Clinical risk factors for preterm birth and evaluating maternal psychology in the postpartum period

BACKGROUND Although the specific pathogenesis of preterm birth(PTB)has not been thoroughly clarified,it is known to be related to various factors,such as pregnancy complications,maternal socioeconomic factors,lifestyle habits,reproductive history,environmental and psychological factors,prenatal care,and nutritional status.PTB has serious implications for newborns and families and is associated with high mortality and complications.Therefore,the prediction of PTB risk can facilitate early intervention and reduce its resultant adverse consequences.AIM To analyze the risk factors for PTB to establish a PTB risk prediction model and to assess postpartum anxiety and depression in mothers.METHODS A retrospective analysis of 648 consecutive parturients who delivered at Shenzhen Bao’an District Songgang People’s Hospital between January 2019 and January 2022 was performed.According to the diagnostic criteria for premature infants,the parturients were divided into a PTB group(n=60)and a full-term(FT)group(n=588).Puerperae were assessed by the Self-rating Anxiety Scale(SAS)and Self rating Depression Scale(SDS),based on which the mothers with anxiety and depression symptoms were screened for further analysis.The factors affecting PTB were analyzed by univariate analysis,and the related risk factors were identified by logistic regression.RESULTS According to univariate analysis,the PTB group was older than the FT group,with a smaller weight change and greater proportions of women who underwent artificial insemination and had gestational diabetes mellitus(P<0.05).In addition,greater proportions of women with reproductive tract infections and greater white blood cell(WBC)counts(P<0.05),shorter cervical lengths in the second trimester and lower neutrophil percentages(P<0.001)were detected in the PTB group than in the FT group.The PTB group exhibited higher postpartum SAS and SDS scores than did the FT group(P<0.0001),with a higher number of mothers experiencing anxiety and depression(P<0.001).Multivariate logistic regression analysis revealed that a greater maternal weight change,the presence of gestational diabetes mellitus,a shorter cervical length in the second trimester,a greater WBC count,and the presence of maternal anxiety and depression were risk factors for PTB(P<0.01).Moreover,the risk score of the FT group was lower than that of the PTB group,and the area under the curve of the risk score for predicting PTB was greater than 0.9.CONCLUSION This study highlights the complex interplay between postpartum anxiety and PTB,where maternal anxiety may be a potential risk factor for PTB,with PTB potentially increasing the incidence of postpartum anxiety in mothers.In addition,a greater maternal weight change,the presence of gestational diabetes mellitus,a shorter cervical length,a greater WBC count,and postpartum anxiety and depression were identified as risk factors for PTB.

8-Hydroxy-2'-Deoxyguanosine (8-OH-2dG) as a Biomarker of Oxidative Stress (OS) in the Acute Exacerbation of Spontaneous Preterm Birth (SPTB)

Spontaneous preterm birth (SPTB) is characterized by the delivery of a baby before 37 completed weeks of gestation, and this condition is associated with significant health challenges for the newborn. Emerging evidence highlights the importance of biomarkers for understanding the mechanisms underlying SPTB. One such biomarker, 8-OH-2dG, plays a critical role in evaluating oxidative stress and its impact on pregnancy outcomes. It has been demonstrated that 8-OH-2dG is a product of oxidative DNA damage and is widely recognized as a key indicator of cellular oxidative stress. Elevated reactive oxygen species in SPTB result in higher levels of the DNA degradation product 8-OH-2dG in amniotic fluid, causing damage to maternal and fetal tissues that could lead to premature rupture of fetal membranes. Therefore, evaluating the role of 8-OH-2dG in SPTB is of great interest. This review provides an overview of the current knowledge on 8-OH-2dG as a biomarker for SPTB and aims to elucidate its mechanism in this condition.

Evaluating the Efficacy of Cervical Tactile Ultrasound Technique as a Predictive Tool for Spontaneous Preterm Birth

Background: Premature cervical softening and shortening may be considered an early mechanical failure that predispose to preterm birth. Purpose: This study aims to explore the applicability of an innovative cervical tactile ultrasound approach for predicting spontaneous preterm birth (sPTB). Materials and Methods: Eligible participants were women with low-risk singleton pregnancies in their second trimester, enrolled in this prospective observational study. A Cervix Monitor (CM) device was designed with a vaginal probe comprising four tactile sensors and a single ultrasound transducer operating at 5 MHz. The probe enabled the application of controllable pressure to the external cervical surface, facilitating the acquisition of stress-strain data from both anterior and posterior cervical sectors. Gestational age at delivery was recorded and compared against cervical elasticity. Results: CM examination data were analyzed for 127 women at 240/7 - 286/7 gestational weeks. sPTB was observed in 6.3% of the cases. The preterm group exhibited a lower average cervical stress-to-strain ratio (elasticity) of 0.70 ± 0.26 kPa/mm compared to the term group’s 1.63 ± 0.65 kPa/mm with a p-value of 1.1 × 10−4. Diagnostic accuracy for predicting spontaneous preterm birth based solely on cervical elasticity data was found to be 95.0% (95% CI, 88.5 - 100.0). Conclusion: These findings suggest that measuring cervical elasticity with the designed tactile ultrasound probe has the potential to predict spontaneous preterm birth in a cost-effective manner.

Gut microbiota in preterm infants receiving breast milk or mixed feeding

BACKGROUND Preterm birth is the leading cause of mortality in newborns,with very-low-birthweight infants usually experiencing several complications.Breast milk is considered the gold standard of nutrition,especially for preterm infants with delayed gut colonization,because it contains beneficial microorganisms,such as Lactobacilli and Bifidobacteria.AIM To analyze the gut microbiota of breastfed preterm infants with a birth weight of 1500 g or less.METHODS An observational study was performed on preterm infants with up to 36.6 wk of gestation and a birth weight of 1500 g or less,born at the University Hospital Dr.JoséEleuterio González at Monterrey,Mexico.A total of 40 preterm neonates were classified into breast milk feeding(BM)and mixed feeding(MF)groups(21 in the BM group and 19 in the MF group),from October 2017 to June 2019.Fecal samples were collected before they were introduced to any feeding type.After full enteral feeding was achieved,the composition of the gut microbiota was analyzed using 16S rRNA gene sequencing.Numerical variables were compared using Student’s t-test or using the Mann–Whitney U test for nonparametric variables.Dominance,evenness,equitability,Margalef’s index,Fisher’s alpha,Chao-1 index,and Shannon’s diversity index were also calculated.RESULTS No significant differences were observed at the genus level between the groups.Class comparison indicated higher counts of Alphaproteobacteria and Betaproteobacteria in the initial compared to the final sample of the BM group(P<0.011).In addition,higher counts of Gammaproteobacteria were detected in the final than in the initial sample(P=0.040).According to the Margalef index,Fisher’s alpha,and Chao-1 index,a decrease in species richness from the initial to the final sample,regardless of the feeding type,was observed(P<0.050).The four predominant phyla were Bacteroidetes,Actinobacteria,Firmicutes,and Proteobacteria,with Proteobacteria being the most abundant.However,no significant differences were observed between the initial and final samples at the phylum level.CONCLUSION Breastfeeding is associated with a decrease in Alphaproteobacteria and Betaproteobacteria and an increase of Gammaproteobacteria,contributing to the literature of the gut microbiota structure of very low-birth-weight,preterm.

A Time Series Analysis of Outdoor Air Pollution and Preterm Birth in Shanghai, China

Objective To investigate the relation between air pollution exposure and preterm birth in Shanghai, China. Methods We examined the effect of ambient air pollution on preterm birth using time-series approach in Shanghai in 2004. This method can eliminate potential confounding by individual risk factors that do not change over a short period of time. Daily numbers of preterm births were obtained from the live birth database maintained by Shanghai Municipal Center of Disease Control and Prevention. We used the generalized additive model （GAM） with penalized splines to analyze the relation between preterm birth, air pollution, and covariates. Results We observed a significant effect of outdoor air pollution only with 8-week exposure before preterm births. An increase of 10 μg/m^3 of 8-week average PM10, SO2, NO2, and O3 corresponded to 4.42% （95%CI 1.60%, 7.25%）, 11.89% （95%CI 6.69%, 17.09%）, 5.43% （95%CI 1.78%, 9.08%）, and 4.63% （95%CI 0.35%, 8.91%） increase of preterm birth. We did not find any significant acute effect of outdoor air pollution on preterm birth in the week before birth. Conclusion Ambient air pollution may contribute to the risk of preterm birth in Shanghai. Our analyses also strengthen the rationale for further limiting air pollution level in the city.

Ethnic Differences in Preterm Birth Risks for Pregnant Women with Thyroid Dysfunction or Autoimmunity:A Meta-analysis

Objective Abnormal maternal thyroid function is associated with preterm birth.However,this association stays dubious in relevant individual studies for ethnic difference reasons and lack of direct supporting data.This study aimed to evaluate the relationship between preterm birth and thyroid dysfunction or autoimmunity based on ethnic differences.Methods Relevant studies were identified through searches of MEDLINE,Excerpta Medica,Wan Fang,China Biological Medicine disc,and China National Knowledge Infrastructure from inception to June 15,2016.Original articles in which an incidence or prevalence of thyroid dysfunction or autoimmunity before second trimester of pregnancy could be extracted were included.Results Thirty-two unique studies were included for the final meta-analysis.Patients involved were divided into two groups：Group 1（G1） and Group 2（G2） comprising of Asian and Caucasian populations,respectively.Positive thyroid antibodies were associated with the occurrence of preterm birth in both G1 [odds ratio（OR）：3.62,95% confidence interval（CI）：2.83-4.65] and G2（OR：1.35,95% CI：1.17-1.56）;hypothyroidism,only in G2（OR：1.20,CI：1.09-1.33）;and subclinical hypothyroidism or hypothyroxinemia,in neither group.Conclusion Thyroid autoimmunity may be a more favorable factor leading to preterm birth among pregnant women of different ethnicities,compared with thyroid dysfunction.

Application of prolonging small feeding volumes early in life to prevent of necrotizing enterocolitis in very low birth weight preterm infants

Objective:To study the effects of prolonging small feeding volumes early in life on the incidence of necrotizing enterocolitis(NEC)in very low birth weight(VLBW)preterm infants.Methods:A total of 128 VLBW infants who could not be breastfed were assigned into the experimental group(63 cases)and the control group(65 cases)using a random number table.The experiment group was fed 12 mL/(kg·d)on day 1 which was increased to 24 mL/(kg·d)for the first 10 study days.The control group was fed 12 mL/(kg·d)for the first 14e48 hours.Then,the feeding volume increased by 24-36 mL/(kg·d)up to 140e160 mL/(kg·d)and maintained until the 10th day after birth.The incidence of feeding intolerance and NEC,duration of hospitalization,time to full enteral feedings,incidence of intrahepatic cholestasis,and the levels of gastrin and motilin in serum were assessed.Results:The incidence of feeding intolerance was significantly lower in the experimental group compared with the control group(15.87% vs.33.84%).There was a significant reduction in the incidence of NEC between the experimental and control groups(7.9% vs.16% in the control group).Conclusion:A protocol that prolongs small feeding volumes early in life can reduce the incidence and severity of NEC,but still warrants further study.

Risk Factors for Low Birth Weight and Preterm Birth：A Population-based Case-control Study in Wuhan,China

Low birth weight（LBW） and preterm birth（PB） are associated with newborn mortality and diseases in adulthood.We explored factors related to LBW and PB by conducting a population-based case-control study from January 2011 to December 2013 in Wuhan,China.A total of 337 LBW newborn babies,472 PB babies,and 708 babies with normal birth weights and born from term pregnancies were included in this study.Information of newborns and their parents was collected by trained investigators using questionnaires and referring to medical records.Univariate and logistic regression analyses with the stepwise selection method were used to determine the associations of related factors with LBW and PB.Results showed that maternal hypertension（OR=6.78,95% CI：2.27–20.29,P=0.001）,maternal high-risk pregnancy（OR=1.53,95% CI：1.06–2.21,P=0.022）,and maternal fruit intake ≥300 g per day during the first trimester（OR=1.70,95% CI：1.17–2.45,P=0.005） were associated with LBW.BMI ≥24 kg/m^2 of mother prior to delivery（OR=0.48,95% CI：0.32–0.74,P=0.001） and gestation ≥37 weeks（OR=0.01,95% CI：0.00–0.02,P〈0.034） were protective factors for LBW.Maternal hypertension（OR=3.36,95% CI：1.26–8.98,P=0.016）,maternal high-risk pregnancy（OR=4.38,95% CI：3.26–5.88,P〈0.001）,maternal meal intake of only twice per day（OR=1.88,95% CI：1.10–3.20,P=0.021）,and mother liking food with lots of aginomoto and salt（OR=1.60,95% CI：1.02–2.51,P=0.040） were risk factors for PB.BMI ≥24 kg/m^2 of mother prior to delivery（OR=0.66,95% CI：0.47–0.93,P=0.018）,distance of house from road ≥36 meters（OR=0.72,95% CI：0.53– 0.97,P=0.028）,and living in rural area（OR= 0.60,95% CI：0.37–0.99,P=0.047） were protective factors for PB.Our study demonstrated some risk factors and protective factors for LBW and PB,and provided valuable information for the prevention of the conditions among newborns.

Determinants of Preterm Birth at the Postnatal Ward of Kenyatta National Hospital, Nairobi, Kenya

Background: Preterm birth, delivery prior to 37 completed weeks or 259 days gestation, is a worldwide maternal and perinatal challenge and is a leading cause of neonatal morbidity and mortality. Preterm birth remains the leading cause of perinatal and postnatal mortality and morbidity especially in developing countries where the health care services are suffering from limited resources. Premature babies usually suffer from both immediate and long term consequences. Right after birth, they have difficulties in breathing, temperature regulation, bleeding, infection and other problems due to organ immaturity. Their growth and developmental milestones will also be affected leading poor physical, mental, educational and psychosocial problems as a long term consequences. Preterm deliveries were responsible for 1 million out of the 6.3 million deaths of children under5 in2013 REF _Ref493689700 \r \h \* MERGEFORMAT [1]. In Kenyatta National hospital, few studies have been carried out to determine the prevalence and factors associated with preterm birth. Hence the aim of this study is to determine the prevalence and factors associated with preterm birth at Kenyatta national hospital (KNH), Nairobi, Kenya. Materials and Methods: This was a hospital based descriptive cross-sectional study involving randomly selected respondents (N = 183) from post natal ward of Kenyatta National Hospital. Systematic random sampling method was applied to recruit the study respondents. A pre-tested semi-structured questionnaire was employed to collect information on the possible determinants of Preterm birth. Data was analysed usingSPSSsoftware version 22.0. Descriptive analysis was done using mean and frequency proportion. Inferential analysis using chi-square test was used to establish association different variables. The ethical approval to conduct the study was obtained from KNH-University of Nairobi Ethical Review Committee (KNH-UoN ERC). Permission to collect data was sought from the KNH and consent was obtained from the selected respondents before administering the questionnaire. Result: The prevalence rate of preterm birth was 20.2%. History of urinary tract infection during pregnancy [AOR = 4.62;95% CI = 1.56 - 4.67;P = 0.013], history of preterm birth [AOR = 5.8;95% CI = 1.18 - 10.30;P = 0.001], history of abortion [AOR = 3.54;95% CI = 1.18 - 10.41;P = 0.016], history of hypertension during pregnancy [AOR = 2.04;95% CI = 1.14 - 3.64;P = 0.012], maternal age (≥31 years) [AOR = 2.81;95% CI = 1.24 - 5.87;P = 0.012] and alcohol consumption during pregnancy [AOR = 2.56;95% CI = 0.68 - 9.64;P = 0.014] were determined as significant risk factors for preterm birth. Conclusion and recommendation: The determinants of preterm birth are multifactorial including history of abortion, preterm birth, urinary tract infection, hypertension and alcohol consumption during pregnancy. Most of these risk factors of preterm birth are controllable if reproductive age mothers are educated properly. It is very important for antenatal mothers to adhere to the guidelines of antenatal visits so that those at risk are spotted and close monitoring can done in order to reduce this high rate of preterm birth and its negative consequences. Strategies to avert the high prevalence of preterm birth and its associated morbidity and mortality must be given priority at national, regional and international levels, so that the Millennium Development Goal (MDG) 4 can be achieved.

Cervicovaginal Inflammatory Cytokines, Obesity and Inter-Pregnancy Interval Negatively Affect Pregnancy Duration in Pregnant Women at High-Risk for Recurrent Spontaneous Preterm Birth

Objectives: Evaluation of change of cervicovaginal fluid (CVF) cytokines’ levels during pregnancy and its relation to incidence of preterm birth (PTB). Patients & Methods: Pregnant women with history of PTB and cervical length α (TNF-α) and interleukins (IL)-6 and -10 levels. Study outcomes included differences in cytokines’ levels between samples and groups. Results: Sample-I cytokines’ levels were significantly higher in study than control women. Cytokines’ levels in Sample-II were significantly higher in control, while were significantly lower in study women compared to Sample-I. Sixteen study women had PTB and had significantly higher CVF levels of IL-10 and TNF-α estimated in both samples than women had no PTB. Pregnancy duration was negatively correlated with maternal body mass index (BMI) and cytokines’ levels, while was positively correlated with inter-pregnancy interval (IPI). Cytokines’ levels were positively correlated with BMI and negatively correlated with IPI. Short IPI and high TNF-α levels are negative predictors for pregnancy duration. Conclusion: High BMI, short IPI and high CVF inflammatory cytokines’ levels negatively affect pregnancy duration especially in women with history of recurrent PTB. Early prophylactic CC for women at high-risk of SPTB can modulate local immune disturbance, reduce incidence of SPTB and prolong pregnancy duration.

Maternal and obstetric risk factors for low birth weight and preterm birth in rural Gambia: a hospital-based study of 1579 deliveries

Introduction: Low birth weight and prematurity are risk factors for perinatal morbidity and mortality, which is high in Sub Saharan African countries. We determined the frequency of and maternal and obstetric risk factors for low birth weight and preterm birth among hospital births in rural Gambia. Method: We performed a hospital-based retrospective analysis of deliveries from July to December 2008 in two rural hospitals. Maternity records were reviewed and abstracted of the mother’s demographic and reproductive characteristics, obstetric complications and foetal outcome. The maternity records contain important information maternal health and complications during pregnancy and intrapartum period. The records also contain information about the newborn’s vital status and birth weight. To determine the association between low birth weight (LBW), preterm birth (PTB) and maternal demographic characteristics and obstetric complications we calculated odds using logistic regression. Main outcome measure(s): Low birth weight (<2500 grams) and preterm birth (<37 weeks). Results: Our final sample included 1244 singleton live births with complete information about all variables. The rate of LBW and PTB were 10.5% and 10.9% respectively. Ninety-four percent of LBW infants were estimated to be preterm births. The mean birth weight was 3013 g (541 g standard deviation-SD), while the mean gestational age was 37 weeks. The pattern of risk factors was similar for LBW and PTB and both were strongly associated with antepartum haemorrhage and hypertensive pregnancy disorders. Additionally, primi parity was a risk factor for both PTB and LBW. Conclusion: The percentage of low birth weight and preterm birth in rural hospitals in The Gambia is high. The most significant risk factors were those that may be detected during the antepartum period. Thus, vigilant monitoring during pregnancy, early detection and management of obstetric complications coupled with provision of timely obstetric care interventions are crucial for

The Combination of the Fetal Fibronectin Bedside Test and Cervical Length in Preterm Labor Is Useful for Prediction of Preterm Birth

Objective: To determine the value of fetal fibronectin (FFN), cervical length (CL) measurement and their combination as binary predictors for preterm birth (PB) in women with preterm labour (PTL) between 24 + 0 and 34 + 0 weeks. Methods: One hundred fifty-nine patients with signs of PTL (singleton pregnancies (SP) = 125, twin pregnancies (TP) = 34) were evaluated in a retrospective study. Inclusion criteria were contractions > 4/20 min, intact membranes, no bleeding. The cut-off was ≥50 ng/ml for FFN and ≤20 mm for CL measured by transvaginal ultrasound. The primary outcome variable was delivery within 7 days from admission. Results: We evaluated 125 SPs and 34 TPs. In SPs, both methods had a sensitivity of 80%;the specificity was 82% for FFN, and 50% for CL. For the combination of both tests sensitivity was 80% and specificity 88%. In TPs, the sensitivity of both tests was lower (FFN 33%, CL 67%) but the combination of both tests represented the highest result for specificity (77% compared to 68% for FFN alone and 32% for CL alone). Conclusion: The combination of FFN and CL in PTL results in a significant higher specificity in SPs. In TPs the performance of the tests is less accurate.

Socioeconomic, biological and genetic factors influencing preterm birth

The etiology of preterm birth is mostly underestimated in developing countries.Current presumptions are that both environmental and genetic factors contribute towards its onset and are responsible for the higher frequency of neonatal deaths.Despite there being considerable scientific data on preterm births across the world,the frequency of its occurrence and threat to the survival of neonates are alarming.It is important that variations among populations should be considered as the socioeconomic status,climatic zones and other genetic,as well as epidemiological factors vary,so as to draw definitive conclusions on the pathogenesis of preterm birth.Predictive biomarkers,prevention and optimum treatment strategies are still being discovered,but with well-designed studies and collaborative efforts,maternal and child healthcare can be prioritized.The purpose of this review is to understand the contributing factors of preterm birth as it is a critical issue and needs in-depth understanding with planned scientific studies to decrease the rate of preterm birth and complication related to it.Furthermore,the review enlists various factors linked to preterm birth viz.,high maternal age,psychological state,environmental contaminants,infection,cervical length,addiction,cytokine interaction,preeclampsia,genetic composition,ethnicity,oxidative stress and microRNAs.We have summarized the status of preterm birth,its causes,and future line of work required to prevent mortality of mother and neonate that will help us design successful studies which aim to reduce preterm births effectively.

Role of Vaginal Progesterone in Prevention of Preterm Labor in Women with Previous History of One or More Previous Preterm Births

Objective: To evaluate whether prophylactic administration of 200 mg vaginal progesterone can reduce the incidence of preterm birth in women with documented history of preterm birth Setting: Obstetrics and Gynecology Department, Zagazig University Hospital, Egypt. Methods: Ninety patients with previous history of preterm birth prior to 37 week presenting with singleton pregnancy between 20 - 24 weeks were randomly allocated to receive either the progesterone 200 mg vaginal suppository or no treatment. Results: The incidence of preterm labor before 37 weeks of gestation was significantly lower in the study group than in the control group (22.2% vs. 53.3%) especially in earlier gestational ages. While, the mean birth weight was significantly higher in the study group than in control group (2872.67 ± 565.76 gm vs. 2487.78 ± 742.40 gm). The neonatal morbidities and mortality associated with preterm labor were significantly lower in the study group than in the control group as shown by lower incidence of neonatal RDS (13.3% vs. 31.1%;P = 0.043) and lower incidence of the need for NICU admission (15.6% vs. 35.5%;P = 0.03). Conclusion: Administration of prophylactic vaginal progesterone (200 mg, daily) can significantly reduce the rate of preterm birth before 37, 32 and 28 wks of gestation among women with previous spontaneous preterm birth. In addition, the rates of RDS and admission to NICU were significantly decreased among infants of women assigned to progesterone treatment. Also, there was an additional benefit of vaginal progesterone for prevention of preterm birth in women who had prior spontaneous preterm birth and cervical length 25 mm.

What Prevents Eligible Patients from Receiving Progesterone Therapy to Prevent Recurrent Preterm Birth

Objective: The use of intramuscular 17-alpha-hydroxyprogesterone caproate (17-OHPC) has been shown to be beneficial for the prevention of preterm birth (PTB) in women with a prior history. Not all patients with a prior preterm birth receive 17-OHPC. The purpose of this study was to investigate potential barriers to receiving this therapy. Methods: A retrospective chart review of those patients at our institution who received the diagnosis of “previous preterm delivery” in 2010 and 2011 was performed to see whether they were offered and received 17-OHPC. Patients were considered eligible if they had a prior delivery at less than 36 weeks of gestation secondary to idiopathic preterm labor. For those patients that were deemed eligible but did not receive therapy, an explanation was sought. Results: Sixty-six charts were reviewed in detail. Forty-three patients were considered eligible to receive 17-OHPC. The remaining had medical indications for delivery including premature rupture of membranes (PROM) (15), intrauterine growth restriction (IUGR) (1), and hypertension (2). Of the 43 patients deemed eligible, 17 did not receive 17-OHPC. Of these, eight patients were not offered therapy, 2 patients declined therapy, 3 patients presented with therapy after 28 weeks (too late), and 4 received a prophylactic cerclage as their only therapy. There were no significant differences between the two groups. Conclusion: In an effort to increase 17-OHPC use among eligible patients, we must continually identify physician biases and patient barriers that prevent utilization of this intervention. In addition, patients who deliver preterm should be told the importance of presenting early in subsequent pregnancies in order to receive the full benefits of this therapy.

Maternal Euthyroid Hyperthyroxinemia May Reduce Preterm Birth Rate in Multiparous Women

Hypothyroidism, defined as thyrotropin (TSH) above and free thyroxine (fT4) serum level below the reference rage, as well as hyperthyroidism, defined as suppressed TSH and elevated thyroid hormones exceeding the upper limit of the reference range, may have major impacts on fertility and pregnancy outcome. Ideally, euthyroidism, defined as TSH and fT4 in the reference range, should be established and preserved during pregnancy prior to gestation. High estrogen levels during pregnancy stimulate the synthesis of maternal thyroxine-binding-globulin (TBG) in the liver, increasing TBG serum concentration by 2 - 3 fold compared to the initial value and affecting thus maternal fT4 serum level. As a consequence, maternal thyroid function adapts by increasing synthesis and secretion of thyroxine. TBG-induced elevation of serum thyroxine either total or free in the absence of hyperthyroidism is defined as euthyroid hyperthyroxinemia. Since TBG concentration declines first after delivery, pregnancy-induced euthyroid hyperthyroxinemia constitutes a physiological metabolic state. Depending on functional capacity, maternal thyroid may exhaust, resulting in hypothyroxinemia, which increases the risk of fetal neurodevelopmental impairment and preterm birth. The study aims to determine whether L-Thyroxine (L-T4) replacement, sustaining pregnancy-induced maternal euthyroid hyperthyroxinemia during the whole pregnancy by keeping fT4 level in the high normal reference range might reduce preterm birth rate. Preterm birth rate of women with singleton gestation and L-T4-induced high normal fT4 level constituting the study group (n = 918) was compared with the preterm birth rate of women with singleton gestation (n = 6414) who completed a questionnaire concerning L-T4 administration during pregnancy. Two groups were formed. In group A we compared the preterm birth rate between women with L-T4-induced high normal fT4 level and a control group without L-T4 administration during pregnancy. In group B we compared the preterm birth rate of women already receiving L-T4 prior to conception, maintaining dosage to keep fT4 level in the high normal reference range during gestation to a control group with L-T4 intake during pregnancy. The preterm birth rates in group A declined by 51% (p = 0.01) and in group B by 87% (p = 0.001) in multiparous women, while in primiparous the preterm birth rate was similar between study and the control group. Sustaining a high normal fT4 level during pregnancy with L-T4 may significantly reduce preterm birth rate in multiparous women.

Oral Micronized or Parenteral Progesterone versus Health Education in the Prevention of Preterm Birth: A Single Blinded Randomized Controlled Trial

The primary aim of this study was to evaluate the possible prophylactic role of progesterone in women with a history of spontaneous preterm birth (PTB) while the secondary aim was to compare oral or intramuscular progesterone versus health education in such cases. Methods: A randomized, single blinded interventional randomized controlled trial was conducted. It comprised 90 cases with a history of PTB who were divided into 3 equal groups who received oral micronized progestogen capsule 200 mg daily (group A), parenteral 17 α-hydroxyprogesterone caproate 250 mg weekly IM injections (group B) or received health education including rest (group C) starting from 20 weeks till the end of 34 weeks of gestation. Results: This study included eligible 90 pregnant women at high risk of PTB who continued follow-up. For socio-demographic characteristics, there were no significant differences between the groups in respect to age, residence, education level, occupation, gravidity, parity and number of living children apart from significant difference between group A and C regarding mean patients’ age. Mode and place of delivery did not differ between the groups while gestational age at time of delivery was significantly better on using injectable than oral progesterone. Neonatal birth weight was significantly higher in group B if compared separately to groups A and C and was still significantly higher in group A if compared with group C. NICU admission rate was higher in group C if compared to group B or to the combined group A and B. Compliance was significantly higher in group B if compared to both group A and C and was significantly higher in the intervention group A and B if compared to group C. Conclusions: Progesterone supplementation has a significant role in prevention of PTB if compared with just health education. Progesterone injections expressed significantly better results than oral micronized progesterone in terms of prolongation of gestational age, better neonatal birth weight and less admission rate to the NICUs.

Decidual cell expressed tissue factor promotes endometrial hemostasis while mediating abruption associated preterm birth

During human pregnancy, progesterone induced decidual cells protect against hemorrhage: 1) as endovascular trophoblast breech and remodel uterine blood vessels;and 2) in the third stage of labor following preterm and term delivery. De- cidual cells promote hemostasis through enhanced expression of tissue factor (TF), the primary initiator of hemostasis via thrombin generation, and plasminogen activator inhibitor-1, which inactivates tissue type plasminogen activator, the primary fibrinolytic agent. Abruptions (decidual hemorrhage) produce excess thrombin which acts as autocrine/paracrine inducer of decidual cell expressed matrix metalloproteinases and of neutrophil chemoattractant and activator, interleukin-8. The latter mediates aseptic abruption-related neutrophil infiltration. During abruptions, decidual cell and neutrophil-derived proteases effectively degrade the decidual and fetal membrane extracellular matrix to promote preterm premature rupture of the membranes and preterm delivery (PTD). Decidual cell-derived thrombin weakens the amniotic membrane and lowers decidual cell-expressed progesterone receptor levels by increasing phospho-ERK1/2 signaling. The resulting functional progesterone withdrawal accompanies PTD.

Do Protease Inhibitors Increase Preterm Births in Human Immunodeficiency Virus-Infected Patients?

Objective: To compare preterm delivery (PTD) rates in HIV-infected patients on a protease inhibitor (PI)-based and a PI-sparing regimen. Study Design: This is a retrospective review of records of HIV-infected pregnant women between 2000 and 2007 at University Hospital, Newark, NJ. Patients were grouped according to PI exposure during pregnancy. Rates of preterm birth were compared, and the analysis was performed irrespectively of the etiology or indication of the preterm birth. Multivariate analysis including substance use, PI use, initial CD4 count, and history of PTD was performed. Results: There were 129 pregnant women in the PI group and 59 in the PI-sparing group. The PTD rate did not differ between the PI group and PI-sparing group (27.9% vs 25.4%, P = 0.72). 28.6% of those who delivered preterm had a previous PTD compared to 8.4% of those who delivered at term (P = 0.0019). Patients who delivered preterm had a higher rate of substance use (37.3% vs 19.7%, P = 0.0128). In the multivariate analysis, only history of PTD was significant (P = 0.018). Conclusion: Contrary to other studies, PIs were not associated with PTD. Other known risk factors of PTD, specifically past PTD and substance use, should be considered and targeted for risk reduction during pregnancy.

Mental health impact on Black,Asian and Minority Ethnic populations with preterm birth:A systematic review and meta-analysis

BACKGROUND Preterm birth(PTB)is one of the main causes of neonatal deaths globally,with approximately 15million infants are born preterm.Women from the Black,Asian,and Minority Ethnic(BAME)populations maybe at higher risk of PTB,therefore,the mental health impact on mothers experiencing a PTB is particularly important,within the BAME populations.AIM To determine the prevalence of mental health conditions among BAME women with PTB as well as the methods of mental health assessments used to characterise the mental health outcomes.METHODS A systematic methodology was developed and published as a protocol in PROSPERO(CRD420-20210863).Multiple databases were used to extract relevant data.I2 and Egger's tests were used to detect the heterogeneity and publication bias.A trim and fill method was used to demonstrate the influence of publication bias and the credibility of conclusions.RESULTS Thirty-nine studies met the eligibility criteria from a possible 3526.The prevalence rates of depression among PTB-BAME mothers were significantly higher than full-term mothers with a standardized mean difference of 1.5 and a 95%confidence interval(CI)29%-74%.The subgroup analysis indicated depressive symptoms to be time sensitive.Women within the very PTB category demonstrated a significantly higher prevalence of depression than those categorised as non-very PTB.The prevalence rates of anxiety and stress among PTB-BAME mothers were significantly higher than in full-term mothers(odds ratio of 88%and 60%with a CI of 42%-149%and 24%-106%,respectively).CONCLUSION BAME women with PTB suffer with mental health conditions.Many studies did not report on specific mental health outcomes for BAME populations.Therefore,the impact of PTB is not accurately represented in this population,and thus could negatively influence the quality of maternity services they receive.