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Messina A, Mariani A, Brandolisio R, Tavella E, Germano C, Lipari G, Leo L, Masturzo B, Manzoni P. Candidiasis in Pregnancy: Relevant Aspects of the Pathology for the Mother and the Fetus and Therapeutic Strategies. Trop Med Infect Dis 2024; 9:114. [PMID: 38787047 PMCID: PMC11125970 DOI: 10.3390/tropicalmed9050114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
Vulvovaginal candidiasis (VVC) is a common condition that can lead to significant discomfort, affecting approximately 70-75% of women at least once in their lives. During pregnancy, the prevalence of VVC is estimated to be around 20%, peaking at about 30% in the third trimester, with a number of specific risk factors predisposing to yeast infection being identified and needing elucidation. This review aims to provide updated knowledge on candidiasis during pregnancy, addressing risk factors and maternal and neonatal outcomes, as well as discussing optimal therapeutic strategies to safeguard mothers and newborns. The bibliographic search involved two biomedical databases, PubMed and Embase, without imposing time limits. Among all Candida spp., Candida albicans remains the most frequent causative species. The hyperestrogenic environment of the vaginal mucosa and reduced immune defenses, physiological effects of pregnancy, create conditions favorable for Candida spp. vaginal colonization and hence VVC. Recent evidence shows an association between VVC and adverse obstetric outcomes, including premature membrane rupture (PROM), chorioamnionitis, preterm birth, and puerperal infections. Prompt and effective management of this condition is therefore crucial to prevent adverse obstetric outcomes, maternal-fetal transmission, and neonatal disease. Additional studies are required to confirm the benefits of systemic treatment for maternal candida infection or colonization in preventing premature birth or neonatal systemic candidiasis.
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Affiliation(s)
- Alessandro Messina
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, University Hospital “Degli Infermi”, 13875 Ponderano, Italy (A.M.); (C.G.); (G.L.); (B.M.)
| | - Alessia Mariani
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, University Hospital “Degli Infermi”, 13875 Ponderano, Italy (A.M.); (C.G.); (G.L.); (B.M.)
| | - Romina Brandolisio
- Division of Pediatrics and Neonatology, Department of Maternal, Neonatal and Infant Medicine, University Hospital “Degli Infermi”, 13875 Ponderano, Italy; (R.B.); (E.T.)
- Department of Maternal, Neonatal and Infant Medicine, University of Torino School of Medicine, 10125 Turin, Italy
| | - Elena Tavella
- Division of Pediatrics and Neonatology, Department of Maternal, Neonatal and Infant Medicine, University Hospital “Degli Infermi”, 13875 Ponderano, Italy; (R.B.); (E.T.)
- Department of Maternal, Neonatal and Infant Medicine, University of Torino School of Medicine, 10125 Turin, Italy
| | - Chiara Germano
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, University Hospital “Degli Infermi”, 13875 Ponderano, Italy (A.M.); (C.G.); (G.L.); (B.M.)
| | - Giovanni Lipari
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, University Hospital “Degli Infermi”, 13875 Ponderano, Italy (A.M.); (C.G.); (G.L.); (B.M.)
| | - Livio Leo
- Division of Obstetrics and Gynecology, Hopital Beauregard, AUSL Valleè d’Aoste, 11100 Aosta, Italy;
| | - Bianca Masturzo
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, University Hospital “Degli Infermi”, 13875 Ponderano, Italy (A.M.); (C.G.); (G.L.); (B.M.)
| | - Paolo Manzoni
- Division of Pediatrics and Neonatology, Department of Maternal, Neonatal and Infant Medicine, University Hospital “Degli Infermi”, 13875 Ponderano, Italy; (R.B.); (E.T.)
- Department of Maternal, Neonatal and Infant Medicine, University of Torino School of Medicine, 10125 Turin, Italy
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Vacher CM, Bonnin A, Mir IN, Penn AA. Editorial: Advances and perspectives in neuroplacentology. Front Endocrinol (Lausanne) 2023; 14:1206072. [PMID: 37274324 PMCID: PMC10236794 DOI: 10.3389/fendo.2023.1206072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/09/2023] [Indexed: 06/06/2023] Open
Affiliation(s)
- Claire-Marie Vacher
- Department of Pediatrics, NewYork Presbyterian Hospital, New York, NY, United States
- Columbia University Irving Medical Center, Columbia University, New York, NY, United States
| | - Alexandre Bonnin
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Imran N. Mir
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Anna A. Penn
- Department of Pediatrics, NewYork Presbyterian Hospital, New York, NY, United States
- Columbia University Irving Medical Center, Columbia University, New York, NY, United States
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Sun S, Serrano MG, Fettweis JM, Basta P, Rosen E, Ludwig K, Sorgen AA, Blakley IC, Wu MC, Dole N, Thorp JM, Siega-Riz AM, Buck GA, Fodor AA, Engel SM. Race, the Vaginal Microbiome, and Spontaneous Preterm Birth. mSystems 2022; 7:e0001722. [PMID: 35582911 PMCID: PMC9238383 DOI: 10.1128/msystems.00017-22] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/28/2022] [Indexed: 11/20/2022] Open
Abstract
Previous studies have investigated the associations between the vaginal microbiome and preterm birth, with the aim of determining whether differences in community patterns meaningfully alter risk and could therefore be the target of intervention. We report on vaginal microbial analysis of a nested case-control subset of the Pregnancy, Infection, and Nutrition (PIN) Study, including 464 White women (375 term birth and 89 spontaneous preterm birth, sPTB) and 360 Black women (276 term birth and 84 sPTB). We found that the microbiome of Black women has higher alpha-diversity, higher abundance of Lactobacillus iners, and lower abundance of Lactobacillus crispatus. However, among women who douche, there were no significant differences in microbiome by race. The sPTB-associated microbiome exhibited a lower abundance of L. crispatus, while alpha diversity and L. iners were not significantly associated with sPTB. For each order of magnitude increase in the normalized relative abundance of L. crispatus, multivariable adjusted odds of sPTB decreased by approximately 20% (odds ratio, 0.81; 95% confidence interval, 0.70, 0.94). When we considered the impact of douching, associations between the microbiome and sPTB were limited to women who do not douche. We also observed strong intercorrelations between a range of maternal factors, including poverty, education, marital status, age, douching, and race, with microbiome effect sizes in the range of 1.8 to 5.2% in univariate models. Therefore, race may simply be a proxy for other socially driven factors that differentiate microbiome community structures. Future work will continue to refine reliable microbial biomarkers for preterm birth across diverse cohorts. IMPORTANCE Approximately 10% of all pregnancies in the United States end in preterm birth, and over 14% of pregnancies end in preterm birth among Black women. Knowledge on the associations between vaginal microbiome and preterm birth is important for understanding the potential cause and assessing risk of preterm birth. Our study is one of the largest studies performed to date to investigate the associations between vaginal microbiome and spontaneous preterm birth (sPTB), with stratified design for Black and White women. We found that the vaginal microbiome was different between Black and White women. The vaginal microbiome was associated with sPTB, and a lower abundance of L. crispatus increased the risk of sPTB independent of racial differences in microbial community structures. Furthermore, we also found that vaginal douching obscured the associations between vaginal microbiome, race, and preterm birth, suggesting that vaginal douching is an important factor to consider in future studies.
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Affiliation(s)
- Shan Sun
- Department of Bioinformatics and Genomics, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Myrna G. Serrano
- Department of Microbiology and Immunology and the Center for Microbiome Engineering and Data Analysis, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jennifer M. Fettweis
- Department of Microbiology and Immunology and the Center for Microbiome Engineering and Data Analysis, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Patricia Basta
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emma Rosen
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kim Ludwig
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alicia A. Sorgen
- Department of Bioinformatics and Genomics, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Ivory C. Blakley
- Department of Bioinformatics and Genomics, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Michael C. Wu
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Nancy Dole
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - John M. Thorp
- Department of Obstetrics and Gynaecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anna Maria Siega-Riz
- School of Public Health & Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Gregory A. Buck
- Department of Microbiology and Immunology and the Center for Microbiome Engineering and Data Analysis, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Anthony A. Fodor
- Department of Bioinformatics and Genomics, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Stephanie M. Engel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Predominance of Atopobium vaginae at Midtrimester: a Potential Indicator of Preterm Birth Risk in a Nigerian Cohort. mSphere 2021; 6:6/1/e01261-20. [PMID: 33504666 PMCID: PMC7885325 DOI: 10.1128/msphere.01261-20] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Giving birth too soon accounts for half of all newborn deaths worldwide. Clinical symptoms alone are not sufficient to identify women at risk of giving birth too early, as such a pragmatic approach to reducing the incidence of preterm birth entails developing early strategies for intervention before it materializes. Preterm birth (PTB) is the largest contributor to infant death in sub-Saharan Africa and globally. With a global estimate of 773,600, Nigeria has the third highest rate of PTB worldwide. There have been a number of microbiome profiling studies to identify vaginal microbiomes suggestive of preterm and healthy birth outcome. However, studies on the pregnancy vaginal microbiome in Africa are sparse with none performed in Nigeria. Moreover, few studies have considered the concurrent impact of steroid hormones and the vaginal microbiome on pregnancy outcome. We assessed two key determinants of pregnancy progression to gain a deeper understanding of the interactions between vaginal microbiome composition, steroid hormone concentrations, and pregnancy outcome. Vaginal swabs and blood samples were prospectively collected from healthy midtrimester pregnant women. Vaginal microbiome compositions were assessed by analysis of the V3-V5 region of 16S rRNA genes, and potential functional metabolic traits of identified vaginal microbiomes were imputed by PICRUSt (phylogenetic investigation of communities by reconstruction of unobserved states) analysis, while plasma estradiol (E2) and progesterone (P1) levels were quantified by the competitive enzyme-linked immunosorbent assay (ELISA). PTB vaginal samples were characterized by increased microbial richness, high diversity, and depletion of lactobacilli compared to term delivery samples. Women who delivered preterm were characterized by an Atopobium vaginae-dominated vagitype. High relative abundance of Atopobium vaginae at the midtrimester was highly predictive of PTB (area under the receiving operator characteristics [AUROC] of 0.983). There was a marked overlap in the range of plasma E2 and P1 values between term and PTB groups. IMPORTANCE Giving birth too soon accounts for half of all newborn deaths worldwide. Clinical symptoms alone are not sufficient to identify women at risk of giving birth too early, as such a pragmatic approach to reducing the incidence of preterm birth entails developing early strategies for intervention before it materializes. In view of the role played by the vaginal microbiome and maternal steroid hormones in determining obstetric outcome, we assessed the vaginal microbiome composition and steroid hormone during pregnancy and examined their relationship in predicting preterm birth risk in Nigerian women. This study highlights a potential early-driver microbial marker for prediction of preterm birth risk and supports the notion that vaginal microbiome composition varies across populations. A knowledge of relevant preterm birth microbial markers specific to populations would enhance the development of personalized therapeutic interventions toward restoring a microbiome that optimizes reproductive health fitness, therefore reducing the incidence of preterm birth.
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Kelleher MA, Lee JY, Roberts VHJ, Novak CM, Baschat AA, Morgan TK, Novy MJ, Räsänen JP, Frias AE, Burd I. Maternal azithromycin therapy for Ureaplasma parvum intraamniotic infection improves fetal hemodynamics in a nonhuman primate model. Am J Obstet Gynecol 2020; 223:578.e1-578.e11. [PMID: 32343954 PMCID: PMC7591241 DOI: 10.1016/j.ajog.2020.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/09/2020] [Accepted: 04/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ureaplasma parvum infection is a prevalent cause of intrauterine infection associated with preterm birth, preterm premature rupture of membranes, fetal inflammatory response syndrome, and adverse postnatal sequelae. Elucidation of diagnostic and treatment strategies for infection-associated preterm labor may improve perinatal and long-term outcomes for these cases. OBJECTIVE This study assessed the effect of intraamniotic Ureaplasma infection on fetal hemodynamic and cardiac function and the effect of maternal antibiotic treatment on these outcomes. STUDY DESIGN Chronically catheterized pregnant rhesus monkeys were assigned to control (n=6), intraamniotic inoculation with Ureaplasma parvum (107 colony-forming units/mL, n=15), and intraamniotic infection plus azithromycin treatment (12.5 mg/kg twice a day intravenously, n=8) groups. At approximately 135 days' gestation (term=165 days), pulsed and color Doppler ultrasonography was used to obtain measurements of fetal hemodynamics (pulsatility index of umbilical artery, ductus venosus, descending aorta, ductus arteriosus, aortic isthmus, right pulmonary artery, middle cerebral artery and cerebroplacental ratio, and left and right ventricular cardiac outputs) and cardiac function (ratio of peak early vs late transmitral flow velocity [marker of ventricular function], Tei index [myocardial performance index]). These indices were stratified by amniotic fluid proinflammatory mediator levels and cardiac histology. RESULTS Umbilical and fetal pulmonary artery vascular impedances were significantly increased in animals from the intraamniotic inoculation with Ureaplasma parvum group (P<.05). Azithromycin treatment restored values to control levels. Amniotic fluid prostaglandin F2 alpha levels were significantly higher in animals with abnormal umbilical artery pulsatility index (>1.1) than in those with normal blood flow (P<.05; Spearman ρ=0.6, P<.05). In the intraamniotic inoculation with Ureaplasma parvum group, left ventricular cardiac output was significantly decreased (P<.001), and more animals had abnormal right-to-left ventricular cardiac output ratios (defined as >1.6, P<.05). Amniotic fluid interleukin-6 concentrations were elevated in cases of abnormal right-to-left ventricular cardiac output ratios compared with those in normal cases (P<.05). CONCLUSION Fetal hemodynamic alterations were associated with intraamniotic Ureaplasma infection and ameliorated after maternal antibiotic treatment. Doppler ultrasonographic measurements merit continuing investigation as a diagnostic method to identify fetal cardiovascular and hemodynamic compromise associated with intrauterine infection or inflammation and in the evaluation of therapeutic interventions or clinical management of preterm labor.
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Affiliation(s)
- Meredith A Kelleher
- Division of Reproductive and Development Sciences, Oregon National Primate Research Center, Beaverton, OR.
| | - Ji Yeon Lee
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victoria H J Roberts
- Division of Reproductive and Development Sciences, Oregon National Primate Research Center, Beaverton, OR
| | - Christopher M Novak
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Terry K Morgan
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Miles J Novy
- Division of Reproductive and Development Sciences, Oregon National Primate Research Center, Beaverton, OR
| | - Juha P Räsänen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR; University of Helsinki, Helsinki, Finland
| | - Antonio E Frias
- Division of Reproductive and Development Sciences, Oregon National Primate Research Center, Beaverton, OR; Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Irina Burd
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
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Hočevar K, Maver A, Vidmar Šimic M, Hodžić A, Haslberger A, Premru Seršen T, Peterlin B. Vaginal Microbiome Signature Is Associated With Spontaneous Preterm Delivery. Front Med (Lausanne) 2019; 6:201. [PMID: 31552254 PMCID: PMC6746969 DOI: 10.3389/fmed.2019.00201] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/27/2019] [Indexed: 01/12/2023] Open
Abstract
Background: Preterm delivery (PTD) represents an important public health and therapeutic challenge. Despite the reported link between the composition of vaginal microbiome and PTD, previous studies were inconsistent in their conclusions and utilized non-uniform designs. We performed an independent case-control study carried out on the Slovenian population, where we re-evaluated the role of the vaginal microbiome in PTD. Methods: Vaginal microbiomes of pregnant women who delivered preterm were compared to those delivered at term to examine differences in the microbial richness, diversity, and differential abundance of specific taxa. We obtained vaginal swab samples from 155 Caucasian women who were classified as either term (≥380/7 weeks, n = 107) or preterm (≤366/7 weeks, n = 48) in exclusion of any other medical or obstetric conditions. The vaginal microbiomes of these women were characterized by 16S ribosomal RNA (rRNA) gene sequencing of the V3-V4 region on the MiSeq platform. Results: Women who experienced PTD had a higher microbial richness (Chao1, P = 0.011) and alpha diversity (Shannon, P = 0.00059) than women with term deliveries. We report that overall vaginal microbial community composition (beta-diversity) was significantly different by delivery gestational age category (PWeightedUnifrac < 0.001). Women who delivered preterm had decreased Lactobacilli spp. abundance as well as increased abundance of Gardnerella and other bacterial vaginosis (BV) and aerobic vaginitis (AV) associated genera including Atopobium, Sneathia, Gemella, Megasphaera, Dorea, Streptococcus, and Escherichia/Shigella. Conclusions: In the present study, we provide further evidence that vaginal microbiome composition is associated with PTD.
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Affiliation(s)
- Keli Hočevar
- Clinical Institute of Medical Genetics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Aleš Maver
- Clinical Institute of Medical Genetics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Marijana Vidmar Šimic
- Division of Obstetrics and Gynecology, Department of Perinatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Alenka Hodžić
- Clinical Institute of Medical Genetics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Tanja Premru Seršen
- Division of Obstetrics and Gynecology, Department of Perinatology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Borut Peterlin
- Clinical Institute of Medical Genetics, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Castillo MC, Fuseini NM, Rittenhouse K, Price JT, Freeman BL, Mwape H, Winston J, Sindano N, Baruch-Gravett C, Chi BH, Kasaro MP, Litch JA, Stringer JSA, Vwalika B. The Zambian Preterm Birth Prevention Study (ZAPPS): Cohort characteristics at enrollment. Gates Open Res 2019. [PMID: 30706053 DOI: 10.12688/gatesopenres.12820.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background: Sub-Saharan Africa bears a disproportionate burden of preterm birth and other adverse outcomes. A better understanding of the demographic, clinical, and biologic underpinnings of these adverse outcomes is urgently needed to plan interventions and inform new discovery. Methods: The Zambian Preterm Birth Prevention Study (ZAPPS) is a prospective observational cohort established at the Women and Newborn Hospital (WNH) in Lusaka, Zambia. We recruit pregnant women from district health centers and the WNH and offer ultrasound examination to determine eligibility. Participants receive routine obstetrical care, lab testing, midtrimester cervical length measurement, and serial fetal growth monitoring. At delivery, we assess gestational age, birthweight, vital status, and sex and assign a delivery phenotype. We collect blood, urine, and vaginal swab specimens at scheduled visits and store them in an on-site biorepository. In September 2017, enrollment of the ZAPPS Phase 1-the subject of this report-was completed. Phase 2, which is limited to HIV-uninfected women, reopened in January 2018. Results: Between August 2015 and September 2017, we screened 1784 women, of whom 1450 (81.2%) met inclusion criteria and were enrolled. The median age at enrollment was 27 years (IQR 23-32) and median gestational age was 16 weeks (IQR 13-18). Among women with a previous pregnancy (n=1042), 19% (n=194) reported a prior miscarriage. Among parous women (n=992), 41% (n=411) reported a prior preterm birth and 14% (n=126) reported a prior stillbirth. The HIV seroprevalence was 24%. Discussion: We have established a large cohort of pregnant women and newborns at the WNH to characterize the determinants of adverse birth outcomes in Lusaka, Zambia. Our overarching goal is to elucidate biological mechanisms in an effort to identify new strategies for early detection and prevention of adverse outcomes. We hope that findings from this cohort will help guide future studies, clinical care, and policy.
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Affiliation(s)
| | - Nurain M Fuseini
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Global Projects Zambia, Lusaka, Zambia
| | - Katelyn Rittenhouse
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Global Projects Zambia, Lusaka, Zambia
| | - Joan T Price
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Global Projects Zambia, Lusaka, Zambia
| | | | | | - Jennifer Winston
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Benjamin H Chi
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Margaret P Kasaro
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Global Projects Zambia, Lusaka, Zambia
| | - James A Litch
- Global Alliance for the Prevention of Prematurity and Stillbirth, Seattle, WA, USA
| | | | - Bellington Vwalika
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,University of Zambia School of Medicine, Lusaka, Zambia
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8
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Castillo MC, Fuseini NM, Rittenhouse K, Price JT, Freeman BL, Mwape H, Winston J, Sindano N, Baruch-Gravett C, Chi BH, Kasaro MP, Litch JA, Stringer JS, Vwalika B. The Zambian Preterm Birth Prevention Study (ZAPPS): Cohort characteristics at enrollment. Gates Open Res 2019; 2:25. [PMID: 30706053 PMCID: PMC6350406 DOI: 10.12688/gatesopenres.12820.3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Sub-Saharan Africa bears a disproportionate burden of preterm birth and other adverse outcomes. A better understanding of the demographic, clinical, and biologic underpinnings of these adverse outcomes is urgently needed to plan interventions and inform new discovery. Methods: The Zambian Preterm Birth Prevention Study (ZAPPS) is a prospective observational cohort established at the Women and Newborn Hospital (WNH) in Lusaka, Zambia. We recruit pregnant women from district health centers and the WNH and offer ultrasound examination to determine eligibility. Participants receive routine obstetrical care, lab testing, midtrimester cervical length measurement, and serial fetal growth monitoring. At delivery, we assess gestational age, birthweight, vital status, and sex and assign a delivery phenotype. We collect blood, urine, and vaginal swab specimens at scheduled visits and store them in an on-site biorepository. In September 2017, enrollment of the ZAPPS Phase 1-the subject of this report-was completed. Phase 2, which is limited to HIV-uninfected women, reopened in January 2018. Results: Between August 2015 and September 2017, we screened 1784 women, of whom 1450 (81.2%) met inclusion criteria and were enrolled. The median age at enrollment was 27 years (IQR 23-32) and median gestational age was 16 weeks (IQR 13-18). Among women with a previous pregnancy (n=1042), 19% (n=194) reported a prior miscarriage. Among parous women (n=992), 41% (n=411) reported a prior preterm birth and 14% (n=126) reported a prior stillbirth. The HIV seroprevalence was 24%. Discussion: We have established a large cohort of pregnant women and newborns at the WNH to characterize the determinants of adverse birth outcomes in Lusaka, Zambia. Our overarching goal is to elucidate biological mechanisms in an effort to identify new strategies for early detection and prevention of adverse outcomes. We hope that findings from this cohort will help guide future studies, clinical care, and policy.
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Affiliation(s)
| | - Nurain M. Fuseini
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Global Projects Zambia, Lusaka, Zambia
| | - Katelyn Rittenhouse
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Global Projects Zambia, Lusaka, Zambia
| | - Joan T. Price
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Global Projects Zambia, Lusaka, Zambia
| | | | | | - Jennifer Winston
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Benjamin H. Chi
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Margaret P. Kasaro
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Global Projects Zambia, Lusaka, Zambia
| | - James A. Litch
- Global Alliance for the Prevention of Prematurity and Stillbirth, Seattle, WA, USA
| | | | - Bellington Vwalika
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- University of Zambia School of Medicine, Lusaka, Zambia
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9
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Xiao B, Wu C, Song W, Niu X, Qin N, Liu Z, Xu Q. Association Analysis on Recurrence of Bacterial Vaginosis Revealed Microbes and Clinical Variables Important for Treatment Outcome. Front Cell Infect Microbiol 2019; 9:189. [PMID: 31245300 PMCID: PMC6579829 DOI: 10.3389/fcimb.2019.00189] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 05/17/2019] [Indexed: 11/13/2022] Open
Abstract
To investigate the parameters associated with post-treatment recurrence of bacterial vaginosis (BV), clinical factors and vaginal microbiota were examined and analyzed for BV patients who received standard metronidazole therapy. The variables associated with BV recurrence included clinical factors of past BV history, use of intravaginal device, and D7 Nugent score as well as many microbial genera, with Lactobacillus, Enterococcus, Ureaplasma, and Aerococcus being the top contributors. Co-occurrence network analysis showed that whereas overwhelming majority of interbacterial interactions were positive, negative interactions were present and connected mostly to Lactobacillus, Enterococcus, and to a less extent Ureaplasma, suggesting the importance of interbacterial antagonism for treatment outcome. The patients who were cured and recurrent also exhibited clear differences in the species composition of Lactobacillus: although L. iners remained the dominant species at all time points, L. crispatus, L. gasseri, and L. jensenii displayed apparent differences in relative abundance between the cure and recurrent groups. Based on these results, we developed a 5-component panel comprising Enterococcus, L. crispatus, Ureaplasma, Aerococcus, and L. jensenii for predicting recurrence using D7 data and showed that it generated the specificity, sensitivity, and AUC values of 0.80, 0.66, and 0.73 for the discovery cohort and 0.80, 0.67, and 0.69 for the validation cohort. Our findings highlighted key microbial components for BV recurrence and suggested that they could be used to monitor the treatment outcome.
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Affiliation(s)
- Bingbing Xiao
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Chunyan Wu
- Realbio Genomics Institute, Shanghai, China
| | | | - Xiaoxi Niu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Nan Qin
- Realbio Genomics Institute, Shanghai, China
| | - Zhaohui Liu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Qian Xu
- Realbio Genomics Institute, Shanghai, China.,Shenzhen Jinrui Biotechnology, Co., Ltd., Shenzhen, China
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10
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Castillo MC, Fuseini NM, Rittenhouse K, Price JT, Freeman BL, Mwape H, Winston J, Sindano N, Baruch-Gravett C, Chi BH, Kasaro MP, Litch JA, Stringer JS, Vwalika B. The Zambian Preterm Birth Prevention Study (ZAPPS): Cohort characteristics at enrollment. Gates Open Res 2018; 2:25. [PMID: 30706053 PMCID: PMC6350406 DOI: 10.12688/gatesopenres.12820.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2018] [Indexed: 07/19/2024] Open
Abstract
Background:Sub-Saharan Africa bears a disproportionate burden of preterm birth and other adverse outcomes. A better understanding of the demographic, clinical, and biologic underpinnings of these adverse outcomes is urgently needed to plan interventions and inform new discovery. Methods:The Zambian Preterm Birth Prevention Study (ZAPPS) is a prospective observational cohort established at the Women and Newborn Hospital (WNH) in Lusaka, Zambia. We recruit pregnant women from district health centers and the WNH and offer ultrasound examination to determine eligibility. Participants receive routine obstetrical care, lab testing, midtrimester cervical length measurement, and serial fetal growth monitoring. At delivery, we assess gestational age, birthweight, vital status, and sex and assign a delivery phenotype. We collect blood, urine, and vaginal swab specimens at scheduled visits and store them in an on-site biorepository. In September 2017, enrollment of the ZAPPS Phase 1 - the subject of this report - was completed. Phase 2 - which is limited to HIV-uninfected women - reopened in January 2018. Results:Between August 2015 and September 2017, we screened 1784 women, of whom 1450 (81.2%) met inclusion criteria and were enrolled. The median age at enrollment was 27 years (IQR 23-32) and thee median gestational age was 16 weeks (IQR 13-18). Among parous women (N=866; 64%), 21% (N=182) reported a prior miscarriage, 49% (N=424) reported a prior preterm birth, and 13% (N=116) reported a prior stillbirth. The HIV seroprevalence was 24%. Discussion:We have established a large cohort of pregnant women and newborns at the WHN to characterize the determinants of adverse birth outcomes in Lusaka, Zambia. Our overarching goal is to elucidate biological mechanisms in an effort to identify new strategies for early detection and prevention of adverse outcomes. We hope that findings from this cohort will help guide future studies, clinical care, and policy.
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Affiliation(s)
| | - Nurain M. Fuseini
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Global Projects Zambia, Lusaka, Zambia
| | - Katelyn Rittenhouse
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Global Projects Zambia, Lusaka, Zambia
| | - Joan T. Price
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Global Projects Zambia, Lusaka, Zambia
| | | | | | - Jennifer Winston
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Benjamin H. Chi
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Margaret P. Kasaro
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Global Projects Zambia, Lusaka, Zambia
| | - James A. Litch
- Global Alliance for the Prevention of Prematurity and Stillbirth, Seattle, WA, USA
| | | | - Bellington Vwalika
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- University of Zambia School of Medicine, Lusaka, Zambia
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11
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Govindaswami B, Jegatheesan P, Nudelman M, Narasimhan SR. Prevention of Prematurity: Advances and Opportunities. Clin Perinatol 2018; 45:579-595. [PMID: 30144857 DOI: 10.1016/j.clp.2018.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Preterm birth (PTB) rate varies widely and has significant racial and ethnic disparities. Although causal mechanisms are ill understood, socioenvironment, phenotype, and genotype provide insight into pathways for preventing PTB. Data suggest varied response to current medical interventions is explicable Approved by underlying pharmacogenomics. Currently, prevention focuses on minimizing iatrogenic PTB and risk reduction especially in those with prior PTB using proven medical and public health strategies. In the future, preventive approaches will be based on better understanding of sociodemography, nutrition, lifestyles, and underlying individual genetic and epigenetic variation. Statistical approaches and "big-data" models are critical in future study.
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Affiliation(s)
- Balaji Govindaswami
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA.
| | - Priya Jegatheesan
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA
| | - Matthew Nudelman
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA
| | - Sudha Rani Narasimhan
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA
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12
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Relationships Between Perinatal Interventions, Maternal-Infant Microbiomes, and Neonatal Outcomes. Clin Perinatol 2018; 45:339-355. [PMID: 29747892 DOI: 10.1016/j.clp.2018.01.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The human microbiome acquires its vastness and diversity over a relatively short time period during development. Much is unknown, however, about the precise prenatal versus postnatal timing or its sources and determinants. Given early evidence of a role for influences during pregnancy and early neonatal and infant life on the microbiome and subsequent metabolic health, research investigating the development and shaping of the microbiome in the fetus and neonate is an important arena for study. This article reviews the relevant available literature and future questions on what shapes the microbiome during early development and mechanisms for doing so.
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13
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A Lactobacillus-Deficient Vaginal Microbiota Dominates Postpartum Women in Rural Malawi. Appl Environ Microbiol 2018; 84:AEM.02150-17. [PMID: 29305501 PMCID: PMC5835753 DOI: 10.1128/aem.02150-17] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/29/2017] [Indexed: 01/09/2023] Open
Abstract
The bacterial community found in the vagina is an important determinant of a woman's health and disease status. A healthy vaginal microbiota is associated with low species richness and a high proportion of one of a number of different Lactobacillus spp. When disrupted, the resulting abnormal vaginal microbiota is associated with a number of disease states and poor pregnancy outcomes. Studies up until now have concentrated on relatively small numbers of American and European populations that may not capture the full complexity of the community or adequately predict what constitutes a healthy microbiota in all populations. In this study, we sampled and characterized the vaginal microbiota found on vaginal swabs taken postpartum from a cohort of 1,107 women in rural Malawi. We found a population dominated by Gardnerella vaginalis and devoid of the most common vaginal Lactobacillus species, even if the vagina was sampled over a year postpartum. This Lactobacillus-deficient anaerobic community, commonly labeled community state type (CST) 4, could be subdivided into four further communities. A Lactobacillus iners-dominated vaginal microbiota became more common the longer after delivery the vagina was sampled, but G. vaginalis remained the dominant organism. These results outline the difficulty in all-encompassing definitions of what a healthy or abnormal postpartum vaginal microbiota is. Previous identification of community state types and associations among bacterial species, bacterial vaginosis, and adverse birth outcomes may not represent the complex heterogeneity of the microbiota present. (This study has been registered at ClinicalTrials.gov as NCT01239693.) IMPORTANCE A bacterial community in the vaginal tract is dominated by a small number of Lactobacillus species, and when not present there is an increased incidence of inflammatory conditions and adverse birth outcomes. A switch to a vaginal bacterial community lacking in Lactobacillus species is common after pregnancy. In this study, we characterized the postpartum vaginal bacterial community of a large group of women from a resource-poor, undersampled population in rural Malawi. The majority of women were found to have a Lactobacillus-deficient community, and even when sampled a year after delivery the majority of women still did not have Lactobacillus present in their vaginal microbiota. The effect of becoming pregnant again for those who do not revert to a Lactobacillus-dominant community is unknown, and this could suggest that not all Lactobacillus-deficient community structures are adverse. A better understanding of this complex community state type is needed.
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14
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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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15
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Bröms G, Granath F, Stephansson O, Kieler H. Preterm birth in women with inflammatory bowel disease - the association with disease activity and drug treatment. Scand J Gastroenterol 2016; 51:1462-1469. [PMID: 27739352 DOI: 10.1080/00365521.2016.1208269] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The inflammatory bowel diseases (IBD), Crohn's disease (CD) and ulcerative colitis (UC) have been associated with an increased risk of preterm birth. MATERIAL AND METHODS We identified all 246 singleton preterm births among women with IBD between July 2006 and December 2010 as cases and an equal number of controls with IBD from the Swedish national health registers, matched by maternal age, parity and IBD diagnosis (CD/UC). From register data and medical charts, we obtained information on reproductive history, comorbidity, disease activity and drug treatment (corticosteroids, 5-aminosalicylates, sulfasalazine, thiopurines and anti-TNF) as risk factors for preterm birth. Associations were estimated using conditional logistic regression and results were presented as odds ratios (OR) with 95% confidence intervals (CI). RESULTS Previous preterm birth was more common among cases, OR 6.13 (95%CI: 2.51-15.01). Significant activity at any time during pregnancy (OR: 2.20; 95%CI: 1.37-3.53), and in particular both in early and in late pregnancy, was more common for cases (OR: 4.78 95%; CI: 2.10-10.9). The OR for immunosuppressive treatment with thiopurines or anti-TNF was 1.88 (1.04-3.39) without significant activity and 12.78 (95%CI: 3.68-44.72) with. The risk for women who discontinued thiopurines was 6.56 (1.44-29.82). CONCLUSIONS Significant activity and immunosuppressive treatment was associated with preterm birth, particularly in women with both. The existing recommendations to aim at maintaining quiescent disease during pregnancy, even if it means continuing immunosuppressive treatment, are rational.
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Affiliation(s)
- Gabriella Bröms
- a Unit of Clinical Epidemiology , Centre for Pharmacoepidemiology, Karolinska Institutet , Stockholm , Sweden.,b Department of Internal Medicine , Danderyd University Hospital , Stockholm , Sweden
| | - Fredrik Granath
- a Unit of Clinical Epidemiology , Centre for Pharmacoepidemiology, Karolinska Institutet , Stockholm , Sweden
| | - Olof Stephansson
- a Unit of Clinical Epidemiology , Centre for Pharmacoepidemiology, Karolinska Institutet , Stockholm , Sweden.,c Department of Women's and Children's Health, Division of Obstetrics and Gynecology , Karolinska Institutet , Stockholm , Sweden
| | - Helle Kieler
- a Unit of Clinical Epidemiology , Centre for Pharmacoepidemiology, Karolinska Institutet , Stockholm , Sweden
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16
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Xiao B, Niu X, Han N, Wang B, Du P, Na R, Chen C, Liao Q. Predictive value of the composition of the vaginal microbiota in bacterial vaginosis, a dynamic study to identify recurrence-related flora. Sci Rep 2016; 6:26674. [PMID: 27253522 PMCID: PMC4890590 DOI: 10.1038/srep26674] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 05/05/2016] [Indexed: 11/09/2022] Open
Abstract
Bacterial vaginosis (BV) is a highly prevalent disease in women, and increases the risk of pelvic inflammatory disease. It has been given wide attention because of the high recurrence rate. Traditional diagnostic methods based on microscope providing limited information on the vaginal microbiota increase the difficulty in tracing the development of the disease in bacteria resistance condition. In this study, we used deep-sequencing technology to observe dynamic variation of the vaginal microbiota at three major time points during treatment, at D0 (before treatment), D7 (stop using the antibiotics) and D30 (the 30-day follow-up visit). Sixty-five patients with BV were enrolled (48 were cured and 17 were not cured), and their bacterial composition of the vaginal microbiota was compared. Interestingly, we identified 9 patients might be recurrence. We also introduced a new measurement point of D7, although its microbiota were significantly inhabited by antibiotic and hard to be observed by traditional method. The vaginal microbiota in deep-sequencing-view present a strong correlation to the final outcome. Thus, coupled with detailed individual bioinformatics analysis and deep-sequencing technology, we may illustrate a more accurate map of vaginal microbial to BV patients, which provide a new opportunity to reduce the rate of recurrence of BV.
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Affiliation(s)
- Bingbing Xiao
- Department of Obstetrics and Gynecology, Peking University First Hospital, Xi'anmen Street, Beijing 100034, China
| | - Xiaoxi Niu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Xi'anmen Street, Beijing 100034, China
| | - Na Han
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Ben Wang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Xi'anmen Street, Beijing 100034, China.,Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
| | - Pengcheng Du
- Beijing Key Laboratory of Emerging Infectious Diseases, Beijing 100015, China.,Institute of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Risu Na
- Department of Obstetrics and Gynecology, Peking University First Hospital, Xi'anmen Street, Beijing 100034, China
| | - Chen Chen
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China.,Beijing Key Laboratory of Emerging Infectious Diseases, Beijing 100015, China.,Institute of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Qinping Liao
- Department of Obstetrics and Gynecology, Peking University First Hospital, Xi'anmen Street, Beijing 100034, China.,Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
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17
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Deng Y, Deng Y, He X, Chu J, Zhou J, Zhang Q, Guo W, Huang P, Guan X, Tang Y, Wei Y, Zhao S, Zhang X, Wei C, Namaka M, Yi P, Yu J, Li X. Prenatal inflammation-induced NF-κB dyshomeostasis contributes to renin-angiotensin system over-activity resulting in prenatally programmed hypertension in offspring. Sci Rep 2016; 6:21692. [PMID: 26877256 PMCID: PMC4753429 DOI: 10.1038/srep21692] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 01/28/2016] [Indexed: 02/05/2023] Open
Abstract
Studies involving the use of prenatally programmed hypertension have been shown to potentially contribute to prevention of essential hypertension (EH). Our previous research has demonstrated that prenatal inflammatory stimulation leads to offspring's aortic dysfunction and hypertension in pregnant Sprague-Dawley rats challenged with lipopolysaccharide (LPS). The present study found that prenatal LPS exposure led to NF-κB dyshomeostasis from fetus to adult, which was characterized by PI3K-Akt activation mediated degradation of IκBα protein and impaired NF-κB self-negative feedback loop mediated less newly synthesis of IκBα mRNA in thoracic aortas (gestational day 20, postnatal week 7 and 16). Prenatal or postnatal exposure of the IκBα degradation inhibitor, pyrollidine dithiocarbamate, effectively blocked NF-κB activation, endothelium dysfunction, and renin-angiotensin system (RAS) over-activity in thoracic aortas, resulting in reduced blood pressure in offspring that received prenatal exposure to LPS. Surprisingly, NF-κB dyshomeostasis and RAS over-activity were only found in thoracic aortas but not in superior mesenteric arteries. Collectively, our data demonstrate that the early life NF-κB dyshomeostasis induced by prenatal inflammatory exposure plays an essential role in the development of EH through triggering RAS over-activity. We conclude that early life NF-κB dyshomeostasis is a key predictor of EH, and thus, NF-κB inhibition represents an effective interventional strategy for EH prevention.
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Affiliation(s)
- Youcai Deng
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Yafei Deng
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
| | - Xiaoyan He
- Jiangjin District Central Hospital, Chongqing, China
| | - Jianhong Chu
- Suzhou Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China
| | - Jianzhi Zhou
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
| | - Qi Zhang
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
| | - Wei Guo
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
| | - Pei Huang
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
| | - Xiao Guan
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
| | - Yuan Tang
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
| | - Yanling Wei
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
| | - Shanyu Zhao
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
| | - Xingxing Zhang
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
- Department of Pharmacy, Hospital 159 of PLA, Zhumadian, Henan, China
| | - Chiming Wei
- Chongqing Center for Biomedicine and Medical Equipment, Chongqing Academy of Science and Technology, Chongqing, China
| | - Michael Namaka
- Colleges of Pharmacy and Medicine, University of Manitoba, Apotex Center 750, McDermot Avenue, Winnipeg, MB, Canada
- Joint Laboratory of Biological Psychiatry Between Shantou University Medical College and the College of Medicine University of Manitoba, Canada
| | - Ping Yi
- Department of Obstetrics and Gynecology, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Jianhua Yu
- Department of Obstetrics and Gynecology, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Xiaohui Li
- Institute of Materia Medica, College of Pharmacy, Third Military Medical University, Chongqing, China
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18
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Kell DB, Kenny LC. A Dormant Microbial Component in the Development of Preeclampsia. Front Med (Lausanne) 2016; 3:60. [PMID: 27965958 PMCID: PMC5126693 DOI: 10.3389/fmed.2016.00060] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 11/04/2016] [Indexed: 12/12/2022] Open
Abstract
Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of "preeclampsia" that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one.
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Affiliation(s)
- Douglas B. Kell
- School of Chemistry, The University of Manchester, Manchester, UK
- The Manchester Institute of Biotechnology, The University of Manchester, Manchester, UK
- Centre for Synthetic Biology of Fine and Speciality Chemicals, The University of Manchester, Manchester, UK
- *Correspondence: Douglas B. Kell,
| | - Louise C. Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Obstetrics and Gynecology, University College Cork, Cork, Ireland
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19
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Baldwin EA, Walther-Antonio M, MacLean AM, Gohl DM, Beckman KB, Chen J, White B, Creedon DJ, Chia N. Persistent microbial dysbiosis in preterm premature rupture of membranes from onset until delivery. PeerJ 2015; 3:e1398. [PMID: 26644969 PMCID: PMC4671185 DOI: 10.7717/peerj.1398] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 10/20/2015] [Indexed: 01/28/2023] Open
Abstract
Background. Preterm Premature Rupture of Membranes (PPROM) is a major leading cause of preterm births. While the cause for PPROM remains unidentified, it is anticipated to be due to subclinical infection, since a large proportion of PPROM patients display signs of chorioamnionitis. Since subclinical infections can be facilitated by dysbiosis, our goal was to characterize the vaginal microbiome and amniotic fluid discharge upon PPROM, through latency antibiotic treatment, and until delivery, to detect the presence of pathogens, microbiota alteration, and microbial response to treatment. Methods. Enrolled subjects (15) underwent routine institutional antenatal care for PPROM, including the administration of latency antibiotics. Serial vaginal swabs were obtained from diagnosis of PPROM through delivery and the sequencing of the V3-V5 region of the 16S rRNA gene was performed for all collected samples. Results. The results show that Lactobacilli species were markedly decreased when compared to vaginal swabs collected from uncomplicated pregnancy subjects with a matched gestational time. Prevotella and Peptoniphilus were the most prevalent taxa in PPROM subjects at presentation. The vaginal microbiome of the PPROM subjects varied substantially intra- and inter-subjects. Several taxa were found to be significantly reduced during and after the antibiotic treatment: Weeksella, Lachnospira, Achromobacter, and Pediococcus. In contrast, Peptostreptococcus and Tissierellaceae ph2 displayed a significant increase after the antibiotic treatment. However, the relative abundance of Lactobacillus, Prevotella, and Peptoniphilus was not substantially impacted during the hospitalization of the PPROM subjects. The deficiency of Lactobacillus, and constancy of known pathogenic species, such as Prevotella and Peptoniphilus during and after antibiotics, highlights the persistent dysbiosis and warrants further investigation into mitigating approaches. Discussion. PPROM is responsible for one third of all preterm births. It is thought that subclinical infection is a crucial factor in the pathophysiology of PPROM because 25-40% of patients present signs of chorioamnionitis on amniocentesis. Here we sought to directly assess the bacterial content of the vagina and leaking amniotic fluid of subjects at presentation, throughout treatment and up until delivery, in order to search for common pathogens, microbiota changes, and microbial response to latency antibiotic treatment. We have found that the vaginal microbiome of PPROM subjects is highly variable and displays significant changes to treatment. However, the unchanging deficiency of Lactobacillus, and persistence of known pathogenic species, such as Prevotella and Peptoniphilus from presentation, through antibiotic treatment and up until delivery, highlights the persistent dysbiosis and warrants further investigation into mitigating approaches.
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Affiliation(s)
| | | | | | - Daryl M. Gohl
- Genomics Center, University of Minnesota, Minneapolis, MN, USA
| | | | - Jun Chen
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Bryan White
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL, United States
- Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | | | - Nicholas Chia
- Department of Surgical Research, Mayo Clinic, Rochester, MN, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
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Çakıroğlu Y, Çalışkan Ş, Doğer E, Yıldırım Köpük Ş, Dündar D, Çalışkan E. Do the interactions between coital frequency, cervical length, and urogenital infection affect obstetric outcomes? Turk J Obstet Gynecol 2015; 12:66-70. [PMID: 28913045 PMCID: PMC5558378 DOI: 10.4274/tjod.89106] [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: 02/19/2015] [Accepted: 05/24/2015] [Indexed: 12/01/2022] Open
Abstract
Objective: To determine whether interactions between coital frequency, cervical length, and urogenital infection affect obstetric outcomes. Materials and Methods: A total of 268 unselected pregnant women were recruited in the study. The study population consisted of four groups of women: group 1 (n=203) screened negative for bacterial vaginosis (BV) both in the first and second trimesters; group 2 (n=18) screened negative for BV in the first trimester but positive in the second trimester; group 3 (n=33) screened positive for BV in the first trimester but negative in the second trimester; and group 4 (n=14) screened positive for BV both in the first and second trimesters. Urine culture, cervico-vaginal cultures, and bacterial vaginosis were screened between 11-14 weeks and 20-24 weeks. Results: Two hundred fifty women were eligible for analysis in the study after lost-to-follow up patients were excluded. Previous abortion ≥1 and previous preterm delivery at 24-34 weeks ≥1 were statistically significantly higher in group 2. The number of patients who were diagnosed as having preterm premature rupture of membranes (PPROM) was statistically significantly higher in group 4. Sexual intercourse during the first trimester, cervical length during the second trimester, and history of preterm birth (PTB) were statistically significant risk factors for preterm birth <37 weeks (1.27; (1.12-1.44); 5.33; (1.84-15.41); 6.95; (1.58-30.54), respectively). Conclusion: Presence or treatment of BV did not influence rates of PTB. The probability of PPROM would be higher in patients who are BV positive both in the first and second trimesters.
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Affiliation(s)
- Yiğit Çakıroğlu
- Kocaeli University Faculty of Medicine, Department of Obstetrics and Gynecology, Kocaeli, Turkey
| | - Şeyda Çalışkan
- Sakarya University Faculty of Medicine Education and Research Hospital, Department of Clinical Microbiology, Sakarya, Turkey
| | - Emek Doğer
- Kocaeli University Faculty of Medicine, Department of Obstetrics and Gynecology, Kocaeli, Turkey
| | - Şule Yıldırım Köpük
- Kocaeli University Faculty of Medicine, Department of Obstetrics and Gynecology, Kocaeli, Turkey
| | - Devrim Dündar
- Kocaeli University Faculty of Medicine, Department of Clinical Microbiology, Kocaeli, Turkey
| | - Eray Çalışkan
- Kocaeli University Faculty of Medicine, Department of Obstetrics and Gynecology, Kocaeli, Turkey
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Roberts CL, Algert CS, Rickard KL, Morris JM. Treatment of vaginal candidiasis for the prevention of preterm birth: a systematic review and meta-analysis. Syst Rev 2015; 4:31. [PMID: 25874659 PMCID: PMC4373465 DOI: 10.1186/s13643-015-0018-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 02/24/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Recognition that ascending infection leads to preterm birth has led to a number of studies that have evaluated the treatment of vaginal infections in pregnancy to reduce preterm birth rates. However, the role of candidiasis is relatively unexplored. Our aim was to undertake a systematic review and meta-analysis to assess whether treatment of pregnant women with vulvovaginal candidiasis reduces preterm birth rates and other adverse birth outcomes. METHODS We undertook a systematic review and meta-analysis of published randomised controlled trials (RCTs) in which pregnant women were treated for vulvovaginal candidiasis (compared to placebo or no treatment) and where preterm birth was reported as an outcome. Trials were identified by searching the Cochrane Central Register of Controlled Trials, Medline and Embase databases to January 2014. Trial eligibility and outcomes were pre-specified. Two reviewers independently assessed the studies against the agreed criteria and extracted relevant data using a standard data extraction form. Meta-analysis was used to calculate pooled rate ratios (RR) and 95% confidence intervals (CI) using a fixed-effects model. RESULTS There were two eligible RCTs both among women with asymptomatic candidiasis, with a total of 685 women randomised. Both trials compared treatment with usual care (no screening for, or treatment of, asymptomatic candidiasis). Data from one trial involved a post-hoc subgroup analysis (n = 586) of a larger trial of treatment of 4,429 women with asymptomatic infections in pregnancy and the other was a pilot study (n = 99). There was a significant reduction in spontaneous preterm births in treated compared with untreated women (meta-analysis RR = 0.36, 95% CI = 0.17 to 0.75). Other outcomes were reported by one or neither trial. CONCLUSIONS This systematic review found two trials comparing the treatment of asymptomatic vaginal candidiasis in pregnancy for the outcome of preterm birth. Although the effect estimate suggests that treatment of asymptomatic candidiasis may reduce the risk of preterm birth, the result needs to be interpreted with caution as the primary driver for the pooled estimate comes from a post-hoc (unplanned) subgroup analysis. A prospective trial with sufficient power to answer the clinical question 'does treatment of asymptomatic candidiasis in early pregnancy prevent preterm birth' is warranted. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014009241.
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Affiliation(s)
- Christine L Roberts
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia.
| | - Charles S Algert
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia.
| | - Kristen L Rickard
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia.
| | - Jonathan M Morris
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia.
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O'Brien CM, Arbuckle S, Thomas S, Rode J, Turner R, Jeffery HE. Placental inflammation is associated with rural and remote residence in the Northern Territory, Australia: a cross-sectional study. BMC Pregnancy Childbirth 2015; 15:32. [PMID: 25884543 PMCID: PMC4404597 DOI: 10.1186/s12884-015-0458-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 01/27/2015] [Indexed: 01/11/2023] Open
Abstract
Background The Northern Territory has the highest rates of perinatal morbidity and mortality in Australia. Placental histopathology has not been studied in this high-risk group of women. Methods This is the first study to detail the placental pathology in Indigenous women and to compare the findings with non-Indigenous women in the Northern Territory. There were a total of 269 deliveries during a three-month period from the 27th of June to the 27th of August 2009. Seventy-one (71%) percent of all placentas were examined macroscopically, sectioned then reviewed by a Perinatal Pathologist, blinded to the maternal history and outcomes. Results Indigenous women were found to have higher rates of histologically confirmed chorioamnionitis and or a fetal inflammatory response compared with non-Indigenous women (46% versus 26%; OR 2.4, 95% CI 1.3-4.5). In contrast, non-Indigenous women were twice as likely to show vascular related pathology (31% versus 14%; OR 2.77, 95% CI 1.3-5.9). Indigenous women had significantly higher rates of potentially modifiable risk factors for placental inflammation including genitourinary infections, anaemia and smoking. After adjusting for confounders, histological chorioamnionitis and fetal inflammatory response was significantly associated with rural or remote residence (Adjusted OR 2.5, 95% CI 1.08 – 5.8). Conclusion This study has revealed a complex aetiology underlying a high prevalence of placental inflammation in the Northern Territory. Placental inflammation is associated with rural and remote residence, which may represent greater impact of systemic disadvantage, particularly affecting Indigenous women in the Northern Territory.
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Affiliation(s)
- Cecelia M O'Brien
- Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Tiwi, Northern Territory, Australia. .,Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women's and Children's Hospital, North Adelaide, 5006, South Australia, Australia.
| | - Susan Arbuckle
- Department of Anatomical Pathology, The Children's Hospital, Westmead, New South Wales, Australia.
| | - Sujatha Thomas
- Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Tiwi, Northern Territory, Australia.
| | - Jurgen Rode
- Department of Anatomical Pathology, Royal Darwin Hospital, Tiwi, Northern Territory, Australia.
| | - Robin Turner
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia.
| | - Heather E Jeffery
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia.
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23
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Reid G, Brigidi P, Burton JP, Contractor N, Duncan S, Fargier E, Hill C, Lebeer S, Martín R, McBain AJ, Mor G, O'Neill C, Rodríguez JM, Swann J, van Hemert S, Ansell J. Microbes central to human reproduction. Am J Reprod Immunol 2014; 73:1-11. [PMID: 25250861 PMCID: PMC4282787 DOI: 10.1111/aji.12319] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/18/2014] [Indexed: 12/21/2022] Open
Abstract
As studies uncover the breadth of microbes associated with human life, opportunities will emerge to manipulate and augment their functions in ways that improve health and longevity. From involvement in the complexities of reproduction and fetal/infant development, to delaying the onset of disease, and indeed countering many maladies, microbes offer hope for human well-being. Evidence is emerging to suggest that microbes may play a beneficial role in body sites traditionally viewed as being sterile. Although further evidence is required, we propose that much of medical dogma is about to change significantly through recognition and understanding of these hitherto unrecognized microbe–host interactions. A meeting of the International Scientific Association for Probiotics and Prebiotics held in Aberdeen, Scotland (June 2014), presented new views and challenged established concepts on the role of microbes in reproduction and health of the mother and infant. This article summarizes some of the main aspects of these discussions.
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Affiliation(s)
- Gregor Reid
- Lawson Health Research Institute, London, ON, Canada; Departments of Microbiology & Immunology and Surgery, The University of Western Ontario, London, ON, Canada
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Martinez de Tejada B. Antibiotic use and misuse during pregnancy and delivery: benefits and risks. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2014; 11:7993-8009. [PMID: 25105549 PMCID: PMC4143845 DOI: 10.3390/ijerph110807993] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 07/25/2014] [Accepted: 07/28/2014] [Indexed: 11/17/2022]
Abstract
Although pregnancy is considered as a physiological state, most pregnant women in developed countries receive multiple medications to prevent maternal or neonatal complications, with antibiotics among the most frequently prescribed. During pregnancy, antibiotics are often prescribed in the context of preterm labor, intrapartum fever, prevention of neonatal Group B Streptococcus fever, and cesarean section. Outside this period, they are commonly prescribed in the community setting for respiratory, urinary, and ear, nose and throat infection symptoms. Whereas some of the current indications have insightful reasons to justify their use, potential risks related to overuse and misuse may surpass the benefits. Of note, the recent 2014 World Health Assembly expressed serious concern regarding antibiotic resistance due to antibiotic overuse and misuse and urged immediate action to combat antibiotic resistance on a global scale. Most studies in the obstetrics field have focused on the benefits of antibiotics for short-term maternal and neonatal complications, but with very little (if any) interest in long-term consequences.
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