Strategies to prevent preterm birth

Routine transabdominal cervical length screening in mid-pregnancy for the prevention of preterm birth: Is it good enough to use as a screening test?

BACKGROUND

Preterm birth (PTB) is a major pregnancy complication. There is evidence that a short cervical length in mid-pregnancy may predict women at increased risk of PTB.

AIMS

To evaluate the utility of population-based, transabdominal cervical length (TACL) measurement screening in mid-pregnancy for PTB prediction in women.

MATERIALS AND METHODS

A transabdominal approach was initially performed, with a transvaginal (TVCL) approach offered when the TACL was <35 mm, could not be accurately measured, or the pregnancy had risk factors for PTB. TACL was compared to the directly related TVCL, when both were performed at the same assessment. Women with risk factors of PTB were included when they had both TACL and TVCL measurements performed at the same visit.

RESULTS

Data were provided for 9355 singleton pregnancies from 13 participating imaging centres. A transabdominal approach was used in 9006 (96.3%), including 682 (7.3%) TVCL combined with TACL. There were 349 (3.7%) women who had TVCL only. The median TACL was longer (40 mm) than the TVCL (38 mm). In 682 paired TACL and TVCL measurements, TACL <35 mm correctly identified 96.2% of pregnancies with TVCL <25 mm, compared with 65.4% of cases when using a TACL <30 mm. A TVCL <25 mm occurred in 59 (0.6%) women. A TACL <35 mm was associated with birth <37 weeks of gestation in 12.1% of women and birth <32 weeks of gestation in 3.9%.

CONCLUSIONS

Universal TACL is a feasible option for population screening of cervical length in a low-risk population, progressing to TVCL if the TACL is <35 mm or the cervix cannot be transabdominally accurately measured.

Prevention Strategies and Management of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a serious intestinal disease which primarily affects preterm infants. The pathogenesis of NEC is multifactorial. Thus, it is complicated to study, prevent, and manage.

Purpose of Review

The purpose of this review is to provide a comprehensive summary of recent research and provide recommendations for the prevention and management of NEC. Currently, management is supportive and non-specific and long-term outcomes for surgical NEC are poor.

Recent Findings

The most important strategy to prevent NEC is to provide preterm infants with a human milk diet, minimize exposure to antibiotics and avoid medications that disturb the intestinal microbiome.

Summary

Strategies to optimize the infant's intestinal microbiome are critical, as disturbances in the intestinal microbiome composition are a major factor in the pathogenesis of this disease. Optimizing maternal health is also vital to prevent prematurity and neonatal morbidity. Ongoing research holds promise for the implementation of new diagnostic modalities, preventive strategies, and medical treatment options to improve outcomes for premature infants.

Sigmoid volvulus in pregnancy: A rare case report

Sigmoid volvulus in pregnancy is a surgical emergency that requires speedy diagnosis and definitive treatment at an appropriate level of care center as it may provoke preterm labor.

Effect of a chimney-fitted improved stove on pregnancy outcomes in Northwest Ethiopia: a randomized controlled trial

BACKGROUND

Exposure to household air pollution during pregnancy has been linked to adverse pregnancy outcomes. Improved stove was implemented in Ethiopia to reduce this exposure and related health problems. However, the effects of improved stove interventions on pregnancy outcomes remains uncertain.

METHOD

Individually randomized stove replacement trial was conducted among 422 households in six low-income rural kebeles of Northwestern Ethiopia. Pregnant women without known health conditions were recruited at ≤ 24 weeks gestation and randomized to an intervention or control group with a 1:1 ratio. A baseline survey was collected and a balance test was done. Two-sided independent samples t-test for continuous outcomes and chi-square for categorical variables were used to compare the effect of the intervention between the groups. Mean differences with 95% CIs were calculated and a p-value of < 0.05 was considered statistically significant.

RESULT

In this study, the mean birth weight was 3065 g (SD = 453) among the intervention group and not statistically different from 2995 g (SD = 541) of control group. After adjusting for covariates, infants born from intervention group weighed 55 g more [95% CI: - 43 to 170) than infants born from the control group, but the difference was not statistically significant (P = 0.274). The respective percentages for low birth weight were 8% and 10.3% for intervention and control groups respectively (P = 0.346). However, the average gestational age at delivery was higher among improved stove users (38 weeks (SD = 8.2) compared to control groups 36.5 weeks (SD = 9.6) with statistically significant difference at 0.91 weeks (95% CI: 0.52 to 1.30 weeks, p < 0.001). The corresponding difference in risk ratio for preterm birth is 0.94 (95% CI:0.92 to 0.97; p < 0.001). The percentages for maternal complications, stillbirth, and miscarriage in the intervention group were not statistically different from the control group.

CONCLUSIONS

While the increase in average birth weight among babies born to mothers using improved stoves was not statistically significant, babies had a longer gestational age on average, offering valuable health benefits. However, the study didn't find a significant impact on other pregnancy outcomes like stillbirth, miscarriage, or maternal complications.

TRIAL REGISTRATION

The study was registered at the Pan African Clinical Trial Registry website under the code PACTR202111534227089, ( https://pactr.samrc.ac.za/ (Identifier). The first trial registration date was (11/11/2021).

Epidemiology, risk factors, clinical presentation and complications of late-onset neonatal sepsis among preterm neonates in Cyprus: a prospective case-control study

BACKGROUND

Late-onset neonatal sepsis (LOS) is common in preterm neonates, with increasing incidence in recent years. In the present study, we examined the epidemiology, clinical presentation, and complications of LOS in Cyprus and quantified possible risk factors for the development of this condition.

METHODS

The study subjects were preterm neonates admitted in the Neonatal Intensive Care Unit (NICU) of Archbishop Makarios III Hospital, the only neonatal tertiary centre in Cyprus. A prospective, case-control study was designed, and carried out between April 2017-October 2018. Depending on blood culture results, preterm neonates were classified as "Confirmed LOS": positive blood culture - microorganism isolated and LOS symptoms, "Unconfirmed LOS": negative blood culture and LOS symptoms, and "Controls" group: negative blood culture and absence of LOS symptoms. Comparisons between the 3 groups were performed and the associations between demographic, clinical and treatment characteristics with the likelihood of LOS were assessed using univariate and multivariate logistic regression.

RESULTS

A total of 350 preterm neonates were included in the study and the incidence of LOS was 41.1%. 79 (22.6%) and 65 (18.6%) neonates were classified as "Confirmed LOS", and "unconfirmed LOS" cases respectively while 206 (58.9%) served as controls. The rate of confirmed LOS ranged from 12.2% in moderate to late preterm neonates to 78.6% in extremely preterm neonates. In the multivariate model, we demonstrated an independent association between LOS and duration of hospitalization (OR: 1.06, 95%CI: 1.01-1.10), duration of ventilation (OR: 1.23, 95%CI: 1.07-1.43) and necrotising enterocolitis (OR: 3.41, 95%CI: 1.13-10.25).

CONCLUSIONS

The present study highlights the epidemiology of LOS in preterm neonates in Cyprus and its association with the duration of ventilation and hospitalization as well as with necrotizing enterocolitis. Establishment of protocols for the prevention of nosocomial infections during hospitalization in the NICUs and mechanical ventilation of preterm neonates is recommended.

Applications of L-Arginine in Pregnancy and Beyond: An Emerging Pharmacogenomic Approach

L-arginine is a semi-essential amino acid that plays a critical role in various physiological processes, such as protein synthesis, wound healing, immune function, and cardiovascular regulation. The use of L-arginine in pregnancy has been an emerging topic in the field of pharmacogenomics. L-arginine, an amino acid, plays a crucial role in the production of nitric oxide, which is necessary for proper placental development and fetal growth. Studies have shown that L-arginine supplementation during pregnancy can have positive effects on fetal growth, maternal blood pressure, and the prevention of preeclampsia. This emerging pharmacogenomic approach involves using genetic information to personalize L-arginine dosages for pregnant women based on their specific genetic makeup. By doing so, it may be possible to optimize the benefits of L-arginine supplementation during pregnancy and improve pregnancy outcomes. This paper emphasizes the potential applications of L-arginine in pregnancy and the use of pharmacogenomic approaches to enhance its effectiveness. Nonetheless, the emerging pharmacogenomic approach to the application of L-arginine offers exciting prospects for the development of novel therapies for a wide range of diseases.

Digital health utilization during pregnancy and the likelihood of preterm birth

Objective

Given the complex nature of preterm birth, interventions to reduce rates of preterm birth should be multifaceted. This analysis aimed to explore the association between the duration of using Maven, a digital health platform for women's and family health, and the odds of preterm birth.

Methods

Data came from 3326 pregnant, nulliparous Maven users who enrolled in Maven during their pregnancy between January 2020 and September 2022. Chi-square and Fisher's exact tests compared characteristics between users who developed gestational conditions and users who did not. This retrospective cohort study used logistic regression models to estimate the association between the duration of Maven use and odds of preterm birth, stratified by the presence of gestational conditions.

Results

Compared to those without gestational conditions, individuals who developed gestational conditions were more likely to have a preterm birth (8.7% vs. 3.4%; p < 0.001). For every 1 h of Maven use, users experienced a 2% reduction in their odds of experiencing a preterm birth [adjusted odds ratio (AOR) (95% confidence interval (CI)) = 0.98 (0.95, 0.998), p = 0.04]. Among individuals who developed gestational conditions, every 1 h increase in Maven use was associated with a 5% reduction in the odds of experiencing a preterm birth [AOR (95% CI) = 0.95 (0.91, 0.99), p = 0.037]. There was no statistically significant association between Maven use and preterm birth in individuals without gestational conditions.

Conclusion

Among those who developed gestational conditions, use of a digital health platform was associated with a decreased likelihood of preterm birth.

Feasibility of a pregnancy intervention mimicking viral transmission mitigation measures on the incidence of preterm birth in high-risk pregnant women enrolled in antenatal clinics in Melbourne, Australia: protocol for a pilot, randomised trial

INTRODUCTION

Preterm birth is a leading cause of perinatal morbidity and mortality. During the COVID-19 pandemic, reduction in rates of preterm birth in women exposed to viral mitigation measures was reported by multiple studies. In addition, others and we observed a more pronounced reduction of preterm birth in women who had previously experienced a preterm birth. The aim of this pilot study is to establish the feasibility of a lifestyle intervention based on viral mitigation measures in high-risk pregnancies, with the ultimate aim to reduce the incidence of preterm birth.

METHODS AND ANALYSIS

One hundred pregnant women, enrolled in antenatal clinics at two tertiary maternity centres in Melbourne, Australia, who have had a previous preterm birth between 22 and 34 weeks gestation will be recruited. This is a two-arm, parallel group, open-label randomised controlled feasibility trial: 50 women will be randomised to the intervention group, where they will be requested to comply with a set of lifestyle changes (similar to the viral mitigation measures observed during the pandemic). Another 50 women will be randomised to the control group, where they will undergo standard pregnancy care. The primary outcome of this trial is feasibility, which will be assessed by measuring patient eligibility rate, recruitment rate, compliance rate and data completion rate. Secondary outcomes include incidence of preterm birth, maternal satisfaction, maternal quality of life and other pregnancy outcomes. Standard methods in statistical analysis for randomised controlled trials on an intention to treat basis will be followed.

ETHICS AND DISSEMINATION

This trial has been approved by the Monash Human Research Ethics Committee; approval reference number RES-22-0000-122A. Study findings will be reported and submitted to peer-reviewed journals for publication, and presentation at conferences.

TRIAL REGISTRATION NUMBER

ACTRN12622000753752; Pre-results.

Identification of biochemical biomarkers associated with premature cervical shortening in high-risk, asymptomatic pregnant women: a retrospective data analysis

Reliably predicting spontaneous preterm birth remains challenging, therefore it persists as a major contributor to perinatal morbidity and mortality. The use of biomarkers to predict premature cervical shortening, a recognised risk factor for spontaneous preterm birth, is yet to be fully explored in current literature. This study evaluates seven cervicovaginal biochemical biomarkers as possible predictors of premature cervical shortening. Asymptomatic, high-risk women (n = 131) presenting to a specialised preterm birth prevention clinic were analysed through a retrospective data analysis. Cervicovaginal biochemical biomarker concentrations were obtained, and the shortest cervical length measurement, up to 28 weeks' gestation, was recorded. Associations between biomarker concentration and cervical length were then analysed. Of the seven biochemical biomarkers, Interleukin-1 Receptor Antagonist and Extracellular Matrix Protein-1 had statistically significant relationships with cervical shortening below 25 mm. Further investigation is required to validate these findings and any downstream clinical utility, with intentions to improve perinatal outcomes.IMPACT STATEMENTWhat is already known on this subject? Preterm birth is a major cause of perinatal morbidity and mortality. A woman's risk of delivering preterm is currently stratified using historical risk factors, mid-gestation cervical length, and biochemical biomarkers such as foetal fibronectin.What do the results of this study add? In a cohort of high-risk, asymptomatic pregnant women, two cervicovaginal biochemical biomarkers, Interleukin-1 Receptor Antagonist and Extracellular Matrix Protein-1, displayed associations with premature cervical shortening.What are the implications of these findings for clinical practice and/or further research? Further investigation into the possible clinical utility of these biochemical biomarkers is warranted, with a view to improving preterm birth prediction and antenatal resource utilisation, thereby reducing the burden of preterm birth and its sequelae in a cost-effective manner.

Is intimate partner violence and obstetrics characteristics of pregnant women associated with preterm birth in Ethiopia? Umbrella review on preterm birth

BACKGROUND

Preterm birth is a significant contributor to newborns morbidity and mortality. Despite the availability of highly effective and powerful interventions, the burden of preterm birth has not decreased. Given the relevance of the topic to clinical decision-making, strong conclusive and supporting evidence emanating from the umbrella review is required. To this end, this umbrella review study sought to determine the association between intimate partner violence and obstetrics characteristics of women with preterm birth in Ethiopia.

METHODS

Six systematic review and meta-analysis studies searched across multiple databases were included in this umbrella review. The quality of the included systematic review and meta-analysis studies was evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR-2) checklist. STATA version 18 was used for the statistical analysis. A random-effects model was used to calculate the overall effect measurement.

RESULTS

A total of 114 observational studies in the six systematic review and meta-analysis studies involving 75,624 pregnant women were included in this comprehensive analysis. The preterm birth rate among mothers in Ethiopia was 11% (95% CI 10-13%; I2 = 98.08). Preterm birth was significantly associated with intimate partner violence (POR: 2.32; 95% CI 1.74-2.90), multiple pregnancies (POR: 3.36; 95% CI 2.41-4.32), pregnancy-induced hypertension (POR: 4.13; 95% CI 3.17-5.10), anemia (POR: 2.76; 95% CI 1.97-3.56), and premature rupture of pregnancy (POR: 5.1; 95% CI 3.45-6.75).

CONCLUSIONS

More than one out of ten pregnant women experienced preterm birth in Ethiopia. Intimate partner violence is significantly associated with preterm birth. Furthermore, multiple pregnancies, pregnancy-induced hypertension, anemia, and premature rupture of the membrane were significant predictors of preterm birth. Therefore, policymakers should consider further instigations and implementations of policies and strategies closely related to reductions of intimate partner violence. It is also crucial to the early identification and treatment of high-risk pregnancies.

Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda

INTRODUCTION

Preterm birth is a leading cause of under-5 mortality, with the greatest burden in lower-resource settings. Strategies to improve preterm survival have been tested, but strategy costs are less understood. We estimate costs of a highly effective Preterm Birth Initiative (PTBi) intrapartum intervention package (data strengthening, WHO Safe Childbirth Checklist, simulation and team training, quality improvement collaboratives) and active control (data strengthening, Safe Childbirth Checklist).

METHODS

In our analysis, we estimated costs incremental to current cost of intrapartum care (in 2020 $US) for the PTBi intervention package and active control in Kenya and Uganda. We costed the intervention package and control in two scenarios: 1) non-research implementation costs as observed in the PTBi study (Scenario 1, mix of public and private inputs), and 2) hypothetical costs for a model of implementation into Ministry of Health programming (Scenario 2, mostly public inputs). Using a healthcare system perspective, we employed micro-costing of personnel, supplies, physical space, and travel, including 3 sequential phases: program planning/adaptation (9 months); high-intensity implementation (15 months); lower-intensity maintenance (annual). One-way sensitivity analyses explored the effects of uncertainty in Scenario 2.

RESULTS

Scenario 1 PTBi package total costs were $1.11M in Kenya ($48.13/birth) and $0.74M in Uganda ($17.19/birtth). Scenario 2 total costs were $0.86M in Kenya ($23.91/birth) and $0.28M in Uganda ($5.47/birth); annual maintenance phase costs per birth were $16.36 in Kenya and $3.47 in Uganda. In each scenario and country, personnel made up at least 72% of total PTBi package costs. Total Scenario 2 costs in Uganda were consistently one-third those of Kenya, largely driven by differences in facility delivery volume and personnel salaries.

CONCLUSIONS

If taken up and implemented, the PTBi package has the potential to save preterm lives, with potential steady-state (maintenance) costs that would be roughly 5-15% of total per-birth healthcare costs in Uganda and Kenya.

Pre- and Perinatal Risk Factors for Child Maltreatment in Military Families Across the First Two Years of Life

Military families are exposed to a unique constellation of risk factors, which may impact maltreatment outcomes. The present study examined prospective relationships between demographic, health, birth-related, and military-specific risk factors identified prior to a child's birth on their risk for maltreatment in the first two years of life. Data from the Millennium Cohort Study, Department of Defense (DoD) operational records and Family Advocacy Program data on met-criteria maltreatment, and Birth and Infant Health Research program data on suspected maltreatment were linked for 9076 service member parents. Discrete time survival analysis showed that preterm birth increased risk of maltreatment while parents' older age, physical health, and service in the Navy or Air Force decreased risk. Building on DoD's New Parent Support Program, findings suggest the need for universal and targeted prevention efforts, beginning during pregnancy, which limit or eliminate risk factors for maltreatment in military families.

Should case management be considered a component of obstetrical interventions for pregnancies at risk of preterm birth?

Preterm birth remains the leading cause of morbidity and mortality among nonanomalous neonates in the United States. Unfortunately, preterm birth rates remain high despite current medical interventions such as progestogen supplementation and cerclage placement. Case management, which encompasses coordinated care aimed at providing a more comprehensive and supportive environment, is a key component in improving health and reducing costs in other areas of medicine. However, it has not made its way into the general lexicon and practice of obstetrical care. Case management intended for decreasing prematurity or ameliorating its consequences may include specialty clinics, social services, coordination of specialty services such as nutrition counseling, home visits or frequent phone calls by specially trained personnel, and other elements described herein. It is not currently included in nor is it advocated for as a recommended prematurity prevention approach in the American College of Obstetricians and Gynecologists or Society for Maternal-Fetal Medicine guidelines for medically indicated or spontaneous preterm birth prevention. Our review of existing evidence finds consistent reductions or trends toward reductions in preterm birth with case management, particularly among individuals with high a priori risk of preterm birth across systematic reviews, metaanalyses, and randomized controlled studies. These findings suggest that case management has substantial potential to improve the environmental, behavioral, social, and psychological factors with patients at risk of preterm birth.

Autism-like behavior of murine offspring induced by prenatal exposure to progestin is associated with gastrointestinal dysfunction due to claudin-1 suppression

Autism spectrum disorders (ASD) are associated with the contribution of many prenatal risk factors; in particular, the sex hormone progestin and vitamin D receptor (VDR) are associated with gastrointestinal (GI) symptoms in ASD development, although the related mechanism remains unclear. We investigated the possible role and mechanism of progestin 17-hydroxyprogesterone caproate (17-OHPC) exposure-induced GI dysfunction and autism-like behaviours (ALB) in mouse offspring. An intestine-specific VDR-deficient mouse model was established for prenatal treatment, while transplantation of haematopoietic stem cells (HSCT) with related gene manipulation was used for postnatal treatment for 17-OHPC exposure-induced GI dysfunction and ALB in mouse offspring. The in vivo mouse experiments found that VDR deficiency mimics prenatal 17-OHPC exposure-mediated GI dysfunction, but has no effect on 17-OHPC-mediated autism-like behaviours (ALB) in mouse offspring. Furthermore, prenatal 17-OHPC exposure induces CLDN1 suppression in intestine epithelial cells, and transplantation of HSCT with CLDN1 expression ameliorates prenatal 17-OHPC exposure-mediated GI dysfunction, but has no effect on 17-OHPC-mediated ALB in offspring. In conclusion, prenatal 17-OHPC exposure triggers GI dysfunction in autism-like mouse offspring via CLDN1 suppression, providing a possible explanation for the involvement of CLDN1 and VDR in prenatal 17-OHPC exposure-mediated GI dysfunction with ASD.

Reproductive biology research down under: highlights from the Australian and New Zealand Annual Meeting of the Society for Reproductive Biology, 2021

Against the backdrop of a global pandemic, the Society for Reproductive Biology (SRB) 2021 meeting reunited the Australian and New Zealand reproductive research community for the first time since 2019 and was the first virtual SRB meeting. Despite the recent global research disruptions, the conference revealed significant advancements in reproductive research, the importance of which span human health, agriculture, and conservation. A core theme was novel technologies, including the use of medical microrobots for therapeutic and sperm delivery, diagnostic hyperspectral imaging, and hydrogel condoms with potential beyond contraception. The importance of challenging the contraceptive status quo was further highlighted with innovations in gene therapies, non-hormonal female contraceptives, epigenetic semen analysis, and in applying evolutionary theory to suppress pest population reproduction. How best to support pregnancies, particularly in the context of global trends of increasing maternal age, was also discussed, with several promising therapies for improved outcomes in assisted reproductive technology, pre-eclampsia, and pre-term birth prevention. The unique insights gained via non-model species was another key focus and presented research emphasised the importance of studying diverse systems to understand fundamental aspects of reproductive biology and evolution. Finally, the meeting highlighted how to effectively translate reproductive research into policy and industry practice.

Understanding and Reducing Persistent Racial Disparities in Preterm Birth: a Model of Stress-Induced Developmental Plasticity

Preterm birth is a leading cause of neonatal mortality and is characterized by substantial racial disparities in the US. Despite efforts to reduce preterm birth, rates have risen and racial disparities persist. Maternal stress is a risk factor for preterm birth; however, often, it is treated as a secondary variable rather than a primary target for intervention. Stress is known to affect several biological processes leading to downstream sequelae. Here, we present a model of stress-induced developmental plasticity where maternal stress is a key environmental cue impacting the length of gestation and therefore a primary target for intervention. Black women experience disproportionate and unique maternal stressors related to perceived racism and discrimination. It is therefore not surprising that Black women have disproportionate rates of preterm birth. The downstream effects of racism on preterm birth pathophysiology may reflect an appropriate response to stressors through the highly conserved maternal-fetal-placental neuroendocrine stress axis. This environmentally sensitive system mediates both maternal stress and the timing of birth and is a mechanism by which developmental plasticity occurs. Fortunately, stress does not appear to be an all-or-none variable. Evidence suggests that developmental plasticity is dynamic, functioning on a continuum. Therefore, simple, stress-reducing interventions that support pregnant women may tangibly reduce rates of preterm birth and improve birth outcomes for all women, particularly Black women.

The perceptions of obstetric care providers about cervical length screening for preterm birth prevention

BACKGROUND

Routine cervical length (CL) measurement at the mid-pregnancy ultrasound is a central recommendation of the Western Australian Preterm Birth Prevention Initiative (Initiative).

AIM

To evaluate the perceptions and changes in practice of Western Australian obstetric care providers regarding routine CL screening for preterm birth (PTB) prevention following the Initiative introduction.

METHODS

Two self-administered questionnaires were completed by providers from a range of practices. The first was during site visits with the Initiative Outreach team in 2015-2016. The questionnaire was re-issued in 2021 via online dissemination. Participant demographic data and opinions on CL screening for PTB prevention were collected.

RESULTS

Two hundred and fourteen providers participated in 2015-2016 and 109 in 2021. In both surveys, providers were more likely to discuss transvaginal CL screening with high-risk women (48.1%, 76.1%; P < 0.001) compared with low-risk (7.5%, 18.3%; P = 0.002) and the importance of CL screening (13.5%, 40.4%; P < 0.001), in 2015-2016 and 2021, respectively. Responses relating to CL screening, including what constitutes a short cervix on ultrasound were varied. A transabdominal CL <35 mm was classified as short by 46.2% and 37.6% and <25 mm on transvaginal ultrasound by 49.1% and 64.2%, in the respective surveys. Most providers ceased progesterone (68.6%, 75.2%) at >28 weeks gestation.

CONCLUSIONS

Providers focused on women with overt PTB risk factors, rather than a universal CL screening approach. Although there was improvement between the surveys, the definition of what constitutes a short cervix on ultrasound and how to treat and monitor women with a short CL remained varied.

Evaluation of maternal risk factors for preterm delivery in Fatemieh Hospital of Hamadan, Iran, 2019: A case-control study

Background

The present study aimed to evaluate maternal risk factors of preterm delivery in Fatemieh Hospital in Hamadan, Iran, 2019.

Methods

In this case-control study, 7,478 hospital files of live-born neonates and their mothers in Hamadan Fatemieh Hospital in 2019 were examined. According to statistical estimates, 261 preterm deliveries and 736 term deliveries were studied. Information files of neonates and mothers were used to complete the study questionnaire. The data were compared in two separate groups and logistic regression was performed to estimate the crude relationship between demographic and clinical characteristics of term and preterm delivery.

Results

The mean age of women was 27.89 ± 6.48 years. Analysis of data revealed that academic education (OR: 2.02, P = 0.014), age group 25-34 years (OR: 1.5, P = 0.016), age of 35 years and above (OR: 1.66, P = 0.018), previous history of preterm delivery (OR: 5.3, P < 0.001), history of abortion (OR: 1.67, P = 0.004), history of surgery (OR: 1.54, P = 0.007), history of infertility (P = 0.016), and a history of cesarean (OR: 2.11, P < 0.001) were potentially associated with a higher odds of preterm delivery (P < 0.2).

Conclusion

Based on the results, it is important to identify potential risk factors of preterm delivery in mothers and corrective interventions in strengthening consultation and education of pregnant women during pregnancy. Such a measure helps select the type of delivery and strengthen prenatal care in identifying mothers in high-risk groups and performing timely interventions.

Disparities in severe neonatal morbidity and mortality between Aboriginal and non-Aboriginal births in Western Australia: a decomposition analysis

BACKGROUND

The health disadvantages faced by Australian Aboriginal peoples are evidenced in early life, although few studies have focused on the reasons for population-level inequalities in more severe adverse outcomes. This study aimed to examine the scale of disparity in severe neonatal morbidity (SNM) and mortality between Aboriginal and non-Aboriginal births and quantify the relative contributions of important maternal and infant factors.

METHOD

A retrospective cohort study with singleton live births (≥32 weeks' gestation) was conducted using Western Australia linked whole population datasets, from 1999 to 2015. Aboriginal status was determined based on the mothers' self-reported ethnic origin. An Australian validated indicator was adapted to identify neonates with SNM. The Oaxaca-Blinder method was employed to calculate the contribution of each maternal and infant factor to the disparity in SNM and mortality.

RESULTS

Analyses included 425 070 births, with 15 967 (3.8%) SNM and mortality cases. The disparity in SNM and mortality between Aboriginal and non-Aboriginal births was 2.9 percentage points (95% CI 2.6 to 3.2). About 71% of this gap was explained by differences in modelled factors including maternal area of residence (23.8%), gestational age (22.2%), maternal age (7.5%) and antenatal smoking (7.2%).

CONCLUSIONS

There is a considerable disparity in SNM and mortality between Aboriginal and non-Aboriginal births in Western Australia with the majority of this related to differences in maternal sociodemographic factors, antenatal smoking and gestational age. Public health programmes targeting these factors may contribute to a reduction in early life health differentials and benefit Aboriginal population health through the life course.

Data-driven risk stratification for preterm birth in Brazil: a population-based study to develop of a machine learning risk assessment approach

Background

Preterm birth (PTB) is a growing health issue worldwide, currently considered the leading cause of newborn deaths. To address this challenge, the present work aims to develop an algorithm capable of accurately predicting the week of delivery supporting the identification of a PTB in Brazil.

Methods

This a population-based study analyzing data from 3,876,666 mothers with live births distributed across the 3,929 Brazilian municipalities. Using indicators comprising delivery characteristics, primary care work processes, and physical infrastructure, and sociodemographic data we applied a machine learning-based approach to estimate the week of delivery at the point of care level. We tested six algorithms: eXtreme Gradient Boosting, Elastic Net, Quantile Ordinal Regression - LASSO, Linear Regression, Ridge Regression and Decision Tree. We used the root-mean-square error (RMSE) as a precision.

Findings

All models obtained RMSE indexes close to each other. The lower levels of RMSE were obtained using the eXtreme Gradient Boosting approach which was able to estimate the week of delivery within a 2.09 window 95%IC (2.090-2.097). The five most important variables to predict the week of delivery were: number of previous deliveries through Cesarean-Section, number of prenatal consultations, age of the mother, existence of ultrasound exam available in the care network, and proportion of primary care teams in the municipality registering the oral care consultation.

Interpretation

Using simple data describing the prenatal care offered, as well as minimal characteristics of the pregnant, our approach was capable of achieving a relevant predictive performance regarding the week of delivery.

Funding

Bill and Melinda Gates Foundation, and National Council for Scientific and Technological Development - Brazil, (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPQ acronym in portuguese) Support of the research project named: Data-Driven Risk Stratification for Preterm Birth in Brazil: Development of a Machine Learning-Based Innovation for Health Care- Grant: OPP1202186.

Cannabis and tobacco use prior to pregnancy and subsequent offspring birth outcomes: a 20-year intergenerational prospective cohort study

There is increasing evidence that the life-course origins of health and development begin before conception. We examined associations between timing and frequency of preconception cannabis and tobacco use and next generation preterm birth (PTB), low birth weight (LBW) and small for gestational age. 665 participants in a general population cohort were repeatedly assessed on tobacco and cannabis use between ages 14-29 years, before pregnancy. Associations were estimated using logistic regression. Preconception parent (either maternal or paternal) daily cannabis use age 15-17 was associated with sixfold increases in the odds of offspring PTB (aOR 6.65, 95% CI 1.92, 23.09), and offspring LBW (aOR 5.84, 95% CI 1.70-20.08), after adjusting for baseline sociodemographic factors, parent sex, offspring sex, family socioeconomic status, parent mental health at baseline, and concurrent tobacco use. There was little evidence of associations with preconception parental cannabis use at other ages or preconception parental tobacco use. Findings support the hypothesis that the early life origins of growth begin before conception and provide a compelling rationale for prevention of frequent use during adolescence. This is pertinent given liberalisation of cannabis policy.

Furin is involved in uterine activation for labor

The uterus undergoes distinct molecular and functional changes during pregnancy and parturition. These processes are associated with the dramatic changes in various proteins. Given that the maturation and activation of many proteins require proteolytic processing by proprotein convertases (PCs), we sought to explore the role of PCs in uterine activation for labor. First, we found that furin was the most dramatically increased PC member in myometrial tissues from the pregnant women after onset of labor at term. Using the model of cultured human myometrial smooth muscle cells (HMSMCs), we showed that furin inhibitor CMK, D6R treatment and furin siRNA transfection suppressed contractility. Inhibition of furin activity or interfering furin expression decreased connexin 43 (CX43), prostaglandin (PG) endoperoxide synthase-2 (COX-2) and PGF2α receptor (FP) expression and NF-κB activation. In mouse model, administration of furin inhibitors prolonged gestational length. However, D6R treatment did not affect RU38486- and lipopolysaccharides (LPS)-induced preterm birth. Furthermore, D6R and furin siRNA treatment reduced the release of soluble form of tumor necrosis factor (TNF)-related weak inducer of apoptosis (TWEAK), while furin overexpression led to an increase in soluble TWEAK release in cultured HMSMCs. D6R treatment decreased TWEAK level in blood of pregnant mice. TWEAK treatment promoted contractility and NF-κB activation, while TWEAK receptor fibroblast growth factor-inducible 14 (FN14) antagonist treatment inhibited contractility and NF-κB activation in HMSMCs. In pregnant mice, administration of FN14 antagonist prolonged gestational length. Our data suggest that furin can act as a stimulator for uterine activation for labor at term. TWEAK is one of the potential substrates which mediate furin regulation of parturition initiation.

The amniotic fluid cell-free transcriptome in spontaneous preterm labor

The amniotic fluid (AF) cell-free RNA was shown to reflect physiological and pathological processes in pregnancy, but its value in the prediction of spontaneous preterm delivery is unknown. Herein we profiled cell-free RNA in AF samples collected from women who underwent transabdominal amniocentesis after an episode of spontaneous preterm labor and subsequently delivered within 24 h (n = 10) or later (n = 28) in gestation. Expression of known placental single-cell RNA-Seq signatures was quantified in AF cell-free RNA and compared between the groups. Random forest models were applied to predict time-to-delivery after amniocentesis. There were 2385 genes differentially expressed in AF samples of women who delivered within 24 h of amniocentesis compared to gestational age-matched samples from women who delivered after 24 h of amniocentesis. Genes with cell-free RNA changes were associated with immune and inflammatory processes related to the onset of labor, and the expression of placental single-cell RNA-Seq signatures of immune cells was increased with imminent delivery. AF transcriptomic prediction models captured these effects and predicted delivery within 24 h of amniocentesis (AUROC = 0.81). These results may inform the development of biomarkers for spontaneous preterm birth.

Assessment of morbidity and mortality in newborns with late prematurity: experience of a reference maternity in the northeast of Brazil

BACKGROUND

Late preterm infants show high rates of adverse perinatal outcomes. The aim of this study is to assess the morbidity and mortality of newborns (NBs) with late preterm birth in a reference maternity hospital in northeastern Brazil.

METHODS

Retrospective cohort study from March 1 to July 15, 2017. A total of 204 NBs with gestational age between 34 and 36 weeks and six days were evaluated and compared to 205 full-term NBs (39 and 40 weeks and six days). Perinatal outcomes including neonatal morbidity were evaluated. The Student's t and ANOVA tests were used for normal variables, and the Wilcoxon, Mann-Whitney and Kruskal-Wallis tests for non-normal variables.

RESULTS

Late preterm infants showed significant higher rates of hypothermia, hypoglycemia, respiratory distress syndrome, jaundice in need of phototherapy (67.6%), admission to the neonatal intensive care unit (ICU), and difficulty breastfeeding compared to full-term NBs (p<0.001). Respiratory distress was the main indication for the admission of late preterm infants (p<0.001) to neonatal ICU. Late preterm infants had a longer hospital stay (6.9 vs. 3.7 days, p<0.001). There were three deaths in the group of late preterm NBs, and none in the group of term NBs.

CONCLUSIONS

Late preterm NBs presented higher rates of morbidity and mortality when compared to full-term NBs.

Preventing early births in a regional tertiary maternity unit: Evaluating preterm and early term birth rates before and after implementation of the Preterm Birth Prevention Initiative in the Australian Capital Territory

BACKGROUND

A multifaceted preterm birth (PTB) prevention initiative was launched in the Australian Capital Territory (ACT) in 2019. The aim of this initiative was to safely lower the rate of early births across the ACT and the surrounding areas in New South Wales. Modelled on the Western Australian PTB Prevention Initiative, the program included new clinical guidelines and a new PTB prevention clinic at the main tertiary hospital.

AIM

To evaluate the initiative and its effects on preterm and early term birth rates at the main tertiary hospital after 16 months of implementation.

MATERIALS AND METHODS

A before and after intervention study was conducted. Rates of preterm and early term birth before (previous five years) and after 16 months of implementation of the ACT PTB Prevention Initiative were evaluated.

RESULTS

At the main tertiary hospital in The Canberra Hospital, the rate of PTB was significantly reduced by 10% after 16 months of implementation of the initiative. Rates of PTB were lower than any of the preceding five years and resulted in 45 averted or delayed PTBs. The number of planned early term births with no medical indication was significantly reduced by 34.5% and resulted in 77 averted or delayed early term births.

CONCLUSIONS

The multifaceted PTB Prevention Initiative safely lowered the rates of early birth in the ACT context. These results highlight the importance of prioritising early birth prevention, education, research and expanding the initiative nationwide.

Germinal Matrix-Intraventricular Hemorrhage: A Tale of Preterm Infants

Germinal matrix-intraventricular hemorrhage (GM-IVH) is a common intracranial complication in preterm infants, especially those born before 32 weeks of gestation and very-low-birth-weight infants. Hemorrhage originates in the fragile capillary network of the subependymal germinal matrix of the developing brain and may disrupt the ependymal lining and progress into the lateral cerebral ventricle. GM-IVH is associated with increased mortality and abnormal neurodevelopmental outcomes such as posthemorrhagic hydrocephalus, cerebral palsy, epilepsy, severe cognitive impairment, and visual and hearing impairment. Most affected neonates are asymptomatic, and thus, diagnosis is usually made using real-time transfontanellar ultrasound. The present review provides a synopsis of the pathogenesis, grading, incidence, risk factors, and diagnosis of GM-IVH in preterm neonates. We explore brief literature related to outcomes, management interventions, and pharmacological and nonpharmacological prevention strategies for GM-IVH and posthemorrhagic hydrocephalus.

Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies

BACKGROUND

Preterm birth (PTB) remains the foremost global cause of perinatal morbidity and mortality. Thus, the prevention of spontaneous PTB still remains of critical importance. In an attempt to prevent PTB in singleton pregnancies, cervical cerclage, in combination with other treatments, has been advocated. This is because, cervical cerclage is an intervention that is commonly recommended in women with a short cervix at high risk of preterm birth but, despite this, many women still deliver prematurely, as the biological mechanism is incompletely understood. Additionally, previous Cochrane Reviews have been published on the effectiveness of cervical cerclage in singleton and multiple pregnancies, however, none has evaluated the effectiveness of using cervical cerclage in combination with other treatments.

OBJECTIVES

To assess whether antibiotics administration, vaginal pessary, reinforcing or second cerclage placement, tocolytic, progesterone, or other interventions at the time of cervical cerclage placement prolong singleton gestation in women at high risk of pregnancy loss based on prior history and/or ultrasound finding of 'short cervix' and/or physical examination. History-indicated cerclage is defined as a cerclage placed usually between 12 and 15 weeks gestation based solely on poor prior obstetrical history, e.g. multiple second trimester losses due to painless dilatation. Ultrasound-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation for transvaginal ultrasound cervical length < 20 mm in a woman without cervical dilatation. Physical exam-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation because of cervical dilatation of one or more centimetres detected on physical (manual) examination.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

We included published, unpublished or ongoing randomised controlled trial (RCTs). Studies using a cluster-RCT design were also eligible for inclusion in this review but none were identified. We excluded quasi-RCTs (e.g. those randomised by date of birth or hospital number) and studies using a cross-over design. We also excluded studies that specified addition of the combination therapy after cervical cerclage because the woman subsequently became symptomatic. We included studies comparing cervical cerclage in combination with one, two or more interventions with cervical cerclage alone in singleton pregnancies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all retrieved articles, selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of the evidence for this review's main outcomes. Data were checked for accuracy. Standard Cochrane review methods were used throughout.

MAIN RESULTS

We identified two studies (involving a total of 73 women) comparing cervical cerclage alone to a different comparator. We also identified three ongoing studies (one investigating vaginal progesterone after cerclage, and two investigating cerclage plus pessary). One study (20 women), conducted in the UK, comparing cervical cerclage in combination with a tocolytic (salbutamol) with cervical cerclage alone in women with singleton pregnancy did not provide any useable data for this review. The other study (involving 53 women, with data from 50 women) took place in the USA and compared cervical cerclage in combination with a tocolytic (indomethacin) and antibiotics (cefazolin or clindamycin) versus cervical cerclage alone - this study did provide useable data for this review (and the study authors also provided additional data on request) but meta-analyses were not possible. This study was generally at a low risk of bias, apart from issues relating to blinding. We downgraded the certainty of evidence for serious risk of bias and imprecision (few participants, few events and wide 95% confidence intervals). Cervical cerclage in combination with an antibiotic and tocolytic versus cervical cerclage alone (one study, 50 women/babies) We are unclear about the effect of cervical cerclage in combination with antibiotics and a tocolytic compared with cervical cerclage alone on the risk of serious neonatal morbidity (RR 0.62, 95% CI 0.31 to 1.24; very low-certainty evidence); perinatal loss (data for miscarriage and stillbirth only - data not available for neonatal death) (RR 0.46, 95% CI 0.13 to 1.64; very low-certainty evidence) or preterm birth < 34 completed weeks of pregnancy (RR 0.78, 95% CI 0.44 to 1.40; very low-certainty evidence). There were no stillbirths (intrauterine death at 24 or more weeks). The trial authors did not report on the numbers of babies discharged home healthy (without obvious pathology) or on the risk of neonatal death.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to evaluate the effect of combining a tocolytic (indomethacin) and antibiotics (cefazolin/clindamycin) with cervical cerclage compared with cervical cerclage alone for preventing spontaneous PTB in women with singleton pregnancies. Future studies should recruit sufficient numbers of women to provide meaningful results and should measure neonatal death and numbers of babies discharged home healthy, as well as other important outcomes listed in this review. We did not identify any studies looking at other treatments in combination with cervical cerclage. Future research needs to focus on the role of other interventions such as vaginal support pessary, reinforcing or second cervical cerclage placement, 17-alpha-hydroxyprogesterone caproate or dydrogesterone or vaginal micronised progesterone, omega-3 long chain polyunsaturated fatty acid supplementation and bed rest.

Effect of gestational disorders on preterm birth, low birthweight, and NICU admission

OBJECTIVE

Many modifiable maternal behaviors and experiences before and during pregnancy are associated with adverse health outcomes. The relationship between a number of maternal and gestational disorders and perinatal outcomes (preterm birth, low birth weight and neonatal intensive care unit (NICU)) admission in the Central New York population is determined using the Statewide Perinatal Data System, in a retrospective population-based cohort study.

METHODS

Singleton births excluding newborns with congenital anomalies among 165,739 women between 2004 and 2012 are included in this study. Multivariable logistic regression analysis is used to estimate odds ratios (OR) and 95% confidence intervals (CI) adjusted for maternal age, race, education, employment, parity, body mass index, smoking, drug use, depression, abortions, gender of child, prenatal care, and hospital level.

RESULTS

Previous preterm birth and vaginal bleeding are independent high-risk factors for all three perinatal outcomes, pre-pregnancy diabetes (OR 4.95, 95% CI 4.34, 5.64) for preterm birth and (OR 7.45, 95% CI 6.58, 8.44) for NICU admission; and gestational hypertension (OR 4.35, 95% CI 4.03, 4.70) for low birth weight. Among infections, bacterial vaginosis is retained in the multivariable model as a risk factor for preterm and low birth weight while hepatitis C is a risk factor for NICU admission.

CONCLUSIONS

Our findings suggest the continued importance of addressing the need to provide preconception and inter conception care for women since many modifiable risk factors are correlated and need to be addressed well before the woman becomes pregnant.

Community-based, population-focused preterm birth prevention programs - a review

PURPOSE

Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality worldwide. Being born too early contributes to approximately 70% of neonatal mortality and approximately half of long-term neurodevelopmental disabilities. Various PTB prevention programs have been described going back more than 30 years, and some have described possible success in decreasing the rate of PTB. In addition, there are also PTB prenatal care clinics in many parts of the world, each with the singular goal of reducing the PTB rate in their region. Interventions can be directed at all women for primary prevention and reducing the risk of PTB or used to mitigate risk in women identified to be at increased risk.

METHODS

A Medline and ClinicalTrials.gov ( www.clinicaltrials.gov ) search was performed (1982-2018), using preterm birth prevention program as the primary medical subject heading, reporting randomized clinical trials, quasi-experimental trials, and analytic studies (including retrospective and prospective cohort studies). We also searched Google for preterm birth prevention programs and prenatal care clinics published on-line.

RESULTS

Some prevention programs have reported success in lowering rates of PTB, principally using historical controls although the majority were not followed by improved outcomes.

CONCLUSION

Increasing knowledge and the use of social media to enhance education should now enable greater effectiveness of new programs. Development of regional and national PTB prevention programs should now be considered.

Accounting for diverse evolutionary forces reveals mosaic patterns of selection on human preterm birth loci

Currently, there is no comprehensive framework to evaluate the evolutionary forces acting on genomic regions associated with human complex traits and contextualize the relationship between evolution and molecular function. Here, we develop an approach to test for signatures of diverse evolutionary forces on trait-associated genomic regions. We apply our method to regions associated with spontaneous preterm birth (sPTB), a complex disorder of global health concern. We find that sPTB-associated regions harbor diverse evolutionary signatures including conservation, excess population differentiation, accelerated evolution, and balanced polymorphism. Furthermore, we integrate evolutionary context with molecular evidence to hypothesize how these regions contribute to sPTB risk. Finally, we observe enrichment in signatures of diverse evolutionary forces in sPTB-associated regions compared to genomic background. By quantifying multiple evolutionary forces acting on sPTB-associated regions, our approach improves understanding of both functional roles and the mosaic of evolutionary forces acting on loci. Our work provides a blueprint for investigating evolutionary pressures on complex traits.

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

BACKGROUND

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

OBJECTIVES

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

SETTING

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

PARTICIPANTS

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

ANALYSIS

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

OUTCOME MEASURES

Preterm birth.

RESULTS

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

CONCLUSIONS

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

Vaginal compared with intramuscular progestogen for preventing preterm birth in high-risk pregnant women (VICTORIA study): a multicentre, open-label randomised trial and meta-analysis

OBJECTIVE

To compare the efficacy of two types of progestogen therapy for preventing preterm birth (PTB) and to review the relevant literature.

DESIGN

A multicentre, randomised, open-label, equivalence trial and a meta-analysis.

SETTING

Tertiary referral hospitals in South Korea.

POPULATION

Pregnant women with a history of spontaneous PTB or short cervical length (<25 mm).

METHODS

Eligible women were screened and randomised at 16-22 weeks of gestation to receive either 200 mg of vaginal micronised progesterone daily (vaginal group) or an intramuscular injection of 250 mg 17α-hydroxyprogesterone caproate weekly (IM group). Stratified randomisation was carried out according to participating centres and indications for progestogen therapy. This trial was registered at ClinicalTrials.gov (NCT02304237).

MAIN OUTCOME MEASURE

Preterm birth (PTB) before 37 weeks of gestation.

RESULTS

A total of 266 women were randomly assigned and a total of 247 women (119 and 128 women in the vaginal and IM groups, respectively) were available for the intention-to-treat analysis. Risks of PTB before 37 weeks of gestation did not significantly differ between the two groups (22.7 versus 25.8%, P = 0.571). The difference in PTB risk between the two groups was 3.1% (95% CI -7.6 to 13.8%), which was within the equivalence margin of 15%. The meta-analysis results showed no significant differences in the risk of PTB between the vaginal and IM progestogen treatments.

CONCLUSION

Compared with vaginal progesterone, treatment with intramuscular progestin might increase the risk of PTB before 37 weeks of gestation by as much as 13.8%, or reduce the risk by as much as 7.6%, in women with a history of spontaneous PTB or with short cervical length.

TWEETABLE ABSTRACT

Vaginal and intramuscular progestogen showed equivalent efficacy for preventing preterm birth before 37 weeks of gestation.

The elements of success in a comprehensive state-wide program to safely reduce the rate of preterm birth

Background

In 2014, a whole-of-population and multi-faceted preterm birth prevention program was introduced in Western Australia with the single aim of safely lowering the rate of preterm birth. The program included new clinical guidelines, print and social media, and a dedicated new clinic. In the first full calendar year the rate of preterm birth fell by 7.6% and the reduction extended from the 28–31 week gestational age group upwards.

Objective

The objective of this study was to evaluate outcomes in greater depth and to also include the first three years of the program.

Study design

This was a prospective population-based cohort study of perinatal outcomes in singleton pregnancies before and after commencement of the program.

Results

There was a significant reduction in preterm birth in the tertiary center which extended from 28 weeks gestation onwards and was ongoing. In non-tertiary centers there was an initial reduction, but this was not sustained past the first year. The greatest reduction was observed in pregnancies classified at first attendance as low risk. No benefit was observed in the private sector, but a significant reduction was seen in the remote region of the Kimberley where the program was first launched and vaginal progesterone had been made free-of-charge.

Conclusion

Preterm birth rates can be safely reduced by a multi-faceted and whole-of-population program but the effectiveness requires continuing effort and will be greatest where the strategies are most targeted.

A stitch in time: narrative review of interventions to reduce preterm births in Malawi

Background

The rising rate of preterm births (PTBs) is a global concern, and Malawi has a high rate of PTBs (10.5%). The resulting neonatal and under-5 mortality, morbidity and lifelong disability represent a significant loss of human potential affecting individuals, families and society as a whole. This study aims to review the literature to determine the risk factors for PTB in Malawi and to identify effective interventions to prevent PTBs.

Methods

A literature search yielded 22 studies that were categorized according to risk factors implicated for PTBs and health interventions to reduce the risks.

Results

The study has shown that maternal pregnancy factors, infections, nutrition, anaemia and young maternal age are the main causes and risk factors of PTBs in Malawi. The literature revealed no evidence of community-based interventions for reducing the rates of PTBs in Malawi.

Conclusions

Any successful effort to reduce the rate of PTBs will require a multisector, multilevel strategy targeted at the community, homes and individuals as a package to improve the education, nutrition and reproductive health of girls and women as well as focus on improving the delivery of antenatal services in the community.

Challenges in preterm birth research: Ghanaian perspective

Preterm birth is highly prevalent in Ghana. It is a major public health concern because of the high burden as well as the associated immediate and long-term consequences including increased healthcare cost. Studies conducted in high-income countries may not be sufficiently generalizable in our context. Locally generated evidence-based interventions will be indispensable in improving the clinical management and prevention of preterm birth in the country. However, there are limited published literature on preterm birth and prematurity in the country. This review seeks to discuss the major challenges associated with preterm birth research in Ghana and proposes evidence-based strategies to improve biomedical and epidemiological research on preterm birth and prematurity. The limited high quality preterm birth research is partly attributable to a variety of challenges related to accurate gestational age estimation, research training, capacity and support including funding, efficient ethics committees, local and international collaboration as well as effective health management information systems. Other related challenges include unavailability of reliable internet connectivity, poor compensation for researchers and lack of conductive research environment. There is the need to expedite advocacy on implementation of practical interventions and strategies aimed at increasing high quality research in the area of preterm birth and prematurity in the country. A paradigm shift in preterm birth research with appropriate integration of concerted multidisciplinary research groups should be constituted to put basic science research to clinical practice as well as the prevention of preterm birth in the country.

Late preterm infants - Changing trends and continuing challenges

Late preterm infants, defined as newborns born between 340/7-366/7 weeks of gestational age, constitute a unique group among all premature neonates. Often overlooked because of their size when compared to very premature infants, this population is still vulnerable because of physiological and structural immaturity. Comprising nearly 75% of babies born less than 37 weeks of gestation, late preterm infants are at increased risk for morbidities involving nearly every organ system as well as higher risk of mortality when compared to term neonates. Neurodevelopmental impairment has especially been a concern for these infants. Due to various reasons, the rate of late preterm births continue to rise worldwide. Caring for this high risk population contributes a significant financial burden to health systems. This article reviews recent trends in regarding rate of late preterm births, common morbidities and long term outcomes with special attention to neurodevelopmental outcomes.

Impact of erythrocyte long-chain omega-3 polyunsaturated fatty acid levels in early pregnancy on birth outcomes: findings from a Belgian cohort study

OBJECTIVE

To examine the association between maternal erythrocyte long-chain omega-3 PUFA (n-3 LCPUFA), measured in early pregnancy, and pregnancy and birth outcomes.

STUDY DESIGN

One hundred and eight healthy women with a singleton pregnancy were included. Erythrocyte fatty acids were analyzed using gas chromatography. Gestational length, birth anthropometric measures, and pregnancy-associated complications were collected from hospital medical records.

RESULTS

We observed significant positive associations between maternal docosahexaenoic acid (DHA) levels (p = 0.024) and omega-3 index values (p = 0.021) and gestational length in adjusted linear regression models. Each point in maternal DHA level was associated with 2.19 days longer gestational duration (β = 2.19; 95% CI 0.29-4.09). No consistent associations were found between n-3 PUFA levels and composite pregnancy outcome.

CONCLUSION

These findings suggest that the gestational length is positively affected by maternal n-3 LCPUFA status as soon as the early stages of pregnancy.

Preterm birth prediction in asymptomatic women at mid-gestation using a panel of novel protein biomarkers: the Prediction of PreTerm Labor (PPeTaL) study

BACKGROUND

Accurate prediction of spontaneous preterm labor/preterm birth in asymptomatic women remains an elusive clinical challenge because of the multi-etiological nature of preterm birth.

OBJECTIVE

The aim of this study was to develop and validate an immunoassay-based, multi-biomarker test to predict spontaneous preterm birth.

MATERIALS AND METHODS

This was an observational cohort study of women delivering from December 2017 to February 2019 at 2 maternity hospitals in Melbourne, Australia. Cervicovaginal fluid samples were collected from asymptomatic women at gestational week 16⁺⁰-24⁺⁰, and biomarker concentrations were quantified by enzyme-linked immunosorbent assay. Women were assigned to a training cohort (n = 136) and a validation cohort (n = 150) based on chronological delivery dates.

RESULTS

Seven candidate biomarkers representing key pathways in utero-cervical remodeling were discovered by high-throughput bioinformatic search, and their significance in both in vivo and in vitro studies was assessed. Using a combination of the biomarkers for the first 136 women allocated to the training cohort, we developed an algorithm to stratify term birth (n = 124) and spontaneous preterm birth (n = 12) samples with a sensitivity of 100% (95% confidence interval, 76-100%) and a specificity of 74% (95% confidence interval, 66-81%). The algorithm was further validated in a subsequent cohort of 150 women (n = 139 term birth and n = 11 preterm birth), achieving a sensitivity of 91% (95% confidence interval, 62-100%) and a specificity of 78% (95% confidence interval, 70-84%).

CONCLUSION

We have identified a panel of biomarkers that yield clinically useful diagnostic values when combined in a multiplex algorithm. The early identification of asymptomatic women at risk for preterm birth would allow women to be triaged to specialist clinics for further assessment and appropriate preventive treatment.

Cervical Characterization with Tactile-Ultrasound Probe

BACKGROUND

Premature cervical softening and shortening may be considered an early mechanical failure that predisposes to preterm birth. Preliminary clinical studies demonstrate that cervical elastography may be able to quantify this phenomenon and predict spontaneous preterm delivery.

OBJECTIVE

To explore a new approach for cervix elasticity and length measurements with tactile-ultrasound probe.

METHODS

Cervix probe has tactile array and ultrasound transducer designed to apply controllable load to cervix and acquire stress-strain data for calculation of cervical elasticity (Young's modulus) and cervical length for four cervix sectors. Average values, standard deviations, intraclass correlation coefficients and the 95% limits of agreement (Bland-Altman plots) were estimated.

RESULTS

Ten non-pregnant and ten pregnant women were examined with the probe. The study with non-pregnant women demonstrated a reliable acquisition of the tactile signals. The ultrasound signals had a prolonged appearance; identification of the internal os of the cervix in these signals was not reliable. The study with pregnant women with the gestational age of 25.4 ± 2.3 weeks demonstrated reliable data acquisition with real-time visualization of the ultrasound signals. Average values for cervical elasticity and standard deviations of 19.7 ± 15.4 kPa and length of 30.7 ± 6.6 mm were calculated based on two measurements per 4 sectors. Measurement repeatability calculated as intraclass correlation coefficients between two measurements at the same cervix sector on pregnant women was found to be 0.97 for cervical elasticity and 0.93 for the cervical length. The 95% limits of agreement of 1) cervical elasticity were from -22.4% to +14.9%, and 2) cervical length from -13.3% to +16.5%.

CONCLUSIONS

This study demonstrated clinically acceptable measurement performance and reproducibility. The availability of stress-strain data allowed the computation of cervical elasticity and length. This approach has the potential to provide cervical markers to predict spontaneous preterm delivery.

Maternal and severe anaemia in delivering women is associated with risk of preterm and low birth weight: A cross sectional study from Jharkhand, India

BACKGROUND AND OBJECTIVES

Haemoglobin content is the well accepted indicator for anaemia assessment. The high prevalence of anaemia, maternal health care issues and adverse delivery outcome in Jharkhand, we investigated whether delivering women with anaemia would present a modifiable risk of preterm (PTB) and low birth weight (LBW).

METHODS

A facility-based cross-sectional study involving pregnant women, with screening for pregnancy endpoints and haemoglobin assay, were conducted. Anaemia was classified according to World Health Organization's definition of anaemia in pregnancy. Confounding variables were adjusted in a logistic model. The adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were used for analyzing the association among maternal anaemia, PTB and LBW.

RESULTS

We observed a high prevalence of anaemia (78.45%) in delivering women, whereas high prevalence of preterm birth (34.75%) and LBW (32.81%) in delivering women overall. In the adjusted analysis, overall anaemia in pregnancy was strongly associated with preterm birth (OR, 3.42; 95% CI, 1.98-5.88; P ≤ .0001) as compared to LBW (OR, 1.12; 95% CI, 0.65-1.61; P = .0003). The risk of PTB and LBW were dependent on the stratification of the anaemia group, as the strongest association was observed in severe (OR, 4.86) followed by mild (OR, 3.66) and moderate (OR, 3.18) anaemia in PTB; whereas risk of LBW was found in severe (OR, 2.5) followed by moderate (OR, 1.11) and mild (OR, 0.57) anaemia. The risk of PTB and LBW across six pregnancy haemoglobin groups were compared, haemoglobin of 10-10.9 g/dl (OR, 1.25) and ≤ 8 g/dl (OR, 1.03) have shown association with PTB and LBW, respectively. However, high haemoglobin concentration was not associated with either PTB or LBW.

CONCLUSIONS

Anaemia in delivering women was associated with an elevated risk of PTB and LBW and the risk increased with the severity of anaemia in pregnant women.

Updates on an At-Risk Population: Late-Preterm and Early-Term Infants

The American Academy of Pediatrics published a clinical report on late-preterm (LPT) infants in 2007 that was largely based on a summary of a 2005 workshop convened by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, at which a change in terminology from "near term" to "late preterm" was proposed. This paradigm-shifting recommendation had a remarkable impact: federal agencies (the Centers for Disease Control and Prevention), professional societies (the American Academy of Pediatrics and American College of Obstetricians and Gynecologists), and organizations (March of Dimes) initiated nationwide monitoring and educational plans that had a significant effect on decreasing the rates of iatrogenic LPT deliveries. However, there is now an evolving concern. After nearly a decade of steady decreases in the LPT birth rate that largely contributed to the decline in total US preterm birth rates, the birth rate in LPT infants has been inching upward since 2015. In addition, evidence revealed by strong population health research demonstrates that being born as an early-term infant poses a significant risk to an infant's survival, growth, and development. In this report, we summarize the initial progress and discuss the potential reasons for the current trends in LPT and early-term birth rates and propose research recommendations.

Drugs for the Prevention and Treatment of Bronchopulmonary Dysplasia

Rates of bronchopulmonary dysplasia (BPD) are increasing. After preterm birth, there are important developmental periods in which neonates are more vulnerable to stressful events. These periods are opportunities for pharmacologic interventions. Many drugs remain inadequately tested and no new drugs have been approved in more than 25 years for BPD prevention or therapy. More progress is needed in defining appropriate end points based on the pathophysiology of BPD and postdischarge chronic pulmonary insufficiency of prematurity and to develop effective new drugs. In addition, much work is needed to better define perinatal factors, early postnatal findings, and physiologic phenotypes or endotypes.

History of the establishment of the Preterm Birth international collaborative (PREBIC)

INTRODUCTION

The primary aim of PREBIC is to assess the underlying mechanisms and developing strategies for preterm birth (PTB) prevention.

MATERIALS AND METHODS

We used concept mapping and logic models to track goals. This paper reviews our progress over 13 years using working group activities, research developments, guest speakers, and publications.

RESULTS

Using interactions between genetics, environment, and behaviors we identified complex interactions between biological systems. PREBIC determined that epidemiology and biomarkers should be an initial focus. In 2005, we initiated presentations by young investigators, yearly satellite meetings, working groups including nutrition and inflammation, assessment of clinical trials, and accepted an invitation by the WHO to begin yearly meetings in Geneva.

DISCUSSION

PREBIC used epidemiology to identify PTB factors and complex pathways. Candidate genes are associated with the environment, behavior (stress), obesity, inflammation and insulin resistance. Epigenetic changes and production of proteins can be used as biomarkers to define risk. Subsequently, we found risk factors for PTB that were also associated with the risk of cardiovascular disease (CVD) of the mother. Tanz et al. (2017) found that a history of PTB is independently predictive of CVD later in life and suggested that a modest proportion of PTB-CVD association was accounted by CVD risk factors, many of which have been identified in this paper.

CONCLUSION

Our findings support a relationship between genes, environment, behaviors and risk of CVD in women. The next several years must assess which factors are modifiable early in life and before pregnancy to prevent PTB.

Generational Health Impact of PCOS on Women and their Children

Polycystic ovary syndrome (PCOS) is a metabolic disorder with reproductive consequences. Hence, the synergy of the dual maternal challenges of difficulties with conception, set on a background of metabolic disorder and inflammation, understandably leads to increased obstetric risk for the woman. Furthermore, she is more likely than her peers to require assistance with conception, either through induction of ovulation with the attendant risk of a multiple gestation, or in vitro fertilization (IVF) with its recognized increased obstetric risk for woman and her child. The increased obstetric risk for a woman with PCOS is manifested with an increased rate of miscarriage, gestational diabetes, hypertensive disorder and premature delivery. These obstetric complications are due to impairment of placental function, systemic inflammation and metabolic disorder and are markers for the woman herself of her predisposition to cardiometabolic disorder in later life. Consequently, it is inevitable that this environment may induce changes in the fetus during pregnancy, leading to an intergenerational risk from maternal PCOS.

The effect of pregnancy induced hypertension and multiple pregnancies on preterm birth in Ethiopia: a systematic review and meta-analysis

Objective

This systematic review and meta-analysis aimed to estimate the overall pooled prevalence of preterm birth and the effect of pregnancy induced hypertension (PIH) and multiple pregnancies on preterm birth in Ethiopia.

Result

A total of 9 studies with 27,119 participants were included in this systematic review and meta-analysis. The pooled prevalence of preterm birth among mothers who gave births in Ethiopia was found to be 13.32% (95% CI = 7.99, 18.660). Preterm birth was found to be higher among mothers who had pregnancy induced hypertension with odds ratio of 4.69 (95% CI = 2.32, 9.49) and multiple pregnancy with odds ratio of 2.40 (95% CI = 1.06, 5.45) as compared to the counterparts. In subgroup analysis by region, the prevalence of preterm birth was found to be 12.63% (95% CI = 3.26, 22) in Amhara and 10.18% (95% CI = 6.04, 14.32) in Oromia region.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4128-0) contains supplementary material, which is available to authorized users.

Development of a mucoinert progesterone nanosuspension for safer and more effective prevention of preterm birth

Preterm birth (PTB) is a significant global problem, but few therapeutic options exist. Vaginal progesterone supplementation has been demonstrated to reduce PTB rates in women with a sonographic short cervix, yet there has been little investigation into the most effective dose or delivery form. Further, vaginal products like progesterone gel often contain excipients that cause local toxicity, irritation, and leakage. Here, we describe the development and characterization of a mucoinert vaginal progesterone nanosuspension formulation for improved drug delivery to the female reproductive tract. We compare the pharmacokinetics and pharmacodynamics to the clinical comparator progesterone gel in pregnant mice and demonstrate increased vaginal absorption and biodistribution via the uterine first-pass effect. Importantly, the unique plasma progesterone double peak observed in humans, reflecting recirculation from the uterus, was also observed in pregnant mice with vaginal dosing. We adapted a mouse model of progesterone withdrawal that was previously believed to be incompatible with testing the efficacy of exogenous progestins, and are first to demonstrate efficacy in preventing preterm birth with vaginal progesterone in this model. Further, improved vaginal progesterone delivery by the nanosuspension led to increased efficacy in PTB prevention. Additionally, we identified histological and transcriptional evidence of cervical and uterine toxicity with a single vaginal administration of the clinical gel that are absent after dosing with the mucoinert nanosuspension formulation. We demonstrate that a progesterone formulation that is designed for improved vaginal progesterone absorption and vaginal biocompatibility could be more effective for PTB prevention.

Progesterone effects on vaginal cytokines in women with a history of preterm birth

Objective

To determine the effect of intramuscular progesterone on the vaginal immune response of pregnant women with a history of prior preterm birth.

Methods

A prospective, cohort study of women at 11–16 weeks gestation, ≥18 years of age, and carrying a singleton pregnancy was conducted from June 2016 to August 2017 after IRB approval. Women in the progesterone arm had a history of preterm birth and received weekly intramuscular 17-hydroxyprogesterone caproate. Controls comprised of women with healthy, uncomplicated pregnancies. Excluded were women with vaginitis, diabetes mellitus, hypertension, or other chronic diseases affecting the immune response. A vaginal wash was performed at enrollment, at 26–28 weeks, and at 35–36 weeks gestation. Samples underwent semi-quantitative detection of human inflammatory markers. Immunofluorescence pixel density data was analyzed and a P value <0.05 was considered significant.

Results

There were 39 women included, 10 with a prior preterm birth and 29 controls. The baseline demographics and pregnancy outcomes for both groups were similar in age, parity, race, BMI, gestational age at delivery, mode of delivery, and birth weight. Enrollment cytokines in women with a prior preterm birth, including IL-1 alpha (39.2±25.1% versus 26.1±13.2%; P = 0.04), IL-1 beta (47.9±26.4% versus 24.9±17%; P<0.01), IL-2 (16.7±9.3% versus 11.3±6.3%; P = 0.03), and IL-13 (16.9±12.4% versus 8.2±7.4%; P = 0.01) were significantly elevated compared to controls. In the third trimester the cytokine densities for IL-1 alpha (26.0±18.2% versus 22.3±12.0%; P = 0.49), IL-1 beta (31.8±15.9% versus 33.1±16.8%; P = 0.84), IL-2 (10.0±8.4% versus 10.9±5.9%; P = 0.71), and IL-13 (9.1±5.9% versus 10.0±6.5%; P = 0.71) were all statistically similar between the progesterone arm and controls, respectively.

Conclusion

There is an increased cytokine presence in vaginal washings of women at risk for preterm birth which appears to be modified following the administration of 17- hydroxyprogesterone caproate to levels similar to healthy controls.