What does this document on the surgical treatment of endometriosis jointly prepared by the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) provide?This document provides recommendations covering technical aspects of different methods of surgery for endometriomas in women of reproductive age.Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis.A working group of ESGE, ESHRE and WES collaborated on writing recommendations on the practical aspects of endometrioma surgery.This document focused on endometrioma surgery. Further documents in this series will provide recommendations for surgery of deep and peritoneal endometriosis.The document presents general recommendations for surgery of endometrioma and specific recommendations for cystectomy, ablation by laser or by plasma energy, electrocoagulation and a combination of these techniques applied together or with an interval between them.Owing to the limited evidence available, recommendations are mostly based on clinical expertise.These recommendations complement previous guidelines on the management of endometriosis.The meetings of the working group were funded by ESGE, ESHRE and WES. CB declares to be a member of the independent data monitoring committee for a clinical study by ObsEva and receiving research grants from Bayer, Roche Diagnostics, MDNA Life Sciences and Volition. ES received honoraria for provision of training to healthcare professionals from Ethicon, Olympus and Gedeon Richter. The other authors declare that they have no conflict of interest. This paper was produced by a European working group looking at the different types of surgery for endometriosis, a common condition where tissue, which is similar to the lining of the womb, is found elsewhere in the body.The working group looked specifically at how best to treat a type of ovarian cyst called an endometrioma, which can occur in women who have endometriosis. Drug therapies may be used to treat endometriosis, but when endometriomas are found and need treatment, surgery is often used. There are risks associated with surgery as it can damage the follicles in the ovaries and reduce fertility.The working group looked at the main types of surgery which are used to treat endometriomas in women who may want to have children in the future. They considered cystectomy, where the cyst is cut out, ablation, where the cyst lining is removed by using a laser beam or plasma energy, and electrosurgery, where an electric current is used. They also looked at the effectiveness of combining different types of surgery.The paper discusses in detail how different types of surgery should be performed taking potential risks into consideration and stresses that careful planning is essential to ensure the best outcomes.Endometriosis is a common inflammatory condition affecting women, mostly during their reproductive years . EndometIt is generally accepted that endometriosis presents in three different entities, which are frequently found together: peritoneal lesions, deep endometriosis and ovarian endometriotic cysts (endometriomas) . EndometThe pathogenesis of endometriomas remains contentious, with a variety of theories proffered, including invagination and subsequent collection of menstrual debris from endometriotic implants, which are located on the ovarian surface and adherent peritoneum , 10, colEndometriomas frequently present a clinical dilemma as to whether and how to treat them when found during imaging. Overall, currently available treatment options for all types of endometriosis include oestrogen suppression, progestins, surgery or a combination of these . SurgicaPreviously published guidelines have provided recommendations on the management of endometriosis, based on the best available evidence , 11, 22.This document is the first in a series of recommendations covering technical aspects of different methods of surgery for different entities of endometriosis and will focus on endometriomas in women of reproductive age; recommendations dealing with other forms of endometriosis will be addressed in separate subsequent publications. These recommendations should be read in conjunction with the aforementioned evidence-based guidelines on the clinical management of endometriosis.Owing to the scarcity of evidence, these recommendations are mostly based on expert opinion on best clinical practice. The techniques described here may have different levels of efficacy in achieving individualised management goals; hence, background factors such as the woman’s age, her symptoms , primary aim of the treatment , ovarian reserve, unilaterality/bilaterality, number and size(s) of the cyst(s), associated conditions  and history of previous surgery (i.e. recurrence) will need to be taken into consideration when a decision for surgery is made and the type of technique is chosen.https://www.eshre.eu/surendo) or via the ESGE, ESHRE and WES websites.In addition to the recommendations, the working group has set up a web platform with videos on the different options available for surgery of ovarian endometrioma. The web platform is accessible through the following link  ligament, and an anastomosis between the ovarian artery and the ascending branch of the uterine artery/tubal artery in the ovarian ligament. Thus, the larger intra-ovarian vessels are found in the anterolateral aspect of the ovary—the hilum at the insertion of the mesovarium. The surgeon needs to be aware of this and, in particular for endometrioma involving that area, has to possess the skills to avoid excessive bleeding which might lead to destruction of healthy ovarian tissue through cauterisation and disruption of ovarian blood supply.A bimanual examination to check adnexal masses and endometriotic nodulesThe number, size and location  of the cystsPresence of endometriotic nodulesExtent of the Pouch of Douglas obliterationPresence of hydronephrosisPresence of hydrosalpinxPelvic ultrasound (and/or MRI) to determineOvarian reserve tests  when future fertility is a concernAssess the possible extent of disease and the size, number and location  of the ovarian endometriotic cysts before surgery. Meticulous preoperative planning is part of the procedure and should include:Assess serum tumour markers in case of suspicion of malignancy at imaging, as this may be helpful to exclude malignancy. The risk of unexpected malignancy is small but may need to be taken into consideration. The accuracy of serum tumour markers may be limited as some of these are raised in the presence of endometriosis .Obtain appropriate consent from the woman before surgery. She should be fully informed of all possible risks associated with the surgical procedure, including general risks of laparoscopic surgery, a potentially reduced ovarian reserve, and the  risk of loss of the ovary and consequences thereof. Although still controversial, the woman should also be informed about the possibility of preoperative freezing of oocytes, especially in the case of bilateral disease .Refer the woman to a centre of expertise where the necessary surgical expertise is available, if the surgery cannot be performed or completed safely .Handle the ovarian tissue as atraumatically as possible.Be aware of the risk of damage to ovarian reserve in endometrioma surgery. Fertility preservation should be considered when the reserve is already compromised.Consider using anti-adhesion measures such as oxidised regenerated cellulose, polytetrafluoroethylene surgical membrane and hyaluronic acid products, as these may be beneficial in reducing postoperative adhesion formation , 22. OvaInspect the pelvic organs, upper abdomen and appendix.Obtain peritoneal washings and biopsies before mobilising the ovary with endometrioma in the presence of clinically relevant ascites, suspicious peritoneal lesions or ovarian cysts of abnormal appearance. However, for a presumed endometrioma, peritoneal washing is not routinely recommended.Consider using three laparoscopic working ports as these may facilitate surgery.Separate the ovary with endometrioma from the pelvic side wall, where it is usually adherent to, by adhesiolysis. This usually results in drainage of the endometrioma. It is important to visualise the ureter at this stage to avoid damage, as the ovary may be adherent to it. In the presence of dense adherence, start the surgery by dissecting the ureter from the healthy tissue proximal to the adherence point. Endometriotic tissue on the pelvic side wall will need to be removed as well .Where the cyst ruptures, extend the opening in the cyst wall adequately to expose the cyst cavity. Multiple incisions and excessive opening should be avoided to prevent damaging the ovarian cortex, functional ovarian tissue and the hilum. Where feasible, the cyst may be turned inside out to facilitate further treatment.When the ovary is not adherent, the incision should ideally be over the thinnest part of the ovarian endometriotic surface or, if this is not visible, on the antimesenteric border.Irrigate and inspect the cyst cavity to rule out malignancy. Any suspicious area should be biopsied for histological confirmation of any diagnosis.If suspicious for malignancy, local guidelines for further management should be followed.Irrigate and aspirate thoroughly to check for haemostasis and to remove any remaining cyst fluid or blood clots from the abdominal-pelvic cavity.CystectomyAblation by laser or by plasma energyElectrocoagulationThe following options are available for conservative surgical treatment of ovarian endometrioma:These methods, the combined technique and the two- or three-step approach are described below.After mobilisation of the ovary and drainage of the cyst, make an incision to reveal the cleavage plane; this may be either on the edge of the cyst opening or a central incision, which divides the cyst into two halves. With both approaches, the incision should be away from the blood vessels in the hilum/meso-ovarium. Use of cold cut at the edge of the cyst opening may assist in identifying the cleavage plane.To aid dissection and identification of the cyst wall, saline or diluted synthetic vasopressin solution (0.1–1 unit/ml) may be injected under the cyst capsule. The diluted synthetic vasopressin injection has the additional advantage of reduced bleeding during cyst removal. Synthetic vasopressin is not available in all countries and, although rare, may cause intraoperative cardiovascular complications including bradycardia and hypertension.In some cases, a cleavage plane may not easily be identified after the ovarian incision. In such cases, it may be better to take a small part of the cyst wall for histological diagnosis and then use an ablation method, rather than risking damage to the ovary from persistent attempts to perform cystectomy.Once the cleavage plane is identified, use gentle traction and counter-traction with appropriate instruments to dissect the cyst capsule from the ovarian parenchyma. Traction and counter-traction may be effective during the initial part of the dissection. Avoid use of excessive force to separate a highly adherent cyst from the ovary, as this will likely cause tearing of the ovarian tissue, excessive bleeding, plus the need for coagulation or diathermy, and thus further damage the normal ovarian tissue.Careful identification of the cleavage plane and precise spot bipolar coagulation is the key to achieve haemostasis, to prevent unnecessary damage to healthy tissue and to avoid blind or excessive diathermy.Ensure final haemostasis after complete removal of the cyst capsule. Bipolar coagulation, suturing or intraovarian haemostatic sealant agents may also be used for this purpose. It is important to avoid damaging the major blood supply at the hilum coming in from the ovarian and infundibulopelvic ligaments at this stage.After removal of large endometriomas, it may be necessary to reconstruct the ovary and achieve haemostasis with monofilament sutures. For small endometriomas, suturing is often not required as the ovarian opening usually approximates spontaneously. If a suture is used, it should ideally be placed inside the ovary, as the exposed suture may be prone to adhesion formation.Small cyst walls may be divided and retrieved directly through a port. Large cyst walls can be removed in a specimen retrieval bag. Posterior colpotomy is very rarely used for retrieval of endometriomas.2 laser beam and 6–10 W for CO2 fibre  are usually used. The laser should be on the ablate function to widen the beam (e.g. ‘defocus’ or ‘surgiscan’). The laser should be applied in such a mode that it can ablate the tissue while preserving the underlying healthy tissue.Ablate the entire inner surface of the cyst wall using the laser beam. Power settings of 30–55 W for COAim to vaporise the endometriotic cyst lining only until haemosiderin pigment-stained tissue is no longer visible (until the colour changes from reddish to yellow-white). The entire depth of the cyst capsule does not need vaporisation, as endometriotic tissue is present only superficially.Use intermittent irrigation to maintain good visibility and to remove carbon debris.Ensure the border of the cyst opening is completely vaporised.Ablate the entire inner surface of the cyst wall using plasma energy in coagulation mode set at 10 to 40, at a distance averaging 5 mm from the tip of the hand piece , 18.Aim to vaporise the endometriotic cyst lining only until haemosiderin pigment-stained tissue is no longer visible (until the colour changes from reddish to yellow-white). The entire depth of the cyst capsule does not need vaporisation, as endometriotic tissue is present only superficially.Take care to treat all areas and to ablate the edges of the invagination site.When cyst eversion is not feasible, expose the cyst interior progressively to apply the plasma at an angle perpendicular to the inner surface of the cyst.Coagulate the cyst lining systematically using bipolar forceps. The power setting depends on the generator and type of forceps used, but a 25–40 W setting is frequently used. It is advisable to start at a lower power setting and adjust it depending on the effectiveness of coagulation achieved. The key point is to use very short coagulation times to minimise ovarian tissue damage, as the depth of the destruction can be difficult to judge.Monopolar energy may be used in selected areas where there is fibrotic endometriotic tissue located at the hilum. A power setting of 15–20 W is frequently used.Tissue damage tends to be deeper than with laser and plasma energy ablation; hence, the ovary should be cooled frequently with irrigation fluid.Electrosurgery is widely used for the treatment of ovarian endometrioma. Coagulation modes with different techniques and electrodes lead to different voltage levels, including modulation of high-frequency (HF) current with soft coagulation, forced coagulation or spray coagulation. These various application modes result in different effects on the target tissue and cause different degrees of tissue damage Table .CoagulatOpen and drain the cyst followed by identification of the cleavage plane, as described above.Strip 80–90% of the cyst wall and perform a partial cystectomy, as described above, up to the ovarian hilum. Laser, plasma energy or bipolar can then be applied to treat the remaining endometriotic tissue (10–20%).Suturing of the ovary may be considered to restore anatomy.A combined technique using both excision and ablation can be used to prevent excessive bleeding and ovarian tissue removal/damage from the ovarian hilum, particularly for larger endometriomas.The first step involves opening and draining the endometrioma as described in the initial stage section.Inspect the cyst cavity and take a biopsy.Following this initial step, administer a GnRH agonist (GnRHa) therapy for 3 months, during which time the thickness of the cyst wall significantly decreases, with atrophy and reduction in stromal vascularisation of the cyst .2 vaporisation, bipolar diathermy or plasma ablation of the cyst wall lining.Complete the surgery with a second laparoscopy in the form of either cystectomy, COFor large endometriomas, a two- or three-step procedure can be considered.Although women have to undergo two invasive procedures, the potential benefit is that this may facilitate the management of larger ovarian endometriomas, reduce recurrence rates and limit decrease in ovarian reserve.Laparotomy is rarely indicated for benign ovarian endometriomas, regardless of the diameter of the cyst and/or the associated adhesions . If the Oophorectomy may be considered after careful discussion with the woman, particularly in the presence of recurrent or large unilateral endometriomas, or suspicion of potential malignancy. Informed consent, as described above, needs to be obtained in all cases, and fertility concerns need to be discussed.


The effects of prenatal exposures to polychlorinated biphenyls (PCBs), methylmercury, and lead on birth weight remain disputable. The aim of this study was to investigate whether these chemicals affect birth weight of Japanese newborns, with special emphasis on determining whether these effects differ between males and females.The subjects from Tohoku Study of Child Development, which was designed to examine the developmental effects of prenatal exposures to such hazardous chemicals, were 489 mother-newborn pairs with complete data including smoking habit during pregnancy.The mean birth weight of all newborns was 3083  g. The median values of biomarkers in cord blood were 46.0  ng/g–lipid for total PCBs, 10.1 (4.3–22.4) ng/g for total mercury (THg), and 1.0 (0.6-1.7) μg/dL for lead. The birth weight was significantly heavier in the 252 male newborns than in the 237 female ones. A negative association between total PCBs and birth weight was observed in both male and female newborns, even after adjusting for possible confounders. However, a negative association of THg with birth weight was found only in the male newborns. There was no significant relationship between lead and birth weight in both groups.Birth weight appears to be affected by prenatal PCB exposure in Japanese male and female newborns, and the effect of methylmercury exposure on male fetal growth may be stronger than that for females. This implication is that the effects on fetal growth should be assessed in males and females separately. Since polychlorinated biphenyls (PCBs) and methylmercury that are environmentally persistent toxicants cross the placenta, they may affect child development. Prenatal lead exposure seems to result in low birth weight –6. Howevn-3 polyunsaturated fatty acids (PUFAs) masked the effects of methylmercury [In recent years, the exposure levels of environmental pollutants such as PCBs and lead are low in developed countries , 25, prelmercury , 27. Alslmercury , 29, hypWe have been performing a prospective birth cohort study , focusing both on the potential risks and benefits of fish eating during pregnancy to investigate the effects of toxic chemicals on child development in Japan –33. In tThe detailed study design and protocol of TSCD have been already described in our previous paper . The resWe enrolled 687 women in this study with their written informed consent, in accordance with the Declaration of Helsinki of 1964 as revised in 2000; and, 599 mother-newborn pairs were registered by September 2003 . Of them, 489 pairs with complete information on the PCBs, mercury and lead concentrations in cord blood, birth weight, and possible confounders such as gestational age and seafood intake were used in the present study.oC until analysis. All 209 PCB congeners were analyzed using high-resolution gas chromatography/high-resolution mass spectrometry with the isotope dilution method. The laboratory analytical methods and quality control procedures have been described elsewhere [t test  and a high Pearson product-moment correlation coefficient (r = 0.869). The calculated limit of detection (LOD) was 0.03 pg/g-wet, which was identified by the signal-to-noise ratio. The amounts of congeners below the LOD were set at zero. We used the lipid basis for the sum concentration of the all measured PCB congeners (ΣPCB), expressed as ng/g-lipid [Umbilical cord blood was collected into a clean bottle immediately after birth. The samples were frozen at -80 lsewhere . All sam/g-lipid .Total mercury (THg) and lead concentrations in whole cord blood were analyzed by IDEA Consultants, Inc. , using cold vapor atomic absorption spectrometry for THg and inductively coupled plasma mass spectrometry for lead . Materna2) before pregnancy was calculated from the height and body weight. We obtained information about demographics and smoking and drinking habits during pregnancy (presence/absence) from a questionnaire 4 days after delivery. At the same time, maternal intake of fish/seafood during pregnancy also was assessed using a food frequency questionnaire that was administered by trained interviewers.Information about pregnancy, delivery and characteristics of newborns such as maternal height and body weight before pregnancy, gestational age (weeks), delivery type (spontaneous/Caesarean section or vacuum extraction), birth weight and parity (first child or not), was extracted from medical records. The body mass index  of major PCB congener measured by two laboratories seemed to be comparable as mentioned above, they were used after the adjustment for the laboratory by using multiple regression analysis. Pearson product-moment correlation coefficients were used to test the relationships between either birth weight or body weight gain during pregnancy and the relating indicators including exposure biomarkers. Multiple regression analysis was employed to adjust for gestational age, parity, BMI before pregnancy, smoking/drinking habits during pregnancy, and fish/seafood intake, whereas parity showed a strong relation to PCBs, i.e., the first child had higher-level PCBs than the other one [R2), where R is the multiple correlation coefficient; and, a predictor with VIF > 10 is considered as an indicative of serious collinearity [p values, were performed using SPSS Ver. 23.0  and the significance level was set at 5%.Sex differences in basal characteristics and exposure levels were analyzed by Student ther one , 38. In inearity . All anar) between the wet-base and lipid-base was 0.892 (p < 0.001). The median THg concentration in maternal hair was 2.0 (0.9–4.4) μg/g and the r between those in hair and cord blood was 0.841 (p < 0.001). Since birth weight differed significantly between 252 male and 237 female newborns as shown in Table The mean birth weight of 489 newborns was 3083 range, 2412–4240) g, and the gestational age was 39.5 ± 1.3 (SD) weeks. The median values of biomarkers in cord blood were 46.0  ng/g-lipid for ΣPCB, 10.1 (4.3–22.4) ng/g for THg, and 1.0 (0.6–1.7) μg/dL for lead. The median ΣPCB concentration was 0.122 (0.050–0.332) ng/g-wet and the correlation coefficient  but the significance of other variables presented in Table Relations of prenatal biomarkers to birth weight in the mother-newborn pairs are listed in Table p < 0.001) for ΣPCB and THg, 0.069 (p = 0.128) for ΣPCB and fish/seafood intake, and 0.239 (p < 0.001) for THg and fish/seafood intake; and, the VIFs for ΣPCB, THg, and fish/seafood intake were 1.045, 1.097, and 1.078, respectively.As shown in Table Given the concurrent exposure model of environmental pollutants, the principal findings of our study were that birth weight was associated with ΣPCB concentrations in the male and female newborns, and also with THg concentrations in the male ones. However, the significant relation to lead was not seen, probably not only because of low lead levels but also the extremely narrow range of lead exposure, as compared to the values reported previously –6; whereIn the current study, there was a significant negative relationship between cord-blood ΣPCB and birth weight in the 489 newborns, along with in each group of the male and female ones. This is consistent with results of many reports , 41–43. β values of Table A significant association of cord-blood THg with low birth weight was observed in the male newborns, but not in the female ones, while the impact of methylmercury did not seem to be stronger than that of PCBs judging from In examining the relationships between environmental pollutants and fetal growth, gestational weight gain is frequently used as a possible confounder , 20, 43.n-3 PUFAs are essential for normal brain development, we could not determine the levels because of the limited amount of cord blood available. Instead of n-3 PUFAs, we used fish/seafood intake in the data analysis, whereas it is thought to indicate the exposure levels of both beneficial nutrients and toxic substances such as methylmercury and dioxin-like PCBs [r = 0.91) was observed in 49 samples of our participants [There may have been some limitations in this study. Although ike PCBs , 49. Othicipants . Likewisicipants , but neiBirth weight in both male and female newborns appears to be affected by maternal PCB exposure. Intrauterine methylmercury at low levels may also affect male birth weight. Concerning the effect on fetal growth, further studies are necessary to clarify the toxic mechanism of such chemicals, and also to scrutinize sex difference in the outcomes attributable to environmental pollutants other than PCBs and methylmercury.


Angiogenic processes in the placenta are critical regulators of fetal growth and impact birth outcomes, but there are limited data documenting these processes in HIV-infected women or women from low-resource settings.We sought to determine whether angiogenic factors are associated with adverse birth outcomes in HIV-infected pregnant women started on antiretroviral therapy.This is a secondary analysis of samples collected as part of a clinical trial randomizing pregnant women and adolescents infected with HIV to lopinavir/ritonavir-based (n = 166) or efavirenz-based (n = 160) antiretroviral therapy in Tororo, Uganda. Pregnant women living with HIV were enrolled between 12-28 weeks of gestation. Plasma samples were evaluated for angiogenic biomarkers  by enzyme-linked immunosorbent assay between: 16-<20, 20-<24, 24-<28, 28-<32, 32-<36, 36-<37 weeks of gestation. The primary outcome was preterm birth.P > .05 for all). The incidence of adverse birth outcomes was 16.9% for spontaneous preterm births, 25.6% for small-for-gestational-age births, and 2.8% for stillbirth. We used linear mixed effect modelling to evaluate longitudinal changes in angiogenic factor concentrations between birth outcome groups adjusting for gestational age at venipuncture, maternal age, body mass index, gravidity, and the interaction between treatment arm and gestational age. Two angiogenic factors–soluble endoglin and placental growth factor–were associated with adverse birth outcomes. Significantly higher concentrations of soluble endoglin throughout gestation were found in study participants destined to deliver preterm  and in those destined to have stillbirths . By contrast, significantly lower concentrations of placental growth factor throughout gestation were found in those destined to have small-for-gestational-age births  and in those destined to have stillbirths .In all, 1115 plasma samples from 326 pregnant women and adolescents were evaluated. There were no differences in angiogenic factors according to antiretroviral therapy group (An antiangiogenic state in the second or third trimester is associated with adverse birth outcomes, including stillbirth in women and adolescents living with HIV and receiving antiretroviral therapy. Supplemental Materials and Video under article title in Contents at ajog.orgClick It is estimated that 17.8 million of 36.7 million people living with HIV in 2015 were women and girls of reproductive age (>15 years).Robust placental function is essential for fetal growth and development. Vasculogenic processes in the first trimester regulate de novo formation and growth of blood vessels. Angiogenic processes beginning in the second trimester induce remodeling of the underlying placental architecture to allow for increased blood flow and surface area for nutrient exchange.36The vascular endothelial growth factor (VEGF) family of proteins, including placental growth factor (PlGF), are proangiogenic mediators that are synthesized by trophoblast, and endothelial cells of the placental villi. VEGF and PlGF bind VEGF receptor 1 (fms-like tyrosine kinase [Flt]-1) and VEGF binds VEGF receptor 2 on the endothelium to induce vascular proliferation, migration, and sprouting.41Angiogenic processes in the placenta affect pregnancy, but there are limited data documenting these processes in the context of HIV infection and low-resource settings where rates of adverse birth outcomes are the highest. We hypothesize that alterations in angiogenic factors are associated with adverse birth outcomes in pregnant WLHIV. To test this hypothesis we longitudinally characterized circulating plasma levels of angiogenic proteins in a cohort of WLHIV initiated on ART.ClinicalTrials.gov (identifier: NCT00993031).Written informed consent was obtained from all participants. Ethical approval was received from Makerere University School of Medicine ; the Uganda National Council for Science and Technology; the University of California–San Francisco ; and the University Health Network . This trial was registered: http://www.health.go.ug/docs/ucg_2010.pdf). Blood pressure and urine protein was assessed at enrollment and routine antenatal visits. Participants on protease inhibitor–based ART received lopinavir/ritonavir (n = 166) and those on nonnucleoside reverse transcriptase inhibitor–based ART received efavirenz (n = 160). Socioeconomic status was assessed as described.Plasma samples were collected from pregnant WLHIV participating in a randomized controlled trial of protease inhibitor vs nonnucleoside reverse transcriptase inhibitor–based ART in Tororo, Uganda, from 2009 through 2013.+/CD8+ T-lymphocyte subsets. Standardized assessments were completed at delivery including gestational age and birthweight .Blood collection and laboratory work was performed at baseline and at all subsequent antenatal visits. Clinical tests included complete blood cell count and determination of CD4Women were eligible for inclusion in this secondary analysis if they had a singleton pregnancy with known birth outcome, and samples collected within 6 prespecified gestational age bins: 16-<20, 20-<24, 24-<28, 28-<32, 32-<36, 36-<37 weeks of gestation. The primary exposure was biomarker levels and the primary outcome was PTB (so samples were not tested >36 weeks of completed gestation). PTB was defined as delivery <37 weeks of gestation (ultrasound dated), SGA was defined using INTERGROWTH standards,EDTA plasma samples were collected and stored at −80°C prior to testing. Samples were tested in Uganda using commercially available enzyme-linked immunosorbent assays  with the following ranges, dilution factors, and intraassay coefficients of variation: Ang-1 ; Ang-2 ; sEng ; sFlt-1 ; PlGF , and VEGF . All testing was performed blinded to group and outcome.2 and Fisher exact tests were used to compare categorical variables. Linear regression was used to assess whether biomarker levels changed over pregnancy. To assess the effect of gestational age on angiogenic factor concentrations between birth outcome groups, we used the lme4P > .05 for all). Therefore, the data favor the more parsimonious additive models. For models in which the groups had different intercepts, the fitted lines did not significantly converge or diverge over time. For random effects, all models included a by-participant intercept and by-participant slope for the effect of gestational age. The biomarker levels were transformed using the natural logarithm to stabilize their variance. Residual plots did not show any apparent deviation from homoscedasticity or normality. Statistical significance was assessed using likelihood ratio (LR) tests, which compared in a stepwise fashion the null model, the additive model, and the interaction model. As the PlGF values vary quadratically over time, we added a quadratic interaction term to the model, which significantly improved the model fit .Statistical analysis was performed using STATA v14 , R v3.2.12. The majority of participants  were multigravida. None of the participants were diagnosed with chronic hypertension, preeclampsia, or eclampsia during the study period. Adverse birth outcomes in the cohort were common with 18.1% (n = 59) of participants having a low-birthweight infant   . There wfor all) . PlGF lefor all) . VEGF-A P > .05 for all).To determine whether angiogenic factors were associated with maternal health or immune status, we conducted nonparametric bivariate correlations comparing angiogenic proteins and enrollment laboratory tests. There were no differences between angiogenic proteins measured in the first gestational age bin (16-<20 weeks of gestation) and enrollment hemoglobin, platelet count, viral load, or CD4 count (2(1) = 12.28, P < .0005] (2(1) = 5.67, P < .02] (2(1) = 7.89, P < .005] (2(1) = 21.59, P < .0001] (LME modeling evaluated the longitudinal changes in angiogenic factor concentrations between birth outcome groups. The models adjusted for gestational age at venipuncture, maternal age, BMI, gravidity, and the interaction between treatment arm and gestational age . Two ang< .0005] , A and iP < .02] . By cont < .005] , C and i< .0001] . To show< .0001] .Figure 3Angiogenic processes in the placenta are critical regulators of fetal growth, but there are limited data documenting these processes in low-resource settings where maternal infections are common. In this study we assessed longitudinal concentrations in angiogenic proteins in HIV-infected pregnant women and adolescents started on ART. There were no differences in angiogenic factors by treatment arm. All proteins except Ang-1 and VEGF-A were dynamically regulated over gestation. Ang-2 levels declined, while sFlt-1 and sEng increased over gestation, and PlGF increased up to 32 weeks of gestation and then declined. Altered expression of angiogenic factors was associated with spontaneous PTB, SGA, and stillbirth. These data suggest an early shift toward an antiangiogenic state is a common pathway associated with adverse birth outcomes in WLHIV, consistent with data from HIV-uninfected women.We evaluated 1115 plasma samples collected from 326 women and adolescents between 16-<37 weeks of gestation. We compared our findings directly to results from women enrolled in a clinical trial receiving calcium supplementation in pregnancy with longitudinal assessment of sFlt-1, PlGF and VEGF,Despite their important regulatory role in placental vascular development, data on Ang kinetics in pregnancy are limited. Our observations are consistent with a report of decreased placental Ang-2 messenger RNA over pregnancy.There are limited data on the impact of maternal HIV infection on expression of angiogenic factors. Lower PlGF levels have been reported in pregnant WLHIV in South Africa57There have been a number of studies investigating the relationship between placental angiogenesis, vascular remodeling, and stillbirth. In a study of 22 unexplained stillbirths and 44 age-matched live-born controls, stillbirth was associated with increased placental microvascular density, vasculopathy, and increased vascular permeability,Beginning in the second trimester the placenta undergoes a continuous process of sprouting angiogenesis, intercalated growth, and intussusception. This remodeling allows for increased placental volume and surface area for nutrient exchange to support the rapidly growing fetus. Dysregulation of the pathways that mediate these processes midpregnancy may result in preterm delivery or fetal growth restriction if the placenta cannot support this rapid growth. Relative increases in sEng levels across gestation were associated with spontaneous PTB in this cohort, supporting the hypothesis that an antiangiogenic environment can contribute to premature birth.50This study has several strengths including ultrasound-confirmed gestational dating and frequent blood sampling. Despite routine clinical monitoring over pregnancy including monthly blood pressure and proteinuria assessments, no women in this cohort developed preeclampsia. This study is the first to present detailed kinetics data from a low-resource setting where the burden of disease is greatest, but for which we have the least amount of data. The lack of an HIV-uninfected comparison group in this study is a limitation that prevents us from discussing the generalizability of the findings or the relative impact of maternal HIV infection. While we did not observe any changes in angiogenic factor expression by treatment arm, CD4 count, or HIV-1 RNA viral load at enrollment, additional studies are needed to delineate the role of HIV-1 infection on the expression of angiogenic factors to determine whether infection itself modifies also the risk of adverse birth outcomes through dysregulated angiogenesis.This study was conducted in a rural area of southeastern Uganda where the low incidence of preeclampsia is consistent with clinical reports from the region. While the reason for this is unknown, we speculate that a relative absence of risk factors for preeclampsia, including nulliparity, coupled with lower weight gain over gestation contributed to a lower risk of preeclampsia.Early changes in angiogenic proteins may have predictive utility in identifying women at risk of adverse birth outcomes in WLHIV receiving ART. While these findings need to be prospectively validated, early identification of women at increased risk of adverse birth outcomes may facilitate enhanced monitoring and referral to health care facilities equipped to manage high-risk pregnancies .


Hidrocystoma, or sudoriferous cyst, is an eyelid tumor originating from apocrine or eccrine sweat glands. Its presence in the orbit is relatively rare.A full-term female child with severe right eye extrusion was referred to our department two hours after birth. We performed cyst aspiration under ultrasonic guidance; 15 cc straw-colored fluid was obtained and proptosis resolved significantly. Orbital magnetic resonance imaging (MRI) showed a large unilocular retrobulbar mass with hypo-intensity in T1 and hyper-intensity in T2. The case underwent further daily ocular assessment until day 5; when proptosis began to worsen again. On day 6, under general anesthesia, we performed aspiration and then the cyst was completely removed with an intact wall through a trans-conjunctival incision. The diameter of the aspirated cyst was about 4 cm. In pathologic consultation, a cystic cavity lined by a layer of sweat duct like epithelium with apical snouts consistent with the diagnosis of apocrine hidrocystoma was reported.To date, in the literature, six other cases of orbital hidrocystoma have been reported in childhood with protean clinical pictures; none of which presented at birth. Herein, we introduce the first case report at birth and also provide a review on the literature. Our report strongly argues against the well reputed theory of traumatic origin for orbital hidrocystoma; it has been postulated that this tumor may be the result of sweat gland cells implantation through the orbit. We thereby suggest the possible presence of choristomatous ectopic sweat gland cells in the orbit during embryogenesis. Hidrocystoma, or sudoriferous cyst, is an eyelid tumor originating from apocrine or eccrine sweat glands . PresentA full-term, female child with severe right eye proptosis was referred to our department in central Iran two hours after birth by Caesarian section. The baby had a birth weight of 3410 g and Apgar scores of 10 at one and five minutes. She was the second child of a 30-year old healthy mother who had undergone cesarean section for her first child as well. History of trauma and amniocentesis or similar procedures during the pregnancy period was negative. Neither the parents nor the older brother had a history of systemic or ocular problems.Under ocular examination, she had severe right eye extrusion Fig.  and a toPresentation of hidrocystoma in the orbit is extremely rare to the extent that its presentation at birth, as a micro-cyst had only been reported once . The poiAs mentioned earlier, there are 7 other known cases of orbital hidrocystoma in childhood –6 Table. Of the From a pathological standpoint, hidrocystoma is a benign cyst originating from a sweat gland apocrine or eccrine in nature. The apical part of cellular cytoplasm is decapitated in the apocrine type (decapitation), while it remains intact in eccrine (exocytosis) glands . This diIn a review by Shield and Shield, the authors believe that differentiating between the main causes of orbital cysts without bone involvement in childhood may not be possible even with CT scan or MRI . DiffereThe picture of our case strongly argues against the well reputed theory of traumatic origin for orbital hidrocystoma by which it was postulated that this tumor may be the result of sweat gland cells implantation through the orbit . PresentTaken together, orbital hidrocystoma should be considered as a differential diagnosis of small/large; superficial/deep; congenial/post-traumatic; and, childhood/adult orbital cysts.


Intracorneal epithelial cysts are a rare clinical condition that can occur anywhere in the corneal tissue; however, they appear most commonly in the stroma. They are sometimes challenging to treat because of their location, depth, and visual outcomes. Herein, we report a pre-Descemet epithelial cyst that was successfully treated surgically, with guidance from Fourier-domain optical coherence tomography (FD-OCT).This interventional case report presents a patient with gradually decreasing vision caused by a pre-Descemet epithelial cyst. A 4-year-old girl with no history of trauma or ocular surgery showed a deep-seated intracorneal cyst in her left eye . The cyst was threatening the visual axis. An epithelial cyst was diagnosed after drainage on the basis of the cyst contents. We irrigated inside the cyst using 10% trichloroacetic acid (TCA), distilled water, and 1% 5-fluorouracil (5-FU) solutions for chemical cyto-destruction of the lining epithelial cells of the cystic wall. We used a portable FD-OCT during operation to guide this procedure, without perforating the Descemet’s membrane and endothelial layer. Recurrence could be prevented after removal of the cystic tissue located in the sclera area outside of the limbus. No recurrence was noted during the 4-year follow-up.When treating centrally deep-seated intracorneal epithelial cysts, clinicians must consider recurrence, endothelial damage, and visual outcome. Herein we report the case of a deep-seated, intracorneoscleral epithelial cyst that was completely resolved with chemical cyto-destruction and removal of the intrascleral cystic tissue under the guidance with FD-OCT; thus, endothelial damage could be minimized. Intracorneal cysts occasionally occur after penetrating or perforating corneal wounds. Some, however, have a congenital origin, whereby the epithelium invades during the embryonal period. These epithelial nests tend to grow and form cystic lesions that need to be treated when they threaten the visual axis.Intrastromal cysts, which are located in the mid-stromal layer, can be treated using distilled water, 5-fluorouracil (5-FU), or 20% trichloroacetic acid (TCA) without damaging the surrounding tissues. Lamellar keratoplasty is another treatment option for the epithelial cyst removal when the cyst is not deep. A deep cyst close to the endothelium can convert to penetrating keratoplasty, however, due to perforation during lamellar keratoplasty .Fourier-domain optical coherence tomography (FD-OCT) allows for excellent visualization of the cornea. Most FD-OCT systems require that patient is seated in front of the system, however, recently, new portable models enabled the patients to be examined in the supine position.Herein, we report the case of 4 year-old girl with a growing, intractable, pre-Descemet intracorneal epithelial cyst that was treated by injecting several chemicals into the cystic cavity during the surgery under the guidance of portable FD-OCT. Corneoscleral cystectomy followed by lamellar corneoscleral transplantation was performed also to remove the cyst completely.A 4 year-old girl was referred to the Department of Ophthalmology, Severance Hospital because of a white spot in the cornea and non-correctable vision in her left eye. Serial photographs taken before in other clinics as well as ours showed that the lesion had spread toward the visual axis Fig. . She hadWe performed an incision and drainage of the cyst under general anesthesia to determine the type of the cyst. Based on depth measurement data from the surface of the cornea to the anterior cystic wall by corneal FD-OCT, two parallel incisions were made in the paracentral cornea at the 8 o’clock position. The first incision was made 650 μm deep 2 mm from the limbus  for 5 min to completely destroy the epithelial cells. Then, irrigation with 10% TCA for 2 min was performed twice Fig. . Even weVisual acuity in the left eye improved to 0.9 after the third surgery, and recurrence was not observed for 10 months. Eleven months after surgery, the interface showed signs of recurrence, and OCT images revealed fluid collection. Evaluation of results from the previous surgery made us suspect that the original cyst was located in the sclera (arrows, Fig. The lesion did not recur for 4 years after the fourth surgery, and the patient’s BSCVA value was maintained at 0.8 Fig. . Even ceIntrastromal corneal epithelial cysts are usually ovular or circular in shape, and, in advanced stages, they generally contain an opalescent fluid . In the The sequestration of epithelial cells in the corneal stroma, as well as their slow subsequent proliferation, likely accounted for the growth of the cyst. This abnormal positioning of the epithelial cells could have originated from trauma or developmentally, although this is still unclear , 4–7. NoIn previous studies, epithelial cysts have been treated using a number of surgical procedures, with varying degrees of success . When a Usually, TCA is used to destroy the epithelial cells lining the intrastromal cyst. TCA, one of the most popular chemical peeling agents, is used at concentrations varying from 15 to 50%, with higher concentrations producing deeper peels. There are reports on TCA related ocular chemical injuries , 14. SinIn our case, recurrence was finally controlled after destruction of the epithelial nest by lamellar keratosclerectomy with chemical cauterization. This approach could prevent the need for more aggressive procedures, such as lamellar or penetrating keratoplasty.In conclusion, we were able to treat the patient with several surgeries under general anaesthesia through guidance from a portable FD-OCT instrument, which allowed us to evaluate the depth of the corneal cyst. A solution of 10% TCA with distilled water and 1% 5-FU was effective in destroying the epithelial cells that lined the cyst without seriously damaging the corneal endothelial cells separated by Descemet’s membrane. Recurrence can be prevented after removal of the cyst that is located in the sclera outside of the limbus.


Congenital anomalies are important medical and public health conditions. The pattern and prevalence of birth defects may vary over time or with geographical location. We investigated the live birth prevalence and occurrence pattern of birth defects in Golestan Province, northern Iran.This cross-sectional descriptive study was carried out on 144920 live newborns in 13 hospitals in Golestan Province, northern Iran, from 21 Jan 2008 to 19 Mar 2013. The newborns were examined for the presence of birth defects and mothers were interviewed for variables such as maternal age and ethnicity. In addition, data for each newborn was filed in a questionnaire and the coding of birth defects was translated to the International Classification of Diseases 10th revision–clinical modification (ICD-10-CM).Overall, 1690 infants were diagnosed as having birth defects among 144920 live newborns. The prevalence rate of birth defects was 11.66 per 1000 live births, the prevalence of birth defects per 1000 was11.62 in males and 11.42 in females. The prevalence of congenital anomalies among native Fars, Turkmen and Sistani were 13.03, 11.16 and 13.07, respectively, per 1000 live births. Anomalies of the cardiovascular system were the most common defects; the prevalence rate of cardiovascular system was 8.34 per 1000 live birth.The prevalence rate of birth defects in this area was lower than in the other regions in Iran (20.3 per 1000 live births) but higher than in some parts of Asia (7.33 per 1000 live births). With the promotion of immunization in the world, the mortality rate due to congenital malformations increased as the main cause of death . MoreoveFactors involved in congenital anomalies include a plurality, gender, and parental factors such as ethnicity, socioeconomic status, and lifestyle, and drug use, medication during pregnancy, age, body weight, congenital diseases, and environmental exposure .Birth defects take place in 20–30 per 1000 birth and multiple defects involved one-quarter of them. Severe birth defects are the one of the main cause of perinatal mortality, stillbirths, and abortions .2. Patients are usually from moderate to low socioeconomic class families with various ethnic backgrounds. Fars, Turkmen, and Sistani are the three main ethnic groups in the capital, Gorgan. Native Fars is the predominant group of inhabitants and has the most members, Turkmen is the ethnic group that emigrated from central Asia more than three centuries ago, and the Sistani group emigrated from southeastern Iran half a century ago.Golestan Province is one of the 31 provinces of Iran. Located in the north of the country, southeast of the Caspian Sea, it has a population of 1.6 million and an area of 20380 kmAll live newborns delivered in 13 hospitals throughout Golestan Province during the investigation were examined and screened for birth defects by pediatricians.P-value of 0.05 or less was considered statistically significant.The parents of the newborns completed consent forms. Date of birth, gender and type of birth defects according to the International Classification of Diseases, (ICD-10) were recorded. Data for each newborn were filed in a questionnaire. The data were analyzed using SPSS software  and were compared with the Chi-square test. The 95% confidence interval for prevalence was estimated. A The prevalence rate of birth defects was 11.66 per 1000 live births. The prevalence of birth defects was 11.42 per 1000 in females (RR=1.02 CI95%:0.93–1.12) and 11.62 per 1000 in males.According to ethnicity, the prevalence of congenital anomalies among the native Fars, Turkmen and Sistani ethnic groups was 13.03, 11.16 and 13.07, respectively, per 1000 live births.Some newborns had a multiplicity of malformations; therefore, the total number of congenital malformations overpassed the number of affected newborns. Totally, 2545 anomalies were documented in 1690 newborns with birth defects. Anomalies of the cardiovascular system were the most affected; the prevalence rate of cardiovascular system was 8.34 per 1000 live birth; among this group, the most frequent anomalies were ASD (3.06 per 1000 live birth). The musculoskeletal system anomalies were second in frequency; the prevalence rate of musculoskeletal system anomalies was 2.33 per 1000 live birth. Among this group, the most frequent anomalies were clubfoot (0.3 per 1000 live birth). Followed by, nervous system anomalies with the prevalence rate of 1.97 per 1000 live birth. In this group, the most frequent anomalies were congenital hydrocephalus (0.54 per 1000 live birth).Besides, digestive system and Genitourinary System anomalies had the most frequent anomalies. The prevalence rate of anomalies in digestive system was 1.44 and Genitourinary System was 0.77 per 1000 live birth .The relative risk of birth defects for the Turkmen to native Fars and Sistani to native Fars was determined to be 0.86 and 1.003, respectively. Based on the prevalence rate of birth defects in native Fars and Sistani ethnic groups were significantly higher than among Turkmen .In the present study, the prevalence of birth defects in live newborns was 11.66 per 1000 live births, which is comparable with our previous study from in northern Iran  . MoreoveAccording to ethnicity, the rate of birth defects in this study was 13.03, 11.16 and 13.07 per 1000 live births for native Fars, Turkmen, and Sistani, respectively. In this regard, other studies have reported that ethnicity has an impact on the prevalence of birth defects , 17.The risk of birth defects was greater for mothers of Pakistani origin than for those of white British origin  . With reHowever, some studies have reported , 3, 9 muIn a study in Birjand in Southeast of Iran, the rate of nervous system anomalies was 11.23% . In addiThe prevalence rate of birth defects in this area was lower than in the other regions in Iran (20.3 per 1000 live births) but higher than in some areas of Asia (7.33 per 1000 live births). Inadequate diagnosis of birth defects at birth and health policy can be considered the possible reasons for the difference in the prevalence of birth defects between our region and other parts of the world, although, in recent years, this diagnosis has been facilitated more than in past years.Ethical issues  have been completely observed by the authors.


Dear Editor,A 22-year-old female patient sought treatment at our facility with a three-year historyof progressive left retroauricular bulging accompanied by mild pain, with no need foranalgesics, and no other complaints. She also reported having suffered a head injuryfrom a motor vehicle accident at six months of age. Computed tomography (CT) andmagnetic resonance imaging (MRI) scans of the cranium revealed an intraosseousleptomeningeal cyst .. The first case was reported by Weinand et al. in1989. They are also known byother names, including intraosseous leptomeningeal cysts and post-traumatic intradiploicpseudomeningoceles. Thesecysts are characterized by fracture of the inner table of the skull and laceration ofthe dura mater, with accumulation of cerebrospinal fluid in a pouch lined with arachnoidmembrane and located within the diploic space. The most common site is the occipitalregion, although such cysts have also been reported to occur in other regions of theskull. The clinicalpresentation is highly variable, ranging from asymptomatic to calvarial defects tooverlapping neurological complaints.Post-traumatic intradiploic leptomeningeal cysts are extremely rare complications ofcalvarial fractures that occur during childhood.Pressure effects and valve effects due to the growth of the brain during childhood,together with continuous cerebrospinal fluid pulses, act as expansive forces thatpromote the formation and growth of the intradiploic cyst over the years, resulting inwear and remodeling of the outer table of the skull,8.The most widely accepted hypothesis regarding the physiopathology of post-traumaticintradiploic leptomeningeal cysts is herniation of the leptomeninges to the diploicspace through post-traumatic gaps in the dura mater and the inner table of the skull.After a traumatic incident, it can take weeks, months, or years for an intradiploicleptomeningeal cyst to develop.The radiological tools for the diagnosis of the leptomeningeal cyst are those that arealso useful for the evaluation of cranial defects and associated brain lesions. An X-rayof the skull shows expansion of the diploic space and preservation of the outer table. ACT scan allows the evaluation of the extent of the bone defect and of the outer table ofthe skull, thus facilitating the surgical planning. However, MRI is the imaging modalityof choice and is a valuable tool for identifying other lesions, such as dermoid andepidermoid cystsThe differential diagnoses include bone lesions such as myeloma, metastasis, andeosinophilic granuloma, as well as intradiploic arachnoid cyst, which is usuallycongenital and manifests as headache, edema, convulsions, or neurological deficit.Although it is difficult to distinguish between intradiploic arachnoid cyst andpost-traumatic intradiploic leptomeningeal cyst via imaging methods, a history of traumaand the cyst being located in the occipital region favors a diagnosis of the latter.,7. The surgical procedure involves duraplasty followed bycranioplasty with a calvarial bone graft.Surgical intervention is the basis of the treatment for leptomeningeal cyst, and theindications for surgery include severe craniofacial deformity and persistentheadacheIn conclusion, we can infer that post-traumatic intradiploic leptomeningeal cyst is arare condition, with variable neurological symptoms, occurring secondary to calvarialtrauma occurring during childhood. Knowledge and early diagnosis of such cysts areimportant, because surgical intervention, when appropriate, can avoid neurologicalsequelae.


Introduction: Indigenous Australians experience higher rates of renal disease and hypertension than non-Indigenous Australians. Low birth weight is recognized as a contributing factor in chronic disease and has been shown to increase the risk of renal failure in adulthood. A smaller kidney volume with fewer nephrons places an individual at risk of hypertension and renal failure. Indigenous Australians have fewer nephrons than non-Indigenous Australians. In this study, intrauterine fetal and kidney growth were evaluated in 174 Indigenous Australian babies throughout gestation in order to record and evaluate fetal growth and kidney size, within a population that is at high risk for chronic illness.Methods: Pregnant women that identified as Indigenous, or non-Indigenous women that were pregnant with a partner who identified as an Indigenous Australian were eligible to participate. Maternal history, smoking status, blood and urine samples and fetal ultrasounds were collected throughout pregnancy. Fetal kidney measurements were collected using ultrasound. Statistical analysis was performed using the Stata 14.1 software package.Results: 15.2% of babies were born prematurely. 44% of the mothers reported smoking in pregnancy. The median birth weight of this cohort was 3,240 g. Male fetuses had higher kidney to body weight ratios than female fetuses (P = 0.02). The birth weights of term neonates whose mothers smoked during pregnancy were lower  than the birth weights of term babies from non-smoking mothers. The kidney volumes of babies whose mothers smoked were also smaller (P = 0.02), but were in proportion to body weight.Conclusion: In this cohort of Indigenous women smoking was associated with both increased number of preterm births and with a reduction in birth weights, even of term infants. Since kidney volume is a surrogate measure of nephron number and nephrogenesis is complete at birth, babies whose mothers smoked during pregnancy must have fewer nephrons than those from non-smoking mothers. Previous studies have shown that glomerular filtration rate is not related to birth weight, thus infants with smaller kidney volumes are hyperfiltering from birth and therefore are likely to be more susceptible to early onset renal disease in later life. In the 1980's David Barker postulated that the intrauterine environment could influence the future health of an individual  population have much higher rates of renal disease, hypertension and cardiovascular disease than non-Indigenous Australians  and the Aboriginal Health and Medical Research Council of NSW (Ref. no. 654/08).Recruitment for the study began in 2010. Indigenous research assistants attended antenatal clinics at Tamworth Rural Referral Hospital to recruit eligible women. Pregnant women that identified as Indigenous, or non-Indigenous women that were pregnant with a partner who identified as an Indigenous Australian were eligible to participate. Participants were able to enroll at any stage of pregnancy. The women provided written informed consent to participate in the study.At each visit maternal samples of blood and urine were collected for analysis. Personally reported smoking status was also recorded. During the visits, obstetric ultrasound imaging was undertaken, which included routine morphology, growth and fetal well-being assessment. Ultrasound examinations were performed using a Philips Cx50 Portable Diagnostic Ultrasound with a 5 MHz transducer. During each ultrasound, the size of the fetal kidneys was measured; length, antero-posterior diameter (thickness) and transverse diameter (width). Renal length was recorded as the greatest longitudinal length measured, while renal thickness and width was the greatest measurement obtained above the hilum. Renal volume was calculated using the formula for an ellipsoid shape (Volume = Length × Transverse Diameter × Antero-posterior Diameter X 0.5233) . The relationships between fetal growth and gestation were derived using non-linear regression. Kruskal Wallis Test was used to assess the differences in gestational age at delivery and renal kidney volume between the smoker and non-smoker groups. One-way ANOVA was used to assess the differences in birth weight and renal parameters. One hundred and seventy four babies were recruited to this study. There were 8 sets of twins; they were excluded from the analyses leaving a total of 158 infants. Ninety-four babies were male (59.5%) and 64 were female (40.5%). The median gestational age at delivery was 39.1 weeks; age at delivery of males was 39.1 weeks and for females was 39.3 weeks. 134 babies were born at term (>37 weeks), and 24 of the cohort (15.2%) were born prematurely with a median age at birth of 35.3 weeks (IQR = 2 weeks).The median birth weight for the cohort (including those born prematurely) was 3,300 g, with males weighing 3,357 g and females weighing 3,185 g. The median birth weight of term babies was 3,387 g. Males weighed 3,455 g and females weighed 3,217 g but this difference was not significant. Out of the 24 neonates born prematurely, 18 were male and 6 were female. Thirteen were born to mothers that smoked, while 8 were to non-smokers (three neonates did not have their mother's smoking status recorded). The premature males weighed 2,695 g and females weighed 2,862 g. Estimated fetal weight for male and female fetuses during pregnancy were similar, as shown in Figure p < 0.001) between estimated fetal weight and combined renal volume. As shown in Figure p = 0.03). Female fetuses also had a smaller fetal kidney volume: body weight ratio than male fetuses .Figure p = 0.02). Babies of mothers that smoked were smaller at birth , than babies born from non-smoking mothers . Fetuses of mothers who smoked had lower estimated fetal weights than those who did not smoke . Median birth weights of term male and female fetuses from smoking and non-smoking mothers are shown in Table One hundred and thirty-nine out of the 158 mothers completed the smoking survey; 44% reported smoking during pregnancy. The mean gestational age at delivery of the smoking group  was less than the non-smoking group , however, this difference disappeared when sex was taken into account . Since the kidney volume to estimated fetal weight ratios were the same in fetuses from smokers and non-smokers, the reduction in renal volumes of fetuses from smokers was proportional to the reduction in birth weight. Assessing individual renal parameters showed that the renal AP diameter was statistically different between the smoking and non-smoking groups (p = 0.01). This persisted when males were considered separately (p = 0.03), but was not significantly different among females (p = 0.15). There was no significant difference between smokers and non-smokers with regard to transverse diameter. Renal length was significantly different overall between the smoking and non-smoking groups, but when analyzed separately for sex, significance was achieved for males (p = 0.05), but not for females (p = 0.56).Term fetuses of mothers who smoked had smaller kidney volumes than those who did not smoke .We used ultrasound to estimate renal volumes as a surrogate measure of nephron number . This is higher than the rate reported by the NSW Ministry of Health 2016), who reported that 12.7% of Indigenous Australian mothers in NSW delivered prematurely in 2015, compared with just 7.7% of non-Indigenous Australian women , which is consistent with our findings . Maternal smoking is an important public health issue as it predisposes to reduced renal volume, which has been causally linked to hypertension and renal failure in adult life. This is particularly important to address, given the very high rate of smoking amongst pregnant Indigenous women, whose offspring are already a part of a high-risk group for hypertension and renal failure.This paper was the original concept of RS, EL, KP, KR and has been primarily written by CD, KP, EL, and KR. LW, LK: were responsible for recruitment of all participants and the data management for the study; VJ: completed the ultrasound measures on participants. All other authors were involved in the editing and writing of this manuscript and provided critical intellectual comments.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer KC and handling Editor declared their shared affiliation.


Maternal influenza vaccination has increased birth weight in two randomized trials in South Asia but the impact on infant growth is unknown.A randomized placebo-controlled trial of year round maternal influenza immunization was conducted in two annual cohorts in Sarlahi District, southern plains of Nepal, from April 2011 through April 2014. Infants born to women enrolled in the trial had weight, length, and head circumference measured at birth and 6 months of age. The study was powered for the 3 primary trial outcomes but not for stunting and wasting at 6 months of age.3693 women received placebo or influenza vaccine between 17 and 34 weeks gestation, resulting in 3646 live births. About 72% of infants who survived had weight and length measurements between 150 and 210 days of age. Prevalence of stunting (<−2 Z scores length-for-age) was 14.8% in the placebo and 13.6% in the vaccine groups, respectively. Stunting < −3 Z scores was 3.2% versus 2.0% in placebo versus vaccine groups ). Wasting (< −2 Z scores weight for length) was 10.3% versus 11.0% for placebo versus vaccine groups. Severe wasting (< −3 Z scores weight for length) was 3.8% for placebo versus 2.6% for vaccine ). The impact of flu vaccine on wasting was greater in cohort 2 than in cohort 1,  for any wasting), and RR: 0.45  for severe wasting. This corresponded to a larger impact on birth weight and a better vaccine match with circulating viruses in cohort 2.Although maternal immunization reduced low birth weight by 15%, only wasting at 6 months in the 2nd cohort was statistically significantly difference. However, the study was underpowered to detect reductions of public health importance.Trial Registration: Clinicaltrials.gov (NCT01034254). The trial is registered at clinicaltrials.gov (NCT01034254). Methods are described in detail elsewhere The sample size of 1850 women in each of the two trial cohorts was based on detecting a 50% reduction in laboratory confirmed influenza in infants, a 33% reduction in influenza like illness in women and a 25% reduction in LBW with an overall type I error of 5% (0.017 for each of the 3 outcomes) and power of 90% for each trial cohort separately. The study was powered for the 3 primary trial outcomes but not for differences of public health importance in 6 month nutritional status.As soon after birth as possible, data collectors visited the homes of newborns to record the outcome of the pregnancy, weigh the newborn and measure length and head circumference. The same measurements were taken at 6 months post-partum prior to discharge from the trial. Weights at both times were measured with a digital infant scale, either the Seca model 727 (measuring to the nearest 2 g) or the Tanita model BD-585 (measuring to the nearest 10 g). Scales were standardized daily with standard weights before use. Length was measured using a Shorr length board to the nearest 0.1 cm. Three measures were taken and the median recorded for analysis. Head circumference was measured using a Kendall mid upper arm circumference tape to the nearest 0.1 cm. The tape was firmly placed around the frontal bones just superior to the supra-orbital ridges, passed around the head at the same level on each side, and laid over the maximum occipital prominence at the back of the head. The median of three measurements was recorded for analysis. Measurements taken within 72 h of birth were used to estimate birth weight, low birth weight (<2500 g), birth length, head circumference at birth, and SGA  Characteristics of infants whose mothers received placebo and flu vaccine were compared among infants who had anthropometric measurements at 6 months of age. The same characteristics were also compared between all live births who did and did not have 6 month anthropometry. Among those with 6 month anthropometry, the impact of the vaccine was estimated by calculating the mean difference and 95% confidence intervals in weight, height and head circumference between treatment groups. These measures were not adjusted for infant age because the mean age of measurement in each group was identical (175 days). The WHO growth standards were used to calculate length-for-age and weight-for-length z-scores (ref WHO standards) To examine the impact of differences between infants who did and did not have anthropometry at 6 months of age, we imputed missing lengths and weights as a sensitivity analysis only. The following predictor variables were used: age of the child (in days) at the six-month follow-up visit, birthweight, gestational age at birth, sex, death within first six months of life, maternal height (<150 cm vs. ≥150 cm), primiparity, vaccination status (mother received influenza vaccine vs. placebo from study), and gestation in pregnancy at which the vaccine was received. The multiple imputation command “mi” in Stata was used to create 20 imputations which were pooled according to the approach of Rubin Informed consent was obtained from all participants. This trial protocol was approved by the Institutional Review Boards of the Cincinnati Children’s Medical Center, Johns Hopkins Bloomberg School of Public Health (JHBSPH), Institute of Medicine at Tribhuvan University, Kathmandu, Nepal, and the Nepal Health Research Council. IRBs at Seattle Children’s Hospital, the University of Washington, and George Washington University granted oversight to the IRB at JHBSPH. A Data Safety and Monitoring Board reviewed adverse events throughout the trial but no interim outcome analyses were conducted.3A total of 3693 women were randomized to placebo (1846) or influenza vaccine (1847), resulting in 1826 (placebo) and 1820 (influenza) livebirths . 8 infanCharacteristics of infants with anthropometry at six months were comparable between those whose mothers received placebo and those who received flu vaccine . Among tThere were no statistically significant differences in mean weight or length at six months of age between vaccine and placebo groups, and no differences between groups when stratified by LBW, preterm, SGA or trial cohort . HoweverThe mean 6 month weights and lengths were plotted by calendar time overlaid onto the intensity of circulation of influenza virus by strain , Fig. 2bThere were no statistically significant differences in the proportion stunted or wasted at 6 months between the placebo and vaccine groups . HoweverIn order to examine mechanisms by which poorer growth in the first six months of life might occur, we compared the attained mean 6 month weight and length of LBW infants to those of normal birth weight, adjusted for maternal height, parity, infant sex, age at first marriage and treatment group. LBW infants attained an adjusted 1.59  cm and 698 g  less than normal birth weight infants . LBW infImputation of missing weights and lengths at 6 months increased the weights and lengths available from n = 2526 to n = 3197. When the imputed weights, lengths, weight-for-length Z-scores, and length-for-age Z-scores were used in the regression analyses, there were no changes in the inferences from the analyses conducted without the imputed values .4We have previously shown that influenza vaccine reduced influenza-like illness in pregnancy, laboratory-confirmed influenza in infants during the first six months of life in southern Nepal, LBW by 15%, and modestly increased birth weight These results are likely generalizable to rural populations of South Asia among women of low stature and body mass index (BMI), which may have limited the ability to observe a growth effect on infants. There was also little evidence that maternal influenza vaccine benefited any subgroups of infants over others. In particular, infants with adverse birth outcomes such as being born LBW or preterm were not seen to benefit more or less than those without these conditions, although the study was not powered to detect such effect modifications. Although LBW infants had lower attained weight and length than normal birth weight infants at 6 months of age, the impact of the vaccine on 6 month anthropometry did not differ by whether the infant was born LBW or normal birth weight.Among infants with 6-month anthropometric measurements, treatment groups were comparable with regard to birth outcomes and maternal characteristics that might predict nutritional status at six months of age. Overall, 28% of trial infants were missing anthropometry at the six-month visit. Infants in the vaccine group without 6-month data were comparable to those with anthropometry at six months of age. Infants in the placebo group who did not have six-month visits were found to have somewhat poorer birth outcomes than those who had six-month follow-up. Using multiple imputation of missing 6 month weights and lengths, the poorer birth outcomes and maternal characteristics did not appear to change the inferences about treatment effect on nutritional status at 6 months. However, it is possible that the multiple imputation did not include some relevant variables that may have identified biases in the vaccine impact on 6 month anthropometry if included.nd annual cohort, but the sample size and prevalence of severe wasting and stunting limited our ability to detect these differences statistically. Mechanisms by which maternal vaccination might improve infant growth during the first 6 months of life include improved birth weight leading to improved postnatal growth and/or fewer infections in general, or a direct effect of fewer influenza infections early in life. However, influenza is relatively uncommon in young infants in this area of Nepal (5.8% attack rate among those in the placebo group) and the vaccine averted only 56 cases of influenza per 1000 child-years. Hence, at a population-level, such an impact is unlikely to translate into a growth effect, although our data suggest it may at the more extreme end of the malnutrition spectrum. Other mechanisms could be postulated such as the potential impact of fever and increased cytokine release resulting in inflammatory cascades.Maternal influenza or influenza-like illness during pregnancy may increase inflammation and reduce appetite, leading to lower weight gain in pregnancy, poorer intrauterine growth, LBW, and possibly preterm delivery Although this study did not find a statistically significant impact of the vaccine on infant stunting and wasting at 6 months of age, the limits of confidence intervals were consistent with impacts of public health importance, indicating inadequate sample size to refute the hypothesis of no effect. In addition, sizeable point estimates of the vaccine effect were seen for severe wasting and stunting, but the study was underpowered to detect these differences. Another limitation is that although 6 month anthropometry was obtained in 70% of infants overall, 28% of infants for whom anthropometry was not obtained at six months of age had poorer birth outcomes in the placebo group relative to those with six month follow up. This could have led to some bias in our vaccine effect estimates. Multiple imputation of the missing 6 month anthropometry did not indicate such a bias but this analysis is limited by the availability of predictive variables for such imputation. Strengths of this study include a large population-based sample of infants enrolled in a randomized, placebo controlled trial, weight measurements taken with accurate scales, and the median of three length and head circumference measurements used in analysis.The data from this randomized placebo controlled trial suggest that while maternal influenza vaccination did improve birth weight and reduce infant influenza infections, these effects were not large enough to translate into an impact on mild to moderate malnutrition of the population through six months of life, although there was some evidence it reduced severe malnutrition, especially during time periods where the vaccine provided protection against circulating strains. Given a lack of randomized trial data of the impact of maternal vaccination on infant growth and the sample size limitations of this trial, further studies designed to address malnutrition in young infants as a primary outcome are needed.Mark C. Steinhoff, James M. Tielsch, Joanne Katz, Janet A. Englund, and Jane Kuypers contributed to the design of the study.Mark C. Steinhoff conceived of the study and secured funding for the project.Subarna K. Khatry, Steven C. LeClerq, Laxman Shrestha, James M. Tielsch, Luke C. Mullany and Joanne Katz supervised the conduct of the study in the field.Joanne Katz drafted the manuscript, served as the study statistician, and Joanne Katz and Luke C. Mullany designed/implemented the data analysis.Helen Y. Chu assisted in study implementation and cord blood collection.Naoko Kozuki provided data analysis support.Joanne Katz, James Tielsch, Subarna Khatry, Mark Steinhoff, Steven LeClerq, Laxman Shrestha, Naoko Kozuki, Luke Mullany, Helen Chu and Jane Kuypers have no potential conflicts of interest. Janet Englund has been a consultant for Pfizer, a member of a Data Safety Monitoring Board for GlaxoSmithKline (GSK) influenza antiviral studies, and her institution has received research support for clinical studies from GSK, Gilead, Chimerix, and Roche.All authors read and approved the final manuscript.


Several prestigious agencies routinely rank countries based on crude perinatal and infant mortality rates, while more recently, international neonatal networks have begun comparing neonatal mortality and morbidity rates among very preterm and very low-birth-weight infants. We discuss the methodologic challenges that compromise such comparisons and potential remedies.Crude perinatal mortality rates are biased by international variations in birth registration, especially at the borderline of viability. Such bias is demonstrated by significant differences in crude versus birth weight- and gestational age-specific comparisons of perinatal mortality. Comparisons of neonatal mortality among very preterm and very low-birth-weight infants are plagued by incorrect denominators, and this leads to paradoxical findings.A lack of standardization with regard to birth registration and inadequate appreciation of the methods for calculating gestational age-specific mortality rates are responsible for biasing international comparisons of perinatal mortality. International comparisons of perinatal and infant mortality are appealing for various sociological reasons and can serve to spur improvements in a country’s health system performance. Towards this end, several prestigious institutions such as the UNICEF, the World Bank, and the Organization for Economic Cooperation and Development (OECD) publish annual rankings of countries by rates of stillbirth, infant mortality, and child mortality under 5 years of age –3. TheseProblems with international comparisons of perinatal mortality are not restricted to routine reports published by the UNICEF, the World Bank, the OECD, and related institutions. Serious methodologic issues also plague international comparisons of neonatal mortality that have appeared in scientific medical journals –7. TheseBMJ in 2012 [There is substantial variation in stillbirth registration criteria internationally, and this makes crude comparisons of national stillbirth rates less than meaningful. Most of the variation results from differences in stillbirth registration at the borderline of viability, and thus, rankings of countries based on crude stillbirth rates tend to be substantially different from ranking of countries based on stillbirth rates among births with a birth weight ≥1000 g . Table  in 2012 ; Sweden Comparisons of crude and birth weight-specific neonatal mortality rates show a similar pattern when ranks of countries are based on crude rates vs rates from live births with a birth weight ≥1000 g (or a gestation age ≥28 weeks). In the previously mentioned study , Sweden As mentioned, differences in rankings based on crude versus such birth weight-specific rates of stillbirth and neonatal death reflect international differences in the registration of births at the borderline of viability. In fact, the potential for such bias in international comparisons of fetal and infant mortality rates due to differences in birth registration has been recognized for decades and the World Health Organization (WHO) recommends that international comparisons of infant mortality be restricted to live births with a birth weight ≥1000 g , 21.or ≥500-g birth weight, means that the gestational age criterion will restrict registration to stillbirths with a gestational age of ≥22 weeks, whereas the birth weight criterion will require the registration of variable proportions of stillbirths delivered at 19, 20, 21, 22, 23, and 24 weeks’ gestation , health care culture , and the method of gestational age ascertainment.Evidence for these assertions is seen in variations in stillbirth-to-live birth ratios among births at the borderline of viability within different states in the USA . FurtherTable Contemporary stillbirth registration is based on gestational age at birth or birth weight rather than gestational age or weight at the time of fetal death. This leads to some unexpected birth registration conundrums especially because of new technologies such as fetal reduction for multifetal pregnancy , 24. Fetz score), multiple birth, infant sex, and antenatal corticosteroid use.Several neonatal networks have been created in recent years, with neonatologists championing the collection of data from neonatal intensive care units for quality assurance and research purposes. The development of databases documenting the experience of very preterm infants has facilitated comparisons of neonatal mortality and severe morbidity between centers and also between countries –7. For iSuch neonatal intensive care unit network databases have facilitated the conduct of epidemiologic studies examining the effects of maternal characteristics and interventions among very preterm or very low-birth-weight infants. However, some of the studies based on very preterm or very low-birth-weight subpopulations have shown counterintuitive findings. For instance, one such study  showed tOver four decades ago, Yerushalmy showed that neonatal mortality rates among low-birth-weight infants of mothers who smoked were significantly lower than the neonatal mortality rates among low-birth-weight infants of mothers who did not smoke . This asSeveral solutions have been proposed as explanations for this paradox including one based on the fetuses-at-risk approach, which involves a simple reformulation of denominators for calculating gestational age-specific stillbirth and neonatal death rates. Under this fetuses-at-risk formulation, gestational age-specific stillbirth and gestational age-specific neonatal mortality rates are calculated not based on total births or live births at a particular gestation but on the fetuses at risk for perinatal death at that gestation , 18. ThiOther explanations for the paradoxical perinatal mortality crossover include the relative birth weight hypothesis which postulates that each subpopulation  has a mortality pattern related to its birth weight  distribution . ContrasInternational comparisons of the neonatal mortality among very preterm and very low-birth-weight infants are as seriously flawed as comparisons of neonatal mortality by maternal smoking, hypertensive disorders, and multifetal pregnancy, which are restricted to the preterm subpopulation. The problem with international comparisons of neonatal mortality restricted to the very preterm birth range is illustrated in Fig. The combination of a lack of international standardization with regard to birth registration procedures and practices and the methodologic problems inherent in the traditional model of birth weight- and gestational age-specific perinatal mortality mean that comparisons of perinatal mortality rates between countries can only be valid at a gestational age beyond which complete registration occurs and based on the fetuses-at-risk formulation. The latter approach requires that gestational age-specific perinatal mortality comparisons be made at gestational ages ≥24, ≥26, or ≥28 weeks’ gestation, etc., depending on the gestational age at which complete birth registration is assured.Although restricting the population to a gestational age above which complete registration is assured restores validity to international comparisons of perinatal mortality, it results in the exclusion of a substantial fraction of the population. For instance, in countries such as Canada, over 40% of infant deaths occur among live births <28 weeks’ gestation (birth weight <1000 g) and an international comparison of live births ≥28 weeks’ gestation will exclude this vulnerable population . The enoRoutine reports of the UNICEF, World Bank, and OECD include comparisons of crude fetal and infant mortality without adjustment for extraneous characteristics such as maternal age and parity. If international comparisons of perinatal mortality are motivated by a desire to evaluate perinatal health status and perinatal health services, adjustment for maternal age, parity, and other maternal characteristics would be warranted. On the other hand, the neonatal networks making international comparisons of neonatal mortality among very preterm infants adjust for various extraneous determinants including receipt of antenatal corticosteroids and mode of delivery . PresumaIf the motivation behind international comparisons of perinatal mortality is to assess the relative quality of health services, adjustment for obstetric, neonatal, and other health services would be contraindicated, especially if such services were designed to reduce perinatal mortality. In fact, antenatal corticosteroid administration and mode of delivery lie in the causal pathway between the health care system performance and perinatal mortality. One extraneous health service determinant of perinatal mortality, namely, use of assisted reproduction, presents a conceptual challenge in such analyses—should international comparisons of perinatal mortality adjust for use of assisted reproduction? This technology, which enables infertile couples to achieve their reproductive choices, may require adjustment as it is a marker/risk factor for perinatal death and yet distinct in purpose from other perinatal health care services.Although gestational age considerations are vitally important in ensuring standardized international comparisons of perinatal mortality, there are likely differences in the modality of gestational age ascertainment by country. In most high-income countries, early ultrasound dating is used to resolve problems due to inaccurate gestational age estimates based on menstrual dates. However, not all women receive early ultrasonography, the accuracy of such measurement decreases with advancing gestation, and the proportion of women receiving early ultrasonography likely varies by country. Additionally, there are significant differences in how ultrasonographic measurements are made, and between- and even within-observer variation in measurements is not inconsequential . There iA final consideration in international comparisons of perinatal mortality relates to prenatal diagnosis and pregnancy termination for serious congenital malformations. Although the gestational age at which pregnancy termination is carried out following prenatal diagnosis of a serious congenital anomaly is falling rapidly, a significant fraction of such cases occur in the 20–23 weeks’ gestational age range . ExcludiDifferences in birth registration between countries include differences in birth weight and gestational age criteria and also in the requirement to include or exclude pregnancy terminations (that satisfy birth registration requirements) from stillbirth counts. These differences in birth registration compromise international comparisons of crude perinatal mortality rates. International comparisons of perinatal mortality restricted to births above a specific birth weight or gestational age  yield rankings of perinatal mortality that are substantially different from ranks based on crude comparisons. Although gestational age- and birth weight-specific contrasts of births ≥28 weeks’ gestation or ≥1000-g birth weight yield valid results, they suffer the drawback of excluding a substantial group of vulnerable infants from international comparisons. Comparisons of neonatal mortality among very preterm and very low-birth-weight infants, which are based on information from national neonatal networks, are also compromised because rates are based on incomplete denominators. Use of very preterm or very low-birth-weight live births as the denominator leads to the paradox of intersecting perinatal mortality curves and potentially biased results. Although not universally accepted, the fetuses-at-risk approach addresses this problem but requires a change in denominators to the fetuses at risk of perinatal death at each gestation.In summary, international comparisons of crude perinatal mortality rates, while laudable as a means for spurring improvements in national health care systems, remain compromised currently. Remedial action will require both improved standardization with regard to birth registration issues and also conceptual progress with regard to identifying appropriate denominators for calculating gestational age-specific perinatal mortality rates.