The aim of the present paper was to explore the role of partners for the stressful life events of birth and the transition to parenthood.N = 304 dyads) we tested whether relationship quality positively predicted fewer interventions during labor and birth, a more positive birth experience, and better well-being during the first six weeks after birth. In a second study we surveyed mothers  who had given birth during the first lockdown of the COVID-19 pandemic in spring 2020 – some in the absence of their partners – to test the assumption that regardless of relationship quality, the presence of the partner was positively related to low-intervention births and the birth experience.In a first prospective longitudinal study  could be integrated into a Single Indicator model. They revealed that a high relationship quality assessed between week 5 and week 25 of pregnancy had a positive effect on birth experience for the mother and on psychological well-being during the transition to parenthood for both mothers and fathers. Results of the retrospective quasi-experimental field study (Study 2) revealed that the continuous presence of the partner was associated with a higher probability of a low-intervention birth and a more positive birth experience. Presence of a partner for only part of the birth did not positively predict labor and birth, but did positively predict the birth experience. The effects were independent of relationship quality.The results of both studies highlight the importance of partners for psychological well-being during labor and birth and the transition to parenthood. Childbirth and also the transition to parenthood are processes of change that include physical and psychological challenges, such as fatigue, physical vulnerability , psychological processing of labor and birth, and adjustment to the new situation and routines. If relationship quality is high, couples’  support for each other is likely to be higher. Emotional support within the relationship could reduce potential stress, and relationship quality could function as an important buffer against stress. Literature reviews and meta-analytic studies have shown higher marital quality to be related to greater personal well-being , higher A series of studies have focused on the role of attachment for labor and birth and the transition to parenthood. Attachment theory postulates that having a secure attachment style can be a resource during stressful life events . A securIntegrating the available research, it becomes evident that high relationship quality operationalized as e.g., dyadic coping, attachment, or attitudes toward the partner can be a protective factor for stressful life conditions. A study unrelated to pregnancy and birth indicated a physiological stress-reducing effect (reduced cortisol and heart rate response) when there was physical contact between romantic partners prior to a stressful situation, surprisingly, the protective results were independent of relationship quality . That isThe New York Times [nicer to give birth with a partner present trivializes the experience. The question arises, whether the partner’s presence is merely nice to have – and thus dispensable during a pandemic or other crises – or whether there are substantial medical and psychological benefits for women who give birth with their partner present. Moreover, as outlined above, it is of interest whether a potential positive effect would be based on the partner’s presence or whether relationship quality would be the more important factor. Due to the special situation of the COVID-19 pandemic and our two conducted studies using a longitudinal design (covering birth and the transition to parenthood) and a quasi-experimental retrospective study, we were able to approach this question.Today, in many cultures, women giving birth are routinely accompanied by their partners. Because it would be absolutely unethical to manipulate the presence of partners for experimental purposes, it is very difficult to empirically investigate the effect of the presence of the partner (or other close relationship figures) for birth. During the COVID-19 pandemic, however, many hospitals around the world excluded partners from labor and birth to reduce COVID-19-related risk. Exclusion of partners drew considerable media attention, e.g., by rk Times  and was Frequent birth companions are the biological fathers of the babies. Research indicates that fathers do not take only a passive role during labor and birth, e.g., a recent scoping review suggested that fathers experience emotions such as anxiety and helplessness during labor and birth and are concerned about the health of the mother and child . FathersThe aim of this paper was to replicate previous findings indicating close relationships to be a protective factor for stressful life conditions for the two contexts (1) birth and (2) the transition to parenthood (Study 1). By doing so, we propose a model that includes different variables of the relationship quality and includes female and male data, thus dyadic data. We further (Study 2) aimed to test the specific roles of relationship quality versus the presence of the partner during stressful birth-related life events.In Study 1 we first focused on relationship quality, which covered not only one aspect of the relationship , as has been typical in the majority of previous studies e.g., , 13–16),–16,13–16In Study 2, we explored whether independent from relationship quality, childbearing persons might benefit from the presence of the partner. For this purpose, we examined women who gave birth during the COVID-19 pandemic – either with or without the presence of their partners. Specifically, we tested the hypotheses that the partners’ presence at birth increases the probability of (a) a low-intervention birth and (b) a positive birth experience. We also expected a positive but smaller effect if the partner was temporarily present. These assumptions were preregistered (see OSF link below). In additional exploratory analyses we tested whether potential associations of the partner’s presence with low-intervention birth and with birth experience were moderated by relationship quality, emotional well-being experienced before birth (retrospectively assessed), and continuous midwifery support. We also aimed to conceptually replicate the SI model extracted in Study 1 (see below) and explored by whom participants, the birthing persons, felt most supported during labor and birth, and how they evaluated the partner’s support.https://osf.io/9v2y6/?view_only=23a590304c654489a543535ec021a833.Data, SPSS syntaxes, the preregistration of Study 2, and additional results and materials can be found at OSF: Study 1 was part of a broader longitudinal study with different objectives and a variety of measurement times and variables. Data collection took place between 2016 and 2018. For reasons of readability, only the measurement points and variables relevant for this study are presented here. A complete list of all measurement points, variables, the exact order of the questionnaires, and data can be found at OSF. Measures were obtained in the first two trimesters of pregnancy , one time within the first week after birth , and using EMA within the first six weeks after birth (postpartum adjustment). Note, most participants completed questionnaires in the first half of pregnancy. Gestational age at the first measurement time depended on how early in the pregnancy we could engage the women to participate, and varied between week five (0.7%) and week 25 (0.3%) week. The mode was week 15 (11.8%) and seven participants (2%) started between week 21 and week 25, or at the beginning of the second half of pregnancy.Study 2 used a retrospective study design, surveying participants who gave birth during the first COVID-19 lockdown in Germany between March 15 and April 8, 2020. Data collection took place from June 29 to August 24, 2020.For both studies, data collection took place online. For Study 1, t1 and t2 questionnaires had to be completed on the computer due to technical peculiarities. The EMA was performed via mobile phone. For Study 2, participants could choose whether they wanted to answer the questions on a computer or on a mobile phone.Both studies presented in this paper were conducted in Germany, using a German sample. In the first study partnered heterosexual dyads participated. In the second study, only the childbearing parent took part, and participants with and without partners were welcome to participate.Study 1. For the longitudinal study, 304 cisgender, heterosexual, partnered dyads were used. Minor fluctuations in the sample size occurred depending on the time of measurement . At t1 the mean age for the 304 female participants was 30.30 years (SD = 3.99) and for male participants was 32.58 years (SD = 4.51). The majority of couples were married (62.2%) at the beginning of data collection (t1). Only 3.6% indicated a length of relationship of less than a year, and the length of relationship for the remaining sample varied between one year (3.9%) and 20 (1.0%) years with a mode of six years . The vast majority of fathers were present at the birth (97.2%). Prior to data collection women completed a screening questionnaire to assess exclusion criteria. Participants being pregnant with more than one child, artificial insemination, and more than one abortion and/or more than one stillbirth in the past could not take part in the study to avoid unnecessary burden for them. Participants also had to have mobile internet access and be older than 18 years and younger than 38 years. The use of psychotropic drugs was also an exclusion criterion. Women were recruited either by the help of midwives and gynecologists or via Facebook groups and Facebook advertisement. Participating women received 100 euros and participating men 80 euros (as they had to complete fewer questionnaires) as monetary compensation. Incentives were paid after the last measurement time point eight weeks after the birth. Participants were also paid if a measurement point was missed. For the additional assessment point six months after birth no incentive was paid.Study 2. The second study was completed online by 1,160 participants. Participants were recruited mainly through social networks such as Facebook and Instagram. The survey was accessible from June 29 to August 24, 2020. For 180 of the 1,160 participants, preregistered exclusion criteria were met: they did not give birth between March 15 and April 8, 2020 , gave birth in out-of-hospital settings, were men, and/or indicated their data should not be used. Thus, 980 participants  remained in the sample. Our target sample size of 250 was clearly exceeded but in favor of power maximization we retained the sample that remained after exclusion based on the defined criteria above.Measurement time 1 (t1). The measures described immediately below were collected at t1, i.e., between week 5 and 25 of pregnancy.Relationship attachment. We used the partner-specific [strongly disagree to 6 = strongly agree . The responses to the insecure attachment descriptions were recoded and aggregated with secure attachment such that a high score of relationship attachment indicates secure attachment. Cronbach’s α was 0.60 for female participants and 0.59 for male participants.specific  German vspecific ) to asseAttitudes toward romantic partner. For measuring (explicit) attitude toward the romantic partner, we used the scale developed by Banse and Kowalick [I feel good when I am close to my partner) on a six-point Likert scale ranging from 1 = strongly disagree to 6 = strongly agree . Cronbach’s α was 0.83 for both female and male participants.Kowalick . ParticiRelationship satisfaction. The German version [In general, how satisfied are you with your relationship?) that participants answered on a six-point Likert scale. The scale’s endpoint labels depended on the particular question. Cronbach’s α was 0.87 for female and 0.82 for male participants. version  of the R version ) was useDyadic coping. Dyadic coping was measured with the first two subscales of the Dyadic Coping Inventory . The second subscale contains 11 items assessing the partner’s reaction to the expressed stress . The subscales were combined to a single score of dyadic coping, as is also suggested in the test manual [strongly disagree and 6 = strongly agree). Cronbach’s α was 0.87 for female and 0.88 for male participants.ry . The fit manual  and our Birth-related mindset. Birth-related mindset was assessed using the Mindset and Birth Questionnaire , which Measurement time 2 (t2). Low-intervention birth and birth experience were assessed shortly (within the first week) after birth at t2.Low-intervention birth. To summarize the complex process of labor and birth we combined (effect-coded) different birth variables into one variable indicating whether participants had a low-intervention birth (= 1) or not (= -1). The variable low-intervention birth [on birth  is adapton birth . If laboon birth –36; and Birth experience. To assess the participants’ general satisfaction with the birth experience , we used the Birth experience scale [strongly disagree to 6 = strongly agree. Cronbach’s α in the present study was 0.90 for women and 0.85 for men.ce scale . The scaPostpartum adjustment. For assessing postpartum adjustment within the first six weeks after birth we used EMA [used EMA , which yused EMA . In the used EMA ). Links strongly disagree to 6 = strongly agree. The baby’s perceived well-being was assessed with six items using a semantic differential (six points). Items measured the crying and sleeping behavior of the baby, how satisfied, exhausted, and quiet the baby appeared, and how easy the baby could be comforted .For measuring emotional well-being, we used 12 items from the Quality of Life Profile for Chronically Ill Patients ; women: Being primiparous and medical risk. Analogous to previous studies , gi, giBeings , attitudes toward the romantic partner (α = 0.88), relationship satisfaction (α = 0.88), birth-related mindset (α = 0.83), being primiparous (51.1%), medical risk (55.6%), low-intervention birth , and birth experience (α = 0.93) were assessed. For medical risk, in this study we also asked for a SARS-CoV-2 diagnosis at the time of delivery, and four participants had tested positive. Note again the C-section rate in our study was lower than for the German population, which was 29.5% in 2020, and the rate of vaginal deliveries in this study (8.3%) was slightly higher than typical for the German population, which was 6.4%% in 2020 .Partner’s presence. Participants were asked to indicate who was planned to accompany them during labor and birth , whether the partner was able to be present, and if so, to what extent . The majority of the sample (95.1%) had planned for their male partner to accompany them, 1.0% for their female partner, and 3.9% for someone else.presence (1 = partner continuously present at birth or partner temporarily present at birth and 0 = partner not present) and continuous presence (1 = partner continuously present at birth and 0 = partner temporarily present at birth or partner not present) to conduct further analyses. This procedure makes it possible to test the effect of all possibilities  on low-intervention birth and on birth experience.ample 95.% had plaEmotional well-being before birth. To retrospectively assess the participants’ emotional well-being in the days before birth, we again used 10 items of the Quality of Life Profile for Chronically Ill Patients [We would like you to recollect the last few days before giving birth. How were you feeling when thinking of the imminent birth? The answer format for the items was again a six-point Likert scale ranging from 1 = strongly disagree to 6 = strongly agree. Cronbach’s α in the present study was 0.91.Patients , using tPerceived support. In Germany it is possible to hire a freelancing midwife for labor and birth. The advantage over the standard care by a hospital midwife is continuous one-to-one care. For the accompaniment, however, extra costs must be paid and the number of freelancing midwives providing this type of care is limited. To assess one-on-one support, we asked what kind of midwifery support participants were given during labor and birth with the following options: freelancing midwife, hospital midwife, and no midwife. For the analyses the variable was dummy coded. In the present study 12.7% of the participants had access to one-on-one support from a midwife.not at all to 6 = very much. This allowed us to compare the participants’ perception of their partners’ support on different levels to their perception of the medical staff’s support.We also assessed the participants’ perception of different support forms originating from different support sources. The different support forms were based on Hodnett  and inclProcedure. The second study was conducted online. Participants were first informed that their participation was voluntary, anonymous, and could be ended at any time. Then they were presented with questions concerning their age and gender. To minimize a potential influence of the birth experience on the birth-related mindset, participants first completed the MBQ before continuing with the birth-related questions, including those concerning the different prenatal risks, the planned companion, and their companion’s presence. They then completed the Quality of Life Profile and the Birth experience scale, followed by the questions concerning participants’ perception of the different supporters and the different support forms. The relationship questionnaires were answered last, and only by those who had at least planned for their partner to accompany them. In the end, all participants could indicate whether their data should be used or not, leave a personal remark, and share their e-mail address if they wanted us to send them a summary of the results. In this case, the address was registered separately.p-value to 0.01 for all reported results if not stated otherwise.As areas under the curve (AUC) provide better evidence of the strength of associations with a dichotomous outcome than correlation coefficients do  , we use Single Indicator model. We then proceed with the results of Study 2 to test the potential positive effect of partner’s presence at birth. For Study 2, descriptive statistics, AUCs, and zero-order correlations of the key variables are displayed in Table main analyses.We will first briefly discuss descriptive statistics and intercorrelations as well as the relationship variables’ associations with birth, birth experience, and postpartum well-being for Study 1. The results are also presented in Tables t-tests to test for sex differences. Results indicated female and male participants did not differ in attachment, implicit attitudes, relationship satisfaction, or in their evaluation of the infant’s well-being and behavior. These results are also presented in the tables and non-significant mean differences are marked with an index. Zero-order correlations between the relationship measures can be found in Table Means and standard deviations for each of the utilized measures are displayed in Tables Table Model assumptions).In sum, the results of the AUCs and correlation analyses did not suggest that the couple’s relationship quality impacts labor and birth or the birth experience as we had expected. However, we nevertheless included the variables in the a priori hypothesized SI model . The reliabilities of the scores used as indicators were fixed to 0.90 for all variables. Due to the dichotomous coding of the dependent variable low-intervention birth, WLSMV was chosen as the estimator. Analyses were performed in Mplus 7.4  using thdf = 19, p = .604) and the approximate fit indices  also supported the good fit of the model [p < .05). Female postpartum adjustment was negatively related to being primiparous (-0.19), positively related to a positive birth experience (0.33), and also positively predicted by female relationship quality (0.30). Accordingly, male postpartum adjustment was also predicted by male relationship quality (0.34).In Fig. he model . The modhe model ). Women’Thus, results of the SI model indicated that relationship quality was not associated with an increased prevalence of low-intervention birth but did positively predict birth experience for female participants, and postpartum experience for both genders.ps < .001) predicted low-intervention birth, risk: B = -1.396, SE = 0.173; being primiparous: B = -1.752, SE = 0.177; mindset: B = 1.030, SE = 0.134. Contrary to our predictions only continuous presence, B = 0.618, SE = 0.172, p < .001, and not temporary presence, B = 0.423, SE = 0.365, p = .246, predicted the outcome low-intervention birth. That is, only if the attachment figure was continuously present during labor and birth was their presence associated with low-intervention birth. Odds ratios for the above regression coefficients were 1.86 for the contrast between continuous and partial presence, and 1.53 for the comparison of partial presence with absence.When testing our main hypothesis in our second study, we conducted – as preregistered – logistic regression analyses  for the dependent variable low-intervention birth using the control variables medical risk, being primiparous, birth-related mindset, and the two variables presence and continuous presence as predictors. Results indicated all three control variables significantly  using low-intervention birth and the variables presence and continuous presence as predictors. In line with our hypothesis, low-intervention birth, enstein, .3Moderation analyses. We conducted hierarchical multiple regression analyses [z-standardized) resulted in a significant outcome, R2 = 0.13, F = 73.27, p < .001. Adding the interaction term of the two predictors, the amount of variance explained was significantly increased, ΔR2 = 0.01, p = .014. In the final model, the significant interaction effect, β = − 0.10, p = .014, was accompanied by two main effects, continuous presence: β = 0.25, p < .001, and emotional well-being: β = 0.29, p < .001. Thus, new mother’s the evaluation of the birth experience also depended on their emotional well-being before birth. The effect was weaker for non-continuous presence than for continuous presence, but was strengthened by the retrospectively assessed well-being before birth , however, the approximate fit indices  indicated a good fit of the model [he model .Perceived support. Table t-tests for the participant’s perception of different support forms  originating from the different support sources (close attachment figure and maternity caregivers). Results were calculated separately for the two groups: participants with one-on-one support by a freelancing midwife and participants without such support. Results indicated that except for the variable information, the partner provided the strongest support in both groups. In the group with one-on-one support from a freelancing midwife, results revealed that the support provided by the freelancing midwife was rated significantly higher than that provided by the clinic midwife. However, the results do not provide any information on whether this was due to a greater relationship of trust with the freelancing midwife, or simply because in these cases the care was provided mainly by the freelancing midwife.In the present paper we introduced data on the importance of partners and relationship quality for birth, birth experience, and the transition to parenthood using evidence from a longitudinal (Study 1) and a quasi-experimental study (Study 2). Results from Study 1 demonstrated the positive effect of relationship quality on stressful life events for both women and men. However, this effect became especially evident for the phase of transition to parenthood. For this transition, both women and men benefited from greater relationship quality. Men and women who reported greater relationship quality also reported better general and emotional well-being compared to men and women who reported lower relationship quality. The results are consistent with previous research that has investigated mostly single aspects of relationship quality and their associations with the transition to parenthood e.g., , 11, 13), 1311, 1Results of Study 2 indeed demonstrated that regardless of relationship quality the presence of the partner was positively related to low-intervention birth and to a more positive birth experience. The effect of the partner’s presence was strongest when the partner was continuously present. This effect may be because at the beginning of labor women are often alone in the delivery room. A close person can thus provide useful support and thereby reduce the likelihood of interventions such as epidurals and, most importantly, their presence increases the likelihood of a positive birth experience. Having a positive birth experience can, in turn, have a positive effect on subsequent psychological well-being . Future The exploratory moderation analysis in Study 2 suggested that for participants who reported a lower well-being prior to birth, not having the continuous presence of their partners during birth was related to a more negative birth experience than for participants who reported higher before-birth well-being and also lacked continuous presence. It is possible that women felt unwell prior to birth because they were aware they might need to give birth without their partners. For individuals for whom the prospect of birthing without the partner present was particularly distressing, this led to a lower well-being prior to birth and the absence of the partner was perceived as very negative during labor and birth, resulting in a more negative rating of the birth experience. However, since the quality of life was retrospectively assessed it cannot be ruled out that current well-being biased the perception of well-being prior to birth. Indeed, psychological research indicates memory to be subject to biases .All in all, the findings of both Study 1 and Study 2 demonstrate that partners hold more than a purely passive role during labor and birth and therefore underscore the WHO’s  demands As outlined, previous research has indicated that characteristics of high-quality relationships are positively associated with better psychological well-being . The asa nice to have but rather a must-have and the enforced absence of partners represents a disadvantage for childbearing persons. Even without this strong rhetoric, with the current state of knowledge the exclusion of partners from labor and birth does not seem advisable, because it cannot be ruled out that the exclusion might have negative long-term consequences on health and well-being. Previous studies have revealed that labor and birth and the birth experience can have an impact on the development of psychopathological symptoms of parents [As outlined above, the WHO  advocate parents , . A recent editorial called for more studies using dyadic approaches for studying birth and the transition to parenthood [Both Study 1 and Study 2 provide new data and insights into the role of close relationship figures, usually partners, in childbirth and the transition to parenthood using large samples (renthood . Study 1For both studies, the occurrence of possible selection biases and the use of the low-intervention birth index should be critically noted. As described in the method section, both studies were posted on social media channels and were thus not accessible to all pregnant and birthing women. For Study 2, which was retrospective, it is likely that women with negative birth experiences and who were particularly upset about the partner’s absence participated in the study. However, when considering the variation in the birth experience distribution, this possible effect is to be regarded as rather small. It must also be emphasized that C-section rates in both studies were rather low and do not reflect the numbers for the German population in the years the studies were conducted. Thus, it is not possible to make inferences about the prevalence of different interventions based on the study results. However, this was not aim of the present study and would require a research design specializing to this question.As stated in the method section, Study 1 was part of a broader longitudinal study with different objectives, one of which was measuring the effects of the birth-related mindset on labor and birth outcomes . In the The aim of the present paper was to investigate the relevance of partners for the stressful life events of birth, birth experience, and the transition to parenthood. The results suggested that the presence of the partner is positively related to low-intervention birth processes and the birth experience. Furthermore, Study 1 results indicated a positive effect of relationship quality on the transition to parenthood: the higher the relationship quality, the better the well-being during this challenging phase. This effect seems to be independent from gender. Some questions could not yet be answered by the present studies, e.g., questions concerning causality and potential underlying psychological and physiological bases for the found effects. Nevertheless, it became evident that partners serve as an important resource and contribute to psychological well-being during stressful life phases in the medical and family context.


Logistic regression, discrete-time survival, and linear models were applied to assess the associations. After adjustment for demographics and socio-economic status (SES) factors, we found increases in the second and third trimesters and total pregnancy O3 exposures were significantly linked to preterm birth. Exposure to the second and third trimesters O3 was significantly associated with lower birth weight, and exposure to NO2 during the first trimester was linked to an increased risk of GDM. O3 exposures in the first trimester were connected to an elevated risk of GH. We didn’t observe consistent associations between adverse pregnancy and birth outcomes with PM2.5 exposure. Our findings indicate there is a positive link between increased O3 exposure during pregnancy and a higher risk of preterm birth, GH, and decreased birth weight. Our work supports limiting population exposure to air pollution, which may lower the likelihood of adverse birth and pregnancy outcomes.Neonatal mortality and morbidity are often caused by preterm birth and lower birth weight. Gestational diabetes mellitus (GDM) and gestational hypertension (GH) are the most prevalent maternal medical complications during pregnancy. However, evidence on effects of air pollution on adverse birth outcomes and pregnancy complications is mixed. Singleton live births conceived between January 1st, 2000, and December 31st, 2015, and reached at least 27 weeks of pregnancy in Kansas were included in the study. Trimester-specific and total pregnancy exposures to nitrogen dioxide (NO In 2020, the prevalence of preterm birth in the United States (U.S.) was 10.09%, and that of low birth weight was 8.24%3. Preterm birth complications range from early impacts on the digestive, respiratory, and central nervous systems to late consequences on cognitive, motor, auditory, visual, behavioral, and social-emotional function, as well as a variety of implications for growth and health4. The financial burden linked to preterm birth in the U.S. in 2016 was estimated to be on average $76,153 per infant, and low birth weight (< 2500 g) was associated with average expenses of $114,4375. Previous epidemiological studies have suggested that ambient air pollution may increase the risks of preterm birth and low birth weight, although the evidence remains inconsistent across different pollutants and exposure windows7. Variations in epidemiologic modeling strategies and exposure assessment methods between research may contribute somewhat to these discrepancies8.Preterm birth and low birth weight are leading causes of neonatal morbidity and mortality, and also associate with increased morbidity in adulthood9. Previous research has shown that developing diabetes before the 24th week of pregnancy increases the risk of preterm birth10, and that women with pregnancy-induced hypertension had a 3.89-fold increased  chance of delivering low birth weight newborns11. GDM prevalence varies between 5.8 and 12.9%12, and a previous study reported that 7.1–9.2% of GDM mothers would develop type 2 diabetes within 5 years13. In the U.S., GH complicates up to 10% of pregnancies14 and the prevalence of GDM and GH is increasing globally. Both are related to short- and long-term health risks and a significant burden on maternal and child health, including the risk for cardiovascular and cardiometabolic disorders development in later life16. Previous epidemiological research has investigated the connections between air pollution and pregnancy complications (including GDM and GH)20. However, because of differences in population, study design, exposure measurement, and GDM diagnosis, the links between air pollution and pregnancy complications have conflicting results and are less conclusive.Gestational diabetes mellitus (GDM) and gestational hypertension (GH) are the most prevalent maternal medical complications during pregnancy2), particulate matter with an aerodynamic diameter less than 2.5 μm (PM2.5), and ozone (O3), and two birth outcomes (preterm birth and birth weight) and two pregnancy complications (GDM and GH) in the State of Kansas. We also presented the effect modification of those associations by maternal race, maternal ethnicity, maternal age, and maternal residual address zip code level percent below poverty. To the best of our knowledge, this is the first epidemiologic research on air pollution and pregnancy outcomes in Kansas.In this study, we investigated the connections between three ambient air pollutants of nitrogen dioxide  and second trimesters . The birth outcomes of interest were preterm birth , term  birth weight, GDM (self-reported), and GH (self-reported). We excluded births with (a) missing census tract information; (b) maternal age < 10 years or > 55 years; (c) birth weight < 250 g or > 7500 g. For the outcomes of GDM and GH, we also excluded mothers with pre-existing diabetes or pre-existing hypertension. Figure Birth certificate data were obtained from the Bureau of Epidemiology and Public Health Informatics, Kansas Department of Health for the period 1999–2016. Inform consent was not obtained or required because this study relies on secondary data analysis of registry data, and no contact with participants were initiated. The study was approved by the Institutional Review Board of the Kansas Department of Health. We confirm that informed consent was obtained from all subjects and/or their legal guardian(s) by the Kansas Department of Health. To minimize fixed-cohort bias and establish a cohort defined by conception rather than birth date with constant gestational age distributions over calendar time2 (1-h maximum), PM2.5 (24-h average), and O3 (8-h maximum) concentrations were calculated at a 1 km × 1 km spatial resolution across the United States from 2000 to 201622. In particular, the ensemble-based models utilized over one hundred predictors and incorporated three machine learning algorithms  with good prediction performance23. For each day, air pollution data were averaged to the at-delivery census tract of the mother by averaging the daily concentrations of all 1 km2 grid cells whose centroids were within the census tract boundary.Employing spatiotemporal ensemble models, daily ambient air pollution data for NOt) and total pregnancy (pregnancy week 1 to the end of week t) to avoid bias because of varying exposure periods between preterm and full-term births24. Linear regression models were used to examine term birth weight as a continuous outcome and mean air pollution concentrations for the first trimester, second trimester, third trimester, and total pregnancy exposure windows. For GDM, we utilized logistic regression to assess the connections between GDM and averaged pollutant concentrations during the first trimester, and second trimester because screening for GDM is typically completed between 24 and 28 weeks of gestation25. Logistic regression models were utilized to evaluate the relationship between GH and averaged pollutant levels during the first trimester, second trimester, third trimester, and total pregnancy exposure windows.We examined associations between air pollution concentrations and birth outcomes in single-pollutant models for each exposure window of interest for all analyses. We applied logistic regression to determine relationships between preterm birth (< 37 weeks of gestation) and mean air pollution concentrations during the first trimester (weeks 1–13 of gestation), and second trimester (weeks 14–26 of gestation), and a discrete-time survival model to assess relationships during the third trimester , race , maternal ethnicity , maternal age modeled employing natural cubic spline with 3 degrees of freedom, marital status , birth parity , and smoking status during pregnancy (Yes or No). Temporal controls included the season of conception  and a natural cubic spline with 5 degrees of freedom on the conception date used for a long-term temporal trend. Areal-level covariates included ZIP code-level percent below poverty information from the 2010 Census. Census tract-level land area and water surface area (square meters) as well as percent of greenspace, both were calculated from the National Land Cover Database (NLCD) of the United States Geological Survey. Finally, we included indicators for each of the 106 maternal residential counties in all models.We stratified the data by maternal race , maternal ethnicity (Hispanic versus Non-Hispanic), maternal age (27 years versus > 27 years), and maternal residential address zip code level percent below poverty (12% versus > 12%), with different regression models apply to each stratum, in order to analyze effect modification of the relationship between air pollution and each birth outcome.26, we run a single model to jointly estimate the association with each of the three trimester-average exposures  for outcomes of preterm birth, birthweight, and GH, and two trimester-average exposures (trimester 1 and trimester 2) for the outcome of GDM. Fourth, we fitted multi-pollutant models by including trimester specific NO2, PM2.5, and O3 in the model simultaneously.Several sensitivity analyses were performed to assess the validity of our key findings. First, we fitted the model by adjusting the long-term temporal trend using a natural cubic spline with 8 and 10 degrees of freedom on the conception date, or adjusted the conception year as a categorical variable. Second, since labor inductions are typically medically indicated, we further restricted to births without maternal induction of labor. Third, to control the confounding by exposures in other windowsWe report odds ratios (ORs) and mean differences for each interquartile range (IQR) increment in air pollution concentrations. Average pollutant levels during pregnancy were utilized to compute the IQRs, and we applied the same IQR values derived from the preterm birth cohort to report results from the birth weight, GDM, and GH outcomes. R software, version 4.0.2, was employed to perform all statistical analyses and all methods were performed in accordance with the relevant guidelines and regulations.Human subjects research approved by Emory University IRB #00102330.The preterm birth cohort comprised 596,926 singleton births across 106 Kansas counties, of which 41,936 (7.0%) were preterm. Compared to full-term birth mothers, preterm birth mothers had a high chance to deliver low birth weight babies, have gestational diabetes and chronic diabetes, have gestational hypertension and chronic hypertension, have lower education level, be of younger age, be unmarried, have higher parity, smoke during pregnancy, and live in more impoverished zip code area  in Kansas during the sixteen-year study period are presented in Fig. 2 and PM2.5 decreased from 2000–2004 to 2010–2015 , but the daily mean of 8-h maximum O3 increased from 40.82 to 42.43 µg/m3 during the same periods. The interquartile range (IQR) of the of specific pollutants and pregnancy exposure window pairs are: first trimester NO2: 10.90 (ppb); second trimester NO2: 10.88 (ppb); third trimester NO2: 11.01 (ppb); total pregnancy NO2: 10.16 (ppb); first trimester PM2.5: 2.86 (µg/m3); second trimester PM2.5: 2.89 (µg/m3); third trimester PM2.5: 3.04 (µg/m3); total pregnancy PM2.5: 2.86 (µg/m3); first trimester O3: 13.82 (µg/m3); second trimester O3: 13.51 (µg/m3); third trimester O3: 14.26 (µg/m3); total pregnancy O3: 6.23 (µg/m3) , and Fig. 2, PM2.5, and O3. Correlations between pollutants in the same exposure window were low to moderate (< 0.45), while correlations between trimesters of the same pollutant can be high due to its seasonality.The census tract-level spatial distributions of three air pollutants (NO3) Table . Figure 2, PM2.5, O3) on preterm birth, birth weight, GDM, and GH during different pregnancy exposure windows. We identified elevated risks of preterm birth with IQR increment in second trimester O3 , third trimester O3 , and total pregnancy O3 . Per IQR increase in the second and third trimester O3, mean difference in term birth weight were − 9.86  and − 7.93  grams. Second-trimester exposure to NO2 was positively related to the risk of GDM . O3 in the first trimester (T1) of pregnancy were connected to increased risk of GH . We didn’t observe any associations related to PM2.5 exposure. Effect estimates and 95% CI for all outcomes, pollutants and exposures are given in Table Figure 2 and preterm birth are 0.98  and 1.04  for mothers living in ZIP codes with lower versus higher percent below poverty, respectively.Table Our findings were robust to a number of sensitivity analyses. First, we examined the sensitivity of results to the approach for adjusting for long-term trend by fitting the model using a spline with 8 and 10 degrees of freedom on the conception date, or adjusting the conception year as a categorical variable. The estimated effects remained largely stable compared to the main analysis Table . Second,2, PM2.5, O3) exposure during pregnancy and the risks of adverse birth outcomes (preterm birth and birth weight) and pregnancy complications (GDM and GH) using spatially-resolved exposure assessment methods. Our findings indicate that higher O3 exposure during pregnancy elevates the risk of preterm birth, lower birth weight, and gestational hypertension. We also observed that early-pregnancy NO2 exposure elevated the risk of GDM.This retrospective cohort study aimed to examine the relationship between ambient air pollution  reported that the pooled effect per 10 µg/m3 increment in second trimester exposure to O3 was 1.05 28. This finding is consistent with our results—an elevated 5% risk during the second trimester per IQR of 13.51 µg/m3. For the associations of whole-pregnancy O3 exposure and preterm birth, one previous paper also reported a 3% higher risk of birth before 37 weeks and a 13% enhanced risk of preterm birth deliveries per IQR of 7.1 µg/m329. The biological mechanisms underlying the link between O3 exposure and preterm birth are primarily mediated by oxidative stress and systemic inflammation30. Animal models have shown that O3 exposure alters the circulating serum cytokines, which may affect normal placentation, uterine artery vascularity, impaired trophoblast invasion, migration, and decreased trophoblast metabolic capability30. These biological mechanisms establish a rational explanation for how exposure to O3 during pregnancy might trigger preterm birth.Our observation that exposure to O3 exposure during the second and third trimesters and term birth weight. Our results are generally consistent with earlier research34. For example, one previous study discovered that the OR of low birth weight for each IQR increase in ozone concentration was 1.04  in a California population31. However, some previous research reported no relationship between exposure to O3 and birth weight1. These inconsistent results could be attributed to the various study designs, diverse study populations, and various levels of ozone exposure. Our results suggested significant effect of O3 exposure in the second and third trimester on birth weight in the trimester-specific analyses. This finding partially matched the previous results. According to earlier research, the first and third trimesters may be the most vulnerable time period for exposure to adverse birth outcomes36. However, Salam et al.34 reported a link between O3 exposure in the second and third trimesters and decreased birth weight which is consistent with our birth weight results. The underlying reasons for the differences remained unknown. Still, to assess the accurate effect of O3 exposure on birth weight, additional studies using various epidemiological approaches, different geographic locations, and more participants are needed. The possible underlying biological mechanisms by which O3 exposure may lead to reduced birth weight, including inflammatory reactions, blood flow, placental development and function, and oxidative stress38. Additionally, because pregnancy is characterized by organ formation, high levels of cell proliferation, and changing metabolic capacity, pregnant mothers are more susceptible to the impacts of air pollution40.We detected a negative relationship between O2 exposure and GDM. Previous studies reported inconsistent associations between NO2 and GDM. For example, a birth cohort of 256, 372 subjects in New York City found NO2 exposure in the first trimester was significantly linked to higher odds of GDM 41. But another study from Southern California with 239,574 subjects reported a weak but not statistically significant relationship between NO2 first trimester exposure and GDM 18. The heterogeneity between studies is likely influenced by differences in exposure assessment approaches, or differences in outcome assessment, medical care, population characteristics, or pollution mixtures. Our results also show significant negative associations between early pregnancy O3 exposure and GH. One previous study reported that O3 exposure during the first two trimester is associated with hypertension during pregnancy (HDP), and early pregnancy is a critical window of exposure42. Multiple biological pathways have been proposed to underlie O3 and HDP. Hypertension is linked to physiologic reactions to environmental variables, according to previous animal and toxicological research43. Pregnant women have been demonstrated to have higher levels of oxidative stress, and inflammation when exposed to air pollution44. These inflammatory reactions may also result in endothelial dysfunction, autonomic instability, and altered blood rheology, all of which have been associated to an elevated risk of hypertension46.We discovered significant relationship between first trimester NO2.5 exposure. Previous meta-analysis studies suggested consistent associations between ambient PM2.5 and reduced birth weight, especially the effect estimates based on the entire pregnancy exposure1. However, the associations between PM2.5 and preterm birth1, GDM47, and GH48 are inconsistent. For example, Tang et al.47 did a meta-analysis study based on 1,547,154 individuals, and they concluded increased exposure to PM2.5 was not associated with the increased risk of GDM . The possible explanations for our results include Kansas is a relatively underdeveloped state in the U.S., and it has many rural areas compared to other states, so the PM2.5 components of black carbon and sulfate should be relatively lower compared to states with more urban areas. Black carbon and sulfate have been linked to several adverse birth and pregnancy outcomes50.We didn’t obverse consistent associations between adverse pregnancy and birth outcomes with PM23, which provided complete coverage over the entire Kansas state geographic region. This approach differs from previous methods that were limited to air quality metrics from only stationary monitors, which lack spatial and temporal resolution. Second, we used a time-to-event framework to model the effect of the third trimester and total pregnancy exposure to air pollution on the risk of preterm birth24. This design enables us to evaluate risk for third trimester effectively by minimizing the potential bias brought on by variations in the length of third trimester averaging period between preterm and full-term births51. Last, the Kansas birth records contain comprehensive maternal information, which removes the potential recall bias associated with gestational age based on the last menstrual period52.Our study has several strengths. First, our analysis was based on a large population of over 500,000 births, and exposure assessment using spatiotemporal ensemble models with high temporal and spatial resolutions54. Additionally, among mothers who moved, they remained close enough to their previous home address. Therefore, mobility is unlikely to have significantly impacted our findings55. Second, GDM and GH were identified through medical records, is subject to outcome misclassification. According to a previous study56, GDM misclassification using birth certificate data would lead to an underestimation of the GDM prevalence and further underestimate the relative risk. Third, while we controlled for multiple risk factors in our models, including maternal clinical characteristics and ZIP code level percent below poverty, there are still issues with residual confounding. Known risk factors, such as maternal alcohol use, illicit drug use, mother’s mobility information during pregnancy, previous preterm birth, and previous preeclampsia information, were unavailable from the Kansas birth certificate data. Fourth, we had about 25% GDM missingness from the birth records data, and the GDM results were based on subjects without GDM missingness. We did not perform any imputation for this missingness because we did not know the mechanism of this missingness. Even though we did not expect the missingness to be correlated with air pollution levels, the GDM results should be interpreted carefully. Last, our results were based on live birth only, and we didn’t consider the effects of air pollutants on pregnancy loss and fetal death. However, air pollution to fetal death is an emerging field, and current studies do not provide consistent results60.Our research also has a few limitations. First, maternal address at birth is the only address available in our birth certificate data. However, some women may have resided at a different address during pregnancy. This may result in nondifferential exposure misclassification, which might bias the results toward the null. Previous research reported exposure misclassification due to pregnant women’s home address change was limited because most pregnant women did not move throughout their pregnancyFor future research, it is possible that the true exposure window does not fit neatly within the boundaries of a trimester, and our trimester specific analysis may miss this association. Therefore, future work can explore exposures at finer temporal scale  to better identify critical exposure window. Also, since the Kansas air pollutant exposure ranges are relatively small, we were unable to assess the non-linearity associations. But we recommend future studies consider this.3 exposure during pregnancy and the increased risk of preterm birth and gestational hypertension, as well as decreased birth weight. We also noted that early-pregnancy NO2 exposure elevated the risk of GDM. Our study contributes to the body of knowledge regarding O3 detrimental impact on public health. Additionally, it demonstrates the significance of reducing exposure to air pollution in pregnant women for the purpose of lower the risk of adverse birth outcomes and pregnancy complications. Personal exposure assessment studies will be required to validate these connections.In summary, our findings indicate significant relationships between higher OSupplementary Information.


Intrasellar arachnoid cysts represent around 1% of all selar lesions. Generally, patients are asymptomatic and when they exhibit visual and/or hormonal disturbances, the indication for surgery is prompted. A 51-year-old woman with a known purely intrasellar arachnoid cyst diagnosed 23 years prior to presentation, evolved with gradual campimetric evaluation. Magnetic resonance imaging showed significant growth of the lesion, now extending into the left middle fossa through the cavernous sinus. The patient underwent cyst fenestration via the transsphenoidal approach. This is the first case in the literature of a patient with an intrasellar arachnoid cyst extending into the middle cranial fossa. Intrasellar arachnoid cysts represent around 1% of all sellar lesions and only three percent of arachnoid cysts, they are rarely seen in this localization with few reports available in the literature [A 51-year-old woman, with a known purely intrasellar arachnoid cyst, was diagnosed 23 years ago after a headache episode, remaining asymptomatic after the diagnosis, she had no medical history. She continued to follow-up with image surveillance, showing a stable lesion until 2019, magnetic resonance imaging (MRI) evidenced growth of the cyst, with extension to the suprasellar cistern and left middle fossa (Figure Campimetric evaluation showed left temporal hemianopia and right superior temporal quadrantanopia so surgical treatment was proposed. Preoperative pituitary hormones were within normal range.A right mono-nostril endoscopic transsphenoidal approach was performed. After the opening of the sphenoidal sinus, it was noticed that the floor of the sella was thinned Figure .After the opening of the sella and dura, the cyst was drained. Direct endoscopic visualization of the cavity showed the pituitary gland pushed back against the dorsum sellae, and the optic chiasm and optic nerves pushed upward with evidence of atrophy. Fenestration of the cyst to the interpeduncular cistern was then performed to avoid recurrence. Closure of the cavity was achieved with oxidized cellulose, fibrin glue, fat, and fascia obtained from the abdominal wall, and nasal cartilage, followed by repositioning of the nasoseptal flap, sterile compressed sponge, and nasal packing. A lumbar drain was left in place for 72 hours to reduce the chance of a CSF leak. Postoperative MRI showed complete drainage of the cyst Figure .The early postoperative period was uneventful and the patient was discharged on the fourth postoperative day. In his neurosurgical follow-up of one year, no abnormality was observed.The arachnoid cyst was first described in Bright’s Reports of Medical Cases in 1831 , whereasGenerally, a sellar arachnoid cyst is an asymptomatic lesion, an incidental finding in brain MRI, and about 50% are found in the Sylvian fissure ,8. Sella. Regardless of the approach, patients usually have a good recovery with progressive improvement of the preoperative deficits [When surgery is proposed for a sellar arachnoid cyst, it usually is done by a transsphenoidal or transcranial approach . Regardldeficits . The maideficits .A parasellar extension of a sellar arachnoid cyst has not been previously reported. These are rare lesions that seldom require treatment, unless they become symptomatic. Deciding which is the safest access route and its possible complications makes the best treatment possible. The endocopic transsphenoidal approach is a safe way to access these lesions with good patient outcomes.


A large hepatic cyst cause abdominal bloating and other symptoms. Surgical deroofing or ethanol sclerosis has been reported as the treatment options. We have treated patients surgically. However, an experience with postoperative bile leakage prompted us to reexamine our treatment options. It has been reported that the cause of bile leakage is the connection between the hepatic cyst and the bile duct. Therefore, we planned to observe the lumen of the hepatic cyst by endoscopy to evaluate the bile duct connection.An 82-year-old woman presented to our hospital for abdominal bloating. An abdominal computed tomography (CT) scan revealed a large hepatic cyst. Respiratory function was decreased due to diaphragmatic compression caused by the cyst. Endoscopic observation of the cyst was performed to evaluate the bile duct connection. There were no obvious abnormalities in her cyst. The patient was discharged 7 days after this procedure.Laparoscopic deroofing is recommended for the treatment of a large hepatic cyst when a patient can take surgery. However, deroofing has the potential for postoperative bile leakage. Careful consideration should be given to the treatment approach for each patient. Ethanol sclerotherapy has the potential for recurrence, but in this case, we confirmed the absence of bile duct connection. The ethanol sclerosis was effective, and there was no postoperative bile leakage.Endoscopic observation during puncture of the hepatic cyst allowed the evaluation of bile duct connection and search for malignant disease. Ethanol sclerotherapy was also effective. •We report a case of endoscopic observation of the lumen of a large hepatic cyst.•It allowed the evaluation of bile duct connection and search for malignant disease. Most si2An 82-year-old woman came to our hospital because of abdominal bloating. She had a history of cerebral infarction and hypertension and was being treated with clopidogrel. An abdominal computed tomography (CT) scan showed a large hepatic cyst . Blood t3Hepatic cysts are a common disease. Prevalence in the population has been reported to be 3–5 % in ultrasound series and as high as 15–18 % in CT series ,12. Asym4An intra-cystic evaluation was performed endoscopically for the treatment of a large hepatic cyst. There was no obvious malignant disease or bile duct connection. Symptomatic large hepatic cysts require treatment, often treated by laparoscopic deroofing. Deroofing, however, has the potential for postoperative bile leakage. This technique allows preoperative evaluation of bile duct connection and the presence of malignant disease. This technique may be an option for the treatment of a large liver cyst.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.Ethical approval for this study (No. 2023-3) was provided by the Ethical Committee of Haibara General Hospital, Shizuoka, Japan on 15th August 2023.Authors did not receive funding for this research.Shoryu Takayama.Not applicable.All authors namely, Dr. Takahumi Hyodo, Dr. Takuya Banba and Dr. Shoryu Takayama were involved in the management of this patient. This manuscript has been drafted by all authors.The authors report no declarations of interest.


The purpose of this study was to analyze the outcomes of the combination of ultrasound (US)-guided percutaneous external drainage and subsequent definitive operation to manage complicated choledochal cyst in children.This retrospective study included 6 children with choledochal cyst who underwent initial US-guided percutaneous external drainage and subsequent cyst excision with Roux-en-Y hepaticojejunostomy between January 2021 and September 2022. Patient characteristics, laboratory findings, imaging data, treatment details, and postoperative outcomes were evaluated.Mean age at presentation was 2.7 ± 2.2 (0.5–6.2) years, and 2 patients (2/6) were boys. Four patients (4/6) had a giant choledochal cyst with the widest diameter of ≥ 10 cm and underwent US-guided percutaneous biliary drainage on admission or after conservative treatments. The other 2 patients (2/6) underwent US-guided percutaneous transhepatic cholangio-drainage and percutaneous transhepatic gallbladder drainage due to coagulopathy, respectively. Five patients (5/6) recovered well after US-guided percutaneous external drainage and underwent the definitive operation, whereas 1 patient (1/6) had liver fibrosis confirmed by Fibroscan and ultimately underwent liver transplantation 2 months after external drainage. The mean time from US-guided percutaneous external drainage to the definitive operation was 12 ± 9 (3–21) days. The average length of hospital stay was 24 ± 9 (16–31) days. No related complications of US-guided percutaneous external drainage occurred during hospitalization. At 10.2 ± 6.8 (1.0–18.0) months follow-up, all patients had a normal liver function and US examination.Our detailed analysis of this small cohort suggests that US-guided percutaneous external drainage is technically feasible for choledochal cyst with giant cysts or coagulopathy in children, which may provide suitable conditions for subsequent definitive operation with a good prognosis.Retrospectively registered. Choledochal cyst, a relatively uncommon congenital malformation characterized by biliary tract dilatation with an incidence of around 1:13,000 in Asian populations versus 1:100,000 in Western populations, often presents with abdominal pain, abdominal lump, and jaundice in pediatric patients , 5. GivePatients with complicated choledochal cyst often had a distal biliary obstruction that led to bile stasis and ultimately developed severe complications, such as acute cholangitis, abnormal liver function, and even perforation of choledochal cysts and coagulopathy –13. ThesThis study aimed to report the early clinical experience of the combination of US-guided percutaneous external drainage and subsequent definitive operation to manage choledochal cyst in children in a small cohort and evaluate its safety and effect.This retrospective study was approved by the Ethics Committee of Beijing Children’s Hospital  and the need for informed consent was waived. The medical records of patients diagnosed with choledochal cyst and admitted to the department of general surgery, Beijing Children’s Hospital, from January 2021 to September 2022, were reviewed. The diagnosis of choledochal cyst was based on abdominal US with computed tomography (CT) or magnetic resonance cholangiopancreatography (MRCP). Patients who underwent US-guided percutaneous external drainage and subsequent definitive operation (cyst excision with Roux-en-Y hepaticojejunostomy) were included in this study. The exclusion criteria were as follows: (I) underwent surgery at other hospitals before admission; (II) underwent the definitive operation at our center before 2021; (III) no definitive operation; (IV) underwent one-stage definitive operation; and (V) underwent traditional open external drainage and definitive operation . Patient characteristics, laboratory findings, imaging data, treatment details, and postoperative outcomes were analyzed. Patient characteristics included sex, age, presenting symptoms, features of the choledochal cyst (types and size), and preoperative hepatobiliary complications. The types of choledochal cyst were defined using Todani’ s classification, and the choledochal cyst with a maximum diameter of ≥ 10 cm was defined as a giant cyst , 20. TheThe imaging data included the images of US, CT, and MRCP performed at our center, including images during US-guided percutaneous external drainage. The treatment details had three aspects: conservative, interventional, and surgical treatments. The conservative treatments of each patient were based on the laboratory results on admission, mainly including nil-per-os, somatostatin injected with a microinfusion pump (3.5 µg/kg/h), intravenous omeprazole (1–2 mg/kg), antibiotic treatment, and total parenteral nutrition. Telephone interviews were performed in October 2022 to ask the patients’ parents about the child’s prognosis and postoperative complications.The decision to perform external drainage was based on the patients’ laboratory and imaging results (CT or MRCP). If a patient had a giant cyst with abnormal liver function or especially coagulopathy and did not improve after conservative treatments, US-guided percutaneous external drainage would be considered. Every patient fasted for a minimum of 6 h and was re-evaluated by US to determine the extent of intrahepatic bile duct dilation, the size of extrahepatic cyst and gallbladder to help select the specific methods of external drainage. The US-guided percutaneous external drainage was performed by a pediatric radiologist (CKL) with more than 5 years of experience in interventional US techniques, after obtaining informed consent from the parents of patients. The preferred method was US-guided percutaneous biliary drainage (PBD), especially for patients with a giant extrahepatic cyst. In addition, US-guided percutaneous transhepatic cholangio-drainage (PTCD) was performed in patients with a small extrahepatic cyst, but significant dilatation of the intrahepatic bile duct, and US-guided percutaneous transhepatic gallbladder drainage (PTGD) was performed in patients with a large gallbladder Fig. .All procedures are accomplished under general anesthesia by anesthesiologists or local anesthesia with the support of oral chloral hydrate as a sedating agent by continuous close monitoring, including the preparation of emergency medications and oxygen therapy devices. At the supine position, the right upper quadrant of patients was draped in a sterile manner. Lidocaine (2%) was used as a local anesthetic. First, after the puncture point was determined by ultrasound and the skin was cut through by a sharp scalpel, the right position of the puncture needle was ensured by real-time US guidance and introduced guide wire. This process should be far away from the abdominal organs and blood vessels as possible. Second, after the puncture, tract dilation was done under real-time US guidance. Finally, a Pig-tail catheter (6–8 Fr) was inserted along the introduced guide wire to decompress the biliary system, and the external fixation to the skin was made Fig. . In US-gAfter external drainage, conservative treatments were performed, including intravenous broad-spectrum antibiotics and hemostatic agents, and patients resumed oral intake as soon as possible to avoid electrolyte disturbances. Laboratory tests were performed on the 1st, 3rd, and 7th day after external drainage to check the improvement of the liver and coagulation function. Once needed, patients were re-examined every 7 days until the liver and coagulation function was appropriate for definite surgery. Usually in our center, CT or MRCP would be repeated prior to the definitive operation Fig. .Continuous variables were expressed as the mean and SD with ranges. Categorical variables were expressed as numbers and proportions.During the study period, 6 patients with choledochal cyst were treated by a combination of US-guided percutaneous external drainage and subsequent definitive operation, and their clinical characteristics were provided in Table According to the laboratory and imaging results, the main indications for US-guided percutaneous external drainage were giant cyst and coagulopathy. Four patients  had a giant choledochal cyst and underwent US-guided PBD on admission or after conservative treatments. The size of their cysts decreased after US-guided PBD Fig. . Of thesThe study demonstrated the feasibility of the combination of US-guided percutaneous external drainage and subsequent cyst excision with Roux-en-Y hepaticojejunostomy to manage the complicated choledochal cyst in children, especially for choledochal cyst with giant cysts or coagulopathy, although the applicable conditions should be further studied given the small sample size of patients.Early cyst excision has been recommended for children with choledochal cyst to reduce the risk of long-term complications, such as biliary infections and cancer development –28. MoreUS is a good method to diagnose biliary diseases, including choledochal cyst, and US-guided percutaneous external drainage has been widely used in adult biliary disorders, such as acute cholecystitis, but few studies have reported its application in pediatric patients , 32. ComFor patients with complicated choledochal cyst, US-guided percutaneous external drainage is minimally invasive and effective in relieving the symptoms of biliary obstruction, but it also has risks of electrolyte disturbance and infection , 16, 18.Many studies have shown that minimally invasive operations, including laparoscopic- or robot-assisted, have obvious advantages in treating choledochal cysts , 35, 36.This study was limited by the small sample of patients, the isolated use of ultrasound, and the lack of a control group. Based on the present findings and the absence of a control group, it is not possible to prove the superiority of US-guided percutaneous external drainage over simple conservative treatments for patients with complicated choledochal cyst. Therefore, to what extent complicated choledochal cyst should be performed US-guided percutaneous external drainage before the definitive operation needs further studies. Further accumulation of cases is expected in the future.Our detailed analysis of this small cohort suggests that US-guided percutaneous external drainage is technically feasible for choledochal cyst with giant cysts or coagulopathy in children, which may provide suitable conditions for subsequent definitive operation and has a good prognosis.


It is economically significant to perform early selection of breeding goats. Given that the effect of genetic and environmental factors on growth can be estimated more accurately, estimation of adult body weight is viable, and rapid genetic progress can be achieved in the herd through the application of selection in this manner. Thus, profitability can be increased in goat breeding. Additionally, genetic and maternal influences on pre-weaning growth traits are important in identifying variation between individuals. In this study, herd, sex, age of dam, type and year of birth, and maternal genetic influence were considered according to their effects on pre-weaning growth characteristics in Turkish Saanen kids. As a result of the study, it has been determined that the economic significance of the maternal effect is high due to its effect on the growth characteristics of Turkish Saanen kids. In the selection program for offspring who grew up alongside their mothers from birth until weaning, it is recommended to account for the maternal effect as well as environmental factors.Data on 4487 Turkish Saanen kids from 176 bucks and 1318 dam-goats, obtained from the Turkish Saanen goats in the Izmir region and collected between 2018 and 2019, were analyzed to examine the effect of genetic and non-genetic factors on growth traits. The average birth weight of the kids was determined as 3.33 ± 0.68 kg, the average W60 was 13.06 ± 2.94 kg, the average WW was 18.38 ± 4.14 kg, and the average PreWDG until weaning was 0.17 ± 0.04 g. Model 1, which does not account for the maternal effect, and Model 2, which includes the maternal effect, were used in the estimation of genetic parameters. The heritability estimates of BW, W60, WW, and PreWDG ranged from 0.05 to 0.59 in both models. It is recommended to consider the maternal effect as well as the environmental factors in the selection program for the best early breeder selection of kids growing alongside their mothers until the weaning period. The Turkish Saanen breed was developed by crossing the Saanen breed with native Turkish breeds . Turkish Saanen goats are known for their high milk production and fertility efficiency and are commonly used in goat husbandry in Turkey, especially in Western Anatolia. The male kids are generally marketed for meat ,2,3. As On the other hand, by revealing the effect of genetic and environmental factors on growth, a more accurate estimation of adult live weight is possible, and rapid genetic progress can be achieved in the herd with the application of selection in this direction . AccuratThe goal of this study was to determine the most appropriate time, accounting for maternal effects, to determine early selection based on the growth characteristics of Turkish Saanen kids. Therefore, genetic parameters for pre-weaning growth traits in Turkish Saanen kids were estimated. Based on their effects on pre-weaning growth traits, herd, gender, dam age, type of birth and birth year, and maternal genetic effect were all considered.The dataset collected from the Turkish Saanen Goat subproject in the Izmir region as part of the National Sheep and Goat Improvement Project was examined in this study. A total of 4487 Turkish Saanen kids, including 176 bucks and 1318 dams, were studied. Growth trait records of Turkish Saanen kids were collected from 15 herds between the years 2018 and 2019. Birth weight (BW), 60th day live weight (W60), weaning weight (WW), and pre-weaning daily live weight gain (PreWDG) were employed as the growth traits in kids. The kids were fed alongside their mothers until weaning and were weaned on the 90th day.Herd, gender, type of birth, age of dam, and birth year effects on BW, W60, WW, and PreWDG of Turkish Saanen kids were analyzed. Analyses of variance components and heritability were carried out for BW, W60, WW, and PreWDG records. For this purpose, the model is structured with herd, gender, age of dam, type of birth, and birth year being the fixed effects; BW as a covariate effect for W60, WW, and PreWDG; and age of dam also as a covariate effect for BW. Animals’ additive genetic, maternal genetic, and residual effects were considered to be random effects. Descriptive statistics of the growth traits of Saanen kids are given in BW, W60, WW, and PreWDG were 3.33 ± 0.68 kg (CV = 20.51%), 13.06 ± 2.94 kg (CV = 22.51%), 18.38 ± 4.14 kg (CV = 22.51%), and 0.17 ± 0.04 g (CV = 26.89%), respectively .The following single trait and single record animal models were used:Y: a vector of BW, W60, WW and PreWDG; b: a vector of herd, gender, type of birth, age of dam, and birth year as fixed effects; BW as a covariate for W60, WW, and PreWDG; and age of dam also as a covariate effect for BW; a: direct additive genetic effects; m: maternal genetic effects; e: residual effect, X, and Z are incidence matrices relating observations to b, a, and m, respectively. The estimates of variance components for each trait were estimated using the Average Information-Restricted Maximum Likelihood (AI-REML) method by Meyer .p < 0.01). On the other hand, the effects of birth type on PreWDG were not significant (p = 0.39). Therefore, all effects were included in the model to obtain estimates of variance components. When the flocks were examined, the average BW was 3.26 ± 0.68 kg, the highest BW was 3.63 kg in the 6th herd, and the lowest BW was in the 10th flock at 2.74 kg. It was observed that W60 averaged 13.06 ± 2.94 kg and ranged between 8.53–16.04 kg, and WW averaged 18.38 ± 4.14 kg and varied between 11.64–21.65 kg. The average daily live weight gain was 0.17 ± 0.05 kg. Male kids were found to be heavier than female kids in all growth stages (p < 0.01). It was observed that twin births were the most common in Turkish Saanen kids, followed by singleton and triplet births, and quadruplet births had the lowest rate of 3%. The weights of single-born kids were found to be higher than those of multiple-born kids in all growth periods. For BW, 5-year-old mothers were found to have heavier kids than mothers of other ages, and for W60 and WW, kids of 7-year-old mothers were found to be heavier. The effect of the year of kids on live weights was found to be higher and more significant in 2018 than in 2019 , where the maternal effect was better accounted for than in Model 1 (0.33 ± 0.002).p < 0.01) in males than in females. Birth type was determined as effective on BW (p < 0.01); weaning age with WW as effective on daily body weight gain (p < 0.05), gender (excluding BW (p < 0.01)), WW (p < 0.05), and daily body weight gain (p < 0.01); and the season of birth as effective on BW, WA, and daily live weight gain (p < 0.01), excluding WW. Supakorn and Pralomkarn [p < 0.05). Atouı et al. [p < 0.05) effect on BW. Alade et al. [p < 0.01). Cappai et al. [Many studies have been conducted to determine the factors that influence live weight in kids at various stages of development. Thiruvenkadan et al.  stated talomkarn  found thı et al.  reportede et al.  discoveri et al.  investigp < 0.01). These results were found to be similar to the study by Tozlu and Olfaz [p < 0.05) on the daily live weight gains of kids between birth and after 30 days, the viability of kids at the age of 30 days was significantly affected by gender, and the viability of males was higher than that of females (p < 0.01). Ghimir et al. [p < 0.05). They did not, however, find any significant effect of dam age or season on body weight or daily body weight gain at any period (p > 0.05). Similarly, they reported that WW and PreWDG were not affected by any factor. According to Alade et al. [p < 0.01) among singletons compared to those born with multiples. They found that kids born to mothers aged five years had the highest BW (p < 0.01). In this study, singletons and males had significantly higher body weights compared to multiples and females at all growth stages (nd Olfaz , which re et al. , Akdag ee et al. , and Toze et al. , male kiAccording to Atouı et al. , fixed eOn the other hand, Otuma and Osakwe  found thKuthu et al.  found heIn the present study, heritability estimates in growth traits were found to be higher in Model 1, in which maternal effect was not taken into consideration. On the other hand, in Model 2, where maternal effect was also included, estimates were observed to be lower. Therefore, model 2 resulted in lower, and possibly more realistic, variance components. Maternal effects play a significant role in the expression of pre-weaning traits. As a result of this, it is important to know the extent of both maternal genetic and environmental effects, in addition to the additive genetic effects. Hammoud and Salem  reportedIn the study in which they estimated the variance components and genetic parameters for birth and weaning weights, Gholizadeh et al.  found thIn conclusion, the effects of environmental factors such as herd, birth year, gender, birth type, and age of dam were significant for all growth traits in Turkish Saanen kids. At the same time, the maternal effect is of great importance due to its effect on the growth characteristics of Turkish Saanen kids. As a result of comprehensive knowledge of these traits, it is possible to design the successful inheritance of economically significant traits in goat breeding. This information is considered an important step in the planning and implementation of any successful selection or breeding program aimed at improving the genetic gain of animals. While Turkish Saanen goats, of which there is a substantial population, are used for milk production, some of the offspring born are used for breeding and a significant amount are used for butchery. Therefore, it is recommended that early selection that considers environmental factors as well as maternal effects at the pre-weaning age may be delivered for genetic progress in Turkish Saanen kids growing with their mother from birth to weaning. This effect should also be considered in fertility programs. In addition to these, further studies examining the primary effect at the F2 level are required.


In Malaysia approximately 7% of births result in a preterm birth (< 37 weeks). Research in many other countries has found that mothers of preterm infants experience poorer psychological wellbeing. However, there has been limited research in Malaysia. We examined wellbeing, using the WHO Quality of Life brief version questionnaire (WHOQOL-BREF), in mothers who have preterm and full-term infants.Data was collected as part of the South East Asian Community Observatory MISS-P project. A total of 3221 mothers (7.9% with a preterm and 92.1 with a full-term birth) completed a survey, with a range of measures, including the WHOQoL-BREF and sociodemographic questions.p < 0.05) with a lower quality of life, and there was a weak effect for ethnicity for some domains. The effects were strongest for mothers’ education level.For the physical health, psychological wellbeing and quality of their environment WHOQOL-BREF domains, a lower gestational age, a lower education level, and having had an emergency caesarean delivery were significantly associated (There is a weak but significant relationship between the gestational age of an infant and the mother’s quality of life. Mothers in Malaysia with a preterm infant or a lower level of education may benefit from additional support.The online version contains supplementary material available at 10.1186/s12884-023-05823-y. In 2020, 6.63% of births in Malaysia were preterm, with the highest rates for Orang Asli and Indian women and women aged 40 years and above . Of pretHowever, research to date has focused on Western countries, with limited research into the psychological wellbeing of mothers of preterm infants in Malaysia specifically, and Asia more generally. Differences in health systems, and cultural norms around family relations and support for new mothers, mean we cannot assume findings from Western cultures apply to Malaysia or other Asian countries , 24. ResMoreover, while there has been extensive research on psychological distress in mothers of preterm infants, less research has focused on other measures of wellbeing, such as post-traumatic growth or life satisfaction. Porat-Zyman et al.’s  longitudThere has also been inconsistency in findings regarding whether maternal demographic characteristics predict psychological wellbeing in mothers of preterm infants, with a call for further research to examine their potential role, including in Malaysia . ApproprThe study was conducted in the Segamat district where the South East Asian Community Observatory (SEACO) operates. There were 3221 participants in the study recruited between 2013 to 2021. Two hundred and fifty-four had a preterm birth (< 37 weeks gestation) and 2967 had a full-term birth. The Mothers and Infants in SEACO Segamat Project (MISS-P) was established in 2013 to investigate maternal and child health and well-being. All women in five designated sub-districts of SEACO’s catchment area, Bekok, Chaah, Jabi, Gemereh, and Sg Segamat Malaysia, who were known to have given birth were approached by trained data collectors within 0–16 weeks after childbirth. We obtained the monthly birth lists containing basic demographic details of mothers from government clinics. Mothers were approached at their houses by the field team and asked to participate in a structured survey-based interview. Mothers who provided informed consent were interviewed individually, for about 20–40 min. If it was inconvenient to be interviewed, mothers were asked to fill in a questionnaire consisting of the same questions as the interview protocol. Upon the emergence of the COVID-19 pandemic data was collected through telephone interviews. A baby pack was given to each mother as a token of appreciation regardless of whether they consented to an interview. This study was approved by the Monash University Human Research Ethics Committee .Participants were asked to provide demographic information, including their age, nationality, ethnicity, education level, and marital status. Additionally, participants were asked about their number of pregnancies and infant births.very poor) to 5 (very good). There are multiple parameters assessed under each domain. Details of this are available in the Supplementary file  domain and acceptable for the psychological (α = 0.73), social relationships (α = 0.80) and environment (α = 0.83) domains. These values are comparable to the internal consistencies of domains reported in the original international field trial of the WHOQOL, which revealed Cronbach’s alpha values ranging from 0.66 to 0.80.Domain scores were computed by averaging the items within each domain, with items 3, 4 and 26 reverse-coded. Scores were then transformed to a range between 4–20 , to be comparable with the scores used in the original WHOQOL-100. Higher domain scores indicated a higher perceived quality of life in each respective domain. In this study, the internal consistency of the WHOQOL was marginal for the physical health (N = 15) were very preterm.Information regarding the sex of infant , gestational age (weeks), birth weight (kg), type of delivery , birth complications (if any), and APGAR scores (at 1 and 5 min) were obtained from the baby record books available at the clinics in the relevant sub-district. Maternal breastfeeding habits were also assessed, including duration and reasons for not breastfeeding. Approximately 7.9% of births were preterm (< 37 weeks gestation), while 92.1% were full-term births. Only 0.5% of births  and who their primary supporter was .All variables had less than 2.5% of missing data, with the exception of the variables ‘smoking’ (missing = 44.64%), ‘intake of regular medication during pregnancy’ (missing = 44.92%) and ‘reasons for not breastfeeding’ (missing = 11.29%) which were not considered for the regression analyses. For the WHOQOL-BREF domains, any necessary cleaning was carried out in accordance with the official guideline provided. If any two items were missing from the domain, the domain score was not calculated. This is with the exception of Domain 3, where the domain score was calculated if less than 1 item was missing. The domain scores were also transformed to a range between 4–20, to be comparable with the WHOQOL-100.p values for the F-test for all WHOQOL-BREF domains were statistically significant (> 0.0001) and the R2 ranged from 0.02 to 0.07. Multicollinearity tests were carried out using variance inflation factor. The assumption of linearity and the presence of influential points and outliers were checked. Besides that, the test for goodness of fit, independence of observations, homoscedasticity of residuals, and model specification were also considered. Further details on the data cleaning, recoding, missing data .The sociodemographic and clinical characteristics of the mothers are presented in Table p < 0.001) between the 2 gestational groups, with the median weight for full-term infants being 3.1 kg (IQR 2.8–3.4) and the preterm group being 2.4 kg (IQR 2.0–2.9). Most infants were born through the standard/breech vaginal delivery for both full-term (77.8%) and preterm (65.0%) categories, however there were significantly higher cases of emergency caesarean for the preterm group (27.2%) compared to the full-term group (12.9%). Most infants were also found to have no birth complications for both full-term (81.1%) and preterm (70.5%), and this was reflected in the APGAR scores (at one minute and at five minutes), with the median score being 9 for both groups. In terms of breastfeeding habits, most mothers did breastfeed their infants for both the full-term (98.3%) and preterm (96.1%) groups, with the median duration of the breastfeeding being 11 weeks (IQR 7–17) for full-term and 12 weeks (IQR 7–17) for preterm at the time of the survey.The sociodemographic and clinical characteristics of the infants and the breastfeeding habits of the mother are presented in Table p < 0.05) with a lower quality of life.The results of the comparisons between mothers of preterm and full-term infants are presented in Table SIn the physical health domain, a higher gestational age, those of indigenous ethnicity versus Malays, and those with a higher one-minute Apgar score were associated with a higher quality of life, while non-citizens, those with less than a pre-university education compared to those with a university education, and those who had an emergency caesarean versus a standard delivery had a lower quality of life. For the psychological health domain, a higher gestational age, and a higher one-minute Apgar score were associated with a higher quality of life, while non-citizens, those with less than a university education, those who were primarily supported by their parents versus their husbands, and those who had an emergency caesarean had a lower quality of life.For the social relationships domain those of indigenous or Chinese ethnicity, and those who were primarily supported by their mothers-in-law had a lower quality of life. In terms of education level, when compared to those with a university education, those with lower than a pre-university education had negative associations with quality of life but only the secondary education category was statistically significant. In the environmental health domain, a higher gestational age, and those of Indian ethnicity, were associated with a higher quality of life, while those of indigenous ethnicity, those with less than a pre-university education versus university education, and those who had an emergency caesarean had a lower quality of life.Our study examined the relationship between a preterm birth and Malaysian mothers’ quality of life across the 4 domains of the QoL scale. As a secondary aim we investigated whether there was a relationship between demographic factors and QoL. Overall, we found that there was a positive relationship between gestational age of the infant and mothers’ self-reported physical health, psychological wellbeing and quality of their environment. No relationship was found for the domain of social relationships. Our findings for psychological wellbeing are consistent with much previous research finding that the birth of a preterm infant is associated with higher rates of stress, depression and anxiety , 15, 16.It is not surprising that poorer physical health was associated with lower gestational age, given the higher caesarean rate in mothers of preterm infants, as well as the association between a range of medical conditions and a higher rate of preterm birth. However, it is notable that these differences were still evident some weeks after the birth of the infant. It is less obvious why there is a significant relationship between gestational age and satisfaction with the quality of their environment. Follow up research is needed to explore this finding.At the same time, it is important not to overstate our findings, as we were only able to explain a relatively small proportion of the variances in mothers’ scores for the four domains. The effects were found when we used gestation age as a continuous variable rather than as a categorical variable, which suggests that the effects are stronger for mothers of more preterm infants. However, we did not have sufficient sample size to test between groups of preterm and very preterm infants. In addition, our findings demonstrated that the strongest effects were for education, as well as some effects for ethnicity. A number of previous studies across varied countries including Spain, Portugal, and Iran have similarly found effects for education on QoL –32.Our findings demonstrate that mothers of preterm infants in Malaysia, as well as mothers with lower levels of education or of a minority ethnic group, may benefit from interventions targeting their physical and psychological health following the birth of a preterm infant. While there is evidence regarding the effectiveness of interventions in a range of countries , 34 to dThere are a number of limitations to our study. Our study was conducted in one region in Malaysia that has a higher proportion of Malays and other Bumiputera (indigenous peoples) and lower levels of income and education than the overall population. Moreover, mothers were surveyed within the first 16 weeks of their infant’s life. Future research needs to examine whether the differences between mothers of term and preterm infants dissipate over time, as found in some other studies.In conclusion, much past research has focused on psychological distress in mothers of preterm infants, predominantly in western, educated, industrialised, rich democratic (WEIRD) countries. While psychological distress may be important for diagnostic purposes, there is an increasing recognition of the importance of considering other measures of wellbeing. Our study examined the life satisfaction of mothers who had term and preterm infants in Malaysia, finding that gestational age and education had a positive relationship with a number of domains of life satisfaction.Additional file 1. Supplementary materials.docx. Information on data cleaning and recoding, and results from additional analyses.