternal and foetal Doppler findings. Doppler ultrasound findings were compared in 40 pregnant women diagnosed with COVID-19 disease who required hospitalisation (group 1) and 30 healthy pregnant women (group 2). Maternal characteristics and birth histories were recorded. Body mass index, gestational week at birth, type of delivery, oligihydroamnios, pre-term birth (<37 weeks), low birth weight (<10 percentile), perinatal death and f1st and 5th minute Apgar scores were recorded. Birth weights and foetal biophysical profile (BPP) scores in group 1 were significantly lower than those in group 2. There was a statistically significant between-group difference in the umbilical artery pulsatility index (PI), umbilical artery resistive index (RI), middle cerebral artery (MCA) PI, MCA RI, mean uterine artery (UtA) PI, mean UtA RI and cerebroplacental ratio (CPR), the parameters used to evaluate foetal-maternal blood flow. In the pregnant group diagnosed with COVID-19 and hospitalised, all foetal-maternal Doppler indicators of foetal-maternal blood flow were impaired, and birth weights and BPP scores in these patients were statistically significantly lower than those in the healthy controls.Impact statementWhat is already known on this subject? Foetal and maternal vascular malperfusion characterised by decidual arteriopathy have been reported in pathologies of placentas from pregnant women with SARS-CoV-2 infection.What the results of this study add? It was determined that COVID-19 disrupted foetal and maternal blood flow.What the implications are of these findings for clinical practice and/or further research? Foetal biometric measurements and foetal Doppler may be useful in the follow-up of perinatal outcomes in pregnant women with COVID-19.

A systematic review to determine the anti-vaccination thoughts of pregnant women and the reasons for not getting vaccinated

The aim of this study was to determine the anti-vaccination thoughts of pregnant women and the reasons for not getting vaccinated. In this study, data was obtained by retrospectively scanning the cross-sectional and qualitative studies published in the databases of 'PubMed, Cochrane, EBSCOhost, ULAKBİM and Google Scholar' in Turkish and English languages between 2011-2021. The PRISMA method was used in the preparation of the systematic review. In the studies reviewed, it was determined that the rate of pregnant women who were against the vaccine ranged from 6.2% to 98.6%, and the opinions of pregnant women against vaccination and the reasons for not getting vaccinated are presented under seven themes. The results of the study were considered important in terms of showing that quality and important studies were carried out in the literature on the subject and that the data were presented.IMPACT STATEMENTWhat is already known on this subject? Today, with the global coronavirus pandemic, vaccines and their effects are on the agenda again. Especially in pregnant women, opposition to vaccination and not getting vaccinated have emerged for various reasons.What do the results of this study add? The anti-vaccine thoughts of the pregnant women and the reasons for not getting vaccinated were mostly as follows: insufficient level of knowledge, mistrust of vaccines, perception of low infection risk, misconceptions and beliefs about the safety, content, side effects and efficacy of vaccines, worry and fear about the side effects of vaccines, the thought that the vaccine will harm herself and the baby, causes arising from healthcare professionals, financial, temporal and logistical barriers.What the implications are of these findings for clinical practice and/or further research? Scientific studies that can provide comprehensive and strong evidence about vaccine hesitancy and its causes, methods of increasing social approval in vaccination, and solutions should be proposed in the light of these researches in the fight against vaccine rejection.

Attitude of pregnant and lactating women toward COVID-19 vaccination in Jordan: a cross-sectional study

OBJECTIVES

The objective of this study was to survey pregnant and lactating toward COVID-19 vaccination in Jordan and determine the predictors of this attitude.

METHODS

This study used a 10 min anonymous, online, cross-sectional survey to collect data. The survey was carried out between September and October 2021. Eligible study participants included all pregnant and lactating women in Jordan. The participants were recruited through social media, midwives, and gynecologists. Survey was used to collect data from the participants.

RESULTS

The mean attitude of pregnant and lactating women toward COVID vaccination was moderate 71 (SD=100.5). Many factors were predicted the attitude of pregnant and lactating women toward COVID-19 vaccination. The factors were source of data regarding COVID-19 (B=-0.140, p=0.009), level of income (B=-0.141, p=0.009), and social status (B=0.130, p=0.034). These results mean lower income, people who frequently hearing news from news channel or ministry of health and married are showed more positive attitude toward COVID-19 vaccination for children.

CONCLUSIONS

This is a large national study regarding attitude of pregnant and lactating women toward COVID-19 vaccination in Jordan. This study found that more than 50% for the parents were hesitant to allow their children to receive COVID-19 vaccination. There were no differences between pregnant and lactating women toward COVID-19 vaccination.

Comparison irisin peptide serum level in pregnant women with and without gestational diabetes mellitus: A case-control study

INTRODUCTION

Gestational diabetes mellitus (GDM) is a metabolic disease that affects mother and foetus during pregnancy, causing acute and chronic adverse effects. Irisin is proposed as a novel marker to predict GDM. The aim of this study was to assess the role of irisin peptide serum levels in gestational diabetes and compare with healthy pregnant women.

METHODS

This case-control study was conducted on women at 24 to 34 weeks of gestation in Ghaem Hospital affiliated with Mashhad University of Medical Sciences between May 2016 and June 2019. In two study groups, GDM and non-GDM women, an association between maternal serum irisin levels and clinical and biochemical parameters were evaluated. Maternal serum irisin levels were measured by an enzyme immunoassay method. Body mass index, serum levels of glucose, oral glucose tolerance test (OGTT), insulin, haemoglobin A1C, homeostatic model assessment of insulin resistance (HOMA IR) and irisin were evaluated.

RESULTS

Totally, 56 participants (30 non-GDM women and 26 women with GDM) were enrolled. Not statistically significant was observed in serum irisin levels between GDM and non-GDM women. (p = .814) Irisin levels were not significantly associated with maternal age, systolic and diastolic blood pressure, the number of pregnancies, gestational age, fasting blood sugar, insulin, HOMA IR, one-hour and two-hour serum glucose and body mass index.

CONCLUSIONS

There is no significant difference between GDM and non-GDM groups in the case of irisin value and later, no association of irisin with metabolic and anthropometric parameters. These findings need to be assessed in future experiments.

Retrospective Evaluation of Toxoplasma Serology in Patients Admitted to a Training and Research Hospital Between 2017-2021

OBJECTIVE

In this study, it was aimed to retrospectively evaluate the anti-Toxoplasma IgG, IgM and avidity index results of patients who were requested for Toxoplasma serology in our hospital between 01.01.2017 and 31.12.2021.

METHODS

Anti-Toxoplasma antibodies are studied with Abbott Architect İ2000 SR device that using the chemiluminescent microparticle immunoassay method (CMIA), according to the company's recommendations. The age, gender, nationality, sending clinic/polyclinic, and pregnancy status information of patients were scanned from the hospital system.

RESULTS

In the five-year period between 2017 and 2021, 29.58% of anti-Toxoplasma IgG tests requested from 12694 patients and 0.94% of anti-Toxoplasma IgM tests sent from 12546 patients were found positive. It is striking that the number of test requests is higher in women. IgG positivity is highest in women in the age group of 30-39 (9.97%), and in men in the age group of 60-69 (6.97%). IgM positivity is higher in both women and men in the 20-29 age group (0.48% and 0.38%, respectively). Anti-Toxoplasma IgG was positive in 27.78% and IgM in 0.64% of the pregnant women. IgG positivity in Turkish and Syrian pregnant women were determined as 25.88%; 47.10% and IgM positivity as 0.49% and 1.83%, respectively, and the difference was statistically significant (p<0.001).

CONCLUSION

Our anti-Toxoplasma antibody positivity was found to be compatible with studies conducted in different centers in our country. The fact that IgM positivity in women is high in the 20-29 age group, which is the childbearing age, emphasizes the importance of screening before and during pregnancy. Consistent with other studies in the literature, the rate of seropositivity in Syrian pregnant women was found to be higher than Turkish. This is important in terms of showing the effect of socio-cultural behaviors on prevalence.

Sociodemographic Indicators, Household Food Security and Associations with Choline Intake in Pregnant Women: The NuEMI Study

Higher sociodemographic status is associated with adequate nutrient intake and food security. Adequate choline intake is vital during pregnancy to support fetal development. In this cross-sectional study, information was obtained from 682 pregnant women attending an ante-natal clinic in Bloemfontein, South Africa. Sociodemographic indicators that were bivariately significantly associated with a choline intake below the adequate intake level (AI) included a higher household density ratio, no access to own flush toilets at home, household not owning a refrigerator or microwave, as well as a lower level of education. Approximately one-third of participants were severely food-insecure. Logistic regression analysis, adjusted for energy intake, showed that household overcrowding increased the odds of a choline intake below the AI (OR 1.71).

Newborn Skin Maturity Medical Device Validation for Gestational Age Prediction: Clinical Trial

Background

Early access to antenatal care and high-cost technologies for pregnancy dating challenge early neonatal risk assessment at birth in resource-constrained settings. To overcome the absence or inaccuracy of postnatal gestational age (GA), we developed a new medical device to assess GA based on the photobiological properties of newborns’ skin and predictive models.

Objective

This study aims to validate a device that uses the photobiological model of skin maturity adjusted to the clinical data to detect GA and establish its accuracy in discriminating preterm newborns.

Methods

A multicenter, single-blinded, and single-arm intention-to-diagnosis clinical trial evaluated the accuracy of a novel device for the detection of GA and preterm newborns. The first-trimester ultrasound, a second comparator ultrasound, and data regarding the last menstrual period (LMP) from antenatal reports were used as references for GA at birth. The new test for validation was performed using a portable multiband reflectance photometer device that assessed the skin maturity of newborns and used machine learning models to predict GA, adjusted for birth weight and antenatal corticosteroid therapy exposure.

Results

The study group comprised 702 pregnant women who gave birth to 781 newborns, of which 366 (46.9%) were preterm newborns. As the primary outcome, the GA as predicted by the new test was in line with the reference GA that was calculated by using the intraclass correlation coefficient (0.969, 95% CI 0.964-0.973). The paired difference between predicted and reference GAs was −1.34 days, with Bland-Altman limits of −21.2 to 18.4 days. As a secondary outcome, the new test achieved 66.6% (95% CI 62.9%-70.1%) agreement with the reference GA within an error of 1 week. This agreement was similar to that of comparator-LMP-GAs (64.1%, 95% CI 60.7%-67.5%). The discrimination between preterm and term newborns via the device had a similar area under the receiver operating characteristic curve (0.970, 95% CI 0.959-0.981) compared with that for comparator-LMP-GAs (0.957, 95% CI 0.941-0.974). In newborns with absent or unreliable LMPs (n=451), the intent-to-discriminate analysis showed correct preterm versus term classifications with the new test, which achieved an accuracy of 89.6% (95% CI 86.4%-92.2%), while the accuracy for comparator-LMP-GA was 69.6% (95% CI 65.3%-73.7%).

Conclusions

The assessment of newborn’s skin maturity (adjusted by learning models) promises accurate pregnancy dating at birth, even without the antenatal ultrasound reference. Thus, the novel device could add value to the set of clinical parameters that direct the delivery of neonatal care in birth scenarios where GA is unknown or unreliable.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-027442

Maternal-Fetal Drug Development: An Industry Perspective

Medicines and vaccines prescribed to pregnant women often have not had pregnant women or lactating women included in clinical trials and products are often not approved by regulatory agencies for use in pregnant women. As a result, practitioners may need to prescribe medicines and give vaccines to this special population with limited drug efficacy and safety information available. Multiple regulatory guidance documents regarding the development of medications for pregnant and lactating women have been developed to encourage drug development and the investigation of medicines and vaccines used in this population. However, clinical, regulatory, ethical, and drug development challenges are encountered when designing clinical trials that include pregnant women and their fetuses, in which innovative methods and trial designs are essential. This article provides an overview of an industry perspective on maternal–fetal drug development that includes a review of the regulatory landscape for developing medicines for pregnant women and their fetuses, trial designs that include pregnant women, identification of gaps and challenges, and strategies for potential maternal–fetal drug development considerations for the future development of medicines and vaccines for pregnant women. Early involvement and discussion of drug and vaccine products with multiple stakeholders, including therapeutic experts, patients, physicians, and regulators, is encouraged to optimize the development of safe and effective medicines and vaccines for pregnant women and their fetuses.

Glycemic response to acute high-intensity interval versus moderate-intensity continuous exercise during pregnancy

The present study investigated the glycemic response to an acute high-intensity interval training (HIIT) session (10 one-minute intervals ≥90% HRmax interspersed with one-minute of active recovery) versus a moderate-intensity continuous training (MICT) session (30 min at 64%-76% HRmax ) during pregnancy. Twenty-four normoglycemic females with a singleton pregnancy (27.8 ± 4.7 weeks of gestation, 31.5 ± 4.1 years of age, body mass index: 25.2 ± 11.3) participated in a randomized crossover design study. A flash glucose monitor and accelerometer were worn continuously for 7 days recording glycemic response, physical activity, and sleep. Nutritional intake and enjoyment of the exercise were self-reported. Average heart rate during exercise was higher for HIIT (82 ± 4% HRmax ) compared with MICT (74 ± 4% HRmax ; p < 0.001) and participants achieved a peak heart rate of 92 ± 3% during HIIT (range 85%-97% HRmax ) compared with 81 ± 4% during MICT (p < 0.001). The change in glucose values from pre-to-postexercise were not different between conditions (HIIT: -0.62 ± 1.00 mmol/L; MICT: -0.81 ± 1.05 mmol/L; p = 0.300) with the exception that fewer individuals experienced postexercise hypoglycemia immediately following HIIT compared with MICT (8% versus 33% respectively; p = 0.041). Other glucose variables was not different between exercise protocols. Physical activity (p = 0.07) and caloric intake did not differ (p = 0.10). The majority of participants preferred HIIT (87.5%) and had greater perceived enjoyment compared to MICT (HIIT: 7.8 ± 1.5; MICT: 6.6 ± 2.0; p = 0.015). Sleep duration was 52 ± 73 min longer after participating in HIIT compared with the night prior (main effect for time p = 0.017); no significant changes for MICT. Overall, an acute session of HIIT appears to be well tolerated and demonstrates no adverse effects on maternal glycemic response.

Dynamic immune profile in French toxoplasmosis patients

BACKGROUND

Toxoplasma gondii infection is usually benign in Europe due to the strong predominance of type II strains. Few studies have been conducted to examine the immunological course of infection in humans and have yielded conflicting results, maybe influenced by heterogeneous parasite strains.

METHODS

We measured 23 immune mediators in 39, 40, and 29 sera of French non-infected, acutely infected, and chronically infected immunocompetent pregnant women, respectively.

RESULTS

Four different cytokine patterns were identified regarding their dynamics through infection phases. For eleven of the cytokines, IFN-β, IFN-γ, IL-4, IL5, IL-6, IL-10, IL-12, IL-15, CXCL9, CCL2 and CSF2, the serum levels were significantly elevated during acute infection. The inflammatory mediators IL-1β, IL-17A, IL-18, TNF-α and CSF3 remained unchanged during acute infection, while they were significantly lower in chronically infected compared to non-infected patients. As for the anti-inflammatory cytokines TGF-β and CCL5, their levels remained significantly elevated during chronic infection. We also observed a significant negative correlation of several cytokine concentrations with IgG levels, indicating a rapid decline of serum concentrations during the acute phase.

DISCUSSION

These results indicate an anti-inflammatory pattern in chronically infected patients in a type II dominated setting and demonstrate the highly dynamic immune situation during acute infection.

Meta-analysis of race and age influence on the vaginal microbiome in pregnant and nonpregnant healthy women

Aim: The presence of microbial species in reproductive tubes plays an essential protective role against the proliferation of harmful organisms and is an important factor in reproductive health. High-throughput culture-independent technologies allow the study of the vaginal microbiome on a large scale. This study aimed to compare the vaginal microbiota between pregnant and nonpregnant women of different ages and races using the meta-analysis method. Materials & methods: Seven articles with 16S rRNA gene sequences were studied and analyzed using CLC Genomics Workbench 20.1.1. Results & conclusion: This study revealed new insights into the effects of age and ethnicity on the pregnant and nonpregnant vaginal microbiome and found that the microbiome of Chinese women is more distinct than that of other ethnicities.

Beyond Abortion: The Consequences of Overturning Roe

The upcoming U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization has the potential to eliminate or severely restrict access to legal abortion care in the United States. We address the impact that the decision could have on abortion access and its consequences beyond abortion care. We posit that an abortion ban would, in effect, mean that anyone who becomes pregnant, including those who continue a pregnancy and give birth to healthy newborns and those with pregnancy complications or adverse pregnancy outcomes will become newly vulnerable to legal surveillance, civil detentions, forced interventions, and criminal prosecution. The harms imposed by banning or severely restricting abortion access will disproportionately affect persons of color and perpetuate structural racism. We caution that focusing on Roe as a decision that only protects ending a pregnancy ignores the protection that the decision also affords people who want to continue their pregnancies. It overlooks the ways in which overturning Roe will curtail fundamental rights for all those who become pregnant and will undermine their status as full persons meriting Constitutional protections. Such a singular focus inevitably obscures the common ground that people across the ideological spectrum might inhabit to ensure the safety, health, humanity, and rights of all people who experience pregnancy.

Barriers and facilitators of alcohol abstinence during pregnancy

Fetal Alcohol Spectrum Disorders (FASD) is a common and under-recognised health burden in South Africa. There is a limited understanding of why pregnant women drink in the South African context, particularly in rural settings, where the prevalence of FASD is highest. A purposive sample included eight women from a rural ante-natal clinic in the Northern Cape province of South Africa. Participants participated in a semi-structured interview. A process of thematic analysis was used to generate themes from the interviews. All participants were aware of the link between alcohol use during pregnancy and adverse fetal outcomes. Furthermore, most participants reduced drinking after pregnancy recognition. Participants described barriers and facilitators of alcohol abstinence. Barriers included social pressure, life stressors, and cravings and habits. Facilitators included the desire to avoid FASD, supportive relationships, availability of alternative activities. Addressing barriers at community and individual levels may aid women in reducing harmful drinking during pregnancy.

Short-term exposure to radiofrequency radiation and metabolic enzymes' activities during pregnancy and prenatal development

Radiofrequency radiation (RFR) as an environmental and physical pollutant may induce vulnerability to toxicity and disturb fetal development. Therefore, the potential health effects of short-term mobile phone like RFR exposure (GSM 1800 MHz; 14 V/m, 2 mW/kg specific absorption rate (SAR) during 15 min/day for a week) during pregnancy and also the development of fetuses were investigated. Hepatic glucose regulation and glutathione-dependent enzymes' capacities were biochemically analyzed in adult (female) and pregnant New Zealand White rabbits. Pregnant rabbits' two-day-old offspring were included to understand their developmental stages under short-term maternal RFR exposure. We analyzed two regulatory enzymes in the oxidative phase of phosphogluconate pathways to interpret the cytosolic NADPH's biosynthesis for maintaining mitochondrial energy metabolism. Moreover, the efficiencies of maternal glutathione-dependent enzymes on both the removal of metabolic disturbances during pregnancy and fetus development were examined. Whole-body RFR exposures were applied to pregnant animals from the 15th to the 22nd day of their gestations, i.e., the maturation periods of tissues and organs for rabbit fetuses. There were significant differences in hepatic glucose regulation and GSH-dependent enzymes' capacities with pregnancy and short-term RFR exposure. Consequently, we observed that intrauterine exposure to RFR might lead to cellular ROS- dependent disturbances in metabolic activity and any deficiency in the intracellular antioxidant (ROS-scavenging) system. This study might be a novel insight into further studies on the possible effects of short-term RF exposure and prenatal development.

Effects of Structured Supervised Exercise Training or Motivational Counseling on Pregnant Women's Physical Activity Level: FitMum - Randomized Controlled Trial

Background

Physical activity (PA) during pregnancy is an effective and safe way to improve maternal health in uncomplicated pregnancies. However, compliance with PA recommendations remains low among pregnant women.

Objective

The purpose of this study was to evaluate the effects of offering structured supervised exercise training (EXE) or motivational counseling on PA (MOT) during pregnancy on moderate-to-vigorous intensity physical activity (MVPA) level. Additionally, complementary measures of PA using the Pregnancy Physical Activity Questionnaire (PPAQ) and gold standard doubly labeled water (DLW) technique were investigated. The hypotheses were that both EXE and MOT would increase MVPA in pregnancy compared with standard care (CON) and that EXE would be more effective than MOT. In addition, the association between MVPA and the number of sessions attended was explored.

Methods

A randomized controlled trial included 220 healthy, inactive pregnant women with a median gestational age of 12.9 (IQR 9.4-13.9) weeks. A total of 219 women were randomized to CON (45/219), EXE (87/219), or MOT (87/219). The primary outcome was MVPA (minutes per week) from randomization to the 29th gestational week obtained by a wrist-worn commercial activity tracker (Vivosport, Garmin International). PA was measured by the activity tracker throughout pregnancy, PPAQ, and DLW. The primary outcome analysis was performed as an analysis of covariance model adjusting for baseline PA.

Results

The average MVPA (minutes per week) from randomization to the 29th gestational week was 33 (95% CI 18 to 47) in CON, 50 (95% CI 39 to 60) in EXE, and 40 (95% CI 30 to 51) in MOT. When adjusted for baseline MVPA, participants in EXE performed 20 (95% CI 4 to 36) minutes per week more MVPA than participants in CON (P=.02). MOT was not more effective than CON; EXE and MOT also did not differ. MVPA was positively associated with the number of exercise sessions attended in EXE from randomization to delivery (P=.04). Attendance was higher for online (due to COVID-19 restrictions) compared with physical exercise training (P=.03). Adverse events and serious adverse events did not differ between groups.

Conclusions

Offering EXE was more effective than CON to increase MVPA among pregnant women, whereas offering MOT was not. MVPA in the intervention groups did not reach the recommended level in pregnancy. Changing the intervention to online due to COVID-19 restrictions did not affect MVPA level but increased exercise participation.

Trial Registration

ClinicalTrials.gov NCT03679130; https://clinicaltrials.gov/ct2/show/NCT03679130

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2020-043671