It is well known that maternal smoking during pregnancy and maternal pre-pregnancy overweight have opposite effects on the infants’ birth weight. We report on the association of the combination between both risk factors and the infants’ birth weight.We studied 3241 infants born at term in the PIAMA birth cohort. Maternal smoking during pregnancy and pre-pregnancy height and weight were self-reported. Multivariable regression analysis was performed to assess the associations between infants of mothers who only smoked during pregnancy, who only had pre-pregnancy overweight and who had both risk factors simultaneously, on term birth weight and the risk of being SGA or LGA.Of 3241 infants, 421 infants (13%) were born to smoking, non-overweight mothers, 514 (15.8%) to non-smoking, overweight mothers, 129 (4%) to smoking and overweight mothers and 2177 (67%) to non-smoking, non-overweight mothers (reference group). Infants of mothers who smoked and also had pre-pregnancy overweight had similar term birth weight , SGA risk , and LGA risk  as the reference group.Our findings suggested that the effects of maternal smoking during pregnancy and maternal pre-pregnancy overweight on infants’ birth weight cancel each other out. Therefore, birth weight may not be a good indicator of an infant’s health status in perinatal practice because it may mask potential health risks due to these maternal risk factors when both present together. Maternal smoking during pregnancy and pre-pregnancy overweight are well-known examples of obstetric risk factors that have an impact on infants’ health –5. InfanRelatively little is known about the combined effect of maternal smoking during pregnancy and maternal pre-pregnancy overweight on birth weight. The individual, opposite effects of maternal smoking and maternal overweight may either cancel each other out resulting in normal birth weight as was observed in a recent large population-based study , or the Therefore, the present study examined the combined effect of maternal smoking during pregnancy and pre-pregnancy overweight on term birth weight, the risk of being born SGA or LGA in the PIAMA birth cohort, a prospective birth cohort in the Netherlands.The present study is part of a population-based Dutch birth cohort study: The Prevention and Incidence of Asthma and Mite Allergy (PIAMA) Study. A detailed description of the study design has previously been published . In brien = 33), maternal pre-pregnancy overweight (n = 451), and birth weight (n = 15) from the analysis. Therefore, the population for analysis consisted of 3241 infants.Of 3963 infants, we excluded 190 infants who were born < 37 weeks of gestation as well as 33 infants with missing information on gestational age. We additionally excluded infants with missing values on maternal smoking during pregnancy  and parity was assessed by questionnaire at 3 months after the child’s birth. Data on maternal educational level, weight and height before pregnancy were collected in the 1-year questionnaire and maternal ethnicity in the 2-year questionnaire.2). We dichotomized pre-pregnancy maternal BMI into overweight and obesity (BMI ≥ 25 kg/m2) and non-overweight (BMI < 25 kg/m2). With these two binary variables of maternal smoking and maternal overweight, infants were classified into four groups that will be referred to as: infants who were born to (i) non-smoking, non-overweight (the reference group), (ii) smoking, non-overweight, (iii) non-smoking overweight, and (iv) smoking, overweight mothers.Maternal smoking during pregnancy was categorized into smoking and non-smoking and refers to those who reported smoking during at least the first 4 weeks of pregnancy. This variable was created based on information on current smoking during pregnancy and on information on timing of quitting in mothers who reported to be former smokers. Information on current smoking status, smoking intensity and months since quitting was assessed at the time of completing the ‘pregnancy questionnaire’: 95% of the ‘pregnancy’ questionnaires were completed in the 3rd trimester of pregnancy . Smoking intensity was asked only if mothers were still smoking at the time of completion of the questionnaire, and represent only the number of cigarettes they were smoking at that time. Maternal pre-pregnancy body mass index (BMI) was calculated as body weight (kg) divided by height squared (mThe primary outcome was term birth weight (grams). In the 3-months questionnaire, parents were asked to report their infant’s birth weight and gestational age from the delivery report. SGA was defined as infants with birth weight below the 10th percentile for gestational age, and LGA was defined as infants with birth weight above the 90th percentile for gestational age according to the standard national growth curve taking into account the infant’s sex and parity .Maternal age, ethnicity, educational level and parity (parity for birth weight only) were considered as potential confounders which were set at priori based on literature . Maternap < 0.05. Baseline characteristics of study participants were reported according to the four exposure categories. Differences in proportions for categorical variables were evaluated using Chi square or Fisher’s exact tests. Means with standard deviations were used to describe the distribution of continuous variables. One-way ANOVA with Bartlett’s test for equal variances was used to test the difference in means between exposure groups.All statistical analyses were performed with Stata statistical software version 12.1 . Statistical significance was defined by a two-sided alpha-level p-value of < 0.20. This conservative level was chosen to be sure that no confounders were missed.Multivariable linear regression analysis was performed to examine the association of maternal smoking during pregnancy, pre-pregnancy overweight, and the combination thereof on term birth weight. The beta-coefficients represent the difference in term birth weight between infants with the exposure of interest and the reference category. Multivariable logistic regression analysis was used to assess the associations of maternal risk factors with the risk of being SGA or LGA. Associations are reported as odds ratios (ORs) with 95% confidence intervals. All potential confounders were included in the full model, then backward elimination was performed to exclude non-significant confounders one at a time until all variables in the model had a After assessing the main effects of maternal smoking and maternal pre-pregnancy overweight, we performed stratified analyses to assess the presence of effect modification. We examined whether (1) the association between maternal smoking during pregnancy and infants’ term birth weight, and the risk of being SGA is modified by maternal pre-pregnancy overweight, (2) the association between maternal pre-pregnancy overweight and birth weight, and the risk of being LGA is modified by maternal smoking during pregnancy.To assess the joint effect of maternal smoking during pregnancy and maternal pre-pregnancy overweight with 95% confidence intervals, we used a 4-category exposure variable  in the regression models with adjustment for the same set of confounders using infants of non-smoking, non-overweight mothers as the reference category. The presence of interaction was not tested statistically due to a lack of power.2), and obese (BMI ≥ 30 kg/m2). Second, we performed a sensitivity analysis taking smoking intensity into account. We expressed smoking intensity (number of cigarettes per day) as a categorical variable. Infants of non-smoking mothers formed the reference category, and infants of smoking mothers were categorized in quartiles of the numbers of cigarettes per day: > 0–2, 3–5, 6–10, and > 10 cig/d. Information on smoking intensity was available for mothers who were current smokers at the time of filling in the ‘pregnancy questionnaire’ which was in the 3rd trimester of pregnancy for 95% of the mothers. Since we defined our maternal smoking variable as smoking during ‘at least the first 4 weeks of pregnancy’, and since 22% of the smoking mothers had quit by the time of filling the ‘pregnancy questionnaire’, we have data on smoking intensity of 78% (429/550) of the infants with smoking mothers. To compare the effect estimates of maternal smoking intensity on birth weight with the effect estimates of the dichotomous smoking variable on birth weight, we repeated the main analysis  were born to smoking, non-overweight mothers, 514 (15.8%) to non-smoking, overweight mothers, 129 (4%) to smoking and overweight mothers. The reference group consisted of 2177 (67.2%) infants who were born to non-smoking, non-overweight mothers. The characteristics of the study population are described according to these categories in Table In infants of mothers who smoked during pregnancy (irrespective of pre-pregnancy overweight) the mothers more often were younger than 25 years, compared to the reference group (9.8 and 10.2% versus 4.9% respectively). In infants of mothers who smoked and also had pre-pregnancy overweight, the mothers more often had a low educational level.In the overall analysis on the association of maternal smoking during pregnancy with birth weight and SGA, infants of smoking mothers had a lower term birth weight than those of non-smoking mothers, with an adjusted mean difference in birth weight of − 158.4 g . The lower birth weight was of similar magnitude in both strata of maternal pre-pregnancy overweight with an adjusted mean difference in birth weight of − 164.5 g  in the stratum without maternal pre-pregnancy overweight and − 145.2 g  in the stratum with maternal pre-pregnancy overweight  than those of non-smoking mothers. The greater risk of being SGA in infants from smoking versus non-smoking mothers was of similar magnitude in both strata of maternal pre-pregnancy overweight with an adjusted OR of 1.96  in the stratum without pre-pregnancy overweight and 1.89  in the stratum with pre-pregnancy overweight . The higher birth weight was of similar magnitude in both strata of maternal smoking during pregnancy with an adjusted mean difference in birth weight of 118.2 g  in the stratum without maternal smoking and 147.7 g  in the stratum with maternal smoking  than those of non-overweight mothers. The greater risk of being LGA in infants from overweight versus non-overweight mothers was of similar magnitude in both strata of maternal smoking during pregnancy where an adjusted OR was 1.79  in the stratum without maternal smoking and 1.61  in the stratum with maternal smoking  using infants of non-smoking, non-overweight mothers as a reference group. Infants of mothers with both risk factors had a similar term birth weight with an adjusted mean difference of − 26.6 g  and a similar risk of being SGA , and LGA  as infants of mothers without both risk factors , risk of being SGA  and LGA  comparable to those of mothers without these risk factors , the lower term birth weight  and increased risk of being SGA  for infants of smoking mothers was also observed in the stratum of obese mothers, and these effects were not different for obese and overweight mothers  was comparable to that in the general population (approximately 5–9%),  but it wThe main effects of maternal smoking during pregnancy  and maternal pre-pregnancy overweight (121.8 g higher birth weight and a 1.75 higher risk of being born LGA compared to infants of non-overweight mothers) that we observed in our study are consistent with findings reported in the literature. Lower birth weight due to maternal smoking in pregnancy may range from 150 to 300 g . For matThe association of lower birth weight with maternal smoking during pregnancy may be explained by many potent constituents of cigarette smoke such as carbon monoxide, polycyclic aromatic hydrocarbons and nicotine , 6, 17. The association of higher birth weight with maternal pre-pregnancy overweight may be explained by maternal over-nutrition, although the exact mechanisms remain unclear , 5, 18. The biological pathways of maternal smoking and maternal overweight on the fetus differ and our study results do not suggest that these biological pathways interfere when both risk factors are present in pregnant women. This indicates that the fetus may be at risk of different adverse outcomes depending on whether the exposure consists of maternal smoking or maternal pre-pregnancy overweight because separate pathways are involved in the exposure-outcome relationship. For example, sudden infant death syndrome and stillbirth are attributed to maternal smoking , 2, 4 anOur findings may have important implications for perinatal practice. We observed that the effects of maternal smoking during pregnancy and maternal pre-pregnancy overweight on the infant’s term birth weight cancel each other out, but the potential adverse health effects during childhood are different for each maternal risk factor and these may add up. Since the infant’s birth weight is often used as a health indicator in perinatal practice, this may mask potential health risks over the life course.Infants from mothers who smoked during pregnancy and who also had pre-pregnancy overweight had a similar term birth weight and similar risk of being SGA and LGA as infants from mothers without these risk factors. This indicates that the lower birth weight associated with maternal smoking and the higher birth weight associated with maternal pre-pregnancy overweight cancel each other out.Additional file 1: Table S1. Associations of maternal smoking during pregnancy with term birth weight and the risk of being SGA; overall and in strata of pre-pregnancy overweight. Table S2. Associations of maternal pre-pregnancy overweight, obesity with term birth weight and the risk of being LGA; overall and in strata of maternal smoking during pregnancy. Table S3. The effects of the combinations of maternal risk factors on term birth weight and the risk of being SGA and LGA. Table S4. Smoking intensity in mothers who smoked during pregnancy by pre-pregnancy overweight status and birth weight of their infants. Table S5a. Association of smoking intensity and birth weight: overall and in strata of maternal pre-pregnancy overweight. Table S5b. Associations of maternal smoking during pregnancy with term birth weight and the risk of being SGA: overall and in strata of maternal pre-pregnancy overweight, similar to Table Table S6. The effects of the combinations of exposure to maternal smoking during pregnancy and pre-pregnancy overweight on term birth weight and the risk of being SGA and LGA.


Hyperhomocysteinemia may be a risk factor for endothelial dysfunction. Folate and vitamin B12 regulate the homocysteine metabolic process. This study aimed to evaluate the associations between subsequent events of adverse pregnancy outcome and early variables of homocysteine, folate, and vitamin B12 in pregnant women.This multicenter, retrospective, case–control study involved 563 pregnant women with adverse pregnancy outcome and 600 controls. Adverse pregnancy outcomes included one or more of the following events: preeclampsia, preterm birth, low birth weight, and stillbirth. The associations between subsequent events of adverse pregnancy outcome and early variables of homocysteine, folate, and vitamin B12; metabolic parameters; inflammatory markers; anthropometrics; and lifestyle habits at 11–12 weeks of gestation were analyzed using the logistic regression model.P < 0.001), folate , folate supplementation  during early pregnancy were independently associated with subsequent events of adverse pregnancy outcome, and vitamin B12 was rejected. Of these, the homocysteine revealed the highest odds ratio in all risk variables, and folate showed the lowest odds ratio in all protective variables.Compared to the lower quartile homocysteine concentrations, the upper quartile homocysteine concentrations were associated with preeclampsia, preterm birth and low birth weight. On the contrary, the lower quartile folate concentrations were associated with preeclampsia, preterm birth and low birth weight compared with the upper quartile folate concentrations. The incidence of adverse pregnancy outcome increased progressively from the first to fourth homocysteine quartiles but decreased progressively from the first to fourth folate quartiles. After adjusting for confounding factors, multivariate logistic regression analysis showed that besides systolic blood pressure, diastolic blood pressure, body mass index and age, homocysteine (IV vs I quartile, aOR 5.89, 95% CI 4.08–8.51, Higher homocysteine concentration and lower folate level during early pregnancy were associated with adverse pregnancy outcome. However, no association was found between vitamin B12 and adverse pregnancy outcome. Supplementation with folate in early pregnancy may reduce adverse pregnancy outcome. Adverse pregnancy outcome (APO) is defined as an event that reduces the opportunity of having a healthy newborn, including preeclampsia, preterm birth, low birth weight, stillbirth, and so on. APOs may lead to severe complications, such as massive postpartum hemorrhage and neonatal death , 2. PreePrevious studies demonstrated that elevated levels of homocysteine (Hcy) were associated with an increased risk of vascular diseases and may cause direct damage to endothelial cells both in vitro and in vivo , 8. MateDespite the harmful effects of Hcy on pregnancy outcomes, numerous related issues remain unknown. This study aimed to analyze retrospectively the relationship between subsequent events of APO and early variables of metabolic parameters, inflammatory markers, anthropometrics, and lifestyle habits in pregnant women at 11–12 weeks of gestation. It also explored the associations of subsequent events of APO with early maternal serum Hcy and folate concentrations and the VB12 status in pregnant women.This multicenter retrospective case–control study was conducted between October 2016 and March 2017 in Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, and Mianyang Hospital of Traditional Chinese Medicine. It included 563 pregnant women with APO, aged 19.33–48.25 (29.78 ± 5.97) years, and 600 non-APO pregnant women aged 21.25–46.68 (28.02 ± 4.38) years matched for age and lifestyle habits (controls).(1) Preeclampsia, which is defined as a new onset of hypertension and proteinuria after the 20th gestational week, or a new onset of hypertension in the absence of proteinuria but combined with hematological complications, renal insufficiency, impaired liver function, neurological symptoms, or uteroplacental dysfunction, diagnosed based on the International Society for the Study of Hypertension in Pregnancy criteria ;(2) Preterm birth, which is defined as babies born alive before 37 completed weeks of gestation;(3) Low birth weight, which is defined by the WHO as a birth weight less than 2500 g, regardless of gestational age, caused by either preterm birth or IUGR, or a combination of both;(4) Stillbirth, which is defined as in utero fetal death at 20 weeks of gestation or greater, unexplained by chromosomal abnormality, anatomic malformation, or congenital infection.A total of 563 APOs in this study included the following events: 234 preeclampsia without other APOs, 118 preterm birth without other APOs, 92 low birth weight without other APOs, 16 stillbirth without other APOs, 30 preeclampsia with preterm birth, 16 preeclampsia with low birth weight, 2 preeclampsia with stillbirth, 12 preeclampsia with preterm birth and low birth weight, 43 preterm birth with low birth weight.(1) Similar age: The age difference between the controls and pregnant women with APO was ≤1 year, and the closest one was selected first.(2) Similar habits: The controls were close to pregnant women with APO in terms of smoking, drinking, and supplementation with folate and VB12.(3) Close delivery time: The delivery time of the controls was less than 1 week from that for pregnant women with APO, and the closest was preferred.While selecting 600 controls, their information of these controls was matched with that of pregnant women with APO as follows:Women with the following causes and diseases were excluded from this study: missing data on some basic information, family history of hereditary diseases, congenital diseases, thyroid dysfunction, cancer, leukemia, or autoimmune diseases, or recent infection of TORCH, abortion, or multiple pregnancies.Fasting blood was sampled with a vacuum blood collection tube in the morning, and the blood was transferred, making it flow down the wall of the tube to minimize the mechanical disruption or turbulence that might result in hemolysis or activation. The sampled blood was vertically placed; the plasma was separated within 30 min, and the serum was separated within 60 min after blood collection. If the serum could not be separated within 60 min, the blood was vertically placed in the refrigerator at 4 °C but separated within 4 hs.The blood was centrifuged for 10 min at 3000 rpm to separate plasma or serum. Fresh plasma was used for measuring the fasting plasma glucose (FPG) level. An aliquot of fresh serum was used for determining the levels of Hcy, folate, VB12, total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), uric acid (UA), and high-sensitivity C-reactive protein (hs-CRP). Another aliquot of serum was frozen and stored at − 80 °C. When the sample collection was completed, the frozen serum was brought up to room temperature by gradual thawing and centrifuged for 10 min at 3000 rpm. The serum supernatant fluid was used for determining the interleukin-6 (IL-6) level.The Sichuan Homocysteine Study was conducted by the Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, the Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, and the Mianyang Hospital of Traditional Chinese Medicine. Standard operating procedures were developed, including inclusion/exclusion criteria, project implementation, biological sample collection, storage, testing, and data collection. Moreover, the main inspection projects of all laboratories participated in the External Quality Assessment (EQA) of the National Center for Clinical Laboratories and achieved good results.The data were retrospectively collected from early pregnant women at 11–12 weeks of gestation. Complete laboratory and clinical data measured by the medical staff  included serum concentrations of Hcy, folate, VB12, TC, TG, LDL-C, HDL-C, FPG, UA, IL-6, and hs-CRP; height; body weight; and blood pressure. Basic information filled in by pregnant women included ethnicity, age, gestational age, reproductive history, history of illness, family history of disease, vitamin (folate and VB12) supplementation (yes or no), and lifestyle habits such as smoking and drinking (yes or no). Non-smoking is defined as never smoked or quit smoking for more than a year, while excessive drinking is defined as drinking more than 200 mL of over 45% alcohol once a week. Information related to pregnancy, labor, birth, and maternal, fetal, and neonatal out comes was also collected. Pregnant women underwent a comprehensive examination (including some free items) when they had a health care data card in early pregnancy, benefiting from the government’s provision of free pregnancy eugenic tests for every couple of childbearing age. The data were completed, and the collection was not so difficult.The concentration of Hcy was determined by the enzymatic cycling assay using a Hitachi 7600 Automatic Biochemistry Analyzer . The levels of TC, TG, LDL-C, HDL-C, FPG, and UA were measured by commercial test kits using the aforementioned analyzer. The concentrations of folate and VB12 were detected by chemiluminescent immunoassay using an ADVIA Centaur XP and matched reagent, calibrator, and quality control materials .Hypercholesterolemia and hypertriglyceridemia, low HDL-C level, and high LDL-C level were defined as TC ≥ 6.22 mmol/L and TG ≥ 2.26 mmol/L, HDL-C < 1.04 mmol/L, and LDL-C ≥ 4.14 mmol/L, respectively, according to the Chinese guidelines on the prevention and treatment of dyslipidemia in adults . GestatiThe cutoff values for quartile distribution of each metabolic parameters considered in the study were Hcy (μmol/L): I < 7.03, II 7.03–7.98, III 7.99–12.60, IV > 12.60; folate (nmol/L): I < 18.31, II 18.31–21.43, III 21.44–29.25, IV > 29.25; VB12 (pmol/L): I < 255.81, II 255.81–401.28, III 401.29–546.90, IV > 546.90; TC (mmol/L): I < 4.43, II 4.43–5.29, III 5.30–5.87, IV > 5.87; TG (mmol/L): I < 1.35, II 1.35–1.57, III 1.58–1.88, IV > 1.88; LDL-C (mmol/L): I < 2.27, II 2.27–2.89, III 2.90–3.65, IV > 3.65; HDL-C (mmol/L): I < 1.22, II 1.22–1.37, III 1.38–1.62, IV > 1.62; FPG (mmol/L): I < 4.25, II 4.25–4.57, III 4.58–4.83, IV > 4.83; and UA (μmol/L): I < 271.63, II 271.63–299.09, III 299.10–372.09, IV > 372.09.The level of hs-CRP was measured by the noncompetitive near-infrared particle immunoassay with a matched high-sensitivity CRP Kit . The concentration of IL-6 was quantified by the step sandwich method with an ACCESS 2 Immunoassay System and matched a reagent and calibrator . Systolic blood pressure (SBP), diastolic blood pressure (DBP), body weight, and height were measured with standard techniques. The body mass index (BMI) was calculated as body weight (kg) divided by the square of height (m).2, 24.0 to < 28.0 kg/m2, and ≥ 28 kg/m2, respectively, according to the guidelines for the prevention and control of overweight and obesity in Chinese adults [2) I < 19.03, II 19.03–21.60, III 21.61–23.40, IV > 23.40.Hypertension was diagnosed when patients’ SBP was ≥140 mmHg and/or DBP ≥ 90 mmHg. Underweight, overweight, and obesity were defined as BMI < 18.5 kg/me adults . The cutt test. Continuous variables with skewed distribution were presented as median (25th to 75th percentiles), and the difference in data between the two groups was analyzed using the Mann–Whitney U rank-sum test. Categorical variables were presented as a percentage and analyzed using the chi-square test.Data were statistically analyzed using the Statistical Package for Social Science version 19.0 . Continuous variables with a normal distribution were expressed as mean ± standard deviation, and the difference in data between the two groups was analyzed using the independent-samples P value < 0.25 in the univariate analysis were retained for further multivariate logistic regression analysis. The adjusted odds ratio (aOR) and its 95% CI were calculated by the multivariate logistic regression analysis  to select the variables independently associated with APO. All P values were two-tailed, and a P value < 0.05 was considered statistically significant.The associations of APO with each of the metabolic parameters, inflammatory markers, anthropometrics, and lifestyle habits  were evaluated by the univariate logistic regression analysis. They were expressed as the odds ratio (OR) and its 95% confidence interval (95% CI). Variables with a P < 0.05). No significant differences were found in hs-CRP, IL-6, and UA concentrations (P > 0.05). Moreover, pregnant women with APO had higher rates of age > 35 years, hypercholesterolemia, low HDL-C, high LDL-C, gestational diabetes, hypertension, overweight, and obesity, and lower rates of folate and VB12 supplementation compared with controls (P < 0.05). No significant difference was observed in the rates of smoking, excessive drinking, hypertriglyceridemia, and underweight between the two groups (P > 0.05). The principal characteristics of 1163 early pregnant women at 11–12 weeks of gestation according to subsequent events of APO and non-APO are reported in Table Compared with controls, pregnant women with APO were characterized by increased serum concentrations of Hcy, TC, TG, LDL-C, and FPG; higher value of SBP, DBP, and BMI; older age; and decreased serum levels of folate, VB12, and HDL-C (P < 0.001), preterm birth (P < 0.001), and low birth weight (P < 0.001). On the contrary, the lower-quartile folate concentrations were associated with preeclampsia (P < 0.001), preterm birth (P < 0.001), and low birth weight (P = 0.001) compared with the upper-quartile folate concentrations. However, compared with the upper-quartile VB12 levels, the lower-quartile VB12 concentrations were associated with only preterm birth (P = 0.008) and not with preeclampsia (P = 0.087) and low birth weight (P = 0.292). No association was observed between the upper-quartile and lower-quartile Hcy, folate, and VB12 for stillbirth.The relative risks of APO categories by quartiles of Hcy, folate, and VB12 in pregnant women are shown in Table P < 0.001). On the contrary, the incidence of APO decreased progressively from 15.99% in quartile I to 13.41% in quartile II, to 10.32% in quartile III, and to 8.68% in quartile IV of the folate distribution (P < 0.001). Similarly, the incidence of APO progressively decreased from 13.93% in quartile I to 11.78% in quartile II, to 11.69% in quartile III, and to 11.01% in quartile IV of the VB12 distribution (P = 0.032). Four APO categories, including preeclampsia, preterm birth, low birth weight, and stillbirth, by quartiles of Hcy, folate, and VB12 distribution in 1163 pregnant women are shown in Figs. The incidence of APO by quartiles of Hcy, folate, and VB12 distribution in 1163 pregnant women are shown in Fig. P < 0.001) and VB12 supplementation . However, it was not significantly associated with smoking  and excessive drinking . Among quantitative variables, Hcy (quartile IV vs I), folate (quartile IV vs I), VB12 (quartile IV vs I), TC (quartile IV vs I), HDL-C (quartile IV vs I), SBP (quartile IV vs I), DBP (quartile IV vs I), BMI (quartile IV vs I), and age (quartile IV vs I) were significantly associated with APO (P < 0.05). However, hs-CRP (quartile IV vs I), IL-6 (quartile IV vs I), TG (quartile IV vs I), LDL-C (quartile IV vs I), FPG (quartile IV vs I), and UA (quartile IV vs I) were not significantly associated with APO (P > 0.05). The associations of APO with each of the early variables of metabolic parameters, inflammatory markers, and anthropometric variables in 1163 pregnant women, as detected by the univariate logistic regression analysis, are shown in Table Among qualitative variables, APO was significantly associated with folate supplementation ; VB12 was rejected. Of these, Hcy revealed the highest OR in all risk variables , and folate showed the lowest OR in all protective variables . The results of the multivariate logistic regression analysis are shown in Table After adjusting for confounding factors, the multivariate logistic regression analysis  showed that Hcy (quartile IV vs I), folate (quartile IV vs I), SBP (quartile IV vs I), DBP (quartile IV vs I), BMI (quartile IV vs I), age (quartile IV vs I), and folate supplementation (yes vs no) during early pregnancy were independently associated with subsequent events of APO (P < 0.05). In addition, pregnant women with APO had higher age (> 35 years), hypercholesterolemia, low HDL-C, high LDL-C, gestational diabetes, hypertension, overweight, and obesity compared with controls (P < 0.05). However, pregnant women with APO had lower folate level and VB12 supplementation compared with controls (P < 0.05). No significant difference was found in the rates of smoking, excessive drinking, hypertriglyceridemia, and underweight between the two groups (P > 0.05).A number of factors before and during pregnancy may affect the events of APO, including maternal age , smokingThe vascular endothelium plays a pivotal role in regulating vasoconstriction and vasodilatation, coagulation and thrombosis, inflammation, and so on . EndotheP < 0.001), preterm birth (P < 0.001), and low birth weight (P < 0.001) compared with the lower-quartile Hcy levels. The incidence of APO increased progressively from quartile I to IV of Hcy levels. After adjusting for confounding factors, the multivariate logistic regression analysis showed that, besides SBP, DBP, BMI, and age, Hcy (quartile IV vs I) was independently associated with APO. Of these, Hcy revealed the highest OR in all risk variables. The present study provided valuable evidence that higher serum Hcy concentrations during early pregnancy were independently associated with subsequent events of APO.In the present study, the upper-quartile Hcy concentrations were associated with preeclampsia . They concluded that low red blood cell folate levels and high Hcy concentrations in women with the second trimester were associated with subsequent reduced fetal growth. A case–control study by Serrano et al. [Folate and VB12 are two vital regulators of the metabolism of Hcy . A signio et al.  confirmeHowever, folate adequacy during pregnancy was associated with a decreased risk of pregnancy-related complications, such as preterm birth, low birth weight, and fetal growth restriction . A birthP < 0.001) and VB12 levels , folate supplementation , and VB12 supplementation . After adjusting for confounding factors, the multivariate logistic regression analysis revealed that the folate level (quartile IV vs I) and folate supplementation (yes vs no) were independently associated with APO, while the VB12 level and VB12 supplementation were rejected. These findings suggested that lower serum folate concentrations during early pregnancy were independently associated with subsequent events of APO.The lower-quartile folate concentrations were associated with preeclampsia, preterm birth, and low birth weight compared with the upper-quartile folate concentrations. The incidence of APO decreased progressively from quartile I to quartile IV of folate concentrations. The univariate logistic regression analysis showed that APO was significantly associated with folate  . AnotherP = 0.04) and 19% lower risk of small for gestational age (SGA) birth  compared with controls [More recently, a large cohort study, including 240,954 pregnant women, demonstrated that folate supplementation before pregnancy was associated with 8% lower risk of preterm birth  and SGA < 5th percentile . It concluded that supplementation with folate significantly reduced the risk of SGA at birth [In addition, a systematic review and meta-analysis based on the UK regional population database analyzed the significance of folate supplementation in pregnancy. It revealed that the pre-pregnancy commencement of folate supplementation was associated with the reduced risk of SGA < 10th percentile . This study also showed that supplementation with 4.0 mg/day folate beyond the first trimester did not prevent preeclampsia in women at high risk of this condition. It indicated that more evidence is needed to explore the relationship between folate and APO.In a multicenter study by Wen et al. , which w2 and ≥ 28 kg/m2, respectively, because the participants were all Chinese, which differed from the usual cutoff of 25–29.9 kg/m2 and 30 kg/m2, respectively, in the general Western population. The prevalence of overweight and obesity, as shown in Table 1, might have slightly changed if the cutoff value appropriate for the Western population was used. However, the result that APO was independently associated with BMI  did not change because BMI quartiles without threshold were used in the logistic regression analysis. Furthermore, APO and control groups had a very low percentage of smoking (2.49% vs 1.67%) and excessive drinking (3.73% vs 4.17%), leading to distorted results of the logistic regression analysis due to sampling bias.The present study had several limitations. First, it did not evaluate the efficacy and safety of the use of high doses of folate supplementation during early pregnancy for APO prevention because it was a retrospective case–control study. In addition, it only measured the concentration of VB12, but not its activity. It is necessary to further determine the activity of VB12 so as to provide a more reliable assessment of VB12 status in early pregnancy. Second, the quantitative parameters were expressed as the quartiles during data analysis in this study, leading to significant bias . Third, the BMI threshold for overweight and obesity in this study was defined as 24.0–27.9 kg/mThis study demonstrated that higher Hcy concentration as a risk factor and lower folate level as a protective factor during early pregnancy were associated with subsequent events of preeclampsia, preterm birth, and low birth weight. The incidence of APO increased progressively from quartile I to IV of Hcy levels, but decreased progressively from quartile I to IV of folate concentrations. Hcy (quartile IV vs I) and folate levels (quartile IV vs I) and folate supplementation (yes vs no) during early pregnancy were independently associated with subsequent events of APO. However, no association was found between VB12 and APO. Supplementation with folate in early pregnancy may reduce APO.


Globally, every year greater than twenty million newborns are born weighing less than 2500grams, of which over 96% of them were in developing countries. It contributes to sixty to eighty percent of all neonatal deaths, annually. These infants weighing less than 2500gram will have a poor immune system and are at risk of morbidity and mortality. This study was aimed to investigate the survival status and predictors of mortality among neonates admitted with low birth weight at public hospitals in Ethiopia.st March 2018 to 28st February 2019. Data were entered into Epi data version 3.02 and exported to STATA V 14 for analysis. The Kaplan Meier survival curve together with log rank test was used to estimate the survival time of the newborns. Variables which had p-value <0.05 in multivariable analysis using the cox proportional hazard model were declared as statistically significant.A prospective cohort study was conducted among selected 216 newborns admitted with low birth weight who were admitted in neonatal intensive care unit at Arba Minch General hospital, Sawla General Hospital and Chencha district hospital from 1The cumulative proportion of surviving at the end of third days was 99.01% . Similarly it was 97.81% , 96.27%  and 94.33%  at the end of fourth, fifth and sixth day respectively. The overall mean survival time was 17.13 days . The incidence of mortality among neonates admitted with low birth weight was 83 per 1000 live births. Mothers with DM , maternal HIV infection, not keeping the newborn under KMC and initiating exclusive breast feeding within one hour were statistically significant in multivariable cox regression analysis.The risk of mortality among neonates admitted with low birth weight was high at the early admission period and the incidence of mortality was high. Maternal history of diabetes mellitus, HIV/AIDS infection, keeping the newborn under kangaroo mother care and exclusive breast feeding initiation were statistically significant predictors of mortality. Special emphasis should be given for neonates with low birth weight at the early follow up periods and Kangaroo mother care practice should be a usual practice. Low birth weight (LBW) is defined by the World Health Organization (WHO) as newborn weight less than 2500 grams . It showGlobally, every year greater than twenty million newborns have LBW, of which over 96% of them were in developing countries. These LBW infants will have a poor immune system and at are at a higher risk of early growth retardation, nutritional deficiencies, decreased muscle strength throughout the life span, higher occurrence of cardiovascular disease, mental disabilities, infectious diseases, delay in developmental status, lower intelligence quotient (IQ) which interferes their school and work performance and death during infancy and childhood ages –7. It isWorld health organization (WHO) launches a strategy mentioned as Global Nutrition Targets 2025: LBW policy brief to achieve a thirty percent reduction in the number of LBW newborn by the year 2025. This strategy will contribute to a three percent reduction per year between the time frame 2012 and 2025 and lowers nearly twenty million to fourteen million infants with low weight at birth [The Ethiopian demographic health survey (EDHS 16) indicate that the estimated neonatal mortality rate (NMR) at 2015/16 was twenty eight per 1000 live births and this estimate accounts 47.5% of the total rate of child mortality . From thDespite the magnitude of low birth weight, the survival time of neonates, incidence of mortality among neonates admitted with low birth weight was not well investigated. Therefore; this study was aimed to estimate the survival and the mortality and investigate predictors of mortality of low birth weight neonates admitted at public hospitals in Ethiopia, 2018–2019.st March 2018 to 28th February 2019.A prospective cohort study was conducted at neonatal intensive care units of Arba Minch General Hospital, Chencha District Hospital and Sawla General Hospital from 1st March 2018 and closed on 28th February 2019. The neonates were followed until they had a maximum age of 28 days. The end point of this study was either death or recovery, loss to follow up, transferred to another institution and follow up time was completed without outcome happening. The study was an open cohort study and any newborn with low birth weight within the study period was entered and leaves the study. Within this time frame, there were a total of 216 neonates with diagnosed low birth weight and the study was conducted among all the diagnosed cases.All neonates admitted to the neonatal intensive care unit (NICU) with diagnosed low birth weight and who had age less than 28 days were the source populations. The follow up period was initiated at admission to the NICU on 1The dependent variable was time to death and the independent variables were socio-demographic factors , maternal medical and obstetrical factors  and neonatal factors .The hemoglobin level of a postnatal mother less than 11gm/dl.If she has chlamydia OR human papilloma virus OR syphilis OR Gonorrhea OR trichomoniasis OR herpes.Individuals who were chewing khat within 3 months preceding the study.The total number of times that the woman has been pregnant.A low birth weight neonate who had perinatal asphyxia OR birth injury OR hypothermia OR clinical or confirmed sepsis OR malaria OR neonatal jaundice OR any other health problem.Data were collected by trained data collectors using a structured checklist. Both primary and secondary data were used. Primary data were collected from the mothers after admission to the hospital (post admission) at the postnatal ward, which was private for each of the mothers. Data quality was assured by caring out careful design of data extraction tools, training of both the data collectors and supervisors. Over more; pretest was conducted in 5% of the populations to improve the skill of data collectors and to ensure the consistency of the data extraction tool.Epi data version 3.02 was used to enter the data, code the data, edit the data and clean the data and finally exported to STATA version 14 to conduct statistical analysis. The empirical relationship among the outcome variable and the explanatory variables was determined using bivariate statistical analysis. Both Crude hazard ratio (CHR) and adjusted hazard ratio (AHR) together with the corresponding 95% confidence interval and P-value were used to assess the strength of association and statistical significance. The Kaplan Meier survival curve together with log rank test was fitted to determine the survival time. Variables which had p-value <0.05 in bivariate analysis were considered as candidate for multivariable analysis and variables which had p-value <0.05 in multivariable cox regression analysis were considered as statistically significant.Ethical clearance was obtained from Arba Minch University, college of medicine and health sciences ethical review board. In addition; permission letter was obtained from the Arba Minch University. A written consent was obtained directly from the mothers. Mothers who did not read and write were informed about the information written on the informed consent. Over more, mothers were informed about the objective and significance of the study prior to the data collection. Appropriate measures were applied to ensure the confidentiality of the data.In this study, a total of 216 neonates admitted with low birth weight were involved. Among them, 18 neonates were died. A total of 175(81%) of the neonates were categorized under the age less than seven days. This age category accounts 11(61.1%) of them were of the dyed neonates. In addition; a total of 133, 10, nine and seven neonates were admitted at the age of first, second, third and fourth days of life respectively. There was no any observed death at the first days of life while equal numbers of neonates (two neonates) were died at second, third and fourth days of life respectively. Males account 12(65.7%) of the total admitted newborns with low birth weight and 61.1% of the dyed neonates. In considering maternal age, 29(13.4%), 147(68.1%) and 40(18.5%) were categorized under less than 20 years old, 20–34 years old and more than 34 years old respectively. Similarly, 3(16.7%), 6(33.3%) and 9(50%) of the dyed new born categorized on the same maternal age respectively.In considering the marital status of the mothers, nearly one tenth (9.7%) of the mothers were singles in their marital status and 77.8% of the dyed neonates were delivered from single mothers. Regarding their religious status, majority of the mothers were Orthodox and Protestant which accounts 94(43.5%) and 70(32.4%) respectively. Most of the mothers (30.6%) attended grade 1–8 followed by read and write (24.1%). The remaining 28(13%), 44(20.4%) and 26(12%) were unable to read and write, grade 9–12 and college and above in their study.Regarding the occupational status of the mothers, nearly one tenth (10.2%) and one fourth (25.5%) of the mothers were house wives and self-employee respectively. The remaining 31%, 22.7% and 10.6% were farmers, merchants and civil servants respectively. In considering the family size and estimated monthly income of the families, 101(46.8%) have family size less than four and 65(30.1%) had four to six family sizes. In addition 15(6.9%), 52(24.1%), 76(35.2%) and 73(33.8%) have estimated monthly income less than 40$, 40$-56$, 57$-73$ and more than 73$ respectively. In considering the mortality, 61.1% of the neonates were died among families having family size more than six and 44.4% were among the families having estimated monthly income of less than 40$.Table 1).Most of the mothers (72.2%) were urban residents and around one fifth (19.9%) have a distance more than 50 kilometers between their home and the nearby hospital. Similarly, 43(19.9%) of them have between 10–50 kilometers and 130(60.2%) had less than 10 kilometers between their home and the nearby hospital. In considering the maternal habits, 23(10.6%) of the mothers and 27(12.5%) of the mothers had a habit of chewing khat and alcohol intake respectively Regarding to the number of antenatal care visits, 24(11.1%) of the mothers did not attend any antenatal care. The remaining 66(30.6%), 49(22.7&), 47(21.8%) and 30(13.9%) of the mothers attend one, two, three and four and above antenatal visits respectively. In considering mortality among the dyed newborns, maximum number (33.3%) of the dyed were among mothers who did not attend any antenatal visits while the remaining 5(27.8%), 3(16.7%), 2(11.1%) and 2(11.1%) were among the categories of mothers who have attended one, two, three and four & above antenatal visits respectively. In considering total number of pregnancy, 74(34.3%), 44(20.4%) and 98(45.4%) of the mothers were primigravid, two to four and above four instance of pregnancy respectively. Seventy four (34.3%), 44(20.4%) and 98(45.%) of the mothers had one, two to four and above four number of alive births respectively and among them 8(44.4%), 6(33.3%) and 4(22.2%) of the newborns were dyed among each categories of parity respectively.Nearly three fourth (75.5%) of the neonates were delivered at health institution and 102(47.2%) of the new born delivery was attended by health professionals and the remaining 61(28.2%), 26(12%) and 27(12.5%) were attended by health extension workers, trained traditional birth attendants and relatives respectively. Magnitude of mortality was high (66.7%) among the home delivered newborns and least number (11.1%) of neonates were died among delivery attended by health professionals. Regarding to the gestational age of the newborn, 89(41.2%), 126(58.3%) and 1(0.5%) of the newborns were delivered at less than 36, 37–72 and more than 42 weeks of gestation respectively and among each categories of gestational age, 10(55.6%), 7(38.9%) and1(5.6%) died respectively.Table 2).Regarding the medical history of the mothers, 57(26.4%), 55(25.5%), 37(17.1%), 51(23.6%), 19(8.8%) and 22(10.2%) of the mothers have a history of pregnancy induced hypertension, bleeding during pregnancy, urinary tract infection or sexually transmitted infection, iron deficiency anemia, diabetes mellitus HIV/AIDS respectively  were cried immediately at birth. Among the newborns delivered at health institution, 33(15.3%) and 130(60.2%) had first minute APGAR score less than seven and above seven respectively. Similarly, 30(13.9%) and 133(61.6%) had the fifth minute APGAR score less than seven and above seven respectively. Similarly, 14(6.5%) of the newborns were resuscitated at birth.Table 3).Regarding the exclusive breast feeding initiation among the admitted newborns with low birth weight, 126(58.3%) were initiated exclusive breast feeding within one hour after delivery and 154(71.3%) feed only breast milk during their ages. Similarly, 165(76.4%) were kept in kangaroo mother care within one hour and 42(19.4%) had concurrent health problems .The cumulative proportion of surviving at the end of third days was 99.01% . Similarly it was 97.81% , 96.27% , 94.33%  and 91.46%  at the end of fourth, fifth, sixth and seventh day respectively. The overall mean survival time was 17.13 days  while the overall median survival time was 16 days . There was no any observed death at the first follow up day and there were equal number of death (two deaths) at the second, third, fourth and fifth days. More than one fourths (22.2%) of the deaths were reported within the first three days and 44.4% of the deaths were observed within the first seven days whereas the number of deaths observed within the first 14 days of follow up were 44.8%. In this study, 18(8.3%) of the newborns with low birth weight were died and 198 (91.7%) were recovered. In addition, there was no transfer out, no neonate who withdrew treatment, no any loss to follow up and no any follow up period completed before their status was known .Table 4).Among the socio demographic characteristics, marital status, place of residence, maternal history of chewing khat, maternal history of alcohol intake were variables which have p-value less than 0.05 in log rank estimate of mortality (Table 5).Among the maternal and obstetrical factors, place of delivery, maternal history of pregnancy induced hypertension, history of maternal iron deficiency anemia, history of maternal diabetes mellitus and history of maternal diagnosed HIV status were variables having p value less than 0.0 in log rank survival estimate (Table 6). Figs Figs In considering variables related to the neonatal characteristics, neonates kept in kangaroo mother care within one hour, exclusive breast feeding initiation within the first hour of delivery, type of feeding within the first 28 days of life and having history of concurrent health problems were factors that have p-value less than 0.05 in log rank estimate of mortality (Table 7).In this study, since the maximum observation time was censored, the median survival time was not determined; hence the mean survival time was the best measure of central tendency. The overall mean survival time for the predictor maternal history of diabetes maternal history of having HIV infection mellitus, keeping the newborn in kangaroo mother care within one hour of delivery and initiating exclusive breast feeding within one hour was 17.13: 95%CI: 12.76, 21.49) days .Newborns with low birth weight who have developed by mothers with history of diabetes mellitus have four times higher hazard of mortality as compared with the counterparts who did not have history of diabetes mellitus . The risk of mortality among newborns with low birth weight delivered by mothers with a history of HIV/AIDS was 6 times higher as compared with mothers who did not have a history of HIV/AIDS . Newborns with low birth weight who did not kept in kangaroo mother care within one hour of delivery had 13 times higher hazard of mortality as compared with the counterparts who were kept in kangaroo mother care within one hour . The risk of mortality among newborns with low birth weight who have initiate exclusive breast feeding within one hour was 81% higher as compared with those who did not initiate exclusive breast feeding within one hour . This study finding is consistent with the study conducted at rural Ethiopia . This miConsistent with the study conducted at University of Gonder specialized hospital, the risk of mortality among newborns with low birth weight delivered by mothers with a history of HIV/AIDS was 6 times higher as compared with mothers who did not have a history of HIV/AIDS  .Similar with the study conducted at Palwal and Firdabad districts in the state of Haryana, India, newborns with low birth weight who did not kept under kangaroo mother care within one hour of delivery had 13 times higher hazard of mortality as compared with the counterparts who were kept under kangaroo mother care within one hour  . This miEvidence derived from hospital-based studies shows that kangaroo mother care results in a forty percent relative reduction in mortality, a fifty eight percent relative reduction in the risk of hospital acquired infections or sepsis, short duration of hospital admission, and a lower risk of reduced respiratory tract infections. In addition; it increases babies’ needs of warmth, increased breast feeding, and protects the baby from infection, safety, and love . SimilarThe risk of mortality among newborns with low birth weight who had initiate exclusive breast feeding within one hour was 81% higher as compared with those who did not initiate exclusive breast feeding within one hour . This study finding was consistent with the study conducted at Ghana . This coThe first minute and the fifth minute APGAR score, gestational age, multiple gestation, concurrent health problems and feeding of the neonate within the first 28 days of life were declared as statistically significant in previous studies but they are not statistically significant in this study , 38–40. The survival status of the neonates admitted with low birth weight was low at the early admission period especially at the first week and gradually increases at the later follow up weeks (after two weeks of follow up). The incidence of neonatal mortality was high and maternal history of diabetes mellitus, HIV/AIDS infection, keeping the newborn in kangaroo mother care and exclusive breast feeding initiation were statistically significant in multivariable cox regression analysis.Neonates admitted to the NICU with LBW should be intensively followed especially at the early admission periods and the practice of keeping the newborn under KMC within one hour should be highly encouraged. In addition; mothers should be informed and encouraged to initiate exclusive breast feeding immediately after birth and neonates delivered with mother having DM and HIV/AIDS should be followed and encouraged to attend the health institution regularly.S1 Data(DTA)Click here for additional data file.S2 Data(DOCX)Click here for additional data file.


Maternal lifestyle is an important factor in the programming of an infant’s epigenome, in particular when considered alongside the mode of birth and choice of feeding method . Beginning in utero, and during the first two years of an infant’s life, cells acquire an epigenetic memory of the neonatal exposome which can be influential across the entire lifespan. Parental lifestyle  can modify both the maternal and paternal epigenome, leading to epigenetic inheritance in their offspring. This review aims to outline the origin of early life modulation of the epigenome, and to share this fundamental concept with all the health care professionals involved in the development and provision of care during childbirth in order to inform future parents and clinicians of the importance of the this process and the key role it plays in the programming of a child’s health. S-adenosyl-methionine (SAM), the universal methyl donor, which is the final product of the one carbon cycle. In particular, the one carbon cycle combines the folic acid cycle with the methionine cycle to synthetize the SAM, which donates methyl groups to both DNA-methyltransferases (DNMTs) and HMTs [Nutri-epigenetics is the study of the role of dietary components in the modulation of the epigenome ,2. Food and HMTs . Indeed,and HMTs ,5 and coand HMTs . DNA metand HMTs ,2,3. To NF-kB which controls the gene expression of proinflammatory cytokines [Gut microbiota also play an important function in epigenome remodeling . The metytokines . ButyratConsidering the interplay between nutrition, gut microbiota and the epigenome, the first aim of this review is to describe the connections between early life nutrition , childbirth  and mode of care with gut microbiota modulation. Second, the role of maternal lifestyle in the programming of the infant’s health will be described, highlighting the impact of early life modulation of the epigenome. Finally, this review aims to share this fundamental information with all the health care professionals involved in maternity care, in order to promote the delivery of the best practices around birth.Epigenetics etymologically means “on top of” or “in addition to genetics” to highlight the fact that it modulates gene expression without any change in the nucleotide sequence. Epigenetics contributes to cell differentiation during the first 1000 days of life—a period that includes forty weeks of pregnancy plus the first two years of life. DNA methylation switches genes off in order to differentiate more than 250 cell types that characterize tissues and organs in our body. Cells acquire an epigenetic memory of the neonatal exposome which is maintained throughout life.Environmental cues  can regulate phenotypic diversity in the same genome and can influence the inheritance of epigenetic marks ,12,13,14Therefore, if the environmental cues are unhealthy , unwanted changes in the epigenome can occur, and alterations of gene expression could be observed later in life  increasing the risk for multifactorial environmentally driven diseases ,5.IL10, INS-IGF2, GNASAS, LEP, ABCA1 and MEG3) [RXRA) in umbilical cord blood and an increase of fat mass in 6- and 9-year-old children [50) during their brain development [In support of this theory, several studies have found that maternally induced epigenetic programming and malnutrition  during pregnancy can modulate body mass index, glucose tolerance, cardiovascular disease risk in the infant. The extent to which epigenetic programming is affected is influenced by both gender and the period of exposure to environmental factors. Severe maternal famine  exposure during the first trimester of pregnancy has been associated with changes in the promoter methylation of several genes  ,16,17. Lnd MEG3) ,16,17. Mnd MEG3) . The conchildren . Correlachildren . Stress children . Perkeybchildren  demonstrchildren . This evchildren ,25. Streelopment .Paternally induced epigenetic programming has been observed . OffspriIn summary, both epigenetic marks from mothers before and during pregnancy as well as those acquired from fathers can be inherited by the fetus. Malnutrition, alcohol, stress, smoking, xenobiotics and drugs can modify the epigenome of the future parents and the altered epigenetic marks potentially can be inherited by their offspring leading to epigenetic changes associated with the features of metabolic syndrome ,33,34.Moreover, further evidence derived from studies carried out on rodents demonstrates that small non-coding RNAs (sncRNAs) levels in sperm are influenced by the father’s life-style and environment. These sncRNAs contribute to the regulation of gene expression and endogenous mRNA transcription, and they play an important role in the post-fertilization zygote influencing early embryonic development . Early pDrosophila, also when the offspring received a normal fat diet (NFD) [Both intergenerational  and transgenerational  inheritance have been demonstrated in animal models . Cardiacet (NFD) . A signiet (NFD) . This stet (NFD) ,39. The et (NFD) ,39. Humaet (NFD) .The epigenetic impact of environmental cues and the epigenetic reversibility have their main plasticity during the first 1000 days of life: this is the “window of plasticity”, i.e., the period of life when the control of the future generations’ health can be properly addressed.Bacteroides and Bifidobacterium compared to infants born full term [It is yet to be established if any interaction with different bacteria via the placenta, umbilical cord or amniotic fluid actually occurs ,41,42 anull term . Their mull term . Moreoveull term .Staphylococci. Dominguez-Bello et al., [Lactobacillus, Prevotella or Sneathia spp.) were commonly found in infants born vaginally while maternal skin microbes  were prevalent in infants born by CS. Shao et al., [Bacteroides strains and opportunistic pathogens , and that a similar picture can be observed in babies born by vaginally from mothers treated with antibiotics as well as in infants who are formula fed. Microbial composition in babies born vaginally consisted of up to 68.3% of Bifidobacterium, Escherichia, Bacteroides and Parabacteroides species [Bacteroides and Parabacteroides in infants born vaginally, while an increase in the Staphylococcus was described following CS. Penders et al., [Bifidobacteria and Bacteroides fragilis when compared to those born vaginally. A 100-fold higher level of Clostridium difficile strains and increased level of Escherichia coli have been identified in the gut of babies delivered by CS than in those who were born vaginally and received exclusively breastfeeding [Actinobacteria and Bacteroidetes phyla and a higher abundance and diversity of the phylum Firmicute than in vaginally delivered infants. In addition, colonization of Bifidobacterium and Bacteroides genera, are present more frequently in vaginally derived infants when compared to babies delivered by CS, who in turn are preferentially colonized by Clostridium [Acinetobacter spp., Bifidobacterium spp. and Staphylococcus spp., while infants born by CS predominantly have Citrobacter spp., E. coli and Clostridium difficile strains. Shi et al. [Propionibacterium species in vaginally delivered babies, while in infants delivered by CS, there was a high presence of Bacillus licheniformis.Babies born by CS have more contact with the environmental microbiota  than with their mother’s microbiota (where exposure takes place in the vagina), resulting in a strong presence of epidermal  et al.,  identifi et al.,  observed species . Wampach species  similarl et al.,  observedtfeeding . A systetfeeding  highlighstridium . Moreovestridium  on Chinei et al.  observedBifidobacterium in the infant’s gut when compared to those who are formula-fed [Lactobacillaceae, inducing the production of the protective IL-22 and enhancing gut barrier. Animal food  has been associated with a decrease of Firmicutes  and an increase of Enterobacteriaceae (Shigella and Escherichia), while a high fiber diet promotes an increase in Bacteroidetes  and depletion of Firmicutes [Bifidobacterium, Lactobacillus, Akkermansia and Faecalibacterium sp. and decrease in pathogenic organisms  [Lactobacillus and Bifidobacterium and decreasing E. coli [Subdoligranulum, Ruminiclostridium, Intestinimonas, Pseudoflavonifractor, Paenibacillus, Marvinbryantia) which have been associated with an antihypertensive function in later life [Bifidobacteria, Akkermansia and Lactobacilli) [Gut microbiota are healthier and more diverse in babies born vaginally when compared with infants born by CS. In addition, babies born vaginally also demonstrate an increased richness and diversity in microbiota which are associated with a healthy phenotype. The presence of different strains of bacteria in the gut can be modulated by food intake and postnatal factors such as maternal diet, breast feeding, formula-feeding and weaning . Breastfmula-fed . The cromula-fed  showed trmicutes . Polyphecus sp.) . Vitamin E. coli . Pre- an E. coli . Vitaminter life . Vitaminbacilli) . This evThe composition of gut microbiota can influence neuronal development and homeostasis in the infants ,64. The Administering antibiotics has the potential to selectively alter the composition of gut microbes. The effect on both mother’s and child’s health of administering antibiotics during pregnancy or around the time of birth has not been completely elucidated. Several studies have been carried out to investigate the potential adverse effects of using antibiotics prenatally, during pregnancy or neonatally on the baby’s gut microbiome and the development of the infant immune system—possibly leading to childhood atopy, asthma, allergy and obesity ,68.In contrast, studies in which mice had their microflora remodeled by broad-spectrum antibiotics show that this treatment induces changes in regulatory T-cells conferring protection against experimental autoimmune encephalomyelitis (EAE), in animal model of CNS demyelinating disorders . This toCurrent research regarding the effect of antibiotic administration during pregnancy and birth gives insufficient attention to the confounding variables . In most studies, there is a lack of control for the timing of the use of antibiotics, the type and class of antibiotic and whether it is broad spectrum or not, the indication and the number of antibiotic courses administered ,74.In conclusion, gut microbiota composition at birth can be modulated by vaginal or CS birth, antibiotic administration and maternal diet. Since the presence of different strains of bacteria in the gut are associated with the production of metabolites able to positively modulate immune and metabolic responses in the infants, particular attention should be given by clinicians and healthcare professionals to promote gut microbiota diversity, maternal diet and mode of birth in order to maximize outcomes for mother and infant.”in the absence of other indications for early delivery, cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks; and, given the high repeat cesarean delivery rate, patients should be informed that the risks of placenta previa, placenta accreta spectrum, and gravid hysterectomy increase with each subsequent cesarean delivery” [Significant progress in terms of surgical skills, blood transfusion, the development of antibiotics, etc., has reduced the mortality associated with CS and has reduced the risk to both mothers and neonates. As CS became a safer procedure, CS rates have increased worldwide . For example, in Italy, CS rates in the 1980s were approximately 11% and had peaked to 38% by 2018. Similarly, in Australia, rates have increased from 11.8% to 47.4% across 81 hospitals with rates of 82.1% among 61,894 maternities with one previous CS . This hielivery” .An inappropriate use of surgery in childbirth has led not only to an increase in CS births, but also to a corresponding fall in vaginal birth after cesarean (VBAC) rates without any improvement in maternal or neonatal mortality . MoreovePerforming a VBAC is difficult as it remains prohibited in some countries contrary to the evidence and guidance produced by the National Institute of Health (NIH) and the American College of Obstetricians and Gynecologists (ACOG) who continue to recommend a “Trial of Labor after Cesarean” (TOLAC) for women who had one previous CS . The safMode of birth is not only an obstetric issue as giving birth by CS affects the epigenetic state of different neonatal systems. In the case of CS birth, many babies are born before or at 39 weeks gestation, most mothers receive intraoperative antibiotics which has been shown to affect microbiota colonization of the infant’s gut which have been linked with a higher risk of specific diseases such as asthma, coeliac disease, obesity . This isMode of birth does affect the epigenetic state of hematopoietic stem cells . This maOf note, it has been shown that infants who were born by CS may experience cognitive and motor development delay at nine months of age . AnotherHuman breast milk is an optimal food for infants, not only because of its constituents, but also because of its dynamic nature, which changes to meet infant requirements as he/she grows. The variety of nutrients and bioactive molecules contained in breastmilk contribute positively to healthy growth and neurodevelopment. Several studies have shown that maternal nutritional status has an impact on milk composition, which in turn affects infant development .Epidemiological studies on the long-term effect of breastfeeding on health have shown that breastfeeding in the first six months of life positively impacts on the infant’s anti-inflammatory responses, body mass index and blood pressure ,99,100. rhesus macaques, Liu et al. [Observational studies have shown that a high protein intake associated with formula feeding is connected to rapid weight gain and obesity later in life in . A multiu et al.  demonstrLongitudinal studies on children have shown that breastfed babies have healthier dietary patterns later in life, compared to children who were formula-fed ,107. TheExclusive breastfeeding (EBF) plays an important role in establishing the neonatal gut microbiota, leading to short and long-term benefits across different populations . AlthougBacillales, Lactobacillales and Clostridiales when compared to other infants in different feeding groups. In preterm infants there is a high risk of dysbiosis of the gut microbiome as prematurity of the gut microbiota together with the preterm breast milk composition and the environment of the neonatal intensive care unit, pose a significant challenge in neonatal nutritional care [While EBF has been found to be beneficial for the composition of the gut microbial colonization in term infants, there is limited evidence about the influence of type of feeding on the gut microbiome of preterm infants . Studiesnal care .Although the benefits of breastfeeding are widely accepted, challenges to find optimal ways to support mothers to continue to BF following initiation remain. Begley at al.  found thIn summary, breastfeeding has a key role in the modulation of gut microbial composition and as a consequence has a positive impact on health in the long-term. The duration of breastfeeding, whether its exclusive or not and maternal nutritional status while breastfeeding can have a significant impact on the infant’s health. Midwifery care in particular when targeted towards women who require additional support may have benefits to mothers and babies across the lifespan .Birth is the outcome of a complex evolutionary process in which an intricate neurohormonal system mediated by oxytocin  plays a To date, our understanding of the role of mode of birth  is limited in terms of knowing if vaginal birth or CS can actually result in negative physiological consequences for infants, either in the short or in the long-term or both. It has been established that the normal process of labor, which often takes many hours, exposes the infant to many mechanical, hormonal and oxidative stresses potentially influencing physiology and life-long health. The three main mechanisms proposed to explain why mode of delivery, spontaneous, induced and/or augmented vaginal delivery versus CS, may affect neonatal development are: (1) exposure to varying levels of physical stress and stress hormone surges during birth; (2) differences in microbial colonization of the infant intestinal tract between vaginal birth and CS; and (3) epigenetic modifications of gene expression ,116. HowBirth in hospital with a concurrent increase in the medicalization of the birth process has resulted in an overuse of intrapartum interventions and a global rise in CS as “mode of birth” . TherefoHowever, further research is required to establish if a link exists between maternal and infant epigenetic outcomes and the level of intervention/interference in the childbirth process ,121, incThe study of nutri–epigenetic processes highlights important potential changes in the epigenome related to mode of birth, maternal lifestyle, method of infant feeding, etc. that can develop our understanding of how adult health is programmed during the first 1000 days of life. The parental epigenome can be modified across the lifespan and the epigenetic marks of events that occur in utero can be inherited by progenies. Therefore, clinicians and healthcare professionals, who are offering care to families during pregnancy and childbirth should take the opportunity to inform parents of the long-term effects of an unhealthy diet and the benefits of breastfeeding across the lifespan. The positive impact of breastfeeding on gut microbiota differentiation and control of proinflammatory biomarkers later in life for the child and mother should be emphasized in order that women can make an informed choice for their own health and that of their newborn. Therefore, the importance of epigenetic research as a way of understanding the intergenerational impact of birth practices on the programming of the infant’s epigenome should not be underestimated.


Previous studies showed that thyroid dysfunction in women with gestational hypertension could negatively affect maternal and fetal outcomes. In this study, we aimed to investigate whether thyroid dysfunction assessed in the second half trimester contributed to neonatal outcomes of pregnancy in different subtypes of gestational hypertension disease.We performed a retrospective case-control study and collected data from 135 singleton pregnant women with gestational hypertension disease and their offspring who delivered in Renmin Hospital of Wuhan University from January 2015 to June 2017. We classified the patients based on the severity of the preeclampsia into three groups: pregnant induced hypertension (PIH), mild preeclampsia (MPE) and severe preeclampsia (SPE). Based on the onset time of preeclampsia, we classified the patients into PIH, early onset preeclampsia (EPE) and late onset preeclampsia. Demographic data and levels of thyroid hormones, as well as the adverse maternal and neonatal outcomes were collected from Electronic Medical Records. Logistic regression was used to estimate the associations between thyroid dysfunction and neonatal outcomes in these patients.P < 0.001). Thyroid dysfunction was more frequent in the SPE group than in the MPE group (P = 0.01). Incidences of both preterm birth and low birth weight were significantly higher in patients with thyroid dysfunction . After adjustment, both severity of gestational hypertension  and thyroid dysfunction  were associated with higher risk of preterm birth and low birth weight, while the onset time of preeclampsia  was negatively associated with the risk of preterm birth and low birth weight.Gestational weeks and neonatal birthweight were significantly lower, while incidence of preterm birth was significantly higher in the SPE and EPE groups than those in the PIH group (Severe and early onset preeclampsia, as well as thyroid dysfunction are associated with higher risk of preterm birth and low neonatal birth weight. Therefore, our data suggest that monitoring thyroid hormones in women with preeclampsia might help to predict adverse neonatal outcomes. Preeclampsia is a major public health problem due to its frequency as well as its related maternal and perinatal morbidity and mortality, with a prevalence of 4.6% among pregnant women worldwide . It is nThyroid dysfunction is common among pregnant women. According to previous reports, the prevalence of clinical overt hyperthyroidism or subclinical hyperthyroidism is about 0.1–0.4% during pregnancy. The prevalence of hypothyroidism is about 2.5%, with clinical hypothyroidism accounting for 0.2–0.3%, and subclinical hypothyroidism for 2–3% [. do not find any increased incidence of preeclampsia in subclinical hypothyroid women [Hypothyroidism is known to be one of the causes of hypertension . Both unid women . Medici id women  have fouTherefore, the relationships between thyroid dysfunction and pregnancy outcomes in preeclampsia still needs to be clarified. It is known that the placental dysfunction is more likely to occur in the early onset preeclampsia at < 34 weeks of gestation , 27 and This was a retrospective case-control study. Overall, 135 singleton pregnant women who developed gestational hypertension disease and their offspring delivered in Renmin Hospital of Wuhan University from January 2015 to June 2017 were consecutively enrolled in the study. All the data were collected from the electronic medical record system, such as age, gestational age, prenatal examination, neonatal information and neonatal complications, etc. Blood routine, hepatic and renal functions, blood glucose, blood lipid, coagulation function and thyroid functions were all performed at the laboratory department of our hospital during hospitalization in the second half trimester of pregnancy. The primary outcomes were the maternal and fetal complications, i.e. preterm birth and low birth weight. The Ethics Committee of Renmin Hospital of Wuhan University approved the study (in accordance with the Helsinki declaration). Inclusion criteria: 1. maternal age between 20 and 40 years old; 2. no chronic diseases before pregnancy, such as chronic hypertension, cardiovascular and cerebrovascular diseases, autoimmune diseases (SLE etc.), thrombotic diseases, diabetes, thyroid endocrine diseases, hepatic and renal diseases, mental diseases, etc.; 3. it was a singleton pregnancy; 4. adequate iodine intake in daily diet; 5. delivered in our hospital. Exclusion criteria: 1. pregnant women with history of thyroid related diseases before pregnancy and taking medicines for thyroid diseases; 2. pregnant women with unhealthy diet habit; 3. pregnant women without follow-up; 4. pregnant women without results of thyroid function test; 5. pregnant women with diabetes or gestational diabetes or some other endocrine diseases.  if they had a systolic blood pressure ≥ 140 mmHg and/ or diastolic blood pressure ≥ 90 mmHg on at least two occasions first occurring after 20 gestational weeks.Preeclampsia was defined as gestational hypertension in combination with one or more of the following new-onset conditions: proteinuria (urinary protein dip sticks ≥1+ or ≥ 300 mg/24-h); other maternal organ dysfunction, including renal insufficiency, hepatic dysfunction, neurological complications, and hematological complications; and uteroplacental dysfunction [Preterm birth was defined if babies were born before 37 gestational weeks.Low birth weight was defined as birth weight less than 2500 g.According to the guidelines for the management of thyroid disorders during pregnancy and postpartum issued by the American thyroid association in 2017 , the defClinical hypothyroidism: a. serum thyrotropic hormone (TSH) > 4 mIU/L, and serum free thyroxine (FT4) < lower limit of normal reference b. serum TSH > 10 mIU/L, with or without FT4 reduction.Subclinical hypothyroidism: serum TSH > 4 mIU/L but no more than 10 mIU/L, serum FT4 is within the reference range.Hypothyroxinemia: serum FT4 < the lower limit of normal reference value, and TSH is within the range of gestation-specific thyroid function reference value.Gestational thyrotoxicosis: when TSH is less than 0.1 mIU/L, FT4 > gestational specific value reference upper limit.Hashimoto thyroiditis: serum thyroid peroxidase antibody (TPOAb) ≥ 40 mIU/L.Serum TSH, FT4, free triiodothyronine (FT3) and TPOAb levels were measured using electrochemi-luminescence immunoassay . The reference ranges of FT4 in our hospital is 0.89–1.8 ng/dL; the reference ranges of FT3 in our hospital is 2.3–4.2 pg/mL.Based on the severity of the preeclampsia, we classified the patients into three groups 1) pregnancy induced hypertension (PIH), 2) mild preeclampsia (MPE), PIH with urinary protein dip sticks ≥1+ or ≥ 300 mg/24-h, and 3) severe preeclampsia (SPE), MPE plus at least one additional adverse condition including systolic blood pressure ≥ 160 mmHg and/ or diastolic blood pressure ≥ 110 mmHg or urinary protein dip sticks ≥3+ or ≥ 5 g/24-h or other maternal organ dysfunction. According to the onset time of the preeclampsia, we classified the patients also into three groups a) PIH b) early onset preeclampsia (EPE), preeclampsia appearing before 34 gestational weeks, and c) late onset preeclampsia (LPE), preeclampsia appearing at or after 34 gestational weeks . The comP < 0.05 was considered to indicate statistical significance, while P < 0.017 was considered statistically significant for multiple comparisons in chi-square test and Kruskal Wallis Test. All calculations were performed using the SPSS Version 19.0.The data were expressed as frequencies or percentages for categorical variables and as means and standard deviations for normally distributed continuous variables, or medians and interquartile ranges for non-normally distributed continuous variables. Differences between the groups were compared by the chi-square or Fisher’s exact test for categorical variables and multiple comparisons in ANOVA or Kruskal Wallis Test for continuous variables. Associations between thyroid dysfunction, gestational hypertension disease and neonatal outcomes were assessed by using the logistic regression. Unadjusted and adjusted odds ratios , as well as 95% confidence intervals (95%CIs) were calculated. P < 0.001). Thyroid dysfunction was more frequent in the SPE group than in the MPE group (P = 0.01). Brain natriuretic peptide (BNP) was significantly higher in the SPE group than that in the PIH group (P = 0.002).Of the 135 patients, 30 were PIH, 20 were MPE, and 85 were SPE. There were 7 cases of fetal growth restriction (FGR), 3 cases of placental abruption and 2 cases of pleural effusion in these patients. All 7 cases of FGR, 2 cases of pleural effusion and 2 cases of placental abruption occurred in patients with SPE, while only one case of placental abruption was found in patients with MPE. Table P = 0.010, P = 0.005 respectively). The gestational week was significantly earlier, the neonatal birth weight was significantly lower, and the preterm birth rate was significantly higher in the EPE group compared with the other two groups (P < 0.001). The EPE group also had the highest rate of thyroid dysfunction (71.9%).Table P = 0.008; 45.1% vs. 27.1%, P = 0.047). In the study population, both the severity of gestational hypertension  and thyroid dysfunction  were associated with a higher risk of preterm birth, while the onset time of preeclampsia  was negatively associated with the risk of preterm birth. Similarly, both the severity of gestational hypertension  and hypothyroidism  were associated with an increased risk of low birth weight, while the onset time of preeclampsia  was negatively associated with the risk of low birth weight. Results of logistic regression analysis for thyroid dysfunction and fetal outcomes were summarized in Table The rates of preterm birth and low birth weight was significantly higher in the patients with thyroid dysfunction than those without , giving more emphasis on the thyroid hormones in those patients with EPE might reduce some adverse maternal and fetal outcomes.Preeclampsia is one of the major causes of maternal and perinatal death . To bettHypothyroidism has been shown to have various vascular pathogenic effects, including endothelial cell dysfunction  which isMany studies focused only on the first trimester , 39, 40,Our study had a few limitations. First, as a retrospective investigation, we could only analyze variables that were appropriately documented, and we were not able to investigate those patients without results of thyroid hormones. Second, this was a single center study with a small sample size, so the sensitivity and specificity of results were not quite satisfactory. With the popularity of thyroid function tests, we will get more accurate and precise data in China. Due to the retrospective design and the small size of our study, currently we cannot determine whether thyroid dysfunction in the first half trimester or in the second half trimester have a greater effect on maternal and fetal pregnancy outcomes. Data are also lacking regarding whether the treatment is obligatory for patients with FT3 and FT4 both under the lower limit but normal TSH to prevent adverse neonatal outcomes. Certainly, further studies are needed to widen our understanding on thyroid dysfunction and neonatal outcomes.Our data indicate that more severe and early onset preeclampsia, as well as thyroid dysfunction were associated with significantly increased risk of neonatal adverse outcomes such as preterm birth and low neonatal birth weight. Therefore, monitoring thyroid hormones in women with preeclampsia might help to predict and consequently reduce the adverse neonatal outcomes.