Research on adults has identified an immigrant health advantage, known as the ‘immigrant health paradox’, by which migrants exhibit better health outcomes than natives. Is this health advantage transferred from parents to children in the form of higher birth weight relative to children of natives?Western Europe and Australia.We use data from nine birth cohorts participating in the LifeCycle Project, including five studies with large samples of immigrants’ children: Etude Longitudinale Française depuis l’Enfance—France (N=12 494), the Raine Study—Australia (N=2283), Born in Bradford—UK (N=4132), Amsterdam Born Children and their Development study—Netherlands (N=4030) and the Generation R study—Netherlands (N=4877). We include male and female babies born to immigrant and native parents.The primary outcome is birth weight measured in grams. Different specifications were tested: birth weight as a continuous variable including all births (DV1), the same variable but excluding babies born with over 4500 g (DV2), low birth weight as a 0–1 binary variable (1=birth weight below 2500 g) (DV3). Results using these three measures were similar, only results using DV1 are presented. Parental migration status is measured in four categories: both parents natives, both born abroad, only mother born abroad and only father born abroad.Two patterns in children’s birth weight by parental migration status emerged: higher birth weight among children of immigrants in France  and Australia  and lower birth weight among children of immigrants in the UK  and the Netherlands  compared with natives’ children. Smoking during pregnancy emerged as a mechanism explaining some of the birth weight gaps between children of immigrants and natives.The immigrant health advantage is not universally transferred to children in the form of higher birth weight in all host countries. Further research should investigate whether this cross-national variation is due to differences in immigrant communities, social and healthcare contexts across host countries. This study includes data from nine cohorts in six countries, allowing for a comparison of varied national contexts and diverse immigrant groups.Results are based on a large combined sample of more than 38 000 children.The use of harmonised health outcomes and sociodemographic variables, as well as standardised statistical analyses enables a rigorous multinational comparative study.Yet, some of the cohort samples are representative at the national level while others are at the local level, which limits the generalisability of the findings for certain cohorts.Some of the most vulnerable, recently arrived immigrant groups may be underrepresented in certain cohorts, potentially biasing the results for these immigrant communities.Birth weight is an important health indicator that has been associated with lifelong development, morbidity and mortality.4Research on adults has identified an immigrant health advantage, known as the ‘immigrant health paradox’,11There is a less research on these relationships in Europe, although the available evidence suggests similar patterns, that is, better birth health of children born to first-generation migrant mothers.Parental socioeconomic status is also an important determinant of children’s health outcomes,18Parental health behaviours also constitute an important possible mechanism that may contribute to health inequality at birth.This study focuses on the differences in birth weight between children of natives and children of immigrants using recent data from eight European countries and Australia to investigate three questions. First, do children of immigrants exhibit higher or lower birth weight relative to children of natives? Second, how do these associations vary across host countries? Third, can maternal smoking during pregnancy explain any of these differences?Data come from the Horizon 2020-funded LifeCycle Project-EU Child Cohort Network,24A total of nine cohorts collected data on migration status and were able to harmonise variables on socioeconomic and migrant status associated with health at birth. The results presented in the main text are based on five cohorts with a sufficiently large sample size (>1700 children of immigrants) to conduct multivariate analyses. These cohorts include: the Etude Longitudinale Française depuis l’Enfance—ELFE (France), a nationally representative cohort study following 18 329 births in France to mothers aged 18 and over in 2011;29The other participating cohorts with smaller sample sizes (<1700 children of immigrants) included the NINFEA study ,10.1136/bmjopen-2022-060932.supp1Supplementary dataParticipants were recruited prior to and during pregnancy, as well as in childhood. All data have been deidentified. Ethical and legal responsibility for data management and security is maintained by the source studies or home institutions.24The dependent variable is the child’s birth weight, a continuous variable measured in grams. Different specifications of our dependent variable are tested . Children’s migration status is measured in four categories: second-generation children, with both parents born abroad; 2.5 generation children with a mother born abroad, and native-born father; 2.5 generation children with a father born abroad and a native-born mother; and natives (reference), which included children with both parents born in the host country. Mothers’ region of birth was measured in 10 categories: host country (reference for each cohort study), Western Europe, Eastern Europe, Other Europe and Central Asia, East Asia and Pacific, South Asia, Middle East and North Africa, sub-Saharan Africa, Latin America and the Caribbean, and North America.Child characteristics at birth that were used as control variables included: the child’s sex; a binary indicator for multiple births ; birth order measured with continuous variables indicating the mother’s parity; and the child’s gestational age (in days).Basic controls for mother’s characteristics included maternal height (cm) and pre-pregnancy weight (kg), measured as continuous variables.We consider two indicators of socioeconomic background: mother’s education and household income at the child’s birth. Mother’s level of education was measured in three categories: high (reference), medium and low education. Household income quintile was measured using a cohort-specific log of the equivalised total disposable household monthly income in 2011, predicted using pan-European Union Statistics on Income and Living Conditions data.https://pubmed.ncbi.nlm.nih.gov/33884544/). Quality control checks were conducted to ensure the correct harmonisation of variables across cohorts.Finally, we included a binary indicator of mother’s smoking behaviour during pregnancy . Each of the participating cohorts conducted the variable harmonisation for all the variables, following strict step-by-step protocols . Second, we excluded babies born with a birth weight higher than 4500 g (DV2) given their higher risk of negative health outcomes. Finally, we modelled low birth weight as a 0–1 binary variable where 1 indicates birth weight below 2500 g (DV3). As the results for these three models were very similar, only DV1 is presented in the Results section. Models using the other specifications are available as Analyses were conducted separately for each cohort. Each cohort conducted two sets of models for all three birth weight specifications. The first set predicted birth weight regressed on children’s migration status, while the second set regressed birth weight on maternal region of birth. Each set of models included three nested models. Model 1 (M1) controlled for basic characteristics at birth, including the child’s sex, birth order, gestational age, and the mother’s height and pre-pregnancy weight. Model 2 (M2) additionally controlled for family socioeconomic characteristics, including the mothers’ education and family income. Model 3 (M3) further adjusted for mothers’ smoking during pregnancy.increased compared with natives and was significant for the 2nd generation  and the 2.5 generation mother . By contrast, for the Raine Study, controlling for socioeconomic factors somewhat decreased children of immigrants’ birth weight relative to children of natives, the few marginally significant differences became non-statistically significant. M3, which additionally controlled for mothers’ smoking during pregnancy (black bars), showed a reduction in the magnitude of the coefficients for children of immigrants for both cohorts, which is still significant and positive for ELFE’s 2.5 generation mother .In the first pattern, depicted by two cohorts, ELFE (France) and Raine , children of immigrants exhibited on average higher weight at birth relative to children of natives, as shown in The opposite pattern is observed in For the Dutch cohorts (ABCD and Generation R), the differences in birth weight for children with two immigrant parents and for those with one immigrant father are somewhat reduced after controlling for socioeconomic characteristics (M2), suggesting that the lower birth weight might be due to immigrants’ disadvantaged socioeconomic position within the host country. By contrast socioeconomic factors do not seem to play an important role in explaining birth weight differences for the BiB (UK) cohort.35As in the first group, mothers’ smoking during pregnancy had a negative effect on children’s birth weight. Despite mothers’ lower prevalence of smoking during pregnancy, children of immigrants’ still exhibit lower birth weight than children of natives after controlling for this variable. As shown in In sum, we find higher birth weight for children of immigrants in our southern European studies, such as in France and in the smaller cohorts representing Italy and Spain, as well as in Australia; and lower birth weight for children of immigrants in central and northern European countries, such as the UK and the Netherlands. These patterns could result from differences in the immigrants’ regions of origin across host countries. We therefore analyse birth weight differences by maternal region of origin in the next section.Results from the models by mothers’ region of origin are presented in In the Raine Study, children of Western Europeans, the largest immigrant group, showed slightly higher birth weight than natives, but differences were not statistically significant. Children of North American mothers also reported heavier weights at birth , although these estimates are based on small sample sizes. Children with a South Asian and sub-Saharan’s background tended to have lower birth weight than children of natives, but the difference was again not statistically significant.For BiB, the observed pattern is driven by children of South Asian immigrants, the largest immigrant group in Bradford, who weighed less at birth than children of natives . By contrast, children of European and East Asia and Pacific as well as North American immigrants showed a higher, but non-significant, birth weight than children of natives. The weight disadvantage among children of South Asian immigrants was partly explained by socioeconomic status. Adjusting to mother’s smoking during pregnancy exacerbated this disadvantage.For ABCD, children of women from South Asia and Latin America and Caribbean exhibited significantly lower birth weight, even after controls. Children of East Asian mothers had a significantly higher birth weight after controlling for socioeconomic variables and mother’s smoking.For Generation R , both patterns also coexist: children of women born in sub-Saharan Africa and Latin America and Caribbean exhibited significantly lower birth weight, even after controls. Children of East Asian and of other European and Central Asian mothers had, on the contrary, significantly higher birth weights.Research in developed countries has identified an immigrant health advantage among adults,Prior studies on the role of immigration on birth weight have focused on Latin-American immigrants in the USA, providing mixed evidence, for example, finding lighter birth weight among Mexican and Cuban babies and heavier birth weight among Puerto Rican babies relative to US-born white women.Our second aim was to explore in more detail birth weight variation by mother’s country of origin, controlling for the mother’s height and pre-pregnancy weight. Previous studies indicate that geographic origins could be associated with children of immigrants’ birth weight. For example, previous work has highlighted higher birth weights for infants born in Spain to African and Latin-American mothers,12 36Our third aim was to evaluate the impact of mother’s smoking during her pregnancy. Our results seem to go in the same direction as previous studies,The strength of our work lies in the use of the recent and harmonised cross-country EU Child Cohort Network data.The patterns of birth weight of children of first-generation immigrants relative to natives differ across host countries. Some of this cross-country variation seems to be due to the diverse composition of immigrant communities across Europe and Australia. Further research should investigate whether these variations are also partly driven by the different social and health policies in host countries. Improving access to healthcare, especially during pregnancy, and more inclusive social policies are needed to reduce the inequalities in birth weight, especially for disadvantaged immigrant groups, while supporting positive parental health behaviours. Our results confirm the protective effects of not smoking during pregnancy for child’s birth weight, highlighting the importance of maintaining immigrants’ healthier practices.


A congenital pulmonary airway malformation (CPAM) occurring concurrently with an enteric duplication cyst is a rare anomaly. Definitive management for both abnormalities is usually surgical resection. We present the uncommon case of a neonate with a CPAM and ileal duplication cyst, including pre-natal and post-natal workup. The patient was brought to the operating room for laparoscopic duplication cyst excision at 3 months of age. The patient returned to the operating room for a thoracoscopic right lower lobectomy at five months of age. This case presents a rare congenital anomaly with the concurrent presentation of a CPAM and enteric duplication cyst, with both being successfully excised minimally invasively. Congenital pulmonary airway malformations (CPAM) and enteric duplication cysts are congenital abnormalities of two independent organ systems—the lung and the gut. CPAMs are a heterogenous group of benign cystic pulmonary lesions and are the most common congenital lung anomaly . Type IIEnteric duplication cysts are congenital cystic or tubular structures attached to a portion of the alimentary tract with an incidence of 1 in 4500 births . They moA 26-year-old female presented for a routine ultrasound at 20 weeks gestation, which demonstrated a right lung lesion suspicious for a CPAM with a CPAM volume ratio of 0.25. Additionally, a cystic structure was identified in the abdomen. A subsequent fetal MRI at 24 weeks gestation demonstrated a hyperintense lesion in the right lower lobe with cystic components and no identifiable feeding vessel, concerning for a CPAM or hybrid lesion. The abdominal mass was also redemonstrated as a unilocular cystic structure with a differential including enteric duplication cyst, choledochal cyst, mesenteric cyst, or lymphatic malformation. Subsequent ultrasounds showed no additional anatomic abnormalities or evidence of fetal hydrops. Fetal whole genome sequencing was completed with no abnormalities.A 3.5 kg male was born via spontaneous vaginal delivery at 38 weeks. A chest radiograph demonstrated opacity at the medial right lung base  consisteAn additional abdominal ultrasound was obtained at two months of age, which redemonstrated a growing hypoechoic cystic structure with the persistence of a gut signature. A chest CT scan was obtained per institutional protocol for congenital lung malformations at ten weeks of age, which demonstrated an ill-defined area containing small cysts in the medial right lower lobe without systemic vascular supply or bronchial distribution consistent with a CPAM. Excision of both lesions was recommended, which the parents agreed to. The decision was made to proceed with laparoscopic duplication cyst resection followed by thoracoscopic right lower lobectomy 6 weeks later.The patient underwent laparoscopic enteric cyst excision at 3 months of age. The cyst was found to be intimately connected to the mesentery of the ileum with no apparent connection to the bowel itself. It was carefully dissected with a laparoscopic LigaSure, without injury to the mesenteric vessels. The procedure was well tolerated, and the patient was discharged home on postoperative day 1. Pathology was consistent with an enteric duplication cyst.The patient recovered well and was returned to the OR at 5 months of age for a thoracoscopic right lower lobectomy. The superior and basal segmental bronchi were identified and clipped. The basal bronchus and inferior pulmonary vein were stapled using vascular loads. The patient tolerated the procedure well and was discharged home on postoperative day 2. Surgical pathology was consistent with a CPAM, type 2.This case presents a rare congenital anomaly with the concurrent presentation of a CPAM and enteric duplication cyst, with both being successfully excised minimally invasively. Individually, surgical excision for each anomaly has been established as optimal therapy to avoid subsequent complications, including the risk of infection, malignant transformation, or compensatory lung growth for CPAMs, and risk of abdominal pain, obstruction, bleeding, or cyst rupture for enteric duplication cysts , 5. Due et al. [et al. [While the pulmonary and enteric systems are independent organ systems, they originate from one common embryonic organ, the foregut. The respiratory system develops from an endodermal diverticulum arising from the ventral foregut, where the esophagus develops from the dorsal wall of the foregut . This shet al. , 8 repor [et al.  reportedet al. [We decided to proceed with enteric duplication cyst excision first due to the more immediate risks associated with the duplication cyst. Once the patient had fully recovered and some time had elapsed between anesthetics, he was returned to the OR for CPAM excision. Both lesions were managed minimally invasively, with prior reports demonstrating the efficacy of minimally invasive surgery while avoiding the morbidity of an open procedure, including longer hospital stays, increased postoperative pain, a higher rate of wound infections, and worse cosmetic results . Sukja eet al.  presenteet al. . Additioet al. .In summary, the results of the present study demonstrate a rare case of congenital CPAM presenting simultaneously with an ileal duplication cyst, with both being excised minimally invasively. This study highlights the workup and management of a rare anomaly that can help guide the treatment of patients presenting with similar pathology.


Gout is the most common inflammatory arthritis and is almost exclusively managed in primary care, however the course and severity of the condition is variable and poorly characterised. This research aims improve understanding about the frequency of, and factors associated with, gout flares in the UK and characterise the factors associated with the initiation of ULT.Using the Clinical Practice Research Database, patients with a coded incident gout diagnosis without a prior prescription for urate-lowering therapy (ULT) were identified. Gout flares post diagnosis and ULT initiation were identified through prescribing and coded data. Patient characteristics, co-morbidities and co-prescribing were co-variants. Factors associated with gout flares and ULT initiation were analysed using cox-proportional hazard model and logistic regression.Fifty-one thousand seven hundred eighty-four patients were identified: 18,605  had experienced ≥ 1 recurrent flare, 17.4% (95%CI 17.1–17.8%) within 12 months of diagnosis. Male sex, black ethnicity, higher BMI, heart failure, CKD, CVD and diuretic use were associated with flares, with the highest HR seen with high serum urate levels . ULT initiation was associated with similar variables, although higher alcohol intake and older age were associated with lower odds of ULT initiation but were not associated with flares. ULT was initiated in 27.7% (95%CI 27.3–28.0%): 5.7% (95%CI 5.5–5.9%) within 12 months of diagnosis. ULT initiation rates were higher in patients with recurrent flares.Approximately one in six people with incident gout had a second flare within 12 months. Factors associated with flare recurrence and ULT initiation were similar, but ULT initiation occurred later after diagnosis than previously thought.The online version contains supplementary material available at 10.1186/s12875-023-02201-7. Gout is the most common inflammatory arthritis, affecting around 2.5% of the UK population with men having a significantly higher prevalence than women (4.0% Vs 1.1% respectively) [The medical management of gout is typically focused around the treatment of flares, the prevention of flares through lifestyle modification and using urate-lowering therapies (ULT) and the management of comorbidities.  In the UIt is known that ULT initiation rates in the UK and internationally are low , 10, 11 A potential barrier to use of ULT is the lack of evidence around, and consensus on, who should be offered this treatment and at what point in the disease course . One of A previous study using routinely collected primary care data  found thInvestigation of gout flares in a cohort of prevalent cases has shown distinct gout flare trajectories  This expThe purpose of this study was to improve understanding about the frequency and factors associated with gout flares following diagnosis of gout in the UK for patients not prescribed ULT. A secondary aim was to characterise the clinical and non-clinical factors associated with the initiation of ULT for patients diagnosed with gout.This retrospective cohort study comprised patients with incident gout in the Clinical Practice Research Datalink (CPRD) GOLD database . CPRD GOThe primary outcome variable of interest was gout flares identified by documented episodes of gout subsequent to the index event according to criteria previously used in the literature . Thus, aDemographics, co-morbidities, co-prescribing and flare status of patients were described. The difference in the distribution of characteristics between patients who experienced a recurrent flare and those that did not were tested using a Chi-Squared test. The difference between means of continuous variables were compared using the T-test. Multiple testing was accounted for using the Bonferroni Adjustment. The pattern of gout flares was described using the number of flares, time to first recurrent flare, and proportion of people having a first recurrent flare by the end of each complete year of follow up. ULT initiation was described by recurrent flare status and the proportion of patients initiated on ULT within 12 months of diagnosis and within 12 months of first recurrent flare (where applicable).For diagnoses and medications, missing data was accepted as the absence of that diagnosis or medication. For all other variables, a missing category was employed as missingness could not be assumed to occur at random.The association between covariates and the frequency of recurrent flares was analysed using logistic regression. A time to event analysis considering multiple events was performed using the Anderson-Gill Cox model with covariates as predictors and flares as the outcome , 26 This2 and over half  had one or more relevant co-morbidity. At least one recurrent flare was identified in 18,605 cohort members . All variables apart from type 1 diabetes were significantly different between the patients who had at least one recurrent flare and those who did not flare. Patients who did not experience a recurrent flare during follow-up were more likely to be female, younger, of white ethnicity, normal BMI, drink less alcohol, not have a co-morbidity or be prescribed aspirin or a diuretic, and have lower serum urate. A large proportion of the cohort did not have a serum urate measured at any time  with females having a slightly lower rate of missing urate than males (38.0% Vs 41.3% respectively).In total, 51,784 patients were included in the cohort . 17.4% (95%CI 17.1–17.8%) of patients experienced a first recurrent flare within 12 months of first diagnosis  and more likely in those of black ethnicity  and with a higher BMI (Table p < 0.001). Only 5.7% (95%CI 5.5–5.9%) of the cohort  were initiated on ULT within 12 months of diagnosis, 5.4%  of patients without a recorded recurrent flare and 6.2%  of those with one or more recurrent flare. Of the 18,605 people experiencing one or more recurrent flares, 3,590  were initiated on ULT within 12 months of the first recurrent flare. The mean time between diagnosis and ULT initiation was shorter for people who did not experience any recurrent flares than those who did . Figure ULT was initiated in 14,318 individuals , with a higher initiation rate in patients who experienced one or more recurrent flares (48.5% (95%CI 47.7–79.2%) vs 16.0% (95%CI 15.6–16.4%) in those with no recurrent flare, The odds ratios for initiating ULT were highest for higher serum urate levels, but were also increased in those with CKD, diuretic and aspirin use, heart failure and higher BMI. All levels of alcohol consumption were associated with a lower odds ratio for ULT initiation as were type 2 diabetes, female sex and older age.In this large cohort of patients diagnosed with gout who did not commence ULT, 35.9% of patients experienced a recurrent flare during a median follow-up period of 4.1 years. Approximately one in six (of these recurrent flares) occurred within 12 months of diagnosis. After 5 years of follow-up, first recurrent flares were unlikely. 14,318 of the cohort were initiated on ULT . A significantly higher proportion of ULT initiations were to people who had evidence of a recurrent flare after diagnosis (48.5% Vs 16.0%) although there may have been unrecorded flares before or after diagnosis that influenced decision-making. Of the people who were initiated on ULT, the time between diagnosis and ULT initiation was considerably lower in people who did not experience a recurrent flare which is likely due to the therapeutic effect of ULT.When comparing factors associated with the likelihood of a flare with factors associated with ULT initiation we found that age did not seem to influence flare risk, but the odds of being prescribed ULT decreased significantly in older age groups indicating that older people may not be getting an opportunity to benefit from ULT to the same extent as younger people. Prescribing omissions in other areas of prevention including cardiovascular disease, anticoagulation and anti-osteoporotic drugs been found to be more likely in older people and those with polypharmacy and multimorbidity , 28 FemaOur findings are similar to those of Rothenbacher et al. who reported that 36.9% of patients experienced a recurrent flare over a mean follow-up of 3.8 years and that the median time to first recurrent flare was 385 days . RothenbThe use of ULT is known to be low in the UK with prescribing rates of 37.6% in people with prevalent gout and 27.3% of people being initiated on gout within 12 months of diagnosis  and otheIn terms of predictors of ULT initiation; CKD, diuretic use and being overweight have previously been observed to be associated with ULT initiation  but thisThe majority of flares in this cohort were managed with colchicine (80.6%) but previous research has shown flares in the UK are usually managed with NSAIDs, with colchicine making up a minority of prescriptions , 17. ThiThis large cohort uses established methods to update what is known about the management of gout in the UK. Due to the nature of the dataset, and almost universal use of electronic prescribing, we can be confident that prescribing data are accurate and generalisable although it is acknowledged that the number of practices contributing to this dataset was declining during the study period due to a move away from the electronic patient record software utilised. Excluding patients with ULT prescriptions prior to gout diagnosis allows more confidence that the index coding represents incident gout than has been previously described resulting in a more accurate description of ULT initiation and flares post-diagnosis. However, only one coded gout diagnosis was required for inclusion, raising the possibility of misclassification.In the analysis of gout flares, accounting for multiple events instead of only the first recurrent flare allows for different gout trajectories  to contrOne of the main limitations of this and all other observational studies using routinely collected data to investigate gout flares is that some flare events will be managed by patients without seeking medical input meaning there will be under-reporting of flare events. However the other main method of characterising gout flares would be through prospective self-reporting and this is not without challenge either . It is lIn identifying gout flares it is important to note that colchicine may (rarely) be used in conditions other than gout and it is possible that NSAIDs or oral steroids were prescribed for other indications. The temporal association of gout codes with NSAIDs and oral steroid would reduce this risk. It is worth noting that other methods of defining flares also require this temporal coding association for colchicine related events as well . HoweverMany people with gout are not initiated on ULT and, although this has been highlighted in the past, by creating a more accurate incident cohort we have estimated the rate of ULT initiation after diagnosis to be considerably lower than previously reported. This suggests that many more people are not getting the opportunity to reduce their risk of flares than previously thought. Two thirds of people may not have a recurrent flare in the years following diagnosis, but those who do suffer recurrent attacks could potentially be initiated on ULT earlier in the progression of their disease. With one in six people experiencing a recurrent flare within 12 months of diagnosis, the potential benefits of ULT should be discussed early in the disease course to allow patients to consider their options through shared decision making. This study should help inform decision making by giving clinicians more insight into the risk of recurrent flares, with a particular focus on serum urate levels as the highest risk factor for recurrent flares. However, serum urate was not recorded for 41% of the cohort. Ensuring that all patients with gout have their serum urate measured soon after diagnosis and using this information in to inform ULT decision making could improve the management of this debilitating condition.Additional file 1. Additional file 2.


Preterm birth is one of the key causes of morbidity and mortality among neonates in low-income countries. In Rwanda, at least 35,000 babies are born prematurely each year, and 2600 children under the age of five die due to direct complications of prematurity each year. A limited number of studies have been conducted locally, many of which are not nationally representative. Thus, this study determined the prevalence as well as the maternal, obstetric, and gynecological factors associated with preterm birth in Rwanda at the national level.A longitudinal cohort study was conducted from July 2020 to July 2021 among first-trimester pregnant women. A total of 817 women from 30 health facilities in 10 districts were included in the analysis. A pre-tested questionnaire was used to collect data. In addition, medical records were reviewed to extract relevant data. Ultrasound examination was used to assess and confirm gestational age on recruitment. A multivariable logistic regression analysis was performed to determine the independent maternal, obstetric, and gynecological factors associated with preterm birth.The prevalence of preterm births was 13.8%. Older maternal age- 35 to 49 years , secondhand smoke exposure during pregnancy , a history of abortion , premature membrane rupture , and hypertension during pregnancy  were identified as independent risk factors for preterm birth.Preterm birth remains a significant public health issue in Rwanda. The associated risk factors for preterm birth were advanced maternal age, secondhand smoke, hypertension, history of abortion, and preterm membrane rupture. This study therefore recommends routine antenatal screening to identify and closely follow-up of those high-risk groups, in order to avoid the short- and long-term effects of preterm birth. Preterm birth is the delivery of the fetus before 37 weeks of gestation. According to estimates from the World Health Organization, 15 million (or one in ten) babies are born early each year . On averPreterm birth is the primary cause of perinatal illness and mortality worldwide . It is oStudies have found a number of risk factors for preterm birth, which can be categorized as: (1) Maternal risk factors, such as maternal age, education level, low socioeconomic status, marital status, maternal malnutrition, substance use, inadequate antenatal care (ANC), and stress, among others –17, (2) In Rwanda, despite the improvement of maternal and child health services, at least 35,000 babies are born too soon each year, and 2600 children under five die due to direct preterm complications . The facRwanda is a landlocked country located in central-eastern part of Africa. It is a low-income country with a population of about 13 million people. The country ‘health system is a pyramid with the top of pyramid, being the Ministry of health responsible for sector coordination and oversight, and setting health policies and strategies; Rwanda Biomedical Centre responsible of implementation of health programs such as Tuberculosis, Malaria, HIV and Maternal and child health; Rwanda Food and Drugs Authority for regulation of human and veterinary medicines, vaccines and other biological products, processed food, poisons, medical cosmetics, medical devices, and other products; and Rwanda Medical Supply with the mandate of ensuring availability of medicines, medical supplies and consumables to the health facilities. Currently, Rwanda has 565 public health facilities including 504 Health centers, 7 Medicalised Health Centers, 40 District, 4 Provincial, 4 Specialized and 8 Referral hospitals. Health posts are entities working at lowest level and operating under public-private partnership models; there are 1222 Health Posts (HPs) in Rwanda. Private health facilities are 317 and distributed as follow: 115 private dispensaries, 113 general clinics, 33 specialized clinics, 28 polyclinics, 9 dental clinics, 6 nutrition cabinets, 4 Private Hospitals, 4 Specialized hospitals, 3 Psychology clinics, and 2 laboratories .A health facility follow-up study using a longitudinal single baseline cohort design among first-trimester pregnant women was conducted from July 2020 to July 2021. The study was conducted in 30 health facilities including hospitals and health centers located in 10 districts around the country. The sampling unit was hospital and then convenience sampling was used to select one health center in urban area and one health center in rural area under each selected hospital. Therefore, pregnant women in the first trimester from 10 hospitals and 20 health centers were recruited in the study.Participants in this study were pregnant women in their first trimester. Being in the first trimester of pregnancy (within the 13 weeks gestation), intending to stay in the study for the duration of the study, and being able to sign or thumbprint informed consent were the inclusion criteria. However, pregnant women with chronic diseases such as hypertension, heart disease, and renal disease were excluded.A multi-stage sampling strategy was adopted, with the first stage consisting of the simple random selection of 30 health facilities (acting as clusters) from around the nation Fig. . Then, p30 qualified nurses and midwives collected the data under the direct supervision of 10 team leaders from Mount Kenya University, and the study team. Team leaders, nurses and midwives received one-day training on the study protocol, inclusion criteria, sampling, and research tools, and data collection procedures. The questionnaire was pretested among 50 pregnant women who attended two health centers in Kigali City for ANC services. With the results of this pilot study, the study tool was adjusted as necessary. Pregnant women were told about the goal of the study during the data collection procedure, and they consented to participate.Face-to-face interviews were used to gather the data using a structured questionnaire, and antenatal care records were examined to gather some additional medical information on maternal conditions. The questionnaire was adopted from the literature and contextualized according to Rwandan context. The questionnaire was initially prepared in English, and then translated into Kinyarwanda, then back into English. At the base line (first trimester) as well as in the end line (shortly after delivery) factors related to maternal characteristics , obstetric  and gynecologic  were collected.Preterm delivery, which is defined as a live birth at less than 37 weeks of gestation, was the main outcome in this study. The latest menstrual period (LMP) date was used to estimate the gestational age, and an ultrasound examination was used to confirm this. Since ultrasounds are not typically performed at health centers, the pregnant women recruited from the health centers were directed to the nearest hospital for ultrasound examination. Ultrasound examination was done by the obstetrician or general practitioner at hospital.Using IBM SPSS Statistics 25, data was entered and examined. Counts and percentages were used to describe the characteristics of respondents. Tables and text were used to present the results. For each categorical independent variable, a Chi-square assumption was made. Then, binary logistic regression using bivariate and multivariate analysis was used to identify the risk factors related to preterm birth. For the multivariable logistic regression analysis, variables having a p-value of less than 0.2 in the bivariate logistic regression were taken into account. The Adjusted Odds Ratio (AOR) with a 95% confidence interval was determined in the multivariable logistic regression analysis. Finally, factors were deemed significant if their p-value was less than 0.05. The Hosmer-Lemeshow test was used to gauge the model’s fitness.With reference No. 131/RNEC/2020, the Rwanda National Ethics Committee granted its approval, and each of the chosen hospitals provided a letter of permission. Participants in the study were given a thorough description of the study’s objectives before providing their written informed consent. Legally authorized representatives of illiterate participants provided informed consent for the study. Informed consent was obtained from a parent and/or legal guardian for participants aged under 16.Participants in the study had the freedom to decline or leave at any moment without incurring any penalties. Furthermore, the participants received assurances regarding the confidentiality of the data, and no personal identifying information was included on the questionnaires.A total of 817 women and new-born pairs were included in the study to achieve the objectives. The prevalence of preterm birth was 13.83%, with a 95% confidence interval of 11.54% and 16.39%. The majority of new-born babies (63.2%) were female; however, this was not significantly associated with preterm birth. Similarly, there was no statistically significant association observed between risk of preterm birth and residence, marital status, level of education, occupation, and social class, as well as alcohol consumption and smoking during pregnancy. However, a significant association was observed between maternal age, partners’ smoking status, and the risk of preterm birth. The proportion of mothers who delivered preterm babies was significantly higher in the 35–49 age group  . Preterm birth was 1.9 times more likely to occur among mothers exposed to secondhand smoke . Mothers who had previously had an abortion had a 1.9-fold increased risk of preterm birth  and 4.4 times more common among hypertensive mothers .The purpose of this study was to establish maternal, obstetric, and gynecological factors associated with preterm birth in Rwanda. In our study, the prevalence of preterm birth was found to be 13.8%. After adjusting for potential confounders using a multivariable logistic regression model, the identified independent risk factors associated with preterm birth were advanced pregnancy age, secondhand smoke, abortion history, preterm membrane rupture, and pregnancy-induced hypertension.The prevalence of preterm birth in Rwanda was higher than studies done in multi-center health facilities in Iran (5.1%)  and in AHowever, this prevalence is lower than recent cross-sectional studies done in teaching hospitals in Ghana, whereby it was reported at 37.3% , and 25.Our study showed that advanced maternal age was associated with preterm birth. Several studies have also found that advanced maternal age is a risk factor for preterm birth , 37–39. It is acknowledged that the primary risk factor for preterm birth is premature membrane rupture . AccordiIn concordance with other previous studies, , 47, 48,The current study found that women with a history of abortion were significantly more likely to give birth prematurely. This is in agreement with other studies as well as a systematic review and a meta-analysis , 51, 52.Our study also revealed that pregnant women exposed to secondhand smoking had significantly higher odds of delivering premature babies. There has been evidence that pregnant women who smoke cigarettes are at increased risk of preterm birth , 29, 55.Although UTI and ANC attendance were significant in bivariate analysis, they were not significant in multivariate analysis. This finding is similar to that of a study conducted in Kenya which reported no significant association between preterm birth and number of ANC visits . In contOne of the study’s strengths is its large representative sample drawn from 30 health facilities selected in 10 districts. The findings thus represent the prevalence of preterm births in Rwanda with reasonable certainty. This study does have some drawbacks, though. The many independent variables and preterm birth do not necessarily have a cause-and-effect connection. Additionally, there may be a chance of recollection bias because the data were obtained through interviews. Loss to follow-up (LTFU) among recruited persons was another constraint (24.97%), but after comparing the baseline characteristics of the LTFU and those of participants included in the data analysis, there were no significant discrepancies, ensuring the internal validity of the study.The magnitude of preterm birth was slightly higher than in the most recent Rwandan demographic health survey. It was independently affected by advanced age during pregnancy, secondhand smoke, a history of abortion, preterm membrane rupture, and pregnancy-induced hypertension. Therefore, it is preferable to take into account pregnant women who are older, exposed to secondhand smoke, have had abortions before, and have hypertension when screening and intervening in order to avoid the short- and long-term effects of premature birth.


Premature birth, perinatal asphyxia, and infections are the main causes of neonatal death. Growth deviations at birth also affect neonatal survival according to week of gestation at birth, particularly in developing countries. The purpose of this study was to verify the association between inappropriate birth weight and neonatal death in term live births.This is an observational follow-up study with all term live births from 2004 to 2013 in Sao Paulo State, Brazil. Data were retrieved with the deterministic linkage of death and birth certificates. The definition of very small for gestational age (VSGA) and very large for gestational age (VLGA) used the 10th percentile of 37 weeks and the 90th percentile of 41 weeks + 6 days, respectively, based on the Intergrowth-21st. We measured the outcome in terms of time to death and the status of each subject (death or censorship) in the neonatal period (0–27 days). Survival functions were calculated using the Kaplan–Meier method stratified according to the adequacy of birth weight into three groups . We used multivariate Cox regression to adjust for proportional hazard ratios (HRs).The neonatal death rate during the study period was 12.03/10,000 live births. We found 1.8% newborns with VSGA and 2.7% with VLGA. The adjusted analysis showed a significant increase in mortality risk for VSGA infants , independent of sex, 1-min Apgar score, and five maternal factors.The risk of neonatal death in full-term live births was approximately four times greater in those with birth weight restriction. The development of strategies to control the factors that determine fetal growth restriction through planned and structured prenatal care can substantially reduce the risk of neonatal death in full-term live births, especially in developing countries such as Brazil. Although a reduction in the number of neonatal deaths has occurred in recent decades, mainly related to the greatest availability of technical and clinical resources, many newborns continue to die worldwide . GloballThe risk of neonatal death is closely associated with three preventable and treatable conditions: complications of prematurity, intrapartum-related neonatal deaths (including birth asphyxia), and neonatal infections . Other aAdequate intrauterine growth has been the focus of many studies that identified changes in the growth of the embryo/fetus associated with neonatal death and clinical/metabolic outcomes at all stages of life. The nutritional classification at birth has been used as a marker for morbidity and mortality in newborns and in all pediatric age groups .On the one hand, newborns small for gestational age (SGA), especially severe SGA, are at greater risk of neonatal death than those who do not show signs of intrauterine growth restriction. On the other hand, newborns large for gestational age (LGA) have a higher frequency of morbidities such as brachial plexus and skeletal injuries, hypoglycemia, and perinatal complications. When present, these morbidities may lead to complications that contribute to neonatal death, such as asphyxia in term births –6.Neonatal deaths associated with inappropriate birth weight differ according to gestational age, the method used to classify birth weight adequacy, and the ethnic and racial characteristics of the population studied . The risThere are few population-based studies that assess the association of these growth deviations at birth with neonatal death, specifically in term newborns, who do not suffer the clinical consequences of the functional immaturity of preterm newborns and potentially have the greatest chances of surviving the neonatal period –6.The aim of the study was to verify the association between inappropriate birth weight and neonatal death in term live births.This is an observational follow-up study during the neonatal period (0–27 days of life), including all term live births with gestational age ≥37 weeks and <42 weeks from 2004 to 2013 from mothers residing in the State of Sao Paulo, Southeast Brazil. Sao Paulo is the richest and most populous Brazilian state, with 45,289,733 inhabitants as on January 16, 2023 (approximately 20.8% of the Brazilian population)  and greater than 3 for 41 weeks and 6 days of gestation  were considered subjects with values that differed significantly from other observations (outliers) and, therefore, were removed from the sample , values lower than the 10th percentile of birth weight for 37 weeks  were considered. To define very large for gestational age (VLGA), values higher than the 90th percentile of birth weight for 41 weeks and 6 days  were considered. These values were based on the Intergrowth-21st birth weight tables .Neonatal death (death 0–27 days after birth) was defined as the main outcome of the study, which was measured as time to death (in days) during the neonatal period (0–27 days) and the status of each subject (death or censorship) until the end of the observation period.p-values under 0.20 led variables to be eligible to enter multiple model analysis.Categorical variables are presented as the relative frequency according to birth weight adequacy. Survival functions were calculated and displayed using the Kaplan–Meier curve according to the birth weight for gestational age . We used the log-rank test for equality of survivor functions. Univariate and multivariate survival analyses using Cox regression were performed to investigate neonatal death-associated factors. Univariate associations with The annual trend of the neonatal mortality rate was assessed by Prais–Winsten generalized linear regression through the calculation of the annual percentage change (APC). In addition, the interaction between birth weight adequacy and year of birth associated with neonatal death was estimated in the adjusted Cox regression analysis.p-value equal to 0.05) was chosen to indicate a statistically significant association.All statistical analyses were performed using Statistical Package Stata/SE 14.2 . A maximum level of 5%  and by the Board of Directors of SEADE Foundation. There was no direct contact with the study subjects or any personal identification. The dataset was accessed from October 2018 to June 2021, and confidentiality of information was fully preserved before access.From 2004 to 2013, there were 6,059,454 live births in the São Paulo State, Brazil. Of these, 5,860,736 (96.7%) had known gestational age. Of these, 575,441 (9.8%) were preterm births. Among the 5,285,295 identified term births, 143,614 were excluded because of one or more exclusion criteria. The other 399,279 subjects were excluded only from the multivariate analysis due to the absence of data on the selected variables to compose the final logistic model. Therefore, a total of 5,141,681 term live births were selected and studied in the univariate/bivariate analysis and 4,742,402 in the multivariate analysis, amounting to a sample loss of 2.7% and 7.6%, respectively.n = 90,822) and 2.7% , respectively. There were 6,186 term infant deaths in the first 27 days of life (0.12%), with a neonatal mortality rate of 12.03 for 10,000 live births during the period of 2004 to 2013. The prevalence rates of VSGA and VLGA were 1.8% (p < 0.001). Newborns with both VSGA  and VLGA  had a higher probability of not surviving the neonatal period.Additionally, the year of birth was associated with neonatal death. Standardized mortality rates showed a descending trend in the analyzed period, from 14.99 per 10,000 live births in 2004 to 9.39 per 10,000 live births in 2013  .p < 0.001). However, VLGA did not remain significantly associated with neonatal death in the multiple Cox regression model. Seven other variables were associated with the risk of dying during the neonatal period, regardless of the year of birth: male sex, 1st minute Apgar score <7, <7 prenatal visits, single mothers, multiparity, maternal age <20 years, and less education time , showing that the risk of neonatal death for both VSGA and VLGA did not vary significantly over the years.Additionally, in the adjusted Cox regression analysis, there was no interaction between birth weight adequacy and year of birth associated with neonatal death  framework and consequently received less attention and investment . AccordiThe present study shows a neonatal mortality rate in the state of Sao Paulo from 2004 to 2013 of 12.03 for 10,000 live-term births, which represents 15% of the neonatal mortality rate identified in all newborns in the same period and region   can substantially reduce the risk of neonatal death. Despite this, it should be noted that our results should be carefully compared with other studies, as SGA is variously defined as the lowest 10th, 5th, 3rd, or 2.5th percentiles of birth weight according to gestational age . MoreoveThe complex nature of neonatal death determinants motivated the multivariate statistical analyses to independently identify the association between anthropometric nutritional status at birth and this outcome in term live births. Therefore, the findings gain greater validity and provide the broad perspective necessary to understand events that are triggered by multiple factors . HoweverOn the other hand, São Paulo is the only Brazilian state that developed, over decades, its own system of producing independent vital statistics, which manages to relate continuous data from the civil registry with epidemiological data originating from death and live birth certificates, producing comprehensive information that allows a consistent analysis of child health indicators .In this context, the risk of neonatal death in full-term live births was approximately four times greater in those with birth weight restriction in the São Paulo State. We did not identify VLGA as a risk factor for neonatal death. Despite the need to take some precautions, the findings of the present study can be generalized to areas or countries with socioeconomic characteristics such as those of the State of São Paulo, a middle-income setting.Once countries are advised to prioritize child survival policy and programs based on their child cause-of-death composition, our findings may guide prevention and management strategies in line with the Sustainable Development Goals target for child survival . The preAdditional evaluations of population-based databases in different socioeconomic contexts and those that include clinical characteristics of the neonatal period should be carried out to confirm the findings of this study.


Independently, active maternal and environmental tobacco smoke exposure and maternal stress have been linked to an increased risk of preterm birth and low birth weight. An understudied relationship is the potential for interactive effects between these risk factors.Data was obtained from the All Our Families cohort, a study of 3,388 pregnant women < 25 weeks gestation recruited from those receiving prenatal care in Calgary, Canada between May 2008 and December 2010. We investigated the joint effects of active maternal smoking, total smoke exposure  and prenatal stress , measured at two time points (< 25 weeks and 34–36 weeks gestation), on preterm birth and low birth weight.A marginally significant association was observed with the interaction active maternal smoking and Spielberger State-Trait Anxiety Inventory scores in relation to low birth weight, after imputation . No significant joint effects of maternal stress and either active maternal smoking or total smoke exposure with preterm birth were observed. Active maternal smoking, total smoke exposure, Perceived Stress Scores, and Spielberger State-Trait Anxiety Inventory scores were independently associated with preterm birth and/or low birth weight.Findings indicate the role of independent effects of smoking and stress in terms of preterm birth and low birthweight. However, the etiology of preterm birth and low birth weight is complex and multifactorial. Further investigations of potential interactive effects may be useful in helping to identify women experiencing vulnerability and inform the development of targeted interventions. Preterm birth  and low birth weight < 2500 g) are ongoing issues globally, with rates increasing in many countries, despite our advances in knowledge and interventions aimed at known risk factors , 2. In C500 g arePreterm birth and low birth weight have multifactorial etiologies, likely affected by a combination of genetic, biological, behavioral, environmental, social, and other factors , 7. AmonThere is evidence to indicate that these independent relationships may be modified by other factors , 18–22. All our Families (AOF) is a prospective cohort study of pregnant women in Calgary, Canada set up to investigate determinants of maternal, infant and child wellbeing and health service utilization during and after pregnancy . The stua priori from the literature and included in the models were: maternal age, derived from mother’s birthdate at the time the first maternal questionnaire was administered (< 25 weeks gestation); maternal highest level of education categorized into high school or less/some trade school, college, or university/graduated trade school, college, university/some graduate school, completed graduate school; household income grouped into <$40,000/$40,000 to <$60,000/$60,000 to <$80,000/$80,000 to <$100,000/≥$100,000; body mass index (BMI) categorized as underweight (< 18.5 kg/m2)/normal weight (18.5-<25.0 kg/m2)/overweight (25.0-<30.0 kg/m2)/obese (≥ 30.0 kg/m2); and parity .This study examined two outcomes: preterm birth defined as < 37 weeks gestation and infant low birth weight defined as < 2,500 g among primiparous women. Exclusions included multiple births as this is an independent risk factor for poorer maternal mental health, preterm birth and low birth weight –34. The a priori sample size of 3,241 was estimated for a multiplicative interaction, based on findings from a prior study examining cumulative psychosocial stress and late (34–366/7 weeks) preterm birth  using the same cohort data [A Generalized Estimating Equation logistic regression approach was used to account for the two stress measures assessed at < 25 weeks and 34–36 weeks gestation. To explore the hypotheses that maternal stress  may trigger maternal smoking behavior, we also conducted multiple linear regression. Adjusted models also included the potential confounders described above. Recognizing that prior preterm birth is an important predictor of subsequent adverse birth outcomes,  we conduort data , the assort data , and matort data .We conducted full conditional specification multiple imputation, including auxiliary variables, for the outcomes preterm birth (10.8% missing), low birth weight (15.0% missing), total smoke exposure (11.7% missing), active total smoke exposure (13.1% missing), perceived stress scale scores for the first and second time point , Spielberger State-Trait Anxiety Inventory scores for the first and second time point , PSS-total smoke exposure interactions (15.5% missing), STAI-total smoke exposure interactions (15.2% missing) and parity (1.5% missing) . InteracThe All Our Families cohort included 3,387 women who completed at least one questionnaire . The meaTwenty-four percent of the women in the cohort were exposed to either active or environmental tobacco smoke during pregnancy Table . Of thesInconsistent results were observed for PSS and STAI scores. Both PSS and STAI scores, in adjusted models, were modestly associated with an increased odds of preterm birth . STAI but not PSS scores were associated with an increased odds of low birth weight.Active maternal smoking was associated with a strongly increased odds of preterm birth, though low birth weight did not indicate evidence of an association. Total smoke exposure  was also found to be strongly associated with preterm birth but not low birth weight in models without interactions Tables  and 3.Interaction terms examining total smoke exposure , PSS and STAI scores with preterm birth and low birth weight were nonsignificant Tables  and 3. AActive maternal smoking was associated with both PSS and STAI scores in this study. Active maternal smoking was positively associated with PSS scores . Active maternal smoking was also observed to be positively associated with STAI scores .In this study, there was no evidence of interactive effects between total smoke exposure and measures of perinatal stress in relation to preterm birth and low birth weight. With imputation, a marginal association between the interaction of active maternal smoking and STAI scores and low birth weight was observed. A positive association was also found between active maternal smoking and STAI scores. This may indicate that certain measures of perinatal stress are linked to the propensity to smoke during pregnancy.Work is emerging regarding behavioral-psychosocial interactions such as smoking and stress or social support in pregnant women. Lobel et al.  found thStress during pregnancy may act as a smoking cessation barrier , 29. BulAnother hypothesis could be that smoking is a coping mechanism for pregnant women experiencing pregnancy-related anxiety. However, smoking may actually worsen negative emotional states such as stress –48. The Prior studies have observed the modification of the stress-preterm birth/low birth weight relationship by other exposures. Nkansah-Amankra et al.  observedStudy findings also suggest that stress, as assessed through Perceived Stress Scale and Spielberger State-Trait Anxiety Inventory scores, are independently associated with an increased odds of preterm birth and/or low birth weight. Both active maternal and total smoke exposure were also observed to be independently associated with preterm birth but not low birth weight in this study. Interactive effects between active maternal smoking, total smoke exposure  and maternal stress were not observed, though active smoking and maternal stress were positively associated.Our findings were also consistent with other studies that observed an independent positive association between higher maternal stress and preterm birth and low birth weight. Bussières et al.  observedData from the 2006 Canadian Maternal Experiences Survey show an estimated prevalence of 10.5% for smoking during pregnancy across Canada, with a reported prevalence of 11.8% in Alberta,  which isThere are several limitations of the study that must be kept in mind when interpreting these findings. One limitation was the lack of a more refined measure of smoking, which is a recommendation for future work in this area. Information about smoking was also only collected at baseline (< 25 weeks gestation) so smoking habits or exposures may have changed by the time of the second wave of data collection (34–36 weeks gestation). However, prior studies have shown that those who report smoking at the beginning of their pregnancy are likely to continue throughout, though fluctuations in smoking intensity were reported as occurring , 64. FurStatistically significant interactions between smoke exposure, stress, and anxiety were not observed in this study with preterm birth. A significant interaction between active maternal smoking and Spielberger State-Trait Anxiety in terms of low birth weight was observed only in imputed analyses. Nonetheless, the etiology of adverse birth outcomes points to the role of several factors , 7. The


Presacral cysts are cystic or cyst–solid lesions between the sacrum and rectum, almostinvolving adjacent pelvic floorstructures including sacrococcygeal fascia, rectum, andanal sphincter. Presacral cysts are usually benign, currently believed to arise fromaberrant embryogenesis. Presacral cysts are clinically rare and the true incidence isunknown. Surgical resection remains the major treatment for presacral cysts. Unless thecysts are completely resected, recurrence is unavoidable. Recurrent cysts or hard-to-healsinuses in the sacrococcyx cause patients extreme pain. However, the current knowledge ofpresacral cysts is insufficient. They are occasionally confused with other diseases suchas ovarian cysts and perianal abscesses. Moreover, lack of the correct surgical conceptand skills leads to palliative treatment for complex presacral cysts and seriouscomplications such as impairing the function of the anal sphincter or important bloodvessels and nerves. The consensus summarizes the opinions and experiences ofmultidisciplinary experts in presacral cysts and aims to provide clinicians with a moredefined concept of the treatment, standardize the surgical approach, and improve theefficacy of presacral cysts. The members of the expert group were from two associations  and from most provinces, cities, and autonomous regions in China.Major fields included colorectal surgery, gynecological oncology, oncology, radiotherapy,imaging, and pathology, etc.The first consensus draft was written by the experts, and then the relevant problems andrules in the first draft were fully discussed by the experts in the consensus seminar, andthe relevant statements were finally formed by experts voting in multiple rounds ofmeetings.(i) 100% voting consensus: all experts reached a consensus and unanimously recommended;(ii) 75%–99% voting consensus: most experts reached consensus and recommended; (iii)50%–74% voting consensus: most experts reached consensus and recommended, but a fewexperts disagreed; (iv) <50% voting consensus: not recommended.It is a common belief that presacral cysts result from incompletely degenerated primitiveembryonic structures during embryonic development, mainly including the tailgut, neural gut,and primitive streak . The taiPresacral cysts are classified into two types: benign and malignant, and most of them arebenign, including epidermoid cysts, dermoid cysts, enteric cysts , neurenteric cysts, teratomas, etc. , 11.An epidermoid cyst is a benign single-cystic lesion and contains dry keratinized materialon gross macroscopic examination. The cyst wall is only lined with stratified squamousepithelium and without skin appendage structure.A dermoid cyst is a benign teratoma of a single germ layer with only ectodermaldifferentiation, which can be monocystic or polycystic, and a few are solid and filledwith thick, cloudy, or sebaceous secretions, and may have hair. The cyst wall is linedwith stratified squamous epithelium and there is skin adnexal differentiation, such aspilosebaceous glands or sweat glands.An enterogenic cyst is partially or completely lined with intestinal mucosa and dividedinto a caudal tailgut cyst and cystic rectal duplication. (i) A tailgut cyst is usuallypolycystic, with different types of gastrointestinal epithelial cells such as columnarepithelium, squamous epithelium, transitional, or stratified columnar epithelium. The cystfills with clear, yellowish, or pasty viscous liquid. (ii) Cystic rectal duplication isusually monocystic, lined with the epithelium of the respiratory tract andgastrointestinal tract, and with two layers of muscularis (muscularis mucosa andmuscularis propria) and nerve plexus outside.Compared with the tailgut cyst, the major difference is that a neuroenteric cyst hasclear lamina propria and more mature endodermal mucosal differentiation  .Teratomas are germ-cell tumors, which are composed of mature tissue of two or three germlayers  , and areThe main body of a central presacral cyst is located behind the anorectum and in frontof the sacrococcyx. The upper pole of the cyst can reach the sacral 2 (S2) level and thelower pole can reach the subcutaneous tissue or even the skin behind the anus. Themiddle and upper part of the anterior wall of most cysts are densely adhered to therectal wall or posterior vaginal wall, only a few are membranous adhesions, and thelower part of the anterior wall of the cyst often adheres tightly to the anorectalcircular muscle. The posterior wall has a close relationship with the coccygeal fasciaand most of them have membranous adhesion with the sacral fascia. If the presacral cystis complicated with infection or bleeding, the posterior wall will be tightly adhered tothe presacral fascia. The walls on both sides of the cyst are adjacent to the gluteusmaximus and “U”-shaped levator ani muscle  and parts of the cyst walls reach the ischialtuberosity. Most of the cyst walls adhere to the gluteus maximus and levator ani muscle.The main body of the eccentric presacral cyst is located on one side of the presacralspace and the anterior wall of the cyst is adjacent to the pubis and the musclesassociated with the pubis. The adjacent structure of the posterior wall is basicallysimilar to the central presacral cyst. The adjacent structures of the medial wall of thecyst include the vaginal wall , prostate , rectal wall, anorectal ringmuscle group, etc. The lateral wall of the cyst is closely related to the adjacentstructures, such as ligaments of ischial tuberosity, gluteus maximus, coccygeus,iliococcygeus, pubococcygeus, and puborectalis muscles .However, the coccyx, sacrococcygeal ligament, part of the levator ani, and the externalanal sphincter are cut off during the operation, which does not damage the integrity ofthe anorectal ring muscles, and the internal anal sphincter is not impaired, so the analfunction is generally preserved .The associated blood vessels around the presacral cyst mainly include: (i) the lateralsacral artery branches to the sacrococcygeal ligament, accompanying veins and presacralvenous plexus; (ii) the terminal branch of the internal iliac artery and vein , and the internal pudendal artery and vein to the gluteusmaximus, levator ani muscle, rectum, and anal canal; (iii) the internal vessels of themesorectum  Figure .The most common bleeding sites during the operation are sacrococcygeal ligament arterybleeding, internal pudendal artery branch bleeding near the ischial tuberosity, and rectalmuscle layer and mesentery bleeding. Most bleeding can be stopped by using sutures orcoagulation, although coagulation should be avoided as far as possible when the bowel wallis weak.The nerves associated with presacral cyst surgery mainly include the pelvic and perinealnerves  Figure . The pelThe nerve injury of presacral cyst resection via an abdominal approach is similar to thatof rectal cancer resection via an abdominal approach. For example, the injury of thepelvic visceral nerve may cause dysuria or sexual dysfunction , 25.HowThe sciatic nerve, which is involved in the important function of the lower limbs,originates from the lumbar 4–5 (L4–L5) and sacral 1–3 (S1–S3) nerve roots, passes throughthe connecting area between S1, S2, S3, and the pelvic wall, passes through the sciaticforamen, and exits the pelvic cavity . TherefoMost patients have no specific clinical symptoms and some patients have pelvic organand nerve-compression symptoms, such as abdominal distension, frequent urination,urgency, difficulty in defecation, abnormal perineum sensation of lower limbs, andhabitual abortion, etc.Computed tomography (CT) or magnetic resonance imaging (MRI) shows the cystic or cysticsolid lesions behind the rectum and in front of the sacrococcyx, which are closelyrelated to the sacrococcygeal fascia. The cysts show expansile growth and most squeezethe surrounding organs and tissues, and even protrude downward to the subcutaneoustissue of the buttocks and perineum.Compared with CT, MRI has the advantage of high resolution of soft tissue and canpresent different signal intensities according to different components in the lesion,which is helpful for identifying types of cysts or other lesions. Meanwhile, MRI canclearly show the location of the cyst and the relationship between the cyst andsurrounding important organs and blood vessels through multiparameter andmultidirectional imaging. Therefore, MRI is recommended as the first choice for thepreoperative diagnosis of presacral cysts.Endoscopic ultrasonography (EUS) is used to evaluate the origin of the cyst and itsrelationship with the rectal wall. It can show cystic or cystic solid masses behind therectum, which closely adhere to the lower rectum but the structure of the rectal wall iscomplete.Some patients have sunken and wrinkled skin in the posterior midline of the buttock andthere is no redness, swelling, heat, or tenderness around the anus. Digital rectalexamination or double combination examination can touch the external pressure cysticmass behind the rectum, with poor mobility, no obvious tenderness, and no abnormalrectal mucosa. Abdominal palpation is not easy to perform.A perianal abscess usually has infection symptoms, including heat, swelling, pain, andtenesmus, while a presacral cyst does not. During digital rectal examination, a perianalabscess can be touched with a wave motion and obvious tenderness around the rectum, anda presacral cyst only with wave motion. A presacral cyst with infection is easilyconfused with a perianal abscess, although enhanced MRI can be performed todifferentiate them. The MRI of a presacral cyst with infection shows uneven thickeningof the cyst wall and obvious enhancement of the signal after enhancement, and a perianalabscess is located in a low position, usually near the anal sphincter. MRI shows typicaldiffusion-weighted high signal and the abscess wall is enhanced circularly afterenhancement.The internal opening of an anal fistula is located in the rectal cavity and the shapeof the anal fistula sinus and the position of the internal opening of the anal fistulacan be detected by using sinography or MRI. The sinus of an unhealed presacral cyst is ablind end and angiography or MRI shows that the sinus does not communicate with therectal cavity.Ovarian cysts are located in the pelvic cavity and most of them can be palpated bydigital rectal examination and digital vaginal examination. Some tumors are difficult tobe pushed due to their large volume, but there is a clear boundary with the sacrococcygealfascia. Presacral cysts are located in the retroperitoneum of the pelvic floor and areclosely related to the sacrococcygeal fascia; the cysts are fixed and cannot be pushed byrectal digital examination. CT or MRI is an important method to differentiate the twodiseases.Uterine fibroids are not adjacent to the sacrococcygeal fascia. Active mass can bepalpated by digital rectal examination and digital vaginal examination. The imagingfindings show solid mass, which is closely related to the uterus. Presacral cysts arelocated and fixed in the retroperitoneum of the pelvic floor and cannot be pushed byrectal digital examination. The imaging findings are cystic or cystic solid tumors.Presacral neurogenic tumors are located in the retroperitoneum of the pelvic floor,with a clear boundary with the sacrococcygeal fascia, and most of them have a gap withthe rectum. Digital rectal examination and imaging examinations show a solidextra-rectal mass. Presacral cysts are also located in the retroperitoneum of the pelvicfloor and are generally closely related to the rectum and sacrococcygeal fascia. Digitalrectal examination and imaging examinations suggest a cystic or solid cystic mass withexternal rectal pressure.A pseudopresacral cyst is a cystic mass that is not shown on preoperative imaging andappears after surgery. Mostly pseudocysts are formed by mucus secreted by recurrenttumors or residual rectal mucosa, with no adjacent relationship with the sacrococcygealfascia. However, the primary presacral cysts are mostly congenital, without history ofsurgery before the first discovery.Rectal stromal tumors originate from the submucosal muscle layer and presacral cystsmostly originate from the sacrococcygeal fascia. EUS and MR can effectively distinguishthem.When a chordoma grows forward and protrudes into the sacral fossa, the diagnosis ofpresacral cyst needs to be differentiated from chordoma. The MRI of chordoma mainlyshows bone destruction and soft-tissue mass; T2WI and enhanced MRI showed that the lowsignal fibers in the tumor separate the high signal tumor matrix and tumor cells intomultiple lobules, forming a typical “honeycomb sign.” Presacral cysts do not have theabove imaging findings.The cyst wall must be removed intact or completely, otherwise it can lead to recurrenceof the cyst. The sacrococcygeal fascia may be the origin of the presacral cyst and itsremnants can also lead to cyst recurrence.Because of the close relationship between the coccyx and the sacrococcygeal fascia,resection of the coccyx is recommended to ensure complete removal of the sacrococcygealfascia.Electrocautery and anhydrous alcohol treatment of the cyst wall cannot destroy thesecretory function of the residual cyst wall, which may be a main factor contributing tothe recurrence of presacral cysts.There is insufficient clinical evidence for the use of sclerosing agents to disrupt thesecretory function of the cyst wall. Clinical experience has also demonstrated thatpresacral cysts treated with sclerosing agents remain secretory and make the removal ofpresacral cysts more difficult.Drainage cannot cure the presacral cyst, but instead causes inflammatory edema around thecyst and increases the difficulty of separating the cyst wall from the surrounding organs.Decompression by drainage is not recommended unless the presacral cyst is compressing therectum or urethra causing difficulty in defecation or urination, or if the patient isphysically intolerant to the operation.When the presacral cyst compresses the rectum and causes defecation disorder or the cystruptures and causes surrounding infection requiring emergency puncture and drainage, it isrecommended to perform extra-rectal puncture and drainage as far away from the anus aspossible and to avoid transrectal puncture and drainage.Because presacral cysts are highly tense and have poorly elastic walls, routine needlebiopsy tends to increase the risk of infection and sinus-tract formation. For presacralcysts of suspected malignancy , needle biopsy can be performed to clarify the nature of thecyst.This is recommended for patients with small cysts whose upper pole is lower than the S4level and can tolerate S4 and S5 vertebral body resection. Patients are placed in thejackknife position and the incision is made along or parallel to the gluteal sulcus Figure . During This is recommended for cysts with an upper pole located below S2. For presacral cystswhose upper pole is below S4, the lithotomy position or the jackknife position can beperformed, and the jackknife position is better. For presacral cysts with the upper poleabove S4, the lithotomy position is recommended. Using the tip of the coccyx as a mark,it is positioned between the tip of the coccyx and the anus, and the left and right arepositioned at the inner edge of the ischial tuberosity, connecting three points to forma transverse arc incision , 22 Fig. During Compared with the longitudinal incision, the biggest advantage of this incision is toprovide enough operation space for cyst separation and presacral hemostasis. However, inthe lithotomy position, the tension of the incision is large, which is prone to poorincision healing.This incision is only suitable for the resection of cysts with very low location andsmall volume. The patient is placed in the lithotomy position and a “V” incision orradial incision is made behind the anus; the anal canal, internal sphincter, andexternal sphincter are bluntly separated through the sphincter space, up to the level ofthe levator ani muscle.This is recommended for the initial treatment of presacral cysts with a loose spacebetween the sacrococcygeal and rectal walls, and do not cross the back of the sacrum,and the surgical team is required to have skilled laparoscopic techniques.The patient's position and trocar position are the same as those for rectal cancersurgery , 31. ForThis is recommended for resecting cysts with a history of open surgery and severepelvic adhesions, or cysts with a high position that are not suitable fortransperineal resection.This is recommended for presacral cysts with large volume, superior pole higher than S4level, and inferior pole closely related to the sacrococcygeal region. The lithotomyposition with a presacral transverse arc incision or the lithotomy position followed bythe jackknife position with a presacral transverse arc incision or longitudinal incisionis performed. The presacral cyst is first dissociated to the level of the pelvic floormuscle by laparoscopy or laparotomy, and then the distal end of the cyst is dissociated bythe perineal approach. The perineal approach is relatively simple and the incision isrelatively small, although the whole operational procedure is relatively complex and thepatient’s position needs to change during the operation; there are sexual and voidingdysfunctions caused by the injury of the hypogastric plexus through the abdominalapproach.(i) The presacral bleeding spots are located below the level of S4 and electrocauterycoagulation can effectively stop the bleeding. (ii) The presacral bleeding spots arelocated above the level of S4 and this can be managed by using presacral suture withvascular suture. If not, cotton pads can be used to stop the bleeding by compressing thebleed spots in the presacral residual cavity , 33.(1) Local repair can be performed and a pedicled greater omentum or transferred muscleflap is used to reinforce the repaired rectal wall . (ii) IfThe incision should be as distant from the anus as possible, which is conducive toreducing incision pollution and improving the blood supply of the flap; the presacralresidual cavity and incision are fully drained or rinsed to avoid effusion and infectionbut if they occur, it is recommended to disassemble the incision for drainage, wipe, orsitz bath.The weak rectal wall after cyst separation should be reinforced and preventiveenterostomy should be performed when necessary; avoid rectum being corroded bypost-operative presacral residual cavity infection, but if it occurs, local resection orrepair of the diseased rectum is required and preventive fistula should beperformed.Anorectal ring muscles should be protected during the operation. If damage occurs,anal-constriction exercises, biofeedback therapy, or magnetic therapy can be performed,and the reconstruction of the anorectal ring muscles can be performed when necessary.The pelvic nerves should be protected as much as possible during operation. If damageoccurs, acupuncture, traditional Chinese medicine, and other conservative treatment arerecommended.The sciatic nerve and branches should be protected as much as possible during theoperation and the cystic fluid can be sucked to better expose the surgical field toprotect the nerve for giant presacral cysts. If damage occurs, conservative treatmentand functional exercise are recommended, e.g. acupuncture and traditional Chinesemedicine.Diet adjustment is recommended and intestinal function adjustment drugs are used ifnecessary.Benign presacral cysts are recommended to be followed up every 6 months within 2 years, andonce a year after 2 years. MRI, CT, and ultrasound are recommended to check for cystrecurrence or malignant transformation. If the patient has sudden intractable pain in thesacrococcygeal region after surgery, it may indicate that the cyst has a high possibility ofmalignant transformation.Malignant presacral cysts are addressed using supplementary treatment after surgeryaccording to the recommendations of multiple disciplines, such as pathology, orthopedics,anorectal, imaging, radiotherapy, and medical oncology. It is recommended to be followed upevery 3 months within 2 years, and every 6 months after 2 years. MRI, CT, andultrasonography are recommended to be performed for the follow-up.Presacral cysts, as congenital diseases located in the presacral space, are mostly benignand some have the possibility of malignant transformation. At present, it is believed thattheir origin is related to abnormal embryonic development, whereas the specific incidence isunknown. Cyst resection is the main cure method and the key point is complete resection ofthe cyst wall. Several surgical approaches for the resection of presacral cysts have beenreported that mainly include transabdominal, transperineal, and combined abdominal andperineal approaches, and each has its own advantages and disadvantages. Most studies onpresacral cysts are retrospective, descriptive, or anecdotal, so a prospective,randomized–controlled clinical study needs to be initiated to determine the optimaldiagnosis and treatment strategy for presacral cysts, and improve the complete resectionrate of presacral cysts, reduce the corresponding injuries and post-operative complications,and finally solve the problem of presacral cyst treatment. A flow chart of the consensusdiagnosis of and treatment for presacral cysts is shown in Expert group consultant: Jin Gu , Jianxiong Wu , Chenghua Luo .Head of expert group: Gangcheng Wang .Deputy head of expert group: Lu Yin , Xiaojian Wu ,Yudong Wang , Xin Wang , Xiang Feng .Members of the expert group : Songlin An , Keyun Bai ,Chunqiu Chen , Xiaoxiang Chen , Binbin Cui , Yinlu Ding , Wei Fu , Yang Fu, Wenjing Gong , Chunyi Hao , Ping Huang , Congqing Jiang , Haixing Ju , Yue Kang , Chao Liu , Dianwen Liu , Haiyi Liu , Yingjun Liu , Zheng Liu , Changhong Lian , Bin Li, Huichen Li, Jun Li , Ning Li , Taiyuan Li , Guole Lin , Yongchao Lu , Chengli Miao , Wenbo Niu , Debing Shi , Feng Sun , Li Sun, Yi Sun , Baochun Wang , Guijun Wang , Guiying Wang , Hua Wang , Lei Wang , Meiyun Wang, Zhigang Wang, Jianhong Wu , Wei Wu, Weiqiang Wu, Gang Xiao , Shaomin Yang , Huiming Yin , Wangjun Yan , Yanling Yang , Xiaoxia Xu , Zhiqiang Zhu , Xin Zhang , Yong Zhang , Guohua Zhao .Academic Secretary: Yingjun Liu ,Guoqiang Zhang , Youcai Wang.None declared.