Quantifying low birth weight, preterm birth and small-for-gestational-age effects of malaria in pregnancy: a population cohort study

Heterogeneity in the prevalence of subclinical malaria, other co-infections and anemia among pregnant women in rural areas of Myanmar: a community-based longitudinal study

BACKGROUND

Due to the low prevalence of clinically suspected malaria among pregnant women in Myanmar, little is known about its impact on mothers and newborns. Helminth and Human Immuno-deficiency Virus (HIV) co-infections cause anemia in pregnant women. This study assessed the prevalence of subclinical malaria and co-infections among pregnant women, and its association with adverse outcomes of pregnancy in the presence of infection.

METHODS

A prospective longitudinal study was conducted in 12 villages in two townships in Myanmar between 2013 to 2015. A total of 752 pregnant women, with a mean age of 27 years, were enrolled and followed up once a month until six weeks after childbirth. Prevalence ratio was calculated in the multivariable analysis.

RESULTS

The prevalence of subclinical malaria as measured by nested PCR was 5.7% for either P. falciparum or P. vivax, 2.7% prevalence of P. falciparum and 2.8% prevalence of P. vivax. Helminth infections were prevalent in 17% of women, and one woman with an HIV infection was found in our study. The burden of anemia was high, with an overall prevalence of 37% with or without helminth infection, 42% of the women were malaria positive and 43% had dual infections (both malaria and helminth). Only 11 abnormal pregnancy outcomes (7 stillbirths, 2 premature, 2 twins) were identified. Poisson regression showed that women in their first trimester had a 2.9 times higher rate of subclinical malaria compared to women in the third trimester (PR:2.9, 95%CI 1.19, 7.31, p = 0.019), women who were enrolled during the wet season were 2.5 times more likely to be malaria positive than the women enrolled in the dry season (PR: 2.5, 95%CI 1.27, 4.88, p = 0.008), and the malaria positivity rate decreased by 5% when increased in one year of woman's age (PR:0.95, 95%CI 0.91, 0.99, p = 0.02). In the multivariable regression, the age of respondents was the only significant factor associated with subclinical malaria in pregnancy.

CONCLUSIONS

A comprehensive approach of integrating interventions for malaria, anemia, and helminths should be delivered during antenatal care services for pregnant women in rural areas of Myanmar.

Critical research gaps in treating growth faltering in infants under 6 months: A systematic review and meta-analysis

In 2020, 149.2 million children worldwide under 5 years suffered from stunting, and 45.4 million experienced wasting. Many infants are born already stunted, while others are at high risk for growth faltering early after birth. Growth faltering is linked to transgenerational impacts of poverty and marginalization. Few interventions address growth faltering in infants under 6 months, despite a likely increasing prevalence due to the negative global economic impacts of the COVID-19 pandemic. Breastfeeding is a critical intervention to alleviate malnutrition and improve child health outcomes, but rarely receives adequate attention in growth faltering interventions. A systematic review and meta-analysis were undertaken to identify and evaluate interventions addressing growth faltering among infants under 6 months that employed supplemental milks. The review was carried out following guidelines from the USA National Academy of Medicine. A total of 10,405 references were identified, and after deduplication 7390 studies were screened for eligibility. Of these, 227 were assessed for full text eligibility and relevance. Two randomized controlled trials were ultimately included, which differed in inclusion criteria and methodology and had few shared outcomes. Both studies had small sample sizes, high attrition and high risk of bias. A Bangladeshi study (n = 153) found significantly higher rates of weight gain for F-100 and diluted F-100 (DF-100) compared with infant formula (IF), while a DRC trial (n = 146) did not find statistically significant differences in rate of weight gain for DF-100 compared with IF offered in the context of broader lactation and relactation support. The meta-analysis of rate of weight gain showed no statistical difference and some evidence of moderate heterogeneity. Few interventions address growth faltering among infants under 6 months. These studies have limited generalizability and have not comprehensively supported lactation. Greater investment is necessary to accelerate research that addresses growth faltering following a new research framework that calls for comprehensive lactation support.

Hearing Loss and Disorders: The Repercussions of Climate Change

PURPOSE

Climate change is considered to be the greatest threat to human health in the 21st century, and its effects are accelerating. Extensive research has clearly demonstrated its increasing impact across the continuum of health conditions. Despite this, there has been limited attention to the ramifications of climate change on hearing loss and hearing disorders. This lack of consideration is somewhat surprising as the environment itself and its changing nature have a substantial effect on hearing.

METHOD

Tackling climate change could be the greatest global health opportunity of the 21st century. To address this issue, this tutorial provides a general introduction to climate change and its three major elements (pollution, infectious diseases, and extreme weather events) and their effects on health. The substantial consequences of climate change for the incidence, development, and exacerbation of hearing loss and disorders are clearly described and detailed.

CONCLUSIONS

The challenge of responding to this very real and escalating threat to hearing requires a combination of prevention, advocacy, and education. These three roles place audiologists in the perfect position to take action on the far-reaching effects of climate change on hearing loss and disorders. To respond to this challenge and to fulfill these roles, several strategies, ranging from the individual level to the global level, are delineated for audiologists to incorporate into their practice.

The effect and control of malaria in pregnancy and lactating women in the Asia-Pacific region

Half of all pregnancies at risk of malaria worldwide occur in the Asia-Pacific region, where Plasmodium falciparum and Plasmodium vivax co-exist. Despite substantial reductions in transmission, malaria remains an important cause of adverse health outcomes for mothers and offspring, including pre-eclampsia. Malaria transmission is heterogeneous, and infections are commonly subpatent and asymptomatic. High-grade antimalarial resistance poses a formidable challenge to malaria control in pregnancy in the region. Intermittent preventive treatment in pregnancy reduces infection risk in meso-endemic New Guinea, whereas screen-and-treat strategies will require more sensitive point-of-care tests to control malaria in pregnancy. In the first trimester, artemether-lumefantrine is approved, and safety data are accumulating for other artemisinin-based combinations. Safety of novel antimalarials to treat artemisinin-resistant P falciparum during pregnancy, and of 8-aminoquinolines during lactation, needs to be established. A more systematic approach to the prevention of malaria in pregnancy in the Asia-Pacific is required.

Fetal growth and birth weight are independently reduced by malaria infection and curable sexually transmitted and reproductive tract infections in Kenya, Tanzania, and Malawi: A pregnancy cohort study

OBJECTIVES

Malaria and sexually transmitted and reproductive tract infections (STIs/RTIs) are highly prevalent in sub-Saharan Africa and associated with poor pregnancy outcomes. We investigated the individual and combined effects of malaria and curable STIs/RTIs on fetal growth in Kenya, Tanzania, and Malawi.

METHODS

This study was nested within a randomized trial comparing monthly intermittent preventive treatment for malaria in pregnancy with sulfadoxine-pyrimethamine vs dihydroartemisinin-piperaquine, alone or combined with azithromycin. Fetal weight gain was assessed by serial prenatal ultrasound. Malaria was assessed monthly, and Treponema pallidum, Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, and bacterial vaginosis at enrollment and in the third trimester. The effect of malaria and STIs/RTIs on fetal weight/birthweight Z-scores was evaluated using mixed-effects linear regression.

RESULTS

In total, 1435 pregnant women had fetal/birth weight assessed 3950 times. Compared to women without malaria or STIs/RTIs (n = 399), malaria-only (n = 267), STIs/RTIs only (n = 410) or both (n = 353) were associated with reduced fetal growth (adjusted mean difference in fetal/birth weight Z-score [95% confidence interval]: malaria = -0.18 [-0.31,-0.04], P = 0.01; STIs/RTIs = -0.14 [-0.26,-0.03], P = 0.01; both = -0.20 [-0.33,-0.07], P = 0.003). Paucigravidae experienced the greatest impact.

CONCLUSION

Malaria and STIs/RTIs are associated with poor fetal growth especially among paucigravidae women with dual infections. Integrated antenatal interventions are needed to reduce the burden of both malaria and STIs/RTIs.

Targeted newborn metabolomics: prediction of gestational age from cord blood

OBJECTIVE

Our study sought to determine whether metabolites from a retrospective collection of banked cord blood specimens could accurately estimate gestational age and to validate these findings in cord blood samples from Busia, Uganda.

STUDY DESIGN

Forty-seven metabolites were measured by tandem mass spectrometry or enzymatic assays from 942 banked cord blood samples. Multiple linear regression was performed, and the best model was used to predict gestational age, in weeks, for 150 newborns from Busia, Uganda.

RESULTS

The model including metabolites and birthweight, predicted the gestational ages within 2 weeks for 76.7% of the Ugandan cohort. Importantly, this model estimated the prevalence of preterm birth <34 weeks closer to the actual prevalence (4.67% and 4.00%, respectively) than a model with only birthweight which overestimates the prevalence by 283%.

CONCLUSION

Models that include cord blood metabolites and birth weight appear to offer improvement in gestational age estimation over birth weight alone.

Poor Birth Outcomes in Malaria in Pregnancy: Recent Insights Into Mechanisms and Prevention Approaches

Pregnant women in malaria-endemic regions are susceptible to malaria in pregnancy, which has adverse consequences on birth outcomes, including having small for gestational age and preterm babies. These babies are likely to have low birthweights, which predisposes to infant mortality and lifelong morbidities. During malaria in pregnancy, Plasmodium falciparum-infected erythrocytes express a unique variant surface antigen, VAR2CSA, that mediates sequestration in the placenta. This process may initiate a range of host responses that contribute to placental inflammation and dysregulated placental development, which affects placental vasculogenesis, angiogenesis and nutrient transport. Collectively, these result in the impairment of placental functions, affecting fetal development. In this review, we provide an overview of malaria in pregnancy and the different pathological pathways leading to malaria in pregnancy-associated low birthweight. We also discuss current prevention and management strategies for malaria in pregnancy, and some potential therapeutic interventions that may improve birth outcomes. Lastly, we outline some priorities for future research that could bring us one step closer to reducing this health burden.

Prenatal care and preterm birth in the Western Brazilian Amazon: A population-based study

Brazil is among the top ten countries in preterm delivery worldwide. This study assesses the factors associated with preterm birth in the Western Brazilian Amazon. A population-based cross-sectional study was held between July 2015 to June 2016 in Cruzeiro do Sul, Brazilian Amazon. A total of 1525 births were included in this analysis. Preterm birth was defined as births at gestational age < 37 weeks. A stepwise multiple logistic regression was used to identify factors associated with preterm delivery. The prevalence rate of preterm birth was 7.9% (n = 120; 95% CI: 6.5-9.3). After adjusting for confounding factors, a positive association with preterm birth was observed for pregnant women who completed less than six antenatal care visits (OR: 2.93; 95% CI: 1.89-4.56), who had a birth interval of < 18 months (OR: 2.65; 95% CI: 1.04-6.75), and who experienced bleeding (OR: 2.17; 95% CI: 1.39-3.38) and hypertension during pregnancy (OR: 1.74; 95% CI: 1.07-2.82). Factors associated with preterm birth in the Western Brazilian Amazon were mostly related to the aspects of health care provided to women, and thus could be prevented. Proper, timely, and regular antenatal care visits can help reduce adverse outcomes, such as hypertension and bleeding.

A Proxy for Detecting IUGR Based on Gestational Age Estimation in a Guatemalan Rural Population

In-utero progress of fetal development is normally assessed through manual measurements taken from ultrasound images, requiring relatively expensive equipment and well-trained personnel. Such monitoring is therefore unavailable in low- and middle-income countries (LMICs), where most of the perinatal mortality and morbidity exists. The work presented here attempts to identify a proxy for IUGR, which is a significant contributor to perinatal death in LMICs, by determining gestational age (GA) from data derived from simple-to-use, low-cost one-dimensional Doppler ultrasound (1D-DUS) and blood pressure devices. A total of 114 paired 1D-DUS recordings and maternal blood pressure recordings were selected, based on previously described signal quality measures. The average length of 1D-DUS recording was 10.43 ± 1.41 min. The min/median/max systolic and diastolic maternal blood pressures were 79/102/121 and 50.5/63.5/78.5 mmHg, respectively. GA was estimated using features derived from the 1D-DUS and maternal blood pressure using a support vector regression (SVR) approach and GA based on the last menstrual period as a reference target. A total of 50 trials of 5-fold cross-validation were performed for feature selection. The final SVR model was retrained on the training data and then tested on a held-out set comprising 28 normal weight and 25 low birth weight (LBW) newborns. The mean absolute GA error with respect to the last menstrual period was found to be 0.72 and 1.01 months for the normal and LBW newborns, respectively. The mean error in the GA estimate was shown to be negatively correlated with the birth weight. Thus, if the estimated GA is lower than the (remembered) GA calculated from last menstruation, then this could be interpreted as a potential sign of IUGR associated with LBW, and referral and intervention may be necessary. The assessment system may, therefore, have an immediate impact if coupled with suitable intervention, such as nutritional supplementation. However, a prospective clinical trial is required to show the efficacy of such a metric in the detection of IUGR and the impact of the intervention.

Pregnancy outcomes and risk of placental malaria after artemisinin-based and quinine-based treatment for uncomplicated falciparum malaria in pregnancy: a WorldWide Antimalarial Resistance Network systematic review and individual patient data meta-analysis

BACKGROUND

Malaria in pregnancy, including asymptomatic infection, has a detrimental impact on foetal development. Individual patient data (IPD) meta-analysis was conducted to compare the association between antimalarial treatments and adverse pregnancy outcomes, including placental malaria, accompanied with the gestational age at diagnosis of uncomplicated falciparum malaria infection.

METHODS

A systematic review and one-stage IPD meta-analysis of studies assessing the efficacy of artemisinin-based and quinine-based treatments for patent microscopic uncomplicated falciparum malaria infection (hereinafter uncomplicated falciparum malaria) in pregnancy was conducted. The risks of stillbirth (pregnancy loss at ≥ 28.0 weeks of gestation), moderate to late preterm birth (PTB, live birth between 32.0 and < 37.0 weeks), small for gestational age (SGA, birthweight of < 10th percentile), and placental malaria (defined as deposition of malaria pigment in the placenta with or without parasites) after different treatments of uncomplicated falciparum malaria were assessed by mixed-effects logistic regression, using artemether-lumefantrine, the most used antimalarial, as the reference standard. Registration PROSPERO: CRD42018104013.

RESULTS

Of the 22 eligible studies (n = 5015), IPD from16 studies were shared, representing 95.0% (n = 4765) of the women enrolled in literature. Malaria treatment in this pooled analysis mostly occurred in the second (68.4%, 3064/4501) or third trimester (31.6%, 1421/4501), with gestational age confirmed by ultrasound in 91.5% (4120/4503). Quinine (n = 184) and five commonly used artemisinin-based combination therapies (ACTs) were included: artemether-lumefantrine (n = 1087), artesunate-amodiaquine (n = 775), artesunate-mefloquine (n = 965), and dihydroartemisinin-piperaquine (n = 837). The overall pooled proportion of stillbirth was 1.1% (84/4361), PTB 10.0% (619/4131), SGA 32.3% (1007/3707), and placental malaria 80.1% (2543/3035), and there were no significant differences of considered outcomes by ACT. Higher parasitaemia before treatment was associated with a higher risk of SGA (adjusted odds ratio [aOR] 1.14 per 10-fold increase, 95% confidence interval [CI] 1.03 to 1.26, p = 0.009) and deposition of malaria pigment in the placenta (aOR 1.67 per 10-fold increase, 95% CI 1.42 to 1.96, p < 0.001).

CONCLUSIONS

The risks of stillbirth, PTB, SGA, and placental malaria were not different between the commonly used ACTs. The risk of SGA was high among pregnant women infected with falciparum malaria despite treatment with highly effective drugs. Reduction of malaria-associated adverse birth outcomes requires effective prevention in pregnant women.

Relationship Between Pregnancy-Associated Malaria and Adverse Pregnancy Outcomes: a Systematic Review and Meta-Analysis

BACKGROUND

Pregnancy-associated malaria (PAM) has been associated with adverse pregnancy outcomes like preterm birth (PTB) and low birthweight (LBW), which are among the leading causes of infant mortality globally. Rates of PTB and LBW are high in countries with a high burden of malaria. PAM may be a contributing factor to PTB and LBW, but is not well understood.

METHODS

We conducted a systematic review and meta-analysis of studies examining the relationship between PAM and PTB or LBW using PubMed. The title and abstract of all studies were screened by two reviewers, and the full text of selected studies was reviewed to ensure they met inclusion criteria. Information regarding study characteristics and of PTB and LBW births among women with and without PAM was abstracted for included studies.

RESULTS

Our search terms yielded 2237 articles, of which 18 met our final inclusion criteria. Eight studies examined associations between PAM and PTB, and 10 examined associations between PAM and LBW (population size ranging from 35 to 9956 women). The overall risk of LBW was 63% higher among women with PAM compared with women without PAM (95% CI = 1.48-1.80) and the risk of PTB was 23% higher among women with PAM compared with women without PAM (95% CI = 1.07-1.41).

CONCLUSIONS

These results indicate that infection with PAM is associated with PTB and LBW. Further understanding of the pathogenesis of disease and the immunologic changes that occur during pregnancy is essential for reducing the disproportional effects this disease has on this vulnerable population.

A novel murine model for assessing fetal and birth outcomes following transgestational maternal malaria infection

Plasmodium falciparum infection during pregnancy is a major cause of severe maternal illness and neonatal mortality. Mouse models are important for the study of gestational malaria pathogenesis. When infected with Plasmodium chabaudi chabaudi AS in early gestation, several inbred mouse strains abort at midgestation. We report here that outbred Swiss Webster mice infected with P. chabaudi chabaudi AS in early gestation carry their pregnancies to term despite high parasite burden and malarial hemozoin accumulation in the placenta at midgestation, with the latter associated with induction of heme oxygenase 1 expression. Infection yields reduced fetal weight and viability at term and a reduction in pup number at weaning, but does not influence postnatal growth prior to weaning. This novel model allows for the exploration of malaria infection throughout pregnancy, modeling chronic infections observed in pregnant women prior to the birth of underweight infants and enabling the production of progeny exposed to malaria in utero, which is critical for understanding the postnatal repercussions of gestational malaria. The use of outbred mice allows for the exploration of gestational malaria in a genetically diverse model system, better recapitulating the diversity of infection responses observed in human populations.

Feeding practices and risk factors for chronic infant undernutrition among refugees and migrants along the Thailand-Myanmar border: a mixed-methods study

BACKGROUND

This study aims to provide a comprehensive understanding of maternal risk factors, infant risk factors and maternal infant feeding practices among refugees and migrants along the Thailand-Myanmar border.

METHODS

This study employed a mixed-methods approach with two components: (1) cross-sectional survey (n = 390) and (2) focus group discussions (n = 63). Participants were chosen from one of three clinics providing antenatal and delivery services for Karen and Burman refugees and migrants along the border. Participants were pregnant women and mother-infant dyads.

RESULTS

Refugee and migrant mothers demonstrated high rates of suboptimal breastfeeding and low rates of minimum dietary diversity and acceptable diet. Multivariable regression models showed infant stunting (AOR: 2.08, 95% CI: 1.12, 3.84, p = 0.020) and underweight (AOR: 2.26, 95% CI: 1.17, 4.36, p = 0.015) to have increased odds among migrants, while each 5 cm increase in maternal height had decreased odds of stunting (AOR: 0.50, 95% CI: 0.38, 0.66, p < 0.001) and underweight (AOR: 0.64, 95% CI: 0.48, 0.85, p = 0.002). In addition, small-for-gestational-age adjusted for length of gestation, infant age and gender increased odds of infant's stunting (AOR: 3.42, 95% CI: 1.88, 6.22, p < 0.001) and underweight (AOR: 4.44, 95% CI: 2.36, 8.34, p < 0.001). Using the Integrated Behavioural Model, focus group discussions explained the cross-sectional findings in characterising attitudes, perceived norms, and personal agency as they relate to maternal nutrition, infant malnutrition, and infant feeding practices.

CONCLUSIONS

Inadequate infant feeding practices are widespread in refugee and migrant communities along the Thailand-Myanmar border. Risk factors particular to maternal nutrition and infant birth should be considered for future programming to reduce the burden of chronic malnutrition in infants.

Preterm births and associated factors among mothers who gave birth in Axum and Adwa Town public hospitals, Northern Ethiopia, 2018

OBJECTIVE

The objective of this study was to determine the prevalence and associated factors of preterm births among mothers who gave birth in Axum and Adwa public hospitals, Tigray, North Ethiopia, 2018.

RESULT

This study showed that 13.3% from the total 472 mothers gave a preterm birth. Being a rural resident (AOR = 2.13, 95% CI (1.07,4.22), short inter pregnancy interval (AOR = 5.4, 95% CI (1.32, 22.05), previous preterm birth (AOR = 3.74, 95% CI (1.03, 16.34), Premature rupture of membrane (AOR = 4.14, 95% CI (1.92, 8.89), induced onset of labor (AOR = 2.49, 95% CI (1.06, 5.85) multiple pregnancy (AOR = 5.69, 95% CI (2.27, 14.28), malaria during pregnancy (AOR = 4.71, 95% CI (1.98, 11.23), Presence of chronic illness (AOR = 4.55, 95% CI (1.83, 11.26) were significantly associated with preterm birth.

Adverse birth outcomes among mothers who received intermittent preventive treatment with Sulphadoxine-Pyrimethamine in the low malaria transmission region

BACKGROUND

Malaria in pregnancy increases the risk of adverse birth outcomes such as low birth weight (LBW), maternal and foetal anemia. In Tanzania, some areas have attained low malaria transmission. However, data on the burden of preterm delivery, LBW, maternal and foetal anemia following substantial reduction of malaria transmission in recent years is still scarce in these settings.

METHODS

A study involving 631 pregnant women was conducted at Mwananyamala referral hospital in Dar es Salaam from April to August, 2018. Study enrollment was done prior to delivery. Structured interview and antenatal clinic cards were used to obtain data including the use of intermittent preventive therapy in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). Infants birth weights were recorded, maternal venous and cord blood were taken for testing of malaria and determination of haemoglobin (Hb) levels. Chi-square test and regression analysis were done to identify risk factors for preterm delivery, LBW, maternal and foetal anemia.

RESULTS

The prevalence of malaria among mothers who used at least one dose of IPTp-SP was 0.6% (4/631). Fourteen mothers (2.2%) did not use IPTp-SP and had no malaria infection. The prevalence of maternal anemia, LBW, foetal anemia and preterm delivery was 40.6, 6.5, 5.9 and 9.2% respectively. Participants who were malaria positive had 11 times more risk of LBW compared to those who were negative (AOR, 11; 95%, CI 1.07-132.2; p = 0.04). The risk of delivering babies with LBW was 1.12 times high among mothers who were ≤ 36 weeks of gestation (AOR, 1.12; 95% CI, 0.06-0.25; p = < 0.001). The use of ≥3 doses of IPTp-SP was associated with 83% decrease in risk of LBW compared to those who did not use any dose of IPTp-SP (AOR, 0.17; 95% CI, 0.03-0.88; p = 0.05). Severe anaemia at delivery was associated with seven times increased risk of preterm delivery compared to non-anemic participants (AOR, 6.5; 95% CI, 1.49-28.16; p = 0.013).

CONCLUSION

Despite the reduced malaria transmission and use of IPTp-SP, prevalence of preterm delivery, maternal anemia, LBW and foetal anemia is still high in Tanzania. The recommended ≥3 doses of IPTp-SP should continue be provided even in areas with substantial reduction of malaria.

Excess risk of preterm birth with periconceptional iron supplementation in a malaria endemic area: analysis of secondary data on birth outcomes in a double blind randomized controlled safety trial in Burkina Faso

BACKGROUND

Iron supplementation before a first pregnancy may improve the future health of mother and baby by reducing maternal anaemia. Iron supplementation could, however, increase malaria infections, notably in primigravidae who are most susceptible. The pathogenicity of other iron-utilizing pathogens could also increase, causing inflammation leading to increased risk of adverse birth outcomes. This paper reports pre-specified secondary birth outcomes from a safety trial in Burkina Faso in an area of high malaria endemicity. Primary outcomes from that trial had investigated effects of long-term weekly iron supplementation on malaria and genital tract infections in non-pregnant and pregnant women.

METHODS

A double-blind, randomized controlled trial. Nulliparous, mainly adolescent women, were individually randomized periconceptionally to receive weekly either 60 mg elemental iron and 2.8 mg folic acid, or 2.8 mg folic acid alone, continuing up to the first antenatal visit for those becoming pregnant. Secondary outcomes were ultrasound-dated gestational age, fetal growth, placental malaria, chorioamnionitis and iron biomarkers. Seasonal effects were assessed. Analysis was by intention to treat.

RESULTS

478 pregnancies occurred to 1959 women: 258/980 women assigned iron and folic acid and 220/979 women assigned folic acid alone. Malaria prevalence at the first antenatal visit was 53% (iron) and 55% (controls). Mean birthweight was 111 g lower in the iron group (95% CI 9:213 g, P = 0.033). Mean gestational ages were 264 days (iron) and 269 days (controls) (P = 0.012), with 27.5% under 37 weeks compared to 13.9% in controls (adjRR = 2.22; 95% CI 1.39-3.61) P < 0.001). One-third of babies were growth restricted, but incidence did not differ by trial arm. Half of placentae had evidence of past malaria infection. C-reactive protein > 5 mg/l was more common prior to births < 37 weeks (adjRR = 2.06, 95% CI 1.04-4.10, P = 0.034). Preterm birth incidence during the rainy season was ~ 50% in the iron arm and < 20% in controls (P = 0.001). Chorioamnionitis prevalence peaked in the dry season (P = 0.046), with no difference by trial arm (P = 0.14).

CONCLUSION

Long-term weekly iron supplementation given to nulliparous women in a malaria endemic area was associated with higher risk of preterm birth in their first pregnancy. Trial Registration NCT01210040. Registered with Clinicaltrials.gov on 27th September 2010.

Nutrition in transition: historical cohort analysis summarising trends in under- and over-nutrition among pregnant women in a marginalised population along the Thailand-Myanmar border from 1986 to 2016

The objective of the present study is to summarise trends in under- and over-nutrition in pregnant women on the Thailand-Myanmar border. Refugees contributed data from 1986 to 2016 and migrants from 1999 to 2016 for weight at first antenatal consultation. BMI and gestational weight gain (GWG) data were available during 2004-2016 when height was routinely measured. Risk factors for low and high BMI were analysed for &lt;18·5 kg/m2 or ≥23 kg/m2, respectively. A total of 48 062 pregnancies over 30 years were available for weight analysis and 14 646 pregnancies over 13 years (2004-2016) had BMI measured in first trimester (&lt;14 weeks' gestational age). Mean weight at first antenatal consultation in any trimester increased over the 30-year period by 2·0 to 5·2 kg for all women. First trimester BMI has been increasing on average by 0·5 kg/m2 for refugees and 0·6 kg/m2 for migrants, every 5 years. The proportion of women with low BMI in the first trimester decreased from 16·7 to 12·7 % for refugees and 23·1 to 20·2 % for migrants, whereas high BMI increased markedly from 16·9 to 33·2 % for refugees and 12·3 to 28·4 % for migrants. Multivariate analysis demonstrated low BMI as positively associated with being Burman, Muslim, primigravid, having malaria during pregnancy and smoking, and negatively associated with refugee as opposed to migrant status. High BMI was positively associated with being Muslim and literate, and negatively associated with age, primigravida, malaria, anaemia and smoking. Mean GWG was 10·0 (sd 3·4), 9·5 (sd 3·6) and 8·3 (sd 4·3) kg, for low, normal and high WHO BMI categories for Asians, respectively.

Maternal factors contributing to low birth weight deliveries in Tshwane District, South Africa

BACKGROUND

Low birth weight continues to be a main cause of child morbidity and mortality. Low birth weight can cause complications in adult life, and is therefore a public health concern. In this study, we determined the maternal factors that contribute to low birth weight (LBW) deliveries in Tshwane District, South Africa.

METHODS

We conducted a case control study of 1073 randomly selected mothers who delivered babies in four hospitals in the district. We reviewed antenatal and maternity registers to obtain information about the mothers and their offspring. We fitted a multiple logistic regression to examine relationships between possible factors associated with LBW.

RESULTS

From the total sample of mothers (n = 1073), 77% (n = 824) were adult women, aged 20 to 35 years. Of the adult mothers, 38.54% (n = 412) delivered low birth weight (LBW) infants. The mean gestational age and weight of all infants at birth was 37.16 weeks (SD 2.92) and 2675.48 grams (SD 616.16) respectively. LBW was associated with prematurity, odds ratio (OR) 7.15, 95% confidence interval (CI) 5.18 to 9.89; premature rupture of membranes OR 7.33, 95% CI 2.43 to 22.12 and attending fewer than five antenatal care (ANC) visits OR 1.30, 95% CI 1.06 to 1.61. Male infants were less likely to be LBW, in this population.

CONCLUSION

Women who attended fewer than five ANC visits were predisposed to give birth to low birth weight babies. Mothers should be encouraged to attend ANC visits to detect adverse events like premature rupture of membranes and premature labour timeously.

The assessment of gestational age: a comparison of different methods from a malaria pregnancy cohort in sub-Saharan Africa

BACKGROUND

Determining gestational age in resource-poor settings is challenging because of limited availability of ultrasound technology and late first presentation to antenatal clinic. Last menstrual period (LMP), symphysio-pubis fundal height (SFH) and Ballard Score (BS) at delivery are therefore often used. We assessed the accuracy of LMP, SFH, and BS to estimate gestational age at delivery and preterm birth compared to ultrasound (US) using a large dataset derived from a randomized controlled trial in pregnant malaria patients in four African countries.

METHODS

Mean and median gestational age for US, LMP, SFH and BS were calculated for the entire study population and stratified by country. Correlation coefficients were calculated using Pearson's rho, and Bland Altman plots were used to calculate mean differences in findings with 95% limit of agreements. Sensitivity, specificity, positive predictive value and negative predictive value were calculated considering US as reference method to identify term and preterm babies.

RESULTS

A total of 1630 women with P. falciparum infection and a gestational age > 24 weeks determined by ultrasound at enrolment were included in the analysis. The mean gestational age at delivery using US was 38.7 weeks (95%CI: 38.6-38.8), by LMP, 38.4 weeks (95%CI: 38.0-38.9), by SFH, 38.3 weeks (95%CI: 38.2-38.5), and by BS 38.0 weeks (95%CI: 37.9-38.1) (p < 0.001). Correlation between US and any of the other three methods was poor to moderate. Sensitivity and specificity to determine prematurity were 0.63 (95%CI 0.50-0.75) and 0.72 (95%CI, 0.66-0.76) for LMP, 0.80 (95%CI 0.74-0.85) and 0.74 (95%CI 0.72-0.76) for SFH and 0.42 (95%CI 0.35-0.49) and 0.77 (95%CI 0.74-0.79) for BS.

CONCLUSIONS

In settings with limited access to ultrasound, and in women who had been treated with P. falciparum malaria, SFH may be the most useful antenatal tool to date a pregnancy when women present first in second and third trimester. The Ballard postnatal maturation assessment has a limited role and lacks precision. Improving ultrasound facilities and skills, and early attendance, together with the development of new technologies such as automated image analysis and new postnatal methods to assess gestational age, are essential for the study and management of preterm birth in low-income settings.

Submicroscopic Plasmodium infection during pregnancy is associated with reduced antibody levels to tetanus toxoid

Submicroscopic Plasmodium infections in pregnancy are common in endemic areas, and it is important to understand the impact of these low-level infections. Asymptomatic, chronic infections are advantageous for parasite persistence, particularly in areas where the optimal eco-epidemiological conditions for parasite transmission fluctuate. In chronic infections, the persistence of the antigenic stimulus changes the expression of immune mediators and promotes constant immune regulation, including increases in regulatory T cell populations. These alterations of the immune system could compromise the response to routine vaccination. This study aimed to evaluate the effect of submicroscopic plasmodial infection with P. falciparum and P. vivax during pregnancy on the immune response to the tetanus toxoid vaccine in Colombian women. Expression of different cytokines and mediators of immune regulation and levels of anti-tetanus toxoid (TT) immunoglobulin (Ig)G were quantified in pregnant women with and without submicroscopic plasmodial infection. The anti-TT IgG levels were significantly lower in the infected group compared with the uninfected group. The expression of interferon (IFN)-γ, tumour necrosis factor (TNF) and forkhead box protein 3 (FoxP3) was significantly higher in the infected group, while the expression of cytotoxic T lymphocyte antigen 4 (CTLA-4) and transforming growth factor (TGF)-β was lower in the group of infected. In conclusion, submicroscopic Plasmodium infection altered the development of the immune response to the TT vaccine in Colombian pregnant women. The impact of Plasmodium infections on the immune regulatory pathways warrants further exploration.

Concordance of three alternative gestational age assessments for pregnant women from four African countries: A secondary analysis of the MIPPAD trial

BACKGROUND

At times, ultrasound is not readily available in low resource countries in Africa for accurate determination of gestational age, so using alternative methods is pivotal during pregnancy. These assessments are used to aid the risk analysis for an infant and management strategies for premature delivery, if necessary. Currently, date of last menstrual period, fundal height measurements, and the New Ballard Score are commonly used in resource-limited settings. However, concordance of these measures is unknown for sub-Saharan Africa. We obtained data from an open-label randomized controlled trial, to assess the concordance of these alternative assessment methods. The purpose of our study was to determine the agreement between these alternative methods when used in sub-Saharan African populations.

METHODS

A total of 4,390 pregnant women from Benin, Gabon, Mozambique and Tanzania were included in our analysis. The assessment methods compared were: 1) reported last menstrual period, 2) symphysis-fundal height measurement, and 3) the New Ballard Score. The Bland-Altman method and intraclass correlation coefficient (ICC) were used to test the degree of agreement. Survival range gestational age, used as an inclusion criterion for further analysis, was from 22 to 44 weeks.

FINDINGS

Plots showed a lack of agreement between methods and the 95% limits of agreement too wide to be clinically useful. ICC = 0.25 indicated poor agreement. A post-hoc analysis, restricted from 32 to 42 weeks, was done to check for better agreement in this near-term population. The plots and ICC = 0.16 still confirmed poor agreement.

CONCLUSION

The alternative assessments do not result in comparable outcomes and discrepancies are far beyond the clinically acceptable range. Last menstrual period should not be used as the only estimator of gestational age. In the absence of reliable early ultrasound, symphysis-fundal height measurements may be most useful during pregnancy for fetal risk assessment and the New Ballard Score after delivery as a confirmation of these estimations and for further neonatal management. However, promotion of portable ultrasound devices is required for accurate assessment of gestational age in sub-Sahara Africa.

Burden, pathology, and costs of malaria in pregnancy: new developments for an old problem

Over the past 10 years, knowledge of the burden, economic costs, and consequences of malaria in pregnancy has improved, and the prevalence of malaria caused by Plasmodium falciparum has declined substantially in some geographical areas. In particular, studies outside of Africa have increased the evidence base of Plasmodium vivax in pregnancy. Rapid diagnostic tests have been poor at detecting malaria in pregnant women, while PCR has shown a high prevalence of low density infection, the clinical importance of which is unknown. Erythrocytes infected with P falciparum that express the surface protein VAR2CSA accumulate in the placenta, and VAR2CSA is an important target of protective immunity. Clinical trials for a VAR2CSA vaccine are ongoing, but sequence variation needs to be carefully studied. Health system and household costs still limit access to prevention and treatment services. Within the context of malaria elimination, pregnant women could be used to monitor malaria transmission. This Series paper summarises recent progress and highlights unresolved issues related to the burden of malaria in pregnancy.

Methodology of assessment and reporting of safety in anti-malarial treatment efficacy studies of uncomplicated falciparum malaria in pregnancy: a systematic literature review

Background

Considering the uncertainty of safety of anti-malarial drugs in pregnancy, efficacy studies are one of the few sources of clinical safety data. Complete safety evaluation is not usually incorporated in efficacy studies due to financial and human resource constraints. This review reports the methods used for the assessment of safety of artemisinin-based and quinine-based treatments in efficacy studies in pregnancy.

Methods

Methodology of assessment and reporting of safety in efficacy studies of artemisinin-based and quinine-based treatment in pregnancy was reviewed using seven databases and two clinical trial registries. The protocol was registered to PROSPERO (CRD42017054808).

Results

Of 48 eligible efficacy studies the method of estimation of gestational age was reported in only 32 studies (67%, 32/48) and ultrasound was used in 18 studies (38%, 18/48). Seventeen studies (35%, 17/48) reported parity, 9 (19%, 9/48) reported gravidity and 13 (27%, 13/48) reported both. Thirty-eight studies (79%, 38/48) followed participants through to pregnancy outcome. Fetal loss was assessed in 34 studies (89%, 34/38), but the definition of miscarriage and stillbirth were defined only in 11 (32%, 11/34) and 7 (21%, 7/34) studies, respectively. Preterm birth was assessed in 26 studies (68%, 26/38) but was defined in 16 studies (62%, 16/26). Newborn weight was assessed in 30 studies (79%, 30/38) and length in 10 studies (26%, 10/38). Assessment of birth weight took gestational age into account in four studies (13%, 4/30). Congenital abnormalities were reported in 32 studies (84%, 32/38). Other common risk factors for adverse pregnancy outcomes were not well-reported.

Conclusion

Incomplete reporting and varied methodological assessment of pregnancy outcomes in anti-malarial drug efficacy studies limits comparison across studies. A standard list of minimal necessary parameters to assess and report the safety component of efficacy studies of anti-malarials in pregnancy is proposed.

Electronic supplementary material

The online version of this article (10.1186/s12936-017-2136-x) contains supplementary material, which is available to authorized users.

Relationships between infection with Plasmodium falciparum during pregnancy, measures of placental malaria, and adverse birth outcomes

Background

Malaria in pregnancy has been associated with maternal morbidity, placental malaria, and adverse birth outcomes. However, data are limited on the relationships between longitudinal measures of malaria during pregnancy, measures of placental malaria, and birth outcomes.

Methods

This is a nested observational study of data from a randomized controlled trial of intermittent preventive therapy during pregnancy among 282 participants with assessment of placental malaria and delivery outcomes. HIV-uninfected pregnant women were enrolled at 12–20 weeks of gestation. Symptomatic malaria during pregnancy was measured using passive surveillance and monthly detection of asymptomatic parasitaemia using loop-mediated isothermal amplification (LAMP). Placental malaria was defined as either the presence of parasites in placental blood by microscopy, detection of parasites in placental blood by LAMP, or histopathologic evidence of parasites or pigment. Adverse birth outcomes assessed included low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA) infants.

Results

The 282 women were divided into three groups representing increasing malaria burden during pregnancy. Fifty-two (18.4%) had no episodes of symptomatic malaria or asymptomatic parasitaemia during the pregnancy, 157 (55.7%) had low malaria burden (0–1 episodes of symptomatic malaria and < 50% of samples LAMP+), and 73 (25.9%) had high malaria burden during pregnancy (≥ 2 episodes of symptomatic malaria or ≥ 50% of samples LAMP+). Women with high malaria burden had increased risks of placental malaria by blood microscopy and LAMP [aRR 14.2 (1.80–111.6) and 4.06 (1.73–9.51), respectively], compared to the other two groups combined. Compared with women with no malaria exposure during pregnancy, the risk of placental malaria by histopathology was higher among low and high burden groups [aRR = 3.27 (1.32–8.12) and aRR = 7.07 (2.84–17.6), respectively]. Detection of placental parasites by any method was significantly associated with PTB [aRR 5.64 (1.46–21.8)], and with a trend towards increased risk for LBW and SGA irrespective of the level of malaria burden during pregnancy.

Conclusion

Higher malaria burden during pregnancy was associated with placental malaria and together with the detection of parasites in the placenta were associated with increased risk for adverse birth outcomes.

Trial Registration Current Controlled Trials Identifier NCT02163447

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-2040-4) contains supplementary material, which is available to authorized users.

Malaria, malnutrition, and birthweight: A meta-analysis using individual participant data

BACKGROUND

Four studies previously indicated that the effect of malaria infection during pregnancy on the risk of low birthweight (LBW; <2,500 g) may depend upon maternal nutritional status. We investigated this dependence further using a large, diverse study population.

METHODS AND FINDINGS

We evaluated the interaction between maternal malaria infection and maternal anthropometric status on the risk of LBW using pooled data from 14,633 pregnancies from 13 studies (6 cohort studies and 7 randomized controlled trials) conducted in Africa and the Western Pacific from 1996-2015. Studies were identified by the Maternal Malaria and Malnutrition (M3) initiative using a convenience sampling approach and were eligible for pooling given adequate ethical approval and availability of essential variables. Study-specific adjusted effect estimates were calculated using inverse probability of treatment-weighted linear and log-binomial regression models and pooled using a random-effects model. The adjusted risk of delivering a baby with LBW was 8.8% among women with malaria infection at antenatal enrollment compared to 7.7% among uninfected women (adjusted risk ratio [aRR] 1.14 [95% confidence interval (CI): 0.91, 1.42]; N = 13,613), 10.5% among women with malaria infection at delivery compared to 7.9% among uninfected women (aRR 1.32 [95% CI: 1.08, 1.62]; N = 11,826), and 15.3% among women with low mid-upper arm circumference (MUAC <23 cm) at enrollment compared to 9.5% among women with MUAC ≥ 23 cm (aRR 1.60 [95% CI: 1.36, 1.87]; N = 9,008). The risk of delivering a baby with LBW was 17.8% among women with both malaria infection and low MUAC at enrollment compared to 8.4% among uninfected women with MUAC ≥ 23 cm (joint aRR 2.13 [95% CI: 1.21, 3.73]; N = 8,152). There was no evidence of synergism (i.e., excess risk due to interaction) between malaria infection and MUAC on the multiplicative (p = 0.5) or additive scale (p = 0.9). Results were similar using body mass index (BMI) as an anthropometric indicator of nutritional status. Meta-regression results indicated that there may be multiplicative interaction between malaria infection at enrollment and low MUAC within studies conducted in Africa; however, this finding was not consistent on the additive scale, when accounting for multiple comparisons, or when using other definitions of malaria and malnutrition. The major limitations of the study included availability of only 2 cross-sectional measurements of malaria and the limited availability of ultrasound-based pregnancy dating to assess impacts on preterm birth and fetal growth in all studies.

CONCLUSIONS

Pregnant women with malnutrition and malaria infection are at increased risk of LBW compared to women with only 1 risk factor or none, but malaria and malnutrition do not act synergistically.

Low Utilization of Insecticide-Treated Bed Net among Pregnant Women in the Middle Belt of Ghana

Background

Malaria in pregnancy leads to low birth weight, premature birth, anaemia, and maternal and neonatal mortality. Use of insecticide-treated nets (ITNs) during pregnancy is one of the proven interventions to reduce the malaria burden. However, Ghana has not achieved its target for ITN use among pregnant women.

Methods

A qualitative study was conducted in seven communities purposively selected from the middle belt of Ghana. Participants who had delivered in the six months prior to this study were selected. In all, seven focus group discussions and twenty-four in-depth interviews were conducted between June and August 2010.

Results

Respondents knew of the importance of ITNs and other malaria-preventive strategies. Factors such as financial access and missed opportunities of free distribution denied some pregnant women the opportunity to own or use an ITN. Reasons for not using ITNs during pregnancy included discomfort resulting from heat, smell of the net, and difficulty in hanging the net. Participants maintained their ITNs by preventing holes in the nets, retreatment, and infrequent washing.

Conclusion

Pregnant women know about the causes and prevention of malaria. However, this knowledge is not transformed into practice due to lack of access to ITNs and sleeping discomforts among other logistical constraints.

Longer exposure to a new refugee food ration is associated with reduced prevalence of small for gestational age: results from 2 cross-sectional surveys on the Thailand-Myanmar border

Background: Despite the high risk of compromised nutrition, evidence of the effect of refugee rations on fetal growth is limited. A new ration containing micronutrient-fortified flour without increased caloric content of the general food basket was introduced to the Maela refugee camp in Thailand, July 2004.Objective: The effect of the length of gestational exposure of the new ration on fetal growth was compared with birth outcomes [small for gestational age (SGA), preterm birth (PTB)].Design: In an observational study in 987 newborns from 1048 prospectively followed antenatal clinic (ANC) attendees enrolled in 2 cross-sectional surveys, exposure was categorized in 2004 according to gestation at the time of commencing the new ration and in 2006 as comprehensive (preconception and pregnancy). In both surveys, the pregnancy-specific ration and vitamin supplements were routine.Results: In 2004, the proportions of SGA decreased with longer exposure to the new ration: no exposure during pregnancy (27.7%; n = 13 of 47) and exposure in the third (27.6%; n = 37 of 134), second (18.6%; n = 35 of 188), and first (19.4%; n = 6 of 31) trimesters, respectively (adjusted P-trend = 0.046). In 2006, the new ration was available to all women and there was no significant additional impact of the pregnancy-specific ration and vitamin supplements. Between 2004 and 2006, SGA decreased from 28.9% (13 of 45) to 17.3% (69 of 398) (adjusted P = 0.050), a reduction of 40.1% (95% CI: 34.7%, 45.9%); there was also a decrease in the percentage of underweight women on admission to the ANC (38.2%; 95% CI: 31.4%, 45.5%). PTB rates were low and not significantly different with exposure to the new ration.Conclusions: In 2004, the earlier in gestation in which the new ration was available the greater the effect on fetal growth as shown by a reduced prevalence of SGA. In 2006, additional benefits to fetal growth from the pregnancy-specific ration and vitamin supplements beyond those of the preconception ration were not observed. Good nutrition in pregnancy remains an important challenge for refugee populations. This trial was registered at http://drks-neu.uniklinik-freiburg.de/drks_web/ as DRKS00007736.

Risk factors for small-for-gestational-age and preterm births among 19,269 Tanzanian newborns

Background

Few studies have differentiated risk factors for term-small for gestational age (SGA), preterm-appropriate for gestational age (AGA), and preterm-SGA, despite evidence of varying risk of child mortality and poor developmental outcomes.

Methods

We analyzed birth outcome data from singleton infants, who were enrolled in a large randomized, double-blind, placebo-controlled trial of neonatal vitamin A supplementation conducted in Tanzania. SGA was defined as birth weight <10th percentile for gestation age and sex using INTERGROWTH standards and preterm birth as delivery at <37 complete weeks of gestation. Risk factors for term-SGA, preterm-AGA, and preterm-SGA were examined independently using log-binomial regression.

Results

Among 19,269 singleton Tanzanian newborns included in this analysis, 68.3 % were term-AGA, 15.8 % term-SGA, 15.5 % preterm-AGA, and 0.3 % preterm-SGA. In multivariate analyses, significant risk factors for term-SGA included maternal age <20 years, starting antenatal care (ANC) in the 3^rd trimester, short maternal stature, being firstborn, and male sex (all p < 0.05). Independent risk factors for preterm-AGA were maternal age <25 years, short maternal stature, firstborns, and decreased wealth (all p < 0.05). In addition, receiving ANC services in the 1^st trimester significantly reduced the risk of preterm-AGA (p = 0.01). Significant risk factors for preterm-SGA included maternal age >30 years, being firstborn, and short maternal stature which appeared to carry a particularly strong risk (all p < 0.05).

Conclusion

Over 30 % of newborns in this large urban and rural cohort of Tanzanian newborns were born preterm and/or SGA. Interventions to promote early attendance to ANC services, reduce unintended young pregnancies, increased maternal height, and reduce poverty may significantly decrease the burden of SGA and preterm birth in sub-Saharan Africa.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) – ACTRN12610000636055, registered on 3^rd August 2010.

Preterm or not--an evaluation of estimates of gestational age in a cohort of women from Rural Papua New Guinea

BACKGROUND

Knowledge of accurate gestational age is required for comprehensive pregnancy care and is an essential component of research evaluating causes of preterm birth. In industrialised countries gestational age is determined with the help of fetal biometry in early pregnancy. Lack of ultrasound and late presentation to antenatal clinic limits this practice in low-resource settings. Instead, clinical estimators of gestational age are used, but their accuracy remains a matter of debate.

METHODS

In a cohort of 688 singleton pregnancies from rural Papua New Guinea, delivery gestational age was calculated from Ballard score, last menstrual period, symphysis-pubis fundal height at first visit and quickening as well as mid- and late pregnancy fetal biometry. Published models using sequential fundal height measurements and corrected last menstrual period to estimate gestational age were also tested. Novel linear models that combined clinical measurements for gestational age estimation were developed. Predictions were compared with the reference early pregnancy ultrasound (<25 gestational weeks) using correlation, regression and Bland-Altman analyses and ranked for their capability to predict preterm birth using the harmonic mean of recall and precision (F-measure).

RESULTS

Average bias between reference ultrasound and clinical methods ranged from 0-11 days (95% confidence levels: 14-42 days). Preterm birth was best predicted by mid-pregnancy ultrasound (F-measure: 0.72), and neuromuscular Ballard score provided the least reliable preterm birth prediction (F-measure: 0.17). The best clinical methods to predict gestational age and preterm birth were last menstrual period and fundal height (F-measures 0.35). A linear model combining both measures improved prediction of preterm birth (F-measure: 0.58).

CONCLUSIONS

Estimation of gestational age without ultrasound is prone to significant error. In the absence of ultrasound facilities, last menstrual period and fundal height are among the more reliable clinical measures. This study underlines the importance of strengthening ultrasound facilities and developing novel ways to estimate gestational age.

Preconception blood pressure and risk of preterm birth: a large historical cohort study in a Chinese rural population

OBJECTIVE

To examine the relationship between preconception blood pressure (BP) and the risk of preterm birth (PTB) using a historical cohort of reproductive-aged women and girls from a Chinese rural population.

DESIGN

A historical cohort study established between 2010 and 2013 in People's Republic of China.

SETTING

Local family-planning service agencies and maternal-child care service centers.

PATIENT(S)

A total of 367,425 reproductive-aged women and girls who participated in the National Free Pre-pregnancy Checkups in 2010-2012 and subsequently had a live birth before October 2013.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Incidence rates of PTB in reproductive-aged women and girls across preconception BP levels.

RESULT(S)

Preterm births were defined as babies born alive at 28 to 37 weeks of pregnancy. Compared with the participants with a systolic BP of <120 mm Hg, the multivariable-adjusted odds ratio (OR) for PTB was 0.99 (95% confidence interval [CI]: 0.95-1.03]), 1.21 (95% CI: 1.11-1.32), 1.47 (95% CI: 1.22-1.77), 1.80 (95% CI: 1.25-2.59), and 1.81 (95% CI: 1.20-2.73) for the participants with systolic BP of 120-129, 130-139, 140-149, 150-159, and ≥160 mm Hg, respectively. When the participants with normal BP were used as the reference, the adjusted OR for PTB was 1.04 (95% CI: 1.01-1.08), 1.38 (95% CI: 1.25-1.53), and 1.54 (95% CI: 1.21-1.97) for the participants with prehypertension, stage-1 hypertension, and stage-2 hypertension, respectively. In addition, isolated systolic and diastolic hypertension increased the risk of PTB by 55% and 30%, respectively.

CONCLUSION(S)

Our results indicated a strong linear and independent relationship between BP levels and the risk of PTB in Chinese reproductive-aged women and girls. Maternal hypertension before pregnancy can significantly increase the risk of PTB.

Pregnancy outcome in relation to treatment of murine typhus and scrub typhus infection: a fever cohort and a case series analysis

Background

There is a paucity of published reports on pregnancy outcome following scrub and murine typhus despite these infections being leading causes of undifferentiated fever in Asia. This study aimed to relate pregnancy outcome with treatment of typhus.

Methodology/Principal Findings

Data were analyzed from: i) pregnant women with a diagnosis of scrub and/or murine typhus from a fever cohort studies; ii) case series of published studies in PubMed using the search terms “scrub typhus” (ST), “murine typhus” (MT), “Orientia tsutsugamushi”, “Rickettsia tsutsugamushi”, “Rickettsia typhi”, “rickettsiae”, “typhus”, or “rickettsiosis”; and “pregnancy”, until February 2014 and iii) an unpublished case series. Fever clearance time (FCT) and pregnancy outcome (miscarriage and delivery) were compared to treatment. Poor neonatal outcome was a composite measure for pregnancies sustained to 28 weeks or more of gestation ending in stillbirth, preterm birth, or delivery of a growth restricted or low birth weight newborn.

Results

There were 26 women in the fever cohort. MT and ST were clinically indistinguishable apart from two ST patients with eschars. FCTs (median [range] hours) were 25 [16–42] for azithromycin (n = 5), 34 [20–53] for antimalarials (n = 5) and 92 [6–260] for other antibiotics/supportive therapy (n = 16). There were 36.4% (8/22) with a poor neonatal outcome.

In 18 years, 97 pregnancies were collated, 82 with known outcomes, including two maternal deaths. Proportions of miscarriage 17.3% (14/81) and poor neonatal outcomes 41.8% (28/67) were high, increasing with longer FCTs (p = 0.050, linear trend). Use of azithromycin was not significantly associated with improved neonatal outcomes (p = 0.610)

Conclusion

The published ST and MT world literature amounts to less than 100 pregnancies due to under recognition and under diagnosis. Evidence supporting the most commonly used treatment, azithromycin, is weak. Collaborative, prospective clinical trials in pregnant women are urgently required to reduce the burden of adverse maternal and newborn outcomes and to determine the safety and efficacy of antimicrobial treatment.

Typhus is an under-recognised and under-studied public health problem in Asia. In rural areas of Southeast Asia murine and scrub typhus are probably the most common treatable cause of fever. The estimated number of scrub typhus cases in Southeast Asia, more than 1 million yearly, results in approximately 50–80,000 deaths per year. Treatment delays due to lack of appropriate diagnostics and lack of awareness lead to a substantial health and economic impact in the one of the world's most densely populated regions. Only 97 cases in pregnancy are available from the published world literature over the past 18 years. Only 82 of these had known outcomes, including two maternal deaths. The proportion of poor neonatal outcome including stillbirth, prematurity and low birth weight was high occurring in more than 40% of pregnancies, and higher when the fever clearance time was longer. While poor neonatal outcomes were observed with all antibiotics prescribed, azithromycin appeared to be associated with shorter fever clearance times but this was not statistically significant. Evidence to support the use of azithromycin is weak. The correct antimicrobial or combination for undifferentiated fever in pregnant women in Southeast Asia is unknown.