Preterm birth is associated with increased risk of respiratory symptoms in childhood, often treated with asthma medication. We designed a follow-up study to previous research and investigated whether the association of gestational age with purchasing asthma medication diminishes in adulthood.We conducted a register-based study of a national cohort of all infants born in Denmark in 1980–2009 evaluating longitudinal data on individually prescribed asthma medication  available from 1995–2011. We analyzed the effect of gestational age considering age, birth year, and perinatal variables using logistic regression with a Generalized Estimating Equations model. All data were unambiguously linked through the Civil Registration System.We included 1,819,743 individuals in our study population. We found an inverse dose-response relationship between gestational age and asthma medication in earlier age-groups with a gradual decrease in odds ratios with increasing age and loss of statistical significance in early adulthood (18–31 years). For our oldest generations, there was a significant effect of gestational age , which became insignificant when adjusting for confounding and mediating factors (p = 0.44). There were significant interactions between gestational age and age (p<0.0001) and gestational age and birth year, but these were most important during childhood (0–11 years) and for our youngest generations (born after 1995).per se did not seem to be significant for the development of asthma-like symptoms: most of its effect could be explained by other perinatal factors.The strong association between gestational age and purchase of prescription asthma medication weakens with age into early adulthood, in consistence with the results from our previous study. The risk for purchasing medication to treat asthma-like symptoms was higher in more recent birth years, but the effect of gestational age was small beyond 11 years of age. Gestational age  Individuals born preterm experience increased respiratory symptoms later in life , often rAsthma prevalence in the general population, however, is steadily increasing , and theMost follow up studies on respiratory sequelae after prematurity are cross-sectional and longitudinal trends from early childhood until adulthood are missing ,10. HoweWe conducted a retrospective longitudinal observational register-based study of a national cohort of all infants born in Denmark in 1980–2009, created from a database used in a previous study . The datThe study population was based on a cohort including all registered births in Denmark during the period 01.01.1980–31.12.2009 from the Medical Birth Registry. We excluded individuals who were stillborn, who had missing data on GA, gender or birth weight, or who had abnormal birth weight values defined as differing more than +/- 5 standard deviations (SD) from reference mean birth weights . In addiData from the Danish National Prescription Registry provided the basis of our outcome assessment. The registry contains data on all purchases of prescription medication from all non-hospital pharmacies available during the period 1995–2011 ,17. The a combination of at least one purchase of inhaled selective ß-2 receptor agonist (R03AC) and at least two purchases of one of the following other drugs for obstructive airway disease: inhaled glucocorticoids (R03BA), inhaled anticholinergics (R03BB), teophyllins (R03DA), oral leukotriene-receptor antagonists (R03DC), systemic steroid (H02AB) orat least two purchases of a combination inhaler .The outcome was evaluated from every even birthday starting from 0 years and in the following 2-year period . Only complete 2-year periods within the time frame 1995–2011 were evaluated. The 2-year period was also censored if the follow-up was not complete due to either death before or during the period or due to residence abroad at the start of the period or emigration during the 2-year period.GA: The main exposure of interest was gestational age in full weeks and 4 main groups were considered: term with GA ≥ 37, moderately preterm with GA 32–36, very preterm with GA 28–31 and extremely preterm with GA 23–27 weeks. GA was modelled as an ordinal variable with 4 levels from term to extremely preterm. Thus, the resulting ORs are for a one unit increase in prematurity (e.g. from GA group 32–36 to group 28–31 weeks), with the term group as the reference. This approach was chosen based on superior goodness-of-fit statistics compared with a model treating GA as a categorical variable.Age groups: Each 2-year observation period was categorized according to the following age groups: 0–1 (infants), 2–5 (preschoolers), 6–11 (school-aged children), 12–17 (adolescents), 18–23 and 24–31 years (adults) under parametric assumptions.Birth year: grouped into 1980–1984, 1985–1989, 1990–1994, 1995–1999, 2000–2004 and 2005–2009 under parametric assumptions.In addition, we included the following variables with known associations with preterm birth and asthma in the analysis:Birth weight (BW): Small-for-gestational-age (SGA) was defined as a BW < -2 SD from Marsál’s reference value .Sex.Firstborn.Multiple birth.Delivery method: vaginal birth or cesarean section (emergency and elective).Maternal educational level: evaluated at time of birth and divided into three groups per the International Standard Classification of Education 2011 (ISCED) . Group 1Maternal asthma and atopy medication: Asthma medication followed the same definition as the outcome and was evaluated in a 2-year period prior to birth. Since data were only available from 1995, for births before 1997, a 2-year period beginning in 1995 was used to supply data as close to birth as possible. Atopy medication was defined as at least one purchase of prescribed (ATC-codes): nasal steroid spray (R01AD), facial steroid cream group I (D07AA), steroid cream group III (D07AC) during the same 2-year period.Neonatal respiratory morbidity: assessed from admission data during the first 6 months after birth. The diagnoses used for acute neonatal respiratory disease were : respiratory distress and transitory tachypnea of the neonate (ICD-8 776.290/ICD-10 P22.1 and P22.8), respiratory distress syndrome (ICD-8 776.190/ICD-10 P22.0) and neonatal emphysema (ICD-8 776.200/ICD-10 P25.0). The diagnoses included for chronic neonatal respiratory disease were pulmonary fibrosis (ICD-8 517.010) before 1994 and bronchopulmonary dysplasia (BPD) (ICD-10 P27.1) after the 1994 classification system change.Maternal smoking during pregnancy: self-reported at prenatal visits. The variable was available from 1991 .We analyzed our primary outcome using a logistic regression on the binomial asthma medication outcome. All valid outcome measurements from all individuals were analyzed together, and intra-person dependence was accounted for by using Generalized Estimating Equations (GEE) with an autoregressive working correlation matrix. Thereby, the GEE model allows for several measurements on the same individual to be analyzed together—which is not normally possible due to assumptions of independency—while correcting for potential correlation between measurements on the same individual. The repeated measures allow for an individual follow-up on a potentially decreasing asthma medication purchase over time. Analyses were carried out in two different models:Model 1: adjusted for GA, age, year of birth and both interactions between GA and age groups and GA and birth year groups respectively.Model 2: as model 1 + variables present at birth  and variables from the neonatal period .Observations with missing data in the explanatory variables in model 2 were censored in the analyses.The model 2 analysis was also done on a subgroup from the later years with data available on maternal smoking during pregnancy to explore the effect of this potential confounder.All data management, analyses and graphic illustrations were performed in SAS Statistical Software .A total of 1,819,743 individuals  were included in the study population after the exclusion criteria described in The distribution of missing values in the study population is described in The extraction of data on the outcome purchase of prescription asthma medication yielded a total of 10,521,952 2-year period observations for the included 1,819,743 individuals, of which 299,728 (2.8%) 2-year periods were censored due to emigration or death. Of the non-censored observations, 448,728 (4.4%) were registered as positive for asthma medication.The inverse dose-response relationship between GA and the crude rate of purchase of prescription asthma medication was consistent across all age groups, although the gradient decreased markedly during childhood .The number of observations varied among the birth cohorts and calendar years since medication data was only available from 1995 and considering the latest birth cohorts only had a limited period of observation .per se using the GEE model 2 with the GA groups as a categorical variable to allow for independent estimates of effects. The adjusted analysis supports the findings from our descriptive analyses, illustrating a higher odds-ratio (OR) for more preterm GA-groups until age 12–17 years, a gradual decrease in ORs with age and loss of statistical significance in early adulthood  and GA*birth year  were significant overall. We found a substantial effect of GA in children below 12 years of age and from birth year 1995 , while it was marginal for older individuals and earlier birth years .The sub-group-analysis on individuals with available data on maternal smoking during pregnancy demonstrated that this potential confounder had only little effect. The data consisted of 5,844,148 observations from 1,181,693 individuals born from 1991–2009 which were analyzed with the GEE model 2 both with and without the smoking variable . While mIn this unique longitudinal large dataset, we confirmed our previous findings from the cross-sectional evaluation of the association between GA and purchase of prescription asthma medication : the strThe estimate for the crude risk in 24-31-year-olds was small: +9% per GA group . The adjusted risk was independent of GA.Although children born preterm have a documented higher risk of respiratory complaints , the decper se is not a significant risk factor for asthma medication purchase in adolescence and young adulthood. In fact, it seems that the increase in crude risk is explained by factors associated with the prenatal period or birth , and by factors of the neonatal period (respiratory distress and BPD). Maternal use of atopy medication and asthma medication (OR 1.37 and 5.57 respectively) and neonatal respiratory disease (OR 1.24 for acute disease and 1.44 for BPD) seemed to be particularly strongly associated with the outcome. Put another way, these factors may play a more significant role in determining an individual’s risk of later pulmonary sequelae requiring anti-asthmatic treatment than the fact of being born preterm in itself. Individuals with these risk factors might still be at increased risk of impaired pulmonary function in both child- and adulthood.The presence of a GA effect in young adults in model 1 (the crude risk), but absence in model 2  suggests that GA The observational nature of the study does not permit an exploration of the causal pathways and BPD remains a major risk factor for persistent decreased lung function and pulmonary impairment, presumably throughout life, which emphasizes the need for a continuous follow-up in order to explore the risk for COPD later in life regardless of BPD type (“old” vs. “new”) –24.The important strengths of the study are the inclusion of an almost complete nationwide birth cohort and the access to emigrational data and death both in the country and abroad, resulting in reliable censoring. The Danish National Prescription Registry provides high-quality data on all purchases of prescription medication: purchases are automatically registered from all out-of-hospital pharmacies and digitally reported to the Danish Health Authority, and the records form the basis for the Danish medication reimbursement system . Data arThe most important weaknesses are that the purchase of asthma and atopy medication was used as a proxy for asthma-like symptoms and atopic disease respectively. However, purchase of asthma medication has previously been validated as a good method for identifying asthmatic school children with a high specificity . Furtherper se or rather neonatal respiratory disease that increases the risk of pulmonary impairment later in life.In this longitudinal study, we did not find an association between GA and purchase of asthma medication in older age groups, consistent with our prior belief that the effect of GA towards the risk of asthma diminishes with age. It remains to be investigated if this association will recur in later adulthood and whether it is prematurity S1 TablePLoS Medicine 2015; in press. * Checklist is protected under Creative Commons Attribution (CC BY) license.*Reference: Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, Sørensen HT, von Elm E, Langan SM, the RECORD Working Committee. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement. (DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Comprehensive metabolic panel tests (CMP) are routinely performed in extremely premature infants within the first days of life. The association between the parameters of first postnatal CMP and the risk of bronchopulmonary dysplasia (BPD) remains elusive.  A retrospective analysis was performed to evaluate the correlation between the parameters of first postnatal CMP and the risk of BPD in a cohort of extremely premature infants  at the neonatal intensive care unit, Shenzhen Maternity and Child Healthcare Hospital, from January 2016 to October 2018. A multivariant regression model was built to assess the association of the first postnatal CMP with the development of BPD. P < 0.001 and 0.9 versus 0.8 U/L, P = 0.001, respectively) whereas the level of alkaline phosphatase (ALP) and total protein was significantly lower in infants with BPD . Multiple analysis showed that a higher level of BUN (>8.18 mmol/L) was independently associated with BPD .  A total of 256 extremely premature infants were included in this study. BPD developed in 76 (29.7%) infants. The first CMP in these infants was performed at 5 to 8 days after birth. The levels of blood urea nitrogen (BUN) and magnesium were significantly higher in infants with BPD compared to infants with no BPD  may be a predictor for the development of BPD in extremely premature infants. Bronchopulmonary dysplasia (BPD) occurs in 40% of extremely preterm birth, with pathological characters of arrested alveolar and vascular development , 2. BPD Despite the known risk factors for BPD, little improvement has been made in reducing the prevalence of BPD. Therefore, studies identifying the vulnerable population and the crucial prophylactic window are of paramount importance. Antenatal and postnatal factors have been related to the deterioration of the lung development, including gestational age at birth, maternal complications, placenta abnormalities, infection, and persistent mechanistic ventilation , 7. ReceThis is a retrospective cohort study. All extremely premature infants admitted to the Neonatal Intensive Care Unit (NICU), Shenzhen Maternity and Child Healthcare Hospital, from January 2016 to October 2018 were included in this study. We excluded infants withdrawn from intensive care before attempting extubation. Infants referred from other hospitals were also excluded because their first CMP parameters were missed. Infants with congenital abnormalities were excluded as well.Extreme prematurity was defined as birth at a gestational age less than 28 weeks or birth weight less than 1000 grams. BPD was diagnosed when supplemental oxygen was required at 36 weeks postmenstrual age (PMA) or at discharge , 12. GesInfants' clinical data were retrieved from the electronic medical record. The first postnatal CMP was performed within 5-8 days after birth. All CMP test was performed on UniCel DxC 800 Synchron  using the blood from the umbilical artery catheter of the infants.α = 0.05, 53 infants in each group would be sufficient to detect a significant difference . CMP parameters were displayed as median [interquartile range (IQR)] and analyzed by the unpaired t-test or nonparametric test, as appropriate. Categorical variables were described with numbers and percentages and analyzed by chi-square or Fisher's exact test accordingly. Multivariate and ordinal logistic regression was applied to identify the independent risk factors of BPD. The odds ratios (ORs) and 95% confidence interval (CI) were determined in logistic regression analysis. Subsequently, the receiver-operator curve (ROC) was adopted to calculate the cutoff values to dichotomize the continuous variables independently associated with the occurrence of BPD. Statistical analyses were performed using SPSS version 24 .The sample size calculation was based on the BUN level from our clinical laboratory. At 90% power and The study was conducted in accordance with the Declaration of Helsinki and approved by the Shenzhen Maternity and Child Healthcare Hospital Institutional Ethical Committee (No. [2019]-119).A total of 367 extremely premature infants were admitted to our NICU during the study period. Seventy-one infants referred from other hospitals were excluded because their first CMP results were missed. Thirty-four infants were excluded due to withdrawal from the intensive care prior to attempting extubation. Six infants with congenital abnormalities were excluded as well. As a result, 256 infants were included in our analysis. The diagnosis of BPD  was made in 76 (29.7%) infants . 228 (89P < 0.001), birth weight , 1-minute Apgar score , 5-minute Apgar score , and lower rate of cesarean section delivery , compared to infants with no BPD. Furthermore, BPD infants have higher rate of surfactant treatment , intubation , (suspected) early-onset neonatal sepsis , PDA , and grades III and IV IVH . The levels of alkaline phosphatase (ALP) and total protein were significantly lower in infants with BPD compared with those in no BPD infants , intubation , (suspected) early-onset neonatal sepsis , PDA , ALP , and BUN , a higher level of BUN (>8.18 mmol/L) increased the risk for PAH, ROP requiring interventions, severe IVH, and the duration of intubation compared with infants with lower BUN level (<8.18 mmol/L) [10.9% versus 2.7%, P = 0.024; 16.8% versus 5.5%, P = 0.012; 12.6% versus 2.7%, P = 0.012; and 1.9 versus 0.4 day, P = 0.002, The receiver-operator curve was used to calculate the cutoff value of the BUN and ALP level measured at postnatal days 5-8 for optimally assessing the risk of BPD . Since AIn this cohort of extremely premature infants, we found that several parameters of the first postnatal CMP were different between extremely premature infants with and without BPD. Further analysis indicates that a higher level of BUN (>8.18 mmol/L) was independently associated with the risk of BPD.In current studies, we found gestational age, birth weight, 1- and 5-minute Apgar scores were protective factors of BPD, while C-section, intubation, and PDA were risk factors of BPD, as demonstrated by numerous studies . AdditioTimely and accurate evaluation of the risk of BPD in extremely premature infants is pivotal for implementing prevention strategies. Efforts are made to determine the risk factors predisposing extremely premature infants to the development of BPD. Recently, La Frano et al. found an altered lipid metabolism in the umbilical cord blood from infants progressing to BPD later , highligin vitro [The association between a high level of BUN and an increased risk of BPD could be explained by experimental evidence. Arginine, the substrate of urea, is also a precursor of nitric oxide (NO), the very important small molecule playing a crucial role in neonatal pulmonary disease, like BPD and pulmonary hypertension (PAH). Zheng and his colleagues have reported a disruption in the urea cycle in PAH animals induced by monocrotaline . Despitein vitro  and signγ (INFγ) [We also found that the ALP level was significantly lower in infants with BPD compared to those with no BPD. Elevated ALP is a reliable marker of vitamin D (VD) deficiency. Supplementation of VD alleviates the hyperoxia-induced lung injury in newborn rats by stimulating alveolarization via lipopolysaccharide- (LPS-)toll like receptor 4 (TLR4) pathway and suppression of inflammatory cytokine interferon γ (INFγ) , 28. Çetγ (INFγ)  and BPD.γ (INFγ) . We idenThe main advantage of our research is the clinical applicability. CMP test is routinely performed in daily practice. Since BPD remains a challenge for neonatologists, identification of high-risk infants and timely intervention are pivotal for the prevention of BPD. However, our result should be interpreted with caution. Apart from the retrospective design, excluding the infants who had their intensive care withdrawn before the diagnosis of BPD leads to an inclusion bias in our study, since most of them are potential BPD candidates. Moreover, it would be interesting to explore the association between elevated BUN and BPD in PAH infants. We did not perform the analysis due to limited sample size (only 16 infants developed PAH in the current cohort). Furthermore, it would be interesting to investigate the dynamic change of BUN and ALP in the first month of life and its predictive value for BPD.In conclusion, analysis of this extremely premature cohort indicated a high BUN level (>8.18 mmol/L) measured at postnatal days 5-8 which is independently associated with an elevated risk for BPD. This finding highlighted the relation between neonatal metabolism and the occurrence of BPD. Further experimental studies are needed to investigate the mechanism of nitrogen metabolism and its effect on lung development.


P = 0.001). For EFW and BPD, the curves of the periodontitis group were located lower than those of the non-periodontitis group, with significant differences after 32 weeks and 20 weeks of GA, respectively. In conclusion, periodontal treatment before conception may be recommended and a good periodontal condition in the early stage of pregnancy at the latest is desirable for infant growth.The aim of this prospective cohort study was to investigate the association between intrauterine fetal growth patterns and periodontal status in pregnant women. Fifty-three pregnant women were recruited. Periodontitis was diagnosed based on probing pocket depth and clinical attachment level. Maternal urinary 8-hydroxy-2’-deoxyguanosine levels and body mass index were recorded. Ultrasonographic measurements of the biparietal diameter (BPD), abdominal circumference (AC), and femur length (FL) were recorded, and estimated fetal weight (EFW) was calculated. In addition, approximation spline curves of BPD, AC, FL, and EFW were obtained throughout the gestation period. Recorded delivery outcomes were gestational age (GA), birth weight and length, sex, placental weight, and umbilical cord length. Forty-four participants (34.1 ± 4.9 years) were analyzed. Mean neonatal birth weight was 2906.0 ± 544.4 g. On multiple regression analysis, birth weight was related with periodontitis (standardized β = −0.21,  In Japan, birth weight is decreasing each year, although more than 90% of neonates are born during the normal period of gestation (37–41 weeks). In 2016, the average birth weights were 3.05 kg for males and 2.96 kg for females, and 8.3% and 10.5%, respectively, were delivered with an LBW ( < 2500 g)5. Ethnicity/race, low socioeconomic status, multiple pregnancy, smoking, alcohol, drug abuse, and microbial infection have been reported as risk factors for LBW7. Elucidation of the risk factors that affect fetal growth and birth weight is important.Low birth weight (LBW) neonates are at higher risk of postnatal mortality and morbidity and lifestyle diseases in adulthood10. Local inflammation induced by periodontal pathogens including lipopolysaccharide (LPS) plays important roles in the pathophysiological processes of LBW or other adverse outcomes14. Moreover, there are other possible mechanisms through the increase in oxidative stress related to periodontal tissue inflammation16. Oxidative stress, which results from a disturbance in the balance between the production of reactive oxygen species (ROS) and antioxidant defenses, is reported to be associated with LBW18. A meta-analysis based on the observational studies concluded that there was evidence of an association between periodontal disease and LBW19.Periodontal disease is thought to be one of the risk factors for LBW23. A meta-analysis concluded that treatment of periodontal disease during pregnancy had no significant effect in reducing the incidence of LBW. The onset and duration of the periodontal therapy were generally unclear in the previous trials24. One of the possible reasons for the reported lack of effect of periodontal treatment might be ineffective timing of the intervention. Thus, further studies are needed to determine the appropriate timing of periodontal treatment to avoid the negative effects of periodontal disease on fetal growth.Next, it would be useful to clarify whether periodontal treatment actually prevents LBW. However, some interventional studies reported that treatment of periodontal disease during pregnancy did not prevent adverse pregnancy outcomes25. On the other hand, few studies reported the effect of periodontal disease on longitudinal patterns of intrauterine fetal growth throughout the entire gestational period.Most previous studies focused only on delivery outcomes to see any association between periodontal disease and fetal growth. However, cross-sectional studies based on birth weight could not sufficiently assess fetal/neonatal growth, because the delivery outcome data would be biased by possible growth restriction, such as preterm deliveries associated with maternal complications or iatrogenic preterm deliveries27. Ultrasonography could attempt to assess the pattern of increased fetal weight, the period when growth restriction happens, and the growth process of every part or organ of the fetal body selectively29. However, few studies have investigated the correlation between EFW and periodontal disease using ultrasonography. We hypothesized that the effect of periodontal disease on fetal growth appears at a certain time. The aim of this prospective cohort study was to investigate the association between intrauterine fetal growth patterns and periodontal status in pregnant women.Ultrasonography is the most frequently used tool for assessment of intrauterine fetal growth. Estimated fetal weight (EFW) is calculated using the biparietal diameter (BPD), femur length (FL), and abdominal circumference (AC) measured by ultrasonography. Fetal growth is diagnosed by comparing individual EFW with the standard EFW curveFigure P = 0.016).Table P < 0.05). On the other hand, mean probing pocket depth (PPD) and clinical attachment level (CAL) were negatively correlated with birth weight (both P < 0.05). No significant association was observed between 8-hydroxy-2’-deoxyguanosine (8-OHdG) concentration and birth weight  and positively correlated with GA at delivery  and weight of the placenta .The results of multiple regression analysis are shown in Table Figures 25. These timings were similar to the present study.The comparison of EFW curves between the non-periodontitis group and the periodontitis group showed that a significant difference in EFW began at 32 weeks of GA. The results suggest that the maternal periodontal condition in the first trimester was associated with fetal growth at a later GA. The previous longitudinal study reported that there was a significant difference in EFW between maternal obesity in the first trimester and normal maternal weight after 32 weeks of GAThere was a significant difference in BPD at 20 weeks and later between the periodontitis and non-periodontitis groups, whereas there were no significant differences in FL and AC. EFW is calculated using BPD, FL, and AC measured by ultrasonography. Thus, the difference in BPD between the two groups may mainly contribute to that in EFW in the present study.10. On the other hand, some clinical trials reported that maternal periodontal treatment did not prevent LBW23. Therefore, a systematic review did not recommend routine treatment of periodontal disease during pregnancy for decreasing the risk of LBW24. Based on the present results for the EFW and BPD curves, as well as the previous studies, periodontal intervention should be completed in the early stage of pregnancy at the latest, and maintaining a good periodontal condition afterwards is desirable.The median of birth weight at delivery was significantly higher in the non-periodontitis group than in the periodontitis group. This finding corresponds to the result of the EFW curve in the present study and is supported by the previous studiesP = 0.715) or between concentrations of 8-OHdG and maternal periodontal condition (P = 0.069). Pregnancy itself can induce oxidative stress because of increasing metabolic activity in the placental mitochondria30. When oxidative stress levels are too high, it could interfere with normal placentation. The 8-OHdG levels in urine from pregnant women were associated with decreased birthweight, decreased head circumference, and increased risk of small-for-gestational-age fetus33. However, the present findings are inconsistent with these data. The possible reason for the inconsistency may depend on maternal age and 8-OHdG levels. A previous study reported that the median urinary 8-OHdG level of healthy pregnant women  was 5.51 ng/mg CRE at 12 weeks of GA31. The 8-OHdG level is correlated with age34. In the present study, the mean maternal age was 34 years, and the mean 8-OHdG level was 25.7 ng/mg CRE . Therefore, it is conceivable that the relatively older age of the participants in the present study obscured the difference in 8-OHdG between the two groups.There were no significant associations between concentrations of 8-OHdG as a marker of oxidative stress and neonatal birth weight  was set at 0.2, alpha error at 0.05, and power (1 – beta) at 0.8 for linear multiple regression (number of predictors was 10), and the minimum sample size was estimated to be 42 participants.The present study was a longitudinal observational study. The sample size was calculated by G*Power. The effect size . It was confirmed that all procedures were performed in accordance with the relevant guidelines and regulations. The present study was performed in accordance with the STROBE Statement.35 was also obtained. For PPD and CAL, agreement ± 1 mm was 100% on preliminary calibration.Five trained dentists carried out the periodontal examination in the first or early second trimester. PPD and CAL were assessed at six sites  for all teeth present with a color-coded probe . Bleeding on probing (BOP) was recorded as present or absent after probing. Mean PPD, mean CAL, and percentage of BOP-positive sites (%BOP) were calculated for each subject. The Plaque Index (PlI)36.Participants were divided into two groups according to periodontal status, the non-periodontitis group and the periodontitis group. The presence of 4 or more teeth showing at least one site with PPD ≥ 4 mm and CAL ≥ 3 mm at the same site was diagnosed as periodontitis38. The urinary 8-OHdG concentration was determined by an immunochromatographic assay using an automatic analyzer, the ICR-001 41. The urine sample was diluted 2 times by distilled water, and 100 μl of the diluted sample were dropped on the testing card. After 5 minutes, the adjusted 8-OHdG concentration was expressed as a ratio to the urinary creatinine concentration (ng/mg CRE).The urinary 8-OHdG level was measured to assess oxidative stress on the same day as the oral examination, because 8-OHdG has some advantages as a marker. 8-OHdG is present in the extracellular compartment following DNA damage caused by ROS, and it can be noninvasively obtained from urine, as well as serum. 8-OHdG is stable after sample collection, so that it has been used universally to assess oxidative stress2). Information on maternal age, parity, baseline disease, complications during pregnancy, and medication use were obtained from the medical records. Maternal systemic conditions were decided based on the maternal baseline diseases and pregnancy complications, and divided into 3 groups by the risk to fetal growth of these abnormalities: 1) decreased birth weight, 2) no associations with BW, and 3) increased birth weight.Maternal height (cm) and weight (kg) were recorded at the first prenatal visit, as well as pre-pregnancy weight, and body mass index (BMI) was calculated  and neonatal sex , respectively.The distributions of this data were assessed by using Shapiro-Wilk test. After that, non-paired Multiple regression analysis was performed to analyze the effects of the following independent variables on birth weight as a dependent variable: maternal age, 8-OHdG level, parity, neonatal sex, GA at delivery, placental weight, umbilical cord length, BMI, periodontal group (non-periodontitis/periodontitis), %BOP, and maternal systemic condition (decreased BW/nothing or no associations with BW/increased BW).t-tests.Estimated EFW, BPD, FL, and AC values were compared between the non-periodontitis and periodontitis groups at each GA using non-paired P < 0.05.All data were analyzed and all estimated curves were created using SPSS version 22  with the level of significance set at


The causes of preterm birth are multi-dimensional, including delayed and inadequate prenatal services as well as other medical and socioeconomic factors. This study aimed to examine the different levels of association between preterm birth and major medical co-morbidities among various racial/ethnic women enrolled in Medicaid.This is a retrospective analysis of 457,200 women aged between 15 and 44 with a single live birth from the IBM® MarketScan® Multi-State Medicaid Database from 2014 to 2015. Preterm birth, defined by delivery before 37 completed weeks of gestation, was the primary dependent variable. All births were dichotomously categorized as either preterm or full-term birth using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Independent variables included race/ethnicity, categorized as non-Hispanic white, non-Hispanic black, Hispanic, or other. Medical co-morbidities included smoking, drug dependence, alcohol dependence, diabetes, and hypertension. Total healthy prenatal visit count and high-risk prenatal visit encounters identified during 30 weeks prior to the delivery date were included in the analysis.A significantly higher preterm birth rate was found in black women after controlled for medical co-morbidities, age, prenatal visit count, and high-risk pregnancy. Different levels of association between preterm birth outcome and major medical co-morbidities were examined among various racial/ethnic women enrolled in Medicaid. Drug dependence was associated with higher odds of preterm birth in black  and white women , when controlled for other variables. In Hispanic women, diabetes  and hypertension  were associated with higher odds of preterm birth. White women diagnosed with drug dependence had a 14.0% predicted probability of preterm birth, whereas black women diagnosed with drug dependence had a predicted probability of preterm birth of 21.5%.The associations of medical co-morbidities and preterm births varied across racial and ethnic groups of women enrolled in Medicaid. This report calls for future research on racial/ethnic disparity in preterm birth to apply integrative and qualitative approaches to understand the disparity from a contextual perspective, especially for vulnerable pregnant women like Medicaid enrollees. Preterm birth is defined as the delivery of an infant prior to 37 weeks of gestation and may lead to increased infant mortality and morbidity as well as emotional stress and increased financial burdens to families and to society , 2. MateRace and ethnicity are also associated with preterm birth; Black women have higher rates of preterm birth than other racial groups . NationaEnrollment in Medicaid, which covers nearly half of all births in the United States, is itself an independent predictor of preterm delivery , 16–19. The current study is a retrospective analysis of de-identified administrative claims data available from the IBM® MarketScan® Multi-State Medicaid Database, formerly Truven MarketScan® Multi-State Medicaid Database, from January 1, 2014, and September 30, 2015. This dataset contained unique enrollees from thirteen states, but the individual state is not identified within the data. A cohort of 457,200 women was generated who were aged between 15 and 44 and delivered a single live birth at an inpatient hospital facility . Stillbin=56) and therefore excluded from the regression analysis. Any women with at least one high-risk prenatal visit were then categorized as a high-risk pregnancy. In this study, we focused on the mother’s access and utilization of prenatal care services rather than the actual clinical examination or intervention delivered during the prenatal visit. The ICD-9 codes for prenatal visits for normal and high-risk pregnancy are listed in Preterm birth was the primary dependent variable which was dichotomously categorized as either preterm or full-term using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes . In thisLogistic regression analysis was used to estimate rates of preterm birth associated with other modifying factors: age, race, medical co-morbidities, prenatal visit count, and high-risk pregnancy. All analyses were performed in Stata 15 (StataCorp LLC).Among the 457,200 women aged 15 to 44 who gave birth between January 2014 and September 2015, there were 231,942 white, 141,392 black, 30,903 Hispanic, and 52,963 were of another race or ethnicity. The preterm birth rate within the overall cohort was 8.9%. This was highest for black women (9.9%) compared to both white (7.3%) and Hispanic women (6.2%)  accessed at least one prenatal visit during 30 weeks prior to delivery Fig. . HispaniThe prevalence of hypertension was the highest for black women 16.1%)   (p> 0.05). Maternal smoking was associated with higher odds of preterm birth only for white women . In Hispanic women, diabetes  and hypertension  were associated with higher odds of preterm birth  compared to that of white women  (Table The predicted probabilities of preterm birth among women of different races and ethnicities were estimated by medical co-morbidities and by total prenatal visit counts prior to delivery Fig. . White wFor all racial and ethnic women, those with eight or more prenatal visits were associated with a decreased predicted probability of preterm birth. Compared with women who did not have any prenatal visit, the predicted probability of preterm birth among women with 8 or more prenatal visits decreased from 12.2 to 6.4% in black women, 8.3 to 5.3% in white women, and from 6.7 to 4.4% in Hispanic women, adjusted for age and other medical co-morbidities.Among 457,200 Medicaid-enrolled women from the IBM/Watson Truven Multi-State Medicaid core dataset, black women had 35% higher odds of preterm birth than white women, even when controlling for age, prenatal visit number, and major medical co-morbidities, including smoking, drug dependence, alcohol dependence, diabetes, and hypertension. While a higher preterm birth rate in black women is a well-known finding, this study showed that racial/ethnic disparity in preterm birth persists among women enrolled in Medicaid, who are expected to share some of the common characteristics: significant financial hardship, less likely to be married, and more medical co-morbidities , 19.When stratified by race and ethnicity, each medical condition affected preterm birth outcomes differently. Most notably, black and white women showed strong associations between drug or alcohol dependence and preterm birth outcomes. On the other hand, Hispanic women showed the highest odds of preterm birth associated with diabetes and hypertension, which are more related to lifestyle rather than risky behaviors.The study also provided continued evidence of the Hispanic Paradox, as observed in previous studies: Hispanic women had the lowest utilization of prenatal visits, but they had the lowest preterm birth outcomes among all racial/ethnic groups in the study. Future studies that evaluate Hispanic women’s prenatal health status and how their unique social and cultural context influence health behaviors are necessary , 22.The study finding demands a better understanding of the underlying influences of various medical conditions and its associated social factors to different groups of women. Until now, it is still unclear how race and ethnicity play their role as a predominant determinant of preterm birth. Birth outcomes are different among Hispanic women with different length of immigration years . Risk beThe study also showed adequate prenatal care visits were strongly associated with preterm birth outcomes in all racial/ethnic groups. There have been diverse approaches to support pregnant women in accessing early and adequate prenatal care and reduce preterm birth outcomes. A multi-state study found that merely increasing obstetric providers was not associated with increased utilization of office-based prenatal care by black Medicaid enrolled pregnant women , 26. A rThe analysis was performed on the IBM® MarketScan® Multi-State Medicaid Database of nearly a half-million Medicaid enrolled women from 13 states. The dataset does not identify individual states, and we cannot examine the trends identified in this study are the result of geography and state-level characteristics regarding Medicaid policies. While the vast number of subjects increases the power of the study, we may not be able to generalize the study outcome to other states or non-Medicaid populations as the dataset is not a nationally representative sample. In addition, the dataset did not provide socioeconomic information such as marital status, employment status, or education level. We may assume that women enrolled in Medicaid are likely to share certain sets of socioeconomic characteristics, such as low-income status , 19. HowThe associations of medical co-morbidities and preterm births varied across racial and ethnic groups enrolled in Medicaid. This report calls for future research on racial/ethnic disparity in preterm birth to apply more integrative and qualitative approaches to ultimately understand the disparity from a contextual perspective. This comprehensive understanding will help identify prenatal care strategies and policies to reduce preterm birth outcomes among various profiles of pregnant women, especially the ones from vulnerable backgrounds, such as Medicaid enrollees.


The impact of vertical electrical field on the electron related linear and 3rd order nonlinear optical properties are evaluated numerically for pyramidal GeSn quantum dots with different sizes. The electric field induced electron confining potential profile’s modification is found to alter the transition energies and the transition dipole moment, particularly for larger dot sizes. These variations strongly influence the intersubband photoabsorption coefficients and changes in the refractive index with an increasing tendency of the 3rd order nonlinear component with increasing both quantum dot (QD) size and applied electric field. The results show that intersubband optical properties of GeSn quantum dots can be successively tuned by external polarization. Self-assembled quantum dots have received an increasing interest during the past decades owing to their potentiality for novel optoelectronic devices ,2. IndeeThe self-assembled GeSn QD has been considered to have a pyramidal shape with 1nm thick wetting layer (WL) embedded in Ge matrix which is one of the frequently observed shapes for semiconducting self-assembled QD  as illusm* represent the electron energy level, envelop wave function, potential barrier and effective mass, respectively. To evaluate the QD s- and p- like electrons’ energy levels and associated wave functions in Γ-valley, single band 3D-Schrodinger equation (Equation (1)) is solved in Cartesian coordinates within the effective mass approximation by finite elements method offered by COMSOL multiphysics software   for the lsewhere ,43. The given by ,11:(2)α . Γ=10 pspolation . ωfi is irection ,16,44. The calculation of Γ-s and -p electron energy states and associated envelop wave functions allows to evaluate the In absence of electric field (F = 0 kV/cm), the intraband transition decreases from 74 meV (L = 25 nm) down to 38 meV (L = 40 nm). Applying positive electric field of 100 kV/cm enhances the transition from 6 meV for the smallest QD size up to 10 meV for the largest one. Meanwhile, the energy spacing between p and s states get rather shrank by approximately 6 meV for an external electric field of −100 kV/cm. This behavior is a direct impact of the electric field driven modification of the electron confining potential’s profile. To explain this trend, the electron probability density from s and p states (ZX plane) under an electric field of 100 kV/cm, 0 kV/cm and −100 kV/cm are shown by Further information can be gained through studying the evolution of the dipole moment as a function of the dot size and electric field . The traAccordingly, the impact of the dot size and electric field on the AC, RIC and the corresponding linear and third order nonlinear components are shown by The resonance peak of the linear AC a–c consiFurthermore, the linear RIC  d–f showOur calculations clearly reveal that the intersubband optical nonlinearity can be conveniently tuned by applying an external electric field for a given QD size and incident light intensity. Accordingly, the nonlinear effects can be tuned. This investigation has been conducted on GeSn QD with the available materials parameters remain a subject to experimental validation. Nonetheless, this comprehensive study could also be useful to understand the impact of the applied electric field on the intersubband optical properties of similar QD.We have evaluated the effect of applied electric field on the intersubband optical transition, dipole moment, AC, and RIC for various GeSn QD size. The transition energy and dipole moment are found to be strongly affected by the electric field-induced confining potential profile changes. Larger size QD are found to be more sensitive to the effects of applied electric field. The intersubband-related AC and RIC can be widely tuned by employing external electric field. This comprehensive study could help future realization of CMOS compatible nonlinear optical devices.


Low birth weight infants are at increased risk of infection, difficulty of feeding, and neurologic problems following birth. So far, the prevalence and factors associated with low birth weight have not been studied in the study area after completion of the time set for millennium development goals. Therefore, the study was aimed at assessing the prevalence and associated factors of low birth weight among newborns delivered at University of Gondar specialized referral hospital, Northwest Ethiopia, 2017.Globally, more than 20 million infants are born with low birth weight. The risk of neonatal mortality among low birth weight infants is 25 to 30 times greater than neonates with birth weight p-value of less than 0.05 with corresponding 95% CI.Institution-based retrospective cross-sectional study was conducted from April 1 to May 28, 2017. A total of 240 newborns were included in the study. Systematic random sampling technique was used for selecting study participant’s medical record charts from delivery registration log book. Data were collected using data extraction tool. Binary logistic regression followed by multivariable regression model was fitted and interpretation was made based on the adjusted odds ratio and The prevalence of low birth weight was 12.9% . No history of preeclampsia , negative maternal HIV infection , and being preterm  were significantly associated with low birth weight.The result of this study highlighted that the burden of low birth weight is a public health concern among babies delivered in University of Gondar specialized referral Hospital. Maternal HIV infection, preeclampsia, and prematurity were associated with low birth weight. Prevention and treatment of Human immunodeficiency virus infection during pregnancy, tackling prematurity and prevention of preeclampsia through strengthening of antenatal care service and other comprehensive strategies are strongly recommended. According to the World Health Organization (WHO), low birth weight (LBW) is defined as weight at birth less than 2500 g . Its sevIt is estimated that LBW contributes to 60 to 80% of all neonatal mortality . LBW newStudies show that factors contributing to LBW are multifactorial. The following factors have increased the likelihood of being LBW in the newborn; young maternal age, primiparity, lower education level, and poor maternal nutritional status both preconception and during pregnancy , 15]. A. A15]. AEthiopia has achieved the fourth Millennium Development Goal (MDG) of the United Nations which targeted to reduce child mortality by two-thirds from 1990 to 2015  [19]. HoTherefore, the aim of this study was to determine the prevalence and factors associated with LBW among newborns delivered at University of Gondar specialized referral hospital. This gives an insight into a useful child health indicator and could help in better evidence-based interventions in Ethiopia aimed at further reducing neonatal mortality.A cross-sectional study design was conducted from April 1 to May 28, 2017, at the University of Gondar comprehensive specialized referral Hospital, northwest Ethiopia. The hospital is providing service for more than 7 million people of Gondar town and the catchment area. The maternity division of the hospital is composed of antenatal care (ANC) clinic, postnatal clinic, and two delivery wards. It’s staffed with intern doctors, 37 midwives, 26 obstetricians, and 24 supportive staff. In 2016, a total of 7590 births were attended at the hospital.All weighted live births with complete records delivered at the University of Gondar comprehensive specialized referral Hospital were included.To estimate the sample size, single population proportion formula was used by considering the following statistical assumptions; prevalence of LBW, 17.1% , 95% conThe patients’ medical records and physician order sheet were used as source of data. The data, consisting of socio-demographic variables, clinical and obstetric history as well as birth outcome, were collected using data extraction tool. Four registered nurses collected the data, while two other supervised the data collection process. Data quality was maintained by the following data quality control mechanisms; the data extraction tool was pretested on 5% of the sample (i.e. 12 charts) at Felegehiwot referral hospital. One day training was given to data collectors and supervisors. Strict supervision of the data collection was carried out throughout the data collection period. The collected data was checked for its consistency and completeness before any attempt to enter, code and analyze it.p-value of ≤0.2 in the bi-variable analysis were exported to the multivariable model to control the possible effects of confounders, as well as to identify statistically significant variables. Adjusted odds ratio (AOR) with corresponding 95% confidence interval was computed and variables having p-value of less than 0.05 in the multivariable model were considered significantly associated with LBW.The collected data was coded, entered into Epi-Info version 7, and exported to SPSS version 20 software for analysis. The results were presented using frequency, tables, text, and graphs. Variables with a A total of 240 participants were enrolled in the study. The mean (+SD) age of the mothers was 27.1 (±5.3) Years. About 59.3% were urban residents and the vast majority (97.8%) of them were married. Moreover, 60.8% of the mothers were unemployed (Table One hundred and five (43.5%) of the mothers were primiparous. Almost all (99.8%) of the mothers had 1st ANC follow up. One hundred forty eight (61.9%) had at least four ANC visits during current pregnancy. Dominant number of participants 72.5%) were registered for ANC follow-up in the second trimester. In this study, the majority (86.7%) of pregnant women were supplemented with Iron/Folic acid during the ANC follow up. About one in 10 (10.2%) of participants had history of abortion. Regarding HIV/AIDS infection, the vast majority (97.9%) of the mothers were non-reactive. Majority (85.8%) of women gave birth between 37and 42 weeks of pregnancy. A bit greater than half (54.6%) of newborns were males. Regarding the mode of delivery, 75% were spontaneous vaginal delivery (SVD) . The mean birth weights of newborns was 2882.5 ± 471.3 g. Out of male births, 18 (13.7%) were LBW, while 13 (11.93%) female newborns were LBW.p-value of 0.2. However, in the multivariable model, only gestational age, history of preeclampsia, and maternal HIV infection were significantly associated with LBW.In the bi-variable analysis, history of preeclampsia, hemoglobin level, number of ANC visits, gestational age, maternal HIV infection, place of residence, and iron supplementation were statistically significant at a Accordingly, the likelihood of giving LBW baby among mothers with no history of preeclampsia in the current pregnancy decreased by 81%  as compared to their counterparts. Moreover, mothers who gave birth prematurely (before 37 weeks) were 17.6 times more likely to deliver LBW babies as compared to mothers who gave birth after 37-weeks of gestation .  , and othOn the other hand, this study found lower prevalence of LBW as compared to studies conducted in Jimma Zone, Ethiopia 22.5%) [.5% [22],The result of this study is higher than studies conducted at Laelay Maichew district, Ethiopia (6.3%) , WolaitaThe likelihood of giving LBW baby among mothers with no history of preeclampsia in the current pregnancy was decreased by 81% compared to their counterparts. This study is supported by studies conducted in Norway , TanzaniThe odds of giving birth to LBW baby among mothers who were HIV uninfected was reduced by 98.5% as compared to those mothers who were HIV infected. The finding of this study is in line with a study conducted in Gondar University Hospital , and a sMoreover, this study revealed a positive association between preterm birth and LBW. The likelihood of being LBW baby is increased among premature babies. This is in agreement with studies carried out in Jimma, Ethiopia , Gondar,In summary, this study demonstrated that LBW is a public health problem among babies delivered at the University of Gondar specialized referral Hospital. Absence of maternal HIV infection, preeclampsia, and preterm delivery were factors that positively predicted LBW. Prevention and treatment of HIV infection, prevention of preeclampsia by strengthening ANC services, and preventing prematurity are highly recommended.


A 35 year old male presented to our outpatient department with a slow growing swelling over the left gluteal region for more than 10 years. There was no history of pain, tenderness, fever or previous trauma. On examination there was a 10 cm x 10cm swelling in the upper outer quadrant of left gluteal region. It was soft, cystic, mobile swelling and adherent to overlying skin with a punctum. Ultrasonography revealed a well-defined hypoechoic heterogenous cyst suggestive of an inclusion epidermoid cyst (A). FNAC was done for confirmation. A complete excision of the whole cyst (B) was done with uneventful post-operative recovery.histopathology showed no signs of malignancy. Epidermoid cyst is one of the commonest benign lesions of skin. Size may vary from a few millimetres to few centimetres but cysts more than 5 cm are known as giant epidermoid cysts and are rare clinical occurrence. Giant epidermoid cyst (A) up to 17 cm in greatest dimension have also been reported. They are slow growing lesions and patients tend to neglect them only to present at a later time. These cysts are usually seen over gluteal region but may be seen over the extremities and scalp. Malignant transformation is a known complication leading to squamous cell carcinoma, basal cell carcinoma or melanomas (C). Clinical examination, USG, FNAC will clinch the diagnosis in most cases. MRI gives additional information in cases of atypical or suspected malignant lesions. Complete excision is the treatment of choice.


To the editor,Avoidance of ventilator-induced lung injury (VILI), defined as the damage caused by the application of large pressures or volumes to the lung parenchyma, is one of the main objectives of contemporary ventilatory management. This specific form of injury is triggered by a variety of molecular mechanisms involving mechanosensation and mechanotransduction of physical forces, inflammatory responses, activation of intracellular signals, extracellular matrix remodeling, and dysregulation of different forms of cell death. Among these, inflammation plays a key role in the induction of early damage, but also in later repair. In spite of this knowledge, no treatment aimed to reduce VILI based on these mechanisms has been translated into the clinical practice.The outcome of critically ill ventilated patients depends on the cause of the disease, the specific characteristics of the patient (including comorbidities), and the response to therapies and their consequences. The impact of VILI in outcome falls in this latter category. However, it is not known how previous baseline conditions and applied therapies interact.Sex is one of the main determinants of health and disease. It has been reported that males show worse intensive care unit (ICU) outcomes . In the 2O, PEEP 0 cmH2O, respiratory rate 100 breaths/minute, inspiratory to expiratory ratio 1:1, FiO2 0.21). After 2.5 h, animals were sacrificed and the lungs removed and fixed. There were no differences in lung injury, addressed using a semiquantitative score [n = 6 per condition, p < 0.001 for the effect of ventilation, p = 0.99 for the effect of sex in a two-way ANOVA). Using a more aggressive ventilatory strategy  yielded slightly higher scores but again without differences between sexes . Similarly, there were no differences in neutrophilic infiltrates between sexes . Figure The role of VILI in the difference in ICU outcome between sexes has not been addressed. Most of the experimental research has been conducted in male animals, discarding their female counterparts, and no study has compared male and female animals after mechanical ventilation. To address this question, we ventilated male and female C57BL/6 mice to induce a moderate lung injury . Raw data  were background-corrected and normalized to obtain expression values. These values were fitted to a linear model including sex and ventilation as factors, and lsewhere . MechaniCollectively, these results suggest that there are no differences caused by sex in susceptibility to VILI. Rather than justify the use of animals of a single sex in experimental studies, these findings support the inclusion of both, as advocated by others . Our dat


Antenatal corticosteroid treatment is globally recommended for women at risk of giving birth before 34 weeks of gestation. In Japan, data on the rate of completing recommended antenatal corticosteroid treatment are lacking. This study aimed to: (i) determine the proportion of patients treated for threatened preterm birth with tocolysis who received antenatal glucocorticoids; and (ii) analyze the association between long-term tocolysis and antenatal glucocorticoids treatment as recommended.This was a retrospective cohort study using a national inpatient database in Japan. We selected pregnant women who had undergone treatment in hospitals due to threatened preterm birth and received the tocolytic ritodrine hydrochloride by infusion from July 2010 to March 2016, and delivered at < 34 weeks of gestation. The primary outcome was receiving of antenatal glucocorticoid treatment as recommended. Multivariable logistic regression was performed to evaluate factors associated with receiving antenatal glucocorticoid treatment.Only 23% of 4048 eligible patients received glucocorticoid treatment as recommended. Those with longer durations of ritodrine hydrochloride infusion were significantly less likely to receive glucocorticoid treatment as recommended.In Japan, many patients who receive tocolytic treatment for threatened preterm birth do not receive antenatal glucocorticoid treatment as recommended. Recommended treatment based on apparent evidences should be performed for the patients with threatened preterm birth. Preterm babies have an increased risk of serious illness or death during the neonatal period. Without appropriate treatment, babies born preterm are at increased risk of lifelong disability and poor quality of life , 2. RespAdministration of antenatal corticosteroids is the most beneficial intervention for improving neonatal outcomes among patients who give birth preterm . ExtendeThere may be a gap between the available evidence and actual clinical practice for preterm labour in Japan. First, because the globally commonly administered medications for threatened preterm birth include nifedipine, atosiban, and vaginal progesterone and these agents are not covered by the universal healthcare coverage in Japan, they cannot be used for standard therapy in Japan. Second, some Japanese obstetricians are likely to select long-term (≥ 48 h) tocolysis with intravenous low-dose (50–200 μg/min) infusion of ritodrine hydrochloride, a betamimetic. In particular, long-term tocolysis is more likely to be used in hospitals without neonatal intensive care units. In addition, Japanese clinical guidelines do not recommend repeated courses of antenatal corticosteroids for women at risk of preterm birth , 13.A major concern around this unscientific practice is the possible failure to administer maternal glucocorticoids as recommended before preterm birth. We hypothesized that physicians may not administer glucocorticoids in a timely manner because long-term tocolysis can mask deterioration in threatened preterm birth status. Additionally, there is no scientific data on the success rate of administration of appropriately timed glucocorticoids in Japan. Not only the success rate of administration of antenatal glucocorticoids, but the association between long-term tocolysis and rate of antenatal glucocorticoid administration could be important in improving fetal outcomes among patients who deliver before 34 weeks of gestation.Using a national inpatient database in Japan, the present study aimed to determine the proportion of patients with threatened preterm birth who had received antenatal glucocorticoid treatment, including appropriately timed antenatal glucocorticoid treatment, during hospitalization. The association between long-term tocolysis and proportion of patients receiving glucocorticoids as recommended was also analysed.The Diagnosis Procedure Combination (DPC) database, a national inpatient database for acute-care inpatients in Japan, the details of which have been described elsewhere , was usePregnant women aged 13–50 years who had been diagnosed with threatened preterm birth between 22 and 36 weeks of gestation  and had undergone treatment in hospitals from July 2010 to March 2016 and for whom there was complete data were identified. From this pool, those who had deliveries < 34 weeks of gestation were finally selected as study patients.Age was categorized into ≤19, 20–24, 25–29, 30–34, 35–39, and ≥ 40 years. The duration of ritodrine hydrochloride intravenous administration as tocolytic treatment was categorized into ≤48 h, 3–6 days, 7–13 days, 14–27 days, and ≥ 28 days. Patients who had received intravenous magnesium sulfate prior to administration of intravenous ritodrine hydrochloride were excluded because whether the magnesium sulfate had been administered for the purpose of tocolysis or to prevent cerebral palsy could not be determined for individual patients in the database.We investigated the proportion of patients who received antenatal glucocorticoid as recommended, which was defined as administration of the recommended dosage of maternal glucocorticoids within 7 days before preterm birth (< 34 weeks of gestation) during hospitalization. Intramuscular injection of betamethasone 24 mg or dexamethasone 24 mg qualified patients for inclusion , 10. We 2 test or Fisher’s exact test. Continuous variables  were compared by a t-test or the Mann–Whitney U-test, as appropriate. Multivariable logistic regression analysis was performed to evaluate factors associated with administration of glucocorticoids as recommended. All statistical analyses were performed using IBM SPSS software version 23 . All tests were two-tailed, and the threshold for significance was P < 0.05.Categorical variables  were compared by the χWritten informed consent was not required because of the anonymous nature of the data. The need for written consent was formally waived by the Ethics Committee and the Institutional Review Board of The University of Tokyo approved the study.During the study period, we identified 7298 hospitalized patients with a diagnosis of threatened preterm birth who had given birth before 34 weeks of gestation during hospitalization. Of these, 5197 patients had received intravenous ritodrine hydrochloride as tocolysis. We excluded 1149 of the 5197 patients because they had received intravenous magnesium sulfate prior to administration of intravenous ritodrine hydrochloride. The mean (standard deviation [SD]) age of the 4048 eligible patients was 31.5 (5.4) years, and the mean (SD) gestational age was 28.5 (3.4) weeks.The 4048 patients’ characteristics according to duration of ritodrine hydrochloride infusion are shown in Table n = 1869). The frequency of repeated courses 14 days or later from the first course of glucocorticoids was 1.1% (n = 21) and 44.6% (n = 1805) of patients had received intravenous magnesium sulfate and ritodrine hydrochloride concurrently.The overall proportion of patients receiving any maternal glucocorticoids during hospitalization was 46.2%  days and 1 (1–3) days (medians and interquartile ranges) in women who had received any maternal glucocorticoids and women who had received maternal glucocorticoids as recommended, respectively. The intervals between the last dose of maternal glucocorticoid and preterm birth were 3 (1–9) days and 2 (1–4) days (medians and interquartile ranges) in women who had received any maternal glucocorticoids and women who had received maternal glucocorticoids as recommended, respectively.The results of multivariable logistic regression analysis of maternal glucocorticoid treatment as recommended within 7 days of delivery are presented in Table In the current study, 46.2% of patients received maternal glucocorticoids in various doses and with varying timing during hospitalization, whereas, only one-fourth of the 4048 women who had threatened preterm birth treated with ritodrine hydrochloride and delivered before 34 weeks of gestation received glucocorticoids as recommended. Only 1.1% of participants received repeat courses 14 days or later after their first course of glucocorticoids. Patients who received tocolytic treatment for ≥28 days were least likely to receive glucocorticoids as recommended.Data have been lacking on the percentage of patients who give birth at less than 34 weeks of gestation in Japan and receive glucocorticoids as recommended, although this treatment is a proposed performance measure . A previIn the present study, there was a correlation between a long delay between exposure to glucocorticoids and delivery and duration of tocolytic infusion, indicating that women who do not deliver within 7 days of glucocorticoids administration are exposed to tocolytic infusion for longer periods. In the current study, the multivariable logistic regression analysis of maternal glucocorticoid treatment was adjusted for the effects of measured confounders; however, some unmeasured confounders such as maternal vital signs and results of echography were not taken into account. The duration of hospitalization can also affect outcomes. Additionally, the duration of tocolytic infusion potentially varies in accordance with delay between glucocorticoids administration and delivery. We therefore concluded that the odds ratio in Table In many developed countries, long-term tocolysis with intravenous tocolytic agents is uncommonly or never administered , 18. PreSeveral limitations of this study should be acknowledged. First, it was a retrospective observational study based on an administrative database and therefore lacked some relevant clinical information, such as vital signs, parity, uterine cervical length according to ultrasound, vaginal microorganisms, and blood test findings. Second, there are no relatively small hospitals or clinics in the database we used. However, such hospitals rarely handle patients who deliver at < 34 weeks gestation because they tend to transfer women at high risk of preterm birth to larger centres. Third, because we excluded women who delivered at term from the current study, we were unable to analyze the potential overuse of antenatal glucocorticoids in all women with a diagnosis of threatened preterm birth who received tocolytics. Finally, the negative association between duration of tocolytics and suboptimal use of antenatal corticosteroids identified in the current study is potentially a result of bias introduced by unmeasured confounders. Additionally, our study design did not allow us to clarify whether the relationship between duration of tocolytics and suboptimal use of antenatal corticosteroids is causal. Future studies are warranted to evaluate a possible causal relationship between long-term tocolysis and use of antenatal corticosteroids, including in women who give birth at term.In conclusion, we demonstrated that many patients who receive tocolytic treatment for threatened preterm birth do not receive glucocorticoids as recommended in the present study. Additionally, we found that women with longer durations of ritodrine hydrochloride infusion are significantly less likely to receive optimal glucocorticoid treatment. Recommended treatment based on apparent evidences should be performed for the patients with threatened preterm birth in the real-world clinical setting.


Records from 1,742,183 single births in 2010–2013 were evaluated. Mean PM10 concentrations during pregnancy were calculated and matched to birth data by registered regions. We analyzed the frequency of birth outcomes between groups using WHO criteria for PM10 concentrations with effect sizes estimated using multivariate logistic regression. Women exposed to PM10 > 70 µg/m3 during pregnancy had a higher rate of preterm births than women exposed to PM10 ≤ 70 µg/m3  1.570; 95% confidence interval (CI): 1.487–1.656). The rate of low birth weight in term infants increased when women were exposed to PM10 > 70 µg/m3 , but this difference was not statistically significant . In conclusion, PM10 exposure > 70 µg/m3 was associated with preterm births. Further studies are needed to explore the pathophysiologic mechanisms and guide policy development to prevent future adverse effects on birth outcomes.Air pollution has become a global concern due to its association with numerous health effects. We aimed to assess associations between birth outcomes in Korea, such as preterm births and birth weight in term infants, and particulate matter < 10 µm (PM In particular, the particulate matter (PM) component of air pollution is becoming increasingly important due to several factors, including geographical characteristics, the chemical evolution in Seoul, and overcrowding in urban areas. In 2016, the United States National Aeronautics and Space Administration, the Ministry of Environment in Korea, and the National Institute of Environmental Research studied PM in Korea and released the Korea–United States Air Quality Study, reporting that the PM emitted domestically may exceed the recommendations outlined in the World Health Organization (WHO) air quality guidelines [diabetes ,8,9. Mordiabetes ,12; low diabetes ,14,15; adiabetes . In addidiabetes ,19.Preterm birth has short-term effects on respiratory, central nervous system, and cardiovascular functions in the form of patent ductus arteriosus, respiratory distress syndrome, and intravascular hemorrhage . There a3 to indicate high levels of exposure. This reference value of 70 µg/m3 was based on the interim target-1 in the WHO air quality guidelines [3. We hypothesized that air pollution would be negatively associated with birth outcomes, particularly preterm births and low birth weight.Given the increasing attention on the relationship between exposure to PM and adverse birth outcomes, this study aimed to assess the association of birth outcomes, such as preterm births and low birth weight in term infants, with PM in ambient air pollutants in Korea. We used a cutoff value for PM concentration of 70 μg/m10 during pregnancy. In Korea, all parents must report their child’s birth within 1 month and include the following information: month and date of birth; maternal residential address at the time of birth; place of birth ; parental ages; gestational age (weeks and days); sex; birth weight; birth order; total number of births; and parental education, occupation, and nationality. All data were acquired from Statistics Korea [This nationwide registry-based study analyzed data from 1,862,441 live births in 2010–2013 registered in the Korean national birth registry. The birth weight of term infants and the proportions of preterm births and low birth weight were analyzed according to the concentration of PMcs Korea , which ocs Korea . Moreove10 exposure, we obtained daily mean levels from the National Health Insurance Service (NHIS), which makes air pollution data available through its data sharing website [10 was measured using the ß-ray absorption method at 266 monitoring stations scattered throughout Korea during 2009–2013 [10 concentrations during pregnancy were assigned according to the address; the study population was postulated to be stable (did not change) over the exposure time period. We calculated monthly averages of PM10 concentrations for each address and matched them to individuals based on their gestational age.To assess PM website . The lev009–2013 . Residen10 concentrations and the proportion of preterm births in Korea according to addresses  of monitoring stations and residences. We performed multiple linear regression analysis to assess correlations between mean PM10 level and birth weight in term infants. Multivariable logistic regression was used to assess the effect of PM10 in each residential region on birth weight in term infants and preterm births. The mean PM10 concentrations were categorized in two ways. First, we compared birth outcomes of subjects in the lower first to third quartiles with the subjects in the fourth quartile. As the 75th percentile of the concentration was 54.5325 µg/m3, we calculated odds ratios (ORs) using ≤54.5325 µg/m3 as the reference category. Second, proportions and ORs were analyzed based on ≤70 µg/m3, which is the interim target-1 of the WHO [Using ArcGIS Maps for Office , we visualized PM the WHO ,29,30, iThis study was granted ethical exemption by the institutional review board at Kyung Hee University Hospital , since this was a secondary analysis of de-identified data (IRB No. 2018-01-091). The study was conducted in accordance with the Declaration of Helsinki.10 over five years decreased from 46 to 43 µg/m3, with the lowest level reported in 2012 . The proportion of low birth weight in term infants was higher when the exposure to mean PM10 concentration was >70 µg/m3 than it was when exposure was ≤70 µg/m3 (1.9% vs. 1.7%), although the aOR was not significantly higher than the reference group : 0.953–1.178, P = 0.283) (3 or less) of PM10 exposure . In particular, women exposed to PM10 >70 µg/m3 during pregnancy had a significantly higher proportion of preterm births (7.4% vs. 4.7%) than those exposed to ≤70 µg/m3 . The aOR for the relationship between exposure to PM10 >70 µg/m3 for very preterm births  was also statistically significant  (A 10 µg/m= 0.283) . Women i< 0.001) .10 than those exposed to lower PM10 levels (5.4% vs. 4.6%), and the aOR was statistically significant . However, there was no difference between groups in nonmetropolitan regions. aORs for the association between preterm births and mean PM10 exposure > 70 µg/m3, were statistically significant, irrespective of region  1 g decrease in birth weight among term infants per 10 µg/m3 increase in PM10 exposure during pregnancy. This tendency is consistent with previous research, but the changes in birth weight described previously have been so modest that they may have little clinical importance [10 concentration was >70 µg/m3, but the association was not statistically significant, as measured by the aOR. Finally, we found a tendency for increases in PMportance ,34. The 10 concentration over a five-year period, ambient air pollutants—specifically particulate matter—remain a burden on the economy and human society in Korea and worldwide. The Global Burden of Disease, Injuries, and Risk Factors Study of 2016 identified air pollution, especially ambient air pollution, as the sixth leading risk factor for global disease [Although NHIS data showed a decline in PM disease . At the 3 of PM10, which is relevant to higher risks. However, it is important to note some limitations. First, when we discuss the association between PM and adverse birth effects, such as preterm birth and low birth weight, we should consider other factors that may affect birth results. These include the family history of preterm births, maternal smoking history, low maternal body mass index, prior preterm birth, medical and pregnancy history, occupational exposure, and other factors. These factors could not be analyzed due to the unavailability of the necessary data. Second, until recently, the concentrations of PM10 and PM2.5, which is also thought to be related to adverse birth outcomes, had not been measured in Korea [2, O3, and NO2, comprehensive analyses of the effects of pollutants beyond PM10 on birth outcomes are warranted. Lastly, this study did not analyze results by trimester because detailed data regarding birth history were not available from the KNSO. There was also no data regarding the date of birth or the day of gestational age; therefore, there was no possibility of dividing pregnancies into trimesters.Our study had several strengths, including adjustment for a number of covariates, including maternal age, parity, infant sex, and parental employment, which have been associated with adverse birth outcomes in previous reports ,29,30. Iin Korea ,14,36,37In April 2017, The Lancet published The Lancet Planetary Health to assess the effects of environment change on human health, but also to investigate other factors such as political, economic, and social systems that govern those effects . This re10, was associated with an increased rate of preterm births. Future research priorities should include explorations of the pathophysiological mechanism behind this association. Long-term, multifaceted studies are also needed to guide development of policies to prevent the adverse effects of air pollutants on birth outcomes in the future.In conclusion, we found that exposure to ambient air pollutants during pregnancy, especially PM


Congenital disorders are an important cause of pregnancy loss, premature death and life-long disability. A range of interventions can greatly reduce their burden, but the absence of local epidemiological data on their prevalence and the impact of interventions impede policy and service development in many countries. In an attempt to overcome these deficiencies, we have developed a tool—The Modell Global Database of Congenital Disorders (MGDb) that combines general biological principles and available observational data with demographic data, to generate estimates of the birth prevalence and effects of interventions on mortality and disability due to congenital disorders. MGDb aims to support policy development by generating country, regional and global epidemiological estimates. Here we provide an overview of the concepts and methodological approach used to develop MGDb.The online version of this article (10.1007/s12687-017-0335-3) contains supplementary material, which is available to authorized users. Congenital disorders, often also called birth defects, include “any potential pathological conditions arising before birth, whether they are evident at birth or become manifest later in life”  was created to meet the information needs of health policy-makers. It does so through the generation of country, regional and global estimates for selected congenital disorders, by combining general biological principles and available observational data with demographic data. Here we describe the scope of MGDb and the general principles followed in its implementation; more detailed methodology can be found in other articles within this journal supplement and in the UCL repository    and prevalence . However, the incidence of congenital disorders is usually expressed as birth prevalence because although many congenital disorders arise at or around the time of conception, many affected embryos either fail to implant or miscarry in early pregnancy, and so never come to the attention of health services. Therefore, for practical purposes, their prevalence at birth is counted as their incidence, and expressed as rate per 1000 live births. MGDb follows the European Surveillance of Congenital Anomalies and Twins (EUROCAT) convention in counting all pregnancy outcomes after 20 weeks gestation as births. In keeping with ICD-10, all births with any signs of life following separation from the mother, regardless of gestation, are counted as live births.Baseline, or potential, birth prevalence is the prevalence that would apply in the absence of any intervention. It is the foundation of the MGDb and provides the “envelope” into which all outcomes must fit. It includes stillbirths and live births but excludes miscarriages, and uses “foetal death” (death in utero after 20 weeks’ gestation) as a proxy for stillbirth. Once baseline birth prevalence is known, when appropriate observational data are available baseline births can be allocated to each potential outcome Fig.  thus genThe baseline birth prevalence for most countries worldwide can be calculated from available data or estimated for many congenital disorders Table . The metHowever, data on all other congenital malformations and rare single gene disorders are only available in high-income settings. To generate estimates for congenital malformations for countries outside high-income settings, we have utilised publicly accessible data from the EUROCAT website to obtain average European rates for birth prevalence , can be obtained for most groups of congenital disorders. In any setting, a proportion of the population has access to optimal care; however, there is no routinely collected indicator from all countries that provides this information. We have therefore developed a method for estimating the proportion of access to optimal care using infant mortality as a proxy indicator  to the very severe . Due to this diversity, quantification of physical disability is limited to estimates of the proportion of survivors at age 5 with severe disability (including reduced life expectancy), less severe disability (with lesser or no effect on life expectancy) and effectively cured.Data regarding long-term disability outcomes, depending on the levels of access to care, were obtained through literature review. The proportion of each population without optimal care is assumed to have no access to care. Although we have used the term no-care, this does not refer to the absolute lack of care as this is unlikely to be the case in reality, with supportive care at home or in a facility available in many settings. In addition, we have used estimates for survival with no care based on available data, which in large part is based on survival in the 1950s in “high income” settings . In the absence of intervention, they would be responsible for 2 years loss of life per person born (range 1.7–2.7 years). Figure To plan for current service needs and project future changes, policy-makers need to know the approximate numbers of persons presently living with specific disorders. This information can only be reliably obtained using a patient register. However, few such registers exist even in high-income settings, even for readily diagnosable disorders such as Down syndrome. The method we have developed extends the principles described above  to estimate the number and age distribution of patients currently receiving care. As WPP provides age distribution data from 1950 onwards, it is possible to generate estimates in any year from 1950 onwards, allowing a comprehensive picture of the history of selected disorders up to a chosen year. As an example, Fig. Future projections of the likely effects of implementing interventions, such as folic acid food fortification or prenatal diagnosis with the option of termination of pregnancy are of particular interest to policy-makers. They can be calculated as follows: (a) assuming no change in present policies and (b) assuming worldwide spread of available interventions. Table The absence of epidemiological data on congenital disorders has led to the creation of MGDb. However, as with all modelling initiatives, the estimates produced can only be as accurate as the input data, and they are approximations only. We emphasise that our aim is only to produce order of magnitude estimates that can be used as a starting point for service planning. They must not be considered as definitive, and require continuous improvement and refinement as better information becomes available. In undertaking this task, it proved necessary to clarify some concepts and develop some new methods to address gaps in available observational data. Articles within this journal describe some methodological aspects and further details can be accessed via the UCL repository  a lower birth prevalence of neural tube defects and orofacial clefts among people of Sub-Saharan African origin, and (b) an increased prevalence of congenital malformation syndromes in groups in which consanguineous marriage is customary. Allowances have been made for differences in maternal age distribution, total fertility rate and observed ethnic differences in the birth prevalence of NTD, OFC, CHT and the effect of parental consanguinity by using country-specific data for these conditions and estimating the impact of consanguinity.The fact that some estimates include stillbirths and terminations as well as live births. Due to differences in the definition of stillbirths we have used foetal deaths as an approximation for stillbirths. As many terminations occur before 20 weeks, we have adjusted TOP rates to those that would apply from 20 weeks onwards. In addition, when observed data applied only to live births we added estimates for foetal deaths based on data from registries and the literature.Double counting of infants with more than one congenital disorder. We ensured throughout that numbers and rates apply for affected individuals within the groups specified in Table Overestimating mortality due to congenital disorders in lower income settings. Estimates for mortality in a no-care situation are based on historical data from high-income settings and are likely to underestimate a truly no-care situation.The strength of this approach lies in beginning with baseline birth prevalence, which provides the most robust estimates. It provides the envelope for all possible outcomes; consequently, overestimation of one outcome leads to underestimation of another, for example overestimation of mortality leads to underestimation of disability. We have endeavoured to address factors that can lead to overestimation of mortality and prevalence as detailed by Liu et al. study. GBD estimates are limited to congenital anomalies, defined as disorders included in ICD10 chapter VII (the Q chapter)–“Congenital malformations, deformations and chromosomal abnormalities”; that is, they deal only with developmental structural anomalies. Congenital anomaly groups specified in the GBD are Down syndrome, unbalanced chromosomal rearrangements, neural tube defects, orofacial clefts, congenital heart anomalies and other congenital anomalies. These exclude single-gene disorders or genetic risk factors modelled in MGDb; consequently, they were excluded from the comparison.Table In existing global estimates, confusion about terminology leads to under estimation of the true burden of congenital disorders. For example, estimates of the “congenital” contribution to under-5 mortality published by the GBD study  is over 37/1000 starting from evidence-based estimates of baseline affected birth prevalence; (b) basing estimates for high-income settings on observational data; (c) generating estimates for a baseline no-care situation using the limited observational data supplemented by expert opinion; and (d) using an empirical equation based on infant mortality rates for estimating the proportion of each population with access to the relevant services.ESM 1(DOCX 24 kb)


Giant ovarian cyst is very rare in gravid-puerperium period. It is a cause of a maternal-fetal morbidity. We report a case of a giant benign ovarian cyst in gravid-puerperium period which was diagnosed and managed in a hospital of a low-resource country.Data were collected by historical review, clinical examination, laboratory investigations, imaging examination, and by histopathological study of the excised surgical specimen. It is the case of a 25-year-old woman who was third gravida and third para with unknown pathological history. After she had given birth through vagina, a giant ovarian cyst, unknown during pregnancy, was diagnosed. A left oophorectomy carrying the cyst was performed after laparotomy in Yalgado Ouedraogo University Hospital Center of Ouagadougou (Burkina Faso). The cyst was 42 cm long and weighed 19.7 kg. The histology of the operative specimen revealed serous cystadenoma of the ovary. The postoperative course was uneventful.This case reports that vaginal delivery is possible with a giant ovarian cyst associated with pregnancy. Surgical management of the cyst can be performed in the postpartum with satisfaction. Adnexal masses during pregnancy are common. Indeed, 0.2–2% of pregnancies are accompanied by ovarian cysts  which arThe patient was a 25-year-old woman who dropped school early and got married with a single farmer. She lived with her husband in Kongoussi, a rural commune about 100 km from Ouagadougou, the capital city of Burkina Faso. She did not have any income-generating activity. She had her first menses at 16 years old. She was third gravida and third para with three living children.For her previous pregnancy, the date of the patient’s last menses was not known and no dating ultrasound was performed. She received prenatal care at the health center of her village, but no paraclinic investigation was carried out during her pregnancy.On November 18th, 2018, the patient gave birth to a baby boy at health center of her village. At birth, the baby had Apgar’s score of 8/10 at the first minute, 10/10 at the 5th minute, and weighed 2780 g. The patient reported that after her last delivery her abdomen had remained large as compared to previous deliveries. She also said to have noticed a gradual increase in the volume of her abdomen in the days following delivery. As she unsuccessfully went through traditional care made of decoction, 10 days after giving birth, she decided to go back to the health center of her village for consultation. From this center, she was referred to the Department of Obstetrics Gynecology at Yalgado Ouedraogo University Hospital Center in Ouagadougou, 27 days after giving birth, i.e. on December 15, 2018. At admission, she was complaining of tension-type abdominal pain and was dyspnetic. She weighed 93 kg and was 167 cm tall with a temperature of 37°2 C. On inspection, the abdomen was largely distended  was performed. This CT also showed a fluid mass with no evidence of solid components or septations Fig. . In thisWe performed a midline laparotomy from the lower abdomen up to the umbilicus Fig . that allOvarian cysts occur to 4.9% of pregnant women . Ovarian- a complication such as torsion. This torsion often occurs when the cyst has between 6 and 8 cm diameter, with almost 60% of instances happening during 10–17 weeks of gestation.- a systematic ultrasound carried out for the monitoring of the pregnancy. However, the place where our patient resided, no ultrasound was available.Imaging plays a big role in diagnosis. Compared to ultrasound, Computed tomography (CT) and magnetic resonance imaging (MRI) (which is better than CT) are the best means of analysis of the cyst , 8. In tThe differential diagnosis of an abdominal mass includes benign and malignant gynecologic and non-gynecologic etiologies. A giant ovarian cyst can provoke a differential diagnostic problem with another fluid abdominal mass. In the present case, imaging had evoked both a giant ovarian cyst and a huge mesenteric cyst. Correct preoperative diagnosis is quite difficult due to the rare occurrence or the lack of specific clinical presentation of the giant ovarian cyst. Common symptoms, due to compressive effect such as abdominal pain, distension, bloating, constipation and vomiting can arise. Before surgery, two main arguments made us to think of a giant ovarian cyst rather than a huge mesenteric cyst: the female sex of our patient, and the rarity of mesenteric cysts. In fact, mesenteric cysts are often found among the paediatric population with an annual incidence of 1 for 20,000 and are very rare in the adult population with an annual incidence of only 1 for 100,000 [The management approach depends on the size of cyst, equipment, and level of surgeon’s experience. According to many authors, aspiration of the contents of the cyst should be avoided because of complications such as infection, bleeding, rupture of the cyst, increased risk of peritoneal adhesion –13. Yet,An immediate complication to be feared when removing a giant ovarian cyst is the vacuum shock requiring a good preventive vascular filling . In the Most cysts in the gravid-puerperium period are functional and therefore benign. It is often a luteoma of pregnancy. The other ovarian cysts encountered during pregnancy are, in order of frequency, benign teratomas, mucosal adenomas, rete ovarii tumors and endometriotic cysts . A serouAfter surgery, because our patient’s cyst was benign, the long-term risks were supposed to be very reduced. Those risks are related to surgery rather than pathology. Indeed, it can be argued that the occurrence of adhesions of intra-abdominal organs is possible after surgery. Also, the ovariectomy performed may slightly reduce fertility and decrease the age of onset of menopause.This case report proves that vaginal delivery is possible in the association of giant ovarian cyst and pregnancy. Surgical management of a giant cyst was performed in the postpartum with satisfaction. This cyst, histologically, was known as benign. Indeed, for early diagnosis, a better evaluation through both clinical and systematic ultrasound, during antenatal period and intrapartum, should be encouraged even in low-resource countries.