Pregnancy and infection

Using maternal sepsis patient journeys to map and prioritise barriers to quality maternal healthcare in Malawi: a multidisciplinary stakeholder consultation workshop

BACKGROUND

Malawi has made progress in improving access to maternity care services, shifting the focus to quality of care as an essential determinant of maternal health outcomes. However, no effective mechanisms exist to use patients' experiences of care at health facilities to inform and improve the quality of maternal healthcare.

OBJECTIVE

To use maternal sepsis patient journeys in a workshop with maternal health stakeholders to identify and prioritise barriers in care and recommend interventions to improve maternal healthcare quality in Malawi.

METHODS

In February 2024, in Blantyre, Malawi, using a modified nominal group technique, 28 stakeholders reviewed the patient journeys of three women hospitalised at Queen Elizabeth Central Hospital, who had sepsis after childbirth. Patient journeys narrate events experienced within a healthcare system in the patient's words. In a multiframework approach (Four Delays, Respectful Maternity Care, and WHO Quality of Care), stakeholders identified and prioritised barriers to care and recommended interventions to improve the quality of maternal healthcare. Content analysis of the workshop data linked barriers with stakeholders' suggested interventions.

RESULTS

Nineteen barriers identified included various delays in receiving care, mistreatment by healthcare providers, and suboptimal quality of care. Stakeholders found patient journeys valuable and insightful for identifying gaps in the quality of care and promoting sepsis awareness among healthcare workers and the public.

CONCLUSIONS

Patient journeys are a novel tool for capturing the experience of care in Malawi. They have the potential to guide strategic improvements in maternal healthcare quality and ultimately reduce maternal morbidity and mortality.

Bacille Calmette-Guérin-specific IgG titres among infants born to mothers with active tuberculosis disease in Uganda

BACKGROUND

Infants born to mothers with active tuberculosis disease (ATB) are at risk of poor clinical outcomes such as low birth weight and perinatal mortality. However, little is known about the influence of maternal ATB exposure on their vaccine responses during infancy. The study explored how maternal ATB affects infants' vaccine responses, hypothesising reduced responses to Bacille Calmette-Guérin (BCG) and other infant vaccines.

METHODS

This was a case-control study with a longitudinal component of infants born to mothers with bacteriologically confirmed ATB (cases) and infants born to mothers without ATB (controls) carried out between September 2021 and June 2022. Quantitative BCG, diphtheria, tetanus, and measles-specific IgG ELISA assays were performed on infant plasma harvested from lithium-heparin blood collected on first encounter after birth (0), at 3, 6, and 9 months. We used prism v10.1.2, mixed-effects modelling, and Tukey's multiple comparison testing to determine mean differences (MD) between the cases and controls at all time points.

RESULTS

Exposed infant cases had reduced IgG titres to BCG at baseline compared to the controls (p = 0.032), with a mean of 125.8 vs. 141.1 IU/mL, respectively. This difference was, however, not sustained at the other time points. Similarly, we demonstrated trends towards reduced responses to tetanus, diphtheria, and measles vaccines among infant cases at baseline and three months. However, the trend was not sustained at months six and nine. The mean titres for tetanus at baseline and 3 months for cases versus controls are 1.744 vs. 2.917 IU/mL (p < 0.0001) and 1.716 vs. 2.344 IU/mL (p = 0.018), respectively. The mean titres for diphtheria at 3 months for cases versus controls were 0.022 vs. 0.075 IU/mL (p = 0.006), respectively.

CONCLUSION

We have demonstrated that maternal TB disease influences vaccine responses to BCG and other infant vaccines. This has implications for increased risk of childhood TB and other preventable diseases.

CLINICAL TRIAL NUMBER

Not applicable.

Assessing TB treatment outcomes in pregnant women living with HIV with drug-susceptible TB

BACKGROUND

Limited data exist on TB treatment outcomes among pregnant women with TB. Physiological and immunological adaptations during pregnancy may affect the efficacy of TB treatment. We aimed to evaluate factors associated with unsuccessful TB treatment outcomes among pregnant women living with HIV (PWLHIV) and diagnosed with TB in the Tshepiso study.

METHODS

In this secondary analysis, we used multivariable logistic regression to evaluate factors associated with unsuccessful TB treatment outcomes among PWLHIV with drug-sensitive TB disease enrolled in the Tshepiso study in Soweto, South Africa, from 2011-2014.

RESULTS

This analysis includes 79 PWLHIV diagnosed with drug-sensitive TB during pregnancy; 18 (23%) had an unsuccessful treatment outcome. Factors associated with unsuccessful TB treatment include detectable HIV RNA viral load at enrollment to the study (aOR 5.1, 95% CI 1.1-25.3), presence of extrapulmonary TB (aOR 2.2, 95% CI 0.4-11.7), bacteriological (positive smear and/or culture) confirmation of TB (aOR 2.1, 95% CI 0.7-6.7), and anemia (Hb ≤ 10.5 g/dL) (aOR 1.0, 95% CI 0.3-3.1). The only factor with statistical significance was a detectable HIV RNA viral load.

CONCLUSION

Detectable HIV viral load emerges as a critical factor associated with an unsuccessful TB treatment outcome in pregnant women living with HIV and diagnosed with TB.

Mammary intraepithelial lymphocytes promote lactogenesis and offspring fitness

Breastfeeding is an obligatory requirement of mammalian survival. This fundamental process is associated with the adaptation of maternal physiology, including the transformation of the mammary gland into a milk-secreting organ. How maternal immunity contributes to mammary gland remodeling and function remains largely unknown. Here, we show that maternal adaptive immunity plays a critical role in shaping lactogenesis. Specifically, physiological adaptation during pregnancy is associated with thymic involution and a paradoxical enrichment in intraepithelial lymphocyte (IEL) precursors that no longer migrate to the gut but instead preferentially accumulate within the mammary gland. IEL precursors differentiate into T-bet-expressing unconventional CD8αα lymphocytes in an IL-15-dependent manner. Mammary IELs control milk production by favoring the differentiation and maturation of contractile and milk-secreting cells, thereby promoting offspring fitness. Altogether, this work uncovers a contribution of the maternal adaptive immune system in organismal remodeling during pregnancy that is associated with mammary gland development and function.

Discordance of 3rd and 4th generation QuantiFERON-TB Gold assays by pregnancy stages in India

Background

Pregnancy and HIV affect CD4+ T lymphocytes and impact performance of QuantiFERON-TB Gold (QFT). We compared the results of QFT with QuantiFERON-TB Gold Plus (QFT-Plus), which also measures CD8+ responses to TB antigens, during pregnancy and postpartum.

Methods

We screened 516 pregnant women for TB infection (TBI) with IGRA. From 165 IGRA + pregnant women, QFT vs QFT-Plus results were compared at delivery and postpartum. Longitudinal changes in QFT-Plus were assessed in 74 pregnant women who received QFT-Plus testing at pregnancy, delivery, and postpartum.

Results

Through cross-sectional analysis of the IGRA + cohort, QFT-Plus showed higher positivity than QFT (80 % vs 65 %, p = 0.04) at delivery but no difference postpartum. Among 35 women with HIV, QFT-Plus returned more positive results than QFT at delivery and postpartum (76 % vs 47 %, p = 0.08; 90 % vs 80 %, p = 0.54), though not statistically significant. Longitudinally, QFT-Plus positivity by TB1 or TB2 was highest antepartum vs. delivery and postpartum (74 % vs. 58 % vs. 62 %; p = 0.09) and performed better than TB1 alone (100 % vs 90 %, p = 0.04) in women without HIV but not in women with HIV.

Conclusions

Performance of QFT-Plus was consistent across pregnancy, including at delivery when QFT positivity is lower. QFT-Plus may enhance antenatal TBI detection among pregnant women.

[Pneumonia and pregnancy]

Acute community-acquired pneumonia (CAP) during pregnancy is a frequently encountered and potentially severe condition. CAP incidence and ecology are unchanged during pregnancy as compared with the overall young adult population. Risk factors specifically identified in pregnant women include advanced gestational age, asthma, anemia and repeated courses of corticosteroid therapy for fetal lung maturation. The clinical presentation of CAP is not altered during pregnancy. Key points in the pregnant host encompass: (i) reduced maternal tolerance to hypoxia, due to physiological adaptations during pregnancy; (ii) heightened severity of some infections, notably viral pneumonias such as influenza, varicella or SARS-CoV-2 pneumonia; (iii) potentially deleterious fetal repercussions of infection and maternal hypoxia, with an increased risk of premature delivery and prematurity; (iv) the need for specific attention to the risk of fetal irradiation in the performance of possibly repeated radiological examinations and (v) therapeutic specificities arising from the possible embryo-fetal toxicity of certain anti-infectious agents. CAP prevention is premised on compliance with universal hygiene measures and on vaccination, which guarantees protection against severe forms of pneumonia not only in the mother (Streptococcus pneumoniae, seasonal flu, chickenpox, COVID-19), but also in the child during the first few months of life (whooping cough, RSV).

SARS-CoV-2 Infection and Adverse Maternal and Perinatal Outcomes: Time-to-Event Analysis of a Hospital-Based Cohort Study of Pregnant Women in Rio de Janeiro, Brazil

Understanding perinatal health outcomes following SARS-CoV-2 infection during pregnancy necessitates large-scale studies of mother-infant dyads. Hospital-based studies of pregnant women and their neonates provide valuable insights within the field of perinatal health research. The aim of this study was to evaluate the effect of SARS-CoV-2 infection on maternal and perinatal outcomes among hospitalized pregnant women in Rio de Janeiro during the COVID-19 pandemic.

METHODS

The study consisted of a time-to-event analysis of a hospital-based cohort of 1185 pregnant women ≥ 16 years and their infants from May 2020 to March 2022. Pregnant women were classified as infected if they had a SARS CoV-2 positive RT-PCR or a positive rapid antigen test. An exploratory analysis of qualitative variables was conducted with calculation of absolute and relative frequencies and calculation of 95% confidence intervals. Survival functions were estimated by the Kaplan-Meier method, and the Cox proportional hazards model was employed to interpret the effects of SARS-CoV-2 infection on time to adverse maternal and perinatal outcomes, adjusted for vaccination, comorbidity, and gestational trimester.

RESULTS

A total of 21% (249/1185) women were infected with SARS-CoV-2, with a median age of 26 (range: 16-47). Cesarean section deliveries were performed in 57% (135/237) SARS CoV-2+ participants vs. 43% (391/914) of uninfected participants, p < 0.001. Intensive care unit admission and/or death occurred in 68 of 1185 participants (5.7%), 44 of 249 participants (17.7%) infected with SARS CoV-2 vs. 24 of 936 uninfected participants (2.5%). All 21 participants who died were unvaccinated against COVID-19. Women infected with SARS-CoV-2 were at greater risk of adverse maternal outcomes (crude HR: 5.93, 95% CI: 3.58-9.84; adjusted HR: 5.47, 95% CI: 3.16-9.48) than uninfected pregnant women. SARS CoV-2 vertical transmission was observed in 6 of 169 (3.6%) tested neonates. Preterm deliveries occurred more frequently in patients testing positive for SARS-CoV-2 (30.7% vs. 23.6). In the survival analysis, no effect of SARS-CoV-2 infection was observed on prematurity (HR: 0.92, 95% CI: 0.68-1.23) and adverse perinatal outcomes, including fetal distress (HR: 1.29, 95% CI: 0.82-2.05), stillbirth (HR: 1.07, 95% CI: 0.48-2.38), and neonatal death (HR: 0.96, 95% CI: 0.35-2.67), even after adjusting for vaccination, comorbidity, gestational trimester, and periods of time.

CONCLUSION

The risk of maternal death due to COVID-19 highlights the need for adequate preventive measures, particularly vaccination, during the prenatal and postpartum periods.

CD8+ and CD8- NK Cells and Immune Checkpoint Networks in Peripheral Blood During Healthy Pregnancy

Pregnancy involves significant immunological changes to support fetal development while protecting the mother from infections. A growing body of evidence supports the importance of immune checkpoint pathways, especially at the maternal-fetal interface, although limited information is available about the peripheral expression of these molecules by CD8+ and CD8- NK cell subsets during the trimesters of pregnancy. Understanding the dynamics of these immune cells and their checkpoint pathways is crucial for elucidating their roles in pregnancy maintenance and potential complications. This study aims to investigate the peripheral expression and functional characteristics of CD8+ and CD8- NK cell subsets throughout pregnancy, providing insights into their contributions to maternal and fetal health. A total of 34 healthy women were enrolled from the first, 30 from the second and 40 from the third trimester of pregnancy. At the same time, 35 healthy age-matched non-pregnant women formed the control group. From peripheral blood, mononuclear cells were separated and stored at -80 °C. CD8+ and CD8- NK cell subsets were analyzed from freshly thawed samples, and surface and intracellular staining was performed using flow cytometric analyses. The proportions of CD56+ NK cells in peripheral blood were similar across groups. While CD8- NKdim cells increased significantly in all trimesters compared to non-pregnant controls, CD8+ NKdim cells showed no significant changes. CD8- NKbright cells had higher frequencies throughout pregnancy, whereas CD8+ NKbright cells significantly increased only in the first and second trimesters. The expression levels of immune checkpoint molecules, such as PD-1 and PD-L1, and cytotoxic-activity-related molecules were stable, with notable perforin and granzyme B increases in CD8- NKbright cells throughout pregnancy. Our study shows that peripheral NK cell populations, especially CD8- subsets, are predominant during pregnancy. This shift suggests a crucial role for CD8- NK cells in balancing maternal immune tolerance and surveillance. The stable expression of immune checkpoint molecules indicates that other regulatory mechanisms may be at work. These findings enhance our understanding of peripheral immune dynamics in pregnancy and suggest that targeting CD8- NKbright cell functions could help manage pregnancy-related immune complications. This research elucidates the stable distribution and functional characteristics of peripheral NK cells during pregnancy, with CD8- subsets being more prevalent. The increased activity of CD8- NKbright cells suggests their critical role in maintaining immune surveillance. Our findings provide a basis for future studies to uncover the mechanisms regulating NK cell function in pregnancy, potentially leading to new treatments for immune-related pregnancy complications.

Risk of invasive pneumococcal disease during pregnancy and postpartum and association with adverse maternal and foetal outcomes: A prospective cohort study, England, 2014-19

BACKGROUND

Pneumococcal infections are associated with significant morbidity and mortality, especially at the extremes of age and in those with underlying conditions. Little is known about the risks, presentations or outcomes of invasive pneumococcal disease (IPD) during pregnancy or the postpartum period.

METHODS

The UK Health Security Agency conducts enhanced national surveillance of IPD in England. We used national surveillance data to calculate IPD risk and outcomes in pregnant, postpartum and non-pregnant women of childbearing age with IPD over a five-year period in England.

FINDINGS

There were 1701 IPD cases in women aged 15-44 years between 1 July 2014 and 30 June 2019, including 123 (7.2%) pregnant, 38 (2.2%) postpartum and 1540 (90.5%) non-pregnant women. IPD incidence in pregnant women (0.048/1000 woman-years) was not significantly different compared to non-pregnant women (0.041/1000 woman-years; Incidence Rate Ratio [IRR]: 1.17; 95%CI 0.96-1.40; p=0.11). When stratified by trimester, however, women in their third trimester had a 2.27-fold (95%CI 1.80-2.85, p<0.001) increased risk of IPD, compared to non-pregnant women (IRR 2.27, 95%CI 1.78-2.85, p<0.001), while those in the first (IRR 0.49, 95%CI 0.28-0.80) and second trimester (IRR 0.71, 95%CI 0.47-1.04) had a lower risk, albeit only statistically significant for the first trimester. Postpartum women (0.144 per 1000 woman-years), on the other hand, had a 3.49-fold (95%CI 2.46-4.81, p<0.001) higher IPD risk than non-pregnant women. Most pregnant women developed IPD during their third trimester (80/123, 65.0%), with all but one pregnancy resulting in a live birth. IPD in the second trimester was associated with live birth in 77.8% of cases (21/27), while 22.2% experienced a miscarriage (5/27, 18.5%) or stillbirth (1/27, 3.7%). IPD in the first trimester was associated with live birth in 41.7% of cases (5/12), miscarriages in 41.7% (5/12), and termination in 16.7% (2/12) cases. Only three neonates (3/142) had confirmed IPD. There were no deaths in pregnant women with IPD compared to 5.5% (85/1540) in non-pregnant women.

INTERPRETATION

While pregnant women overall did not appear to have an increased risk of IPD compared to non-pregnant women, those infected in third trimester or postpartum appeared to have more than twice the incidence. Most pregnant and postpartum women had a live birth, and subsequent neonatal infection was rare, occurring in 2% of live births.

Safety, Efficacy, and Effectiveness of Maternal Vaccination against Respiratory Infections in Young Infants

Lower respiratory tract infection (LRTI) is a major cause of neonatal morbidity and mortality worldwide. Maternal vaccination is an effective strategy in protecting young infants from LRTI, particularly in the first few months after birth when infant is most vulnerable, and most primary childhood vaccinations have not been administered. Additionally, maternal vaccination protects the mother from illness during pregnancy and the postnatal period, and the developing fetus from adverse outcomes such as stillbirth and prematurity. In this paper, we review the safety, efficacy, and effectiveness of maternal vaccines against LRTIs, such as pertussis, influenza, coronavirus disease 2019, and respiratory syncytial virus.

Effects of Supranutritional Selenium Supplementation During Different Trimesters of Pregnancy on Humoral Immunity in Beef Cattle at Parturition

Supranutritional Se supplementation may improve immune responses in beef cattle. Immunity is compromised in beef cattle during the periparturient period. This study aims to determine the best time during pregnancy to supplement beef cows with Se-yeast to optimize humoral immunity at parturition. Multiparous, black Angus and Angus cross cows (n = 79) were used in the study. All cows had ad libitum access to a mineral supplement containing 120 mg/kg Se (US FDA regulations) from Na selenite. In addition, all cows except controls (CTR) received Se supplementation of 105 mg Se/week from Se-yeast boluses administered once weekly during their specific treatment trimester of gestation (TR1, TR2, or TR3) for 13 weeks. This dosage was supranutritional equaling 5 × the upper range of US FDA Se administration regulations. Blood was collected at parturition from all cows. Laboratory analyses studied to assess humoral immunity included measuring IBR, BVD types 1 and 2, PI3, and BRSV serum neutralization titers post vaccination, assessing total IgM and antigen-specific IgM concentrations, and determining complement-mediated bacterial killing percentages. Statistical analyses were performed using GraphPad Prism and SAS 9.4. Supranutritional Se-yeast supplementation increased whole-blood (WB) Se concentrations regardless of trimester of supplementation (all P < 0.0001). Supplementation during TR2 and TR3 was more effective in increasing WB-Se concentrations at parturition than during TR1 or CTR (all P < 0.0001). TR2 cows had higher serum neutralization titers for BRSV compared with CRT cows (P = 0.03). Total serum IgM and Vibrio coralliilyticus-specific IgM concentrations were highly correlated (r = 0.78; P < 0.0001). Compared with CTR cows, TR1, TR2, and TR3 cows had similar total IgM concentrations (all P ≥ 0.19) and similar Vibrio coralliilyticus-specific IgM concentrations (all P ≥ 0.47). Complement-mediated bacterial killing percentages were greater in TR2 and TR3 cows (> 99.6%) compared with TR1 (93.9%) and CTR (89.3%) cows, and all Se-supplemented TR groups were greater than CTR cows (all P ≤ 0.05). The significant group differences in the complement-mediated bacterial killing assay reflected WB-Se concentrations. Supranutritional Se-yeast supplementation during TR2 and TR3 is associated with higher serum neutralization titers for some viral antigens, as well as enhanced complement-mediated bacterial killing in cows at parturition. These findings suggest that Se supplementation during later trimesters of pregnancy may help combat infectious disease challenges during the periparturient period in beef cattle.

Cryptosporidium Infection During Pregnancy and Effects on Pregnancy Outcomes in Israel

Cryptosporidium is a parasite that typically causes self-limited gastroenteritis. Little is known about the course of infection and its impact during pregnancy. This retrospective cohort study conducted in Israel assessed the effects of Cryptosporidium infection on pregnancy and obstetrical outcomes. The study population included pregnant women with a positive PCR stool test for Cryptosporidium and a control group of pregnant women with negative tests, matched at a 3:1 ratio based on age, gestational week, and sector. Their medical records were retrieved for symptoms, treatments, pregnancy termination, gestational age, birth weight, Apgar score, and head circumference. Fisher's exact or chi-squared tests were used to determine significance. Between January 2020 and December 2023, 2512 pregnant women underwent PCR stool testing. Of these, 93 were positive for Cryptosporidium, mostly in 2022. Their median age was 31 (range: 23-42 years), and 77.4% were from medium-high socioeconomic status. The most common symptom was diarrhea (90/93, 96.7%). The infection was self-limiting in all cases, with none requiring specific treatment. No significant differences were found in miscarriage rate, delivery week, birth weight, Apgar score, or head circumference compared to the controls. This study illuminates the clinical course of Cryptosporidium infection in pregnant women, emphasizing a generally favorable outcome without the necessity for therapeutic intervention.

Vaccination of pregnant women: an overview of European policies and strategies to promote it

Maternal immunization is a valuable tool for protecting mother and unborn child from vaccine-preventable diseases. However, the implementation of strategies for vaccinating pregnant women has only recently gained traction. This work is aimed at providing an overview of European vaccination strategies and gathering evidence on interventions enhancing vaccination knowledge, attitudes, and behaviors (KAB) in pregnant women. To summarize current pregnancy vaccination strategies in Europe, we consulted literature, institutional national health system websites, and the ECDC Vaccine Scheduler. The review of evidence on interventions targeting pregnant women's vaccination KAB was performed by searching primary studies on PubMed and Web of Science. The 27 EU member states offer various vaccinations in pregnancy, but only 10 recommend all of these: tetanus, pertussis, diphtheria, influenza, and COVID-19, albeit with different administration schedules. The literature review included 7 studies, 3 from Italy and 4 from other European countries (UK, Netherlands, Greece, Poland, and Ukraine). They were conducted in various settings such as childbirth preparation courses, prenatal visits, and online platforms, and all included educational interventions providing information on vaccine safety and efficacy during pregnancy. Knowledge about vaccines and vaccine-preventable diseases, generally low in the pre-intervention period, increased post-intervention, with a rise in awareness of the risks associated with infectious diseases and the recommended vaccines, a reduction in vaccine-related misinformation, and a greater propensity to vaccinate both newborns and themselves. Furthermore, there was a significant increase in adherence to recommended vaccinations, particularly among those with higher educational levels. However, vaccine hesitancy persisted, influenced by factors such as fear of adverse events and the lack of recommendations from healthcare providers. Variations in pregnancy vaccination strategies across Europe emphasize the importance of establishing a unified framework to optimize maternal and fetal health outcomes through evidence-based policies. Educational interventions may positively impact pregnant women's KAB, therefore promoting vaccination uptake.

The Relationship Between Prenatal, Perinatal, and Postnatal Factors and ADHD: The Role of Nutrition, Diet, and Stress

Attention-Deficit Hyperactive Disorder (ADHD) is a neurobehavioral syndrome affecting children aged 6-17 with symptoms manifesting before age 12. ADHD presents heterogeneously and is associated with various psychiatric disorders. The cause remains elusive, but genetic and environmental factors, brain region maturation delays, and neurotransmitter dysregulation are implicated. Effective treatment requires a multi-disciplinary approach, primarily involving pharmacological and behavioral intervention. Stimulants like methylphenidate and amphetamines are first-line medications, but non-stimulants may be considered for some patients. However, stimulants face challenges related to misuse, dependence, and long-term tolerability issues. The etiology of ADHD involved genetic predisposition, environmental influences, and prenatal, perinatal, and postnatal factors. Prenatal causes encompass maternal diet, alcohol consumption, viral infections, and stress. Postnatal factors include head trauma, meningitis, toxin, nutritional deficiencies, as well as iodine deficiency and hypothyroidism. The gut microbiome's role in ADHD is emerging, influencing neurodevelopment through microbiota-gut-brain axis. Understanding these diverse etiological factors is essential for comprehensive ADHD management.

Examining Infant and Child Neurodevelopmental Outcomes After Lyme Disease During Pregnancy

Lyme disease is the most common vector-borne disease in the United States. Recent environmental and socioecological changes have led to an increased incidence of Lyme and other tick-borne diseases, which enhances the urgency of identifying and mitigating adverse outcomes of Lyme disease exposure. Lyme disease during pregnancy, especially when untreated, may lead to adverse pregnancy and neonatal outcomes; however, long-term child outcomes following utero exposure to Lyme disease have not yet been systematically assessed. This concise review describes the current state of knowledge of Lyme disease as a congenital infection and the potential effects of in utero exposure to Lyme disease infection on the neurodevelopment of infants and children. We highlight the importance of distinguishing between acute Lyme disease and a chronic condition termed Post-Treatment Lyme Disease Syndrome, as the impacts of both conditions on the developing fetus and subsequent child development may differ. The importance of placental pathology for patients with acute or chronic symptoms of Lyme disease in pregnancy is explored. Future research aiming to understand and protect neurodevelopment after antenatal Lyme disease must carefully collect potentially confounding variables such as symptomatology and treatment, use clear and standard case definitions, and follow children into school-age and beyond.

A Survey on Companion Animal Owners' Perception of Veterinarians' Communication About Zoonoses and Antimicrobial Resistance in Germany

The intimate bonds between humans and their pets create favourable conditions that support the mutual transmission of pathogens in either direction. In this context, veterinarians are essential in informing and educating pet owners about health risks linked to zoonotic pathogens and antimicrobial resistance (AMR). To effectively convey this information, veterinarians should have strong communication skills. To gather insights on pet ownership, veterinary consultations, and risk communication, an online questionnaire was used to survey dog and cat owners in Germany. The survey evaluated the frequency and perception of communication concerning zoonotic pathogens and AMR, deriving a communication score. The findings showed that pet owners rated veterinarian communication with a high average score, reflecting a high satisfaction level. The longer pet owners had been clients, the more frequently they received information on zoonoses and AMR, and the better they rated the communication. However, the results also indicated that the amount of information on zoonoses and/or AMR provided by veterinarians was still lower than desired by pet owners. Risk factors, including pathogen detection, vulnerable individuals, owning imported animals, and feeding them raw meat, fish, offal, or uncooked bones, were regularly present. These findings underscore the critical role of risk communication in preventing zoonoses and AMR.

Tick-Borne Diseases and Pregnancy: A Narrative Review Evaluating Pregnancy Complications Caused by Tick-Borne Diseases

Ticks are vectors of public health concern because the pathogens they transmit can cause detrimental diseases in humans. Lyme disease, tick-borne relapsing fever, human granulocytic anaplasmosis, Rocky Mountain spotted fever, tick-borne encephalitis, Crimean-Congo hemorrhagic fever, and babesiosis are some of the most common diseases caused by the pathogens transmitted by ticks. The overlap between human activities and tick habitats is growing, contributing to an increase in tick-borne disease cases. Unfortunately, pregnancy as a risk factor for tick-borne diseases is largely ignored. In this narrative review we use case reports, epidemiological studies, and animal studies to evaluate the maternal, pregnancy, and fetal outcomes caused by Lyme disease, tick-borne relapsing fever, human granulocytic anaplasmosis, Rocky Mountain spotted fever, tick-borne encephalitis, Crimean-Congo hemorrhagic fever, and babesiosis during pregnancy.

Trends and predictions of maternal sepsis and other maternal infections among women of childbearing age: a systematic analysis for the global burden of disease study 2019

Background

Maternal sepsis and other maternal infections (MSMIs) are major public health concerns worldwide. However, comprehensive data on their global burden and evolving trends remain sparse. This study aims to explore the epidemiological trends of MSMIs in women of childbearing age (WCBA) from 1990 to 2019, investigate the relationship between disease burden and age, period, and birth cohorts, and then provide a prediction of MSMIs incidence and deaths.

Methods

The estimates and 95% uncertainty intervals (UIs) for the incidence and death number of MSMIs in seven age groups (15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49 years) were obtained from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. The age-standardized incidence and mortality rates of MSMIs in WCBA were estimated utilizing the age standardization by direct method. Joinpoint regression analysis was employed to investigate the changing trends of age-standardized incidence and mortality rates from 1990 to 2019. Age-period-cohort analysis was utilized to estimate the independent effects of age, period, and birth cohorts. Furthermore, a Nordpred age-period-cohort analysis was implemented to predict the global epidemiological trends through 2044.

Results

In 2019, the estimated global age-standardized incidence and mortality rates of MSMIs in WCBA were 1072.90 (95% UI: 725.93 to 1483.46) and 0.86 (95% UI: 0.69 to 1.05), respectively. The highest disease burden existed in the African Region. From 1990 to 2019, the estimated global age-standardized incidence and mortality rates of MSMIs (AAPC: -1.32, 95% CI: -1.34 to -1.30; AAPC: -3.39, 95% CI: -4.28 to -2.48) in WCBA both demonstrated significant declining trends. The changing trends varied significantly across 6 regions and 204 countries. The effects of age, period, and cohort on incidence and mortality rates differed. From 2020 to 2044, the global age-standardized incidence rate of MSMIs in WCBA was predicted to decrease whereas the case number increases slowly.

Conclusion

The global trends in MSMIs incidence and mortality generally showed a decline with considerable heterogeneity, indicating both the effectiveness and unevenness of global management of MSMIs. Moreover, the predicted increased case number highlights prominent challenges in the control of MSMIs.

Discrimination of primary and chronic cytomegalovirus infection based on humoral immune profiles in pregnancy

BACKGROUNDMost humans have been infected with cytomegalovirus (CMV) by midlife without clinical signs of disease. However, in settings in which the immune system is undeveloped or compromised, the virus is not adequately controlled and consequently presents a major infectious cause of both congenital disease during pregnancy as well as opportunistic infection in children and adults. With clear evidence that risk to the fetus varies with gestational age at the time of primary maternal infection, further research on humoral responses to primary CMV infection during pregnancy is needed.METHODSHere, systems serology tools were applied to characterize antibody responses to CMV infection in pregnant and nonpregnant women experiencing either primary or chronic infection.RESULTSWhereas strikingly different antibody profiles were observed depending on infection status, limited differences were associated with pregnancy status. Beyond known differences in IgM responses used clinically for identification of primary infection, distinctions observed in IgA and FcγR-binding antibodies and among antigen specificities accurately predicted infection status. Machine learning was used to define the transition from primary to chronic states and predict time since infection with high accuracy. Humoral responses diverged over time in an antigen-specific manner, with IgG3 responses toward tegument decreasing over time as typical of viral infections, while those directed to pentamer and glycoprotein B were lower during acute and greatest during chronic infection.CONCLUSIONIn sum, this work provides insights into the antibody response associated with CMV infection status in the context of pregnancy, revealing aspects of humoral immunity that have the potential to improve CMV diagnostics.FUNDINGCYMAF consortium and NIH NIAID.

Comparative analysis of COVID-19 pneumonia in pregnant versus matched non-pregnant women: radiologic, laboratory, and clinical perspectives

This study aimed to assess the severity and outcomes of COVID-19 in pregnant women, focusing on laboratory and radiological discrepancies between pregnant women and matched nonpregnant women. In this retrospective cross-sectional analysis, we matched 107 nonpregnant women with 66 pregnant women in terms of age, comorbidities, and the interval between symptom onset and hospital admission. Demographic, clinical, laboratory, and radiological data were collected, and chest CT scans were evaluated using a severity scale ranging from 0 to 5. Logistic regression and adjusted Cox regression models were used to assess the impact of various factors on pregnancy status and mortality rates. Differences in several laboratory parameters, including the neutrophil-to-lymphocyte ratio, liver aminotransferases, alkaline phosphatase, urea, triglycerides, cholesterol, HbA1c, ferritin, coagulation profiles, and blood gases, were detected. Radiologic exams revealed that nonpregnant women had sharper opacities, whereas pregnant women presented with hazy opacities and signs of crypt-organizing pneumonia. A notable difference was also observed in the pulmonary artery diameter. The mortality rate among pregnant women was 4.62%, which was comparable to the 5.61% reported in nonpregnant patients. Compared with nonpregnant patients, pregnancy did not significantly affect the severity or mortality of COVID-19. Our study revealed discernible differences in specific laboratory and imaging markers between pregnant and nonpregnant COVID-19 patients.

Solubilized β-Glucan Supplementation in C57BL/6J Mice Dams Augments Neurodevelopment and Cognition in the Offspring Driven by Gut Microbiome Remodeling

A maternal diet rich in dietary fiber, such as β-glucan, plays a crucial role in the offspring's acquisition of gut microbiota and the subsequent shaping of its microbiome profile and metabolome. This in turn has been shown to aid in neurodevelopmental processes, including early microglial maturation and immunomodulation via metabolites like short chain fatty acids (SCFAs). This study aimed to investigate the effects of oat β-glucan supplementation, solubilized by citric acid hydrolysis, from gestation to adulthood. Female C57BL/6J mice were orally supplemented with soluble oat β-glucan (ObG) or carboxymethyl cellulose (CMC) via drinking water at 200 mg/kg body weight during breeding while the control group received 50 mg/kg body weight of carboxymethyl cellulose. ObG supplementation increased butyrate production in the guts of both dams and 4-week-old pups, attributing to alterations in the gut microbiota profile. One-week-old pups from the ObG group showed increased neurodevelopmental markers similar to four-week-old pups that also exhibited alterations in serum markers of metabolism and anti-inflammatory cytokines. Notably, at 8 weeks, ObG-supplemented pups exhibited the highest levels of spatial memory and cognition compared to the control and CMC groups. These findings suggest a potential enhancement of neonatal neurodevelopment via shaping of early-life gut microbiome profile, and the subsequent increased later-life cognitive function.

Lactoferrin Supplementation in Preventing and Protecting from SARS-CoV-2 Infection: Is There Any Role in General and Special Populations? An Updated Review of Literature

At the beginning of the pandemic, SARS-CoV-2 infection represented a great medical burden worldwide, as targeted and effective therapeutic options were lacking. This resulted in the revival of existing molecules and the increasing popularity of over-the-counter nutritional supplements. Among the latter, lactoferrin has been investigated as an adjuvant in COVID-19 therapy with conflicting results, mainly depending on different study designs. Considering that lactoferrin is one of the main components of human breast milk with anti-microbial and anti-inflammatory activity, it is conceivable that such bioactive molecule could be effective in supporting anti-SARS-CoV-2 infection therapy, especially in infants and pregnant women, two subpopulations that have been poorly evaluated in the existing clinical trials. This narrative review is intended to offer insight into the existing literature on lactoferrin's biological functions and protective effects against COVID-19, with a special focus on pregnant women and their infants.

Association between maternal mRNA covid-19 vaccination in early pregnancy and major congenital anomalies in offspring: population based cohort study with sibling matched analysis

Objective

To examine the association between maternal mRNA covid-19 vaccination during the first trimester of pregnancy and the prevalence of major congenital anomalies in offspring.

Design

Population based cohort study with sibling matched analysis.

Setting

Multiple health administrative databases, linked and analysed at ICES, an independent, non-profit research institute that collects and analyses healthcare and demographic data, Ontario, Canada, from 16 October 2021 to 1 May 2023.

Population

174 296 singleton live births >20 weeks' gestation with an expected birth date between 16 October 2021 and 1 May 2023: 34 181 (20%) born to mothers who received one or two doses of an mRNA covid-19 vaccine in the first trimester and 34 951 (20%) born to mothers who did not receive a vaccine before or during pregnancy. The sibling matched analysis included 13 312 infants exposed to a covid-19 vaccine in the first trimester and 15 089 matched older siblings with the same mother, with an expected birth date after 16 October 2016 and no reported in utero exposure to a covid-19 vaccine.

Main outcome measures

Major congenital anomalies, overall and grouped by specific organ systems, diagnosed within 28 days of birth.

Results

Major congenital anomalies were present in 832 (24.3 per 1000 live births) infants exposed to an mRNA covid-19 vaccine in the first trimester compared with 927 (26.5 per 1000 live births) infants not exposed to a vaccine, resulting in an adjusted prevalence ratio of 0.89 (95% confidence interval (CI) 0.79 to 1.01). Major congenital anomalies were present in 283 (21.3 per 1000 live births) and 343 (22.7 per 1000 live births) infants exposed to an mRNA covid-19 vaccine in the first trimester and their older siblings not exposed to a vaccine, respectively (adjusted prevalence ratio 0.91, 95% CI 0.77 to 1.07). First trimester vaccination was not associated with an increase in major congenital anomalies grouped by specific organ system in the primary or sibling matched analyses. Results were similar across a range of subgroup and sensitivity analyses.

Conclusions

In this large population based cohort study and sibling matched analysis, mRNA covid-19 vaccination during the first trimester of pregnancy was not associated with an increase in major congenital anomalies in offspring, overall or grouped by organ system.

Trends and disparities of disease burden in infections among pregnant women in 131 low-income and middle-income countries, 1990-2019

Background

In low- and middle-income countries (LMICs) and territories, maternal infections impose a non-negligible disease burden. We aimed to analyse the secular trends, age distribution, and associated factors of maternal sepsis and other maternal infections (MSMI) across 131 LMICs from 1990 to 2019.

Methods

We collected yearly data of incidences, deaths, and disability adjusted life years (DALYs) on MSMI in 131 LMICs from 1990 to 2019 from the Global Burden of Disease 2019 (GBD 2019). The sociodemographic index (SDI) and universal health coverage effective coverage index (UHCI) were also acquired. Relative percent change and estimated annual percentage change (EAPC) were used to assess the secular trends. Correlation analyses were also employed to explore the associations between the burden of MSMI with SDI and UHCI.

Results

Between 1990 and 2019, the age-standardised incident rates (ASIRs), age-standardised maternal mortality ratios (ASMMRs) and age-standardised DALYs rates of low-income countries (LICs) were much higher than that of lower-middle-income countries (LMCs) and upper-middle income countries (UMCs), although they all continued to decline. At least six of 131 LMICs had ASMMR greater than 70.00 per 100 000 live births in 2019. The incidences of MSMI increased first till 20-24 years and then decreased with age both in 1990 and 2019, while the ASMMRs were higher in the youngest and the oldest age group. With the growth of SDI and UHCI in 2109, the decreasing trend of ASIR, ASMMR, and age-standardised DALYs rates slowed down.

Conclusions

Although the progress has been made in reducing the burden of MSMI in 131 LMICs, the disease burden in LICs far exceeded that of LMCs and UMCs. Socio-economic status and universal health coverage were both associated with the MSMI burden, and further research is needed to explore the underlying factors contributing to these disparities and to identify effective strategies for reducing the burden of MSMI.

Landscape of in situ cytokine expression, soluble C-type lectin receptors, and vitamin D in patients with recurrent vulvovaginal candidiasis

The immunopathogenesis of recurrent vulvovaginal candidiasis (RVVC) is poorly understood. Recently, it was reported that patients with RVVC present a decrease in both the fungicidal capacity of neutrophils and the proliferative capability of peripheral blood mononuclear cells in response to Candida albicans infection, suggesting an alteration in the innate and adaptive immune response. The aim of this study was to determine the in-situ expression, in the vaginal mucosa, of genes associated with the immune response, as well as the serum concentrations of dectin-1, mannose-binding lectin (MBL), and vitamin D in patients with RVVC. A study was carried out on 40 patients with a diagnosis of RVVC and 26 healthy women. Vaginal scrapings were obtained, and the expression of genes that encode cytokines and transcription factors specific for Th1, Th2, Th17, Treg, pro-inflammatory profiles, and enzymes related to oxidative/microbicidal mechanisms was evaluated by quantitiative polymerase chain reaction (qPCR). Additionally, serum levels of vitamin D and the soluble receptors dectin-1 and MBL were determined by enzyme-linked immunosorbent assay (ELISA). In patients with RVVC, a decreased expression of T-bet, RORγ-T, IL-1β, and IL-17, and an increase in the expression of FOXP3, IL-4, IL-8, IL-10, and IL-18 were observed when compared to healthy women: moreover, decreased levels of MBL were also observed in these patients. These results confirm that patients with RVVC present in-situ alterations in both the specific and adaptive immune response against Candida spp., a fact that could be associated with the exaggerated vaginal inflammatory response.

Acceptance and uptake of vaccines against tetanus, influenza, pertussis, and COVID-19 among pregnant and postpartum women in low- and middle-income countries: a systematic review and meta-analysis protocol

BACKGROUND

Pregnant women, fetuses, and neonates are particularly vulnerable to vaccine-preventable diseases (VPDs). These VPDs are associated with high morbidity and mortality among expectant mothers and their fetuses and neonates. Vaccination during pregnancy can protect the expectant mother from VPDs to which she may be especially vulnerable while pregnant. In addition, the passive transfer of maternal neutralizing immunoglobulin G (IgG) and secretory immunoglobulin A (IgA) also protects the fetus against congenital infections and may further protect the neonate from infection during the first few months of life. Despite this, coverage of recommended maternal vaccines remains suboptimal globally, especially in resource-constrained settings. Determinants of vaccine acceptance and uptake are frequently understudied in low- and middle-income countries (LMICs) and among specific groups such as pregnant and postpartum women. This proposed systematic review will assess the acceptance and uptake of vaccines against tetanus, influenza, pertussis, and COVID-19 among pregnant and postpartum women in LMICs.

METHODS

A Boolean search strategy employing common and medical subject heading (MeSH) terms for tetanus, influenza, pertussis, and COVID-19 vaccines, as well as vaccine acceptance, hesitancy, together with uptake, pregnancy, and postpartum, will be used to search electronic databases for relevant literature published between 2009 and 2024. Only studies conducted in LMICs that investigated determinants of acceptance, hesitancy, and uptake of tetanus, influenza, pertussis, and COVID-19 vaccines among pregnant and postpartum women will be eligible for inclusion in the review. The quality and the risk of bias of all eligible full-text articles will be assessed using the Joanna Briggs Institute's (JBI) critical appraisal tools.

DISCUSSION

This protocol proposes a systematic review and meta-analysis that aims to assess the uptake of maternal vaccines and to systematically appraise and quantify determinants of the acceptance and uptake of recommended vaccines during pregnancy and postpartum in LMICs. A better understanding of these factors and how they influence maternal vaccine decision-making will enable public health practitioners as well as global and national policymakers to design more effective interventions as we look towards expanding the scope and reach of maternal immunization programs.

Updates in the Management of HIV During Pregnancy

Human immunodeficiency virus in pregnant people remains a significant public health issue worldwide. The rate of perinatal transmission is 15% to 40% but can be decreased to less than 1% with appropriate antenatal management. Previous recommendations included a protease inhibitor-based antiretroviral therapy, infant prophylaxis, performance of cesarean section for uncontrolled viremia, and the use of formula for infant feeding. However, recent updates include first line of integrase inhibitor-based regimens and supporting parental choices for safe lactation. In this review, we summarize and provide updated recommendations for the care of people living with human immunodeficiency virus during pregnancy.

Tumour necrosis factor inhibitors and serious infections in reproductive-age women and their offspring: a narrative review

Tumour necrosis factor inhibitors (TNFi) are commonly used to treat patients with chronic inflammatory diseases, and function by inhibiting the pro-inflammatory cytokine tumour necrosis factor-α (TNF-α). Although beneficial in reducing disease activity, they are associated with an increased risk of serious infections. Data on the risk of serious infections associated with TNFi use during the reproductive years, particularly in pregnancy, are limited. For pregnant women, there is an additional risk of immunosuppression in the offspring as TNFi can be actively transported across the placenta, which increases in the second and third trimesters. Several studies have explored the risk of serious infections with TNFi exposure in non-pregnant and pregnant patients and offspring exposed in utero, indicating an increased risk in non-pregnant patients and a potentially increased risk in pregnant patients. The studies on TNFi-exposed offspring showed conflicting results between in utero TNFi exposure and serious infections during the offspring's first year. Further research is needed to understand differential risks based on TNFi subtypes. Guidelines conditionally recommend the rotavirus vaccine before 6 months of age for offspring exposed to TNFi in utero, but more data are needed to support these recommendations because of limited evidence. This narrative review provides an overview of the risk in non-pregnant patients and summarizes evidence on how pregnancy can increase vulnerability to certain infections and how TNFi may influence this susceptibility. This review focuses on the evidence regarding the risk of serious infections in pregnant patients exposed to TNFi and the risk of infections in their offspring.

ICP - could there be a virus in the works?

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver-specific disorder affecting pregnant women, with an Australian incidence of 0.6% pa and recurring in 70% of those affected. ICP causes mild to severe pruritus, often resulting in considerable skin excoriations, profound sleep disturbances, and severe anxiety, and yet the aetiology and optimal treatment or management of this condition remains unknown. In this review, we consider the role of viruses in causing or exacerbating ICP and discuss viruses that have been most closely implicated in the disease, including the role of Hepatitis B and Hepatitis C viruses in ICP.

Prevention, diagnosis and pharmacological treatment of infections in pregnancy: The mobile app GAIA! for healthcare providers and patients

OBJECTIVE

To develop and assess the GAIA! app, designed to assist pregnant women and healthcare professionals in managing infectious diseases during pregnancy, and to bridge the information gap between health professionals and expectant mothers.

STUDY DESIGN

This collaborative initiative in Italy involved partnerships with the University of Florence, Careggi University Hospital, and other institutions. The app, built on the Ionic framework, is available on both Apple and Google App Stores. It offers two distinct modes: "healthcare providers" and "patients." Content for the app was derived from extensive literature reviews and clinical guidelines.

RESULTS

Since its August 2022 launch, the GAIA! app has garnered over 2,500 downloads, indicating its effectiveness and acceptance within the community. The app differentiates itself from others, such as the Sanford Guide, by focusing specifically on the needs of pregnant women. It ensures cross-platform compatibility, a user-friendly interface, and offline functionality.

CONCLUSIONS

The GAIA! app has successfully addressed a niche in infectious disease management for pregnant women, gaining significant traction within the community. While it has seen substantial success, challenges like continuous updates and potential language expansion remain. Future endeavors will address these challenges and further evaluate the app's impact on maternal and child health.

Association of common maternal infections with birth outcomes: a multinational cohort study

PURPOSE

It is unclear whether common maternal infections during pregnancy are risk factors for adverse birth outcomes. We assessed the association between self-reported infections during pregnancy with preterm birth and small-for-gestational-age (SGA) in an international cohort consortium.

METHODS

Data on 120,507 pregnant women were obtained from six population-based birth cohorts in Australia, Denmark, Israel, Norway, the UK and the USA. Self-reported common infections during pregnancy included influenza-like illness, common cold, any respiratory tract infection, vaginal thrush, vaginal infections, cystitis, urinary tract infection, and the symptoms fever and diarrhoea. Birth outcomes included preterm birth, low birth weight and SGA. Associations between maternal infections and birth outcomes were first assessed using Poisson regression in each cohort and then pooled using random-effect meta-analysis. Risk ratios (RR) and 95% confidence intervals (CI) were calculated, adjusted for potential confounders.

RESULTS

Vaginal infections (pooled RR, 1.10; 95% CI, 1.02-1.20) and urinary tract infections (pooled RR, 1.17; 95% CI, 1.09-1.26) during pregnancy were associated with higher risk of preterm birth. Similar associations with low birth weight were also observed for these two infections. Fever during pregnancy was associated with higher risk of SGA (pooled RR, 1.07; 95% CI, 1.02-1.12). No other significant associations were observed between maternal infections/symptoms and birth outcomes.

CONCLUSION

Vaginal infections and urinary infections during pregnancy were associated with a small increased risk of preterm birth and low birth weight, whereas fever was associated with SGA. These findings require confirmation in future studies with laboratory-confirmed infection diagnosis.

Risk Communication on Zoonoses and Antimicrobial Resistance-How Do Exotic Pet Owners Perceive the Communication of Their Veterinarians?

Exotic animals traded and kept as pets can transmit a variety of diseases to humans and other animals, and vice versa. Therefore, it is essential for pet owners, particularly vulnerable groups, to be informed about associated risks. Veterinarians play a crucial role in informing pet owners about health risks associated with zoonotic pathogens and antimicrobial resistance (AMR) and should, therefore, have good communication skills to effectively transfer information to pet owners. Thus, exotic pet owners in Germany were surveyed on animal husbandry, veterinary consultation and risk communication. To evaluate the perception of communication, a self-developed questionnaire was used to derive a communication score. The perception of veterinarian communication received a high average score showing a high level of satisfaction. The duration of the veterinarian-client relationship was associated with better communication perception, and the frequency of communication on zoonoses and AMR was associated with the presence of a permanent veterinarian. However, the results indicated that the frequency of disseminated information on zoonoses and/or AMR from veterinarians was lower than desired by the pet owners. Therefore, more educational material on zoonoses and AMR should be made available, and the awareness concerning risk communication should be increased by further education and training at universities.

Viral infections in pregnancy and impact on offspring neurodevelopment: mechanisms and lessons learned

Pregnant individuals with viral illness may experience significant morbidity and have higher rates of pregnancy and neonatal complications. With the growing number of viral infections and new viral pandemics, it is important to examine the effects of infection during pregnancy on both the gestational parent and the offspring. Febrile illness and inflammation during pregnancy are correlated with risk for autism, attention deficit/hyperactivity disorder, and developmental delay in the offspring in human and animal models. Historical viral epidemics had limited follow-up of the offspring of affected pregnancies. Infants exposed to seasonal influenza and the 2009 H1N1 influenza virus experienced increased risks of congenital malformations and neuropsychiatric conditions. Zika virus exposure in utero can lead to a spectrum of abnormalities, ranging from severe microcephaly to neurodevelopmental delays which may appear later in childhood and in the absence of Zika-related birth defects. Vertical infection with severe acute respiratory syndrome coronavirus-2 has occurred rarely, but there appears to be a risk for developmental delays in the infants with antenatal exposure. Determining how illness from infection during pregnancy and specific viral pathogens can affect pregnancy and neurodevelopmental outcomes of offspring can better prepare the community to care for these children as they grow. IMPACT: Viral infections have impacted pregnant people and their offspring throughout history. Antenatal exposure to maternal fever and inflammation may increase risk of developmental and neurobehavioral disorders in infants and children. The recent SARS-CoV-2 pandemic stresses the importance of longitudinal studies to follow pregnancies and offspring neurodevelopment.

Pregnancy outcomes in women with imported malaria in mainland France: A retrospective study from 2004 to 2014

OBJECTIVES

There is little data on pregnant women with imported malaria in high-income countries, especially regarding offspring outcomes. We wanted to determine pregnancy outcomes of imported malaria in pregnant women in mainland France.

PATIENTS AND METHODS

We conducted a retrospective, descriptive study of outcomes in pregnant women hospitalized with malaria from 2004 to 2014 in two regions of mainland France. An adverse outcome was defined as a miscarriage, stillbirth, preterm birth (<35 weeks of gestation), low birth weight (LBW) defined as less than 2500 g, or congenital malaria.

RESULTS

Of 60 pregnancies, 5 were excluded because of elective abortions; 55 were investigated, of which 11 were primigravidae and 44 multigravidae. Pregnancies were singleton (n = 51) or twin (n = 4). Mean age was 30.4 years (range:19-45 y). Among the 55 cases, 9 ended in a miscarriage (8 singletons and 1 twin pregnancy) and 1 had a stillbirth at 21 weeks of gestation, all immediately after the malarial episode. 45 gave birth (29 vaginal deliveries and 16 caesarean sections) to 48 (42 singletons and 6 twins) newborns. Amongst these, 30 were healthy full-term newborns, 10 had LBW, and 8 were preterm. Overall, 26 of 55 (47.3%) pregnancies, and 29 of 59 (49.2%) offsprings had adverse outcomes. Compared to singleton pregnancies, twin pregnancies were associated with adverse outcomes (p = 0.0438).

CONCLUSIONS

Imported malaria has a severe impact on pregnancy outcomes. Prevention and management of imported malaria in pregnancy should be optimized.

Obstetrical and neonatal outcomes in women with gestational Lyme disease

OBJECTIVE

The incidence of Lyme disease (LD) infections has risen in recent decades. Gestational LD has been associated with adverse pregnancy outcomes; however, the results have been contradictory. The study objective was to examine the effects of gestational LD on obstetrical and neonatal outcomes.

METHODS

Using the Healthcare Cost & Utilization Project National (Nationwide) Inpatient Sample from the United States, we conducted a retrospective cohort study of pregnant patients admitted to the hospital between 2016 and 2019. The exposed group consisted of pregnant patients with gestational LD infection (International Classification of Diseases, Tenth Revision [ICD-10] code A692x), while the comparison group consisted of pregnant patients without gestational LD. Descriptive statistics and multivariate logistic regression models, adjusted for baseline maternal characteristics, were used to determine the associations between gestational LD and obstetrical and neonatal outcomes.

RESULTS

The cohort included 2 943 575 women, 226 of whom were diagnosed with LD during pregnancy. The incidence of LD was 7.67 per 100 000 pregnancy admissions. The incidence of gestational LD was stable over the study period. Pregnant patients with LD were more likely white, older, to have private health insurance, and to belong to a higher income quartile. Gestational LD was associated with an increased risk of placental abruption (adjusted odds ratio [aOR], 3.45 [95% confidence interval (CI), 1.53-7.80]) and preterm birth (aOR, 1.58 [95% CI, 1.03-2.42]).

CONCLUSION

Gestational LD is associated with a higher risk of placental abruption and preterm birth. Pregnancies complicated by LD, while associated with a higher risk of certain adverse outcomes, can be followed in most healthcare settings.

Pathogenesis and clinical features of severe hepatitis E virus infection

The hepatitis E virus (HEV), a member of the Hepeviridae family, is a small, non-enveloped icosahedral virus divided into eight distinct genotypes (HEV-1 to HEV-8). Only genotypes 1 to 4 are known to cause diseases in humans. Genotypes 1 and 2 commonly spread via fecal-oral transmission, often through the consumption of contaminated water. Genotypes 3 and 4 are known to infect pigs, deer, and wild boars, often transferring to humans through inadequately cooked meat. Acute hepatitis caused by HEV in healthy individuals is mostly asymptomatic or associated with minor symptoms, such as jaundice. However, in immunosuppressed individuals, the disease can progress to chronic hepatitis and even escalate to cirrhosis. For pregnant women, an HEV infection can cause fulminant liver failure, with a potential mortality rate of 25%. Mortality rates also rise amongst cirrhotic patients when they contract an acute HEV infection, which can even trigger acute-on-chronic liver failure if layered onto pre-existing chronic liver disease. As the prevalence of HEV infection continues to rise worldwide, highlighting the particular risks associated with severe HEV infection is of major medical interest. This text offers a brief summary of the characteristics of hepatitis developed by patient groups at an elevated risk of severe HEV infection.

Emergency right lower lobectomy for severe pulmonary abscess in a pregnant woman at the 25th week of gestation: a case report

BACKGROUND

Pulmonary abscess is a severe infection commonly seen in patients with chronic obstructive pulmonary disease, interstitial pneumonia, immune deficiency disease, drug-induced immunocompromised state, and congenital pulmonary disease. The treatment strategy in pregnant women with a pulmonary abscess is considered challenging since adverse effects on the fetus must be avoided to ensure safe delivery.

CASE PRESENTATION

A 34-year-old female patient at 24 weeks of gestation (G2P1) was admitted to the Department of Obstetrics and Gynecology due to sudden right chest pain. The patient had no significant medical history, including congenital anomalies, and no history of drug addiction or smoking. Laboratory data indicated high levels of inflammation (white blood cell 12,000/µL, C-reactive protein 16.0 mg/dL), and computed tomography demonstrated a large intrapulmonary cyst located in the middle of the right lower lobe, with some fluid collection. As the patient had no medical history of congenital pulmonary anomalies, she was initially diagnosed with a pulmonary cyst infection and treated with intravenous antibiotics. However, the infection did not resolve for over a week, and a spike in fever developed after admission. There was no definitive evidence concerning the risk of preterm delivery and fetal abortion during non-obstetric surgery. However, to control the severely infected pulmonary abscess that was refractory to antibiotics and obtain a pathological diagnosis while saving the life of both the mother and fetus, we elected to perform an emergent right lower lobectomy by open thoracotomy with a fissureless maneuver after receiving informed consent. Postoperatively, the infection gradually improved, and the patient was discharged on the 16th postoperative day without any major complications in the mother or fetus. Although she later experienced coronavirus disease-19 at 29 weeks of gestation, a boy was born at 40th weeks of gestation without any complications. Pathologically, no infectious agents, malignancies, or congenital anomalies other than lung abscesses associated with the pulmonary infarction were observed. The mother and child were healthy 1 year postoperatively.

CONCLUSIONS

We experienced a rare case of a pulmonary abscess in a pregnant woman who needed an emergent right lower lobectomy to control the severe infection and obtain a correct pathological diagnosis. Under cooperation from an obstetrician and anesthesiologist, emergency pulmonary resection can be performed safely for serious abscess formation even for pregnant women who have several months left until delivery.

Obstetric risk profiles and causes of death: Estimating their association with cesarean sections among maternal deaths in Mexico

BACKGROUND

Maternal mortality is a critical indicator of healthcare quality, and in Mexico, this has become increasingly concerning due to the stagnation in its decline, alongside a concurrent increase in cesarean section (C-section) rates. This study characterizes maternal deaths in Mexico, focusing on estimating the association between obstetric risk profiles, cause of death, and mode of delivery.

METHODS

Utilizing a retrospective observational design, 4,561 maternal deaths in Mexico from 2010-2014 were analyzed. Data were sourced from the Deliberate Search and Reclassification of Maternal Deaths database, alongside other national databases. An algorithm was developed to extract the Robson Ten Group Classification System from clinical summaries text, facilitating a nuanced analysis of C-section rates. Information on the reasons for the performance of a C-section was also obtained. Logistic regression and multinomial logistic regression models were used to estimate the relation between obstetric risk factors, mode of delivery and causes of maternal death, adjusting for covariates.

RESULTS

Among maternal deaths in Mexico from 2010-2014, 47.1% underwent a C-section, with a significant history of previous C-sections observed in 31.4% of these cases, compared to 17.4% for vaginal deliveries (p<0.001). Early prenatal care in the first trimester was more common in C-section cases (46.8%) than in vaginal deliveries (38.3%, p<0.001). A stark contrast was noted in the place of death, with 82.4% of post-C-section deaths occurring in public institutions versus 69.1% following vaginal births. According to Robson's classification, the highest C-section rates were in Group 4 (67.2%, p<0.001) and Group 8 (66.9%, p<0.001). Logistic regression analysis revealed no significant difference in the odds of receiving a C-section in private versus other settings after adjusting for Robson criteria (OR: 1.21; 95% CI: 0.92, 1.60). A prior C-section significantly increased the likelihood of another (OR: 2.38; CI 95%: 2.01, 2.81). The analysis also indicated C-sections were significantly tied to deaths from hypertensive disorders (RRR = 1.25, 95% CI [1.12, 1.40]). In terms of indications, 6.3% of C-sections were performed under inadequate indications, while the indication was not identifiable in 33.1% of all C-sections.

CONCLUSIONS

This study highlights a significant overuse of C-sections among maternal deaths in Mexico (2010-2014), revealed through the Robson classification and ana analysis of the reported indications for the procedure. It underscores the need for revising clinical decision-making to promote evidence-based guidelines and favor vaginal deliveries when possible. High C-section rates, especially noted disparities between private and public sectors, suggest economic and non-clinical factors may be at play. The importance of accurate data systems and further research with control groups to understand C-section practices' impact on maternal health is emphasized.

Maternal-driven immune education in offspring

Maternal environmental exposures, particularly during gestation and lactation, significantly influence the immunological development and long-term immunity of offspring. Mammalian immune systems develop through crucial inputs from the environment, beginning in utero and continuing after birth. These critical developmental windows are essential for proper immune system development and, once closed, may not be reopened. This review focuses on the mechanisms by which maternal exposures, particularly to pathogens, diet, and microbiota, impact offspring immunity. Mechanisms driving maternal-offspring immune crosstalk include transfer of maternal antibodies, changes in the maternal microbiome and microbiota-derived metabolites, and transfer of immune cells and cytokines via the placenta and breastfeeding. We further discuss the role of transient maternal infections, which are common during pregnancy, in providing tissue-specific immune education to offspring. We propose a "maternal-driven immune education" hypothesis, which suggests that offspring can use maternal encounters that occur during a critical developmental window to develop optimal immune fitness against infection and inflammation.

Implication of viruses in the etiology of preeclampsia

Preeclampsia is one of the most common disorders that poses threat to both mothers and neonates and a major contributor to perinatal morbidity and mortality worldwide. Viral infection during pregnancy is not typically considered to cause preeclampsia; however, syndromic nature of preeclampsia etiology and the immunomodulatory effects of viral infections suggest that microbes could trigger a subset of preeclampsia. Notably, SARS-CoV-2 infection is associated with an increased risk of preeclampsia. Herein, we review the potential role of viral infections in this great obstetrical syndrome. According to in vitro and in vivo experimental studies, viral infections can cause preeclampsia by introducing poor placentation, syncytiotrophoblast stress, and/or maternal systemic inflammation, which are all known to play a critical role in the development of preeclampsia. Moreover, clinical and experimental investigations have suggested a link between several viruses and the onset of preeclampsia via multiple pathways. However, the results of experimental and clinical research are not always consistent. Therefore, future studies should investigate the causal link between viral infections and preeclampsia to elucidate the mechanism behind this relationship and the etiology of preeclampsia itself.

Pregnancy and SARS-COV2 Infection

Pachisia AV, Govil D. Pregnancy and SARS-COV2 Infection. Indian J Crit Care Med 2024;28(3):196-197.

How I treat sickle cell disease in pregnancy

ABSTRACT

Fifty years ago, people with sickle cell disease (SCD) were discouraged from becoming pregnant, but now, most should be supported if they choose to pursue a pregnancy. They and their providers, however, should be aware of the physiological changes of pregnancy that aggravate SCD and pregnancy's unique maternal and fetal challenges. Maternal problems can arise from chronic underlying organ dysfunction such as renal disease or pulmonary hypertension; from acute complications of SCD such as acute anemia, vaso-occlusive crises, and acute chest syndrome; and/or from pregnancy-related complications such as preeclampsia, sepsis, severe anemia, thromboembolism, and the need for cesarean delivery. Fetal problems include alloimmunization, opioid exposure, fetal growth restriction, preterm delivery, and stillbirth. Before and during pregnancy, in addition to the assessment and care that every pregnant patient should receive, patients with SCD should be evaluated and treated by a multidisciplinary team with respect to their unique maternal and fetal issues.

A global-scale dataset of bat viral detection suggests that pregnancy reduces viral shedding

Understanding viral infection dynamics in wildlife hosts can help forecast zoonotic pathogen spillover and human disease risk. Bats are particularly important reservoirs of zoonotic viruses, including some of major public health concern such as Nipah virus, Hendra virus, and SARS-related coronaviruses. Previous work has suggested that metapopulation dynamics, seasonal reproductive patterns, and other bat life history characteristics might explain temporal variation in spillover of bat-associated viruses into people. Here, we analyze viral dynamics in free-ranging bat hosts, leveraging a multi-year, global-scale viral detection dataset that spans eight viral families and 96 bat species from 14 countries. We fit hierarchical Bayesian models that explicitly control for important sources of variation, including geographic region, specimen type, and testing protocols, while estimating the influence of reproductive status on viral detection in female bats. Our models revealed that late pregnancy had a negative effect on viral shedding across multiple data subsets, while lactation had a weaker influence that was inconsistent across data subsets. These results are unusual for mammalian hosts, but given recent findings that bats may have high individual viral loads and population-level prevalence due to dampening of antiviral immunity, we propose that it would be evolutionarily advantageous for pregnancy to either not further reduce immunity or actually increase the immune response, reducing viral load, shedding, and risk of fetal infection. This novel hypothesis would be valuable to test given its potential to help monitor, predict, and manage viral spillover risk from bats.

Global Transcriptomic Analysis of Placentas from Women with Gestational SARS-CoV-2 Infection during the Third Trimester of Pregnancy

The COVID-19 pandemic has had a significant and enduring influence on global health, including maternal and fetal well-being. Evidence suggests that placental dysfunction is a potential consequence of SARS-CoV-2 infection during pregnancy, which may result in adverse outcomes such as preeclampsia and preterm birth. However, the molecular mechanisms underlying this association remain unclear, and it is uncertain whether a mature placenta can protect the fetus from SARS-CoV-2 infection. To address the above gap, we conducted a transcriptome-based study of the placenta in both maternal and fetal compartments. We collected placental samples from 16 women immediately after term delivery, seven of which had SARS-CoV-2 infection confirmed by PCR before parturition. Notably, we did not detect any viral load in either the maternal or fetal compartments of the placenta, regardless of symptomatic status. We separately extracted total RNA from placental tissues from maternal and fetal compartments, constructed cDNA libraries, and sequenced them to assess mRNA. Our analysis revealed 635 differentially expressed genes when a false discovery rate (FDR ≤ 0.05) was applied in the maternal placental tissue, with 518 upregulated and 117 downregulated genes in the SARS-CoV-2-positive women (n = 6) compared with the healthy SARS-CoV-2-negative women (n = 8). In contrast, the fetal compartment did not exhibit any significant changes in gene expression with SARS-CoV-2 infection. We observed a significant downregulation of nine genes belonging to the pregnancy-specific glycoprotein related to the immunoglobulin superfamily in the maternal compartment with active SARS-CoV-2 infection (fold change range from -13.70 to -5.28; FDR ≤ 0.01). Additionally, comparing symptomatic women with healthy women, we identified 1788 DEGs. Furthermore, a signaling pathway enrichment analysis revealed that pathways related to oxidative phosphorylation, insulin secretion, cortisol synthesis, estrogen signaling, oxytocin signaling, antigen processing, and presentation were altered significantly in symptomatic women. Overall, our study sheds light on the molecular mechanisms underlying the reported clinical risks of preeclampsia and preterm delivery in women with SARS-CoV-2 infection. Nonetheless, studies with larger sample sizes are warranted to further deepen our understanding of the molecular mechanisms of the placenta's anti-viral effects in maternal SARS-CoV-2 infection.

Clinical Characteristics and Risk of Hypoxemia Development in Women Infected with SARS-CoV-2 during Pregnancy

PURPOSE

There is limited information on the clinical characteristics and prognosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy. The clinical features and risk factors for hypoxemia development were investigated in pregnant women with coronavirus disease-2019 (COVID-19).

MATERIALS AND METHODS

From August 2020 to February 2022, we performed a retrospective cohort study of 410 pregnant women with COVID-19. The clinical characteristics and prognoses were compared between pregnant COVID-19 patients requiring oxygen and those who did not.

RESULTS

Of 410 patients, 100 (24.4%) required oxygen therapy. Among them, fever [163 (52.6%) vs. 81 (81.0%), p<0.001] and cough [172 (56.4%) vs. 73 (73.0%), p=0.003] were more frequently observed than in non-oxygen group. The proportion of unvaccinated women was higher in oxygen group than in non-oxygen group [264 (85.2%) vs. 98 (98.0%), p=0.003]. During the Omicron wave, patients were more likely to have no oxygen requirement [98 (31.6%) vs. 18 (18.0%), p=0.009]. The risk of hypoxemic respiratory difficulty increased if SARS-CoV-2 infection occurred during the third trimester [adjusted odds ratio (aOR) 5.083, 95% confidence interval (CI): 1.095-23.593, p=0.038] and C-reactive protein (CRP) was elevated (≥1.0 mg/dL) at admission (aOR 5.878, 95% CI: 3.099-11.146, p<0.001). The risk was higher in unvaccinated patients (aOR 5.376, 95% CI: 1.193-24.390, p=0.028). However, the risk was lower in patients during the Omicron wave (aOR 0.498, 95% CI: 0.258-0.961, p=0.038).

CONCLUSION

A quarter of SARS-CoV-2-infected women developed hypoxemic respiratory difficulty during pregnancy. SARS-CoV-2 infection during the third trimester, CRP elevation at admission, and no vaccination increased the risk of hypoxemia in pregnant women.

Laboratory Animal Models for Rift Valley Fever Virus Disease

Rift Valley fever virus (RVFV) is an arboviral pathogen of clinical and agricultural relevance. The ongoing development of targeted RVFV prophylactics and therapeutics is overwhelmingly dependent on animal models due to both natural, that is, sporadic outbreaks, and structural, for example, underresourcing of endemic regions, limitations in accessing human patient samples and cohorts. Elucidating mechanisms of viral pathogenesis and testing therapeutics is further complicated by the diverse manifestations of RVFV disease and the heterogeneity of the host response to infection. In this chapter, we describe major clinical manifestations of RVFV infection and discuss the laboratory animal models used to study each.

A biomarker for bacteremia in pregnant women with acute pyelonephritis: soluble suppressor of tumorigenicity 2 or sST2

Objective: Sepsis is a leading cause of maternal death, and its diagnosis during the golden hour is critical to improve survival. Acute pyelonephritis in pregnancy is a risk factor for obstetrical and medical complications, and it is a major cause of sepsis, as bacteremia complicates 15-20% of pyelonephritis episodes in pregnancy. The diagnosis of bacteremia currently relies on blood cultures, whereas a rapid test could allow timely management and improved outcomes. Soluble suppression of tumorigenicity 2 (sST2) was previously proposed as a biomarker for sepsis in non-pregnant adults and children. This study was designed to determine whether maternal plasma concentrations of sST2 in pregnant patients with pyelonephritis can help to identify those at risk for bacteremia.Study design: This cross-sectional study included women with normal pregnancy (n = 131) and pregnant women with acute pyelonephritis (n = 36). Acute pyelonephritis was diagnosed based on a combination of clinical findings and a positive urine culture. Patients were further classified according to the results of blood cultures into those with and without bacteremia. Plasma concentrations of sST2 were determined by a sensitive immunoassay. Non-parametric statistics were used for analysis.Results: The maternal plasma sST2 concentration increased with gestational age in normal pregnancies. Pregnant patients with acute pyelonephritis had a higher median (interquartile range) plasma sST2 concentration than those with a normal pregnancy [85 (47-239) ng/mL vs. 31 (14-52) ng/mL, p < .001]. Among patients with pyelonephritis, those with a positive blood culture had a median plasma concentration of sST2 higher than that of patients with a negative blood culture [258 (IQR: 75-305) ng/mL vs. 83 (IQR: 46-153) ng/mL; p = .03]. An elevated plasma concentration of sST2 ≥ 215 ng/mL had a sensitivity of 73% and a specificity of 95% (area under the receiver operating characteristic curve, 0.74; p = .003) with a positive likelihood ratio of 13.8 and a negative likelihood ratio of 0.3 for the identification of patients who had a positive blood culture.Conclusion: sST2 is a candidate biomarker to identify bacteremia in pregnant women with pyelonephritis. Rapid identification of these patients may optimize patient care.

Seasonal patterns in newborns' health: Quantifying the roles of climate, communicable disease, economic and social factors

Poor health at birth can have long-term consequences for children's development. This paper analyses an important factor associated with health at birth: the time of year that the baby is born, and hence seasonal risks they were exposed to in utero. There are multiple potential explanations for seasonality in newborns' health. Most previous research has examined these in isolation. We therefore do not know which explanations are most important - and hence which policy interventions would most effectively reduce the resulting early-life inequalities. In this paper, I use administrative data to estimate and compare the magnitudes of several seasonal risks, seeking to identify the most important drivers of seasonality in the Northern Territory of Australia, a large territory spanning tropical and arid climates and where newborn health varies dramatically with the seasons. I find that the most important explanations are heat exposure and disease prevalence. Seasonality in food prices and road accessibility have smaller effects on some outcomes. Seasonal fertility patterns, rainfall and humidity do not have statistically significant effects. I conclude that interventions that protect pregnant women from seasonal disease and heat exposure would likely improve newborn health in the Northern Territory, with potential long-term benefits for child development. It is likely that similar impacts would apply in other locations with tropical and arid climates, and that, without action, climate change will accentuate these risks.

Modeling the Progression of Placental Transport from Early- to Late-Stage Pregnancy by Tuning Trophoblast Differentiation and Vascularization

The early-stage placental barrier is characterized by a lack of fetal circulation and by a thick trophoblastic barrier, whereas the later-stage placenta consists of vascularized chorionic villi encased in a thin, differentiated trophoblast layer, ideal for nutrient transport. In this work, predictive models of early- and late-stage placental transport are created using blastocyst-derived placental stem cells (PSCs) by modulating PSC differentiation and model vascularization. PSC differentiation results in a thinner, fused trophoblast layer, as well as an increase in human chorionic gonadotropin secretion, barrier permeability, and secretion of certain inflammatory cytokines, which are consistent with in vivo findings. Further, gene expression confirms this shift toward a differentiated trophoblast subtype. Vascularization results in a molecule type- and size-dependent change in dextran and insulin permeability. These results demonstrate that trophoblast differentiation and vascularization have critical effects on placental barrier permeability and that this model can be used as a predictive measure to assess fetal toxicity of xenobiotic substances at different stages of pregnancy.

Safety of hepatitis E vaccination for pregnancy: a post-hoc analysis of a randomized, double-blind, controlled phase 3 clinical trial

Special attention has been paid to Hepatitis E (HE) prophylaxis for pregnant women due to poor prognosis of HE in this population. We conducted a post-hoc analysis based on the randomized, double-blind, HE vaccine (Hecolin)-controlled phase 3 clinical trial of human papillomavirus (HPV) vaccine (Cecolin) conducted in China. Eligible healthy women aged 18-45 years were randomly assigned to receive three doses of Cecolin or Hecolin and were followed up for 66 months. All the pregnancy-related events throughout the study period were closely followed up. The incidences of adverse events, pregnancy complications, and adverse pregnancy outcomes were analysed based on the vaccine group, maternal age, and interval between vaccination and pregnancy onset. During the study period, 1263 Hecolin receivers and 1260 Cecolin receivers reported 1684 and 1660 pregnancies, respectively. The participants in the two vaccine groups showed similar maternal and neonatal safety profiles, regardless of maternal age. Among the 140 women who were inadvertently vaccinated during pregnancy, the incidences of adverse reactions had no statistical difference between the two groups (31.8% vs 35.1%, p = 0.6782). The proximal exposure to HE vaccination was not associated with a significantly higher risk of abnormal foetal loss (OR 0.80, 95% CI 0.38-1.70) or neonatal abnormality (OR 2.46, 95% CI 0.74-8.18) than that to HPV vaccination, as did distal exposure. Significant difference was not noted between pregnancies with proximal and distal exposure to HE vaccination. Conclusively, HE vaccination during or shortly before pregnancy is not associated with increased risks for both the pregnant women and pregnancy outcomes.