Early neurological assessment in infants with hypoxic ischemic encephalopathy (HIE) treated with hypothermia has not been systematically explored. The aims of the present study were to assess whether the Hammersmith Infant Neurological Examination (HINE) is a good tool to predict later neurodevelopmental outcomes at 2 year from birth in this population of infants. A total of 41 term born infants with HIE treated with hypothermia performed the HINE at 12 months and a neurodevelopmental assessment at 24 months. All the infants who had a global HINE score between 67 and 78 were able to walk independently at 2 years and reported a normal developmental quotient; language disorders were observed in a limited number of infants. HINE scores <67 were always associated with motor impairment. In conclusion, the HINE confirms its role as one of the early neurological examination tools for the diagnosis of high risk infants, even in infants with HIE treated with hypothermia. These results can be useful for clinicians involved in the follow up of these infants for early identification of motor disabilities and in planning appropriate intervention. Neonatal hypoxic ischemic encephalopathy (HIE) remains one of the leading causes of newborn mortality and long term disability worldwide, as it occurs in 3–5 out of 1000 live births ,3. In thNeurological assessment is one of the clinical tools used to monitor development in infants that are at risk of developing neurodevelopmental disabilities ,9. In reIn infants with HIE, this neurologic examination provided additional prognostic information on the severity of the functional motor outcome at 2 and 4 years, showing a good correlation with the MRI performed during the neonatal period . HoweverThe aims of the present study was therefore to test the hypothesis that the HINE could be used to predict later neurodevelopmental outcomes at 2 year from birth in newborns with HIE treated with TH.The infants described in this study were part of a cohort of term infants who were born with perinatal hypoxic-ischemic brain injury and admitted to the Neonatal Unit of the Fondazione Policlinico Gemelli between January 2015 and June 2017 and consecutively enrolled in a follow-up prospective research program. For the purpose of this study, infants with ≥36 weeks gestation, with signs of encephalopathy after 10 min after birth but before 6 h, were recruited if they had one of the following signs suggesting intrapartum hypoxia: (i) a pH ≤ 7.0 or a base deficit ≥16 mmoL/L in the first hour of life on cord or infant arterial blood, or (ii) An abnormal intra-partum course  and either a 10 min Apgar score ≤5 or continued respiratory support at 10 min. Once these criteria were met, all infants underwent a standardized neurologic examination ,13. InfaExclusion criteria were a completely normal neurological exam; inability to enrol at ≤6 h of age; major congenital abnormality, cerebral malformations; neonatal abstinence syndrome; metabolic encephalopathies; a severe growth restriction (birth weight of ≤1800 g); refusal of consent by a parent; moribund infants for whom no further aggressive treatment was planned also were excluded.Parental permission was obtained in all cases. All the infant who met the inclusion criteria and a moderate or severe encephalopathy underwent TH according to the international guideline for 72 h . During A magnetic resonance imaging (MRI) was performed in all the newborns between days 7 to 14 after birth.The Hammersmith Infant Neurological Examination (HINE) was performed at 12 months . An optiA further neurodevelopmental assessment was performed at 2 years; it included a structured neurological examination according to Touwen  and a deCerebral palsy, if present, was classified according to the criteria proposed by Himmelmann et al. .The Ethical Committee of our Institution approved the study. p < 0.01. The anthropometric variables  and HINE scores were reported as median and range. In order to explore the possible influence of gender on birth-weight, gestational age, HINE scores and DQ on Griffitth’ scales, differences in sub-scores and global scores between male and female were analysed by the Mann-Whitney test. Statistical analysis was performed using the “Stata Statistical Software: Release 10” . The level of significance was set at p > 0.05). A total of 48 infants were eligible for the study. Seven of them  did not attend one or more of the assessments and were therefore excluded. Forty-one infants represented the final population  with a median birth-weight of 3190 g (range 2040–5000 gr) and a median gestational age of 39 weeks (range 36–41 weeks). There was no difference between males and females on birth-weight or gestational age  with a similar distribution of normal/abnormal scans between males and females. A total of 23 of the 41 infants had normal scans . Of the 18/41 infants with abnormal scans, 8 had minimal basal ganglia and thalami lesions , 4 had moderate white matter lesions , 3 had moderate white matter and basal ganglia and thalami , while 3 had severe basal ganglia and thalami with diffuse white matter . p > 0.05).At 12 months of age, 30 infants reached an optimality score (≥73) and 11 reported a suboptimal score, 7 with scores between 67 and 72, 3 with scores between 40–66 and only one with scores <40. Thirty-six infants were neurologically normal, 1 had a diplegia, 2 had quadriplegia, and 2 had quadriplegia with dystonia. Thirty-seven of the 41 infants were able to walk independently. The remaining 4 infants showed severely limited self-mobility and unsupported sitting.p > 0.05). In the 37 infants with normal DQ, 7 reported a borderline DQ in the hearing and speech subscale , 4 an abnormal DQ in the hearing and speech subscale , 1 a borderline DQ in the locomotor subscale  and 1 a border DQ in the personal–social subscale .The global DQ of the Griffitths scale was >85 in 37 infants and was abnormal (<70) in the other 4. No difference was found between males and females on global DQ  of the infants with minimal basal ganglia lesions . The scoThirty infants had optimal HINE scores: all walked independently by the age of 2 years and had a normal global DQ. Three of them had abnormal DQ in the hearing and speech subscale  .Seven infants had suboptimal HINE scores (above 67): all were able to walk independently by the age of 2 years and had a normal DQ. One of the 7 had abnormal DQ in the hearing and speech subscale  and another one a borderline DQ in the locomotor subscale and a mild form of diplegia . Three infants had HINE scores between 66 and 40: all of these infants had motor impairment and could not sit unsupported at 2. The only one infant with a HINE score <40 showed severe motor impairment with incomplete head control.This is the first study reporting early neurological assessment in infants with HIE treated with hypothermia. For the purpose of this study, we used the HINE as it has been reported to have a good predictive power for motor outcome in both preterm and term born infants ,10,11,12In pre-hypothermia era, approximately 40% of infants with HIE had suboptimal scores on the HINE that was performed at 9–14 months , with anThe results obtained in our cohort of infants treated with hypothermia showed better HINE scores than those previously reported in a similar population of infants with HIE without TH . The HINIn the present study, only 27% of the infants reported suboptimal HINE scores. The magnitude of the scores were often related to the brain MRI findings. The HINE scores were always optimal or slightly sub-optimal (>67) in the infants with normal neonatal MRI or moderate white matter lesions. At the other extreme, the lowest HINE scores were always associated with very severe lesions such as severe basal ganglia and diffuse white matter lesions. Infants with minimal basal ganglia or with moderate white matter and basal ganglia lesions had more variable scores with both optimal and sub-optimal scores. In a single case, MRI reported a minimal basal ganglia lesions only with a sub-optimal score of <67; this infant showed spastic quadriplegia at 2 years.The HINE scores were also related to the neurodevelopmental outcome at 2 years. Only one infant had a score <40 and showed a severe form of spastic-dystonic quadriplegia without head control. Infants with sub-optimal scores <67 were always associated with motor impairment and unsupported sitting at 2 years. Infants with suboptimal scores but above 67 were always associated with the ability to walk independently at 2 years, only in one case associated with a mild form of diplegia. All the infants with optimal scores had a normal motor outcome. These findings are in agreement with previous published studies correlating the patterns of lesions on MRI with the HINE optimality scores and motor outcome in high-risk term born infants ,12,18. Tn = 7) or abnormal (n = 4) DQ on the hearing and speech subscale. All of them had a normal MRI or minimal basal ganglia lesions, optimal HINE scores in 73% and suboptimal but above 67 in the other 27%. These results are consistent with the few studies investigating language development in children with HIE post-TH, also showing significantly lower scores in expressive language even in the absence of more serious cognitive or motor difficulties or with minimal or no MRI lesions [The possibility to relate the HINE scores to the Griffith’s scales allowed further considerations. It is of interest that among the 37 infants with normal neurodevelopmental outcome, 11 had borderline ( lesions ,20. The  lesions , providi lesions .In the present study there was an overall higher number of males then females; this is not surprising, as the male sex is recognized to be a risk factor for neonatal HIE during the perinatal period even in those treated with hypothermia ; males aIn conclusions our results suggest that the HINE could be used to assess infants with HIE, even in the hypothermia era. These results are very promising but should be interpreted with caution because of the relatively small number of patients included. Larger cohorts and a longer follow up are needed to confirm our preliminary results and to allow a more detailed correlation between clinical and neuroradiological assessments. These findings: even if preliminary, can be useful for clinicians involved in the follow up of infants with HIE treated with hypothermia. Suboptimal HINE scores may help, especially if associated with severe brain lesions, to early identify patients who may benefit from early appropriate intervention. On the other hand, the presence of optimal HINE scores and normal brain MRI or minimal changes will help to reassure parents about a lower risk of developing severe squealae.


Left ventricular pseudoaneurysm is a very rare complication following acute myocardial infarction, which results from a free wall rupture. Hemopericardium and cardiac tamponade caused by rupture of the free wall after acute myocardial infarction are often fatal. It is difficult to fully document the evolution of left ventricular pseudoaneurysm resulted from acute myocardial infarction with conservative treatment.Herein, we followed a 75-year-old female patient for 3 years. Recorded the evolution of the disease: acute lateral myocardial infarction - emergency reperfusion therapy - cardiac rupture - positive successful rescue - the pseudoaneurysm formation - maintaining conservative treatment - gradual enlargement of the pseudoaneurysm - thrombosis in pseudoaneurysm - thrombus filling with pseudoaneurysm - finally stabilized condition - the treatment of coronary revascularization.This case is reported here because of its scarcity, which provides provides us with a complete record of the entire evolution and an astonishing indication of the long-term prognosis of non-surgical treatment for pseudoventricular. Left ventricular pseudoaneurysm is a very rare complication of acute myocardial infarction. Hemopericardium and cardiac tamponade caused by a free wall rupture following the acute myocardial infarction is often fatal. Only a few patients survive and develope left ventricular pseudoaneurysm. Owing to the possibility of death caused by subsequent complete rupture, surgical repair is usually recommended when a left ventricular pseudoaneurysm has been detected. However, we followed a 75-year-old female patient who had a left ventricular pseudoaneurysm for 3 years due to a ruptured left ventricular free wall after an acute myocardial infarction. We recorded the evolution of left ventricular pseudoaneurysm with conservative treatment.A 75-year-old woman was admitted to our hospital for 1 h of persistent severe chest pain. Apart from smoking, she had no cardiac risk factors. At the time of admission, the electrocardiogram showed ST-segment elevation in leads I,avl. Laboratory data showed that the serum creatine kinase and troponin I had elevated. According to the results of electrocardiogram and laboratory data, STEMI was definitly diagnosed. Primary percutaneous coronary intervention (PCI) was indicated immediately. The coronary agiography (CAG) revealed triple vessel disease with left circumflex as the culprit which was occluded in the proximal segment . During the first 2 months of follow-up, the volume of pesudoaneurysm increased to 65 × 55 mm(Fig. 6 months.The symptoms of angina were significantly improved after operation. Our patient continued outpatient follow-up after discharge, and was symptom free. There was no significant change in medication during the 3 years of treatment. Dual antiplatelet therapy was continued for 3 years.Left ventricular free wall rupture is a very serious mechanical complication after AMI with high mortality rate. Myocardial rupture that directly causes death reportedly occurs in 4 to 10% of patients after acute myocardial infarction . CardiacIn this case, the process of left ventricular pseudoaneurysm caused by rupture of left ventricular wall after myocardial infarction was clear. After a long time of follow-up, we were surprised to find that despite the high mortality, the disease could still be self-limiting for a period of time. Thrombus could form in the chamber of the aneurysm and increase gradually. However, it reduced the sustained impact of blood flow on the wall of the pseudoaneurysm. Eventually, the thrombus filled the aneurysm and prevented blood from flowing into the aneurysm from the left ventricular. The patient turned the corner. The dynamic evolution of this case demonstrated the feasibility and long-term benign prognosis of conservative treatment for left ventricular pseudoaneurysm.In one study, 13% of the patients with a left ventricular pseudoaneurysm had systemic embolism as the clinical presentation . In anotThis is a rare case. First of all, timely and accurate treatment in the acute phase saved the life of this patient. Second, after a long period of follow-up, we have obtained the complete evolution of a left ventricular pseudoaneurysm: acute myocardial infarction - cardiac rupture - left ventricular pseudoaneurysm formation - gradual enlargement of the pseudoaneurysm - thrombosis in pseudoaneurysm - thrombus filling with pseudoaneurysm - condition recovery and stability. These data suggest that the evolution process and the long term outcome of the left ventricular pseudoaneurysm may be relatively benign after severe acute pericardial tamponade. Secondary thrombosis in the aneurysm, while increasing the risk of thromboembolism, might be a solution for the aneurysm to repair itself and reduce the risk of fatal rupture in the long term. Therefore, these suggest a possible benign endpoint for long-term prognosis after conservative treatment of left ventricular pseudoaneurysm.


Low red blood cell folate concentrations during early pregnancy might cause neural tube defects. However, the association between folate concentrations and birth defects of other neural crest cell-derived organs remains unknown. We investigated the associations between birth defects and first-trimester serum folate concentrations in a birth-cohort study in Japan.In total, 14,896 women who were prior to 13 weeks of gestation were enrolled from 2003 through 2012. Birth defect information was obtained from medical records and questionnaires. The association between folate levels in the first trimester and birth defects categorized as ICD-10 cord defects and neural crest cell-derived organ defects was examined. The crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) per log-transformed folate concentration were calculated using logistic regression.Blood samples were obtained at a mean of 10.8 weeks of gestation. Median serum folate level was 16.5  nmol/L, and the deficiency level (less than 6.8 nmol/L) was 0.7%. There were 358 infants with birth defects. The adjusted odds ratio for any birth defect, ventricular septal defects, and cleft lip was 0.99 , 0.63 , and 4.10 , respectively. There were no significant associations between first-trimester maternal serum folate and the risk of birth defects.We were unable to demonstrate a relationship between maternal serum folate in the first trimester and birth defects. Potential confounding factors may have influenced our results. These cells are also involved in the development of the heart and face. The relationship between these congenital malformations and folic acid has been studied; however, the association between folate intake and congenital heart defects (CHDs)7–10 and orofacial clefts11–14  remains unknown. Controversy arises in part because of differences in disease definition and type, dose, and intake time of folic acid supplements.11Folic acid supplementation at preconception and during the first trimester reduces the risk of delivering an infant with neural tube defects (NTDs).7–10,14,15 and data on folate intake during pregnancy was usually obtained retrospectively from the mother after birth, resulting in potential recall bias. In addition, in vivo activity of ingested folic acid differs, because of genetic polymorphisms related to folic acid metabolism.16 In some studies, postpartum serum or red blood cell (RBC) folate concentrations were measured in women whose infants had CHDs or orofacial clefts17–22; however, postpartum folate level measurements cannot be used to evaluate the role of folate in organogenesis. In one prospective cohort study examining the association between serum folate during pregnancy and birth defects, serum folate in mid-pregnancy  was not associated with conotruncal heart defects or cleft lip with/without cleft palate (CL ± P).12,23 In another prospective study, the first trimester mean serum folate level was significantly lower in mothers of infants with congenital malformations than in mothers of infants without these malformations,24 thus, the results are inconsistent. Many studies have examined the relationship between periconceptional folic acid intake and birth defects in Europe, the United States, and China.25,26 In Japan, there is no legislation requiring grain fortification with folic acid, and the Ministry of Health and Welfare only officially recommended in 2000 that women planning to conceive take supplements with 400 µg folic acid daily from the month before conception through the first 3 months after conception to reduce the risk of NTDs.27 However, the supplement intake rate of pregnant Japanese women is low, about 30%.28Most studies evaluating the association between maternal folate intake and birth defects were case-control studies,29 and the influence of serum folate concentrations and smoking status in early pregnancy on birth weight.30The Hokkaido Study on Environmental and Children’s Health (Hokkaido Study) is a prospective cohort study that has been carried out in the Hokkaido Prefecture of Japan since 2003. Our previous studies reported the incidence of birth defectsIn this study, we investigated the association between first-trimester maternal serum folate levels and the risk of birth defects by using data from the Hokkaido Study.31–33 Data were gathered using baseline questionnaires, biochemical assays, birth records, and 1- and 2-year postpartum questionnaires. Figure The Hokkaido Study investigated the effects of perinatal environmental chemical exposure on birth outcomes, including birth defects, development, and allergies. We enrolled women during early pregnancy  visiting one of the 37 gynecological hospitals and clinics within Hokkaido, the northernmost prefecture in Japan. The study design was previously described in detail.2), use of assisted reproductive technology, family history of birth defects, alcohol consumption, smoking habits, and medication use (prescription or over-the-counter drugs). We defined maternal alcohol and tobacco use as any reported maternal alcohol and tobacco use before pregnancy and medication use as any reported maternal medication use during the first 12 weeks of gestation.Data were collected from baseline self-administered questionnaires, hospital birth records, and 1- and 2-year postpartum self-administered questionnaires. Participants completed questionnaires during early pregnancy; information obtained included maternal age, parity, maternal educational level, socioeconomic status, medical and reproductive histories, preconception maternal body mass index , gestational age, infant sex, birth weight, maternal medical history during pregnancy, obstetric events, and birth defects identified by the delivery unit physicians. Additionally, we collected self-administered questionnaires from all mothers at 1 and 2 years postpartum to obtain additional information including birth defects.31Non-fasting serum blood samples were obtained to measure serum folate concentrations during the first trimester. Serum folate levels were assayed at a commercial laboratory  using an automated competitive protein binding chemiluminescent enzyme immunoassay with the ADVIA Centaur technique .29 We coded the birth defects according to the International Statistical Classification of Disease and Related Health Problems 10th revision (ICD-10).34 Further, we defined a group of birth defects resulting from the defective development of NCCs. The neural crest is the fold of neural ectoderm at the junction between the neural and epidermal ectoderm in neurula-stage vertebrate embryos. NCCs give rise to a number of cell types and to a number of tissues and organs, such as the heart, craniofacial skeleton, connective tissues, and smooth muscles.35 NTDs are birth defects in the neural tube originating from NCCs, and there has been confirmation that folic acid supplementation prevents the first trimester occurrence of NTDs.16 In order to investigate the preventive effect of folic acid on birth defects of other organs developing from NCCs, we considered NTDs,3–5 CHDs,7,9 orofacial clefts,13,14 hypospadias,36 and limb reduction defects37 as birth defects of organs arising from NCCs.We obtained birth defect information from medical records at birth and self-reported questionnaires at one and two years postpartum, because some diseases, such as CHDs and cryptorchidism, may be diagnosed even after one year following birth. The birth defect was selected from a list of 55 disease names on medical records by physicians, or if the disease was not on the list, described disease names in the unified sheet. These 55 birth defects listed on the unified sheet are possible effect markers of environmental exposure.8–10 The classification of reported birth defects was confirmed by a neonatal specialist.CHDs were classified into five subgroups: 1) isolated septal defects, including isolated ventricular septal defects and isolated atrial septal defects; 2) conotruncal heart defects, including transposition of the great arteries, tetralogy of Fallot, truncus arteriosus, and double-outlet right ventricle; 3) left-sided obstructive malformations, including aortic valve stenosis, hypoplastic left heart syndrome and its variants, coarctation aorta, and interrupted aortic arch; 4) right-sided obstructive malformations, including pulmonary valve stenosis, pulmonary atresia, tricuspid atresia, and Ebstein anomaly, and 5) other CHDs, including complex heart defects, single ventricle, and isolated persistent ductus arteriosus.Serum folate concentrations showed skewed distribution; therefore, folate data were log transformed  before analysis. Serum folate concentrations were expressed as the median (interquartile range [IQR]), and other continuous variables were expressed as the mean (standard deviation [SD]), while categorical variables were expressed as percentages.P values <0.05 and 95% CIs that excluded 1.0 were considered statistically significant. We analyzed the data using SPSS for Windows, version 21.0 .When comparing data between mothers of infants with birth defects and mothers of infants without birth defects, the Mann-Whitney U-test was used as a non-parametric test for serum folate concentrations. We calculated crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) per log-transformed folate concentration in maternal serum folate to establish the association between serum folate concentrations and birth defects using logistic regression. The analyses were adjusted for the following potential confounding factors: maternal age at baseline (continuous variable), parity , education level , maternal BMI at preconception (continuous variable), assisted reproductive technologies , and use of alcohol , cigarettes , and medications  during early pregnancy. Two-tailed 38) was only 0.7%. Notably, median serum folate concentration of all mothers, whether or not their infants were born with birth defects, was 16.5 nmol/L. The serum folate concentrations of sub-groups and phenotypes are shown in Table Subject characteristics at baseline are shown in Table Circulatory system defects were the most frequent birth defects (130 infants), followed by genital organ defects (63 infants) Table . VentricWe estimated the association between maternal serum folate levels in the first trimester and the risk of birth defects from NCCs Table . As log-This prospective study investigated the association between first-trimester serum folate and birth defects. Elevated maternal serum folate concentrations increased the adjusted ORs for birth defects of the nervous system, cleft lip and cleft palate, while the adjusted ORs for birth defects of the urinary and musculoskeletal systems decreased. In birth defects from NCCs, elevated maternal serum folate concentrations increased the adjusted ORs for atrial septal defect and cleft lip, and reduced the adjusted ORs for ventricular septal defects. However, there were no significant associations found between serum folate levels and any birth defects. The NTD risk increased with higher serum folate concentrations; however, because of the small number of NTDs, this result may have been due to chance.24 reported that the mean first-trimester serum folate levels of mothers of infants with congenital malformations (40.85 nmol/L) were significantly lower than those in mothers of infants without these malformations , unlike the results of our study. However, their study had few subjects, and potential confounding factors such as socioeconomic status, prepregnancy BMI, and smoking habits were not mentioned.24 These factors may have influenced the results. In California, Shaw et al14,23 estimated the association between birth defects and serum folate levels at 15–18 gestational weeks by comparing the folate levels of mothers of infants with only conotruncal heart defects or CL ± P to mothers of infants without birth defects. They observed no association between serum folate levels and conotruncal heart defects or CL ± P risk, in agreement with results of the present study. Moreover, the Shaw study ascribed the lack of association between serum folate levels and conotruncal heart defects or CL ± P to the fact that their participants were from a population whose food was fortified with folic acid. The United States began mandatory folic acid fortification in 1998, and the prevalence of low serum folate levels (less than 3.0 ng/mL or 6.8 nmol/L) among women of childbearing age was approximately 0.8% from 1999–2006.39Some prospective studies have investigated the association between folate levels and risk of CHDs and CL ± P. A study in Saudi Arabia40 and Matsuzaki41 reported that the median serum folate level was 23.2 nmol/L (51 pregnant women) and 4.8 ng/mL , respectively. Serum folate concentration of our participants approximated the middle value of the serum folate values of the two aforementioned studies. Most of our participants were also mothers with serum folate levels within the normal range (13.5–45.3 nmol/L) per WHO criteria,38 which might help to explain the lack of a significant association between these levels and birth defects.In previous studies on serum folate concentrations in pregnant women during the first trimester in Japan, Takimoto42 Folic acid may affect cell proliferation in the early stages of development, thereby promoting posterior neural tube closure.43 The association between folic acid supplementation or serum (or RBC) folate levels and birth defects other than NTDs from NCCs has been inconsistent. However, folate status is also affected by gene polymorphisms related to folate metabolism,16 and gene-environment interactions between gene polymorphisms related to folate metabolism with periconceptional folate supplementation have been observed for CHDs and cleft lip.44–46 Furthermore, folate deficiency may modulate the risk of congenital malformations by affecting the bioavailability of methyl groups for DNA methylation reactions or nucleotide synthesis. However, we could not explain the role of folic acid in organogenesis. In a large-scale study such as a national population-based study, a multi-center hospital-based case-control design,3,9,10,13 folic acid supplementation has been shown to reduce the risk of CHD or cleft lip. On the other hand, one study reported that the risk of cleft lip increased with the intake of folic acid supplements before and after conception.14 To determine any adverse effects of the intake of folic acid on the fetus, further research is required, and careful consideration is necessary.Folate is integral to one-carbon metabolism, which produces pyrimidines and purines for the synthesis of DNA and S-adenosylmethionine. Accordingly, folic acid is essential for cell proliferation and/or cell survival.29The strengths of our study are its birth cohort study design and our inclusion of first-trimester evaluations. Most previous studies of birth defects have used folate intake as a proxy for folate during pregnancy. To elucidate the role of folic acid during the organogenesis period, we measured serum folate during the critical period of organ development. In addition, information on possible confounding factors such as smoking, drinking, and medications taken in early pregnancy allowed us to analyze the effect of lifestyle on the risk of folate deficiency without recall bias. Second, our study enrolled women attending community hospitals and clinics as well as university hospitals. Therefore, the frequency of birth defects in this study likely reflects that of the general population of Hokkaido Prefecture.47 In our study, blood samples were collected without the recording of elapsed time after meals. Thus, there is a possibility that the concentration of folate in the obtained serum may have been higher than it would have been in a fasting blood sampling. However, this consequence should have occurred in all mothers, whether or not they had children with birth defects. Third, although the cohort was relatively large, there were few birth defects. In our previous study, the spina bifida incidence was 1.6 per 10,000 births.29 For spina bifida, the minimum required sample size is approximately 130,000 when two dependent variables are included in the logistic regression analysis.48 Finally, potential confounding variables, including environmental factors such as exposure to radiation or air pollution, and infectious diseases, gene polymorphisms, and gene-interactions, were not assessed in this study. Not considering these factors might have resulted in the finding of a non-significant relationship between maternal serum folate levels in the first trimester and birth defects.This study also has several limitations. First, we obtained birth defect information from medical records at birth and supplemented it with self-reported maternal information from questionnaires completed 1 to 2 years after delivery. Therefore, birth defect phenotypes could have been misclassified because they were not medically diagnosed. Second, non-fasting serum folate levels were treated as indicators of folate status. In general, RBC folate concentrations have been viewed as a better long-term measure of folate concentrations. However, the determination of RBC folate is more complex, and serum folate measurement is more common than erythrocyte folate measurement in medical facilities in Japan. Serum folate assays are preferred in large epidemiological studies; therefore, we used serum folate evaluation. We sampled non-fasting blood. With folate-containing food, peak concentrations of plasma folate occur in a few hours, returning to pre-ingestion concentrations at around 8 hours.In this study, we investigated the association between maternal serum folate levels in the first trimester and birth defects; however, we were unable to establish a significant association between them. In future studies, we will examine the association between folate levels, gene polymorphisms of folic acid metabolic enzymes, and birth defects using a nested case-control design or case-cohort design.


Perineural cysts in the spinal canal are usually asymptomatic. However, symptoms can occur when the cyst becomes large enough to compress a nerve root. There are still no established treatment options for this disease. In this report, we describe a case of successful decompression of the large symptomatic perineural cyst using epiduroscope.A 42-year-old male patient visited our pain center complaining of discomfort and pain in his right posterior thigh. Magnetic resonance imaging of the patient showed a large perineural cyst (53 × 31 × 21 mm) compressing the right S1 nerve. No other abnormalities that would explain the patient's symptoms were identified.Perineural cyst at the right S1 nerve.We performed an epiduroscopic decompression of the perineural cyst. After advancing the epiduroscope and locating the cyst, we used the laser to make a hole in the cyst wall. Then, the epiduroscope was advanced into the cyst, and the cystic fluid was aspirated.The symptoms of the patient were relieved after the procedure, without any complications. There was no recurrence of symptoms until 6 months after the procedure.The epiduroscope is a minimally invasive method which can be used safely for decompression of symptomatic perineural cysts in the spinal canal. They are usually asymptomatic; however, in some cases, they can cause symptoms, especially when they are large enough to compresses the nerve root. So far, various treatments methods have been utilized, as there is no standard treatment for symptomatic lumbosacral perineural cysts. After excluding other causes of the patient's symptoms, conservative treatment  is implemented first. If the symptoms persist despite these treatments, cyst decompression is considered. There are surgical and non-surgical methods for decompression of a cyst. With the recent trend towards minimally invasive procedures, a variety of non-surgical methods are being attempted.,5 In this paper, we report a successful case of decompression of a symptomatic perineural cyst in the sacral canal using an epiduroscope. The patient gave the informed consent to publish this case. This case report was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (IRB No. B-1809-495-701).Perineural cysts, also called Tarlov cysts, were first described by Dr Tarlov in 1938.2A 42-year-old male patient visited our pain center complaining of discomfort in the right posterior thigh, which started a year ago. He reported that prolonged standing or sitting worsened his symptoms , and driving for more than an hour was difficult because of the pain. The patient's pain eased when he lay down. Over the past 7 months, the patient had received manipulation therapy and physiotherapy at other hospitals, along with the following oral medications: aceclofenac 100 mg 1 tab bid, limaprost 5 mcg 1 tab bid, and eupatilin 60 mg 1 tab bid; however, the treatments were not effective. On physical examination, there were no abnormalities identified in the lower back or lower extremity, and motor and sensory testing were normal. On the lumbosacral spine MRI obtained at an external hospital, a cystic lesion was observed on the right side of the midline, ranging from S1 to S2 (size: 53 mm × 31 mm × 21 mm). The lesion showed low signal intensity on the T1-weighted image and high signal intensity on the T2-weighted image; it was located in the path of the right S1 nerve root and was compressing the nerve  fills and inflates a cyst, it causes nerve compression, which can induce perineal pain, low back pain, and sciatica. Although the exact mechanism is unknown, recent studies have shown that the unidirectional check valve mechanism could be the main cause of the cyst's size increase. For the patient in this case, there was a cystic lesion in the posterior-superior part of the nerve pathway. Therefore, maintaining a standing or sitting position for a long time caused pain by increasing the pressure of the cyst on the nerves, and lying down relieved the pain by decreasing the pressure. The cyst was easily diagnosed on MRI, showing low signal intensity on the T1-weighted image and high signal intensity on the T2-weighted image.,9 Symptomatic therapy is commonly preferred for perineural cysts, but surgical and non-surgical methods of cyst removal are considered in cases with non-adaptive pain. Current surgical methods used are laminectomy for cyst decompression and nerve root resection; laminoplasty and cyst fenestration; incision and drainage; and lumbo-peritoneal CSF shunting. Open surgery allows for visualization of the entire lesion, but the wide and invasive approach required presents additional risks, such as infection, bleeding, nerve damage, and leakage of the CSF.,11 Commonly executed non-surgical methods are computed tomography (CT)-guided cyst rupture, fluoroscopic fenestration and injection, and trans-foraminal approach and cyst aspiration. It has been reported that relapse is common if anatomical diversity prevents access to the lesion or there is communication with the CSF. The development of endoscopy equipment has led to a variety of treatments for epidural lesions, which are considered more effective compared with the existing CT or fluoroscopy-guided procedures. In this case, we first attempted fluoroscopy-guided decompression; however, since the aspiration of the cyst was not complete, and the symptoms persisted, we performed epiduroscopic decompression. It has been reported that surgical removal of multiple small cysts and endoscopic removal of a single, large cyst in the central region had excellent results. In the patient in this report, a relatively large single cyst that occurred in the central part was thought to be old enough to have caused bone deformation. The color of the fluid aspirated from the cyst was yellowish and sticky like apple juice and the small reduction in the size of the cyst improved the patient's symptoms. Therefore, endoscopic removal was planned, since little to no communication with the CSF was suspected. In cases that are clinically ambiguous or when a more objective evaluation is required, myelography can be performed to assess the inside of the cyst and evaluate for potential communication with the CSF. Moreover, if communication is identified, the area can be accessed using an endoscope, and a laser can be used to cauterize the area or block the entrance with materials, such as fibrin glue. However, there has been a report of meningitis that occurred after treatment using fibrin glue. In addition to perineural cysts, it is also possible to remove lesions inside the spinal canal, such as facet cysts and discal cysts, using a flexible scope. Using the flexible scope, multiple lesions can be removed simultaneously; therefore, the application range of endoscopic procedures will likely continue to widen in the future. The limitations of this case were the absence of cyst fluid analysis prior to epiduroscopic decompression and the lack of histologic examination of the cyst wall for exact classification of the cyst.In this case, symptoms caused by nerve root compression from a large perineural cyst in the sacral canal were successfully relieved using epiduroscopic decompression. Perineural cysts occur in 1.5% of the total population, and approximately 13% of cases are symptomatic.In conclusion, this case demonstrates that the epiduroscope can be used for decompression of symptomatic perineural cysts in the spinal canal, especially when the cyst is large enough to cause symptoms.Conceptualization: Francis Sahngun Nahm.Project administration: Francis Sahngun Nahm.Supervision: Francis Sahngun Nahm.Validation: Eunjoo Choi, Pyung-Bok Lee.Visualization: Jae-Sung Lee.Writing – original draft: Sangmin Jeong.Writing – review & editing: Francis Sahngun Nahm, Woong Ki Han, Ho-Jin Lee.Francis Sahngun Nahm orcid: 0000-0002-5900-7851.


Is birth weight associated with type 2 diabetes and glycemic traits?1c level.This mendelian randomization study found that a 1-SD decrease in birth weight due to the genetic risk score was associated with a higher risk of type 2 diabetes among European and East Asian populations. In addition, a 1-SD decrease in birth weight was associated with a 0.189-SD increase in fasting glucose concentration, but not with fasting insulin, 2-hour glucose, or hemoglobin AA genetic predisposition to lower birth weight was associated with an increased risk of type 2 diabetes and increased fasting glucose, suggesting potential mechanisms through which perturbation of the antenatal and early-life environment affect predisposition to diabetes in later life. This mendelian randomization study examines the association of birth weight with type 2 diabetes and glycemic traits. Observational studies have shown associations of birth weight with type 2 diabetes (T2D) and glycemic traits, but it remains unclear whether these associations represent causal associations.To test the association of birth weight with T2D and glycemic traits using a mendelian randomization analysis.This mendelian randomization study used a genetic risk score for birth weight that was constructed with 7 genome-wide significant single-nucleotide polymorphisms. The associations of this score with birth weight and T2D were tested in a mendelian randomization analysis using study-level data. The association of birth weight with T2D was tested using both study-level data  and summary-level data from the consortia . Data from 180 056 participants from 49 studies were included.Type 2 diabetes and glycemic traits.P = 4.03 × 10−5), among European participants , and among East Asian participants . Similar results were observed from summary-level analyses. In addition, each 1-SD lower birth weight was associated with 0.189 SD higher fasting glucose concentration , but not with fasting insulin, 2-hour glucose, or hemoglobin A1c concentration.This mendelian randomization analysis included 49 studies with 41 155 patients with T2D and 80 008 control participants from study-level data and 34 840 patients with T2D and 114 981 control participants from summary-level data. Study-level data showed that a 1-SD decrease in birth weight due to the genetic risk score was associated with higher risk of T2D among all participants (odds ratio [OR], 2.10; 95% CI, 1.69-2.61; In this study, a genetic predisposition to lower birth weight was associated with increased risk of T2D and higher fasting glucose concentration, suggesting genetic effects on retarded fetal growth and increased diabetes risk that either are independent of each other or operate through alterations of integrated biological mechanisms. Identifying potentially causal risk factors would help guide prevention of the disease.Type 2 diabetes (T2D) has become a worldwide epidemic, with more than 422 million patients in 2014.2 In observational studies, low birth weight, a widely used indicator for fetal growth restriction, has been consistently associated with higher risk of T2D4 and adverse glycemic traits5 in later life. However, both maternal socioeconomic status and unmeasured lifestyle factors might confound these associations; therefore, the causality of these observations remains to be determined. We hypothesized that birth weight may be causally associated with T2D risk and related traits such as fasting glucose concentration, insulin level, insulin resistance, and insulin sensitivity.The thrifty phenotype hypothesis postulates that fetal growth and nutrition play important roles in influencing susceptibility to T2D in later life.11 This method is analogous to a randomized clinical trial where randomization to genotype takes place at conception, and it is less likely to be affected by confounding and reverse causation.12 Previous analyses have provided compelling evidence that fetal genotype has substantial impact on early growth, as measured by birth weight.13Mendelian randomization (MR) analysis has become widely used to assess the potential causal associations of environmental risk factors with disease.15 to perform an MR analysis to examine the association of birth weight with T2D and glycemic traits, using both study-level data and summary-level data.Therefore, in this study, we used the genetic variants for birth weight as an instrumental variableSTROBE) reporting guideline.This study was conducted using summary association data generated by previous studies. Owing to the use of previously collected, deidentified, aggregated data, this study did not require institutional review board approval per the US Federal Policy for Protection of Human Research Subjects. Ethical approval was obtained for all original studies. Reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology (16 (1) the genetic variants used as instrumental variables (IV) are associated with the exposure (birth weight); (2) the genetic variants are not associated with any confounder of the exposure-outcome association; and (3) the genetic variants are conditionally independent of the outcome (T2D and glycemic traits) given the exposure and confounders. The second and third assumptions are known as independence from pleiotropy.16Observational studies are prone to reverse causation, confounding, and biases and can generate unreliable findings in relation to the causal effects of modifiable exposures on disease outcomes. Mendelian randomization is a method aimed at unbiased detection of causal effects and estimation of their magnitudes (eMethods in the 23 (P < 5 × 10−8) from a genome-wide association study (GWAS) in the Early Growth Genetics (EGG) Consortium.23 We analyzed the data within each study using standardized analytic methods. The IV estimator is calculated as the pooled β coefficient from the GRS-T2D association divided by the pooled β coefficient from the GRS–birth weight association. Second, we tested the association of birth weight with T2D and glycemic traits using summary-level data from the EGG Consortium (n = 153 781),23 the Diabetes Genetics Replication and Meta-analysis (DIAGRAM) Consortium (n = 149 821),17 and the Meta-analyses of Glucose and Insulin-Related Traits (MAGIC) Consortium (n = 133 010).22 In this study, the 7-SNP score23 was used as the main IV because the new GWAS that identified 60 SNPs for birth weight was published after the study-level results had already been run. Therefore, we used the 43 SNPs available in this analysis, a subset of the 60 SNPs,13 as the IV for birth weight in summary-level analyses.The study design of this MR analysis consisted of 2 components23 . First, Study-level data including 49 cross-sectional and prospective cohort studies with up to 180 056 participants from the CHARGE-BIG were used  the HapMap II CEU (European) reference panel-imputed genetic information from GWAS or (2) genotype information from a predefined list of proxies that are in high linkage disequilibrium with the SNP (r2 > 0.8). Genotyping platforms, genotype frequencies, Hardy-Weinberg equilibrium P values, and call rates for the 7 SNPs are listed in eTable 4 and eTable 5 in the 23 We assumed that each SNP in the panel acts independently in an additive manner, and the GRS was calculated using a weighted method  (eTable 6 and eTable 7 in the 23 and the 43-SNP GRS (explained 2.0% of variance in birth weight) . Linear regression was used to test the association of the GRS with birth weight after adjustment for age, sex, and principal components for population stratification . Logistic regression was used to test the association of the GRS with risk of T2D after adjustment for age, sex, and PCA. The inclusion of PCA as covariates is commonly used to correct for population stratification according to ancestral background.F statistic for the IV was calculated in the Nurses’ Health Study (NHS) and Health Professionals Follow-up Study (HPFS) cohorts as a measure of the strength of IV for prediction of the birth weight, controlling for covariates . An F statistic greater than 10 is evidence of a strong IV.25To validate assumption 1, that the GRS for birth weight was a strong IV for birth weight . As a consequence, we used random-effects meta-analysis throughout. After meta-analysis, we used the IV estimators to quantify the strength of the association of birth weight with risk of T2D.29 The IV estimator, which is identical to that derived by the widely used 2-stage least-squares method,30 was calculated as the β of the regression coefficients for GRS-T2D and GRS–birth weight associations . All 33For the summary-level data from the EGG, DIAGRAM, and MAGIC consortia, the estimates of the association of birth weight with T2D risk and glycemic traits were pooled using the inverse-variance weighted, MR-Egger, and weighted-median methods for multiple genetic variants (eMethods in the 6 Under the assumption that the association of each genetic variant with the exposure is independent of the pleiotropic effect of the variant (not via the exposure), the MR-Egger test gives a valid test of the null causal hypothesis.16 Using the MR-Egger method, the effect of the IV on the exposure is plotted against its effect on the outcome, and an intercept distinct from the origin provides evidence for pleiotropic effects. Additionally, the slope of the MR-Egger can provide pleiotropy-corrected causal estimates under a weaker assumption (the instrument strength independent of direct effect assumption).16To examine assumption 3, that the IV for birth weight affects risk of T2D only through birth weight, but not through other pathways, the MR-Egger method was used  and R statistical software version 3.2.3 .For analyses of both study-level data and summary-level data, the effect size for each meta-analysis is reported in the main results as the effect of a 1-SD change in birth weight or glycemic quantitative traits, as this metric is more interpretable than an arbitrary difference. Absolute risk increase (ARI) per 1000 participant-years for T2D was also calculated  , among European participants 34 (P = .04) (P = .86) 34 , and amoP = .04) . We did We further conducted stratified analyses of estimated causality by age, sex, body mass index, ethnic group, sample size, study design, and number of SNPs included. An association of birth weight with T2D was observed among both men and women, both obese and normal-weight participants, and both European and East Asian participants. However, evidence for a causal association was not observed in the subsample of individuals younger than 50 years .P = .02) and when using 43 SNPs  .Summary-level data showed a similar association of low birth weight with risk of T2D when using the 7 SNPs  . We furtP = .002) at the Bonferroni-adjusted level of significance (P < .01). Consistently, the inverse-variance–weighted analysis also showed an association of birth weight with fasting glucose concentration   . These ftrations .P = 6.76 × 10−4), providing further evidence of finding robustness.In sensitivity analyses, we used 4 different methods  to estimate the association of birth weight with risk of T2D using summary-level data. The results showed consistent associations , indicatr2 > 0.05). In addition, the intercept term estimated from MR-Egger was centered at the origin with a confidence interval including the null   , suggestP = .94) .In the largest MR study thus far, to our knowledge, we investigated a potential causal role of birth weight in the development of T2D and regulation of glycemic traits using study-level data and summary-level data. Our results show that genetically determined lower birth weight was associated with increased risk of T2D and elevated fasting glucose concentration, supporting an association between lower birth weight and development of T2D.40 For example, data from a meta-analysis of 30 studies found an inverse birth weight–T2D association; the pooled OR of T2D was 1.13  per kilogram decrease in birth weight.3 However, in most of the observational studies included in this meta-analysis, birth weight was associated with potential confounders. Therefore, residual confounding may have contributed to the observed associations, illustrating a major limitation of observational studies in inference of causality. In the present study, we used MR analysis to minimize the potential confounding effect. The GRS used in our study was not correlated with potential confounders, and was validated as a strong and reliable IV for birth weight.15 Therefore, our findings concur with a previous study15 and lend genetic support to prior evidence of observational association between birth weight and risk of T2D.Compelling observational studies have shown that lower birth weight is associated with a higher T2D risk.2 the observed associations may originate in utero where intrauterine growth restriction affects epigenetic alterations and alters intracellular insulin-signaling pathways.42 Such permanent alterations in structure, physiology, and metabolism are thought to result in key disruptions to the endocrine system.43 It has been suggested that the public health implications of the inverse birth weight–T2D association depend on the precise nature of the underlying causal exposure and its amenability to change.3 Our MR results demonstrate that birth weight itself is a causal exposure, implying the public health impact of birth weight modification. Interestingly, previous interventions for increasing birth weight through changes in maternal nutrition have increased birth weight by up to 200 g in populations.44 Such an increase in birth weight could translate into a reduction in T2D risk of up to 10%.3 Therefore, our findings highlight the potential importance of improving fetal growth and nutrition in the prevention of T2D. In addition, ongoing research to understand the mechanistic links between the genetic loci that influence birth weight may lead to novel therapeutic strategies to modify birth weight and subsequently reduce the risk of T2D.45 Importantly, our findings are of public health significance and may help in understanding the mechanisms by which low birth weight increases risk of T2D.Our findings suggest that birth weight may be a useful target for a prevention strategy to mitigate T2D risk in later life. According to the thrifty phenotype hypothesis,F statistic greater than 18.31 For assumption 2, MR assumes the IV (GRS) was not associated with potential confounders. Study-level results showed that GRS was not associated with potential confounders; nevertheless, we could not exclude the possibility that our results might be affected by unmeasured confounders. For assumption 3, MR assumes that the IV for birth weight affects risk of T2D only through birth weight, but not through other pathways. To validate assumption 3,16 the intercept term estimated from MR-Egger regression was centered at the origin with a confidence interval including the null, suggesting that our results were not influenced by pleiotropy.The MR analysis used in this study satisfied 3 assumptions. Assumption 1 requires a strong link between the genetic variants used as an IV and birth weight. The GRS used in our study was demonstrated to be a strong IV with an Our current study has several other strengths. First, to our knowledge, our study is the largest MR analysis assessing the association of birth weight with T2D risk and glycemic traits to date. The large sample size allowed us to assess the consistency of associations across studies and to gain sufficient power for conclusive estimation of associations. Second, sensitivity analyses of 2 different data sources (study-level and summary-level data sets) were conducted. The steps taken in this study reduced the risk of bias and pleiotropy. Importantly, the consistent associations estimated from complementary MR approaches, such as the weighted median regression method, inverse-variance–weighted method, and MR-Egger method, support the robustness of our findings. Finally, most of the studies included were homogeneous, and we used standardized methods and performed the analysis individually in each study. Therefore, the effect of population stratification on the instrumental results should be minimal.49 Therefore, further investigations employing a nonlinear MR approach are warranted to investigate the causality. In addition, we only used 7 SNPs in study-level analyses; this may lead to a weak IV, and thus introduce bias. Second, although the MR-Egger method suggested that our results were not affected by pleiotropy, it is possible that the shared genetic basis between birth weight and T2D may also contribute to the association. Third, although previous evidence indicated that variation in the fetal genome was the predominant driver of the birth weight associations,13 birth weight may be influenced by both fetal and correlated maternal genotypes. Given the correlation (r of approximately 0.5) between maternal and fetal genotype,13 we could not exclude the possibility that associations between fetal genotype and birth weight may result from indirect effects of the maternal genotype influencing birth weight via the intrauterine environment.13 In addition, recent GWAS identified several novel loci for offspring birth weight and highlighted maternal genetic effects that are independent of fetal genetics.50 Therefore, there are limitations in assuming causality on the basis of fetal genotype and fetal phenotype associations; dissecting maternal and fetal effects on adult T2D risk are also needed. In addition, maternal genetic variants could influence both offspring birth weight and other aspects of nurturing. Cross-generation MR studies are susceptible to such dynamic effects, which introduce potential biases. Therefore, future cross-generation MR studies should consider ways to reduce the biases that might result from these assumption violations.51This study has some limitations, and the results should be interpreted with sufficient caution. Although the MR method is theoretically well established, we recognize that there are still many limitations in practice. First, we assumed that the associations of birth weight with T2D and glycemic traits were linear. Indeed, several observational studies suggested U-shaped associations.52 We cannot exclude the possibility that genetic markers for birth weight were associated with other pathways that influence T2D risk. In the present study, we used only the MR-Egger method to examine assumption 3. Although we found that the results were not influenced by pleiotropy, the MR-Egger analysis has limitations and is not able to reliably detect a dose-response relationship in the genetic associations with birth weight and with T2D, and hence cannot distinguish between pleiotropy and causal effect.53 Sixth, even though many relevant covariates, including age, sex, ethnicity, region, total energy, and PCA were included in the statistical models, residual and unmeasured confounding cannot be ruled out. Many established confounders, such as maternal diet, lifestyle, and additional genetic markers, may confound the association of birth weight with T2D risk. Further investigation considering these confounders is needed. In addition, given that the studies involved are overwhelmingly in non-Hispanic white populations, testing for generalizability to other ethnic groups warrants further investigation.Fourth, the widely used GRS may not fit the assumptions for an IV well. Furthermore, most of the risk factors are not static, but dynamic, and this may only be captured by taking both genetic and environmental factors into account over time. Fifth, assumption 3, that genetic markers affect T2D only through birth weight, is sometimes referred to as the exclusion restriction. The MR assumptions are violated if the genetic marker affects T2D through pathways other than through birth weight, which may lead to substantial biases in MR analysis.This study found that genetic predisposition to lower birth weight was associated with increased risk of T2D and impaired fasting glucose concentration. Our results suggest the presence of genetic effects on retarded fetal growth and increased diabetes risk that either are independent of each other or operate through alterations of integrated biological mechanisms.


Adolescent pregnancy rates are high worldwide. However, insufficient information exists regarding the frequency of birth control methods used before the first pregnancy and postpartum. In the current study, we analyzed the association of sociodemographic factors with the knowledge of birth control methods and their use before and after pregnancy in a sample of adolescents in Mexico City. A cohort study was conducted on 600 pregnant adolescents in Mexico City, from 2013 to 2017, at a health care institution providing prenatal care. Participants were assessed during the second trimester and four months postpartum. The questionnaire explored the knowledge of birth control methods, their use, and other associated factors. Two logistic regression models were implemented to identify potential variables associated with the lack of birth control method use before and after pregnancy. The mean age of participants was 15.4 + 1 years, of which, 48% and 65.2% used a birth control method before pregnancy and postpartum, respectively. We found that the main factors associated with increased risk of not using any birth control method before pregnancy included being under the age of 15 years, school dropout, having an educational lag, initiation of sexual life before the age of 15, and having a mother who did not inform their child about contraceptives. By contrast, variables associated with a higher risk of not using any contraceptive methods after pregnancy included educational lag, lower level of education, and the fact that the adolescent had not used any birth control prior to the pregnancy. In 2015, approximately 16 million adolescents between the age of 15 and 19 years were reported pregnant, and about one million females <15 years gave birth—representing ~11% of births worldwide, according to the World Health Organization (WHO). Of these pregnancies, 95% occurred in poor and developing countries, which have large populations with low or middle income .Although the use of birth control methods has increased in many regions of the world, especially Asia and some Latin American countries, its use remains low overall. Worldwide, a slight increase was observed in the frequency of birth control method use over the last two and a half decades, from 54% in 1990 to 57.4% in 2015. In different parts of the world, the proportion of women aged 15–49 years using some method birth control either increased slightly or stabilized from 2008 to 2015. In Africa and Asia, this proportion increased from 23.6 to 28.5% and from 60.9 to 61.8%, respectively. In Latin America and the Caribbean, the proportion was stable at 66.7% [It is estimated that in developing countries, ~225 million women want to postpone or avoid pregnancy. Nevertheless, these women do not opt for using an effective method of birth control. There are reasons that may explain this phenomenon: Low educational level ,7,8. A pEducational level is one of the factors associated with the use of contraceptives. Yago-Simón et al.  demonstrThe information available regarding the use of birth control methods indicates that adolescents have higher rates of failure compared to adults, in addition to lower rates of continuous use and compliance . Young mIn Latin America and the Caribbean, the birth rate among adolescents is 18%, and the fertility rate is the second highest in the world (80 births per 1000 15- to 19-year-old adolescents). Although this rate has decreased globally, the decline has been minimal [The age of sexual activity has declined in Latin America and the Caribbean, depending on gender and socioeconomic level , even thAdequate sex education is not provided in many Latin America countries and the Caribbean, including Mexico, creating the situation where some adolescents do not know how to avoid pregnancy . These pThe knowledge and use of birth control methods in Mexico were evaluated by the National Health and Nutrition Survey in 2012  , which sDespite receiving information from the school and mass media regarding the negative consequences of pregnancy, levels of adolescents’ knowledge with regard to their sexuality and reproductive health remain clearly deficient. In addition, a lack in connecting the understanding of adverse outcomes with behaviors and attitudes of adolescents is evident .In their study, Schor et al.  demonstrA rising trend of sexual activity during adolescence, poor compliance with modern contraceptives, and inadequate use of family planning services, suggest that the likelihood of getting pregnant more than once during adolescence is high .Factors associated with low contraceptive use after pregnancy are not well known, and few studies examine the initiation of postpartum contraception use in adolescent mothers. In addition, our research group previously reported that adolescents had a good level of knowledge about birth control methods; nevertheless, they were not asked about the specific method used or their primary sources of information . In thisA prospective cohort study was conducted with the participation of pregnant adolescents. The study was accomplished with contribution from the Instituto Nacional de Perinatología  and the Escuela Superior de Medicina, Instituto Politécnico Nacional , both located in Mexico City. INPer is a third-level institution that provides medical care to women from Mexico City and nearby states, who have no social security coverage and are from low–medium socioeconomic status, where teenage pregnancy is prevalent.The participants were pregnant adolescents who received prenatal medical care at INPer, and were followed-up four months postpartum, from January 2013 to December 2017. Sampling was non-probabilistic, based on consecutive cases that met the following inclusion criteria: Adolescents aged 10–19, first and singleton pregnancy, no chronic or mental disease. The sample size was calculated based on a 1000 finite population (pregnant adolescents that met the inclusion criteria), an expected percentage of adolescents who did not use birth control methods for their first sexual intercourse of 67%, an acceptable error of 3%, and a confidence of 95%. The study required a total of 486 participants. However, 15% was determined as the expected percentage of losses to follow-up; as such, a total of 572 participants were required. During the recruitment period, 750 adolescents agreed to be part of the study. Nevertheless, only 600 adolescents concluded the assessments regarding the use of birth control methods before and after their first pregnancy. This number was intended to over-represent all pregnant adolescents that had prenatal medical care at INPer, and to avoid statistical error. Written informed consent was obtained from the adolescents as well as from their parents or guardians.Trained nurses and physicians from INPer used a written questionnaire. The questionnaire’s content was previously validated by three researchers with expertise in the field. Moreover, experts outside INPer were consulted to ensure that the questions were understandable. The instrument’s design was based on the most common responses obtained in a prior qualitative study involving 39 semi-structured interviews with adolescents, about their sexuality, sociodemographic, family structure, knowledge about the use of different birth control methods, and the source of this information. The next step was to validate the instrument in a group of adolescents that represented the study participants, with the purpose of finding out the consistency of the questionnaire. Cronbach’s alpha value of reliability was 0.80.The questionnaire consisted of three sections: Section one, regarding sociodemographic and clinical data; Section two assessed the knowledge and sources of information regarding sexuality and birth control methods; and Section three included questions regarding the use of birth control methods. The three sections of the questionnaire were applied at baseline assessment during the second trimester of gestational, and Section three was applied only at four months postpartum.For Section one, the collected sociodemographic data were age, marital status, occupation, level of education, educational lag, age at menarche, age of initiating sexual activity, number of sexual partners, and family structure. Parents’ information regarding age, level of education, occupation, and at what age they had their first child was also obtained.Who gave you the information about birth control methods? What type of information did you receive about your sexuality?). The participants were also asked about the individuals who were the source of that information .Section two consisted of 11 multiple-choice questions regarding what the adolescent knew about menarche, reproductive health, teenage pregnancy, and birth control methods  and if the adolescent had decided to use any of them, as well as what was the source of information leading to the decision of their use. Finally, the participants were asked if the chosen method met her expectations, and if it was suitable for her. This section was conducted twice: At baseline, to gather information about the use of birth control methods before pregnancy, and via a telephone call four months postpartum, to estimae their use after pregnancy.Section three contained questions about birth control methods  living in the same home. Familiy structures that were not nuclear were defined as “others”. The participant’s occupation was defined as student, housewife, or worker. Age of initiating sexual activity was categorized into less than or equal to 15 years and older than 15 years. Planned pregnancy was determined when the adolescent had sexual intercourse with the purpose of getting pregnant.Educational level was defined as “high” or “low” when the adolescent had completed high or elementary/middle school, respectively. Furthermore, an educational lag was determined when the adolescent’s real age was more than two years greater than the typical age in her current school grade.The socioeconomic level was evaluated in six categories according to the Mexican Association of Market Survey and Public Opinion (Asociación Mexicana de Investigación de Mercados y Opinión Pública) questionnaire . The catEach participant and her parents or guardians provided written informed consent. Data confidentiality and anonymity were guaranteed by using file numbers. This research was approved by the Institutional Review Board (number 212250-49481). To compensate for their participation, the adolescents received free nutritional counseling and informational flyers about proper nutrition during pregnancy—recommendations were made by the official Mexican Norm of the Secretariat of Health .t-test, U-Mann Whitney, and Chi-squared tests. Then, two logistic regression models were performed using the enter method to identify variables associated with the use of birth control methods. The first model was performed by using birth control methods before pregnancy as the dependent variable, and the second was done by using birth control methods after pregnancy as the dependent variable. Statistical significance was considered at p < 0.050. The data were analyzed in the SPSS statistical program, version 21 for Windows .Measures of central tendency and dispersion were calculated for quantitative variables, whereas frequencies and percentages were obtained for categorical variables. The sample was divided into users and non-users to compare sociodemographic and knowledge variables, using student’s n = 126) had planned their pregnancy.A total of 600 pregnant adolescents participated in the study, mean age was 15.4 ± 1 years, 48% used a birth control method before pregnancy, and 21%  had an educational lag, and only 145 (24%) continued in school during their pregnancy. The median gestational age at baseline was 28 weeks. The sociodemographic characteristics of adolescent users and non-users and their parents are shown in Of all participants, 94% reported that they had received the necessary information about sexuality at least once, in which case, the mother was the primary source of information for 79% of them, followed by a teacher for 16%, and other informants for the remaining 5%. Regarding the information regarding birth control methods, similar results were observed: Mothers were the primary source of information for 57% of the cases, a teacher for 33%, a physician in 5%, and a friend in 5% of cases .At the onset of menarche, the adolescents were mainly informed about the importance of self-care and being responsible, the possibility of getting infected with human immunodeficiency virus (HIV), and the use of birth control methods. We found that the frequency of these topics was more common in the group of birth control method users, as shown in p = 0.073).Of the 126 (21%) adolescents with planned pregnancies, 56% had received information on sexuality and birth control from their mother. However, the 474 (79%) adolescents who did not plan or want to be pregnant received the information about sexuality and birth control from a teacher, a physician, or a friend .Assessment at four months postpartum showed that the adolescents whose mothers had a higher level of education were more likely to use a birth control method (77%) compared to participants whose mothers had a lower level of education  sometimes used a birth control method, of which the most frequently used were condoms and hormonal methods , followed by a combination of a hormonal method and condoms. Furthermore, emergency contraception (the morning-after pill) was also used as a birth control method.After pregnancy, only 376 participants (63.2%) used some method of contraception, where the most frequent was the intrauterine device .p = 0.001).Of the adolescents who used a birth control method before pregnancy, 232 (80.6%) decided to continue its use after childbirth. Whereas, of the adolescents who did not use any birth control method before pregnancy, 153 (49%) continued without any after childbirth (p = 0.020). The variables that increased the odds of not using any birth control method before pregnancy were being under 15 years old , having dropped out of school , having a low level of education , having an educational lag , and receiving information from someone other than the mother about birth control methods . The variables associated with a higher risk of not using a birth control method postpartum included drop-out of school , and that the adolescent had not used any birth control before the pregnancy   .The knowledge and frequency of the birth control method used before and after pregnancy were studied in a group of adolescents from Mexico City and other nearby states from 2013 to 2017. The possible associations between the use of birth control methods and other variables were considered. We found that the main factors associated with an increased risk of not using any birth control method before pregnancy were the following: Aged under 15 years, school drop-out, having an educational lag, and having a mother who did not provide information about contraceptives. The variables associated with a higher risk of not using any contraceptive methods after pregnancy were educational lag, lower educational level, and that the adolescent had not used any birth control before the pregnancy.Poor and developing countries are of particular interest when studying adolescent pregnancy, since a considerable proportion of adolescents in those countries initiate sexual life when they are 14 years old or less  . In MexiIn Latin America and the Caribbean, between 25 and 38% of 12 to 19 years old are sexually active. Samandari et al. , and GilIn our sample, we found that >90% of participants reported having had prior knowledge about sexuality and the use of contraceptives. However, research conducted in China showed that half of their sample of adolescents received some information about sexuality, and that the main topic was the use of contraceptives . In UganWhen comparing adolescents that obtained information about birth control methods from their mother versus from someone else, a statistically significant difference was found regarding the use of contraceptives. Results from our current study are similar to those reported by Rodríguez-Vignoli and Cavenaghi , who demRegarding sexuality-related information, it was frequent that mothers advised their daughters about the importance of self-care awareness, of being responsible, and the possibility of getting infected with HIV, which was considered as information encouraging the adolescent’s personal hygiene. This type of information is often given by older women, which is similar to the results we obtained . These rOur results show that self-care was a relevant topic of information for adolescents, which was primarily sourced from their mothers, which is in accordance with data published by Atienzo et al. , who demIn our study, we found that the majority (95%) of participants knew the risk of getting a sexually transmitted infection, such as HIV, which was also reported in Uganda  and RomaBeing responsible was another topic of information that was reported in our study. This responsibility means that the adolescent must take care of herself if she becomes pregnant, leaving the men’s responsibility aside .Before pregnancy, condoms were the most commonly used contraceptive, which is in accordance with the analysis done by Allen-Leigh et al.  on data A reason for not using contraceptives might be that when adolescents seek birth control methods from their physician, a parent or guardian must accompany them for consent . Health Another reason for not using birth control methods is the lacking knowledge regarding the different birth control options and limited access to methods other than condoms. In a sample of 7049 women from five countries of Mesoamerica, Ríos-Zertuche et al. [Another possible explanation is that health care professionals are not always updated with the most accurate information on the use of different birth control methods for adolescents. Thus, health care professionals must be better informed on the use of contraceptives by adolescents. For example, some health professionals underestimate the number of sexually transmitted diseases, as well as the frequency of pregnancies and their complications among adolescents . In our Interestingly, the group of non-users received information about birth control methods from people other than their mothers, such as a doctor or a teacher. Hence, it would be pertinent to take advantage of the communication between a mother and her daughter by including the mother in the health sector strategy for sex and reproductive education .A higher probability of not knowing birth control methods has been associated with initiating sexual activity before the age of 15. However, adolescents who use contraceptives before pregnancy are more likely to continue their use following childbirth. Age and pregestational use of birth control methods were also associated with postpartum use of birth control in our study.The ENSANUT-2012  reportedPostpartum, long-acting reversible contraception remains underutilized in our universal health care system, and measures should be used to increase its use, such as improving prenatal counseling and immediate postpartum placement.This study has some limitations. The report on the use of birth control methods was based on self-reporting, which may be subject to recall bias. Furthermore, the sample is not representative of all Mexican adolescents, the INPer brings medical attention to high-risk pregnancies that have no health care coverage, so the results cannot be extrapolated to adolescents from other regions of the country or in other countries. Another limitation could be that knowledge and beliefs regarding the use of contraceptives in adolescents from health care professionals could also affect their use ; howeverOne strength of this study is that the present study reveals novel and relevant information based on a group of pregnant adolescents in the urban and nearby areas of Mexico City. These results offer insights that may contribute to public policy-making aimed at increasing the use of birth control methods, and thus preventing first and later pregnancies during adolescence. Comprehensive attention for adolescents could help encourage the use of birth control methods because despite having the knowledge and sometimes the offer to use them from a healthcare professional, they still choose not to use them. This is highly important, especially in adolescents younger than 15 years, as this age group is one of the most vulnerable in Mexico and the rest of Latin America.The variables that increased the risk of not using any birth control method before pregnancy were being aged under 15 years, having dropped out of school, having an educational lag, initiation of sexual life before the age of 15, and receiving information from someone other than the mother regarding birth control methods. Meanwhile, the variables that were associated with an increased risk of not using any contraceptives after childbirth were the presence of an educational lag, having a lower level of education, and that the adolescent had not used any birth control before the pregnancy.Finally, there is no ideal method of birth control for adolescents. There are also no medical reasons for denying the use of birth control methods due to age. It is necessary to highlight the importance of adolescents having opportunities to learn about different birth control methods in order to make informed decisions about their sexual health.


Dengue is the most common viral mosquito-borne disease, and women of reproductive age who live in or travel to endemic areas are at risk. Little is known about the effects of dengue during pregnancy on birth outcomes. The objective of this study is to examine the effect of maternal dengue severity on live birth outcomes.We conducted a population-based cohort study using routinely collected Brazilian data from 2006 to 2012.We linked birth registration records and dengue registration records to identify women with and without dengue during pregnancy. Using multinomial logistic regression and Firth method, we estimated risk and ORs for preterm birth (<37 weeks’ gestation), low birth weight (<2500 g) and small for gestational age (<10thcentile). We also investigated the effect of time between the onset of the disease and each outcome.We included 16 738 000 live births. Dengue haemorrhagic fever was associated with preterm birth  and low birth weight , but there was no evidence of effect for small for gestational age . The magnitude of the effects was higher in the acute disease period.This study showed an increased risk of adverse birth outcomes in women with severe dengue during pregnancy. Medical intervention to mitigate maternal risk during severe acute dengue episodes may improve outcomes for infants born to exposed mothers. This is the first study to investigate the risk of small for gestational age infants born to women with dengue during pregnancy using a population-based approach with a sufficiently large sample size and controlling for confounders.Due to sample size, we were able to investigate rare exposure (such as dengue haemorrhagic fever).This study relies on the use of secondary data, and therefore identification of the outcome and the exposure is susceptible to misclassification.The linkage process was rigorously validated, and although we were unable to capture all cases, it is unlikely that the linkage process introduced bias, since linkage errors were not associated with any of our variables of interest.Dengue is the most common viral vector-borne disease worldwide, with an estimated 390 million people infected each year, 96 million of whom develop clinical symptoms. It is endemic in over 100 countries  and is spreading to new areas; according to the WHO, approximately half of the world’s population is at risk.10Maternal dengue, and specifically severe dengue, has been associated with fetal deaths,We performed a population-based cohort study by linking routine records of live births with records of women notified and confirmed with dengue disease in Brazil from 1 January 2006 to 31 December 2012. The methods described in this paper are similar to those used in a previously published paper about the effects of dengue on maternal deaths.12The Live Births Information System , which records live births in Brazil; these data are derived from the birth registration, a legal document completed by the health worker who attended the birth. It includes information on the mother ; the pregnancy (length of gestation and mode of delivery); and the neonate .15Notifiable Diseases Information System , which records notifiable diseases. Dengue notifications include information on the individual , symptoms of the disease, laboratory tests and disease severity, assessed clinically and by laboratory according with the Brazilian dengue manual.We used the following data from two Brazilian databases.SINASC defines a live birth as the product of conception that, independent of the duration of pregnancy, breathes or shows any other signs of life , after the separation from the mother’s body.We assessed three birth outcomes: preterm birth (<37 weeks), low birth weight (<2500 g) and small for gestational age, calculated according to the Intergrowth Scale3 or leucometry less than 1000/mmWe defined our exposure as confirmed cases of dengue notified to SINAN during a pregnancy that resulted in a live birth. In Brazil, confirmation of dengue is based either on clinical and epidemiological criteria , or on clinical and laboratory criteria  IgM detection by ELISA, (B) viral RNA detection via PCR, (C) NS1 viral antigen detection or (D) positive viral culture). We refer to laboratory confirmed cases as ‘dengue during pregnancy, laboratory confirmed’. Dengue notifications do not always state whether the woman notified was pregnant; there is a field for this variable, but it is largely missing. We therefore defined maternal dengue cases by linking SINAN-confirmed dengue cases with live birth registrations within the 9 months following disease notification. To categorise disease severity, we used the clinical classification valid in Brazil in the period in which data were collected, which classified dengue into three clinical categories: (A) ‘dengue fever’, (B) ‘complicated dengue’ and (C) ‘dengue haemorrhagic fever/dengue shock syndrome’. Dengue fever is a self-limiting disease, characterised as fever, with a severe headache, pain behind the eyes, muscle and joint pain and rash. Complicated dengue is a probable case of dengue characterised by one of the following: severe changes in the nervous system, cardiorespiratory dysfunction, insufficient hepatic function, gastrointestinal bleeding, cavity spills or thrombocytopenia equal or less than 50 000/mmWe linked records of women with confirmed dengue (SINAN) with records of live births (SINASC) up to 9 months after the SINAN notification to identify those mothers who had dengue during pregnancy. Since there was no unique identifier for linkage between the two data sources, we relied on a set of identifiers available with good data quality in both datasets: name, age or date of birth and the place of residence of the mother at time of delivery/time of notification. We excluded records with missing or implausible names  .We used probabilistic linkage, which generates match weights that represent the likelihood that two records belong to the same individual based on the similarity between records from different datasets. This linkage method takes into account errors and missing values in identifiers and is useful when there is no unique identifier. Match weight calculations used the Fellegi-Sunter method.Linkage followed the same procedure as previously described for linking stillbirth records and the dengue database in Brazil, in which we demonstrated a sensitivity (the proportion of true links captured) of 62% and a positive predictive value (the proportion of true matches among linked records) of 95%.We estimated the crude and adjusted risk ratios (RRs) and CIs from multinomial logistic regression. We compared live births from women without dengue during pregnancy (our reference group) with live births from women with notified dengue during pregnancy. We controlled for maternal age , education  and marital status (single/widow/divorced or married/stable union), as these variables were also available in the data. To assess the sensitivity of results to the validity of clinical/epidemiological diagnosis, we repeated the analyses using laboratory-confirmed dengue cases only.In general, dengue is an acute disease with rapid recovery. However, we investigated the effect of time between disease onset and live birth outcomes. The time between disease onset and birth outcome was calculated using the date of the disease onset (information available in SINAN) and the date when the outcome occurred (date of live birth); we categorised this difference as being less than or equal to 10 days or greater than 10 days.We also evaluated the association between dengue and birth outcomes according to severity of disease. The exposure was classified as mild dengue, dengue with complications and dengue haemorrhagic fever. For this analysis, we calculated the OR using the Firth method  as we were analysing rare events and controlled for maternal age, education and marital status.21There were no patients involved in the research. The data used are administrative routinely collected data.A total of 20 333 482 live births were recorded in SINASC between 2006 and 2012. After exclusions, 16 738 000 live births were included in the study, and 17 673 (0.1%) of their mothers were linked with a dengue notification record .The cohort characteristics by dengue status are described in Maternal dengue was associated with a slight increase in the risk of preterm birth  and low birth weight , although the CI was borderline. There was no association between maternal dengue and being small for gestational age . RestricThere was some evidence that the risk of dengue in pregnancy on birth outcomes depended on the time between dengue onset and the date of live birth: the magnitude of the effect of dengue on adverse birth outcomes was higher during the acute disease period, with some residual effects remaining after the first 10 days for preterm birth and low birth weight .Our study demonstrates that dengue haemorrhagic fever in pregnancy is associated with a doubling of the risk of preterm birth (OR: 2.4) and of low birth weight (OR: 2.1) and that mild dengue fever is associated with an increase of 10%–20% in the risk of preterm birth and low birth weight, respectively. We found no evidence for an increased risk of small for gestational age for either severe or mild disease. The association between dengue and birth outcomes was strongest during the acute disease phase, within the first 10 days of disease onset.et al,Our results are consistent those with Nascimento There is evidence that different infectious diseases in pregnancy can lead to adverse outcomes. The evidence is still fragmented, and there is no consistent effect, which appears to vary according to the pathogen involved and the timing and severity of maternal disease. For instance, studies comparing pregnant women with infection to pregnant women without found: (A) severe influenza increased the risk of preterm birth from 2.4 to 4 times, whereas studies based on mild range of illness did not find an effect23 24One mechanism by which dengue during pregnancy affects preterm birth and low birth weight that is consistent with our results is through maternal illness, rather than a direct effect on the fetus. Since we did not observe an effect on small for gestational age, the effect of dengue in pregnancy on birth weight may have occurred via prematurity of the newborn. This assumption is supported by the higher risk of preterm births observed among mothers within less than 10 days after the onset of the disease and among those with complicated disease and haemorrhagic dengue. The higher risk of preterm birth could be due to the early onset of labour delivery or by early delivery due to medical interventions, such as caesarean section, required because of concern about risk to the mother. However, data on small for gestational age was only available for 2011–2012, which may have affected our ability to observe an effect. Furthermore, analysis according to mode of delivery is complicated due to high rates of caesarean section in Brazil, many of which are not clinically indicated.Limitations of this study include the linkage process and use of secondary data. First, outcome and exposure identification is susceptible to misclassification using secondary sources. Preterm birth and small for gestational age are underascertained in routinely collected data from low-income and middle-income countries. However, as this is likely to have affected both those exposed and not exposed to dengue in a similar way, it is unlikely that results of this study would have been biased.As dengue prevention is not straightforward and mosquito control has failed in Brazil, our findings highlight the crucial role of the clinical management of dengue in pregnant women. Doctors and medical staff in general attending to pregnant women with dengue should closely observe and monitor the patients to be able to intervene timely and avoid adverse outcomes for mothers and babies, especially during the acute phase. We recommend careful observation and notation of dengue in antenatal records and further research into the association between dengue and adverse pregnancy outcomes.In summary, this study demonstrates a doubling in the risk of preterm birth and low birth weight associated with dengue haemorrhagic fever in pregnancy and increases of 10%–20% in women with mild dengue. One contributing factor to adverse birth outcomes may be medical interventions triggered to mitigate mothers risk associated with dengue haemorrhagic fever. We recommend further research in different settings to confirm our results and additional studies of adverse birth outcomes for other vector-borne diseases.