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Schilling AL, Rody A, Bossung V. Antibiotic Use During Pregnancy and Childbirth: Prospective Observational Study on Prevalence, Indications, and Prescribing Patterns in a German Tertiary Center. Geburtshilfe Frauenheilkd 2022; 83:192-200. [PMID: 37151734 PMCID: PMC10155238 DOI: 10.1055/a-1934-1761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/28/2022] [Indexed: 12/04/2022] Open
Abstract
Abstract
Introduction Antibiotics are powerful drugs to prevent and treat perinatal infections. Overuse of antibiotics leads to antibiotic resistance, has potential side effects and
influences the maternal and neonatal microbiome.
Patients and Methods We performed a prospective observational study on the prevalence, indications, and prescribing patterns of antibiotics during pregnancy and childbirth. We
included women who had given birth after 23+0 weeks of gestation at a single tertiary center in Germany from January 2020 to March 2021. Descriptive statistics and binomial regression were
performed to analyze the factors influencing the prescription of antibiotics.
Results We included 522 postpartum women into our study. 337 (64.6%) were exposed to antibiotics during pregnancy and/or childbirth. 115 women received antibiotics during pregnancy,
291 during birth. Most antibiotics during pregnancy were prescribed for urinary tract infections (UTIs) (56.0%). Most prescriptions were issued by obstetrics and gynecology physicians
(65.8%), followed by hospitals (16.7%) and family medicine physicians (8.8%). Most antibiotics during childbirth were given for a cesarean section (64.3%), followed by preterm rupture of
membranes (41.2%). 95.3% of women who had a preterm birth were exposed to antibiotics. In logistic regression models, lower gestational age at birth, higher maternal body-mass-index and
smoking were independently associated with antibiotic use during pregnancy and childbirth.
Conclusion We found a high rate of antibiotic exposure during pregnancy and childbirth. Our results imply an urgent need for antibiotic stewardship programs in perinatal medicine as
well as further research on the effects of perinatal antibiotic exposure on microbiome development and childhood health.
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Affiliation(s)
- Anna-Lara Schilling
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Achim Rody
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Verena Bossung
- Department of Obstetrics, University Hospital of Zürich, Zürich, Switzerland
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Endometrial Microbiome and Women’s Reproductive Health – Review of the Problem Endometrial Microbiome and Reproductive Health. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2021. [DOI: 10.22207/jpam.15.4.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Currently, unlike in the past, the endometrial cavity is not considered to be sterile. The endometrium is supposed to be dominated by Lactobacilli, but also their deficiency can be found in the reproductive tract of asymptomatic healthy women. Sometimes the endometrial microbiome is dominated by various pathological microorganisms, and this can lead to various conditions as chronic endometritis, chorioamnionitis and preterm birth. Their presence causes uterine inflammation and infection, release of pro-inflammatory molecules, uterine contractions, disruption of cervical barrier, premature rupture of membranes. Uterine dysbiosis is associated with recurrent implantation failure and recurrent miscarriages. As the microbiome is important for maintaining immunological homeostasis at the level of gastrointestinal tract Lactobacilli may play a similar function at the level of uterus. The lactobacillus-dominated uterine microbiome is of great importance for maintaining a hostile uterine microenvironment, embryo implantation, early pregnancy development and normal pregnancy outcome.
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Fudaba M, Kamiya T, Tachibana D, Koyama M, Ohtani N. Bioinformatics Analysis of Oral, Vaginal, and Rectal Microbial Profiles during Pregnancy: A Pilot Study on the Bacterial Co-Residence in Pregnant Women. Microorganisms 2021; 9:microorganisms9051027. [PMID: 34064634 PMCID: PMC8151423 DOI: 10.3390/microorganisms9051027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 12/18/2022] Open
Abstract
Preterm birth (PTB) and threatened preterm labor (TPL), an important pre-PTB state, are major obstetric complications during pregnancy. However, their triggers have not been fully elucidated. The vagina is dominated by Lactobacillus species (categorized as community state types; CSTs I, II, III, and V) or by mixed anaerobes (CST IV). An abundance of the latter is associated with bacterial vaginosis (BV) and BV-triggered PTB/TPL. To identify factors that influence the diversity of vaginal microbiota associated with BV and CST IV (BV-type) bacterial profile, we performed a bioinformatic analysis of the microbial taxa using 16S rRNA amplicon sequencing data of bacterial genome in oral, vaginal, and rectal samples collected from 58 pregnant Japanese women. Interestingly, common residence of BV-associated bacteria in the vagina and rectum was individually detected in the CST IV (non-Lactobacillus dominated) group by species-level Spearman correlation coefficient analysis, suggesting that the rectum acts as a reservoir of BV-associated bacterial species in the CST IV group. The current study provides evidence of bacterial co-residence in vagina and rectum in the non-Lactobacillus dominated group, which could be targeted to reduce the risk of preterm incidence in pregnancy.
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Affiliation(s)
- Megumi Fudaba
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan; (M.F.); (D.T.); (M.K.)
| | - Tomonori Kamiya
- Department of Pathophysiology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan;
| | - Daisuke Tachibana
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan; (M.F.); (D.T.); (M.K.)
| | - Masayasu Koyama
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan; (M.F.); (D.T.); (M.K.)
| | - Naoko Ohtani
- Department of Pathophysiology, Graduate School of Medicine, Osaka City University, Osaka 545-8585, Japan;
- AMED-CREST, AMED, Japan Agency for Medical Research and Development, Tokyo 100-0004, Japan
- Correspondence:
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4
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Case report : Actinomyces naeslundii complicating preterm labour in a trisomy-21 pregnancy. IDCases 2021; 23:e01051. [PMID: 33532241 PMCID: PMC7822938 DOI: 10.1016/j.idcr.2021.e01051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 11/21/2022] Open
Abstract
Actinomyces naeslundii causing preterm birth. Inappropriate antibiotics usage postpartum. Treatment of intrapartum Actinomyces naeslundii to prevent preterm birth.
Preterm birth is a global concern with considerable morbidity and mortality. Intrapartum infection is a known cause of preterm birth and Actinomyces infection is one of the infections contributing to preterm birth. We report a case of preterm birth of a trisomy-21 neonate to a mother with positive Actinomyces naeslundii from an intra-operative placental swab sample and discussed the relationship of this bacteria and preterm delivery, and the role of postpartum antibiotics use in this case.
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5
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Luo P, Zhang K, Chen Y, Geng X, Wu T, Li L, Zhou P, Jiang PP, Ma L. Antenatal Antibiotic Exposure Affects Enteral Feeding, Body Growth, and Neonatal Infection in Preterm Infants: A Retrospective Study. Front Pediatr 2021; 9:750058. [PMID: 35004538 PMCID: PMC8727690 DOI: 10.3389/fped.2021.750058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Antibiotics are widely prescribed by obstetricians, which exposes a large number of infants to antenatal antibiotics (AAB). The effect of AAB on various aspects of neonatal development of preterm infants remains unclear. Methods: In this retrospective study, infants born with gestational age (GA) between 22 +0 and 36 +6 weeks at our unit from 2017 to 2019 were included. Multivariable analysis was adopted to examine the associations between AAB exposure and various outcomes related to enteral feeding process, body growth, and neonatal infection after adjusting for potential confounders. Further subanalysis on the exposure level of AAB and stratified analysis by GA (<34 vs. ≥34 weeks) were also conducted. Results: In this cohort comprising 2,543 preterm infants, AAB was associated with decreased risks of feeding intolerance (odds ratio [OR]: 0.63, 95% confidence interval [CI]: 0.48-0.82) and neonatal infection (OR: 0.63, 95% CI: 0.41-0.94). Higher AAB exposure level was associated with higher Z scores of birth weight (β = 0.37, 95% CI: 0.27-0.47), but lower Δbodyweight Z-scores (β = -0.20, 95% CI: -0.27 to -0.13). AAB was positively associated with the parameters related to body growth in infants with GA <34 weeks but negatively associated in those with GA ≥34 weeks. Conclusions: AAB exposure affects the enteral feeding process and neonatal infection. The effects on body growth vary by the exposure level of AAB and GA of infants. A well-designed prospective and preferably multi-centre study with predefined parameters is required to confirm our findings.
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Affiliation(s)
- Ping Luo
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Kun Zhang
- Department of Obstetrics, Bao'an Women and Children's Hospital, Jinan University, Shenzhen, China
| | - You Chen
- Department of Neonatology, Bao'an Women and Children's Hospital, Jinan University, Shenzhen, China
| | - Xiuwen Geng
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Tong Wu
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Li Li
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Ping Zhou
- Department of Neonatology, Bao'an Women and Children's Hospital, Jinan University, Shenzhen, China
| | - Ping-Ping Jiang
- School of Public Health, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-sen University, Guangzhou, China
| | - Liya Ma
- Department of Children Healthcare, Bao'an Women and Children's Hospital, Jinan University, Shenzhen, China
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Batura R, Colbourn T. A stitch in time: narrative review of interventions to reduce preterm births in Malawi. Int Health 2020; 12:213-221. [PMID: 31867622 PMCID: PMC7320425 DOI: 10.1093/inthealth/ihz101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/14/2019] [Accepted: 12/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background The rising rate of preterm births (PTBs) is a global concern, and Malawi has a high rate of PTBs (10.5%). The resulting neonatal and under-5 mortality, morbidity and lifelong disability represent a significant loss of human potential affecting individuals, families and society as a whole. This study aims to review the literature to determine the risk factors for PTB in Malawi and to identify effective interventions to prevent PTBs. Methods A literature search yielded 22 studies that were categorized according to risk factors implicated for PTBs and health interventions to reduce the risks. Results The study has shown that maternal pregnancy factors, infections, nutrition, anaemia and young maternal age are the main causes and risk factors of PTBs in Malawi. The literature revealed no evidence of community-based interventions for reducing the rates of PTBs in Malawi. Conclusions Any successful effort to reduce the rate of PTBs will require a multisector, multilevel strategy targeted at the community, homes and individuals as a package to improve the education, nutrition and reproductive health of girls and women as well as focus on improving the delivery of antenatal services in the community.
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Affiliation(s)
- Rekha Batura
- UCL Institute for Global Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Tim Colbourn
- UCL Institute for Global Health, 30 Guilford Street, London WC1N 1EH, UK
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7
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Gillespie SL, Cole SW, Christian LM. Early adversity and the regulation of gene expression: Implications for prenatal health. Curr Opin Behav Sci 2019; 28:111-118. [PMID: 31815157 PMCID: PMC6897329 DOI: 10.1016/j.cobeha.2019.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Early life, including prenatal development and childhood, is a period of sensitivity, with potential for developmental programming under conditions of adversity. The intergenerational effects of early adversity have received attention, most often studied in relation to fetal development according to maternal exposures. Less often considered but critically important is the effect of early adversity on future prenatal risk (e.g., risk for preeclampsia, preterm birth), which threatens the health of mother and infant. The body's ability to turn collections of genes "on" or "off" across a range of tissues via receptor-driven transcription factors and epigenetic mechanisms (i.e., chemical modifications to the genome) in response to the perceived environment may help to explain such associations. This review aims to summarize discoveries surrounding the effects of early adversity on gene expression, emphasizing prenatal populations. First, we review findings from gene expression studies examining the effects of early adversity on various tissues known to contribute to prenatal health in adulthood. Next, we review several gene regulatory mechanisms thought to underlie differences in gene expression. Finally, we discuss potential implications for prenatal risk among early adversity-exposed mothers according to our current understanding of the biology that contributes to the development of prenatal syndromes.
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Affiliation(s)
| | - Steve W Cole
- Department of Psychiatry & Biobehavioral Sciences and Medicine, UCLA School of Medicine, Los Angeles, CA
| | - Lisa M Christian
- Department of Psychiatry & Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH
- The Institute for Behavioral Medicine Research, The Ohio State University Wexner Medical Center, Columbus, OH
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8
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Voon HY, Pow JY, Tan LN, Suharjono HN, Teo WS. Antibiotic prophylaxis in ragged placental membranes: a prospective, multicentre, randomized trial. BMC Pregnancy Childbirth 2019; 19:240. [PMID: 31296180 PMCID: PMC6624936 DOI: 10.1186/s12884-019-2373-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 06/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ragged placental membranes is a distinct entity from retained placenta and not uncommonly reported in midwifery texts. Although the incidence of postpartum endometritis is merely 1-5% after vaginal births, it remains the most common source of puerperal sepsis, contributing up to 15% of maternal mortality in low income countries. Geographically-remote centres in Malaysia prophylactically administer antibiotics for women with ragged placental membranes after vaginal birth, extrapolating evidence from retained placenta. We sought to clarify the rationale in continuing such practices. METHODS This was an open-label, prospective, multicentre, randomized trial. Three hospitals where the current protocol was to administer prophylactic amoxycillin-clavulanic acid served as the sites of recruitment. Women who delivered vaginally beyond 24+ 0 weeks of gestation with ragged membranes were invited to participate in the trial and randomized into prophylaxis or expectant management with medical advice by blocks of 10, at a 1:1 ratio. A medication adherence diary was provided and patients followed up at 2 weeks and 6 weeks postpartum. RESULTS A total of 6569 women gave birth vaginally in three centres during the trial period, of which 10.9% had ragged membranes. The incidence of endometritis was not significantly raised in women with or without prophylaxis (0.90% vs 0.29%; p = 0.60). All cases of endometritis presented within the first 2 weeks and preventive use of antibiotics did not ameliorate the severity of endometritis since rates of ICU admission, surgical evacuation and transfusion were comparable. CONCLUSION Preventive use of antibiotics after vaginal delivery in women with ragged placental membranes did not result in a reduction of endometritis. Educating women on the signs and symptoms of endometritis would suffice. Based on the reported incidence of ragged membranes, a change in practice would result in 1500 less prescriptions of antibiotics per annum in these three centres. TRIAL REGISTRATION NCT03459599 (Retrospectively registered on 9 March 2018).
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Affiliation(s)
- Hian Yan Voon
- Department of Obstetrics and Gynaecology, Sarawak General Hospital, Hospital Road, 93586, Kuching, Sarawak, Malaysia. .,Department of Obstetrics and Gynaecology, Sri Aman Hospital, Hospital Road, 95000, Sri Aman, Sarawak, Malaysia. .,Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300, Kota Samarahan, Sarawak, Malaysia.
| | - Jun Yan Pow
- Department of Obstetrics and Gynaecology, Sarawak General Hospital, Hospital Road, 93586, Kuching, Sarawak, Malaysia
| | - Lee Na Tan
- Department of Obstetrics and Gynaecology, Bintulu Hospital, Nyabau Road, 97000, Bintulu, Sarawak, Malaysia
| | - Haris Njoo Suharjono
- Department of Obstetrics and Gynaecology, Sarawak General Hospital, Hospital Road, 93586, Kuching, Sarawak, Malaysia.,Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300, Kota Samarahan, Sarawak, Malaysia
| | - Wan Sim Teo
- Department of Obstetrics and Gynaecology, Sarawak General Hospital, Hospital Road, 93586, Kuching, Sarawak, Malaysia
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Unger HW, Hansa AP, Buffet C, Hasang W, Teo A, Randall L, Ome-Kaius M, Karl S, Anuan AA, Beeson JG, Mueller I, Stock SJ, Rogerson SJ. Sulphadoxine-pyrimethamine plus azithromycin may improve birth outcomes through impacts on inflammation and placental angiogenesis independent of malarial infection. Sci Rep 2019; 9:2260. [PMID: 30783215 PMCID: PMC6381158 DOI: 10.1038/s41598-019-38821-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/10/2019] [Indexed: 12/23/2022] Open
Abstract
Intermittent preventive treatment with sulphadoxine-pyrimethamine (SP) and SP plus azithromycin (SPAZ) reduces low birthweight (<2,500 g) in women without malarial and reproductive tract infections. This study investigates the impact of SPAZ on associations between plasma biomarkers of inflammation and angiogenesis and adverse pregnancy outcomes in 2,012 Papua New Guinean women. Concentrations of C-reactive protein (CRP), α-1-acid glycoprotein (AGP), soluble endoglin (sEng), soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) were measured at enrolment and delivery in a trial comparing SPAZ to SP plus chloroquine (SPCQ). At antenatal enrolment higher CRP (adjusted odds ratio 1.52; 95% confidence interval [CI] 1.03–2.25), sEng (4.35; 1.77, 10.7) and sFlt1 (2.21; 1.09, 4.48) were associated with preterm birth, and higher sEng with low birthweight (1.39; 1.11,3.37), in SPCQ recipients only. Increased enrolment sFlt1:PlGF ratios associated with LBW in all women (1.46; 1.11, 1.90). At delivery, higher AGP levels were strongly associated with low birthweight, preterm birth and small-for-gestational age babies in the SPCQ arm only. Restricting analyses to women without malaria infection did not materially alter these relationships. Women receiving SPAZ had lower delivery AGP and CRP levels (p < 0.001). SPAZ may protect against adverse pregnancy outcomes by reducing inflammation and preventing its deleterious consequences, including dysregulation of placental angiogenesis, in women with and without malarial infection.
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Affiliation(s)
- Holger W Unger
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia.
| | - Annjaleen P Hansa
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia.,Central Clinical School and Department of Microbiology, Monash University, Victoria, Australia
| | - Christelle Buffet
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Wina Hasang
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Andrew Teo
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Louise Randall
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.,Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia
| | - Stephan Karl
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.,Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Australia
| | - Ayen A Anuan
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - James G Beeson
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia.,Central Clinical School and Department of Microbiology, Monash University, Victoria, Australia.,Burnet Institute, Melbourne, Victoria, Australia
| | - Ivo Mueller
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia.,Institut Pasteur, Paris, France
| | - Sarah J Stock
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, Queen's Medical Research Institute, Edinburgh, UK
| | - Stephen J Rogerson
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
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Medley N, Vogel JP, Care A, Alfirevic Z. Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2018; 11:CD012505. [PMID: 30480756 PMCID: PMC6516886 DOI: 10.1002/14651858.cd012505.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB. OBJECTIVES We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update. METHODS We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI. MAIN RESULTS We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB. OUTCOME preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions. OUTCOME perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources. OUTCOMES preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm. AUTHORS' CONCLUSIONS Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.
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Affiliation(s)
- Nancy Medley
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Joshua P Vogel
- Burnet InstituteMaternal and Child Health85 Commercial RoadMelbourneAustralia
| | - Angharad Care
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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11
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Newnham JP, Kemp MW, White SW, Arrese CA, Hart RJ, Keelan JA. Applying Precision Public Health to Prevent Preterm Birth. Front Public Health 2017; 5:66. [PMID: 28421178 PMCID: PMC5379772 DOI: 10.3389/fpubh.2017.00066] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/17/2017] [Indexed: 12/12/2022] Open
Abstract
Preterm birth (PTB) is one of the major health-care challenges of our time. Being born too early is associated with major risks to the child with potential for serious consequences in terms of life-long disability and health-care costs. Discovering how to prevent PTB needs to be one of our greatest priorities. Recent advances have provided hope that a percentage of cases known to be related to risk factors may be amenable to prevention; but the majority of cases remain of unknown cause, and there is little chance of prevention. Applying the principle of precision public health may offer opportunities previously unavailable. Presented in this article are ideas that may improve our abilities in the fields of studying the effects of migration and of populations in transition, public health programs, tobacco control, routine measurement of length of the cervix in mid-pregnancy by ultrasound imaging, prevention of non-medically indicated late PTB, identification of pregnant women for whom treatment of vaginal infection may be of benefit, and screening by genetics and other “omics.” Opening new research in these fields, and viewing these clinical problems through a prism of precision public health, may produce benefits that will affect the lives of large numbers of people.
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Affiliation(s)
- John P Newnham
- School of Women's and Infants' Health, The University of Western Australia, Crawley, WA, Australia.,Department of Maternal Fetal Medicine, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - Matthew W Kemp
- School of Women's and Infants' Health, The University of Western Australia, Crawley, WA, Australia
| | - Scott W White
- School of Women's and Infants' Health, The University of Western Australia, Crawley, WA, Australia.,Department of Maternal Fetal Medicine, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - Catherine A Arrese
- School of Women's and Infants' Health, The University of Western Australia, Crawley, WA, Australia
| | - Roger J Hart
- School of Women's and Infants' Health, The University of Western Australia, Crawley, WA, Australia
| | - Jeffrey A Keelan
- School of Women's and Infants' Health, The University of Western Australia, Crawley, WA, Australia
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12
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Mueller NT, Rifas-Shiman SL, Blaser MJ, Gillman MW, Hivert MF. Association of prenatal antibiotics with foetal size and cord blood leptin and adiponectin. Pediatr Obes 2017; 12:129-136. [PMID: 26948966 PMCID: PMC5014721 DOI: 10.1111/ijpo.12119] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/04/2016] [Accepted: 01/17/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early postnatal antibiotic use has been shown to promote excess weight gain, but it is unclear whether intrauterine exposure to antibiotics is associated with foetal growth and adiposity. The objective of this study was to examine associations of antibiotic prescription in each trimester of pregnancy with foetal size and adipokine levels at birth. METHODS In 2128 pregnant women from the pre-birth Project Viva cohort, from electronic medical records, we estimated antibiotic prescribing by timing during pregnancy. Outcomes were sex-specific birth weight-for-gestational-age z-score (BW/GA-z) and levels of umbilical cord leptin and adiponectin. We used linear regression models adjusted for maternal age, pre-pregnancy body mass index, parity, race/ethnicity, education, smoking during pregnancy, household income and child sex and additionally adjusted cord blood leptin and adiponectin models for gestation length. RESULTS Of the 2128 women in our sample, 643 (30.2%) were prescribed with oral antibiotics during pregnancy. Mean (standard deviation) BW/GA-z was 0.17 (0.97), cord blood leptin was 9.0 ng mL-1 (6.6) and cord blood adiponectin was 28.8 ng mL-1 (6.8). Overall, antibiotic prescription in pregnancy was associated with lower BW/GA-z [multivariable adjusted β -0.11; 95% confidence interval {CI} -0.20, -0.01]. In trimester-specific analyses, only second trimester antibiotic prescription was associated with lower BW/GA-z (β -0.23; 95% CI -0.37, -0.08). Overall, antibiotic prescription in pregnancy was not associated with cord blood leptin or adiponectin levels. However, in trimester-specific analyses, third trimester antibiotic prescription was associated with higher cord blood leptin (β 2.28 ng mL-1 ; 95% CI 0.38, 4.17). CONCLUSIONS Antibiotics in mid-pregnancy were associated with lower birth weight for gestational age, whereas third trimester antibiotics were associated with higher cord blood leptin.
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Affiliation(s)
- N T Mueller
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - S L Rifas-Shiman
- Obesity Prevention Program, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - M J Blaser
- Division of Translational Medicine, Department of Medicine, New York University Langone Medical Center, New York, NY, USA
- Department of Microbiology, New York University Langone Medical Center, New York, NY, USA
| | - M W Gillman
- Obesity Prevention Program, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - M-F Hivert
- Obesity Prevention Program, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
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13
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Yellon SM. Contributions to the dynamics of cervix remodeling prior to term and preterm birth. Biol Reprod 2017; 96:13-23. [PMID: 28395330 PMCID: PMC5803764 DOI: 10.1095/biolreprod.116.142844] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 11/01/2016] [Accepted: 11/28/2016] [Indexed: 01/05/2023] Open
Abstract
Major clinical challenges for obstetricians and neonatologists result from early cervix remodeling and preterm birth. Complications related to cervix remodeling or delivery account for significant morbidity in newborns and peripartum mothers. Understanding morphology and structure of the cervix in pregnant women is limited mostly to the period soon before and after birth. However, evidence in rodent models supports a working hypothesis that a convergence of factors promotes a physiological inflammatory process that degrades the extracellular collagen matrix and enhances biomechanical distensibility of the cervix well before the uterus develops the contractile capabilities for labor. Contributing factors to this remodeling process include innervation, mechanical stretch, hypoxia, and proinflammatory mediators. Importantly, the softening and shift to ripening occurs while progesterone is near peak concentrations in circulation across species. Since progesterone is required to maintain pregnancy, the premise of this review is that loss of responsiveness to progesterone constitutes a common final mechanism for remodeling the mammalian cervix in preparation for birth at term. Various inputs are suggested to promote signaling between stromal cells and resident macrophages to drive proinflammatory processes that advance the soft cervix into ripening. With infection, pathophysiological processes may prematurely drive components of this remodeling mechanism and lead to preterm birth. Identification of critical molecules and pathways from studies in various rodent models hold promise for novel endpoints to assess risk and provide innovative approaches to treat preterm birth or promote the progress of ripening at term.
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Affiliation(s)
- Steven M. Yellon
- Longo Center for Perinatal Biology, Departments of Basic Sciences Division of Physiology and Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA 92350, USA
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14
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Sanders AP, Gennings C, Svensson K, Motta V, Mercado-Garcia A, Solano M, Baccarelli AA, Tellez-Rojo MM, Wright RO, Burris HH. Bacterial and cytokine mixtures predict the length of gestation and are associated with miRNA expression in the cervix. Epigenomics 2016; 9:33-45. [PMID: 27936911 DOI: 10.2217/epi-2016-0095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Bacterial vaginosis may lead to preterm birth through epigenetic programming of the inflammatory response, specifically via miRNA expression. METHODS We quantified bacterial 16S rRNA, cytokine mRNA and 800 miRNA from cervical swabs obtained from 80 women at 16-19 weeks' gestation. We generated bacterial and cytokine indices using weighted quantile sum regression and examined associations with miRNA and gestational age at delivery. RESULTS & DISCUSSION Each decile of the bacterial and cytokine indices was associated with shorter gestations (p < 0.005). The bacterial index was associated with miR-494, 371a, 4286, 185, 320e, 888 and 23a (p < 0.05). miR-494 remained significant after false discovery rate correction (q < 0.1). The cytokine index was associated with 27 miRNAs (p < 0.05; q < 0.01). CONCLUSION Future investigation into the role of bacterial vaginosis- and inflammation-associated miRNA and preterm birth is warranted.
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Affiliation(s)
- Alison P Sanders
- Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Chris Gennings
- Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Katherine Svensson
- Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Valeria Motta
- Laboratory of Environmental Epigenetics, Exposure Epidemiology & Risk Program, Harvard TH Chan School of Public Health, Boston, MA 02115, USA.,Department of Clinical Sciences & Community Health University of Milan - Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Adriana Mercado-Garcia
- Center for Evaluation Research & Surveys, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico
| | - Maritsa Solano
- Center for Evaluation Research & Surveys, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico
| | - Andrea A Baccarelli
- Laboratory of Environmental Epigenetics, Exposure Epidemiology & Risk Program, Harvard TH Chan School of Public Health, Boston, MA 02115, USA.,Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA 02115, USA
| | - Martha M Tellez-Rojo
- Center for Evaluation Research & Surveys, National Institute of Public Health, Cuernavaca, Morelos 62100, Mexico
| | - Robert O Wright
- Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Heather H Burris
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA 02115, USA.,Boston Children's Hospital & Harvard Medical School, Boston, MA, USA.,Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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15
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van Zijl MD, Koullali B, Mol BW, Pajkrt E, Oudijk MA. Prevention of preterm delivery: current challenges and future prospects. Int J Womens Health 2016; 8:633-645. [PMID: 27843353 PMCID: PMC5098751 DOI: 10.2147/ijwh.s89317] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Preterm birth (PTB), defined as delivery at <37 weeks of gestation, is the most important cause of neonatal morbidity and mortality. Therefore, preventing PTB is one of the main goals in obstetric care. In this review, we provide an overview of the current available literature on screening for risk factors for PTB and a summary of preventive strategies in both low-risk and high-risk women with singleton or multiple gestations. Furthermore, current challenges and future prospects on PTB are discussed. For an optimal prevention of PTB, risk stratification should be based on a combination of (maternal) risk factors, obstetric history, and screening tools. Cervical length measurements can help identify women at risk. Thereafter, preventive strategies such as progesterone, pessaries, and cerclage may help prevent PTB. Effective screening and prevention of PTB vary between the different pregnancy populations. In singleton or multiple pregnancies with a short cervix, without previous PTB, a pessary or progesterone might prevent PTB. In women with a (recurrent) PTB in the past, progesterone and a cerclage may prevent recurrence. The effect of a pessary in these high-risk women is currently being studied. A strong collaboration between doctors, patients' organizations, pharmaceutical companies, and (international) governments is needed to reduce the morbidity and mortality as a result of spontaneous PTB.
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Affiliation(s)
- Maud D van Zijl
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Bouchra Koullali
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ben Wj Mol
- The Robinson Research Institute, School for Reproductive Health and Pediatrics, University of Adelaide, Adelaide, SA, Australia
| | - Eva Pajkrt
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
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16
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Dingens AS, Fairfortune TS, Reed S, Mitchell C. Bacterial vaginosis and adverse outcomes among full-term infants: a cohort study. BMC Pregnancy Childbirth 2016; 16:278. [PMID: 27658456 PMCID: PMC5034665 DOI: 10.1186/s12884-016-1073-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 09/06/2016] [Indexed: 11/10/2022] Open
Abstract
Background Bacterial vaginosis (BV) during pregnancy is a well-established risk factor for preterm birth and other preterm pregnancy complications. Little is known about adverse neonatal outcomes associated with BV exposure in full-term births, nor its influence on adverse outcomes independent of its effect on gestational age. The purpose of this study was to examine the relationship between BV during pregnancy and adverse neonatal outcomes among full-term and preterm infants. Methods We conducted a retrospective cohort study of Washington State mother/infant pairs from 2003-2013, stratified by full-term (primary outcomes) and preterm births (secondary outcomes). BV-exposed and unexposed women were frequency-matched based on year of delivery. BV exposure and adverse outcomes [assisted ventilation/respiratory distress, neonatal intensive care unit (NICU) admission, neonatal sepsis, fetal mortality, and infant mortality] were identified using birth certificates, ICD-9 codes from linked hospital records, and death certificates. Associations between BV exposure and outcomes were assessed using multivariable Poisson regression, adjusted for maternal demographics, gestational age, and other pregnancy complications, including infections. Results A total of 12,340 mother/infant pairs were included: 2,468 BV-exposed (2198 term, 267 preterm) and 9,872 BV unexposed (9156 term, 708 preterm). Among full-term infants, BV-exposed mothers were younger, more likely to be Black or Hispanic, more likely to have had a sexually transmitted infection, and less likely to have a college degree than unexposed mothers. Term BV exposed infants were more likely to have meconium at delivery. Following adjustment, BV was associated with an increased risk of assisted ventilation/respiratory distress at birth (aRR = 1.28, 95 % CI 1.02-1.61), NICU admission (aRR = 1.42, 95 % CI 1.11-1.82), and neonatal sepsis (aRR = 1.60, 95 % CI 1.13-2.27) among full-term infants. These associations were independent of the presence of chorioamnionitis or meconium. Among preterm infants, BV-exposure was associated with an increased risk for NICU admissions only (aRR = 1.24, 95 % CI 1.04-1.46). Conclusions BV exposure during pregnancy is associated with adverse neonatal outcomes even among infants born full-term. These findings amongst full-term infants are novel, and highlight neonatal implications of BV in pregnancy independent of BV’s effect on preterm birth.
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Affiliation(s)
- Adam S Dingens
- Department of Epidemiology, University of Washington School of Public Health, 1959 NE Pacific Street Health Sciences Bldg, Seattle, WA, 98195, USA. .,University of Washington, Molecular & Cellular Biology Program, 1959 NE Pacific St, Seattle, WA, 98195, USA. .,Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.
| | - Tessa S Fairfortune
- Department of Epidemiology, University of Washington School of Public Health, 1959 NE Pacific Street Health Sciences Bldg, Seattle, WA, 98195, USA
| | - Susan Reed
- Department of Epidemiology, University of Washington School of Public Health, 1959 NE Pacific Street Health Sciences Bldg, Seattle, WA, 98195, USA.,Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.,Harborview Medical Center, 325 Ninth Ave, Seattle, WA, 98104, USA
| | - Caroline Mitchell
- Vincent Center for Reproductive Biology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
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17
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Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Giannattasio M, Gregorini G, Giacchino F, Attini R, Loi V, Limardo M, Gammaro L, Todros T, Piccoli GB. A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy. J Nephrol 2016; 29:277-303. [PMID: 26988973 PMCID: PMC5487839 DOI: 10.1007/s40620-016-0285-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/08/2016] [Indexed: 01/09/2023]
Abstract
Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.
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Affiliation(s)
| | | | | | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milano, Italy
| | | | | | | | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Valentina Loi
- Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | - Linda Gammaro
- Nephrology, Ospedale Fracastoro, San Bonifacio, Italy
| | - Tullia Todros
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Giorgina Barbara Piccoli
- Nephrology, ASOU San Luigi, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.
- Nephrologie, Centre Hospitalier du Mans, Le Mans, France.
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18
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Keelan JA, Payne MS, Kemp MW, Ireland DJ, Newnham JP. A New, Potent, and Placenta-Permeable Macrolide Antibiotic, Solithromycin, for the Prevention and Treatment of Bacterial Infections in Pregnancy. Front Immunol 2016; 7:111. [PMID: 27066004 PMCID: PMC4817400 DOI: 10.3389/fimmu.2016.00111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 03/14/2016] [Indexed: 01/24/2023] Open
Abstract
Intrauterine infection–inflammation is a major cause of early preterm birth and subsequent neonatal mortality and acute or long-term morbidity. Antibiotics can be administered in pregnancy to prevent preterm birth either prophylactically to women at high risk for preterm delivery, or to women with diagnosed intrauterine infection, prelabor rupture of membranes, or in suspected preterm labor. The therapeutic goals of each of these scenarios are different, with different pharmacological considerations, although effective antimicrobial therapy is an essential requirement. An ideal antibiotic for these clinical indications would be (a) one that is easily administered and orally bioactive, (b) has a favorable adverse effect profile (devoid of reproductive toxicity or teratogenicity), (c) is effective against the wide range of microorganisms known to be commonly associated with intra-amniotic infection, (d) provides effective antimicrobial protection within both the fetal and amniotic compartments after maternal delivery, (e) has anti-inflammatory properties, and (f) is effective against antibiotic-resistant microorganisms. Here, we review the evidence from clinical, animal, and ex vivo/in vitro studies that demonstrate that a new macrolide-derived antibiotic – solithromycin – has all of these properties and, hence, may be an ideal antibiotic for the treatment and prevention of intrauterine infection-related pregnancy complications. While this evidence is extremely encouraging, it is still preliminary. A number of key studies need to be completed before solithromycin’s true potential for use in pregnancy can be ascertained.
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Affiliation(s)
- Jeffrey A Keelan
- King Edward Memorial Hospital, School of Women's and Infants' Health, University of Western Australia , Perth, WA , Australia
| | - Matthew S Payne
- King Edward Memorial Hospital, School of Women's and Infants' Health, University of Western Australia , Perth, WA , Australia
| | - Matthew W Kemp
- King Edward Memorial Hospital, School of Women's and Infants' Health, University of Western Australia , Perth, WA , Australia
| | - Demelza J Ireland
- King Edward Memorial Hospital, School of Women's and Infants' Health, University of Western Australia , Perth, WA , Australia
| | - John P Newnham
- King Edward Memorial Hospital, School of Women's and Infants' Health, University of Western Australia , Perth, WA , Australia
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19
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Kim SM, Romero R, Lee J, Chaemsaithong P, Docheva N, Yoon BH. Gastric fluid versus amniotic fluid analysis for the identification of intra-amniotic infection due to Ureaplasma species. J Matern Fetal Neonatal Med 2015; 29:2579-87. [PMID: 26631980 PMCID: PMC5703068 DOI: 10.3109/14767058.2015.1098614] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Early neonatal sepsis is often due to intra-amniotic infection. The stomach of the neonate contains fluid swallowed before and during delivery. The presence of bacteria as well as neutrophils detected by culture or Gram stain of the gastric fluid during the first day of life is suggestive of exposure to bacteria or inflammation. We undertook this study to determine the relationship between gastric fluid analysis and amniotic fluid obtained by transabdominal amniocentesis in the detection of Ureaplasma species, the most frequent microorganisms responsible for intra-amniotic infection. MATERIALS AND METHODS The study population consisted of 100 singleton pregnant women who delivered preterm neonates (<35 weeks) within 7 days of amniocentesis. Gastric fluid of newborns was obtained by nasogastric intubation on the day of birth. Amniotic fluid and gastric fluid were cultured for genital Mycoplasmas, and polymerase chain reaction (PCR) for Ureaplasma species was performed. Intra-amniotic inflammation was defined as an elevated amniotic fluid matrix metalloproteinase-8 concentration (>23 ng/mL). RESULTS (1) Ureaplasma species were detected by culture or PCR in 18% (18/100) of amniotic fluid samples and in 5% (5/100) of gastric fluid samples; (2) among the amniotic fluid cases positive for Ureaplasma species, these microorganisms were identified in 27.8% (5/18) of gastric fluid samples; (3) none of the cases negative for Ureaplasma species in the amniotic fluid were found to be positive for these microorganisms in the gastric fluid; (4) patients with amniotic fluid positive for Ureaplasma species but with gastric fluid negative for these microorganisms had a significantly higher rate of intra-amniotic inflammation, acute histologic chorioamnionitis, and neonatal death than those with both amniotic fluid and gastric fluid negative for Ureaplasma species; and (5) no significant differences were observed in the rate of intra-amniotic inflammation, acute histologic chorioamnionitis, and neonatal death between patients with amniotic fluid positive for Ureaplasma species but with gastric fluid negative for these microorganisms and those with both amniotic fluid and gastric fluid positive for Ureaplasma species. CONCLUSIONS Gastric fluid analysis has 100% specificity in the identification of intra-amniotic infection with Ureaplasma species. However, the detection of Ureaplasma species by culture or PCR in the gastric fluid of neonates at birth did not identify these microorganisms in two-thirds of cases with microbial invasion of the amniotic cavity. Thus, amniotic fluid analysis is superior to that of gastric fluid in the identification of intra-amniotic infection.
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Affiliation(s)
- Sun Min Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
| | - JoonHo Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Piya Chaemsaithong
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Nikolina Docheva
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Bo Hyun Yoon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
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20
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Thinkhamrop J, Hofmeyr GJ, Adetoro O, Lumbiganon P, Ota E. Antibiotic prophylaxis during the second and third trimester to reduce adverse pregnancy outcomes and morbidity. Cochrane Database Syst Rev 2015; 2015:CD002250. [PMID: 26092137 PMCID: PMC7154219 DOI: 10.1002/14651858.cd002250.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Several studies have suggested that prophylactic antibiotics given during pregnancy improved maternal and perinatal outcomes, while others have shown no benefit and some have reported adverse effects. OBJECTIVES To determine the effect of prophylactic antibiotics on maternal and perinatal outcomes during the second and third trimester of pregnancy for all women or women at risk of preterm delivery. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015) and reference lists of retrieved articles. SELECTION CRITERIA Randomised controlled trials comparing prophylactic antibiotic treatment with placebo or no treatment for women in the second or third trimester of pregnancy before labour. DATA COLLECTION AND ANALYSIS We assessed trial quality and extracted data. MAIN RESULTS The review included eight randomised controlled trials. Approximately 4300 women were recruited to detect the effect of prophylactic antibiotic administration on pregnancy outcomes. Primary outcomesAntibiotic prophylaxis did not reduce the risk of preterm prelabour rupture of membranes (risk ratio (RR) 0.31; 95% confidence interval (CI) 0.06 to 1.49 (one trial, 229 women), low quality evidence) or preterm delivery (RR 0.88; 95% CI 0.72 to 1.09 (six trials, 3663 women), highquality evidence). However, preterm delivery was reduced in the subgroup of pregnant women with a previous preterm birth who had bacterial vaginosis (BV) during the current pregnancy (RR 0.64; 95% CI 0.47 to 0.88 (one trial, 258 women)), but there was no reduction in the subgroup of pregnant women with previous preterm birth without BV during the pregnancy (RR 1.08; 95% CI 0.66 to 1.77 (two trials, 500 women)). A reduction in the risk of postpartum endometritis (RR 0.55; 95% CI 0.33 to 0.92 (one trial, 196 women)) was observed in high-risk pregnant women (women with a history of preterm birth, low birthweight, stillbirth or early perinatal death) and in all women (RR 0.53; 95% CI 0.35 to 0.82 (three trials, 627 women), moderate quality evidence). There was no difference in low birthweight (RR 0.86; 95% CI 0.53 to 1.39 (four trials; 978 women)) or neonatal sepsis (RR 11.31; 95% CI 0.64 to 200.79) (one trial, 142 women)); and blood culture confirming sepsis was not reported in any of the studies. Secondary outcomesAntibiotic prophylaxis reduced the risk of prelabour rupture of membranes (RR 0.34; 95% CI 0.15 to 0.78 (one trial, 229 women), low quality evidence) and gonococcal infection (RR 0.35; 95% CI 0.13 to 0.94 (one trial, 204 women)). There were no differences observed in other secondary outcomes (congenital abnormality; small-for-gestational age; perinatal mortality), whilst many other secondary outcomes (e.g. intrapartum fever needing treatment with antibiotics) were not reported in included trials.Regarding the route of antibiotic administration, vaginal antibiotic prophylaxis during pregnancy did not prevent infectious pregnancy outcomes. The overall risk of bias was low, except that incomplete outcome data produced high risk of bias in some studies. The quality of the evidence using GRADE was assessed as low for preterm prelabour rupture of membranes, high for preterm delivery, moderate for postpartum endometritis, low for prelabour rupture of membranes, and very low for chorioamnionitis. Intrapartum fever needing treatment with antibiotics was not reported in any of the included studies. AUTHORS' CONCLUSIONS Antibiotic prophylaxis did not reduce the risk of preterm prelabour rupture of membranes or preterm delivery (apart from in the subgroup of women with a previous preterm birth who had bacterial vaginosis). Antibiotic prophylaxis given during the second or third trimester of pregnancy reduced the risk of postpartum endometritis, term pregnancy with pre-labour rupture of membranes and gonococcal infection when given routinely to all pregnant women. Substantial bias possibly exists in the review's results because of a high rate of loss to follow-up and the small numbers of studies included in each of our analyses. There is also insufficient evidence on possible harmful effects on the baby. Therefore, we conclude that there is not enough evidence to support the use of routine antibiotics during pregnancy to prevent infectious adverse effects on pregnancy outcomes.
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Affiliation(s)
- Jadsada Thinkhamrop
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of MedicineFaculty of Medicine123 Mittraparb HighwayKhon KaenThailand40002
| | - G Justus Hofmeyr
- Frere Hospital, Walter Sisulu University, University of the Witwatersrand, Eastern Cape Department of HealthDepartment of Obstetrics and GynaecologyEast LondonSouth Africa
| | - Olalekan Adetoro
- Olabisi Onabanjo UniversityObafemi Awolowo College of Health SciencesSagamuOgun StateNigeria
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of MedicineFaculty of Medicine123 Mittraparb HighwayKhon KaenThailand40002
| | - Erika Ota
- National Center for Child Health and DevelopmentDepartment of Health Policy2‐10‐1 Okura, Setagaya‐kuTokyoJapan157‐8535
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