Aim: To assess the association between the birth weight of newborns from pregnancies with preterm prelabor rupture of membranes (PPROM) and the presence of acute histological chorioamnionitis (HCA) with respect to the: i) fetal and maternal inflammatory responses and ii) acute inflammation of the amnion.Material and Methods: This retrospective cohort study included 818 women with PPROM. A histopathological examination of the placenta was performed. Fetal inflammatory response was defined as the presence of any neutrophils in umbilical cord  and/or chorionic vasculitis . Maternal inflammatory response was defined as the presence of histological grade 3–4 for the chorion-decidua and/or grade 3 for the chorionic plate and/or grade 1–4 for the amnion. Acute inflammation of the amnion was defined as the presence of any neutrophils in the amnion . Birth weights of newborns were expressed as percentiles derived from INTERGROWTH-21st standards for the i) estimated fetal weight and ii) newborn birth weight.Results: No difference in percentiles of birth weights of newborns was found among the women with the women with HCA with fetal inflammatory response, with HCA with maternal inflammatory response and those without HCA. Women with HCA with acute inflammation of the amnion had lower percentiles of birth weights of newborns, derived from the estimated fetal weight standards, than women with HCA without acute inflammation of the amnion and those with the absence of HCA in the crude  and adjusted (p = 0.02) analyses. The same subset of pregnancies exhibited the highest rate of newborns with a birth weight of ≤25 percentile. When percentiles were derived from the newborn weight standards, no differences in birth weights were observed among the subgroups.Conclusion: Acute inflammation of the amnion was associated with a lower birth weight in PPROM pregnancies, expressed as percentiles derived from the estimated fetal weight standards. Preterm prelabor rupture of the membranes (PPROM) is defined as the rupture of fetal membranes with leakage of amniotic fluid before the onset of regular uterine activity prior to 37 weeks of gestational age . PPROM rThe presence of acute inflammatory lesions of the placenta is characterized by diffuse infiltration of neutrophils in any of the structures of the placenta  and collectively are called acute histological chorioamnionitis (HCA) . DependiThe fetal inflammatory response is known to be the most severe form of HCA that is associated with adverse neonatal outcomes . It is aIt is obvious that placental lesions other than HCA  mainly lead to impaired placental functions, which can be followed by an alteration of fetal growth . CollectNevertheless, some studies have provided evidence for the relationship between impaired fetal growth and HCA . This unHowever, there is a shortage of information on whether the presence of HCA, particularly its most severe forms, with fetal inflammatory response and acute inflammation of the amnion, is related to impaired fetal growth in pregnancies complicated by PPROM. To fill this knowledge gap, a study on women with singleton pregnancies complicated by PPROM was conducted with the following goals: i) to assess birth weight, expressed as percentiles, and to compare the rates of the percentiles of birth weight that are less than or equal to the first, 10th, and 25th percentiles with respect to the presence of HCA with fetal and maternal inflammatory responses and the absence of HCA; ii) to assess birth weight, expressed as percentiles, and to compare the rates of the percentiles of birth weight that are less than or equal to the first, 10th, and 25th percentiles with respect to the presence of HCA with and without acute inflammation of the amnion and the absence of HCA; and iii) to assess birth weight, expressed as percentiles, and to compare the rates of the percentiles of birth weight that are less than or equal to the first, 10th, and 25th percentiles with respect to the severity of acute inflammation of the amnion.This study was a retrospective cohort study conducted in pregnant women with PPROM admitted to the Department of Obstetrics and Gynecology, University Hospital Hradec Kralove in the Czech Republic between May 2008 and March 2021 who met the following criteria: i) singleton pregnancy; ii) gestational age at admission between 24 + 0 weeks and 36 + 6 weeks; iii) maternal age ≥18 years; iv) available histopathological results of the placenta. The exclusion criteria were as follows: i) pregnancy-related complications such as gestational diabetes, gestational hypertension, or preeclampsia; ii) chronic diseases such as pregestational diabetes and chronic hypertension; iii) structural or chromosomal abnormalities of the fetus.Gestational age was determined based on the first-trimester ultrasound scan. The diagnosis of PPROM was established based on visual confirmation of amniotic fluid pooling in the posterior vaginal fornix by a sterile speculum examination. If uncertainty persisted after the clinical examination, the leakage of amniotic fluid was confirmed or ruled out using a test to determine the presence of insulin-like growth factor-binding protein in the vaginal fluid .Women with PPROM at less than 34 weeks of gestation were treated with antibiotics and corticosteroids to accelerate lung maturation. Tocolytics were used only when regular uterine activity appeared during the course of corticosteroids, but not for longer than 48 h. Women with PPROM beyond 34 weeks of gestation were treated with antibiotics only. The women included in this study were managed using two different approaches. Between May 2008 and December 2013, women were treated actively . Labor was induced, or an elective cesarean section was performed after finalizing corticosteroid treatment but no later than 72 h after the rupture of the membranes, depending on the gestational age, fetal status, and maternal serum C-reactive protein concentrations. Since January 2014, the performance of transabdominal amniocentesis to assess the status of the intra-amniotic environment  has been a routine part of the clinical management of women with PPROM . Thus, wAfter delivery, the placenta, fetal membranes, and umbilical cord were fixed in 10% neutral buffered formalin. Tissue samples were obtained from the placenta (at least two samples), fetal membranes , and umbilical cord , which were routinely processed and embedded in paraffin. Sections of the tissue blocks were stained with hematoxylin and eosin.The degree of neutrophil infiltration was evaluated separately in the free membranes (amnion and chorion-decidua), chorionic plate, and umbilical cord based on the criteria provided by Salafia et al. . HistopaThe collection of clinical samples and information was approved by the Ethics Committee of the University Hospital of Hradec Kralove, Czech Republic . Written informed consent was obtained from all the participants. Biological samples  from the women included in this study were used in our previous studies and are presented in the publications. A total of 528 women from this cohort were included in our previous publication, where an association between birth weight and microbial invasion of the amniotic cavity and/or intra-amniotic inflammation was evaluated . All metAll newborns were weighed immediately after birth using a calibrated electronic scale. Birth weights were converted to percentiles derived from the INTERGROWTH-21st standards  for the:HCA was diagnosed based on the histological grade 3-4 for the chorion-decidua and/or grade 3-4 for the chorionic plate and/or grade 1–4 for the umbilical cord and/or grade 1–4 for the amnion . Based oU test, as appropriate, and presented as medians [interquartile range (IQR)]. Categorical variables were compared using the Cochran-Armitage test for trend, and presented as numbers (%). Spearman’s partial correlation was used to adjust the results for the following potential confounders: various methods for managing PPROM, maternal age, nulliparity, smoking, the interval between PPROM and amniocentesis, the interval between amniocentesis and delivery, administration of corticosteroids, mode of delivery. Differences were considered significant at p < 0.05. All p-values were obtained using two-tailed tests. All statistical analyses were performed using GraphPad Prism version 8.4.3 and the Statistical Package for the Social Sciences (SPSS), version 28.0.0.0, for Windows .The normality of the data was tested using the Anderson-Darling test. Continuous variables were compared using the nonparametric Jonckheere-Terpstra test for trend, or Mann-Whitney n = 53); ii) gestational hypertension (n = 19); iii) preeclampsia (n = 5); iv) pre-gestational diabetes mellitus (n = 12); v) chronic hypertension (n = 5); vi) combination of the above-mentioned diseases (n = 6). The remaining 818 women were included in the analysis.A total of 918 women with singleton pregnancies complicated by PPROM were eligible for the study, and 100 women were excluded for the following reasons: i) gestational diabetes mellitus  women. Among women with the presence of HCA, fetal and maternal inflammatory responses were identified in 343 (69%) and 151 (31%) women, respectively. Remaining 324 (60%) women had the absence of HCA. The demographic and clinical characteristics of the study population, as well as short-term neonatal outcomes, with respect to the presence of fetal and maternal inflammatory responses and the absence of HCA are shown in p = 0.02; p = 0.14).A difference in the percentiles of birth weights of newborns was identified among the women with the presence of HCA with fetal  and maternal  inflammatory responses and those with the absence of HCA  in the crude analysis  analyses  than women with the presence of HCA without acute inflammation of the amnion  and those with the absence of HCA  in the crude  analyses.A difference in the percentiles of birth weights of newborns was found among the women with the presence of HCA with acute inflammation of the amnion, when the women were divided into four subgroups based on the severity of acute inflammation of the amnion  in the crude . Differences in the rates of the birth weights of newborns that were less than or equal to the first, 10th, and 25th percentiles were observed among women with HCA with acute inflammation of the amnion, when the women were stratified into the four subgroups based on the severity of acute inflammation of the amnion in the crude  and maternal  inflammatory responses and those with the absence of HCA , grade II , grade III , and grade IV ; p = 0.05). However, the result did not remain significant after adjusting for potential confounders (p = 0.08). No differences were observed in the rates of the birth weights of newborns that were less than or equal to the first, 10th, and 25th percentiles among women with the presence of HCA with acute inflammation of the amnion, when the women were divided into four groups based on the severity of acute inflammation of the amnion  HCA with acute inflammation of the amnion was associated with lower birth weight, expressed as percentiles derived from the estimated fetal weight standards; ii) HCA with acute inflammation of the amnion was related to the highest rate of newborns with a birth weight equal to or below the 25th percentile derived from the estimated fetal weight standards; iii) alteration of fetal growth, expressed as percentiles derived from the estimated fetal weight standards, associated with HCA with acute inflammation of the amnion was dependent on the severity of acute inflammation; and iv) when percentiles were derived from the birth weight standard, no difference in percentiles of the birth weights of newborns was observed among those with the presence of HCA with fetal and maternal inflammatory responses and those with the absence of HCA, as well as among those with the presence of HCA with and without acute inflammation of the amnion and those with the absence of HCA.Neutrophils are not usually present in the placental tissue and fetal membranes . FollowiBesides the placentas from pregnancies complicated by PPROM and spontaneous preterm labor, the presence of HCA with acute inflammation of the amnion has also been reported in preterm pregnancies with impaired fetal growth . SalafiaIn this study, newborns from pregnancies with HCA with acute inflammation of the amnion had the lowest birth weight, expressed in percentile derived from the estimated fetal weight standard. This interesting finding was further supported by the fact that the alteration of fetal growth was dependent on the severity of acute inflammation of the amnion. The lowest percentiles and the highest rates of birth weight equal to or less than the 10th and 25th percentiles were found in the women with the most severe form of acute inflammation of the amnion (grade IV). The mechanistic explanation for this observation is unclear. It can be hypothesized that the placenta is affected by various lesions , which are responsible for impaired fetal growth, might produce endogenous “danger signals”  . These sThe cutoff value of the 10th percentile is widely accepted by obstetricians and pediatricians as a threshold for identifying fetuses/newborns with SGA . This waTwo INTERGROWTH-21st standards  were used in this study to derive percentiles for the birth weights of newborns. Two different growth charts were employed because it is still under debate which standard should be preferred . The maiThis study has two main strengths. First, the study was conducted on a large homogeneous cohort of Caucasian women with a thoroughly defined phenotype of spontaneous preterm delivery. Second, the assessment of HCA was performed by a single, experienced perinatal pathologist who was blinded to the clinical status of the women. However, there are certain limitations to this study. First, this study covers a 13 years-long interval. During this time, two different management strategies (active management and expectant management) of PPROM pregnancies were used. Therefore, attention was paid to this important confounding factor in this study, and the results were adjusted for the same. Second, no data regarding ultrasonographically estimated fetal weight from the time of delivery or shortly before delivery were available. This shortcoming prevented us from assessing the relationship between the estimated fetal weight, expressed in percentiles derived from the estimated fetal weight standards and the presence of acute inflammatory lesions in the placenta. Third, the histopathological assessment of placental lesions other than HCA  were not systematically performed in the placentas from PPROM pregnancies. Last, the risk factors of the development of fetal and maternal inflammatory responses were not assessed and evaluated in this study.In conclusion, in this large retrospective cohort study of singleton pregnancies with PPROM, acute inflammation of the amnion was associated with a lower birth weight but only when the percentiles of birth weight were derived from the standards for estimated fetal weight.


Background: ST-segment changes to the fetal electrocardiogram (ECG) may indicate fetal acidosis. No large-scale characterization of ECG morphology immediately after birth has been performed, but ECG is used for heart rate (HR) assessment. We aimed to investigate ECG morphology immediately after birth in asphyxiated infants, using one-lead dry-electrode ECG developed for HR measurement. Methods: Observational study in Tanzania, between 2013–2018. Near-term and term infants that received bag-mask ventilation (BMV), and healthy controls, were monitored with one-lead dry-electrode ECG with a non-diagnostic bandwidth. ECGs were classified as normal, with ST-elevations or other ST-segment abnormalities including a biphasic ST-segment. We analyzed ECG morphology in relation to perinatal variables or short-term outcomes. Results: A total of 494 resuscitated and 25 healthy infants were included. ST-elevations were commonly seen both in healthy infants  and resuscitated  infants. The apparent ST-elevations were not associated with perinatal variables or short-term outcomes. Among the 32 (6.4%) resuscitated infants with “other ST-segment abnormalities”, duration of BMV was longer, 1-min Apgar score lower and normal outcomes less frequent than in the resuscitated infants with normal ECG or ST-elevations. Conclusions: ST-segment elevation was commonly seen and not associated with negative outcomes when using one-lead dry-electrode ECG. Other ST-segment abnormalities were associated with prolonged BMV and worse outcome. ECG with appropriate bandwidth and automated analysis may potentially in the future aid in the identification of severely asphyxiated infants. Heart rate (HR) assessment is essential when evaluating a compromised newborn infant immediately after birth. Most depressed infants with a HR < 100 beats per minute respond with an increase in HR to basic newborn resuscitation measures including drying, stimulation and mask ventilation ,3.In recent years, ST-analysis (STAN) of the fetal electrocardiogram (ECG) has been used in combination with cardiotocography (CTG) for surveillance of fetal wellbeing. Fetal metabolic acidosis is suspected when an abnormal CTG is accompanied by changes in the ST-segment of the fetal ECG . A CochrImmediately after birth, no standardized delivery room evaluation of myocardial compromise has been possible . Indeed,We recorded one-lead dry-electrode ECG in a large cohort of infants resuscitated with bag-mask ventilation (BMV), and a healthy control group immediately after birth. We aimed to describe ECG morphology during the first minutes of life, and analyze the association between ECG morphology and short-term outcomes using this easily applicable equipment.This observational study is part of Safer Births, a research project on labor surveillance and newborn resuscitation in low-income settings .We used data collected between 01.07.13 and 30.06.18 at Haydom Lutheran Hospital, a rural Tanzanian referral hospital with 3.600–4.600 annual deliveries . NewbornFor this study, term and near-term (from 34 weeks gestation) infants that received BMV and had concomitantly ECG recordings were eligible. See Newborn resuscitation monitors  with dry-electrode ECG were installed in every delivery room and in the operation theatre. The monitors started data recording automatically when used. The ECG bandwidth of the monitor was 1–150 Hz, and it was primarily designed to provide HR feedback. The ECG sensor was typically applied to the torso of the newborn to record ECG, roughly equivalent to lead I of a standard ECG. Trained non-medical research assistants observed all deliveries documenting perinatal information and time intervals . BaselinECG signal data from included infants were extracted, and appropriate processing using Matlab R2020a  was performed. The electronic ECG files were processed using a 50 Hz notch filter and zero-phase forward and reverse filtering to avoid phase distortion.For each individual infant, we searched for and analyzed ECG for two periods (“early” and “late”), during which intra-period variation in HR was < 20 bpm. The early period was defined as the first 30 subsequent QRS-complexes fulfilling the intra-period variation requirement and recorded within 3 min after birth, and the late period as the final 30 subsequent QRS-complexes during HR assessment. ECG-complexes were aligned and overlaid to find the median QRS-complex to improve the signal-to-noise-ratio and construct a representative complex, shown in Morphology of the ECG was interpreted by four researchers  who were blinded to both the HR during the ECG recording and to the individual infant outcome. The early and late ECG episodes were independently classified into three categories; (i) normal, (ii) ST-elevation, or (iii) “other ST-segment abnormalities”, including ST-depression and biphasic ST-segment. Examples are shown in The primary outcome was ECG morphology in relation to three types of short-term outcomes; death , admission to the neonatal unit and alive at one week of age, or “normal outcome” defined as not in need for admission to the neonatal unit. Secondary outcomes include the following “perinatal variables”; mode of delivery, obstructed labor, Apgar scores, HR data immediately after birth and duration of BMV.p < 0.05 was considered statistically significant.We used SPSS  and Matlab R2021a  for statistical analyses. Continuous variables are presented as means with standard deviation (SD) or medians with 25 and 75 percentiles , as appropriate. Categorical variables are presented as numbers (%). Differences between infants with ECG in the different morphological ECG-categories were analyzed with Kruskal–Wallis (continuous variables) or Chi-squared test . A Ethical approval was granted by the National Institute for Medical Research in Tanzania (Ref. NIMR/HQ/R.8a/Vol.IX/1434) and the Regional Committee for Medical and Health Research Ethics in Western Norway (Ref.2013/110). All mothers were informed about the ongoing research. Depending on whether the infant was included in a randomized controlled trial, the mothers gave deferred oral informed consent.During the five-year study period, 19,587 neonates were born, of which 1451 were resuscitated with BMV. The flow of study participants is shown in The ECG sensor was mounted on the infants directly after birth to provide normative HR-data from the time of birth and before and after cord clamping . The ECGWe included ECGs from 547 near-term and term resuscitated infants . After aThe early episodes of ECG were analyzed as soon as the ECG was obtained with acceptable quality and low intra-period HR variation, at a median of 117  seconds after birth. The late episodes of ECG assessment were analyzed at the very end of the resuscitation and stabilization episodes, at a median of 359  seconds after birth.In 125 (25%) infants ECGs were normal both in the early and late period. In 311 (63%) infants the ECG appeared to have ST-segment abnormalities  both in the early and late period. In 32 infants the ST-segment changed from abnormal in the early to normal in the late period. In 16 infants a normal ECG changed to abnormal from the early to the late period. In 10 infants, the ECG was only possible to interpret in the early period . In 4 infants the ECG was only possible to interpret in the late period . We did not observe any infant with ventricular fibrillation (VF) at onset of or during resuscitation.Perinatal and neonatal characteristics in relation to ECG morphological category, based on the early episodes, are presented in In this observational study, we present data on morphological analysis of one-lead dry-electrode ECG with a limited bandwidth from the first minutes of life. ST-segment elevations were observed in 28% of a control group of healthy infants, and in more than 60% of infants resuscitated after birth. In the latter group we found no associations between ST-elevations and perinatal variables or short-term outcomes. However, infants with “other ST-segment abnormalities”, in particular biphasic pattern, were ventilated longer after birth and had lower rates of normal outcome.The equipment used for capturing ECG after birth had a limited 1–150 Hz bandwidth and was primarily designed for HR measurement and not ST-segment analysis. The 1–150 Hz bandwidth constitutes a high pass filter that may lead to a drift of the ST-segment that is falsely interpreted as ST-segment elevation, but in the absence of myocardial ischemia [In contrast, a biphasic ST-segment or other ST-segment abnormalities were associated with indicators of perinatal asphyxia including a lower HR after birth, need for a longer period of BMV, and lower rates of normal outcome. These ECG changes are potentially not subjected to the same possible error in the equipment used. Barberi et al.  reportedThe strength of our study is the large sample size of infants that were resuscitated with BMV and had ECG recordings of adequate quality for visual analysis. No other clinical study has evaluated ECG morphology immediately after birth in a large number of infants in need of BMV. Studies that evaluated ECG morphology the first or second day after perinatal asphyxia are mainly with small numbers and several decades old ,21. The ST-segment elevations may not be a good proxy for severity of asphyxia when recorded with a non-diagnostic bandwidth ECG device intended for HR measurement. In contrast, biphasic ST-segment abnormalities are associated with bradycardia after birth and a need for prolonged BMV and might indicate significant asphyxia when this equipment is being used. Currently, automated systems for ECG classification are established for both adult  and feta


The principal aim of this study was to investigate the presence of factors affecting Baker’s cyst volume in young and middle-aged populations.Open cyst excision with valve and capsule repair, as well as knee arthroscopy, were used to treat eighty-five patients. The cases were categorized in terms of age, effusion, chondral lesion degree, meniscal tear degree, and Lindgren scores. An ultrasonography (USG) device was used to calculate the cyst volume. The IBM-SPSS 22 program was used for statistical analysis and to assess the relationships between variables using Spearman’s correlation tests.The degree of chondral lesion was moderately and positively correlated with cyst volume in the total population .The degree of the chondral lesion was moderately and positively correlated with the degree of effusion . The cyst volume was weakly and positively correlated with the degree of effusion .This study revealed that an increase in chondral lesion severity increases the amount of effusion and cyst volume. Generally, joint pathologies, such as chondral lesions and meniscal tears, cause effusion, which leads to an increase in the cyst (Baker) volume . A cystiIn 1877, Baker confirmed the entity as a “bursal distention” caused by the trapping of fluid in a bursa with a direct relation to the semi-membranous tendon. Moreover, he explained that the communication between the cyst and the joint synovium behaves as a one-way valve, with fluid leaking into the bursa and no possible flow in the reverse direction. Baker defined the possibility of a ruptured bursa resembling venous thrombosis. For that purpose, Baker’s name was incorporated with the clinical entity of a popliteal cyst, that is, “Baker’s cyst” .Baker’s cyst is strongly associated with the existence of intra-articular pathologies, such as chondral lesions and meniscal tears, with a reported incidence of approximately 94% in some series . Any patHowever, the quantification of cyst size  and a probable relationship between cartilage lesion degree, effusion degree, and cyst volume were only reported in one study by Balik et al. . In theiThe main objective of this study was to assess the factors affecting Baker’s cyst volume, its importance on effusion, and the degree of cartilage damage in the young and middle-aged population.This retrospective study was approved by the ethics committee of our institution and was registered under the protocol.The present study was conducted in accordance with a recognized international standard, including the principles of the Declaration of Helsinki.Data from 164 patients with Baker’s cysts ≥3 cm in diameter were collected between January 2009 and December 2017. In the current study, cysts with a diameter of ≥3 cm were included, because we assumed that 3 cm was the asymptomatic limit, referring to the study by Tschirch et al. . ScreeniFinally, 85 patients (53 women and 32 men) who were treated with posterior open cystectomy with valve and repair of the posterior capsule, in addition to arthroscopic treatment of intra-articular lesions, were included in the study.The patients were categorized according to age, sex, effusion level, chondral lesion degree, meniscal tear degree, and Rauschning–Lindgren scores Table . The RauUsing MR images, the meniscal tears were classified as normal meniscus, Grade 0, with Grades I and II having an intra-meniscal signal that did not extend to the free edge. Grade III had a signal shift that abutted the meniscal free border, suggesting a meniscal tear . The LinFor a linear statistical evaluation, cases with two or more separate chondral lesions, such as combined patellofemoral and femoral medial condyle lesions, were assessed. In other words, a case with a medial femoral condyle Grade 3 lesion and an additional patellar cartilage Grade 2 lesion was recorded as Grade 5, suggesting that each chondral lesion had the potential to generate effusion of its own.For cyst volume calculation, the cyst radius was measured in three dimensions, and these measurements were entered into the USG device . The device automatically calculates volumes using a standard formula for calculating the volume of ellipsoidal objects . The degAll raw data obtained from the calculations and measurements are listed in Table The IBM-SPSS 22 software was used for the statistical analysis to assess the relationship between variables using Spearman correlation tests, and to determine the strength and direction of these relationships. The Kolmogorov–Smirnov test was used to assess the normality of the distribution of data, whereas the preoperative and postoperative Lindgren values were evaluated using the Wilcoxon signed-rank test. Chondral lesion and cyst volume variables were recorded and analyzed for a possible relationship, where the statistical significance level was set as p < 0.05 Correlations (denoted as “r”) had different strengths . The relThe relationship between the degree of chondral lesion and age, relationship between the degree of chondral lesion and the change in Lindgren score, relationship between the degree of chondral lesion and grade of effusion, and relationship between the grade of effusion and cyst volume were assessed using the Spearman rank correlation (Spearman's rho) test  and Baker’s cysts is known. However, this study adds new quantitative information regarding the positive correlation between the combined cartilage lesion degree , effusion degree, and cyst volume in the young and middle-aged population.The limitations of this study were that the calculation of the cyst volume yields approximate results, that it was retrospective in nature, and that it involved a relatively small number of patients.Another limitation of the current study was that only symptomatic patients were evaluated postoperatively for recurrence with USG and MRI.The current study revealed that the degree of the chondral lesion was significantly correlated with the amount of effusion and cyst volume in young and middle-aged patients with Baker’s cysts. Moreover, the necessity of eliminating chondral lesions in addition to cyst excision in the treatment of Baker’s cysts was also suggested.


An allantoic cyst is a rare malformation with a frequency of 3 in 1,000,000 that may be seen antenatally by ultrasound assessment when the connection between the cloaca (future bladder) and the allantois fails to regress. A patent urachus that presents as a cyst  is usually considered not to be associated with chromosomal abnormalities, but if it is not repaired after birth this leads to complications such as urinary tract infections and stone formation. We present a case of a fetus diagnosed with allantoic cyst at the first trimester ultrasound assessment at 12 weeks gestation. The follow up scans showed a decrease in size of the allantoic cyst with no other obvious major defects and, when invasive testing  was performed, a rare microdeletion, 1q21.1q21.2 was identified (1.82 Mb deletion).


No recurrence of the cyst was noted 6 months later at a follow-up visit, and she had a normal cosmetic appearance of the external genitalia, with complete disappearance of genital and urinary complaints.An epidermoid cyst is a benign cyst resulting of implantation of superficial epidermal tissue into the dermis or subcutaneous tissue. They are commonly found on the scalp, face, neck, trunk and extremities; and rarely seen in the clitoral or vulvar region, most often associated with prior trauma or surgery to the area, particularly female genital mutilation. Epidermoid cyst of the clitoris is a very uncommon pathological entity, it can be spontaneous present at birth or develop later in life, or often secondary to surgery or trauma at the clitoral region. Herein, we report a case of 33-year-old multiparous woman, without past medical history of vulvar trauma or genital surgery, presented to the emergency department with a history of slowly growing clitoral mass over 11 months, which recently became responsible of sexual discomfort and difficulty in urination, without fever, vaginal discharge or other complaints. On perineal examination a painless midline cystic mass of 5 × 3 cm was noted; it extended from the clitoral region up to the labia minora; the mass was mobile, nontender, well-circumscribed and with a smooth surface . The labia minora and majora were normal, and both the urethral and vaginal openings were normal in position and shape (B). There was no associated bleeding or discharge. The remainder of the physical examination was otherwise unremarkable. Ultrasound testing revealed normal internal genital and urinary tract without communication between the cystic structure and the urethra. The patient underwent a complete surgical excision of clitoral cyst under spinal anesthesia, without compromising the clitoral neurovascular bundle or hood. Histopathological examination revealed an epidermoid cyst lined with stratified squamous epithelium and filled with keratinous material. The final pathologic diagnosis was of a spontaneous nontraumatic epidermoid cyst of the clitoris. The patient´s postoperative course was completely uneventful and she was discharged from the hospital on the 2


Processed food consumption during pregnancy should be carefully considered.Ready-meal consumption is increasing worldwide; however, its impact on human health remains unclear. We aimed to examine the association between processed food and beverage consumption during pregnancy and pregnancy outcomes. Pregnant women were recruited for the Japan Environment and Children’s Study (JECS), a nationwide, large-scale, prospective cohort study. This study included 104,102 registered children (including fetuses or embryos) and collected questionnaire-based data during the first and second/third trimester of pregnancy. Participants’ medical records were transcribed at pregnancy registration, immediately after delivery, and 1 month after delivery. Logistic regression analysis was used to estimate the association between processed food consumption and pregnancy outcomes. The incidence of stillbirth was higher in the group that consumed moderate (1–2 times per week) and high (≥3–7 times per week) amounts of ready-meals (adjusted odds ratio (aOR) = 2.054, 95% confidence interval (CI): 1.442–2.926,  Dietary habits have changed worldwide in the past few decades; the time spent cooking at home has decreased, with more people choosing to frequently dine out . MoreoveHowever, the impact of these new dietary choices, such as consuming beverages stored in plastic containers, on human health remains unclear due to inconclusive evidence. Some studies have reported that ready-made meal consumption is associated with an increased risk of overweight and obesity ; howeverElucidating the impact of processed food consumption on pregnancy-related out-comes is relevant to the formulation of public health policies, as evidence suggests that consumption of such foods is associated with exposure to chemicals, such as bisphenol A (BPA) and Di (2-ethylhexyl) phthalate (DEHP), that may disrupt endocrine function. Our previous study showed that serum BPA levels were significantly higher in women who had recurrent miscarriages than in controls . MeanwhiPregnant women were recruited between January 2011 and March 2014 for the Japan Environment and Children’s Study (JECS), a nationwide, large-scale, prospective cohort study registered in the UMIN Clinical Trials Registry (number UMIN000030786). Expectant mothers were eligible for the present study if they resided in the study area at the time of recruitment, had their due date after 1 August 2011, and were fluent Japanese speakers who could understand and complete a set of self-administered questionnaires ,10,11. Tn = 1003 (0.96%)). Infants born with physical anomalies were excluded (n = 9008 (8.7%)). Twenty-nine (0.03%) participants withdrew from the study. Finally, data from 94,062 pregnancies were included in the main analysis , and was released to all researchers involved with the JECS in June 2016. In cases of multiple pregnancies, outcomes of the second and third pregnancies were excluded to remove duplicates  for the present pregnancy; and obstetric history. Data transcribed from medical records immediately after delivery included details of maternal and gestational age, single/multiple pregnancy status, and pregnancy outcomes, such as live/stillbirth, miscarriage/induced abortion, and the mode of delivery , pregnancy-related complications, perinatal outcomes, and infant sex and weight. Data transcribed from medical records 1 month after delivery included maternal age and information on birth defects.The outcomes of interest were stillbirth, pre-term birth, SGA, and low birth weight. In this study, pre-term birth was defined as delivery between 22 and <37 weeks of gestation. SGA was defined as a birth weight below the 10th percentile, according to the new Japanese neonatal anthropometric charts for gestational age at birth.The frequency of eating ready-made meals , frozen foods, retort pouch foods, convenience foods , and canned foods during second/third trimesters was categorized as <1 time per week, 1–2 times per week, and 3–7 or more times per week based on self-reported lifestyle data . In geneIn addition, we assessed the frequency of coffee consumption, including the type of container when purchased  and the mode of preparation by the consumer. The frequency of black, green, and oolong tea consumption was also evaluated, including whether it was in a can or plastic bottle and if the tea was made from tea leaves by the consumer. To estimate odds ratios (OR), beverage consumption was recalculated separately depending on the source of beverage (can or bottle vs. beans or leaves). Frequency categories were recorded as follows: “less than once a week” became “once a week”, “once or twice a week” became “twice a week”, “three to four times per week” became “four times per week”, “five to six times per week” became “six times per week”, “a cup daily” became “seven times per week”, “2–3 cups daily” became “21 times per week”, “4–6 cups daily” became “42 times per week”, “7–9 cups daily” became “63 times per week”, and “>10 cups daily” became “70 times per week”. Based on self-reported data, the total beverage consumption was defined as <7 times/week, 7–13 times/week, and ≥14 times/week.The covariates of interest included maternal age at registration, body mass index, IVF-ET status, maternal smoking and drinking status, income level, maternal educational status, history of pregnancy loss, parity, maternal working hours, hypertensive disorders of pregnancy, gestational diabetes, maternal energy intake calculated using the Food Frequency Questionnaire  for pregq-value was obtained using the Benjamini–Hochberg procedure in R statistical software (version 3.5.2). A q-value of <0.05 was considered statistically significant. Multiple correspondence analysis (MCA) and hierarchical cluster analysis  were used to investigate the association between dietary habits and beverage intake. All analyses were conducted using SPSS version 23  except for q-value estimates.Descriptive statistics were reported as frequencies. Logistic regression analysis was used to estimate the association between dietary habits and each pregnancy outcome. The OR of each pregnancy outcome was adjusted for covariates. Crude and adjusted odds ratios (aOR) or mean differences with 95% confidence intervals (95% CI) were reported, as suitable. Missing values were handled with multiple imputation methods. To correct the false discovery rate, the The participants’ maternal characteristics and pregnancy outcomes are presented in q < 0·001) and frozen  meals and retort pouch  and convenience  foods. After adjusting for covariates, this association remained significant for ready-made and frozen meals but not for retort pouch or convenience foods  and moderate and high consumption of frozen  meals than in the group that consumed such foods less often than once per week. In addition, the incidence of pre-term birth was higher in the group reporting moderate (1–2 times per week) consumption of ready-made meals , and the incidence of low birth weight was higher in the group reporting moderate consumption of retort pouch foods  than that in the low consumption (less than once a week) group.There was a significant association between the incidence of stillbirth and the consumption of processed foods in all categories except canned food . The incce foods . The incq < 0.001; aOR = 2.930, 95% CI: 1.837–4.673, q < 0.001, respectively) than that in the group reporting low consumption. In addition, the incidence of stillbirth increased in the group reporting moderate and high consumption of beverages extracted from beans or leaves . A similar trend was observed in the incidence of pre-term birth. The incidence of SGA infants increased in drinkers of coffee or tea from bean or leaves, and that of low-birth weight increased in drinkers of coffee or tea from cans or plastic bottles relative to the estimates of the low-consumption group.Beverage consumption was associated with pregnancy outcomes such as stillbirth, pre-term birth, SGA infant, and low birth weight. In particular, the incidence of stillbirth was higher in the group reporting moderate (7–13 times per week) and high (≥ 14 times per week) consumption of beverages (can or plastic bottle) (aOR = 3.484, 95% CI: 2.611–4.649, Estimates could not be obtained for the high-consumption group due to the small sample size.We examined dietary habits in MCA after dividing it into four clusters by HCA . ClusterTo the best of our knowledge, this is the first large-scale birth cohort study to show that consumption of ready-made and frozen meals during pregnancy might increase the risk of stillbirth. Four kinds of processed foods were associated with an increased risk of stillbirth in the crude analysis ; howeverThese findings suggest that food packaging and reheating methods may affect outcomes possibly through exposure to chemicals present in meal packaging that are released in the process of cooking in a microwave . BPA, whPrevious studies have shown that BPA exposure may affect human reproductive health even at doses lower than the tolerable daily intake . SeveralIn the present study, an association with stillbirths at ≥12 weeks’ gestation was found. It remains unclear how consumption of ready-made and frozen meals increases the risk of stillbirths and whether BPA exposure is involved; the risk of aneuploidy decreases with the increase in gestational age. Furthermore, ready-made meal consumption may increase exposure to phthalates, including DEHP , which hThis study revealed an association between beverage intake and the risk of stillbirth. Beverage intake was categorized as out of “a can or plastic bottle” and “extracted from coffee bean or tea leaf”; these categories were associated with ORs of 3.548 and 3.703, respectively. In addition, the consumption of these beverage types was associated with an increased risk of pre-term birth, SGA, and low birth weight. In general, canned and bottled beverages contain large amounts of sugar; consequently, our analyses were adjusted for energy consumption as a surrogate measure of sugar intake. Moreover, caffeine intake has been associated with pregnancy loss, pre-term birth, and low birth weight ; therefoThe present study has three primary strengths. First, it included a large sample of approximately 100,000 participants. Second, the participants were representative of the Japanese pregnant population since the JECS covered rural and urban areas across Japan . Third, The main limitation of this study is that it did not identify underlying mechanisms or substances directly associated with the reported increases in risk; in addition, we did not measure biochemical parameters, such as BPA levels, which should be quantified in future studies. In addition, poor quality, such as excess sugar, fat, saturated fat intake, and lack of dietary fiber, is a problem in a processed-food-rich diet , and theOur findings suggest that processed food and beverage consumption during pregnancy increases the risk of adverse pregnancy outcomes, including stillbirth. This finding may result from exposure to chemicals contained in food packaging, which may increase with microwave cooking. The present findings suggest that dietary and nutritional advice should be included in prenatal counseling to help prevent serious adverse outcomes . The env


Although low birth weight in Japan has slightly increased over the past several decades, the association between maternal birth weight and pregnancy outcomes remains poorly understood.In this hospital-based, prospective cohort study conducted at the National Center for Child Health and Development, we obtained information on pregnant women’s birth weight via their maternal and child health handbook. We analyzed 944 women born at term after dividing them into five categories according to their birth weight: <2500 g, 2500–2999 g, 3000–3499 g, 3500–3999 g, and ≥4000 g. Multivariate logistic regression analysis and trend analysis were used to elucidate the extent to which maternal birth weight was associated with small-for-gestational-age and low birth weight in offspring, as well as with hypertensive disorders of pregnancy.Compared with women with a birth weight of 3000–3499 g, those born with a birth weight <2500 g had a significantly higher risk of low birth weight  and small-for-gestational-age  infants. No significant association was found between the incidence of hypertensive disorders of pregnancy and preterm birth. A linear relationship was observed between the lower birth weight categories and a higher risk of low birth weight and small-for-gestational-age , but no linear relationship was observed for the risk of preterm birth and hypertensive disorders of pregnancy .Our findings suggest that lower maternal birth weight is associated with small-for-gestational-age and low birth weight in offspring of women born at term. The risk of the development of chronic diseases, such as diabetes mellitus, hypertension, and obesity, in adulthood is influenced by environmental factors in early life, including the fetal period , 2. SeveLower birth weight comprises both preterm births and SGA. Preterm births in Japan have slightly increased over the past several decades , and somWe obtained data for this prospective cohort study conducted at National Center for Child Health and Development (NCCHD) in Japan from maternal and child health handbooks. Pregnant women were recruited at their antenatal visit in the first or second trimester between April 2010 and November 2013 and were asked to bring their maternal and child health handbook to subsequent prenatal visits. The maternal and child health handbook is a very popular, prospective form of record-keeping in Japan designed to record specific test results, such as those of urinalysis; any events occurring during the perinatal period; and other data points, including blood pressure, neonatal birth weight, and the gestational week at birth. The data in the handbook are recorded by healthcare providers.Women with multiple pregnancies, missing data on birth weight in their maternal and child health handbook, or a history of childbirth at another hospital besides the NCCHD were excluded. Women who were born preterm were also excluded to eliminate the possible effect of maternal preterm birth on pregnancy outcomes. Furthermore, women with missing data on maternal demographics were excluded. All participants gave their written informed consent at the time of recruitment. The study protocol was approved by the Institutional Review Board at the NCCHD in May 2011 (No. 484) and was performed in accordance with the guidelines of the Declaration of Helsinki and other nationally valid regulations.The primary variable of interest was the birth weight of pregnant women, as documented in their maternal and child health handbook. Pregnant women were categorized by their own birth weight into the following groups: <2500 g, 2500–2999 g, 3000–3499 g, 3500–3999 g, and ≥4000 g.We considered the adverse birth outcomes of preterm birth, LBW, and SGA, all of which were calculated from the gestational age (days) and birth weight (g) in the medical records, as well as the presence of HDP. We defined preterm birth as <37 weeks of gestation , 18, LBW2). Information on covariates and adverse outcomes was also retrieved from the medical records.Other variables pertaining to the mother and grandmother were categorized as follows: age at delivery , parity (primipara or multipara), and prepregnancy BMI . P-values <0.05 were considered statistically significant.Of the 1,028 women participating in the study, one with a current multiple pregnancy, 17 with missing data on their own birth weight or weeks of gestation, 25 who were born preterm, and 41 with missing data on their prepregnancy BMI were excluded, leaving 944 women for enrollment in this study. The characteristics of the 944 pregnant women and their mothers are presented in The association between women’s birth weight and their pregnancy outcomes is shown in The results of a sensitivity analysis adjusted by grandmothers’ age and parity are shown in In line with previous studies, we observed that among women born at term, maternal birth weight had a significant inverse linear trend in terms of the risk of having offspring with LBW and SGA. In contrast, we failed to find any association between maternal birth weight and the risk of preterm birth and developing HDP. This is the first study to examine birth weight and the risk of adverse pregnancy outcomes in Japanese women.We found a significant inverse relationship between maternal birth weight and the risk of LBW and SGA in the subjects’ offspring among women born at term. Although low birth weight has two causes, namely, SGA and preterm birth, our findings suggested a transgenerational vicious cycle in which lower maternal birth weight was an independent risk factor for lower birth weight in offspring. This also implied that SGA caused by reasons other than the transgenerational effect may lead to the onset of a new vicious cycle. Thus, it is crucial to avoid new occurrences of this vicious cycle caused by other controllable factors. Changing dietary patterns and body consciousness in reproductive-aged Japanese women and the relatively strict recommended limit on weight gain during pregnancy have been proposed as the major reasons for the decreasing trend in the birth weight of Japanese infants , 16, 21.We failed to find a significant association between maternal birth weight and the risk of preterm delivery. Previous studies investigating this association have shown inconsistent results. Two studies in Brazil and the USA that enrolled 1,982 and 2,678 women, respectively, showed that lower maternal birth weight (including preterm births) was significantly associated with a higher risk of preterm offspring , 6. HoweWe failed to find a significant association between women born with lower birth weight and those who experience HDP, inconsistent with previous studies showing increased HDP risk among women with LBW –9. A posAlthough comparable in size with previous studies, the present study has the advantage of more accurate data on birth weight due to recording of the information by healthcare providers using the maternal and child health handbook, thereby minimizing recall bias , 26, 27.Our results suggest that birth weight is inversely related to the risk of SGA and LBW in offspring among Japanese women born at term and contributes to a vicious cycle in the intergenerational relationship of adverse birth outcomes. These findings may pave the way for interventions to prevent LBW and SGA, not least by motivating young Japanese women to better manage weight gain during pregnancy.S1 Table(DOCX)Click here for additional data file.


SLE is characterized by relapses and remissions. We aimed to describe the frequency, type and time to flare in a cohort of SLE patients.SLE patients with one or more ‘A’ or ‘B’ BILAG-2004 systems meeting flare criteria (‘new’ or ‘worse’ items) and requiring an increase in immunosuppression were recruited from nine UK centres and assessed at baseline and monthly for 9 months. Subsequent flares were defined as: severe (any ‘A’ irrespective of number of ‘B’ flares), moderate (two or more ‘B’ without any ‘A’ flares) and mild (one ‘B’).s.d.) was 40.7 years (12.7) and mean disease duration (s.d.) was 9.3 years (8.1). A total of 195 flares re-occurred in 76 patients over 781 monthly assessments (flare rate of 0.25/patient-month). There were 37 severe flares, 32 moderate flares and 126 mild flares. By 1 month, 22% had a mild/moderate/severe flare and 22% had a severe flare by 7 months. The median time to any ‘A’ or ‘B’ flare was 4 months. Severe/moderate flares tended to be in the system(s) affected at baseline, whereas mild flares could affect any system.Of the 100 patients, 94% were female, 61% White Caucasians, mean age (. In a population with active SLE we observed an ongoing rate of flares from early in the follow-up period with moderate–severe flares being due to an inability to fully control the disease. This real-world population study demonstrates the limitations of current treatments and provides a useful reference population from which to inform future clinical trial design. In this observational study, SLE patients flare early on in the follow-up period.The median time to any ‘A’ or ‘B’ flare (BILAG-2004 index) was 4 months.This real-world population study provides a useful reference which can inform future clinical trial design.SLE is a major autoimmune multi-system rheumatic disease that is most common in women during the childbearing years . It can ‘a measurable increase in disease activity in one or more organ systems involving new or worse clinical signs and symptoms and/or laboratory measurements. It must be considered clinically significant by the assessor and usually there would be at least consideration of change or an increase in treatment’ [Flare is defined by International Consensus as eatment’ . Flares eatment’ , 7, SLEDeatment’  and the eatment’ . For theeatment’ , 10, 11.eatment’ .Flares have been associated with more hospitalizations  and moreUnderstanding the pattern of flares in SLE patients would be informative not only in the day to day management of these patients, but also in the interpretation of clinical trials of new medications where frequency and type of flares are included as outcome measures. This study describes the flare rates and types of flares in a prospective observational multicentre study of patients with active SLE after treatment of a flare.The study was granted Multicentre Research Ethics Committee (MREC 02/5/035) approval and participants from the collaborating centres gave written informed consent. The collaborating rheumatology units were UK centres with an interest in SLE as part of the BILAG: Bangor, Birmingham (two centres), Blackburn, University College London, Nottingham, Manchester, Doncaster and Sheffield.The inclusion and exclusion criteria of the patients recruited, and the demographic and clinical data collected have been detailed previously in the longitudinal study to determine the sensitivity to change of the LupusQoL . Patients.d.), medians (interquartile ranges) and/or frequency counts. Flare rates were expressed as the number of flares per patient-month. Time to flare was also estimated using the Kaplan–Meier method.Patient data were summarized using the following descriptive statistics; means (s.d.) age and disease duration of 40.7 (12.7) years and 9.3 (8.1) years, respectively. The study population consisted of 94% females, 62.6% White Caucasians, 15.2% south Asians, 8.1% Black Caribbean, 4% Black Africans, 5% mixed and 1% Chinese. At baseline , the median (range) numerical BILAG-2004 score was 14 (10–21). The baseline characteristics are summarized in We recruited 100 patients with a mean . By 1 month, 22% of all patients had a mild/moderate/severe flare; 22% of all patients had a moderate/severe flare by 3 months; and 22% of all patients had a severe flare by 7 months. The BILAG-2004 system(s) that had ‘A’ and/or ‘B’ flares at baseline were as follows: musculoskeletal (39.4%), mucocutaneous (21.8%), cardiorespiratory (13.5%), renal (11.8%), constitutional (7.7%), neuropsychiatric (2.4%), gastrointestinal (2.4%) and ophthalmic (1.2%). The systems affected at baseline were compared with those affected at the time of the first severe, moderate and mild flares. Severe (13.6% discordant) and moderate (5.3% discordant) flares tended to be in the same system(s) affected at baseline, whereas mild flares were more likely to affect any system (34.3% discordant) .This multicentre prospective observational study captured the frequency of subsequent flare in a population entering the study at the time of moderate or severe flare. Using the BILAG-2004 index, we have described the pattern of flares in patients with SLE who were treated for severe or moderate flares over a 9-month period. These patients were followed monthly and were treated with various medications. We found that 76% of patients had a subsequent flare and the flare rate was 0.25/patient-month, of which 19% were severe, 16% moderate and the rest were mild flares. The flares were predominantly in the original organ system, demonstrating the inadequacy of current treatment to control disease and to prevent further flares that increase the risk of future organ damage.Rheumatology online, in studies that have used the BILAG index as a disease activity measure and a similar definition of flare [There are only a small number of studies in the literature exploring incidence of flare in SLE as an outcome. These studies are difficult to compare with our study or with each other for the following reasons; different study populations and various methodological differences including study design , duration of study, outcome measures employed and flare definitions. The challenges of making cross study comparisons are illustrated in of flare .Our study presents real-world data on patterns of flares and flare frequency in SLE patients in the UK after treatment of a severe or moderate flare with conventional therapy . Thus, tkeaa777_Supplementary_DataClick here for additional data file.


Only physical IPV was associated with length‐for‐age z‐scores (LFAZ) at birth. Antenatal maternal alcohol and tobacco use mediated IPV‐growth relationships at birth. Postnatally, among 783 mother–infant pairs, emotional and physical IPV were associated with reduced WFAZ at 12 months. Only emotional IPV was associated with LFAZ at 12 months. Maternal tobacco use was a mediator postnatally. Findings highlight the role of physical and emotional IPV as risk factors for compromised fetal and infant growth. Findings underscore the importance of programmes to address interrelated risk factors for compromised infant growth, specifically IPV and substance use, which are prevalent in high‐risk settings.Intimate partner violence (IPV) has been linked to poor fetal and infant growth. However, factors underlying this relationship are not well understood, particularly in the postnatal time period. In a South African cohort, we investigated (1) associations between IPV in pregnancy and growth at birth as well as postnatal IPV and child growth at 12 months and (2) whether maternal depression, tobacco or alcohol use or infant hospitalizations mediated IPV‐growth relationships. Mothers were enrolled in pregnancy. Maternal IPV was measured during pregnancy and 10 weeks postpartum; depression, alcohol and tobacco use were measured during pregnancy and at 6 months postpartum. Child weight and length were measured at birth and 12 months and converted to z‐scores for analysis. Linear regression and structural equation models investigated interrelationships between IPV and potential mediators of IPV‐growth relationships. At birth, among 1,111 mother–infant pairs, maternal emotional and physical IPV were associated with reduced weight‐for‐age  In the current study, both maternal emotional and physical IPV were associated with child growth at birth and 12 months.Alcohol and tobacco use emerged as mediators antenatally and tobacco use as a mediator in postnatal IPV‐growth relationships; these may represent an important pathway via which maternal IPV impacts child growth and related interventions should address these.Increasing evidence links emotional IPV to adverse child growth; it is important that screening and referral efforts integrate support for emotional IPV alongside physical and sexual IPV.IPV remains a highly prevalent public health problem, impacting not only maternal health but child health outcomes, including compromised child growth.1Growth faltering, a slow rate of gain in a child's weight or height, is an important indicator of poor child health and is prevalent in low‐ and middle‐income country (LMIC) settings. In particular, growth faltering during infancy and early childhood has been linked to adverse short‐ and long‐term health outcomes, including poorer performance in school, delayed child development  on child growth outcomes. Meta‐analyses have found IPV during pregnancy to increase the risk of low birth weight   a birth cohort study in South Africa, following mother–child dyads from pregnancy through early life with ongoing, detailed follow up including psychosocial risk factor and clinical outcome data. This study therefore provides an opportunity to address key gaps in the literature specifically by (1) investigating IPV and growth using longitudinal data, (2) investigating IPV subtypes in IPV‐growth relationships and (3) exploring the potential role of mediators in these relationships. Previous work in this cohort has shown that physical IPV during pregnancy is associated with low birthweight but did not explore mediators of this relationship . Results from the cohort study have also shown high rates of interpersonal violence, substance use and child malnutrition  and TC Newman (serving a mixed‐ancestry community). Mothers were enrolled in their second trimester while attending routine antenatal care and have completed assessments antenatally and following birth (ongoing). Women were eligible for the study if they were 18 years or older, between 20 and 28 weeks of gestation, planned attendance at the two recruitment clinics and intended to remain in the area. Data included in the current study were collected antenatally at 28–32 weeks of gestation, at birth, and postnatally at 10 weeks, 6 and 12 months, Figure 2.3Between March 2012 and March 2015, 1,225 pregnant women were enrolled into the DCHS, as has been described  and length‐for‐age z‐scores (LFAZ) were calculated using weight and length measurements at 12 months, based on age and gender using Anthro software  in light or no clothing using a Tanita digital platform scale . Recumbent length was measured using a Seca length‐measuring mat , performed on a firm surface by two staff members. Equipment was checked and calibrated weekly  is a 12‐item inventory adapted from the WHO multicountry study Jewkes,  and the 2.6Socio‐demographic variables were collected from a shortened questionnaire used in the South African Stress and Health (SASH) study, a large population‐based study , where not normally distributed. Normality of data was assessed using Shapiro–Wilkes. Mann–Whitney rank sum and Kruskal–Wallis tests were used to test for associations between categorical and continuous variables. Pearson chi‐square test was used to determine if significant associations existed between categorical variables.p < 0.05). Second, we investigated bivariate associations between IPV subtypes and each hypothesized mediator . Third, we ran adjusted linear regression models, adjusting for covariates and potential mediators to identify mediators that were significantly (p < 0.05) associated with growth outcomes considered . These relationships were then used to inform criteria, as laid out below, for running formal mediation analyses using SEM. IPV subtypes were included separately in adjusted models due to collinearity. Adjusted linear regression models considered key factors known to affect growth, namely, maternal education, household income, maternal height, maternal HIV status and child sex. Additionally, WFAZ at birth was considered in models investigating growth at 12 months. Covariates were included based on strength of association  with the growth outcome explored. Final models were estimated using the maximum likelihood method. Variance inflation factor (VIF) was used to check for multicollinearity. These analyses were run using STATA 15.0.To investigate potential mediators of IPV‐growth relationships in this study, we used an iterative approach. Specifically, we used linear regression to identify significant relationships within the proposed models  prior to formally testing mediation using structural equation models (SEMs). To do this, the following steps were taken. First, we explored bivariate relationships between IPV subtypes and growth outcomes , specifically between antenatal IPV and WFAZ and LFAZ at birth as well as between postnatal IPV and WFAZ and LFAZ at 12 months, and further analyses were only done where these relationships were significant (p < 0.05) in adjusted models (Path b). Hypothesized mediators that did not meet these criteria but were associated with growth outcomes were included as covariates in final models. SEMs were used to estimate the indirect effect of IPV subtypes on growth outcomes via proposed mediators as well as the direct effect of IPV on growth outcomes (Path c′), Figure As a final step, multiple mediation analyses were conducted using a SEM approach, which allowed for the estimation of direct and indirect effects, Figure 2.9The DCHS was approved by the Human Research Ethics Committee at the University of Cape Town (401/2009) and by the Western Cape Provincial Health Research committee. Mothers completed informed consent in their preferred language: isiXhosa, Afrikaans or English. Study staff were trained on the ethical conduct of violence research, including confidentiality, mandatory reporting and safety issues. Where substance abuse or mental health issues were identified, staff referred participants to social services or appropriate care in the Paarl area.3Detailed baseline characteristics are presented in Table 3.1β = −0.04, 95% CI: −0.07, −0.02 and physical IPV β = −0.04, 95% CI: −0.07, −0.02), Table β = −0.04, 95% CI: 0.08, −0.00), Table In adjusted linear regression analyses, antenatal emotional and physical IPV were inversely associated with WFAZ at birth  bivariate relationships with the outcome explored.Prior to running formal mediation models, linear regression analyses were run to test for associations between IPV subtypes and hypothesized meditators , the emotional IPV‐WFAZ association at birth Model 2), and the physical IPV‐LFAZ association at birth (Model 3). In Model 1, the relationship between antenatal physical IPV and WFAZ was partially mediated by tobacco and alcohol use . The direct effect of physical IPV on WFAZ remained significant after including potential mediators and confounders. In Model 2, the relationship between antenatal emotional IPV and WFAZ at birth was fully mediated by tobacco and alcohol use . In Model 3, the relationship between antenatal physical IPV and LFAZ at birth was fully mediated by alcohol use in pregnancy (proportion mediated = 36%). Tobacco use did not mediate this relationship. Results are summarized in Figure , and the3.3β = −0.07, 95% CI: −0.11, −0.04; physical IPV β = −0.03, 95% CI: −0.05, −0.00), Table β = −0.07, 95% CI: −0.10, −0.04).In adjusted analyses, emotional and physical IPV were inversely associated with WFAZ at 12 months  bivariate relationships with the outcome explored. Postnatal alcohol use was associated with WFAZ and LFAZ in bivariate analyses (Path b), but maternal depression and child hospitalizations were not. Therefore, alcohol use was included as a covariate but not investigated as a mediator. Both postnatal emotional and physical IPV were associated with maternal depression, alcohol use and tobacco use but not child hospitalizations (Path a).Initial steps of the analytic approach tested associations between IPV subtypes and hypothesized mediators , the emotional IPV‐WFAZ association (Model 5), and the emotional IPV‐LFAZ association at 12 months (Model 6). In Model 4, the relationship between postnatal physical IPV and WFAZ was fully mediated by tobacco use (proportion mediated = 62%). In Model 5, the relationship between postnatal emotional IPV and WFAZ at 12 months was partially mediated by tobacco use (proportion mediated = 23%). In Model 6, the relationship between postnatal emotional IPV and LFAZ at 12 months was partially mediated by tobacco use (proportion mediated = 24%). Emotional IPV maintained a direct effect on WFAZ and LFAZ at 12 months. Results are summarized in Figure 4In this study, investigating maternal IPV and infant growth outcomes in a South African birth cohort, we describe high prevalence of both maternal antenatal and postnatal IPV. At birth, both maternal emotional and physical IPV were associated with lower WFAZ, with physical IPV associated with lower LFAZ at birth. Maternal alcohol use and tobacco use during pregnancy mediated the relationship between maternal IPV and WFAZ, whereas alcohol use mediated the relationship between physical IPV and LFAZ at birth. Postnatally, both maternal emotional and physical IPV were associated with lower infant WFAZ at 12 months of age, whereas emotional IPV was associated with lower child LFAZ at 12 months of age. Postnatal maternal tobacco use mediated these relationships. Findings build on previous research by investigating IPV's impact on child growth through infancy and by formally testing multiple mediators collected in a birth cohort study.Our results linking IPV during pregnancy with growth at birth is consistent with previous literature; specifically associations with low birth weight are well‐established (Donovan et al., In the postnatal period, the association between emotional IPV and compromised infant growth is a novel finding. We found that both maternal physical and emotional IPV are associated with reduced child WFAZ at 12 months and that there is an association between recent emotional IPV and child LFAZ at 12 months. In contrast, a study, in Brazil, investigated past‐year maternal emotional or physical abuse, found severe physical and not verbal or less severe physical abuse, to be associated with child WFAZ in the first 2 years of life (Hasselmann & Reichenheim, Maternal smoking mediated the IPV‐growth relationship at 12 months of age, after adjusting for clinical and socio‐demographic variables. Exposure to tobacco smoke has been linked to poor child growth, in particular, reduced linear height as well as stunting (Nadhiroh et al., To date, only one study investigating IPV and postnatal growth has formally investigated potential mediators (Neamah et al., 4.1The majority of women in South Africa as well as worldwide attend antenatal care, offering an opportunity to screen for maternal IPV as well as substance use and refer for help. Public health efforts have made huge strides in informing mothers of the potential negative child health sequelae of alcohol and tobacco use, specifically during pregnancy. However, this has also created stigma, establishing a barrier to disclosure or treatment Stone, . Existin4.2Inclusion criteria for the parent study were broad; however, study recruitment was done during routine antenatal care and mothers who did not present or presented very late for antenatal care were not included. This may have resulted in the highest risk mothers being underrepresented; however, this would likely have strengthened findings. Key mediators were also self‐reported, specifically maternal depression, alcohol and tobacco use, which may have been underreported, particularly in pregnancy given the stigma, in particular relating to alcohol use perinatally. Some instances of child hospitalizations may have been missed where not reported by mothers or if they occurred outside the study area; however, active surveillance systems were strong to capture these. Postnatal IPV was measured at 10 weeks and may therefore overlap antenatal IPV exposure; however, postnatal IPV was measured at multiple points postnatally and found to be correlated with stable intensity profiles through 2‐year postpartum (Barnett et al., 4.3http://www.paediatrics.uct.ac.za/scah/dclhs.Collaborations from external researchers are welcome. The study has a large and active group of investigators and postgraduate students with a track record of successful partnership with researchers or students from other institutions. Researchers who are interested in collaborations or access to study datasets can find additional information on our website The authors declare that they have no conflicts of interest.WB and SLH conceived the study and WB conducted the data analysis with support from RN and JP. HJZ is the principal investigator of the DCHS and DJS leads the psychosocial aspects. WB drafted the manuscript; all authors reviewed, contributed to and approved the final manuscript.Figure S1. Timing of measuresClick here for additional data file.Figure S2. Flow diagram of attendance and loss to follow up from enrolment through the first year of life.Table S1. Comparison of psychosocial, demographic and clinical data between child observations included in final models and those not included.Table S2. Mediator adjusted associations between intimate partner violence and growth outcomes at birth and through 12 months.Table S3. Unadjusted associations between intimate partner violence and proposed mediators.Table S4. Unadjusted associations between covariates, intimate partner violence and mediators and infant weight‐for‐age z‐scores and length‐for‐age z‐scores at birthClick here for additional data file.


Birth defects are conditions that exist at birth and cause structural changes in one or more parts of the body. In order to plan proper management and design preventive activities of these conditions, accurate tracking, registration and analyses of the registered data are important. We assessed the practice of birth defect registration at Addis Ababa health facilities.We retrospectively checked the existence of a separate birth defect registry book and assessed the delivery room registration book for completeness in registering birth defects. We also assessed the total number of birth defects registered during 2010–2015.We assessed the practice of birth defect registration at 37 delivery service providing health facilities in Addis Ababa, 20 public and 17 private institutions. Of the 37 health institutions assessed, 23 registered birth defects . The remaining 14 did not register any congenital anomaly. Of the institutions that do not register congenital anomalies, 10 are private and four are public.Only three delivery providing health facilities had a dedicated birth defect registry book which is close to ideal for a birth defect registration. There is a need for others to do the same until an electronic birth defect registration is established. This registration will serve as a resource for clinical governance and studies into quality of life, quality of care, etiology and prevention. Birth defects are structural or functional/developmental abnormalities present at birth. They can cause physical disability, intellectual and developmental disability, and other health problems. Birth defects are a major contributor to infant mortality, and the care might cost billions of dollars  Major stBirth defects cause significant burden to the victim and to society. They are the main cause of early abortion, stillbirth, perinatal and infant death and birth disability. This is definitely a public issue of population quality and population health. Birth defects are considered as a curse in many developing countries, including Ethiopia, leading to stigmatization and effect on quality of life. A systematic and well-planned data registry is very important to analyze the extent of the problem and its burden on the society. In order to properly manage birth defects and plan preventive strategy, it is very important to establish a standard birth defect registry system. It can also be a very efficient and cost-effective means of identifying eligible children for treatment and providing timely referral to specialized services . Due to The objective of this surveillance was to assess how organised and comprehensive registration of birth defects is at Addis Ababa delivery service providing health facilities.This study is part of the larger Ethiopian genetics study entitled “Investigating the role of genetics and environmental factors in the occurrence of orofacial clefts in the Ethiopian population” for which ethical approval was obtained from the Institutional Review Board, College of Health Sciences, Addis Ababa University  and have been renewed every year. In addition, we obtained written permission from Addis Ababa City Administration Health Bureau (5/01/2007 E.C) and retrospectively assessed the Birth defect registry system at 37 delivery service providing health facilities in Addis Ababa. We collected the following information using open questions and observation:The existent of a separate birth defect registry bookIf training was provided on birth defect registryIf, after registering a birth defect, is there an onward referral to a specialized centerWe evaluated the practice of birth defect registration at 37 delivery service providing health facilities in Addis Ababa, 20 public and 17 privates. All the 17 private health facilities are general hospitals and the public health facilities are five referral hospitals and the rest are health centers. These were the main delivery service providing institutions in Addis Ababa when we did the survey. Of the 37 health facilities, 23 registered birth defects . The remaining 14 have not registered any congenital anomaly. Of the institutions that did not register congenital anomalies, 10 are private and four are public. Only three of the health facilities have midwives who have some orientation and training on birth defects and the importance registration, all the three were from the private hospitals.The total number of live births at the study health facilities from 2010–2015 was 156,272, and there were 3215 (2.06%) still births. During this time, 543(0.35%) birth defects of different types were registered since there is only one column in the delivery ward registry book, detailed information about the type of birth defect and its severity was not registered. Of the children born with congenital anomalies registered, 196(36.1%) were still born.We got a response from few delivery services providing midwives who were working at the health centers. These responses include “I did not register a birth defect because I did not know what it is called, so I just told them to go to Tikur Anbessa Hospital”. Tikur Anbessa Hospital is the largest pediatrics referral center for the country. The others said, “I did not know what it is called, so I just wrote congenital anomaly and told them to go to Tikur Anbessa Hospital”. Some said, “I delivered a child with cleft lip and referred to Yekatit 12 Hospital because I know they treat cleft patients”.In addition to being a health and financial burden to communities, birth defects can also be a source of psychosocial problem to the patient and patient's family. Birth defects are considered as a curse in many developing countries including Ethiopia. Proper birth defect registry and surveillance is indispensable to address this issue. The findings of our study indicated that there is no established system of birth defect registration at health facilities in Addis Ababa, the capital city of Ethiopia. We feel it is the same in other parts of the country. The Sixty-third World Health Assembly, in 2010 recognized the importance of birth defects as a cause of stillbirths and neonatal mortality. During this same time, it was made clear that the lack, or inadequacy of birth defect registration systems and inaccurate records of the causes of death, in developing countries became a barrier to estimating the burden of public health problems associated to birth defects in this part of the world. EthiopiBirth defects play a major role in neonatal mortality and stillbirth; therefore, proper birth defect registry system is crucial to know the magnitude of birth defect and plan a preventative mechanism.The 0.35% birth defect report found in this study is a clear underestimate of birth defect at the studied institutions. As stated by Christianson and Modell, in 2004  there isThe availability of accurate information is vital in order to take decisions on prevention and control of birth defects. It is also important to provide care and support to individuals affected by birth defects. The sixty third world health assembly urged member states to develop and strengthen registration and surveillance systems for birth defects within the framework of national health information systems.Every year, around 3–6% of infants or approximately 8 million are born with a serious birth defect worldwide the majority, 90% of these infants are born in low- and middle-income countries and the impact of birth defects is mainly severe in these countries.Of the children born with congenital anomalies registered, 196(36.1%) were still born. This indicates that birth defect is associated with high still birth. Since there is no proper registration and follow-up on those who were born alive with congenital anomalies, it is not known whether they survive or not. This has a negative impact in fulfilling the Sustainable Development Goals 3.2   worldwide, 12 TherIn conclusion, Ethiopia is the second most populace country in Africa next to Nigeria. There is no established birth defect registration system in Ethiopia. Since there is no established training on birth defects, the delivery ward staff have a problem in registering birth defects. We recommend a proper birth defect registry and surveillance for Addis Ababa and for the country. This is a huge task which requires workforce training, developing a birth defect registration strategy and resource allocation. This study showed that birth defect is a major contributor for stillbirth. Therefore, we recommend to initiate a preventative activity to reduce birth defects which will contribute to the reduction of stillbirths. We also recommend to initiate new born screening programs which have a huge role in early identification of birth defects


This was a cross-sectional frequency-matched case–control study.The serum lipid profile of lipoprotein(a) [Lp(a)] level and apolipoprotein B/apolipoprotein A1 ratio (Apo B/Apo A1) ratio were found to be more representative for serum lipid level and were recognized as the independent risk factors for various diseases. Although the blood levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were found to be associated with symptomatic intervertebral disk herniation (IDH), no studies to date have evaluated the association of Apo AI, Apo B, Lp(a), and Apo B/Apo AI levels with symptomatic IDH. This study aimed to assess the link between blood lipid levels and symptomatic IDH.The study included 1839 Chinese patients. Of these, 918 patients were diagnosed with IDH and enrolled in the experimental group. A control group of 921 patients underwent a physical examination during the same period. The serum lipid levels of TC, TG, LDL-C, HDL-C, Lp(a), Apo B, and Apo B/Apo AI were examined and analyzed. The control group comprised randomly selected patients who met the baseline levels of the aforementioned lipid molecules.P = 0.201). The odds ratio (OR) for the incidence of IDH with elevated levels of LDL-C, TC, TG, Lp(a), Apo B, and Apo B/Apo AI was 1.583, 1.74, 1.62, 1.58, 1.49, and 1.39, respectively. The correlation analysis revealed the correlation between elevated LDL-C, TC, TG, Apo B, Lp(a), and incidence of IDH was significant  = 0.021) (P < 0.05).Patients with IDH exhibited significantly higher TC, TG, LDL, Apo B, and Lp(a) levels than controls. The percentage of high TC, high TG, high LDL, high Apo B, and high Lp(a) were obviously higher in the IDH group than in the control group. However, hyperlipidemia had no relationship with the degenerated segment of the IDH , and Apo B/Apo AI were associated with a higher risk of IDH. This study provided useful information to identify a population that might be at risk of developing IDH based on elevated lipid levels. Intervertebral disk herniation (IDH) is the main cause of disability, especially work-related disability –3. PathoWith the increased research on serum lipids, the lipoprotein fraction of apolipoprotein AI (Apo AI) and apolipoprotein B (Apo B) and the ratios of apolipoprotein B/apolipoprotein AI (Apo B/Apo AI), and lipoprotein(a) [Lp(a)] have received considerable attention in investigating dyslipidemia-related diseases in recent years; Apo B/Apo AI and Lp(a) were recognized as the independent risk factors for various diseases, including osteoarthritis and AS –21. HoweIn this study, a frequency-matched case–control study of blood lipid levels of patients with symptomatic IDH was conducted to assess the link between blood lipid levels and symptomatic IDH.n = 155), multiple IDHs (n = 367), spondylolysis (n = 98), foraminal or central canal stenosis (n = 187), spinal trauma (n = 67), primary osteoarthritis of the operated and/or contralateral joint (n = 367), inflammatory joint disease (n = 211), diabetes (n = 311), coronary heart disease (n = 516), cerebrovascular disease (n = 217), hypertension (n = 467), and smoking (n = 468). Further, 918 patients  met the inclusion criteria and were included in the study in group 1 (symptomatic IDH group). A total of 921 patients (control group) , who underwent a physical examination and an MRI scan during the same period, were matched with the baseline of the symptomatic IDH group (Table P > 0.05). This study has been reported according to the strengthening the reporting of cohort studies in surgery (STROCSS) criteria [All procedures in the present study were approved by our ethics committee. All patients signed the written informed consent. The detailed primary flow charts are presented in Fig. criteria .Fig. 1TPatients in group 1 with (a) symptomatic cervical spondylotic myelopathy and thoracic and lumbar IDH were enlisted in the study. The diagnosis of cervical spondylotic myelopathy and thoracic and lumbar IDH was conducted on the basis of clinical presentation, physical examination, radiography, electromyography, computerized tomography, and/or MRI. (b) Also, patients with no symptom relief despite adequate medical treatment were included.The inclusion criteria for group 2 were as follows: 1) The patients who underwent physical examination in the same period and were excluded for IVDD from 2009 to 2019 [ The patiThe exclusion criteria for groups 1 and 2 were as follows: history of spinal disorders, multiple IDHs, spondylolysis, spondylolisthesis, foraminal or central canal stenosis, spinal trauma, spondyloarthritis, primary osteoarthritis of the operated and/or contralateral joint, inflammatory joint disease, diabetes, coronary heart disease, cerebrovascular disease, hypertension, smoking, and age less than 18 years .(1) Typical sensorial nerve root symptoms (pain or sense abnormity) were always present. (2) Motion (weakness and atrophy), sense (hypesthesia or paresthesia), and reflex (weakened or absent tendon reflex), if present, were confined to one dermatome and/or myotome that corresponded to pain and/or paresthesias; positive signs: a positive Spurling’s test, Eaten test, and Hoffman sign. (3) Clinical symptoms and physical signs were related to the degree of root compression caused by disk herniation and/or spondylotic lateral stenosis.Localized axial back pain and/or axial back pain with radiation into the lumbar spine; sensory impairment; (2) special nerve root irritation signs: the pain can even simulate heart disease and/or shoulder pain and/or abdominal pain; (3) neurologic deficit: paraparesis and monoparesis; spasticity and hyperreflexia; bladder dysfunction (knee jerk or ankle reflex).Low back pain with unilateral or bilateral lower limb radicular pain; (2) Bragard’s sign: straight leg raising test and strengthening test were positive; (3) Neurologic deficit: myasthenia, numbness, and/or disappearance of reflex (knee jerk or ankle reflex).All the patients enrolled in the present study underwent the spine examination with a 1.5 T or 3.0 T MRI scanner. Both T2- and T1-weighted images were combined for evaluating the IVDD from C1/2 to L5/S1 regions by an experienced spine surgeon who knew nothing about the study. The degree of IVDD on MRI was based on the Pfirrmann grade system . The criAll blood samples were collected in the same way between 07.30 and 08.30 a.m. after midnight fast. Biochemical analyses of blood samples were conducted on fresh specimens. Fasting serum samples were collected, and 5 mL of each sample was centrifuged at 4000 rpm for 6 min. The serum was collected from the samples, and the concentrations of TC, TG, LDL-C, high-density lipoprotein cholesterol (HDL-C), Apo AI, Apo B, and Lp(a) were measured in the same way with an automatic biochemical analyzer. The normal levels of the following indexes exhibited the following range: TC from 0 to 5.2 mmol/L; TG from 0 to 1.7 mmol/L; LDL-C from 0 to 3.4 mmol/L; HDL-C from 0.7 to 2.0 mmol/L; ApoEA1 from 1 to 1.6 g/L; Lp(a) from 0 to 30 mg/mL; and Apo B from 0.6 to 1.1 g/L. The normal value of the ratio of Apo B/Apo AI was 0.87 for the male participants and 0.65 for the female participants [t tests. Categorical variables were expressed as percentages and analyzed with a chi-square test. The normality analysis was carried out for the continuous variables. SPSS (Version 20.0) was used for all statistical analyses. The data of continuous variables in the present study followed an ordinary normal distribution. The adjustment for multiple comparisons was conducted in the study. A P value lower than 0.007 (P < 0.007) indicated a statistically significant difference following the adjustment for multiple comparisons , TG (P = 0.00), LDL-C (P = 0.00), Apo B (P = 0.00), and Lp(a) (P = 0.006). No statistically significant differences were noted in HDL-C (P = 0.125) and Apo AI levels (P = 0.326). The ratios of Apo B/Apo AI were higher in patients with symptomatic IDH compared with the controls .The serum levels of TC, TG, LDL-C, HDL-C, Apo AI, Apo B, and Lp(a) were measured in all patients Table . The patP = 0.000, P = 0.00, P = 0.02, P = 0.000, and P = 0.000, respectively). No statistically significant differences were noted in the levels of HDL-C (P = 0.189) and Apo AI (P = 0.412).The percentage of dyslipidemia incidence in the control and IDH group was further investigated in the study. The percentage of high TC, high TG, high LDL-C, low HDL-C, Apo AI, Apo B, and Lp(a) was 31.19, 13.85, 20.17, 7.52,14.9, 30.8, and 28.9%, respectively, in group 1 compared with 23.33, 15.34, 14.8, 5.98, 13.6, 51.14, and 21.76% in group 2, respectively  = 0.021, P < 0.008). These results showed that higher levels of LDL-C, TC, TG, Lp(a), Apo B, and Apo B/Apo AI were closely related to disk herniation.The correlation analysis was conducted between serum lipid abnormalities and the degree of IVDD (Pfirrmann grade) to investigate further the correlation of symptomatic IDH with elevated levels of LDL-C, TC, TG, Lp(a), Apo B, and Apo B/Apo AI. As shown in Fig. n = 689) exhibited the following percentages of degenerated segments in the cervical, thoracic, and lumbar regions: 13.9, 1.3, and 84.8%, respectively. Compared with the hyperlipidemic samples, the participants with normal serum lipid levels exhibited the incidence of 18.8, 1.3, and 79.9% that corresponded to the cervical, thoracic, and lumbar regions, respectively (n = 229). No significant differences in the herniation segments were noted between these two groups (P = 0.201)  and C5–C6 (P = 0.373) segments with regard to TC levels  and C5–C6 segments with regard to LDL-C levels (P = 0.254) . With regard to Apo A1 , Apo B, and Apo B/Apo AI levels. As shown in Table The relationship between blood lipid and IVDD-related disease has been examined by a multitude of studies –16. HighApoA1 is the main protein component of HDL particles, which plays a key role in reversing cholesterol transport and regulating inflammatory response and antioxidant processes . Apo B iIn the present study, the relationship between the levels of Apo AI, Apo B, and Lp(a), and symptomatic IDH was examined for the first time. As a result, the levels of Apo B and Lp(a) were shown to be positively associated with the incidence of symptomatic IDH. For the LDL-C, Apo B can facilitate cholesterol delivery to the tissues. However, Apo AI can facilitate the peripheral cell uptake of cholesterol and help in the transport of cholesterol to the liver for digestion. Thus, the levels of these Apo B/Apo AI can mirror cholesterol transport ability to the peripheral tissues and determine the level of cholesterol in plasma , 37. HigThe exact pathophysiologic mechanism underlying the relationship between blood lipid levels and lumbar disk herniation is still uncertain. The increased levels of TC, TG, LDL-C, Apo B, and Lp(a) in patients with IDH might be due to several reasons. First, the IVD is a barely vascularized region; its nutrient supply is through the blood capillaries of endplate cartilage and annulus fibrosis . High leIncreased levels of TC, TG, LDL-C, Apo B, and Lp(a) and decreased level of HDL-C are atherogenic lipid markers. The management of the cardiovascular disease has traditionally focused on reducing serum lipid levels . This stThe level of TC, TG, LDL-C, Apo B (Apo B/Apo AI), and Lp(a) positively correlated with the incidence of symptomatic IDH. However, hyperlipidemia had no effect on the degenerated segment of the intervertebral disk. This association provided novel evidence regarding the risk of symptomatic IDH disease are related with the elevated serum lipid levels and also indicated that a decrease in serum lipid levels could be a promising target for treating IDH. This study provided useful information to identify a population that might be at risk of developing disk herniation based on elevated lipid levels and helped to identify the possible mechanism of IVDD.