Despite extensive research concerning the impact of health insurance on the advancement of infant health in developed countries, few studies have adjusted their results for potential confounding due to adverse selection in insurance coverage, wherein those who anticipate a need for health services tend to be the ones that acquire insurance. The presence of compulsory health insurance in China, such as the Urban Employee Basic Medical Insurance (UEBMI) scheme may provide an opportunity to estimate the effect of health insurance on infant health, by reducing the endogeneity problem into insurance due to the adverse selection. The objective is to assess the relationship between UEBMI and infant health outcomes in one sizeable municipal-level obstetrics hospital in Shanghai, East China.n = 101,153) and women without any insurance coverage . A propensity score matching approach using conjoint quantile regression and probit regression models was used to eliminate latent endogeneity of UEBMI coverage in order to garner robust results. Further analysis stratified by maternal migrant status was conducted to further assess the sensitivity of the findings to distinct patient subgroups.Medical records data from the Shanghai First Maternity and Infant Hospital from January 1, 2013 to April 30, 2019 were used to form an analysis dataset of 160,429 live births which was comprised of Shanghai residents with UEBMI coverage . This finding was evident in other five different birth outcomes . After stratifying by migrant status, the UEBMI was shown to have a greater effect on migrants compared to local residents of Shanghai.The UEBMI scheme was shown to be associated with improvements in infant birth outcomes. The scheme was associated with: an increase in birth weight of about 30 g (Our findings suggest that health insurance coverage for pregnant women, especially for migrants, has the potential to significantly and directly improve infant health outcomes. Further research is required to determine whether these findings can be replicated for other Chinese jurisdictions. Health insurance has the potential to improve access to health care services by removing financial barriers to utilization. In turn, such insurance has the potential to improve infant health. Despite extensive research concerning the impact of health insurance on the advancement of infant health –4, thereReductions in financial barriers to accessing health care services have been argued as one of the most important mechanisms by which population health may be advanced, in general, and infant health improved, in particular . While oThe introduction of the Urban Employee Basic Medical Insurance (UEBMI) scheme in 1998 for employed urban residents in China may provide an opportunity to assess the effect by reducing the potential confounding due to adverse selection in insurance coverage on health outcomes as the scheme was compulsory. Coverage was financed through a payroll tax of 6% on employers and 2% on employees with the balanced paid by the government , 8. A clIn China, the health of migrants tends to be worse than that of urban residents, especially for maternal and infant health, since migrants often are excluded from urban services . MigrantThis study aims to estimate the effect of the UEBMI scheme on infant health outcomes in China. To achieve our research objective, we used a propensity score matching method to eliminate potential endogeneity bias. Six separate birth outcomes were assessed in our evaluation: birth weight; and the incidence of having a premature birth, a child with low birth weight, a child with very low birth weight, a low Apgar score, and the incidence of having a child with an abnormal health condition at birth.In the next section, we offer a brief overview of the literature concerning the relationship between insurance and infant health outcomes. Data and methods are described in Section 3. Section 4 summarizes our results and considers the robustness and sensitivity of our findings. Our findings are discussed in Section 5 in the context of the literature. Section 6 offers a brief set of conclusions and policy implications.There are various ways in which health insurance has been shown to impact infant health. First, health insurance tends to increase both the quantity  and the While the theory underlying the effect of health insurance on infant health is well developed, the empirical literature is inconsistent. Using regression analysis, Currie and Gruber 1996) showed that an expansion in Medicaid was associated with a decline in child mortality and a smaller decline in the incidence of low birth weight (LBW) . Hanratt showed tWith increasingly rich data and improvements in econometric methods, there is the potential to assess the impact of insurance coverage on an array of health outcomes, including infant mortality, birth weight, low Apgar scores, premature birth, gestational weeks, and other birthweight-related outcomes, such as the occurrence of an abnormal health condition after birth as diagnosed by a pediatrician . Among tThere have also been improvements in econometric methods to deal with confounding and other statistical challenges include propensity score matching (PSM), instrumental variables (IV), and the difference in differences (DID) approach. When combined innovative econometric techniques and detailed clinical data have the potential to identify the unique impact of health insurance on infant health outcomes, thereby potentially yielding a more consistent set of results. Using fixed effects (FE) and instrumental variables (IV) methods, Bitler & Currie 2005) demonstrate that participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the US reduced the probability of low birth weight (LBW) and very low birth weight (VLBW) . Joyce, 05 demonsWith improvements in methods and data, the literature has moved forward to address issues, such as confounding, though residual effects still remain given the imperfections in dealing with the statistical challenges and the absence of natural experiments . One posIn this study, we contribute to the literature in several ways. First, we take advantage of the introduction of compulsory health insurance, which eliminates the potential for adverse selection into insurance; we believe this is the first study to assess the effect of China’s UEBMI scheme on infant health outcomes. Second, we use matching methods to match individual characteristics and pregnancy-related health indicators to weaken the effect of potential confounding. Third, we consider the impact of insurance on six distinct infant health outcomes to examine the robustness of the results.Four different estimation strategies were employed. We begin with ordinary least squares (OLS) regression and quantile regression (QR) to evaluate the impact of the UEBMI scheme on birth weight (in grams). Then, we estimate probit regression of UEBMI coverage on five other infant health outcomes, which are: premature (< 37 weeks); low birth weight (< 2500 g); very low birth weight (< 1500 g); low Apgar score (< 7 scores); and abnormal health condition at birth (AHCAB).We then proceed further to use propensity score matching (PSM) to evaluate all six birth outcomes in order to address the potential heterogeneity of insurance. Specifically, we matched women with similar characteristics in order to control for potential confounding, then estimated the independent effect of insurance coverage. We use three matching estimators: one-to-one matching; caliper matching (0.03); and nearest-neighbor matching, to ensure a robust set of estimates. Finally, a probit regression approach was used to analyze the association between insurance coverage under the UEBMI scheme and indicators of maternal health behaviors.All estimates were performed using STATA 14. For propensity score matching (PSM), we used the “teffects psmatch” command in STATA. While this command allows for the calculation of corrected standard errors of the propensity score estimate, it does not offer balance covariates across treatment groups and within strata. We follow the advice given by Garrido et al. (2014) to use the “psmatch2” command to evaluate the propensity score’s ability to balance covariates across treatment groups and within strata .This study used medical records data on all women who gave birth between January 1, 2013 and April 30, 2019 at the Shanghai First Maternity and Infant Hospital. The medical data contain patient demographics and clinical details. Maternal health information and abnormal health conditions at birth were coded using the international classification of diseases, 10th revision (ICD-10). This study was approved by the Ethics Committee of Shanghai First Maternity and Infant Hospital.n = 101,153 live births); and those live births where the mother did not have any insurance coverage, and consequently, covered the entire costs of care themselves . Because migrants that moved to Shanghai to hold occupations of standing may be able to acquire UEBMI coverage, migrants are represented in both groups under review.While there were 160,669 live births over the study period, the analysis sample was restricted by excluding live births where the mother had insurance coverage other than UEBMI coverage, for example, Urban Resident Basic Medical Insurance (URBMI) coverage or private insurance coverage. These restrictions excluded 240 live births and yielded an analysis sample of 160,429 live births. This analysis sample was divided into two mutually exclusive and exhaustive groups: those live births where the mother had UEBMI insurance coverage  Birth weight (in grams); (2) Low birth weight, defined as a birth weight below 2500 g ; (3) Very low birth weight, defined as a birth weight below 1500 g ; (4) Low Apgar score, defined as an Apgar score below seven ; the Apgar score is a test performed shortly after birth to assess the health of a newborn on a scale from 1 to 10; (5) Premature birth, defined as a baby that is born before the completion of 37 weeks of pregnancy ; and an (6) Abnormal health condition at birth (AHCAB), defined as the assignment of any infant diagnostic code at birth by a pediatrician based on use of the International Classification of Diseases, 10th Revision, Clinical Modification (1CD-10-CM), . An abnormal health condition at birth (AHCAB) includes fetal disease, neonatal malformation, neonatal disease, and other diseases. This includes conditions such as macrosomia, accessory finger(s), undescended testicle, cleft lip, ABO isoimmunization of newborn, congenital pneumonia, neonatal jaundice and other similar infant health conditions. Birth weight is the only continuous variable among the six infant health outcome variables assessed. The other variables were binary.Second, we used the same set of indicators of maternal health behaviors as those used by Dave et al. 2018) in their assessment of the impact of the Medicaid expansion on maternal health behaviors during pregnancy . These i8 in thein = 101,153 live births), and 36.9% without any insurance coverage .Maternal insurance status was divided into two groups as those covered by the UEBMI scheme and those without any insurance coverage . The analysis sample comprised 160,429 live births over this study period with 63.1% having UEBMI coverage , nationality , marriage status , employed , and mode of delivery . We also included maternal health indicators for whether a woman had any of three conditions , high risk of pregnancy and pregnancy complications as defined previously.Since having a cesarean section are common and fairly strongly associated with worse pregnancy outcomes, we excluded the cesarean section variable from our PSM methods. As a result, the propensity score control variables are maternal age at the child’s birth, age squared, gravidity, birth parity, ethnicity, nationality, marriage status, employed, maternal health indicators, high risk of pregnancy and pregnancy complications.Table The medical records data contain an array of birth outcome measures. Panel B in Table The data set also contains information about prenatal maternal health. Panel C of Table p <  0.001). The quantile regression (QR) estimates indicate that UEBMI coverage was associated with a significant increase in birth weight at all quantiles: 43.290 g  at the 10% quantile; 30 g  at the 25% quantile; 25.096 g  at the 50% quantile; 23.429 g  at the 75% quantile; and 15.109 g  at the 90% quantile. These results demonstrate that UEBMI coverage was associated with an improvement in infant birth weight, but this gain in birth weight was smaller at higher quantiles. Consequently, UEBMI coverage had the most significant gain in birth weight for infants with lower weights.We begin by presenting the effects of UEBMI coverage on infant birth weight (in grams) by using ordinary least squares (OLS) and quantile regressions (QR), as shown in Table p <  0.001); low birth weight, 0.009 ; very low birth weight, 0.002 ; low Apgar score, 0.002 ; and a reduction in the likelihood of having an abnormal health condition at birth (AHCAB), 0.056 . Notably, some of the control variables have a statistically significant association with infant birth weight. For instance, parity had negative effects on adverse birth outcomes, which suggests that having more children improved such outcomes. In contrast, detrimental effects on infant health outcomes were found for infants born via cesarean delivery and those where the mother had a high-risk pregnancy.We extended the results to other birth outcomes using probit regression methods. The results showing the impact of UEBMI coverage on the incidence of premature birth, low birth weight, very low birth weight, low Apgar score, and having an abnormal health condition at birth (AHCAB) are reported in Table To reduce the potential for confounding, we used propensity score matching (PSM) methods to compare the women with UEBMI coverage to those without any insurance coverage . We derived separate estimates for each of our six birth outcomes, using three different propensity score matching (PSM) approaches, namely one-to-one matching; caliper matching (0.03); and nearest-neighbor matching, and we summarized the sample sizes for each matching approach as shown in the supplementary material (Table 7 of the p < 0.001). The results shown in the Premature birth Panel demonstrate that UEBMI coverage was associated with a significant reduction in the likelihood of premature birth by 0.013 . Similarly, the low birthweight Panel shows that UEBMI coverage was associated with a significant reduction in the probability of having an infant of low birth weight by 0.011 ; the very low birthweight Panel demonstrates that UEBMI coverage was associated with a lower probability of having a very low birth weight by 0.003 (rows1 to 3 p < 0.001); and the Low Apgar Score Panel demonstrates that UEBMI coverage was associated with a lower probability of having a low Apgar score by 0.002 (rows1 to 3 p < 0.001). In terms of having an abnormal health condition at birth (AHCAB), UEBMI coverage was associated with a significantly lower probability of this outcome by 0.054 to 0.055 . Almost all of the propensity score matching methods yield findings that are consistent with the ordinary least squares (OLS) results shown in Tables The results of propensity score matching (PSM) methods as shown in Table p < 0.001), but a much larger increase of 61.777 g for the children born to migrants . These results are impressive and signal the large differential impact of UEBMI coverage by migrant status. Other infant health outcomes also demonstrate a differential positive effect of UEBMI coverage on migrants compared to that for locals. Having UEBMI coverage was associated with a small but insignificant increase in the probability of having a premature birth by 0.001 for Shanghai-born women , but the reduction was significant and larger for migrants at 0.036 . Similar results hold for low birth weight, very low birth weight, and low Apgar scores where the improvement for Shanghai-born mothers was not statistically significant, but the improvement for migrants was larger and statistically significant. For migrants, the UEBMI coverage reduced the probability of having low birth weight by 0.030 ; reduced the probability of having very low birth weight by 0.009 ; and reduced the probability of having a low Apgar score by 0.006 . In terms of the probability of an abnormal health condition at birth (AHCAB), UEBMI coverage was associated with the statistically significant reduction that was larger for migrants by 0.073  than that for locals by 0.044 .Table p < 0.001). In the case of a high-risk pregnancy, it was shown that UEBMI coverage was associated with a reduction in the likelihood of a high-risk pregnancy by 0.032 . Similarity, the UEBMI coverage was shown to be associated with a reduction in the likelihood of having any of the three conditions  by 0.045 .Health insurance may improve infant health outcomes through improvements in maternal health behaviors. Consequently, we tested for the effect of UEBMI coverage on each of the three separate maternal health behavior indicators. The results of the marginal effects are shown in Table We examined how robust our results were to alternative estimation techniques and how the results may have changed with modification to the definition of some variables. First, in the case of each of the three alternative matching methods, all the results were very similar Table  and the Evaluating whether health insurance coverage would improve infant health is a challenge as the issues of potential adverse selection and heterogeneity into insurance groups need to be overcome. This study addressed this question by estimating the effect of China’s compulsory insurance scheme (UEBMI) on six separate infant birth outcomes while using propensity score matching methods to control for potential confounding. Our analysis yields three key findings.First, UEBMI coverage was shown to be associated with improvements in all six of the infant birth outcomes assessed. Specifically, the results suggest that UEBMI coverage was associated with: an increase in birth weight of about 30 g; a reduction in the incidence of having a premature birth by 0.013; a reduction in the incidence of having a child with low birth weight by 0.011; a reduction in the incidence of having a child with very low birth weight by 0.003; a reduction in the incidence of having a low Apgar score by 0.002, and a reduction in the incidence of having a baby diagnosed with the disease at birth by 0.054 to 0.055. Our findings also reveal that UEBMI coverage had the most significant gain in birth weight for infants of lower weight. These findings were in keeping with the main theme in the literature. Specifically, the significance and direction of the coefficients on UEBMI coverage on birth weight, low birth weight, very low birth weight, low Apgar score, and having a premature birth were consistent with previous findings , 24, 25.Second, after stratifying by maternal migrant status, UEBMI coverage was shown to have a greater effect on migrant mothers compared to local residents of Shanghai. Specifically, we found that UEBMI coverage increased the birth weight by 61.777 g for the babies of migrants compared to 12.4 g for the babies of local residents of Shanghai. The direction and magnitude of results for the other five infant birth outcomes were similar. The underlying health condition of migrants was much worse than that for urban residents in China, which is a major policy issue within the academic community and government , 26. SomThird, we found evidence that UEBMI coverage was associated with improvements in maternal health behaviors. Specifically, our results demonstrated that UEBMI coverage significantly reduced the likelihood of having pregnancy complications by 0.030, was associated with a reduction in the likelihood of having a high-risk pregnancy by 0.032, and was associated with a reduction in the likelihood of having any of the following three conditions  by 0.045. Increasing maternal health behavior during pregnancy is one of the possible channels through which health insurance may improve infant birth outcomes. Our findings were consistent with the way in which health insurance may shift maternal health behaviors that result in improvements in infant birth outcomes.There are a range of limitations to highlight. First, our study was based on inpatient data from a single hospital in Shanghai, which may limit the generalizability of the findings. While single-center studies pose challenges for generalizability, this hospital is situated in one of the most diverse regions of China and the women included in the study were diverse in clinical, demographic and ethnic background, which helps to improve generalizability. Moreover, the study hospital is one of the largest obstetrical hospitals in China and is associated with the largest annual number of births nationwide at more than 30,000 births.Second, while the information used for this study was drawn from hospital administrative data that comprised comprehensive maternal medical diagnostic and demographic data, there were some variables that were not captured in that database and consequently, there is the possibility of omitted variable and misspecification bias. However, we used six different birth outcomes  and a range of estimation techniques to ensure that our estimates were robust. Consequently, we believe that these concerns, if still present, maybe small.Third, the study offers estimates of the effects of insurance after controlling for a range of potential confounding variables, yet, unmeasured and residual confounding may still persist. While our results are robust to each of the propensity score approached assessed, we cannot exclude the possibility that some remaining confounding might persist for all of those estimation approaches.Finally, we were unable to directly test for the impact of a change in specific maternal health behaviors, such as smoking and drinking, during pregnancy when they had UEBMI coverage. This absence of information limited our interpretation of the channels through which UEBMI coverage might improve infant birth outcomes to those associated with “black box” changes associated with the maternal health behaviors explored, e.g., high-risk pregnancies, pregnancy complications, and has any of the following three conditions: gestational diabetes; pregnancy-induced hypertension; or anemia. Further research is needed to garner a more complete picture of women’s behavior during pregnancy.This paper demonstrated the UEBMI coverage was associated with improvements in infant birth outcomes after using propensity score matching to deal with potential confounding. This finding was evident in each of six different birth outcomes . When subgroup analyses were conducted, there were larger potential gains in infant health outcomes among migrant mothers than their local counterparts. We also explored possible mechanisms through which health insurance might impact infant health and demonstrated that UEBMI coverage tended to alter maternal health behaviors, such as reducing the possibility of having a pregnancy complication, a reduction of the likelihood of a high-risk pregnancy, and a reduction of the possibility of having any of the following three conditions: gestational diabetes; pregnancy-induced hypertension; or anemia. Our findings suggest that health insurance coverage for pregnant women, especially for migrant mothers, have the potential to directly and significantly improve infant health outcomes. Further research is required to determine whether the effectiveness findings can be replicated for other Chinese jurisdictions, and a detailed understanding of the cost-effectiveness of a policy to expand insurance coverage is warranted.


ONAGE birth cohort study . Using a weighted gene co-expression network analysis, we identified 17 correlated gene modules. Three of these modules were associated with both maternal pre-pregnancy BMI and newborn birth weight. A gene cluster enriched for genes involved in immune response and myeloid cell differentiation was positively associated with maternal BMI and negatively with low birth weight. Two other gene modules, upregulated in association with maternal BMI as well as birth weight, were involved in processes related to organ and tissue development, with blood vessel morphogenesis and extracellular matrix structure as top Gene Ontology terms. In line with this, erythrocyte-, angiogenesis-, and extracellular matrix-related genes were among the identified hub genes. The association between maternal BMI and newborn weight was significantly mediated by gene expression for 5 of the hub genes . As some of the identified hub genes have been linked to obesity in adults, our observation in placental tissue suggests that biological processes may be affected from prenatal life onwards, thereby identifying new molecular processes linking maternal BMI and fetal metabolic programming.Maternal body mass index (BMI) before pregnancy is known to affect both fetal growth and later-life health of the newborn, yet the implicated molecular mechanisms remain largely unknown. As the master regulator of the fetal environment, the placenta is a valuable resource for the investigation of processes involved in the developmental programming of metabolic health. We conducted a genome-wide placental transcriptome study aiming at the identification of functional pathways representing the molecular link between maternal BMI and fetal growth. We used RNA microarray (Agilent 8 × 60 K), medical records, and questionnaire data from 183 mother-newborn pairs from the ENVIR In 2016, 39% of the world’s adult population was overweight, and 13% was obese . In the Recent advances in molecular technologies suggest that the placenta is the master regulator of the fetal environment, representing a higher level of control of fetal programming compared to other tissues . The plaDespite the central role of the placenta in fetal programming, only a limited number of studies have assessed the genome-wide effect of maternal weight on the human placental transcriptome . StudiesThe identification of a placental gene expression signature related to maternal BMI as well as fetal growth may provide new insights into the molecular mechanisms underlying the intrauterine programming of metabolic health. To the best of our knowledge, no study so far has looked at the overlap between placental transcriptome profiles related to maternal pre-pregnancy BMI and fetal growth. Using WGCNA, we identified placental co-expressed gene modules and hub genes associated with both maternal pre-pregnancy BMI and weight of the newborn and we investigated whether these modules and hub genes mediated the association between pre-pregnancy BMI and newborn weight.ONAGE , mother-newborn pairs were recruited upon arrival for delivery at the East-Limburg Hospital in Genk, Flanders (n = 5), a birth weight below 1000 g (n = 1), or low quality of extracted RNA (RNA integrity number below 6) (n = 6), were excluded from the analysis, resulting in a final sample size of 183.Within the framework of the ongoing Belgian birth cohort ENVIRFlanders . Procedu2), normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obese (30.0 kg/m2 or above). Maternal pregnancy weight gain was calculated from the pre-pregnancy weight and the weight measured on admission to the delivery ward. Low birth weight was defined as a birth weight below the 10th percentile of the sample (2643 g), and high birth weight as a birth weight above the 90th percentile (3963 g).Information on variables such as gestational age, birth weight, maternal pre-pregnancy weight, height, and weight before delivery were retrieved from the medical records of the hospital. Gestational age was estimated based on the mother’s last menstrual period in combination with ultrasound data. Maternal height and weight were measured at the first antenatal visit (weeks 7–9 of gestation) wearing no shoes and light clothes. Pre-pregnancy BMI was calculated as weight in kilograms divided by the square of height in meters and categorized into four groups: underweight , and current smokers (smoked cigarettes during pregnancy). Parity was categorized into 1, 2, and ≥3 children. Classification of ethnicity is based on the native country of the neonates’ grandparents as either European (at least two grandparents were European) or non-European (at least three grandparents were of non-European origin).later  at 4°C for at least 12 h and maximally 24 h, followed by storage at -20°C. Total RNA was extracted from one placental tissue biopsy using the miRNeasy mini kit  according to the manufacturer’s protocol. RNase-Free DNase treatment was performed on RNA samples according to the manufacturer’s instructions . RNA quantity and purity was assessed by spectrophotometry  and RNA integrity by Agilent 2100 Bioanalyzer .Placental tissue was collected within 1 h after delivery. Four standardized biopsies were taken from the fetal side, at fixed locations across the middle point of the placenta around 4 cm distance from the umbilical cord . The colhttps://github.com/BiGCAT-UM/arrayQC_Module. Further preprocessing included removal of probes showing > 30% flagged data, merging of replicate probes based on the median, and imputation of missing values by means of K-nearest neighbor imputation (K = 15). Batch effects were corrected for by using an empirical Bayes method (ComBat)  and hybridized onto Agilent Whole Human Genome 8 × 60 K microarrays. Microarray signals were detected using the Agilent DNA G2505C Microarray Scanner (Agilent Technologies). Scan images were converted into TXT files using the Agilent Feature Extraction Software . An in-house developed quality control pipeline in R software was used to preprocess raw data as follows: local background correction, omission of controls, flagging of bad spots and spots with too low intensity, log2 transformation and quantile normalization using arrayQC. More information about the flagging and the R-scripts of the pipeline are available at (ComBat) . For genThe association between maternal pre-pregnancy BMI  and birth weight was assessed through a linear regression model adjusting for date of delivery, newborn sex, gestational age, ethnicity, parity, maternal age, maternal smoking, and weight gain during pregnancy.First, we assessed the associations of transcripts levels  with maternal pre-pregnancy BMI and with birth weight using univariate models, correcting for the same variables as above. We adjusted for multiple testing by controlling the Benjamini–Hochberg false discovery rate (FDR) at 5%.n = 14,040) genes were calculated to generate a signed similarity. A weighted adjacency matrix was obtained by raising the signed similarity matrix to a power β, which was set to 14 after a sensitivity analysis of scale-free topology (R2 > 0.9). The adjacency matrix was then converted to a topological overlapping matrix (TOM) network, which was used as input for a hierarchical clustering analysis. Finally, modules were identified by implementing a dynamic tree cutting algorithm on the TOM-based dendrogram, using the parameters deepSplit = 2 and minClusterSize = 30. The resulting gene clusters (modules) get a color name as identifier, with gray denoting background genes outside of modules. The module eigengene (ME), calculated as the eigenvector associated with the first principal component of the expression matrix, serves as a summary measure for the module. A cut height of 0.35 was used to merge modules with a correlation between MEs of 0.65 or greater.Then we constructed a gene co-expression network by using the WGCNA package  in R, foP-values), using the ppcor package in R  and pathway enrichment analyses. Overrepresented GO biological processes and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways inside each module were identified by using WebGestalt , consideP-values) were obtained as described for the MEs and were corrected for the same set of variables. Hub genes were defined as genes with |MM| ≥ 0.8 and P < 0.05 for at least one maternal BMI variable and at least one birth weight variable. In separate sensitivity analyses, associations of traits of interest with MEs and hub genes were tested after excluding non-European newborns (n = 26), mothers with gestational diabetes (n = 6), and mothers with gestational hypertension (n = 8) from the study population.For the modules of interest, highly connected intramodular genes (hub genes) related to maternal pre-pregnancy BMI and birth weight were selected based on two criteria: (1) the module membership (MM), calculated as the Pearson correlation between the expression of a gene and the ME, and (2) the significance of the partial Pearson correlations between expression levels of individual genes and the traits of interest . Partial Pearson correlations  from the R mediation package .n = 183) are provided in th–90th percentile) = 3328 (2643–3963) gram compared to 3360 (2740–3965) gram] and characteristics such as maternal age, parity, sex, and ethnicity , but birth weight of those from obese mothers was significantly higher . The estimated increase in birth weight for a 1 kg increase in maternal weight gain during pregnancy was 16.7 g .A histogram of birth weight and a scatterplot of birth weight versus maternal pre-pregnancy BMI with unadjusted and adjusted regression lines are presented in P-values for maternal BMI and birth weight were < 0.05 for 832 and 745 genes respectively, with an overlap of 101 genes  with at least one of the maternal BMI variables and at least one of the birth weight variables were darkgray (n = 69 genes), darkred (n = 1091 genes), gray60 (n = 204 genes), and lightgreen (n = 451 genes). The darkgray module showed a positive correlation with maternal pre-pregnancy BMI  and a negative correlation with low birth weight . The darkred module was positively associated with maternal BMI , with maternal obesity , and with birth weight . Also gray60 was positively associated with maternal BMI , maternal obesity , and birth weight . The lightgreen module showed a negative correlation with maternal underweight , as well as with high birth weight .Weighted gene co-expression network analysis identified 17 co-expressed gene modules . The gran = 1) and overweight mothers with a low birth weight baby (n = 4) from the partial correlation analysis (our sample did not contain obese mothers with a low birth weight baby). We noticed that the correlations observed in the lightgreen module were driven by the one underweight mother with a high birth weight baby . Exclusion of this particular observation did not alter the associations observed in the darkgray, darkred, and gray60 modules, neither did the exclusion of the four overweight mothers having a newborn with low birth weight. Consequently, only the darkgray, darkred, and gray60 modules were considered for further analyses.We checked the robustness of the above associations by excluding underweight mothers with a high birth weight baby , with blood vessel morphogenesis as top GO term (lowest FDR). The most enriched KEGG pathway was vascular smooth muscle contraction, and other pathways involved signal transduction (six pathways), endocrine system (four pathways), cancer (three pathways), and environmental adaptation (two pathways)  were related to organ and tissue development, with extracellular structure organization as the most enriched process. The gray60 module contained seven enriched KEGG pathways, including PI3K-Akt signaling, focal adhesion, protein digestion and absorption, and extracellular matrix receptor interaction.In the modules rocesses  and 0, 2rocesses , respectrocesses . The fivustering , which iathways) . Also inP < 0.05) correlated with at least one maternal BMI variable and at least one birth weight variable  and in the gray60 module  showed a positive correlation with maternal BMI and/or obesity, as well as with birth weight. TRPC1 and COL16A1 in the gray60 module were also negatively correlated with maternal underweight. Fourteen of these genes  were also picked up in the univariate models , but FDR values were > 0.05.Hub genes for the modules of interest were selected according to the criteria: |MM| ≥ 0.8 and significantly . The exclusion of mothers with hypertension, however, resulted in smaller and non-significant partial correlations with maternal BMI in the darkgray module, both for the ME as for the five hub genes.Associations between traits of interest and MEs or hub genes were assessed after excluding non-European newborns , mothersdarkred and gray60 modules showed some evidence for mediation . The proportion of mediation  ranged from 8.7 to 20.2% for hub genes from the darkred module and from 10.3 to 17.0% for hub genes from the gray60 module. Significant (P < 0.05) mediation was observed for five of these genes: FZD4, COL15A1, GPR124, COL6A1, and COL1A1.Finally we tested whether the identified modules and genes mediated the association between maternal pre-pregnancy BMI and newborn birth weight . AlthougFZD4, COL15A1, GPR124, COL6A1, and COL1A1).Using WGCNA as an alternative method to conventional differential gene expression analyses, we found interesting clusters of co-expressed genes and intramodular hub genes in placental tissue that were correlated with both maternal pre-pregnancy BMI and birth weight of the newborns. Identified gene modules were mainly related to the immune and vascular system, organ and tissue development, and extracellular structure organization. Mediation analyses suggested that identified genes may be on the causal pathway of the association between maternal BMI and newborn weight, with significant mediation effects observed for five of the hub genes (darkgray) was associated with maternal pre-pregnancy BMI and with low birth weight [below the 10th percentile (2643 g)] and was enriched for genes involved in the defense response to external stimuli. In adults, excess adiposity has been linked to a reduced immune function and host defense, possibly due to the obesity-associated low-grade chronic inflammation and disturbed levels of circulating nutrients and metabolic hormones  (AHSP) (HBQ1)   , periphe) (AHSP) , and men) (HBQ1) . In addi infants , whereas latter) .darkred and gray60) were positively correlated with maternal BMI, maternal obesity, and birth weight. The correlation between these modules (Pearson correlation between eigengenes = 0.648) is reflected in the overlap in GO terms related to tissue and organ development. The darkred module contained several vascular-related genes, with blood vessel morphogenesis as top GO term, and vascular smooth muscle contraction as top KEGG pathway. Alterations in placental vasculature have an impact on the exchange of nutrients and gasses between mother and fetus, thereby affecting fetal growth. Animal models suggest an increased placental nutrient transport capacity as the mechanistic link between maternal obesity and fetal overgrowth, whereas reduced vascular branching in placentas with hypertensive disorders such as preeclampsia may be an underlying mechanism restricting fetal growth in obese pregnancies , a marker of platelet activation that is greater in obese than in lean subjects  proteins and plays an important role in retinal vascularization. In male adults, hyperinsulinemia was found to be associated with a decreased expression of Wnt signaling genes (including FZD4) in adipose tissue, while expression was increased in skeletal muscle, which might reflect a compensatory mechanism to increase muscle glucose uptake and to generate new fat cells  plays a crucial role in adipocyte development and function. Instability of the ECM may be a direct consequence of adipocyte overgrowth, or may indirectly result from obesity-associated hypoxia  of observations inside the low birth weight category.As in all epidemiological studies, findings of this study do not necessarily reflect causal associations. Observed alterations in expression of some genes may be due to confounding factors that also correlate with transcript variability. However, in contrast to most studies using WGCNA, associations between expression levels (of modules and genes) and phenotypic traits were corrected for potential confounders such as ethnicity, maternal smoking, and gestational weight gain. In addition, the placenta represents a heterogeneous mixture of cells and expression levels are expected to vary between cell types. Although biopsies were taken at a fixed location at the fetal side using a standardized sampling method, residual confounding by cell composition cannot be ruled out completely. Finally, associations observed between low birth weight and (hub genes inside) the Using a co-expression approach, we identified pivotal placental gene clusters that may shed new light on the molecular link between maternal and offspring metabolic health. Interestingly, this study indicated genes involved in immune defense and erythrocyte-related hub genes to be upregulated in association with maternal pre-pregnancy BMI and downregulated in association with low birth weight. Moreover, modules enriched for developmental, vascular, and extracellular matrix-related genes were positively correlated with maternal BMI and birth weight. Given the critical role of the placenta in regulating gestational development and the intrauterine environment, the identified gene networks may reflect molecular mechanisms underlying placental dysfunction associated with BMI and may be involved in fetal metabolic programming.This study was carried out in accordance with the recommendations of the Ethical Committee of Hasselt University and the East-Limburg Hospital with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Ethical Committee of Hasselt University and the East-Limburg Hospital.ONAGE birth cohort and designed the current study together with BC, MP, and KV. KN prepared the placental samples and TdK was responsible for the microarray analysis. BC performed the statistical analysis and, with contribution of MT and EW, the bioinformatical analysis. BC and MT wrote the first draft of the manuscript. All authors were involved in data interpretation and critical revision of the manuscript.TN coordinates the ENVIRThe 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.


Gastric duplication cyst is an anomaly that primarily occurs to children. Apart from the conventional use of surgical resection, few cases using endoscopic treatment have been reported.A 5-month-old female infant was hospitalized with the chief complaint of gastric cyst. No significant abnormalities were identified by physical examination.Endoscopic submucosal dissection (ESD) was performed successfully for the infant and the duration was less than 20 minutes. The patient showed no postoperative complications.At 4 months during the follow-up, upper endoscopy revealed a small scar at the previous site of the lesion and no recurrence.According to the results of PUBMED review, she was the youngest with gastric duplication cyst removed with ESD. The less invasive ESD should be considered an effective therapeutic option to remove gastric duplication cyst in children. Endoscopic submucosal dissection (ESD), an minimal invasive technique, can achieve a high rate of en bloc resection and reduce the pain after surgery for patients with early upper and lower gastrointerology trace neoplasia. Eom et alfirst reported a gastric duplication cyst that had been resected completely by ESD in a 28-year-old man in 2011. However, ESD resection of gastric duplication cysts in newborns is rarely reported. This case report was about a 5-month-old female infant whose gastric duplication cyst was removed with ESD without any complication. According to the results of PUBMED review, she was the youngest with gastric duplication cyst removed with ESD.Accounting for 2% to 7% of all gastrointestinal duplications, gastric duplication cyst is an anomaly that primarily occurs to children and rarely to adults.2A 5-month-old female infant was hospitalized with the chief complaint of gastric cyst in the fetal period. Six months before, the patient was diagnosed of intragastric cysts as her mother did prenatal examination in the local hospital. The child at birth was asymptomatic, without any vomiting, abdominal pain, abdominal distension, and other discomfort. Physical and laboratory examination showed she had no obvious abnormalities after being referred to our hospital. Upper endoscopy revealed an ellipsoid submucosal polyp at gastric fundus Fig. A. EndoscWhen the child was in general anesthesia, upper endoscopy revealed a polyp at gastric fundus. The disposable OLYMPUS snared over the base. It was impossible to remove the lesion via electrocoagulation due to the wide base. OLYMPUS IT knife was used to peel off the lesion base (6 times of cutting). Biopsy forceps were used to stop the bleeding in the wound at the lesion base (10 times of clamping). Histopathologic examinations revealed a cystic lesion (2.0 cm × 2.0 cm) lined with a mucosa of columnar epithelium. Gastric duplication cyst was confirmed Fig. . A 10 # 3 Gastric duplication cyst can be found anywhere in the stomach, but the distal greater curvature is most vulnerable. In the gastrulation phase, duplication cyst develops from an endomesenchymal tract between the yolk sac and the amnion. Several theories have attempted, but all failed to explain the embryological development of gastric duplication cyst.The first case report of gastric duplication cyst was published by Wendel in 1911. Duplication cysts are described as spherical or tubular. The spherical cyst is more common  and does not communicate with the bowel lumen. The tubular cyst is commonly seen in the large and small bowels and communicates with the bowel lumen.The essential criteria for diagnosing a gastric duplication cyst are: the wall of the cyst is contiguous with the stomach wall; the smooth muscle in the cyst is continuous with that of the stomach; the cyst wall is lined with gastric epithelium or other types of gut mucosa.The clinical presentation of gastric duplication cyst is examined based on its size and position. Most patients are asymptomatic and the cyst is discovered incidentally by radiological examination or upper endoscopy. However, the patients may later show symptoms like epigastric pain, epigastric fullness, vomiting, weight loss, dysphagia, dyspepsia, and anemia. In the physical examination, a palpable abdominal mass is most indicative. Occasionally, complications arise, such as gastric outlet obstruction, gastric perforation. ESD is an emerging technique characterized with less wound pain, lower cost, decreased hospital stay, quicker postoperative recovery, and less wound-related complications. Eom et al first reported the case of a complete resection of gastric duplication cyst by ESD in 2011. However, ESD is still little used to remove gastric duplication cyst, especially for infants.Close observation and follow-up are usually recommended for small and asymptomatic duplication cyst. To remove a gastric duplication cyst, conventional treatments include surgical resection, minimal invasive surgery, and laparoscopic treatment.The patient in this case was only 5 months. Gastric cyst was found at week 40 in the gestational period. The patient's parents insisted on the removal and ESD was performed. The operation was successful without any complication. The operating time was less than 20 minutes. Histopathologic examinations confirmed the diagnosis of gastric duplication cyst.We believe that ESD is a minimal invasive and safe treatment that can completely remove children's gastric duplication cyst. ESD can be considered an effective therapeutic option to remove gastric duplication cyst.Conceptualization: Ping-Hong Zhou.Resources: Tianjiao Gao, Hongbin Yang.Supervision: Shiyang Ma, Quanlin Li.Validation: Ying Fang, Ping-Hong Zhou.Writing – original draft: Ying Fang.Writing – review & editing: Ping-Hong Zhou.


Apo J is involved in several important pathological processes in thetransport of lipids, and in the differentiation of vascular smooth muscle cells (VSMC),including cell death by apoptosis, cell cycle regulation, cell adhesion, tissueremodeling, regulation of the immune system and oxidative stress, playing a role in thedevelopment of clinical atherosclerosis.5,6 In theprocess of attenuating atherosclerosis, Apo J can promote the export of cholesterol andphospholipids from foam cells of macrophages,7 and show cytoprotective and anti-inflammatory actionsinteracting with many known inflammatory proteins that may act in the initial phase ofclinical cardiovascular events, and may play an important role in mediatingatherosclerotic disease, such as C-reactive protein, paraoxonase and leptin.8 There are studies reporting that Apo Jcan stimulate the proliferation and migration of VSMC, and promote restenosis,9,10 and there have been studies showing thatoverexpression of CLUs can inhibit migration and proliferation of VSMC, and inhibitcellular apoptosis.11 In view of thesecontroversial results, the authors sought to elucidate the role of Apo J in neointimalhyperplasia, using the rat carotid artery in vivo, with or without rosuvastatin.The study by Yang et al.The results of the study published here suggest that rosuvastatin can inhibit intimalhyperplasia due to the high expression of Apo J in the active proliferation andmigration phase of VSMC, after balloon injury in rats. In the present study, the authorsevidenced an increase in the intimal/media (I/M) area rate after the balloon injury thatreached the maximum value in the fourth week in the model group; in addition, I/M wasincreased at week 2, and such increase ceased after the administration of rosuvastatin.These results suggest that rosuvastatin can significantly reduce the degree of intimalhyperplasia in the balloon-injured carotid arteries in rats. The levels of MessengerRibonucleic Acid (mRNA) and Apo J were increased in the carotid arteries in the groupusing rosuvastatin, when compared to the model group, reaching the maximum in the secondweek, earlier than in the model group, suggesting that rosuvastatin can inhibit intimalhyperplasia by increasing Apo J after balloon injury in rats. Therefore, Apo J has beenidentified as having a central role in the migration, adhesion and vascularproliferation process, and that it can contribute significantly to restenosis aftervascular injury.The results of this study showed that Apo J can be an acute phase reagent after ballooninjury in the carotid arteries of rats; therefore, it plays a favorable role, decreasingthe development of restenosis, which in spite of all existing interventions remains as achallenge to be overcome. Rosuvastatin, a potent inhibitor of the HMG-CoA(hydroxymethylglutaryl-CoA) reductase enzyme, seems to reduce neointimal thickeningafter vascular endothelial injury in rats.This study opens new perspectives by highlighting possible mechanisms involved in thegenesis of restenosis after percutaneous interventions, opening the way for clinicalstudies researching the action of Apo J as a new predictor and a therapeutic target forthe protection of the vessel after PTCA.


A tail-gut cyst can be often a misleading clinical entity. In half of the patients there is no presenting symptom. On the other half, the patients most commonly present with a variety of symptoms such as rectal pain, constipation, lower back pain, dysuria or dyspareunia. The recommended treatment of choice for the tail-gut cyst is complete surgical excision without rupture of the cyst. We present the case of a 29-year-old female with history of dyspareunia over a 5-month period, who discovered an “ovarian” cyst during an annual scheduled ultrasound appointment. However, the intraoperative findings were surprising. The bottomline is always to keep in mind the Pandora’s Box of the retrorectal space. Because of this normal folding, the cloacal membrane becomes more ventral comparing to the caudal part of the hindgut and finally encloses it. That’s how the tail-gut is normally formed. The latter structure involutes until the 8th week of development, but if not it becomes a congenital/developmental retrorectal cyst  space. According to Mayo clinic data, the estimated incidence of retrorectal lesions is approximately 1 in 40000 , 3. In 1tal cyst . In halftal cyst . On the tal cyst . Tail-gutal cyst , 6. The tal cyst . These mtal cyst . The rectal cyst .We present the case of a 29-year-old female with history of dyspareunia over a 5-month period, who discovered an “ovarian” cyst during an annual scheduled ultrasound appointment. The present study is based on information derived from the patient`s medical record. The study received ethical approval by the Institutional Board of Bioethics of “Attikon" University Hospital (IRB number: 0052/18) and is in accordance with the Declaration of Helsinki and its latter amendments concerning animal and human. According to the ultrasound findings, the patient had a single unicolar cyst (85x74x83mm) which seemed to originate from the right ovary. The cyst had no irregular inner walls or papillary nodules, showed no blood flow during the colored Doppler examination, and inner ground glass appearance (imaging compatible with endometriosis) . The physical examination revealed no abdominal sensitivity, however the patient mentioned mild tenderness at cervical examination (chandelier sign positive), especially to the left.The anal sphincter had normal tone and the rectal vault was empty while no abnormal masses were palpated. Blood tests revealed white blood cell count and inflammation markers as well as neoplasia markers  within normal rates. However, the intraoperative findings were surprising. The uterus as well as the ovaries had no pathological findings. The patient suffered from a large cyst that originated from the retrorectal space , 7x8x9cm in dimensions, which caused symptoms due to its close proximity to the cervix and the anal canal. The cyst was completely resected and sent for histopathological examination. Frozen section analysis was reported as negative for malignancy. Histology disclosed a cystic space lined mostly with non-keratinizing squamous epithelium , with arLack of structured intestinal wall excluded an enterogenous duplication cyst, absence of neural elements a neurenteric duct cyst, whereas absence of other tissues excluded a presacral teratoma , 12. No The tail-gut cyst is a rare entity with misleading clinical presentation, which often results in a diagnostic challenge. A history of multiple procedures or drainage attempts should alert the clinician about the possibility of a developmental cyst. In many cases the patients had been misdiagnosed before referral. In the above mentioned case, the patient was referred to our department for abdominal pain, with strong clinical suspicion of endometrioma. Once suspected, the correct diagnosis can be made with a careful and more detailed examination before surgery. The gold standard for the treatment of tail-gut cysts is complete surgical excision. Chronic infection usually complicates 30-50% of the developmental cysts . Also duWhich often results in a diagnostic challenge. In complicated cases, a multidisciplinary team approach is the safest choice in order to achieve the desirable outcome.


Background: Some individuals appear prone to multiple adverse outcomes, including poor health, school dropout, risky behavior and early reproduction. This clustering remains poorly understood. Drawing on evolutionary life history theory, we hypothesized that maternal investment in early life would predict the developmental trajectory and adult phenotype of female offspring. Specifically, we predicted that daughters receiving low investment would prioritize the life history functions of “reproduction” and “defense” over “growth” and “maintenance,” increasing the risk of several adverse outcomes.Methods: We investigated 2,091 mother-daughter dyads from a birth cohort in Pelotas, Brazil. We combined data on maternal height, body mass index, income, and education into a composite index of “maternal capital.” Daughter outcomes included reproductive status at 18 years, growth, adult anthropometry, body composition, cardio-metabolic risk, educational attainment, work status, and risky behavior. We tested whether daughters' early reproduction (<18 years) and exposure to low maternal capital were associated with adverse outcomes, and whether this accounted for the clustering of adverse outcomes within individuals.Results: Daughters reproducing early were shorter, more centrally adipose, had less education and demonstrated more risky behavior compared to those not reproducing. Low maternal capital was associated with greater likelihood of the daughter reproducing early, smoking and having committed violent crime. High maternal capital was positively associated with the daughter's birth weight and adult size, and the likelihood of being in school. Associations of maternal capital with cardio-metabolic risk were inconsistent. Daughters reproducing early comprised 14.8% of the population, but accounted for 18% of obesity; 20% of violent crime, low birth weight and short stature; 32% of current smoking; and 52% of school dropout. Exposure to low maternal capital contributed similarly to the clustering of adverse outcomes among daughters. Outcomes were worst among daughters characterized by both low maternal capital and early reproduction.Conclusion: Consistent with life history theory, daughters exposed to low maternal capital demonstrate “future discounting” in behavior and physiology, prioritizing early reproduction over growth, education, and health. Trade-offs associated with low maternal capital and early reproduction contribute to clustering of adverse outcomes. Our approach provides new insight into inter-generational cycles of disadvantage. There is major public-policy interest in investing in children, in order to allow them to achieve their full potential in health and human capital, and flourish in adult life. This is particularly relevant to high-risk groups, who have been shown to contribute disproportionately to adverse adult outcomes. For example, a recent analysis of the Dunedin cohort of ~940 individuals showed that “a segment comprising [only] 22% of the cohort accounted for 36% of the cohort's injury insurance claims; 40% of excess obese kilograms; 54% of cigarettes smoked; 57% of hospital nights; 66% of welfare benefits; 77% of fatherless child-rearing; 78% of prescription fills; and 81% of criminal convictions”   physioloThere is increasing interest in applying life history theory to both physiology and behavior in humans . NonetheWe have developed a conceptual approach emphasizing that the initial source of environmental variability experienced by placental mammals derives not directly from the external environment, but from maternal phenotype . During The magnitude of maternal capital may vary markedly within a population, through the differential exposure of mothers to factors such as poverty, malnutrition, infectious disease and gender inequality , 23, as Such trade-offs may be especially relevant in hierarchical populations, in which social inequality is propagated over generations , 25. SubWe tested these hypotheses in a large prospective birth cohort in southern Brazil, a country with very high levels of social inequality. We used early child-bearing (<18 years) as a key marker of life history trade-offs among the daughters, as reproduction before 18 years is associated with health risks and other penalties among both mothers and offspring , and is The birth cohort we studied is located in the city of Pelotas , in the southern Brazilian state of Rio Grande do Sul. According to data for 1991, shortly before the cohort was established, 91.6% of Pelotas inhabitants lived in urban areas, the crude birth rate was 19.3 births per 1,000 population, the Human Development Index was 0.558 and the Gini index for income distribution was 0.59 1.The birth cohort was established in 1993, when all mothers who delivered a newborn in the five hospitals of the city and who resided in the urban area were invited to participate in a birth cohort study  . ThroughIn all phases of the study, ethical approval was obtained from the Medical School Ethics Committee of the Federal University of Pelotas and full informed consent was provided by parents or their legal representatives (if the subject was aged under 18 years) or by cohort members. Verbal consent was provided in the perinatal phase.At the initiation of the study when the cohort members were born, data were collected on maternal phenotype including nutritional status, behavioral traits, reproductive history, educational attainment and family circumstances . A strenData on family characteristics, pregnancy exposures, and early breast-feeding were obtained by questionnaires administered while the mother was still in hospital, and in a subsample at a 1 year follow-up. Family income at the time of birth was assessed in units of minimum wages . Maternal smoking and alcohol consumption during pregnancy were collected retrospectively at birth. Gestational age was recorded in weeks. Exclusive breast-feeding was recorded in days. Maternal parity was recorded, and was used to create several dummy variables for analysis as described in more detail below. Maternal age was recorded in relation to the date of the daughter's birth.Offspring birth weight and length were measured at the hospital by the research team. Weight and length at 12 months were measured in a subsample at the cohort participant's household. Information on the daughter's age at menarche was obtained from the mother at the 15 years visit, and confirmed by the subject at the 18 years visit. Age at menarche was assessed as the age of occurrence of the first menstrual cycle.At 18 years, weight and height were measured and used to calculate body mass index (BMI). Waist circumference was measured using a non-elastic measuring tape. Fat-free and fat mass were assessed using air-displacement plethysmography.n = 59). Random glucose was measured by an automatic enzymatic colorimetric method. HbA1c was measured by the Variant  ion-exchange high-performance liquid chromatography (HPLC) method. Lipids were measured using an automatic enzymatic colorimetric method in a biochemistry analyzer . We excluded two individuals with implausibly high triglyceride values. Blood pressure was recorded in the seated position using a calibrated digital wrist monitor  at the start and end of the visit, and the mean of the measurements used in the analysis.Cardiovascular risk markers measured at the 18-year follow-up included: glucose, glycated hemoglobin (HbA1c), total cholesterol (TC), HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C), triglycerides (TGL), and systolic (SBP) and diastolic (DBP) blood pressure. The ratio of total cholesterol to HDL was also calculated, with higher values indicating a less favorable cholesterol profile. Venous blood samples were collected regardless of fasting status, left at room temperature for 30 min and then centrifuged for 15 min at 2,000 g. Serum aliquots were stored at −80°C until analysis. Blood samples were not taken in pregnant or suspected pregnant participants , participants were asked to select from a list of 10 possible reasons accounting for this: difficulty learning; illness; work; no school or travel available; education not considered important; having children; married; violence; failed vestibular examination; other.A questionnaire was used to establish schooling status at 18 years, including categorical data  and continuous data (completed years of education). For those not studying  and the amount in Reais (Rs). Questionnaires were also used to establish smoking behavior, and whether the participant had ever committed a violent crime.We categorized daughters according to whether or not they had reproduced early (by 18 years) or not.We categorized mothers according to the magnitude of their capital. This approach combined markers of somatic capital  and social or material capital  into a composite index. Each of these four traits has been widely associated with phenotypic variability in the next generation –38. For Height: <157 cm2Pre-pregnancy BMI: <21 kg/mMaternal education: <6 yearsFamily income: <3 minimum salaries+-borns. However, for descriptive analysis we also generated a category for high maternal parity, defined as the daughter being fourth/fifth-born.The four dummy variables were then summed, allowing mothers to be assigned a score based on the number of “capital penalties” with values ranging from 0 to 4 . We used this variable to explore continuous associations of maternal capital with daughter outcomes. In addition, those with a score of 4 were categorized as the “low” composite maternal capital group, while those with a score of 0 categorized as the “high” composite maternal capital group. This allowed us to compare outcomes of daughters between these two contrasting maternal capital groups. For logistic regression analyses, we also divided maternal age into three groups, namely <22, 22–28, and >28 years. For the same purpose, we divided the daughters into three groups in relation to maternal parity, namely first-borns, second-borns, and third2, short stature as height <157 cm, and school dropout as those reporting not studying during the last year. Self-reported current smoking and having committed violent crime were additional adverse outcomes. Finally, we included low birth weight as an adverse outcome, as those with this characteristic remain at elevated risk of non-communicable disease through adult life  and markers of growth, health and education, which we interpret as trade-offs as predicted by life history theory. For this purpose, we analyzed several broad groups of outcomes of the daughters. The first comprised growth trajectory, comprising birth weight, infant growth, age at menarche, and adult size . The second comprised markers of metabolic health, blood pressure and blood biochemistry. The third comprised behavioral profile, focusing on education, income, and risky behavior (smoking). We used these outcomes to assess relative investment during development in the competing life history functions of growth, maintenance and reproduction. Markers of risky behavior , were considered indicative of future discounting. We conducted these analyses by comparing daughters with vs. without offspring at 18 years, using independent samples  Our second analytical step tested our novel “maternal capital” model, by defining groups of mothers with different composite levels of maternal capital and quantifying associations with the daughters' phenotype. Using the composite maternal capital index, we tested the hypothesis that variability in maternal phenotype predicted the likelihood of early reproduction by the daughter, and hence also predicted variability in the traits that either trade off against early reproduction, or correlate directly with it. We first fitted logistic regression models to confirm that multiple individual maternal traits predicted reproductive status of the daughter (had a child or not by age 18 years). These models included the four variables used to generate the composite index of maternal capital, but also additional markers of the capacity for maternal investment (age and parity) as well as “risky maternal behaviors” (smoking during pregnancy) that might constrain maternal investment.t-tests. Outcomes included the daughters' gestational age and early growth trajectory, breast-feeding experience, adult size and body composition, cardio-metabolic risk markers, risky behaviors, educational attainment, and early onset of reproduction, as well as maternal parity and the mother's risky behavior . For growth, we were able to assess whether differences extended to the third generation, by analyzing birth weight of the daughter's own offspring. Third, we then ran regression models testing dose-response associations of daughter traits with the number of maternal capital penalties. We highlighted the contrast between daughters of low- vs. high-capital mothers using graphic analysis, supported by independent-sample 2), short stature (<157 cm), current smoking, school dropout, violent crime, and low birth weight, as justified above. We also explored the interactive associations of low maternal capital and early reproduction by the daughter with these adverse daughter outcomes. Our fourth analytical step followed the approach of Caspi et al.  to evalu Associations between early reproduction in daughters and adverse outcomes might potentially be confounded by direct mother-daughter transmission of the outcome, due to shared genes or household environments. To exclude this possibility, we fitted regression models in which associations of the daughter's early childbearing with various outcomes were adjusted for equivalent traits in the mother.n = 723) over-sampled those with low birth weight. This was addressed using a weighting variable in the relevant regression models.Of the 2,645 female participants, 2,091 participated in the follow-up and provided questionnaire responses, of whom 2004 also underwent the physical measurements of anthropometry and body composition, and 1936 completed the blood test. There were small numbers of missing data for individual variables, hence we used all available data for every analysis. The subsample at 1 year  in sympercent terms  of the regression model to generate conditional nt terms .To establish which maternal factors independently predicted daughters' reproduction status at 18 years, logistic regression models were fitted. Maternal capital was divided into groups as follows, in order to identify high-risk groups and test for threshold effects:Age <22, 22–28, 28+ yearsHeight <155, 155–162, 162+ cmEducation 0–4, 5–7, 8+ yIncome 0–2, 3–4, 5+ minimum wages+-bornParity First-born, second-born, thirdSmoking in pregnancy Yes, no2Maternal BMI <21, 21–23.5, 23.5+ kg/mLogistic regression models were also used to test the association of daughter phenotype with the odds of early reproduction, without or with adjustment for the equivalent trait in the mother.To test the interactive associations of low maternal capital and early daughter reproduction with adverse daughter outcomes, we conducted chi-squared tests on dichotomous variables . We compared simple exposures  against a composite exposure . Due to the small sample size of the lowest maternal capital group , we combined the 3 and 4 capital penalty groups to give a larger “low maternal capital” group for this analysis and compared them against those with 0 capital penalties. We used the likelihood ratio value to compare these models for their ability to explain variability in the dichotomous outcomes.All analyses were conducted in SPSS version 24  and R version 3.4.1 .2, 95%CI −0.1, −0.8) compared to those followed up. Though statistically significant, these differences were all of small magnitude, and no other differences in baseline maternal or child characteristics were evident  were followed up at 18 years, representing a 79.0% retention rate of the 2,645 individuals originally recruited at birth. Those not followed up had lower birth weight , birth length , gestational age  and maternal pre-pregnancy BMI ; 7.4% for blood biochemistry; and 11.7% for violent crime. These missing outcome data could not be imputed, hence n = 87) missing data from the physical examination at 18 years  had mothers who were shorter , younger , and less educated  compared to the mothers of daughters with complete data, but no other differences were apparent. Daughters (n = 155) missing data from the blood sampling did not demonstrate any differences in maternal phenotype compared to daughters with complete data. Daughters (n = 244) missing data on violent crime had mothers who had lower income  compared to the mothers of daughters with complete data, but no other differences were apparent.For birth weight, birth length, age at menarche, and gestational age, data was missing at random. Daughters  and were more likely to be obese . They had higher total fat mass index, however this was accompanied by lower triceps but higher subscapular skinfold, in combination indicating a more central fat deposition , but similarly in weight, while in adolescence the two groups had similar age at menarche. Overall, the early-reproducing daughters showed a growth trajectory favoring weight gain at the expense of linear growth  and lighter (Δ = 143 g), and had shorter gestation length (Δ = 0.2 weeks). Daughters with children also grew significantly less in length between birth and 1 year  and the strongest contrasts were daughters without children being more likely to have left school to work, for marriage, or for an unstated reason.Daughters bearing children early were much less likely than those still childless to have studied over the last year, or to be in school at the time of the follow-up, and had completed on average 2.4  years less education. Among a subset with relevant data (n = 317), the most common reason that daughters with children gave for not being in school was being a mother (69%) or being married (10%), whereas for those without children, the most common reasons were work (37%), or not considering education important (17%) . When thDaughters with children were less than half as likely to have received a monthly allowance  or payment for work in the last month, though if they had, the amount was similar to that received by daughters without children . They were more than three times as likely to declare themselves current smokers, and to have smoked at least once during the last week, and 1.5 times more likely to have committed violent crime.+-born. Their mothers were twice as likely to have smoked in pregnancy, but were no different in terms of alcohol intake. Their mothers were on average significantly younger , shorter , poorer , and had less education , but they did not differ in BMI .The two groups further showed significant contrasts in the characteristics of their mothers. Compared to those without children, early-reproducing daughters with children were less likely to be first-born and more likely to be fourthThese findings were essentially unchanged if multiple imputation was used to address the small proportion of missing data relating to maternal predictors.Overall, early reproduction by daughters was associated with poorer growth and educational attainment, a more unhealthy distribution of body fat, and an increased likelihood of risky behavior. These trade-offs appeared to have their origins in early life, indicated by associations of early reproduction with growth trajectory and with maternal capital indicators.This analysis justifies our use of a composite index of maternal capital to explore variability in daughter phenotype, as the effects of maternal capital components on offspring life history trajectory are independent and therefore likely to be cumulative.Our maternal capital score was expressed as the cumulative number of penalties across the four traits, ranging from 0 to 4. The characteristics of individual maternal traits varied in a dose-response manner in association with the composite score . Thus, ap = 0.002), indicating a more central fat distribution in daughters receiving low maternal investment (p < 0.004), but the magnitude of this effect was very small , educational attainment , and family income . Low-capital mothers were more than twice as likely to smoke during pregnancy, but no more likely to drink alcohol. Low-capital mothers were nearly three times more likely than high-capital mothers to be high-parity (4+ offspring), but were similarly likely to be first-time mothers. Daughters of low-capital mothers were 3.2 times as likely as those of high-capital mothers to have reproduced by 18 years, and 8.6  times more likely to have two or more children by this age.Daughters of low-capital mothers were lighter and shorter at birth and remained smaller at 1 year than those of high-capital mothers, and achieved menarche 5 months later. Low-capital daughters remained 6.3 cm shorter and 1.2 kg lighter at 18 years, and had lower lean body mass and whole-body fat mass. They had lower triceps but similar subscapular skinfold, indicating a more central abdominal fat distribution. Taking into account the average age at menarche and adult height of each group, we estimate that the daughters of low-capital mothers would on average have been shorter and lighter than those of high-capital mothers at the time of menarche.Daughters of low-capital mothers did not differ from those of high-capital mothers in their fasting glucose, triglycerides or blood pressure. They had lower total cholesterol, with this difference due to significantly lower HDL  whereas “unhealthy” LDL cholesterol was similar between the groups. Thus, in contrast to the associations with body size and body composition, maternal capital was not a good predictor of daughters' cardio-metabolic physiology.Daughters of low-capital mothers were only one fifth as likely as high-capital daughters to have studied over the previous year, or to be in school at the time of the follow-up, and on average they had completed 2.5  fewer years education. Low-capital daughters were less likely to have received a monthly allowance in the previous month, though if they did it was of similar magnitude to that received by high-capital daughters . They were equally likely to have been paid for work, and for those working, the monthly payment was similar to that received by high-capital daughters . Low-capital daughters were almost twice as likely to smoke, and more than twice as likely to have committed violent crime.Overall, lower maternal capital was associated with an increased risk of early reproduction in the daughter, along with poorer linear growth, less healthy fat distribution, lower educational attainment, and greater likelihood of risky behavior.We considered two possible drivers of clustering of adverse outcomes in the daughters: early reproduction and low maternal capital. First, we compared all daughters who had reproduced by 18 years against those who had not. Daughters who reproduced by 18 years comprised 14.8% of the population, but accounted for 18.4% of obesity, 20.0% of violent crime, 20.3% of short stature, 32.2% of current smoking and 52.0% of school dropout. They also accounted for 20.2% of low birth weight.n = 359), and compared this group against the remainder of the cohort. The low capital group comprised 18.6% of the population of daughters, and accounted for 17.5% of obesity, 19.6% of violent crime, 24.9% of smoking, 27.7% of short stature, 28.6% of low birth weight, 32.1% of school dropout, and 34.1% of early reproduction. Thus, the most common adverse outcome in the low capital segment was early childbearing.In turn, we combined the daughters from the two groups characterized by the lowest levels of maternal capital  were characterized by trade-offs favoring reproductive potential over growth and the maintenance of health  and therefore could not test for independent effects of paternal investment. Although we treated household income as a component of maternal capital, it may commonly relate to both parents' earning capacity. Similarly, education is characterized by assortative mating, with men tending to marry women of equal or fewer years of schooling, hence we cannot differentiate a specific association attributable to the mother's education. If height of the two parents is correlated, then likewise, the reduced early growth rates of offspring of shorter mothers might in part reflect a low paternal growth drive. However, while acknowledging these paternal effects, we could also consider such assortative mating with low capital fathers to represent the “extended phenotype” of the low-capital mother , since hFifth, we had information on only a single child within each family, and could not therefore test how maternal investment might vary through the reproductive career. The fact that low-capital mothers tended to have higher parity than high-mothers suggests greater competition between the offspring of low capital mothers for a smaller pool of maternal resources. Since mothers may accumulate capital through the life-course, and since low capital mothers tend as we have shown to reproduce early, the adverse consequences for the offspring of low capital mothers might be greatest if they are also first-borns. Given the birth order differences in our sample, our findings may therefore be conservative. More generally our findings relate to a specific time period and specific city in southern Brazil, and it is unclear how they might generalize to other periods or geographical settings.Sixth, our analysis was observational, and could not demonstrate causal associations of maternal capital and daughter outcomes, nor direct trade-offs between the different daughter outcomes. While correlations between life history traits are widely interpreted as demonstrating trade-offs in human studies –66, an eFuture work in this area could extend our approach to male offspring, and could use alternative approaches to derive cumulative maternal capital scores. Regarding outcomes, it would be valuable to assess more direct markers of immune function such as leptin, or the status of pro-inflammatory markers. Finally, while our focus here was on the manifestation of trade-offs at the onset of adulthood when aging effects are modest, longer-term follow-up would allow us to investigate how these trade-offs might change across the daughter's reproductive career. In addition, it would be possible investigate how daughters' lifetime fitness itself varies in association with the timing of reproduction and the magnitude of maternal capital to which they were exposed in early life.In conclusion, our study has shown that early reproduction is associated with an increased likelihood of adverse adult outcomes, which are expected to impact adversely on future generations. In this way, we highlight the central role of trade-offs associated with early reproduction in perpetuating inter-generational cycles of disadvantage. We further showed that the life history trajectory and adult phenotype of daughters can be predicted from a composite index of maternal capital, with both physical and socio-economic maternal traits contributing. Both behavioral and physiological outcomes demonstrated a common pattern of future discounting.Our life history approach helps understand why some segments of a population may contribute disproportionately to traits that generate a large economic burden on the population . We explDifferences in female growth up to age 18 had largely been determined by the end of infancy in our study, while other studies indicate that secular trends in height are also largely accounted for by growth prior to 2 years . The poljonathan.wells@ucl.ac.uk.The datasets for this manuscript are not publicly available because the data on this longitudinal birth cohort are curated by the Federal University of Pelotas and must safe-guard participant privacy. The dataset analyzed during the current study is available from the corresponding author on reasonable request. Requests to access the datasets should be directed to In all phases of the study, ethical approval was obtained from the Medical School Ethics Committee of the Federal University of Pelotas and full informed consent was provided by parents or their legal representatives (if the subject was aged under 18 years) or by cohort members. Verbal consent was provided in the perinatal phase.JW, TC, MC-B, and AMa designed the analysis. The Pelotas 1993 birth cohort is overseen by AMe, who steered the 18-year follow-up conducted by FW, PO, HG, and IO. Initial statistical analysis was undertaken by JW, TC, and MC-B, and revised in light of feedback from AMa, JM, AMe, RS, and DL. JW and MC-B developed the composite 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.


Neonatal morbidity and mortality can be influenced by maternal health status. Information on maternal and fetal biomarkers of adverse health outcomes is limited. This work aims at identifying maternal biomarkers associated with low and high birth weight for gestational age groups.Population-based prospective cohort study of the potential adverse health effects of exposure to environmental contaminants on pregnancy and infant health.th percentile and large for gestational age (LGA) ≥90th percentile groups.Third trimester maternal plasma samples (n = 1588) from a pregnancy cohort  were analyzed for changes in a target spectrum of biomarkers of vascular health , inflammation  by affinity-based multiplex protein array analyses. Multivariate logistic regression analyses were done to examine associations between target plasma biomarkers, maternal-infant characteristics, and birth weight outcomes assessed as small for gestational age (SGA) ≤10Our results revealed that maternal plasma biomarkers monocyte chemoattractant protein-1 MCP-1  and VEGF  along with parity = 1  and gestational hypertension  were associated with SGA births. Meanwhile, LGA was associated with maternal plasma VEGF  and MMP-9  and gestational hypertension , pre-pregnancy body mass index , parity  and education .Third trimester maternal plasma biomarkers in combination with maternal health and socioeconomic characteristics can be useful in predicting SGA and LGA outcomes. Maternal vascular health and inflammatory status may contribute to both SGA and LGA births through distinct molecular mechanisms. There is growing impetus to understand maternal and in-utero environmental changes that can influence both maternal and infant health , 2, 3. Mth sex-specific birth weight percentile for gestational age, and is commonly used as a surrogate for fetal growth restriction. SGA infants are reported to show early signs of metabolic disturbance, abnormal distribution of body fat and thus may be at risk for early onset of diabetes and heart disease , chemokines , vascular endothelial growth factor (VEGF-A), acute phase proteins C-reactive protein (CRP), soluble intracellular adhesion molecule (ICAM-1), soluble vascular cell adhesion molecule (VCAM-1) and matrix metalloproteinases (MMPs) by affinity-based multiplex protein array assays using Bio-Plex Pro Human panels  and Milliplex Map kits . Briefly, plasma samples were incubated with capture antibody-coated magnetic beads, then washed and reacted with biotinylated-detection antibodies followed by incubation with streptavidin-phycoerythrin. The bead complex was washed and re-suspended in sheath fluid  and analysed using a Bioplex 100 instrument with Bioplex Manager 6.0 software .Statistical analyses were restricted to pregnant women from the MIREC study who had singleton live births (with birth weight recorded) and provided a blood sample during their third trimester of pregnancy . Our analysis focused on a spectrum of nineteen maternal third trimester plasma target biomarkers implicated in oxidative stress, inflammation and vascular function, and their relationship with small and large for gestational age (SGA/LGA) outcomes. Newborns were defined as small for gestational age (SGA), large for gestational age (LGA) or appropriate for gestational age (AGA) based on the birth weight percentile for gestational age reference values reported on the Canadian population study by Kramer et al. (2001) , taking Biomarker levels were compared across recruitment sites to ensure that no bias by recruitment site existed. Given the large percentage (28%) of missing values for gestational diabetes, this variable was not included in the analyses. Any plasma marker results below the limits of detection (LOD) were substituted with LOD/2. Maternal characteristics were chosen based on their known relationships with SGA and LGA, and their availability from the MIREC datasets. These included education , ethnicity , marital status , and smoking status . Gestational hypertension and preeclampsia (GH) were based on the Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines, as follows: an elevated average systolic and/or diastolic blood pressure at >20 weeks gestation; a diagnosis of GH; taking antihypertensive therapy after >20 weeks gestation; or an elevated systolic and/or diastolic blood pressure after admission for delivery on two separate measurements taken 4 hours apart . The category of household income was based on the income threshold  for the Canadian two-parent family . CaffeinInitially, descriptive statistics and plots were done on maternal plasma biomarkers to illustrate the distribution of data (not shown). For the analysis of associations with birth outcomes, biomarker data were log-transformed due to their positively skewed distributions. Normality tests were satisfactory following these transformations. Subsequently, univariate analyses using simple logistic regression and contingency tables were done to examine the distribution of continuous variables with respect to the different birth weight for gestational age groups . The relIn the second part of our analyses, to test the association between all maternal plasma biomarkers and birth weight outcomes using multivariate models, we used a 20% significance level for inclusion of the covariates, as a variable-reduction method.  AGA was In our study, 93 (5.9%) newborns were identified as SGA and 204 (12.9%) as LGA. There were 828 boys (52.5%) and 749 girls (47.5%). The majority of mothers had completed college, trades or post-secondary education (86.4%), were white (81.9%), married or in common-law (95.4%), and their yearly household income was at least $80,000 (58.0%). There were 699 (44.3%) first-time mothers, most reported taking multi-vitamin preparations (87.5%), and 22.7% reported having chronic conditions (22.7%).2). Average maternal age at delivery was 33 years and average GA at delivery slightly under 40 weeks. Caffeine and alcohol consumption were rare events .Descriptive statistics results on the distribution patterns  for plasma biomarkers and maternal characteristics (for continuous data) are provided in In the univariate analysis, significant associations (p<0.05) with SGA and LGA are also included in The results of our multivariate analyses for the relationship between maternal parameters and SGA, LGA outcomes are provided in Our preliminary work conducted on maternal plasma biomarkers from small subsets of the MIREC study subjects suggested that disruption in mechanisms associated maternal vascular function or immune health status may influence infant birth weight outcomes , 32. Alshttp://www.phac-aspc.gc.ca/rhs-ssg/phi-isp-2013-eng.php).Our current findings from the MIREC cohort revealed a wide range of plasma biomarker concentrations among the MIREC mothers, during the third trimester. Alcohol consumption and smoking were minimal for the participants from this study. Small and large for gestational age cases in this mother-infant cohort were about 5.9 and 12.9%, respectively, compared to 8.3 and 10.4% in the 2010 general Canadian birth population  between maternal third trimester plasma VEGF-A and SGA . The vasMeanwhile, plasma MCP-1 was positively associated with SGA births.  Increase+ IFN-γ+ TNF-α+ MCP-1+IL-2+ IL-6+ IL-8)/(IL-10), using the mean values from We employed a reductionist approach for the multivariate model analyses to identify potential maternal determinants of adverse birth outcomes with the adjustment for a rich set of covariates, while obtaining a parsimonious model . Our finOur results also showed that the LGA births were associated with increased third trimester maternal plasma VEGF, decreased MMP-9 levels, positively associated with gestational hypertension, pre-pregnancy BMI, and parity (one previous birth) and negatively associated with maternal education. In contrast to the SGA outcome, the association of VEGF with the LGA outcome is positive, suggesting perhaps increased endothelial NO production thus favouring vasodilation pathways, and thus potentially enhanced utero-placental perfusion . The negBased on our findings, it appears that different inflammatory and vascular pathways may be operative in maternal/fetal programming for SGA/LGA birth outcomes . Since wThe advantages of this study include the prospective design, large mother-infant cohort, measurements of various mother-infant parameters obtained by trained professionals and the rich set of covariates. To our knowledge, this is the first work that has integrated the third trimester maternal plasma biomarkers in a large Canadian mother-infant cohort with maternal socioeconomic status, and maternal physiological parameters (e.g blood pressure) as an intermediate outcome to investigate the adverse pregnancy outcomes SGA and LGA. Our findings suggest VEGF-related vascular mechanisms, neutrophil recruitment-related inflammatory mechanisms and extracellular matrix remodelling pathways roles in precipitating SGA, LGA outcomes, with clear differences in mechanistic pathways for these adverse birth outcomes. However, due to consideration of parsimony in the multivariate statistical analyses used in this study, the mechanistic information is not visible. Also, the small subset of plasma biomarkers that reached significance in the best fit model for the SGA/LGA outcomes  may act The MIREC study population is not representative of the Canadian population at large, since the study was based on a convenience sample and participants were generally above the national average in terms of income and education . CertainOur findings suggest that perturbation in vascular function, activation of pro-inflammatory pathways and changes in extracellular matrix remodelling in mothers during the third trimester of pregnancy can be some of the determining factors of SGA or LGA births. These results also reveal that although inflammatory cascades and vascular biochemistry may contribute to adverse birth weight outcomes, pathway-specificity can be critical in defining these different phenotypes. Future focus on high-content maternal proteomic, metabolomic and epigenetic biomarkers can add value by increasing the sensitivity and specificity of such analyses to distinguish these phenotypes of adverse birth outcomes, based on comprehensive molecular mechanisms.