Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis

Preterm birth and neonatal acute kidney injury: implications on adolescent and adult outcomes

As a result of preterm birth, immature kidneys are exposed to interventions in the NICU that promote survival, but are nephrotoxic. Furthermore, the duration of renal development may be truncated in these vulnerable neonates. Immaturity and nephrotoxic exposures predispose preterm newborns to acute kidney injury (AKI), particularly in the low birth weight and extremely preterm gestational age groups. Several studies have associated preterm birth as a risk factor for future chronic kidney disease (CKD). However, only a few publications have investigated the impact of neonatal AKI on CKD development. Here, we will review the evidence linking preterm birth and AKI in the NICU to CKD and highlight the knowledge gaps and opportunities for future research. For neonatal intensive care studies, we propose the inclusion of AKI as an important short-term morbidity outcome and CKD findings such as a reduced glomerular filtration rate in the assessment of long-term outcomes.

Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: a cluster-randomised facility-based trial

Background

Although gains in newborn survival have been achieved in many low-income and middle-income countries, reductions in stillbirth and neonatal mortality have been slow. Prematurity complications are a major driver of stillbirth and neonatal mortality. We aimed to assess the effect of a quality improvement package for intrapartum and immediate newborn care on stillbirth and preterm neonatal survival in Kenya and Uganda, where evidence-based practices are often underutilised.

Methods

This unblinded cluster-randomised controlled trial was done in western Kenya and eastern Uganda at facilities that provide 24-h maternity care with at least 200 births per year. The study assessed outcomes of low-birthweight and preterm babies. Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention group or the control group. All facilities received maternity register data strengthening and a modified WHO Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. Liveborn or fresh stillborn babies who weighed between 1000 g and 2500 g, or less than 3000 g with a recorded gestational age of less than 37 weeks, were included in the analysis. We abstracted data from maternity registers for maternal and birth outcomes. Follow-up was done by phone or in person to identify the status of the infant at 28 days. The primary outcome was fresh stillbirth and 28-day neonatal mortality. This trial is registered with ClinicalTrials.gov, NCT03112018.

Findings

Between Oct 1, 2016, and April 30, 2019, 20 facilities were randomly assigned to either the intervention group (n=10) or the control group (n=10). Among 5343 eligible babies in these facilities, we assessed outcomes of 2938 newborn and fresh stillborn babies (1447 in the intervention and 1491 in the control group). 347 (23%) of 1491 infants in the control group were stillborn or died in the neonatal period compared with 221 (15%) of 1447 infants in the intervention group at 28 days (odds ratio 0·66, 95% CI 0·54–0·81). No harm or adverse effects were found.

Interpretation

Fresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening.

Funding

Bill & Melinda Gates Foundation.

Working with what you have: How the East Africa Preterm Birth Initiative used gestational age data from facility maternity registers

Objective

Preterm birth is the primary driver of neonatal mortality worldwide, but it is defined by gestational age (GA) which is challenging to accurately assess in low-resource settings. In a commitment to reducing preterm birth while reinforcing and strengthening facility data sources, the East Africa Preterm Birth Initiative (PTBi-EA) chose eligibility criteria that combined GA and birth weight. This analysis evaluated the quality of the GA data as recorded in maternity registers in PTBi-EA study facilities and the strength of the PTBi-EA eligibility criteria.

Methods

We conducted a retrospective analysis of maternity register data from March–September 2016. GA data from 23 study facilities in Migori, Kenya and the Busoga Region of Uganda were evaluated for completeness (variable present), consistency (recorded versus calculated GA), and plausibility (falling within the 3^rd and 97^th birth weight percentiles for GA of the INTERGROWTH-21^st Newborn Birth Weight Standards). Preterm birth rates were calculated using: 1) recorded GA <37 weeks, 2) recorded GA <37 weeks, excluding implausible GAs, 3) birth weight <2500g, and 4) PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks.

Results

In both countries, GA was the least recorded variable in the maternity register (77.6%). Recorded and calculated GA (Kenya only) were consistent in 29.5% of births. Implausible GAs accounted for 11.7% of births. The four preterm birth rates were 1) 14.5%, 2) 10.6%, 3) 9.6%, 4) 13.4%.

Conclusions

Maternity register GA data presented quality concerns in PTBi-EA study sites. The PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks accommodated these concerns by using both birth weight and GA, balancing issues of accuracy and completeness with practical applicability.

Potential pregnancy days lost: an innovative measure of gestational age

In Brazil, the excess of interventions that anticipate childbirth, such as cesarean sections and labor inductions, has resulted in the shortening of pregnancy, with negative consequences on maternal-infant outcomes. This commentary presents a novel way to measure gestational age: the continuous variable "Potential pregnancy days lost." Using data from the Live Birth Information System (SINASC), we counted the missing days between the period until childbirth and the average duration of pregnancy (280 days), or the lost weeks. This measure can be used as an outcome variable (socioeconomic-demographic characteristics of the mother, type of childbirth, financing, etc.) or exposure variable (for neonatal, infant, and maternal outcomes). The indicator can be used in municipal and national cohorts and intervention studies to analyze hospitals and regions. We discuss the limits and scope of gestational age measures and, given their inaccuracies, the importance of studying their trends.

Trends in reported antibiotic use among children under 5 years of age with fever, diarrhoea, or cough with fast or difficult breathing across low-income and middle-income countries in 2005-17: a systematic analysis of 132 national surveys from 73 countries

BACKGROUND

Global assessments of antibiotic consumption have relied on pharmaceutical sales data that do not measure individual-level use, and are often unreliable or unavailable for low-income and middle-income countries (LMICs). To help fill this evidence gap, we compiled data from national surveys in LMICs in 2005-17 reporting antibiotic use for sick children under the age of 5 years.

METHODS

Based on 132 Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 73 LMICs, we analysed trends in reported antibiotic use among children under 5 years of age with fever, diarrhoea, or cough with fast or difficult breathing by WHO region, World Bank income classification, and symptom complaint. A logit transformation was used to estimate the outcome using a linear Bayesian regression model. The model included country-level socioeconomic, disease incidence, and health system covariates to generate estimates for country-years with missing values.

FINDINGS

Across LMICs, reported antibiotic use among sick children under 5 years of age increased from 36·8% (uncertainty interval [UI] 28·8-44·7) in 2005 to 43·1% (33·2-50·5) in 2017. Low-income countries had the greatest relative increase; in these countries, reported antibiotic use for sick children under 5 years of age rose 34% during the study period, from 29·6% (21·2-41·1) in 2005 to 39·5% (32·9-47·6) in 2017, although it remained the lowest of any income group throughout the study period.

INTERPRETATION

We found a limited but steady increase in reported antibiotic use for sick children under 5 years of age across LMICs in 2005-17, although overlapping UIs complicate interpretation. The increase was largely driven by gains in low-income countries. Our study expands the evidence base from LMICs, where strengthening antibiotic consumption and resistance surveillance is a global health priority.

FUNDING

Uppsala Antibiotic Centre, Uppsala University, Uppsala University Hospital, Makerere University, Gothenburg University.

Schizophrenia around the time of pregnancy: leveraging population-based health data and electronic health record data to fill knowledge gaps

BACKGROUND

Research in schizophrenia and pregnancy has traditionally been conducted in small samples. More recently, secondary analysis of routine healthcare data has facilitated access to data on large numbers of women with schizophrenia.

AIMS

To discuss four scientific advances using data from Canada, Denmark and the UK from population-level health registers and clinical data sources.

METHOD

Narrative review of research from these three countries to illustrate key advances in the area of schizophrenia and pregnancy.

RESULTS

Health administrative and clinical data from electronic medical records have been used to identify population-level and clinical cohorts of women with schizophrenia, and follow them longitudinally along with their children. These data have demonstrated that fertility rates in women with schizophrenia have increased over time and have enabled documentation of the course of illness in relation with pregnancy, showing the early postpartum as the time of highest risk. As a result of large sample sizes, we have been able to understand the prevalence of and risk factors for rare outcomes that would be difficult to study in clinical research. Advanced pharmaco-epidemiological methods have been used to address confounding in studies of antipsychotic medications in pregnancy, to provide data about the benefits and risks of treatment for women and their care providers.

CONCLUSIONS

Use of these data has advanced the field of research in schizophrenia and pregnancy. Future developments in use of electronic health records include access to richer data sources and use of modern technical advances such as machine learning and supporting team science.

Hippocampal subfield volumes are nonspecifically reduced in premature-born adults

Reduced global hippocampus volumes have been demonstrated in premature‐born individuals, from newborns to adults; however, it is unknown whether hippocampus subfield (HCSF) volumes are differentially affected by premature birth and how relevant they are for cognitive performance. To address these questions, we investigated magnetic resonance imaging (MRI)‐derived HCSF volumes in very premature‐born adults, and related them with general cognitive performance in adulthood. We assessed 103 very premature‐born (gestational age [GA] <32 weeks and/or birth weight <1,500 g) and 109 term‐born individuals with cognitive testing and structural MRI at 26 years of age. HCSFs were automatically segmented based on three‐dimensional T1‐ and T2‐weighted sequences and studied both individually and grouped into three functional units, namely hippocampus proper (HP), subicular complex (SC), and dentate gyrus (DG). Cognitive performance was measured using the Wechsler‐Adult‐Intelligence‐Scale (full‐scale intelligence quotient [FS‐IQ]) at 26 years. We observed bilateral volume reductions for almost all HCSF volumes in premature‐born adults and associations with GA and neonatal treatment intensity but not birth weight. Left‐sided HP, SC, and DG volumes were associated with adult FS‐IQ. Furthermore, left DG volume was a mediator of the association between GA and adult FS‐IQ in premature‐born individuals. Results demonstrate nonspecifically reduced HCSF volumes in premature‐born adults; but specific associations with cognitive outcome highlight the importance of the left DG. Data suggest that specific interventions toward hippocampus function might be promising to lower adverse cognitive effects of prematurity.

Clinical information extraction for preterm birth risk prediction

This paper contributes to the pursuit of leveraging unstructured medical notes to structured clinical decision making. In particular, we present a pipeline for clinical information extraction from medical notes related to preterm birth, and discuss the main challenges as well as its potential for clinical practice. A large collection of medical notes, created by staff during hospitalizations of patients who were at risk of delivering preterm, was gathered and analyzed. Based on an annotated collection of notes, we trained and evaluated information extraction components to discover clinical entities such as symptoms, events, anatomical sites and procedures, as well as attributes linked to these clinical entities. In a retrospective study, we show that these are highly informative for clinical decision support models that are trained to predict whether delivery is likely to occur within specific time windows, in combination with structured information from electronic health records.

Influence of Maternal Age and Gestational Age on Breast Milk Antioxidants During the First Month of Lactation

Breast milk (BM) is beneficial due to its content in a wide range of different antioxidants, particularly relevant for preterm infants, who are at higher risk of oxidative stress. We hypothesize that BM antioxidants are adapted to gestational age and are negatively influenced by maternal age. Fifty breastfeeding women from two hospitals (Madrid, Spain) provided BM samples at days 7, 14 and 28 of lactation to assess total antioxidant capacity (ABTS), thiol groups, reduced glutathione (GSH), superoxide dismutase (SOD) and catalase activities, lipid peroxidation (malondialdehyde, MDA + 4-Hydroxy-Trans-2-Nonenal, HNE), protein oxidation (carbonyl groups) (spectrophotometry) and melatonin (ELISA). Mixed random-effects linear regression models were used to study the influence of maternal and gestational ages on BM antioxidants, adjusted by days of lactation. Regression models evidenced a negative association between maternal age and BM melatonin levels (β = -7.4 ± 2.5; p-value = 0.005); and a negative association between gestational age and BM total antioxidant capacity (β = -0.008 ± 0.003; p-value = 0.006), SOD activity (β = -0.002 ± 0.001; p-value = 0.043) and protein oxidation (β = -0.22 ± 0.07; p-value = 0.001). In conclusion, BM antioxidants are adapted to gestational age providing higher levels to infants with lower degree of maturation; maternal ageing has a negative influence on melatonin, a key antioxidant hormone.

Decreased cortical thickness mediates the relationship between premature birth and cognitive performance in adulthood

Cortical thickness (CTh) reflects cortical properties such as dendritic complexity and synaptic density, which are not only vulnerable to developmental disturbances caused by premature birth but also highly relevant for cognitive performance. We tested the hypotheses whether CTh in young adults is altered after premature birth and whether these aberrations are relevant for general cognitive abilities. We investigated CTh based on brain structural magnetic resonance imaging and surface-based morphometry in a large and prospectively collected cohort of 101 very premature-born adults (<32 weeks of gestation and/or birth weight [BW] below 1,500 g) and 111 full-term controls at 26 years of age. Cognitive performance was assessed by full-scale intelligence quotient (IQ) using the Wechsler Adult Intelligence Scale. CTh was reduced in frontal, parietal, and temporal associative cortices predominantly in the left hemisphere in premature-born adults compared to controls. We found a significant positive association of CTh with both gestational age and BW, particularly in the left hemisphere, and a significant negative association between CTh and intensity of neonatal treatment within limited regions bilaterally. Full-scale IQ and CTh in the left hemisphere were positively correlated. Furthermore, CTh in the left hemisphere acted as a mediator on the association between premature birth and full-scale IQ. Results provide evidence that premature born adults have widespread reduced CTh that is relevant for their general cognitive performance. Data suggest lasting reductions in cortical microstructure subserving CTh after premature birth.

Trends in preterm birth in twin pregnancies in Victoria, Australia, 2007-2017

BACKGROUND

Preterm birth is a major cause of perinatal morbidity and mortality worldwide. In many countries, the preterm birth rate in women with a multiple pregnancy is increasing, mostly due to an increase in iatrogenic preterm birth.

AIMS

To investigate trends in preterm birth in twin pregnancies in Victoria, Australia, in relation to maternal and perinatal complications.

MATERIALS AND METHODS

We conducted a retrospective population-based cohort study in all women with a twin pregnancy who delivered at or after 20 weeks of gestation in the state of Victoria, Australia between 2007 and 2017. Annual spontaneous and iatrogenic preterm birth rates were calculated and trends analysed. Incidence of adverse pregnancy outcomes, maternal complications and risk factors for preterm birth were analysed.

RESULTS

We studied 12 757 women with a twin pregnancy. Between 2007 and 2017 the preterm birth rate increased from 641/1231 (52%) to 803/1158 (69%), mainly due to an increase in iatrogenic preterm birth from 342/1231 (28%) to 567/1158 (49%). This was irrespective of the presence of pregnancy complications. Our study showed neither a decrease in perinatal mortality from 28 weeks of gestation nor in preterm average weekly prospective stillbirth risk.

CONCLUSION

Preterm birth rates in twins in Victoria are increasing, mainly driven by an increase in iatrogenic preterm birth. This occurred both in complicated and non-complicated twin pregnancies, and has not been accompanied by reduction in perinatal mortality from 28 weeks.

Cost-Consequences Analysis of Increased Utilization of Triple-Chamber-Bag Parenteral Nutrition in Preterm Neonates in Seven European Countries

The safety of parenteral nutrition (PN) remains a concern in preterm neonates, impacting clinical outcomes and health-care-resource use and costs. This cost-consequence analysis assessed national-level impacts of a 10-percentage point increase in use of industry-prepared three-chamber bags (3CBs) on clinical outcomes, healthcare resources, and hospital budgets across seven European countries. A ten-percentage-point 3CB use-increase model was developed for Belgium, France, Germany, Italy, Portugal, Spain, and the UK. The cost-consequence analysis estimated the impact on compounding error harm and bloodstream infection (BSI) rates, staff time, and annual hospital budget. Of 265,000 (52%) preterm neonates, 133,000 (52%) were estimated to require PN. Baseline compounding methods were estimated as 43% pharmacy manual, 16% pharmacy automated, 22% ward, 9% outsourced, 3% industry provided non-3CBs, and 7% 3CBs. A modeled increased 3CB use would change these values to 39%, 15%, 18%, 9%, 3%, and 17%, respectively. Modeled consequences included −11.6% for harm due to compounding errors and −2.7% for BSIs. Labor time saved would equate to 41 specialized nurses, 29 senior pharmacists, 26 pharmacy assistants, and 22 senior pediatricians working full time. Budget impact would be a €8,960,601 (3.4%) fall from €260,329,814 to €251,369,212. Even a small increase in the use of 3CBs in preterm neonates could substantially improve neonatal clinical outcomes, and provide notable resource and cost savings to hospitals.

Preterm delivery and long term mortality in women: national cohort and co-sibling study

OBJECTIVES

To examine the long term mortality associated with preterm delivery in a large population based cohort of women, and to assess for potential confounding by shared familial factors.

DESIGN

National cohort study.

SETTING

Sweden.

PARTICIPANTS

All 2 189 477 women with a singleton delivery in 1973-2015.

MAIN OUTCOME MEASURES

All cause and cause specific mortality up to 2016, identified from nationwide death records. Cox regression was used to calculate hazard ratios while adjusting for confounders, and co-sibling analyses assessed the potential influence of unmeasured shared familial (genetic and environmental) factors.

RESULTS

In 50.7 million person years of follow-up, 76 535 (3.5%) women died (median age at death was 57.6). In the 10 years after delivery, the adjusted hazard ratio for all cause mortality associated with preterm delivery (<37 weeks) was 1.73 (95% confidence interval 1.61 to 1.87), and when further stratified was 2.20 (1.63 to 2.96) for extremely preterm delivery (22-27 weeks), 2.28 (2.01 to 2.58) for very preterm delivery (28-33 weeks), 1.52 (1.39 to 1.67) for late preterm delivery (34-36 weeks), and 1.19 (1.12 to 1.27) for early term delivery (37-38 weeks) compared with full term delivery (39-41 weeks). These risks declined but remained significantly raised after longer follow-up times: for preterm versusfull term births, 10-19 years after delivery, the adjusted hazard ratio was 1.45 (95% confidence interval 1.37 to 1.53); 20-44 years after delivery, the adjusted hazard ratio was 1.37 (1.33 to 1.41). These findings did not seem to be attributable to shared genetic or environmental factors within families. Several causes were identified, including cardiovascular and respiratory disorders, diabetes, and cancer.

CONCLUSIONS

In this large national cohort of women, the findings suggested that preterm and early term delivery were independent risk factors for premature mortality from several major causes. These associations declined over time but remained raised up to 40 years later.

Neonatal Survival in Sub-Sahara: A Review of Kenya and South Africa

Introduction

The majority (99%) of the children who die during the first 4 weeks of life do so in the poorer parts of the world, especially in sub-Saharan Africa and South Asia. In 2018, sub-Saharan Africa had a neonatal mortality rate of 28 deaths per 1000 live births. The purpose of the review was to explore and describe the trends of neonatal mortality within the two sub-Saharan countries.

Methods

We did a literature search in biomedical databases of data published, in English, between Jan 1, 1975, and November 30, 2019. The databases included Scopus, Web of Science, Science Direct, Cochrane Library, PUBMED, OVID and Google scholar. The keywords used in the search: “Neonatal Survival”, “Sub-Sahara”, “Kenya” and “South Africa”.

Results

The search generated 2209 articles of which only 27 met the inclusion criteria. The present study qualitatively analysed data. Data were presented and organized under two thematic domains: 1) trends of national neonatal mortality rates in South Africa and Kenya and 2) causes of neonatal mortality.

Conclusion

The current review results noted that in 2018, the neonatal mortality rate for Kenya was 19.6 deaths per 1000 live births. The neonatal mortality rate has fallen gradually from 35.4 deaths per 1000 live births in 1975. On the other hand, South Africa has had its neonatal mortality rate fall from 27.9 deaths per 1000 live births in 1975 to 10.7 deaths per 1000 live births in 2018. Most neonatal deaths resulted in preterm birth complications followed by intrapartum-related events for the two countries. Within the sub-Saharan region, disparities exist as neonates born in South Africa are more likely to survive during the neonatal period compared to Kenya.

Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes

Background

Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes.

Methods

Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence.

Results

The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21–0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33–1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73–0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30–0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40–1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07–1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37–0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67–0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96–1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70–1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97–1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74–1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47–1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07–1.12; 2 studies; 530 women; very low-certainty evidence).

Conclusion

PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes.

Factors Associated with Treatment Outcome of Preterm Babies at Discharge from the Neonatal Intensive Care Unit (NICU) of the Tamale Teaching Hospital, Ghana

Background

Preterm birth and complications are now the leading cause of death in children under 5 years globally. In Ghana, studies assessing the survival rate of preterm babies and associated factors in Neonatal Intensive Care Units (NICU) are limited. Therefore, this study was designed to assess the survival rate and associated factors in this group of babies in a teaching hospital in the Northern Region of Ghana.

Methods

This was a 7-month retrospective descriptive study conducted in the NICU of the Tamale Teaching Hospital, Ghana. It involved review of charts of all preterm babies admitted between 1 March 2017 and 30 September 2017. Data retrieved from all eligible patients was analyzed using Stata version 12.1 software to generate descriptive statistics. Relationship between dependent and independent variables was tested using Pearson chi square. A logistic regression model was estimated to assess determinants of the treatment outcome.

Results

The overall survival rate at discharge in this cohort was 60.73%. The survival rate was lowest in the extremely low birth weight group (3/21; 14.3%) and extremely preterm babies (4/20; 20%). Significant association was observed between birth weight (P = 0.0001), gestational age (P = 0.0001), and survival. Preterm babies who were hypothermic at presentation, had respiratory distress syndrome, and had jaundice were 7.2 times (AOR = 7.2; 95%CI = 1.9‐28.1; P = 0.004), 10.2 times (AOR = 10.2; 95%CI = 3.7‐27.9; P ≤ 0.0001), and 2.9 times (AOR = 2.9; 95%CI = 1.0‐8.5; P = 0.045), respectively, more likely to die on admission compared to neonates who did not have these comorbidities.

Conclusion

We found a high mortality rate in the preterm babies admitted to our unit, and that mortality rate decreased with increasing gestational age and birth weight. A number of neonatal factors, either in isolation or in combination, were significantly associated with in-hospital mortality.

MicroRNAs isolated from peripheral blood in the first trimester predict spontaneous preterm birth

OBJECTIVE

To predict spontaneous preterm birth among pregnant women in an African American population using first trimester peripheral blood maternal immune cell microRNA.

STUDY DESIGN

This was a retrospective nested case-control study in pregnant patients enrolled between March 2006 and October 2016. For initial study inclusion, samples were selected that met the following criteria: 1) singleton pregnancy; 2) maternal body mass index (BMI) <30 kg/m2; 3) blood sample drawn between 6 weeks to 12 weeks 6 days gestation; 4) live born neonate with no detectable birth defects. Using these entry criteria, 486 samples were selected for study inclusion. After sample quality was confirmed, 139 term deliveries (38-42 weeks) and 18 spontaneous preterm deliveries (<35 weeks) were selected for analysis. Samples were divided into training and validation sets. Real time reverse transcription quantitative polymerase chain reaction (rt-qPCR) was performed on each sample for 45 microRNAs. MicroRNA Risk Scores were calculated on the training set and area-under-the-curve receiver-operating-characteristic (AUC-ROC) curves were derived from the validation set.

RESULTS

The AUC-ROC for the validation set delivering preterm was 0.80 (95% CI: 0.69 to 0.88; p = 0.0001), sensitivity 0.89, specificity of 0.71 and a mean gestational age of 10.0 ±1.8 weeks (range: 6.6-12.9 weeks). When the validation population was divided by gestational age at the time of venipuncture into early first trimester (mean 8.4 ±1.0 weeks; range 6.6-9.7 weeks) and late first trimester (mean 11.5±0.8 weeks; range 10.0-12.9 weeks), the AUC-ROC scores for early and late first trimester were 0.79 (95% CI: 0.63 to 0.91) and 0.81 (95% CI: 0.66 to 0.92), respectively.

CONCLUSION

Quantification of first trimester peripheral blood MicroRNA identifies risk of spontaneous preterm birth in samples obtained early and late first trimester of pregnancy in an African American population.

Adult outcomes after preterm birth

Extremely preterm birth reflects global disruption of the third trimester environment. Young adults born preterm have an adverse cardiovascular and metabolic health profile, together with molecular evidence of accelerated ageing and a reduced life expectancy. The underlying mechanism for these observations is unknown. This review summarises recent evidence of the lifetime effects of preterm birth and highlights the risks survivors face.

Cord Malaria Infection, Complement Activation, Oxidative Stress, Gestational Age, and Birth Weight, Characterized by High Plasmodium falciparum Prevalence in Bamenda, Cameroon

Background

It is unknown whether the presence of Plasmodium falciparum malaria parasites in umbilical cord blood denotes activation of complement and oxidative stress to affect the duration of pregnancy and birth weight.

Methods

In a cross-sectional study conducted from January to April 2019 in Bamenda, Cameroon, cord blood samples were collected from 300 women at delivery. Parasitaemia was determined microscopically. Babies' weight and age of gestation were recorded. Plasma levels of complement and oxidative stress were measured by specific tests.

Results

Cord blood malaria prevalence was 21.33%. Babies with an infected cord showed a low birth weight and gestation age than those with uninfected cords. More babies with infected cords had LBW (6.25%) compared to the counterparts (5.50%). The levels of parasitaemia and the babies' weight showed a weak positive correlation. The prevalence of preterm and postterm birth was 4.33% and 24.33% respectively, with a weak negative correlation between the age of gestation and the umbilical cord parasitaemia. There was correlation between cord parasitaemia and levels of complement haemolytic activity titter (CH₅₀) and specific classical pathway activity (CPA) in cord blood. CH₅₀ and CPA levels, however, were significantly higher in infected cord blood samples, compared with uninfected cord blood samples. CH₅₀ showed a negative correlation with the birth weight and gestational age in infected cord blood samples. The levels of total oxidative stress (TOS) and total antioxidant defense were significantly lower in infected cord blood than uninfected. TOS displayed a positive correlation with the density of parasitaemia and a weak negative correlation with the birth weight and gestational age in infected cord blood.

Conclusion

Cord blood infection lowers the complement haemolytic titter, oxygen radicals and total antioxidant defense in neonates. This lowering of complement haemolytic titter and oxygen radical compounds in umbilical cord malaria are associated with low birth weight and preterm birth.

Targeting Bronchopulmonary Dysplasia-Associated Pulmonary Hypertension (BPD-PH): Potential Role of the FGF Signaling Pathway in the Development of the Pulmonary Vascular System

More than 50 years after the first description of Bronchopulmonary dysplasia (BPD) by Northway, this chronic lung disease affecting many preterm infants is still poorly understood. Additonally, approximately 40% of preterm infants suffering from severe BPD also suffer from Bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH), leading to a significant increase in total morbidity and mortality. Until today, there is no curative therapy for both BPD and BPD-PH available. It has become increasingly evident that growth factors are playing a central role in normal and pathologic development of the pulmonary vasculature. Thus, this review aims to summarize the recent evidence in our understanding of BPD-PH from a basic scientific point of view, focusing on the potential role of Fibroblast Growth Factor (FGF)/FGF10 signaling pathway contributing to disease development, progression and resolution.

The Relationship between Maternal Personality Disorder and Early Birth Outcomes: A Systematic Review and Meta-Analysis

(1) Background: Women with personality disorder are at risk of social and emotional problems which impact deleteriously on everyday functioning. Moreover, a personality disorder diagnosis has been established to have an adverse impact upon pregnancy outcomes and child health. Understanding this impact is critical to improving both maternal and child outcomes. This systematic review and meta-analysis will evaluate the contemporary evidence regarding these relationships. (2) Methods: Prospero and Cochrane were searched for any systematic reviews already completed on this topic. Academic Search Premier, CINAHL Complete, MEDLINE, PsycARTICLES, PsycINFO via the EBSCO host, and the Web of Science Core Collection were searched to include research articles published between 1980 and 2019. A total of 158 records were identified; 105 records were screened by reviewing the abstract; 99 records were excluded; 6 full text articles were assessed for eligibility; 5 records were included in the review. (3) Results: All the included studies reported on preterm birth. The meta-analysis indicates significant risk of preterm birth in women with personality disorder (overall odds ratio (OR) 2.62; CI 2.24–3.06; p < 0.01). Three studies reported on low birth weight, with the meta-analysis indicating a raised risk of low birth weight of the babies born to women with personality disorder (overall OR 2.00 CI 1.12–3.57 (p = 0.02)). Three studies reported on appearance, pulse, grimace, activity, and respiration (APGAR) score, with the meta-analysis of OR’s indicating a risk of low APGAR score in women with personality disorder (overall OR 2.31; CI 1.17–4.55; p = 0.02). (4) Conclusions: The infants of women with personality disorder are at elevated risk of preterm birth, low birth weight and low APGAR score.

Enteral Lactoferrin Supplementation for Preventing Sepsis and Necrotizing Enterocolitis in Preterm Infants: A Meta‑Analysis With Trial Sequential Analysis of Randomized Controlled Trials

Background

Several clinical trials investigated the effects of enteral lactoferrin supplementation on the prevention of sepsis and necrotizing enterocolitis (NEC) in preterm infants, but the efficacy and safety remain disputed. Therefore, we systematically evaluated the effect of enteral lactoferrin supplementation in preterm infants through a meta‑analysis with trial sequential analysis (TSA).

Methods

We searched six databases to identify randomized controlled trials (RCTs) that evaluated the effects of lactoferrin supplementation compared with placebo or no intervention in preterm infants. RevMan version 5.3 software was used to estimate pooled relative risks (RRs) with the random-effects model. TSA, subgroup analyses, and meta-regression analyses were also performed.

Results

Nine RCTs with 3515 samples were included. With low to moderate quality of evidence, compared with placebo, enteral lactoferrin supplementation did not significantly decrease the incidences of late-onset sepsis (RR = 0.63, 95% CI: 0.38 to 1.02, P = 0.06), NEC stage II or III (RR = 0.68, 95% CI: 0.30 to 1.52, P = 0.35), all-cause mortality (RR = 0.89, 95% CI: 0.51 to 1.57, P = 0.69), bronchopulmonary dysplasia (RR = 1.01, 95% CI: 0.90 to 1.13, P = 0.92), retinopathy of prematurity (RR = 0.80, 95% CI: 0.49 to 1.32, P = 0.38), invasive fungal infection (RR = 0.27, 95% CI: 0.02 to 3.94, P = 0.34), intraventricular hemorrhage (RR = 1.40, 95% CI: 0.39 to 5.08, P = 0.61), and urinary tract infection (RR = 0.35, 95% CI: 0.11 to 1.06, P = 0.06). Subgroup analysis revealed that lactoferrin significantly reduced the incidence of sepsis in infants with a birth weight below 1500 g (RR = 0.43, 95% CI: 0.22 to 0.84, P = 0.01). TSAs of the primary outcomes showed that the evidence is insufficient and further data is required.

Conclusions

Limited evidence suggested that enteral lactoferrin supplementation was associated with a reduction of late-onset sepsis in infants with a birth weight below 1500g, however, did not decrease the incidence of NEC stage II or III, all-cause mortality, and other adverse events in preterm infants. The present evidence was insufficient to inform clinical practice.

Maternal and fetal outcomes of lupus pregnancies: A collective effort by Karnataka Rheumatologists

INTRODUCTION

Identifying factors predicting adverse pregnancy outcomes involving systemic lupus erythematosus (SLE) is a research priority. The aims of this study were to investigate (a) the maternal and fetal outcomes of pregnant lupus patients and the factors associated with adverse pregnancy outcomes, and (b) the effect of pregnancy on lupus disease activity of these patients.

METHODS

This was an ambi-directional study collecting information from five multi-specialist referral centres across the state of Karnataka, India over 5 years (2013-2018). Clinical details of pregnancies and outcomes that were temporally associated with lupus disease were recorded using a structured pro forma. The Safety of Estrogen in SLE National Assessment-SLE Disease Activity Index (SELENA-SLEDAI) was used to assess lupus activity during the 6 months prior to pregnancy and the intra- and post-partum periods. Modifications suggested in the SLE Pregnancy Disease Activity Index were considered while scoring.

RESULTS

A total of 121 pregnancies in 80 SLE patients with a mean age of 27.1 (±4.5) years and with a mean disease duration of 4.6 (±4.1) years were reviewed. Largely patients were in clinical remission (109/121; 90.1%). Antiphospholipid antibody positivity was seen in 45/121 (37.2%) patients. A history of lupus nephritis was noted in 29/121 (24%) patients. Maternal complications (32%) were mainly due to hypertensive disorders of pregnancy (HDP; 19/121; 15.7%). Adverse fetal outcomes (58%) were mainly in the form of spontaneous first-trimester abortions (21/121; 16%), stillbirth (14/121; 11.6%) and prematurity (24/121; 20%). HDP is strongly associated with stillbirth and prematurity and is independent of active lupus. Disease activity was associated with a three-fold increased risk of adverse fetal outcome in univariate analysis. The risk of major flare during pregnancy is low (4.1%) when conception occurs during stable disease. Hydroxychloroquine (HCQ) use was associated with reduced risk of flare (p = 0.001) in patients in remission at the time of conception.

CONCLUSIONS

The risk of major flare during pregnancy is low when conception happens during stable disease. HCQ use was associated with reduced risk of flare in patients in remission at the time of conception. HDP was strongly associated with stillbirth and prematurity and are independent of active lupus in our cohort.

Maternal cigarette smoking before and during pregnancy and the risk of preterm birth: A dose-response analysis of 25 million mother-infant pairs

BACKGROUND

Most of the women who smoke before pregnancy continue smoking during pregnancy, and some start to quit smoking after being pregnant, although existing guidelines for pregnancy recommend that women who smoke should quit smoking before pregnancy. Findings about the timing and intensity of maternal smoking, especially low-intensity smoking (1-9 cigarettes per day), and preterm birth are still inconsistent and ambiguous. This study aimed to examine the association of the timing of smoking and doses of smoking before pregnancy and during the first or second trimester of pregnancy with preterm birth in a large-scale population-based retrospective cohort study.

METHODS AND FINDINGS

We used nationwide birth certificate data from singleton mother-infant pairs in the United States National Vital Statistics System, 2011-2018. All adult women with live singleton births, without preexisting hypertension or diabetes, and with complete data on smoking and gestational age at delivery were included. Participants reported their smoking status (yes or no) and daily number of cigarettes consumed before and during each trimester of pregnancy. The outcome of interest was preterm birth, defined as a birth before 37 weeks of gestation. Logistic regression models were used to estimate the odds ratio (OR) with 95% confidence intervals (CIs) of preterm birth associated with smoking status and the number of cigarettes consumed, adjusting for maternal age, race/ethnicity, parity, education levels, prepregnancy BMI, previous history of preterm birth, marital status, infant sex, and initiation of prenatal care. This study included 25,623,479 women, with a mean age of 29 years (range 20-50 years); 13,742,486 (53.6%) participants were of non-Hispanic white ancestry, 5,971,598 (23.3%) of Hispanic ancestry, and 3,417,456 (13.34%) of non-Hispanic black ancestry. The prevalence of preterm birth was 9.3% (n = 2,378,398). We found that maternal smoking during pregnancy, even at a very low level of intensity, was associated with an increased risk of preterm delivery. The adjusted ORs (95% CI) of preterm birth for mothers who smoked 1-2, 3-5, 6-9, 10-19, and ≥20 cigarettes per day during the first trimester compared with mothers who did not smoke were 1.31 (1.29-1.33), 1.31 (1.30-1.32), 1.33 (1.31-1.35), 1.44 (1.43-1.45), and 1.53 (1.52-1.55), respectively (all P values < 0.001), whereas for those who smoked during the second trimester, the corresponding ORs were 1.37 (1.35-1.39), 1.36 (1.35-1.38), 1.36 (1.34-1.38), 1.48 (1.47-1.49), and 1.59 (1.58-1.61), respectively (all P values < 0.001). Furthermore, smokers who quit before pregnancy, regardless of smoking intensity, had a comparable risk of preterm birth with nonsmokers, although this was not the case when cessation occurred in the first or second trimester of pregnancy. The major limitation of this study is the self-reported information about smoking, which may be subject to information bias. In addition, we cannot rule out the possibility of residual confounding caused by unmeasured factors in an observational research design.

CONCLUSIONS

In this study, we observed that low-intensity cigarette consumption during either the first or second trimester of pregnancy, even as low as 1-2 cigarettes per day, was associated with an increased risk of preterm birth. These findings suggest that there is no safe level or safe trimester for maternal smoking during pregnancy. Women of reproductive age who smoke should be strongly encouraged and supported to quit smoking before pregnancy.

Uterocervical angle as a predictor of preterm birth on a high-risk collective between 20 and 31 weeks of gestation: A cohort analysis

INTRODUCTION

The cervical length (CL) measurement is a widely used method to estimate the risk of preterm birth. Due in particular to the high false-positive rate, the establishment of markers with improved test characteristics is a great challenge. A potential predictor of preterm birth is the uterocervical angle (UCA) and this additional measurement may improve the risk assessment. It was the aim of this study to compare the test properties of CL and UCA on patients at risk for preterm birth.

MATERIAL AND METHODS

109 patients with at least one of the following signs of threatening preterm birth between 20^+0/7 and 31^+6/7 weeks were included in a prospective cohort analysis: regular (>3/30 min) or painful uterine contractions, CL below 25 mm or a history of preterm birth. Exclusion criteria were premature rupture of membranes, hypertensive disorders, vaginal bleeding, surgical cerclage, Arabin pessary or cervical dilation of more than 30 mm. The determination of the UCA was carried out in a standardized manner using the image documents captured by vaginal sonographic CL measurement. The primary endpoint was preterm birth <34 weeks, secondary endpoints were delivery <37 weeks and within 7 days.

RESULTS

The UCA was on average 103° and the mean UCA in preterm and term groups did not differ significantly (P = .924). The UCA was not predictive for threatened preterm birth, even if only singletons were considered. For CL the best predictive accuracy for preterm birth <34 weeks was observed at a cut-off value of 14 mm with sensitivity 0.50, specificity 0.80, positive predictive value 0.30, negative predictive value 0.90, positive likelihood ratio 2.4, negative likelihood ratio 0.6 and an odds ratio of 3.9 (95% confidence interval 1.3-11.7, P = .016).

CONCLUSIONS

The assessment of UCA in patients at risk for preterm birth was not suitable to predict the probability of a threatened preterm birth. Measurement of UCA cannot be recommended in this situation.

Identifying women giving birth preterm and care at the time of birth: a prospective audit of births at six hospitals in India, Kenya, Pakistan and Uganda

Background

Globally, 15 million infants are born preterm each year, and 1 million die due to complications of prematurity. Over 60% of preterm births occur in Sub-Saharan Africa and south Asia. Care at birth for premature infants may be critical for survival and long term outcome. We conducted a prospective audit to assess whether women giving birth preterm could be identified, and to describe cord clamping and neonatal care at hospitals in Africa and south Asia.

Methods

This prospective audit of livebirths was conducted at six hospitals in Uganda, Kenya, India and Pakistan. Births were considered preterm if between 28^+ 0 and 33^+ 6 weeks gestation and/or the birthweight was 1.00 to 1.99 kg. A pre-specified audit plan was agreed with each hospital. Livebirths before 28 weeks gestation with birthweight less than 1.0 kg were excluded. Data were collected on estimated and actual gestation and birthweight, cord clamping, and neonatal care.

Results

Of 4149 women who gave birth during the audit, data were available for 3687 (90%). As 107 were multiple births, 3781 livebirths were included, of which 257 (7%) were preterm. Antenatal assessment correctly identified 148 infants as ‘preterm’ and 3429 as ‘term’, giving a positive predictive value of 72% and negative predictive value of 97%. For term births, cord clamping was usually later at the two Ugandan hospitals, median time to clamping 50 and 76 s, compared with 23 at Kenyatta (Kenya), 7 at CMC (India) and 12 at FBH/LNH (Pakistan). At the latter two, timing was similar between term and preterm births, and between vaginal and Caesarean births. For all the hospitals, the cord was clamped quickly at Caesarean births, with Mbale (Uganda) having the highest median time to clamping (15 s ‘term’, 19 ‘preterm’). For preterm infants temperature on admission to the neonatal unit was below 35.5 °C for 50%, and 59 (23%) died before hospital discharge.

Conclusions

Antenatal identification of preterm birth was good. Timing of cord clamping varied between hospitals, although at each there was no difference between ‘term’ and ‘preterm’ births. For premature infants hypothermia was common, and mortality before hospital discharge was high.

A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group

The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome setsfor infants, children and young people that are tailored to the priorities of the pediatric surgical population.Focusing on four age-dependent patient subpopulations determined a priori for core outcome set development: i) neonates and former preterm infants (up to 60 weeks postmenstrual age); ii) infants (>60 weeks postmenstrual age - <1 year); iii) toddlers and school age children (>1-<13 years); and iv) adolescents (>13-<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age-dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across pre-determined age groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children and adolescents. Clinical indicators, particularly cardiorespiratory or medication-related adverse events, were the most common outcomes for neonates and infants < 60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under-represented in perioperative trials. Patient-centered outcomes, heath care utilization, and bleeding/transfusion related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the post-anesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age-specific group.

Heterogeneity in Brain Microstructural Development Following Preterm Birth

Preterm-born children are at increased risk of lifelong neurodevelopmental difficulties. Group-wise analyses of magnetic resonance imaging show many differences between preterm- and term-born infants but do not reliably predict neurocognitive prognosis for individual infants. This might be due to the unrecognized heterogeneity of cerebral injury within the preterm group. This study aimed to determine whether atypical brain microstructural development following preterm birth is significantly variable between infants. Using Gaussian process regression, a technique that allows a single-individual inference, we characterized typical variation of brain microstructure using maps of fractional anisotropy and mean diffusivity in a sample of 270 term-born neonates. Then, we compared 82 preterm infants to these normative values to identify brain regions with atypical microstructure and relate observed deviations to degree of prematurity and neurocognition at 18 months. Preterm infants showed strikingly heterogeneous deviations from typical development, with little spatial overlap between infants. Greater and more extensive deviations, captured by a whole brain atypicality index, were associated with more extreme prematurity and predicted poorer cognitive and language abilities at 18 months. Brain microstructural development after preterm birth is highly variable between individual infants. This poorly understood heterogeneity likely relates to both the etiology and prognosis of brain injury.

A Message from the Human Placenta: Structural and Immunomodulatory Defense against SARS-CoV-2

The outbreak of the coronavirus disease 2019 (COVID-19) pandemic has caused a global public health crisis. Viral infections may predispose pregnant women to a higher rate of pregnancy complications, including preterm births, miscarriage, and stillbirth. Despite reports of neonatal COVID-19, definitive proof of vertical transmission is still lacking. In this review, we summarize studies regarding the potential evidence for transplacental transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), characterize the expression of its receptors and proteases, describe the placental pathology and analyze virus-host interactions at the maternal-fetal interface. We focus on the syncytium, the barrier between mother and fetus, and describe in detail its physical and structural defense against viral infections. We further discuss the potential molecular mechanisms, whereby the placenta serves as a defense front against pathogens by regulating the interferon type III signaling, microRNA-triggered autophagy and the nuclear factor-κB pathway. Based on these data, we conclude that vertical transmission may occur but rare, ascribed to the potent physical barrier, the fine-regulated placental immune defense and modulation strategies. Particularly, immunomodulatory mechanisms employed by the placenta may mitigate violent immune response, maybe soften cytokine storm tightly associated with severely ill COVID-19 patients, possibly minimizing cell and tissue damages, and potentially reducing SARS-CoV-2 transmission.

Association between antenatal care visit and preterm birth: a cohort study in rural Bangladesh

BACKGROUND

Strengthening the antenatal care programme is suggested as one of the public health strategies to reduce preterm birth burden at a population level. However, the evidence so far available is inconclusive.

OBJECTIVES

To evaluate the association between antenatal care (ANC) visit and preterm birth; and also to explore to what extent the increased usage of ANC after the initiation of the Maternal, Neonatal and Child Health (MNCH) project in Matlab, Bangladesh, contributed to the reduction of preterm birth.

SETTING

This population-based cohort study was conducted in Matlab, a subdistrict under Chandpur. The analysis was based on data collected from 2005 to 2009. In 2007, an MNCH project was initiated in the area that strengthened the ongoing ANC services.

PARTICIPANTS

In total, 12 980 live births with their mothers during the study period were included in the analysis.

ANALYSIS

We performed logistic regression with generalised estimating equation models to evaluate the associations.

OUTCOME MEASURES

Preterm birth.

RESULTS

The number of ANC visits was associated with preterm birth in a dose-dependent way (p for linear trend <0.001). The adjusted odds of preterm birth were 2.4-times higher (OR 2.37, 95% CI 2.07 to 2.70) among women who received ≤1 ANC compared with women who received ≥3 ANC. We observed a significant reduction of preterm birth rates (OR 0.69, 95% CI 0.61 to 0.77) in the period after (2008 to 2009) MNCH project initiation in comparison to the period before (2005 to 2006). Controlling for ANC visits substantially attenuated this observed effect of the MNCH project on preterm birth (OR 0.88, 95% CI 0.77 to 0.99) (Sobel test of mediation p<0.001).

CONCLUSIONS

ANC visits are associated with decreased occurrences of preterm births. Strengthening the ANC services should be prioritised in countries with high preterm birth rates to reduce the preterm birth burden at the population level.

Incidence, risk factors and consequences of preterm birth - findings from a multi-centric observational study for 14 months in Nepal

Background

Preterm birth is a worldwide epidemic and a leading cause of neonatal mortality. In this study, we aimed to evaluate the incidence, risk factors and consequences of preterm birth in Nepal.

Methods

This was an observational study conducted in 12 public hospitals of Nepal. All the babies born during the study period were included in the study. Babies born < 37 weeks of gestation were classified as preterm births. For the association and outcomes for preterm birth, univariate followed by multiple regression analysis was conducted.

Results

The incidence of preterm was found to be 93 per 1000 live births. Mothers aged less than 20 years (aOR 1.26;1.15–1.39) had a high risk for preterm birth. Similarly, education of the mother was a significant predictor for preterm birth: illiterate mothers (aOR 1.41; 1.22–1.64), literate mothers (aOR 1.21; 1.08–1.35) and mothers having basic level of education (aOR 1.17; 1.07–1.27). Socio-demographic factors such as smoking (aOR 1.13; 1.01–1.26), use of polluted fuel (aOR 1.26; 1.17–1.35) and sex of baby (aOR 1.18; 1.11–1.26); obstetric factors such as nulliparity (aOR 1.33; 1.20–1.48), multiple delivery (aOR 6.63; 5.16–8.52), severe anemia during pregnancy (aOR 3.27; 2.21–4.84), antenatal visit during second trimester (aOR 1.13; 1.05–1.22) and third trimester (aOR 1.24; 1.12–1.38), < 4 antenatal visits during pregnancy (aOR 1.49; 1.38–1.61) were found to be significant risk factors of preterm birth. Preterm has a risk for pre-discharge mortality (10.60; 9.28–12.10).

Conclusion

In this study, we found high incidence of preterm birth. Various socio-demographic, obstetric and neonatal risk factors were associated with preterm birth. Risk factor modifications and timely interventions will help in the reduction of preterm births and associated mortalities.

Trial registration

ISRCTN30829654.

Gestational Diabetes Mellitus: A Harbinger of the Vicious Cycle of Diabetes

Gestational diabetes mellitus (GDM), characterized by a transitory form of diabetes induced by insulin resistance and pancreatic β-cell dysfunction during pregnancy, has been identified as one of the major obstacles in achieving improved maternal and child health. Approximately 9-25% of pregnancies worldwide are impacted by the acute, long-term, and transgenerational health complications of this disease. Here, we discuss how GDM affects longstanding maternal and neonatal outcomes, as well as health risks that likely persist into future generations. In addition to the current challenges in the management and diagnosis of and the complications associated with GDM, we discuss current preclinical models of GDM to better understand the underlying pathophysiology of the disease and the timely need to increase our scientific toolbox to identify strategies to prevent and treat GDM, thereby advancing clinical care.

Vaginal Progesterone Has No Diabetogenic Potential in Twin Pregnancies: A Retrospective Case-Control Study on 1686 Pregnancies

Background: In this study, we aimed to investigate the incidence of gestational diabetes mellitus (GDM) in women who carried twin pregnancies and received vaginal progesterone. Methods: In this retrospective cohort study, 203 out of 1686 women with twin pregnancies received natural progesterone (200 mg/day between gestational weeks 16 + 0 and 36 + 0) vaginally for ≥ 4 weeks. The control group consisted of 1483 women with twin pregnancies without progesterone administration. Pearson’s Chi squared test, Fisher’s exact test, and Student’s t-test was used to compare differences between the control and the progesterone-treated groups. A multivariate binary logistic regression was performed to assess relative independent associations on the dependent outcome of GDM incidence. Results: Vaginal progesterone treatment in twin pregnancies had no significant influence on developing GDM (p = 0.662). Higher pre-pregnancy BMI (OR 1.1; p < 0.001), GDM in previous pregnancy (OR 6.0; p < 0.001), and smoking during pregnancy (OR 1.6; p = 0.014) posed an increased risk for developing GDM. Conclusion: In twin pregnancies, the use of vaginal progesterone for the prevention of recurrent preterm delivery was not associated with an increased risk of GDM.

Planned delivery route and outcomes of cephalic singletons born spontaneously at 24-31 weeks' gestation: The EPIPAGE-2 cohort study

INTRODUCTION

The objective of this study was to investigate the association between planned mode of delivery and neonatal outcomes with spontaneous very preterm birth among singletons in cephalic presentation.

MATERIAL AND METHODS

Etude Epidémiologique sur les Petits Ages Gestationnels 2 is a French national, prospective, population-based cohort study of preterm infants. For this study, we included women with a singleton cephalic pregnancy and spontaneous preterm labor or preterm premature rupture of membranes at 24-31 weeks' gestation. The main exposure was the planned mode of delivery (ie planned vaginal delivery or planned cesarean delivery at the initiation of labor). The primary outcome was survival at discharge and secondary outcome survival at discharge without severe morbidity. Propensity scores were used to minimize indication bias in estimating the association.

RESULTS

The study population consisted of 1008 women: 206 (20.4%) had planned cesarean delivery and 802 (79.6%) planned vaginal delivery. In all, 723 (90.2%) finally had a vaginal delivery. Overall, 187 (92.0%) and 681 (87.0%) neonates in the planned cesarean delivery and planned vaginal delivery groups were discharged alive, and 156 (77.6%) and 590 (76.3%) were discharged alive without severe morbidity. After matching on propensity score, planned cesarean delivery was not associated with survival (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 0.48-2.28) or survival without severe morbidity (aOR 0.64, 95% CI 0.36-1.16).

CONCLUSIONS

Planned cesarean delivery for cephalic presentation at 24-31 weeks' gestation after preterm labor or preterm premature rupture of membranes does not improve neonatal outcomes.

IL-37 Exerts Anti-Inflammatory Effects in Fetal Membranes of Spontaneous Preterm Birth via the NF-κB and IL-6/STAT3 Signaling Pathway

Spontaneous preterm birth (sPTB), defined as delivery before 37 weeks of gestation, is thought to be a multifactorial syndrome. However, the inflammatory imbalance at the maternal-fetal interface promotes excessive secretion of inflammatory factors and induces apoptosis and degradation of the extracellular matrix (ECM), which can subsequently lead to preterm birth. As an anti-inflammatory molecule in the IL-1 family, interleukin-37 (IL-37) mainly plays an inhibiting role in a variety of inflammatory diseases. However, as a typical inflammatory disease, no previous studies have been carried out to explore the role of IL-37 in sPTB. In this study, a series of molecular biological experiments were performed in clinical samples and human amniotic epithelial cell line (Wistar Institute Susan Hayflick (WISH)) to investigate the deficiency role of IL-37 and the potential mechanism. Firstly, the results indicated that the expression of IL-37 in human peripheral plasma and fetal membranes was significantly decreased in the sPTB group. Afterward, it is proved that IL-37 could significantly suppress the production of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and interleukin-6 (IL-6) in WISH cells. Simultaneously, once silence IL-37, LPS-induced apoptosis and activity of matrix metalloproteinases (MMPs) 2 and 9 were significantly increased. In addition, the western blot data showed that IL-37 performed its biological effects by inhibiting the NF-κB and IL-6/STAT3 pathway. In conclusion, our results suggest that IL-37 limits excessive inflammation and subsequently inhibits ECM remodeling and apoptosis through the NF-κB and IL-6/STAT3 signaling pathway in the fetal membranes.

Factors Associated With Late Prematurity in the University Hospital of Valle Cali, Colombia During 2013-2014

Introduction: The birth rate of late premature babies has been increasing in recent years, composing now 75% of all premature births. This growing trend can be explained by different demographic transformations such as an increase in the demand for infertility treatments, older maternal age and the higher incidence of multiple pregnancies, cesarean sections, and labor induction. These premature babies contribute 30% to the global neonatal mortality rate. Objective: To identify the factors associated with late prematurity at the Hospital Universitario del Valle during the years 2013-2014. Methodology: Case and control design, 424 patients, 212 cases and 212 controls participated. Cases were defined as newborns with gestational age between 34 and 36 weeks and 6 days old. For the analysis, logistic regression models were developed and association forces (OR) were determined. Results: A univariate analysis shows that the proportion of teenage pregnant women corresponds to 22.64%. Bivariate analysis shows the maternal morbidity due to hypertensive disorders was 1.6 times higher (95% CI 1.06-2.63), the obstetric alterations in 2.9 times (CI of 95% 1.56-5.44), late preterm infants require more oxygen support 3.26 times (95% CI 1.76-6.03). After adjusting the model, it was found that late premature infants have a 3-fold probability of requiring some resuscitation maneuver (ORa 3.23 95% CI 2.09-4.99), birth is higher by cesarean section by 4.17 times (ORa 4.17 IC 95% 2.50-6.98), maternal morbidity was higher in 1.37 times (ORa 1.37 95% CI 1.14-1.65). The morbidity of the newborn was greater, close to the statistical significance for late premature infants in 1.26 times (ORa 1.26 95% CI 0.97-1.64). Conclusions: Late premature births in this study show a higher probability of developing morbidity, have a greater opportunity to be born by cesarean section, are products of mothers with morbidity (specifically hypertensive disorders), and require further resuscitation with a need of early obstetric intervention.

Integration of an interpretable machine learning algorithm to identify early life risk factors of childhood obesity among preterm infants: a prospective birth cohort

BACKGROUND

The early life risk factors of childhood obesity among preterm infants are unclear and little is known about the influence of the feeding practices. We aimed to identify early life risk factors for childhood overweight/obesity among preterm infants and to determine feeding practices that could modify the identified risk factors.

METHODS

A total of 338,413 mother-child pairs were enrolled in the Jiaxing Birth Cohort (1999 to 2013), and 2125 eligible singleton preterm born children were included for analyses. We obtained data on health examination, anthropometric measurement, lifestyle, and dietary habits of each participant at their visits to clinics. An interpretable machine learning-based analytic framework was used to identify early life predictors for childhood overweight/obesity, and Poisson regression was used to examine the associations between feeding practices and the identified leading predictor.

RESULTS

Of the eligible 2125 preterm infants (863 [40.6%] girls), 274 (12.9%) developed overweight/obesity at age 4-7 years. We summarized early life variables into 25 features and identified two most important features as predictors for childhood overweight/obesity: trajectory of infant BMI (body mass index) Z-score change during the first year of corrected age and maternal BMI at enrollment. According to the impacts of different BMI Z-score trajectories on the outcome, we classified this feature into the favored and unfavored trajectories. Compared with early introduction of solid foods (≤ 3 months of corrected age), introducing solid foods after 6 months of corrected age was significantly associated with 11% lower risk (risk ratio, 0.89; 95% CI, 0.82 to 0.97) of being in the unfavored trajectory.

CONCLUSIONS

The trajectory of BMI Z-score change within the first year of life is the most important predictor for childhood overweight/obesity among preterm infants. Introducing solid foods after 6 months of corrected age is a recommended feeding practice for mitigating the risk of being in the unfavored trajectory.

Does Low Maternal Exposure to Per- and Polyfluoroalkyl Substances Elevate the Risk of Spontaneous Preterm Birth? A Nested Case-Control Study in China

Previous animal and human studies suggest potential links between maternal exposure to per- and polyfluoroalkyl substances (PFASs) and adverse birth outcomes. As spontaneous preterm birth (SPB) represents a major cause of infant mortality and precursor to future morbidity, we conducted a prospective nested case-control study in Shanxi Province, China to investigate the association between prenatal PFAS exposure and SPB risk, as well as the associations with biomarkers of oxidative stress and systemic inflammation. Among 4229 women enrolled during 2009-2013, 144 SPB cases and 375 controls were included in this study. Seventeen PFASs, as well as monocyte chemoattractant protein-1 (MCP-1), interleukin-8 (IL-8), and heme oxygenase-1 (HO-1), were measured in maternal plasma or serum collected during 4th-22nd gestational weeks. Perfluorooctanoic acid (PFOA), perfluorooctane sulfonate (PFOS), and its alternative chlorinated polyfluoroether sulfonic acid (6:2 Cl-PFESA) were detected in more than 90% samples with a median concentration of 0.79, 1.79, and 0.34 ng/mL, respectively. The analyses revealed no significant associations between plasma PFASs and the SPB risk after adjusting for potential confounders. However, concentrations of PFOS and 6:2 Cl-PFESA were both significantly and positively associated with MCP-1 levels, while PFOA was inversely associated with IL-8. Our findings suggested that maternal exposure to the determined low levels of PFAS did not induce an elevated risk of SPB, but the exposure may disturb potential biochemical pathways of inflammation. The latter has important implications for possible birth outcome effects and developmental effects in fetuses and newborns, which warrants close attention.

[Neuropsychological development of late preterm infants and early term infants at the age of 1 year: a follow-up study]

OBJECTIVE

To study the level of neuropsychological development in late preterm infants and early term infants at the age of 1 year.

METHODS

A total of 1 257 children with a corrected age of 1 year were enrolled as subjects. According to gestational age at birth, they were divided into an early preterm group (28-33+6 weeks), a late preterm group (34-36+6 weeks), an early term group (37-38+6 weeks), and a full-term group (39-41+6 weeks). Gesell Developmental Schedules were used to assess the neuropsychological development of the children, and the groups were compared in terms of neuropsychological development at the age of 1 year.

RESULTS

There were significant differences in the developmental quotients of the five functional areas (adaptability, gross motor, fine motor, language and social ability) between the four groups at the age of 1 year (P<0.05), and the full-term infants had the highest development quotients, followed by the early term infants, the late preterm infants, and the early preterm infants (P<0.05). The full-term infants had the lowest rate of developmental delay in each functional area, while the early preterm infants had the highest rate (P<0.05). Compared with the full-term infants, the early term infants had a higher risk of developmental delay in adaptability (OR=1.796, P<0.05), and the late preterm infants had a higher risk of developmental delay in adaptability (OR=2.651, P<0.05) and fine motor (OR=2.679, P<0.05), while the early preterm infants had a higher risk of developmental delay in adaptability (OR=4.069, P<0.05), fine motor (OR=3.710, P<0.05), and social ability (OR=3.515, P<0.05).

CONCLUSIONS

The risk of neuropsychological developmental delay decreases with the increase in gestational age in children at the age of 1 year, with a dose-response effect. There are varying degrees of developmental delay in early term infants and late preterm infants, and health care follow-up for early term infants and late preterm infants should be taken seriously.

[Neuropsychological development of late preterm infants and early term infants at the age of 1 year: a follow-up study]

OBJECTIVE

To study the level of neuropsychological development in late preterm infants and early term infants at the age of 1 year.

METHODS

A total of 1 257 children with a corrected age of 1 year were enrolled as subjects. According to gestational age at birth, they were divided into an early preterm group (28-33⁺⁶ weeks), a late preterm group (34-36⁺⁶ weeks), an early term group (37-38⁺⁶ weeks), and a full-term group (39-41⁺⁶ weeks). Gesell Developmental Schedules were used to assess the neuropsychological development of the children, and the groups were compared in terms of neuropsychological development at the age of 1 year.

RESULTS

There were significant differences in the developmental quotients of the five functional areas (adaptability, gross motor, fine motor, language and social ability) between the four groups at the age of 1 year (P<0.05), and the full-term infants had the highest development quotients, followed by the early term infants, the late preterm infants, and the early preterm infants (P<0.05). The full-term infants had the lowest rate of developmental delay in each functional area, while the early preterm infants had the highest rate (P<0.05). Compared with the full-term infants, the early term infants had a higher risk of developmental delay in adaptability (OR=1.796, P<0.05), and the late preterm infants had a higher risk of developmental delay in adaptability (OR=2.651, P<0.05) and fine motor (OR=2.679, P<0.05), while the early preterm infants had a higher risk of developmental delay in adaptability (OR=4.069, P<0.05), fine motor (OR=3.710, P<0.05), and social ability (OR=3.515, P<0.05).

CONCLUSIONS

The risk of neuropsychological developmental delay decreases with the increase in gestational age in children at the age of 1 year, with a dose-response effect. There are varying degrees of developmental delay in early term infants and late preterm infants, and health care follow-up for early term infants and late preterm infants should be taken seriously.

Food insecurity as a risk factor for preterm birth: a prospective facility-based cohort study in rural Haiti

INTRODUCTION

Haiti has an estimated neonatal mortality rate of 32/1000 live births, the highest in the Western Hemisphere. Preterm birth and being born small for gestational age (SGA) are major causes of adverse neonatal outcomes worldwide. To reduce preterm birth and infants born SGA, it is important to understand which women are most at risk and how risk varies within countries. There are few studies estimating the prevalence and risk factors for these conditions in Haiti, particularly in rural regions.

METHODS

We conducted a prospective cohort study of pregnant women at a rural tertiary care centre in Haiti from May to December 2017. We collected data during interviews and from the medical record. We built multivariable models to identify risk factors for preterm birth and being born SGA among women who had a facility-based delivery.

RESULTS

1089 pregnant women delivered at the hospital and were included in this analysis. Median gestational age at delivery was 38 weeks (IQR 36-40). In multivariable analyses, risk factors for preterm birth included maternal age <20 years (adjusted OR (AOR) 1.76, 95% CI 1.14 to 2.72) and >34 years (AOR 1.46, 95% CI 1.01 to 2.11) and severe hunger in the household (AOR 1.57, 95% CI 1.09 to 2.26). Risk factors for SGA were age >34 years (AOR 1.76, 95% CI 1.18 to 2.59), twin pregnancy (AOR 3.28, 95% CI 1.20 to 8.95) and first pregnancy (AOR 1.57, 95% CI 1.12 to 2.23). Number of prior abortions was associated with reduced risk for SGA (AOR 0.41, 95% CI 0.17 to 0.97).

CONCLUSIONS

Food insecurity as a risk factor for preterm birth stands out as an important addition to the understanding of the risk of neonatal morbidity and mortality. This association highlights a potentially important intervention target to improve birth outcomes and suggests that food support has an important role to play for pregnant women who are food insecure in low-income settings.

Cervical pessary to prevent preterm birth in asymptomatic high-risk women: a systematic review and meta-analysis

BACKGROUND

Randomized controlled trials that have assessed the efficacy of cervical pessary to prevent preterm birth in asymptomatic high-risk women have reported conflicting results.

OBJECTIVE

To evaluate the efficacy and safety of cervical pessary to prevent preterm birth and adverse perinatal outcomes in asymptomatic high-risk women.

DATA SOURCES

MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS (from their inception to October 31, 2019), Cochrane databases, Google Scholar, bibliographies, and conference proceedings.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials that compared cervical pessary with standard care (no pessary) or alternative interventions in asymptomatic women at high risk for preterm birth.

STUDY APPRAISAL AND SYNTHESIS METHODS

The systematic review was conducted according to the Cochrane Handbook guidelines. The primary outcome was spontaneous preterm birth <34 weeks of gestation. Secondary outcomes included adverse pregnancy, maternal, and perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. Quality of evidence was assessed using the GRADE methodology.

RESULTS

Twelve studies (4687 women and 7167 fetuses/infants) met the inclusion criteria: 8 evaluated pessary vs no pessary in women with a short cervix, 2 assessed pessary vs no pessary in unselected multiple gestations, and 2 compared pessary vs vaginal progesterone in women with a short cervix. There were no significant differences between the pessary and no pessary groups in the risk of spontaneous preterm birth <34 weeks of gestation among singleton gestations with a cervical length ≤25 mm (relative risk, 0.80; 95% confidence interval, 0.43-1.49; 6 trials, 1982 women; low-quality evidence), unselected twin gestations (relative risk, 1.05; 95% confidence interval, 0.79-1.41; 1 trial, 1177 women; moderate-quality evidence), twin gestations with a cervical length <38 mm (relative risk, 0.75; 95% confidence interval, 0.41-1.36; 3 trials, 1128 women; low-quality evidence), and twin gestations with a cervical length ≤25 mm (relative risk; 0.72, 95% confidence interval, 0.25-2.06; 2 trials, 348 women; low-quality evidence). Overall, no significant differences were observed between the pessary and no pessary groups in preterm birth <37, <32, and <28 weeks of gestation, and most adverse pregnancy, maternal, and perinatal outcomes (low- to moderate-quality evidence for most outcomes). There were no significant differences in the risk of spontaneous preterm birth <34 weeks of gestation between pessary and vaginal progesterone in singleton gestations with a cervical length ≤25 mm (relative risk, 0.99; 95% confidence interval, 0.54-1.83; 1 trial, 246 women; low-quality evidence) and twin gestations with a cervical length <38 mm (relative risk, 0.73; 95% confidence interval, 0.46-1.18; 1 trial, 297 women; very low-quality evidence). Vaginal discharge was significantly more frequent in the pessary group than in the no pessary and vaginal progesterone groups (relative risks, ∼2.20; high-quality evidence).

CONCLUSION

Current evidence does not support the use of cervical pessary to prevent preterm birth or to improve perinatal outcomes in singleton or twin gestations with a short cervix and in unselected twin gestations.

Advances in paediatrics in 2019: current practices and challenges in allergy, endocrinology, gastroenterology, public health, neonatology, nutrition, nephrology, neurology, respiratory diseases and rheumatic diseases

We highlight the main developments that have been published during the first semester of the last year in the Italian Journal of Pediatrics. We have carefully chosen information from numerous exciting progresses issued in the Journal in the field of allergy, endocrinology, gastroenterology, neonatology, nutrition, nephrology, neurology, public health, respiratory diseases and rheumatic diseases. The impact on the care of patients has been placed in the broader context of studies that appeared in other journals. We think that many observations can be used directly to upgrade management of patients.

Bronchopulmonary dysplasia: what are its links to COPD?

Emerging evidence suggests that adverse early life events can affect long-term health trajectories throughout life. Preterm birth, in particular, is a significant early life event that affects approximately 10% of live births. Worldwide, prematurity is the number one cause of death in children less than 5 years of age and has been shown to disrupt normal lung development with lasting effects into adult life. Along with impaired lung development, interventions used to support gas exchange and other sequelae of prematurity can lead to the development of bronchopulmonary dysplasia (BPD). BPD is a chronic respiratory disease of infancy characterized by alveolar simplification, small airways disease, and pulmonary vascular changes. Although many survivors of BPD improve with age, survivors of BPD often have chronic lung disease characterized by airflow obstruction and intermittent pulmonary exacerbations. Long-term lung function trajectories as measured by FEV1 can be lower in children and adults with a history BPD. In this review, we discuss the epidemiology and manifestations of BPD and its long-term consequences throughout childhood and into adulthood. Available evidence suggests that disrupted lung development, genetic susceptibility and subsequent environment and infectious events that occur in prenatal and postnatal life likely increase the predisposition of children with BPD to develop early onset chronic obstructive pulmonary disease (COPD). The reviews of this paper are available via the supplemental material section.

Intra-Amniotic Infection with Ureaplasma parvum Causes Preterm Birth and Neonatal Mortality That Are Prevented by Treatment with Clarithromycin

Preterm birth is the leading cause of neonatal morbidity and mortality worldwide. Multiple etiologies are associated with preterm birth; however, 25% of preterm infants are born to a mother with intra-amniotic infection, most commonly due to invasion of the amniotic cavity by Ureaplasma species. Much research has focused on establishing a link between Ureaplasma species and adverse pregnancy/neonatal outcomes; however, little is known about the taxonomy of and host response against Ureaplasma species. Here, we applied a multifaceted approach, including human samples, in vivo models, and in vitro manipulations, to study the maternal-fetal immunobiology of Ureaplasma infection during pregnancy. Furthermore, we investigated the use of clarithromycin as a treatment for this infection. Our research provides translational knowledge that bolsters scientific understanding of Ureaplasma species as a cause of adverse pregnancy/neonatal outcomes and gives strong evidence for the use of clarithromycin as the recommended treatment for women intra-amniotically infected with Ureaplasma species.

Intra-amniotic infection is strongly associated with adverse pregnancy and neonatal outcomes. Most intra-amniotic infections are due to Ureaplasma species; however, the pathogenic potency of these genital mycoplasmas to induce preterm birth is still controversial. Here, we first laid out a taxonomic characterization of Ureaplasma isolates from women with intra-amniotic infection, which revealed that Ureaplasma parvum is the most common bacterium found in this clinical condition. Next, using animal models, we provided a causal link between intra-amniotic inoculation with Ureaplasma species and preterm birth. Importantly, the intra-amniotic inoculation of Ureaplasma species induced high rates of mortality in both preterm and term neonates. The in vivo potency of U. parvum to induce preterm birth was not associated with known virulence factors. However, term-derived and preterm-derived U. parvum isolates were capable of inducing an intra-amniotic inflammatory response. Both U. parvum isolates invaded several fetal tissues, primarily the fetal lung, and caused fetal inflammatory response syndrome. This bacterium was also detected in the placenta, reproductive tissues, and most severely in the fetal membranes, inducing a local inflammatory response that was replicated in an in vitro model. Importantly, treatment with clarithromycin, a recently recommended yet not widely utilized antibiotic, prevented the adverse pregnancy and neonatal outcomes induced by U. parvum. These findings shed light on the maternal-fetal immunobiology of intra-amniotic infection.

Achieving accurate estimates of fetal gestational age and personalised predictions of fetal growth based on data from an international prospective cohort study: a population-based machine learning study

Background

Preterm birth is a major global health challenge, the leading cause of death in children under 5 years of age, and a key measure of a population's general health and nutritional status. Current clinical methods of estimating fetal gestational age are often inaccurate. For example, between 20 and 30 weeks of gestation, the width of the 95% prediction interval around the actual gestational age is estimated to be 18–36 days, even when the best ultrasound estimates are used. The aims of this study are to improve estimates of fetal gestational age and provide personalised predictions of future growth.

Methods

Using ultrasound-derived, fetal biometric data, we developed a machine learning approach to accurately estimate gestational age. The accuracy of the method is determined by reference to exactly known facts pertaining to each fetus—specifically, intervals between ultrasound visits—rather than the date of the mother's last menstrual period. The data stem from a sample of healthy, well-nourished participants in a large, multicentre, population-based study, the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st). The generalisability of the algorithm is shown with data from a different and more heterogeneous population (INTERBIO-21st Fetal Study).

Findings

In the context of two large datasets, we estimated gestational age between 20 and 30 weeks of gestation with 95% confidence to within 3 days, using measurements made in a 10-week window spanning the second and third trimesters. Fetal gestational age can thus be estimated in the 20–30 weeks gestational age window with a prediction interval 3–5 times better than with any previous algorithm. This will enable improved management of individual pregnancies. 6-week forecasts of the growth trajectory for a given fetus are accurate to within 7 days. This will help identify at-risk fetuses more accurately than currently possible. At population level, the higher accuracy is expected to improve fetal growth charts and population health assessments.

Interpretation

Machine learning can circumvent long-standing limitations in determining fetal gestational age and future growth trajectory, without recourse to often inaccurately known information, such as the date of the mother's last menstrual period. Using this algorithm in clinical practice could facilitate the management of individual pregnancies and improve population-level health. Upon publication of this study, the algorithm for gestational age estimates will be provided for research purposes free of charge via a web portal.

Funding

Bill & Melinda Gates Foundation, Office of Science (US Department of Energy), US National Science Foundation, and National Institute for Health Research Oxford Biomedical Research Centre.

Building a global policy agenda to prioritize preterm birth: A qualitative analysis on factors shaping global health policymaking

Background: Preterm birth, defined as infants born before 37 weeks of gestation, is the largest contributor to child mortality. Despite new evidence highlighting the global burden of prematurity, policymakers have failed to adequately prioritize preterm birth despite the magnitude of its health impacts. Given current levels of political attention and investment, it is unlikely that the global community will be adequately mobilized to meet the 2012 Born Too Soon report goal of reducing the preterm birth rate by 50% by 2025. Methods: This study adapts the Shiffman and Smith framework for political priority to examine four components contributing to policy action in global health: actor power, ideas, political context, and issue characteristics. We conducted key informant interviews with 18 experts in prematurity and reproductive, maternal, newborn, and child health (RMNCH) and reviewed key literature on preterm birth. We aimed to identify the factors that shape the global political priority of preterm birth and to describe policy opportunities to increase its priority moving forward. Results: The global preterm birth community (academic researchers, multilateral organizations, government agencies, and civil society organizations) lacks evidence about the causes of and solutions to preterm birth; and country-level data quality is poor with gaps in the understanding required for implementing effective interventions. Limited funding compounds these challenges, creating divisions among experts on what policy actions to recommend. These factors contribute to the lack of priority and underrepresentation of preterm birth within the larger RMNCH agenda. Conclusion: Increasing the political priority of prematurity is essential to reduce preventable newborn and child mortality, a key target of the 2030 Sustainable Development Goal for health (target 3.2). This study identifies three policy recommendations for the preterm birth community: address data and evidence gaps, clarify and invest in viable solutions, and bring visibility to prematurity within the larger RMNCH agendas.

Effects of Combined Use of Mother's Breast Milk, Heartbeat Sounds, and Non-Nutritive Sucking on Preterm Infants' Behavioral Stress During Venipuncture: A Randomized Controlled Trial

PURPOSE

Even routine procedures can cause pain and stress, and can be harmful to the fast-growing brain of preterm infants. Mitigating pain and stress with sucrose and analgesics has side effects; thus, an alternate choice is the use of natural breast milk and infants' sensory capabilities. Therefore, this study examined the effects of different integrations of sensory experiences-mother's breast milk odor and taste (BM-OT), heartbeat sounds (HBs), and non-nutritive sucking (NNS)-on preterm infant's behavioral stress during venipuncture.

DESIGN

This study was a prospective, randomized controlled trial.

METHODS

Infants born preterm (<37 weeks' gestational age) were enrolled in the study through convenience sampling, and randomly assigned to the following conditions: (condition 1) routine care (n = 36); (condition 2) BM-OT (n = 33); (condition 3) BM-OT + HBs (n = 33); or (condition 4) BM-OT + HBs + NNS (n = 36). Crying duration from puncture to recovery period was recorded using a voice recorder. Facial actions and body movements were measured using an infant behavioral coding scheme and transformed into frequencies during seven stages: baseline (stage 0), disinfecting (stage 1), venipuncture (stage 2), and the recovery period for 10 minutes (stages 3-6).

FINDINGS

Data were analyzed for 138 preterm infants. The corresponding median times to stop crying for conditions 1, 2, 3, and 4 were 137, 79, 81, and 39 s, respectively; the instantaneous occurrence rates of stopping crying for conditions 2, 3, and 4 were 1.469, 1.574, and 2.996 times greater than for condition 1, respectively. Infants receiving conditions 3 and 4 had significantly fewer occurrences of facial actions (stage 6 and stages 4-6, respectively) and body movements (stages 3-6 for both); however, there were no significant reductions in stress behaviors for condition 2 (BM-OT).

CONCLUSIONS

The combination of BM-OT, HBs, and NNS could be provided to preterm infants as interventions to prevent and reduce behavioral stress, and facilitate pain recovery during venipuncture procedures.

CLINICAL RELEVANCE

Clinicians should be educated about how to recognize preterm infants' behavioral stress, and to incorporate different sensory combinations of respective mothers' BM, HBs, and NNS into painful procedures to help preterm infants recover from distress.