Prenatal micronutrient supplements have been found to increase birth weight, but mechanisms for increased growth are poorly understood. Our hypotheses were that 1) women who receive lipid-based nutrient supplements (LNS) during pregnancy would have lower mean salivary cortisol concentration at 28 wk and 36 wk gestation compared to the multiple micronutrient (MMN) and iron-folic acid (IFA) supplement groups and 2) both salivary cortisol and perceived stress during pregnancy would be associated with shorter duration of gestation and smaller size at birth.Women were enrolled in the trial in early pregnancy and randomized to receive LNS, MMN, or iron-folic acid (IFA) supplements daily throughout pregnancy. At enrollment, 28 wk and 36 wk gestation, saliva samples were collected and their cortisol concentration was measured. Self-report of perceived stress was measured using questionnaires. Gestation duration was indicated by ultrasound dating and newborn anthropometric measurements  provided indicators of intrauterine growth.p = 0.039; 36 wk: β = −0.04, p = 0.037) and birth weight  but not associated with length-for-age or head circumference-for-age z-scores. Perceived stress at 36 wk was significantly associated with shorter newborn LAZ (p = 0.001). There were no significant associations with the risk of small for gestational age, preterm birth, or low birth weight.Of the 1391 women enrolled in the trial, 1372, 906 and 1049 saliva samples were collected from women at baseline, 28 wk and 36 wk, respectively. There were no significant differences in mean cortisol concentrations by intervention group at 28 wk or 36 wk gestation. Cortisol concentrations were negatively associated with duration of gestation (Baseline: β = −0.05, Maternal salivary cortisol concentration was strongly associated with birth weight and duration of gestation in rural Malawi, but these data do not support the hypothesis that LNS provision to pregnant women would influence their salivary cortisol concentrations.NCT01239693Clinicaltrials.gov identifier  Intrauterine growth restriction and shortened duration of gestation are risk factors for neonatal morbidity and mortality  and are Interventions to improve birth outcomes in LMIC have had limited success at increasing size at birth or duration of gestation. Maternal multiple micronutrient (MMN) supplements have been found to result in a small increase in birth weight of 22 g and an increase in the duration of gestation , 10. OthIn impoverished communities, malnutrition is compounded by a variety of physical and psychosocial stressors that may further compromise pregnancy. Acute or chronic psychosocial experiences  and the Despite the physiologic explanations for a normal rise in cortisol during pregnancy, higher than expected increases in cortisol and CRH concentrations have important short- and long-term negative functional consequences on the health of the pregnancy and the offspring in later life , 25. In In the present study, we aimed to evaluate 1) whether maternal cortisol concentration would be affected by nutritional supplementation starting early in pregnancy and 2) whether maternal perceived stress and salivary cortisol concentration during pregnancy are associated with smaller newborn size and shorter duration of gestation. These questions were examined within the context of a three-armed, randomized controlled trial of LNS, MMN, or iron-folic acid tablets (IFA) during pregnancy in rural Malawi. Our hypotheses were that 1) women who receive LNS during pregnancy would have lower salivary cortisol concentration at 28 wk and 36 wk gestation compared to the MMN and IFA groups and 2) both salivary cortisol and perceived stress during pregnancy would be associated with shorter duration of gestation and smaller size at birth.To evaluate these questions, we nested a substudy within the iLiNS trial in Malawi. Details of the overall study design methods and primary outcome results have been published previously . In brieA statistician independent of the research group generated randomization codes by creating four unique lists (one for each enrollment site) in blocks of nine (3 codes for each of the 3 interventions). The codes were inserted into individual opaque envelopes and eligible participants selected one from a shuffled stack of 6 envelopes. This code determined both the participant’s group allocation as well as her identification number.Based on their randomization code, women received one of three supplements to be consumed daily throughout pregnancy: 1) small quantity LNS; 2) MMN; or 3) IFA. The nutrient content for each of the supplements can be found in Table At enrollment, trained nurses confirmed pregnancies and gestational age estimates using ultrasound imagers . Study nurses were trained in ultrasound assessment by two study physicians and they conducted all measurements in duplicate. Anthropometrists measured in triplicate maternal height using a stadiometer , weight using a flat scale , and mid-upper arm circumference (MUAC) using a non-stretchable tape . Research nurses tested for malaria using rapid diagnostic tests , haemoglobin concentration , and HIV . Positive HIV tests were repeated using another whole blood antibody test .During a follow-up home visit, trained interviewers asked mothers about demographic and socioeconomic characteristics, including questions on household food insecurity. Mothers were asked to return to the clinic for repeat visits at 32 and 36 wk gestation. A follow-up home visit was also conducted at 28 wk gestation. At enrolment, 28 wk, and 36 wk gestation, interviewers asked women about stress during the previous month using the 10-item Perceived Stress Scale , a tool The research nurses collected saliva samples during the clinic visits at baseline and 36 wk gestation and during the 28 wk home visit between 8 am and 4 pm after a 30 minute fast. Time of collection, time of waking, and time of last food or drink were recorded by the nurse. Saliva collection occurred before any other measurements or sample collection. Nurses asked each woman to place an inert polymer cylindrical swab  under her tongue for approximately two minutes, while moving her tongue and jaw as if she were chewing to stimulate saliva. The woman removed the swab and placed it in a capped tube and then it was refrigerated or placed on ice packs. Swabs were brought to room temperature, then centrifuged for 15 min at 3,000 RPM (1500 x g) to extract saliva, which then was frozen at −20 °C. After a maximum of 2 days, samples were transferred to a −80 °C freezer for longer term storage. Samples were shipped to Davis, CA for analysis. Lab technicians measured cortisol concentrations in duplicate using an ELISA method , which can detect cortisol concentrations ranging from 0.193 to 82.77 nmol/L (0.007-3.0 μg/dL). The intra- and inter-assay coefficient of variability is 3.5 % and 5.1 %. The mean of each duplicate measure was used for analysis.Research nurses collected venous blood samples at baseline and 36 wk gestation using 7.5 mL trace mineral-free syringe . Lab technicians measured zinc protoporphyrin in washed red blood cells within 30 hr of collection using a hematofluorometer . They also measured soluble transferrin receptor, c-reactive protein (CRP), and alpha-1-acid glycoprotein (AGP) by immunoturbidimetry on the Cobas Integra 400 system .Research assistants measured infants’ weight as soon as possible after birth either at home or in the health center. Of the recorded birth weights, 89 % were measured within 48 h of delivery while the remainder were back-translated from a measurement within 14 days. They also collected early neonatal measurements, including length to the nearest 1 mm using an infantometer , weight to the nearest 10 g using an infant scale , head circumference and arm circumference using non-stretchable tape.Women provided written informed consent or indicated their consent to participate in the study with a thumbprint. In Malawi, individuals ≥15 y are able to provide consent themselves and so parental consent was not obtained. The institutional review boards at the College of Medicine Research and Ethics Committee (COMREC), University of Malawi and the Ethics Committee of Pirkanmaa Hospital District, Finland reviewed and approved the trial protocols at all of the hospitals and health facilities.Sample size estimates for the main trial were calculated to be 370 per group, based on an effect size (difference between groups divided by the pooled SD) of 0.23, assuming a two-sided α = 0.05 and β = 0.2. That would correspond to a detectable difference of 0.83 nmol/L in cortisol and a 1.2 point difference in the perceived stress score (PSS). We used standard scoring methods to calculate the PSS . We checWe used the Household Food Insecurity Access Scale  to estimFor all analyses, participants were included if they had non-missing data on either cortisol or the perceived stress score at any time-point. We compared characteristics for those with complete data vs. those who were missing data on cortisol at 28 wk gestation. We also compared baseline characteristics between women in each of the three intervention groups.p-values <0.05 were considered statistically significant. We considered covariates for inclusion in the model if they were significantly (p < 0.1) associated with salivary cortisol. These included baseline cortisol, age, gestational age, maternal BMI and height, season, malaria infection, HIV status, hemoglobin, iron status, inflammatory markers, household food insecurity, asset index, parity (primiparous or multiparous), infant sex, site of enrollment, and maternal PSS. We included time since waking and time since last meal in all models, regardless of their association with the outcome variables. Interaction terms were created by the cross product of the intervention group and maternal age, parity, baseline BMI, and infant gender and these were evaluated in linear regression models. Interaction term p-values <0.1 were considered to be statistically significant.To evaluate the effect of the nutritional interventions on cortisol and PSS, we tested group-wise differences using ANOVA and ANCOVA models, using the Tukey-Kramer adjustment for multiple comparisons, and To examine the associations between cortisol or PSS and birth outcomes , we used linear regression models and present standardized regression coefficients. We used Poisson regression models with robust estimation of the standard errors to estimate relative risk for dichotomous birth outcomes, including preterm birth (<37 wk gestation), low birth weight , stunting (LAZ < −2), small head circumference (HCZ < −2), and small for gestational age . We consMissing data were considered in two ways. We first compared baseline characteristics between those with complete data and those with missing data. Secondly, we imputed missing values  for 28 wOf the total of 1391 women enrolled in the trial, 1372 women had baseline data on cortisol concentration and PSS. Baseline characteristics of women in the three intervention groups are shown in Table n = 883) vs. those with missing data at 28 wk (n = 477 women), the time point with the highest rate of missing data. We found that women with complete data were less likely to be anemic . Other characteristics, such as age, baseline cortisol, education, BMI, HIV status, prevalence of primiparity, and malaria at enrollment were generally similar between those in the analytical sample compared to those with missing data. We repeated this comparison for those with missing 36 wk data (n = 342) and found no significant differences compared to those with complete data.There was some loss to follow-up or missing data on cortisol or PSS at baseline, 28, and 36 wk gestation Fig. , but misp = 0.032) with the highest concentration in the IFA group (6.1 ± 4.7 nmol/L) compared to 5.4 ± 3.0 and 5.5 ± 3.3 nmol/L in the MMN and LNS groups, respectively , but when the model was further adjusted for CRP and AGP, the point estimate was attenuated and the difference was no longer statistically significant (p = 0.066). Cortisol concentration was not found to be associated with newborn WAZ, LAZ, or HCZ at any time point, however. There was less of a consistent relationship between PSS and birth outcomes. Perceived stress at 28 wk and 36 wk was not associated with duration of gestation but the 36 wk measure was significantly associated with shorter newborn LAZ (p = 0.001). No other associations were significant.In this sample, the mean birth weight was 2971 SD 445) g, birth length was 49.7 (SD 2.2) cm and duration of gestation was 39.4 (SD 2.1) wk. Salivary cortisol concentration was associated with a number of birth outcomes in this study population. Higher cortisol concentration at enrolment and 36 wk gestation, but not at 28 wk gestation, was associated with a shorter duration of gestation in crude and adjusted models . There was a relatively consistent association between higher cortisol at 28 wk or 36 wk gestation and an increased risk of LBW. Those with a cortisol concentration in Q3 or Q4 had a roughly 2-fold increased risk of LBW compared to those in the lowest quartile. Cortisol concentration was not significantly associated with SGA in adjusted models. Finally, we also examined the association between PSS dichotomized into high vs. low using a median value cutoff. High PSS at 36 wk gestation was associated with a 71 % higher risk of newborn stunting , but was not significantly associated with the other birth outcomes (data not shown).We also examined the association between cortisol categorized into quartiles and dichotomous birth outcomes Table . Here wep = 0.034). Among multiparous women, there was no difference in birth weight with increasing cortisol concentration; however, among primiparous women, cortisol concentrations in the 3rd or 4th quartile were associated with lower mean WAZ at birth .The present study tested the hypothesis that the provision of LNS would alter maternal salivary cortisol concentrations during gestation, and evaluated the associations between biologic markers of stress response or perceived stress during pregnancy and birth outcomes. Our results did not support the primary study hypothesis; we observed no association between LNS exposure and cortisol concentrations during mid- to late gestation and so we conclude that there was no effect of the intervention. In this study population, cortisol concentration at varying points during gestation was associated with duration of gestation, birth weight, and risk of LBW, but not risk of SGA. We also found that a woman’s report of perceived stress in the past month was associated with a modest increase in the risk of newborn stunting.2 and 45 % were between 18–25 y, salivary cortisol concentrations did not differ between intervention groups overall. However, there was evidence of an interaction with maternal age whereby maternal cortisol concentrations were 1.06 nmol/L lower among younger women (<25 y) in the LNS group compared to similarly aged women in the IFA control group [2 and approximately 30 % were <19 y, maternal serum cortisol concentrations were marginally lower by 1.32 μg/dL (p = 0.062) in the MMN group relative to the vitamin A control group [2).Our intervention effect results are similar to recent results from a trial in Ghana and two trials in Burkina Faso , 48, butol group . This diol group  during pol group . In the 2) at enrollment during early pregnancy. An alternative explanation is that the nutrients provided by LNS or MMN were insufficient to alter maternal cortisol concentrations. In this trial, there was no overall significant effect of LNS or MMN on duration of gestation or newborn anthropometric indicators [There are a number of possible explanations for why there was no impact of the supplements on maternal cortisol concentrations in this study but some apparent differences between groups in the other four trials, either in main or subgroup analyses. First, it is possible that nutrient deficiencies may not have been severe enough in our study setting to serve as a trigger for elevated maternal cortisol concentration as was seen in the Nepal trial. Maternal underweight was relatively uncommon in the Malawi study population, where only 5 % of women had low BMI (<18.5 kg/mdicators , althougdicators , 13. Botdicators , 49. A tdicators , so elevdicators , which iWe found that there were strong associations between maternal cortisol concentrations at some time points during pregnancy and birth weight or duration of gestation, and that the association with birth weight was strongest among primiparous women. Associations were attenuated with adjustment for CRP and AGP, which suggests that infection or inflammation were related to this relationship, either as confounding or mediating factors. There was no association with the risk of SGA, which suggests that the observed differences in birth weight were likely due to the earlier timing of birth, rather than due to intrauterine growth restriction. Late gestation perceived stress was also associated with lower newborn length. These findings are consistent with a number of other studies, including the Ghanaian and Nepali trials described above. Numerous studies have reported an association between maternal cortisol or psychosocial stress during pregnancy and adverse birth outcomes, primarily shorter duration of gestation, the descriptions of which can be found in a number of well-written reviews , 17. OurStrengths of the present study include the large prospective design with multiple measures during pregnancy and generally high rates of follow-up. Imputation of missing data did not substantially change the interpretation of the main findings. The randomized controlled trial design reduced the potential for confounding and bias in the analysis of the effects of the maternal supplements and cortisol concentrations during pregnancy. Unfortunately, resource constraints limited our ability to measure CRH and logistical constraints in the field limited our ability to highly control the timing and sampling protocols for salivary cortisol. Cortisol follows a strong diurnal pattern and is responsive to recent events. While we attempted to control for this by standardizing the timing of the sample collection during the course of the clinic visit, we were not able to control the timing of arrival of the participants. Thus, the samples were collected throughout the day and we adjusted for time since waking and time since last meal in all of our analyses. Ideally, one would collect multiple samples at standardized times over the course of the day and/or before and after an HPA challenge ; howeverWe did not observe an effect of maternal supplementation with LNS or MMN on cortisol concentrations in late gestation among Malawian women. Nevertheless, we found that maternal cortisol concentrations were strongly associated with newborn anthropometric measurements and duration of gestation, reiterating findings from studies in other populations regarding the importance of this hormone for pregnancy outcomes.


T) to achieve gas exchange.If infants fail to initiate spontaneous breathing, resuscitation guidelines recommend respiratory support with positive pressure ventilation (PPV). The purpose of PPV is to establish functional residual capacity and deliver an adequate tidal volume (V2), VT, and rate of carbon dioxide elimination (VCO2) to assess lung aeration in preterm infants requiring respiratory support immediately after birth.The aim of our pilot study was to measure changes in exhaled carbon dioxide  or PPV immediately after birth had V2 values during the first 10 min after birth compared to infants receiving PPV (n = 20) . At 10 min no significant difference in ECO2 values was observed. VT was lower in the CPAP group compared to the PPV group over the first 10 min ranging between 5.2–6.6 vs. and 7.2–11.3 mL/kg (p<0.05), respectively.Fifty-one preterm infants (mean (SD) gestational age 29 (3) weeks and birth weight 1425 (592 g)) receiving respiratory support in the delivery room were included. Infants in the CPAP group (n = 31) had higher ECOT and ECO2 potentially optimize lung aeration without excessive VT administered.Immediately after birth, spontaneously breathing preterm infants supported via CPAP achieved better lung aeration compared to infants requiring PPV. PPV guided by V To our knowledge, there is no information available regarding the changes in lung aeration after birth in preterm infants who are given CPAP or PPV as respiratory support at birth. The aim of this pilot study was to examine ECO2 and VT changes in preterm infants either supported by CPAP or requiring PPV within the first 10 minutes after birth. In addition, we examined the rate of carbon dioxide elimination (VCO2) and minute ventilation. We also report the associated changes in hemodynamic and cerebral oxygenation parameters, which were recorded during the resuscitation of these preterm infants.In utero the airways are liquid-filled and the lungs take no part in gas exchange, which occurs across the placenta This study was carried out at The Royal Alexandra Hospital, Edmonton, a tertiary perinatal center admitting more than 350 infants with a birth weight of <1500 g to the neonatal nursery annually. The Royal Alexandra Hospital Research Committee and Health Ethics Research Board, University of Alberta approved the study and parental consent was obtained to use the recordings. Infants <37 weeks post menstrual age and who were judged clinically to have inadequate breathing in the first minutes after birth were eligible for the trial. Infants were excluded if there was uncertainty about their gestational age or if they had a congenital abnormality that might adversely affect their breathing. Between March and July 2013, 70 deliveries of infants <37 weeks gestation were attended by the research team in addition to the Resuscitation-Stabilization-Triage team . The research team was not involved in the clinical care of the infants.2O and PEEP of 6 cm H2O. Local protocol dictated predefined intubation criteria if chest compressions were required, HR remained <100 despite 60 sec of PPV, or prolonged PPV of >10 min. The clinical team adjusted PIP, PEEP or fraction of inspired oxygen according to the infant’s need. All practitioners attending deliveries were trained in the use of equipment and in the Neonatal Resuscitation Program resuscitation protocol. In addition, all members of the neonatal resuscitation team are trained to use VT and ECO2 monitoring and have experience and education with MRSOPA Cord clamping was routinely performed for 60 sec after delivery unless the obstetric team noted contraindications . Respiratory support was provided with a T-piece  – a continuous flow, pressure-limited device with a built-in manometer and a positive end expiratory pressure (PEEP) valve. The default settings used were a gas flow of 8 L/min, peak inflation pressure (PIP) of 24 cm HT, airway pressure, and ECO2 were continuously measured with the NM3 cardiopulmonary management monitor . Airway pressure and gas flow were measured using fixed orifice differential pressure pneumotachometer. The NM3 calculates VT by integrating the flow signal, the minute ventilation (MV) by integrating VT and respiratory rate, and ECO2 using a non-dispersive mainstream infrared absorption technique. ECO2-value represents the peak value  during expiration. In addition, the NM3 also measures carbon dioxide elimination (VCO2). According to the manufacturer the accuracy for the gas flow is ±0.125 L/min and for ECO2 ±2 mmHg and the dead space of the flow sensor is ∼1mL.Gas flow, VIntelliVue MP50  monitors were used to continuously record HR, arterial oxygen saturation, and blood pressure. A Masimo Radical pulse oximeter  probe set at maximum sensitivity and two-second averaging was placed around the infant’s right wrist to measure oxygen saturation 2). The transducer contains a single light emitting diode and two sensors that measure pooled hemoglobin saturation within two different tissue paths. The Invos Cerebral/Somatic Oximeter Monitor calculates the crSO2, which is expressed as the percentage of oxygenated hemoglobin . The transducer was positioned on the left fronto-parietal forehead and secured with a wrap in each infant, regardless of mode of delivery. The clinical team was able to observe all monitors; only the alarms at the NM3 and Invos Cerebral/Somatic Oximeter Monitor were disabled to avoid distraction of the clinical staff by research measurements.An Invos Cerebral/Somatic Oximeter Monitor  with the neonatal sensor was used to measure cerebral regional tissue oxygen saturation . HR, oxygen saturation, oxygen requirements, and crSO2 were recorded for the first 30 min after birth. Blood pressure was measured every minute for the first 15 minutes, at 20, 25, and 30 min.Data collection started immediately after the baby was transferred to the resuscitation unit. In infants receiving delayed cord clamping (n = 29) data collection started around 90 sec after birth and infants without delayed cord clamping (n = 22) data collection started at around 30 sec after birth. All variables were stored continuously in a multichannel system “alpha-trace digital MM”  for subsequent analysis. Values of gas flow, VT, and ECO2 was performed and expired VT, airway pressure, gas flow, and ECO2 of all breaths and inflations were measured. In the PPV group respiratory parameters measured for spontaneous breaths and inflations were recorded. Mask leak was corrected for body temperature, pressure and water vapor saturation using a standardized equation. Spontaneous breaths and inflations with a mask leak >30% were excluded from further analysis as these could underestimate the expired VT and ECO2 values. The data are presented as mean±standard deviation (±SD) for normally distributed continuous variables and median (interquartile range (IQR)) when the distribution was skewed. For all respiratory parameters, the median value for each infant was calculated first and then either the mean or median of the median calculated for parametric and non-parametric data, respectively. Data were compared using Student’s t-test for parametric and Mann-Whitney U test for nonparametric comparisons of continuous variables, and χ2 for categorical variables. P-values are 2-sided and p<0.05 was considered statistically significant. Statistical analyses were performed with Stata .Demographics of study infants were recorded. A breath-by-breath analysis of airway pressure, gas flow, VA total of 51 preterm infants (31 received CPAP and 20 received PPV) were included in the study. 19 infants did not require respiratory support at birth and were excluded from the analysis. The demographics of the studied infants are displayed in 2 values (except at 5 and 10 minutes) compared to infants requiring PPV (T was significantly lower in the CPAP group compared to the PPV group over the first 10 minutes (except at two minutes)  . Minute minutes) . In the er birth .2O and 6.5 (5.6–7.3) cm H2O (p = 1.0), respectively, and PIP in the PPV group was 24.7 (23.3–27.9) cm H2O.In the CPAP group infants had a median (IQR) respiratory rate of 39 (32–50) breaths per min and in the PPV group 41 (30–49) inflations per min (p = 1.0). PEEP in the CPAP and PPV group was 6.2 (5–6.6) cm HChanges in HR over the first 10 min after birth were similar between groups . More in2 levels after birth, indicating lower lung aeration. We also observed a worse cerebral oxygenation. We infer that the lower ECO2 levels represent a delay in establishing FRC. This inference is supported by the observation that at 25 to 30 minutes of age, the PPV group had higher oxygen requirements , which potentially confounds the interpretation of SpO2, crSO2, HR measurements. In addition, we did not examine different breathing patterns to assess their impact on lung aeration, which is a limitation of the current study. A correlation of ECO2 values with the gold standard an arterial blood gas would have added to our manuscript, however this is not possible with the observed time frame. Although, end-tidal CO2 and arterial partial CO2 pressure are closely correlates in the neonatal intensive care unit 2 measurements are dependent on percentage of mask leak and airway obstruction, which are common problem during mask PPV 2 values, which is a strength of the current study. The added dead space of the flow sensor potentially increases CO2 rebreathing, however the dead space is ∼1 mL and we did not observe any CO2 rebreathing. There are an increasing number of monitoring devices introduced into the delivery room Although infants in the CPAP group were significantly older and heavier and therefore were likely to have more mature lungs, we believe that our results demonstrate that ECO2 values despite lower VT throughout the first minutes after birth, suggesting improved lung aeration, compared to infants receiving PPV for respiratory support. Measuring ECO2 has the potential to assess lung aeration and to guide respiratory support after birth. Future delivery room studies should assess how newborn infants achieve lung aeration in detail and future trials should try to mimic the infant’s technique, which might have the potential to reduce short- and long-term outcomes in preterm infants.Infants who breathe spontaneously have higher ECO


We describe a case of a lingual thyroglossal duct cyst diagnosed prenatally by ultrasound at 26 weeks of gestation. The follow-up ultrasound scans revealed no changes in the cyst measurement. Surgical treatment was performed without any complication 72 hours after delivery with good results. Thyroglossal duct anomalies are the most common malformation in the neck –7; they Lingual presentation is uncommon. Published papers describe this type of presentation from 2.1 to 8% , 4, 7 anIt is important to make a differential diagnosis with other anomalies. When prenatal diagnosis is made, a follow-up to detect cyst growth is recommended and its final size and characteristics will determine the mode of delivery.A 24-year-old primigravida with a singleton pregnancy was referred to our center because of the finding of an oral cyst diagnosed during a routine ultrasound at 26 weeks of gestation.The medical history of the parents was unremarkable and they were nonconsanguineous.The first and second trimester scans performed at 12 and 20 weeks of gestation in another center were normal.Ultrasounds were performed using a GE Voluson 730 Expert.The initial examination performed at 28 weeks of gestation showed a single male fetus with an oral cystic lesion of 18 × 10 mm, located under the tongue. The tumor appeared to be fluid and homogeneous, without solid components, with well-defined limits and it moved with the tongue movements. The most likely diagnosis with that ultrasound appearance was a congenital ranula or a thyroglossal duct cyst.The fetal anatomic study found no other abnormalities, except a left renal pelvic dilatation of 7.3 mm; fetal biometric parameters and amniotic fluid index were normal .Follow-up ultrasound scans performed every 2 weeks always showed appropriate fetal growth (75–90 percentile) and a normal amniotic fluid index. There were no changes in the measurements of the oral cyst and the most striking finding was that the fetus kept his mouth open during all examinations .Fetal magnetic resonance imaging was performed at 31 weeks and revealed a moderate left renal pelvic dilatation and an orofacial lesion of 18 × 14 mm located before the free edge of the tongue and above the lower lip, with cystic characteristics and the same echogenicity as the amniotic liquid, without evidence of fat or signal diffusion restriction. That image could correspond with a cyst probably dependent on the salivary glands .At term, the oral tumor did not show any changes in measurements and characteristics, there was no evidence of polyhydramnios, and the stomach was visible; we also could see complete tongue movements and we occasionally observed that the fetus was able to close his mouth.We discussed the mode of delivery in this case with a multidisciplinary team of pediatrics, anesthesiologists, and obstetricians and we decided to try a vaginal delivery in the first place, as the tumor did not seem to compromise the fetal airway.Labor was induced at 40 weeks and a normal 4300 g male was born by caesarean section performed by failure to progress in labor. The Apgar score was 10/10 at 1 and 5 minutes of life.The neonatal examination showed that the oral tumor was under the tongue with the same measurement seen at the intrauterine scans, without airway or digestive compromise, and the newborn did not require immediate admission to neonatal care unit .72 hours after birth, the infant was admitted to the neonatal care unit due to a decrease of 600 g of weight and for excision of the cyst with a suspected diagnosis of congenital tongue mucocele. This procedure was performed without any complications and pathological definitive diagnosis was persistent thyroglossal duct of the tongue. Postoperative course was normal.At the first medical examination when the infant was one month old, he had an adequate growth, uncomplicated breastfeeding and he was able to close his mouth completely.The follow-up by endocrinologists at 4 and 8 months of life was normal. It included an ultrasound of the neck and thyroid gland and thyroid hormone determinations to rule out any aberrant thyroid tissue in other locations.Thyroglossal duct anomalies might not become evident until adult life  and theyThe thyroid gland appears in the third week of life as a well-defined endodermal sac between the first pair of pharyngeal pouches, attached to the pharynx by a narrower neck known as thyroglossal duct, which connects the primitive thyroid with the tongue temporarily. At six weeks this canal becomes solid and disappears. When this degeneration process does not occur, the partial or total persistence of the thyroglossal duct can result in fistulas or cyst formation .The typical location for this type of cysts is the cervical midline. The lingual thyroglossal duct cysts are often located on the tongue base and its anterior presentation is poorly described in the literature , 10, 11.Prenatal diagnosis of congenital head and neck masses is becoming more frequent with the improvement of ultrasound technology although it can be difficult to establish the etiology, which often is done by the histological exam. The magnetic resonance imaging can help us to know the precise location and extension of the tumor and so contribute to a better evaluation of the case.Once the diagnosis is done, it should be necessary to monitor the cyst size, its mobility, and the amniotic fluid volume because a rapid tumor growth could hinder fetal swallowing and produce polyhydramnios, which increases the possibility of preterm delivery or sudden infant death by asphyxia if it is misdiagnosed , 11, 14.The mode of delivery should be planned by a multidisciplinary team , 14 alwaIn the differential diagnosis, we must consider other formations such as congenital ranula, which was our suspected diagnosis, submandibular duct anomalies, and heterotopic gastric cysts . In the In the present case, the suspected pre- and postnatal diagnosis were a congenital ranula, because of the characteristics of the cyst, its mobility, and its location under the tongue and not on its base that is the usual location for the thyroglossal duct cyst.The neonatal prognosis is usually good and uncomplicated and it depends on the tumor size, as shown in this case. An immediate excision after delivery could be required in cases of large cysts that block the newborn's airway or make the breastfeeding difficult.A follow-up of these children by pediatrician and endocrinologists to test the thyroidal function is recommended.The thyroglossal duct cyst of the tongue is an unusual finding. When a prenatal cyst in the oral cavity is diagnosed, an adequate follow-up is necessary to assess the size and growth potential of the cyst and possible associated complications. According to this, the mode of delivery will be decided, as well as the need for immediate action to ensure the airway of the newborn after delivery. Definitive diagnosis is achieved after histological study.


Elephas maximus). We categorise birth month into stressful vs. not-stressful periods based on longitudinal measures of glucocorticoid metabolites in reproductive-aged females, which peak during heavy workload and the start of the monsoon in June-August. Females born in these months exhibit faster reproductive senescence in adulthood and have significantly reduced lifetime reproductive success than their counterparts born at other times of year. Improving developmental conditions could therefore delay reproductive ageing in species as long-lived as humans.Senescent declines in reproduction and survival are found across the tree of life, but little is known of the factors causing individual variation in reproductive ageing rates. One contributor may be variation in early developmental conditions, but only a few studies quantify the effects of early environment on reproductive ageing and none concern comparably long-lived species to humans. We determine the effects of ‘stressful’ birth conditions on lifetime reproduction in a large semi-captive population of Asian elephants ( Cervus elaphus)Strix aluco)Tamiasciusus hudsonicus)Whilst senescent declines in reproduction as well as survival are now evident across taxa35678The one long-lived species studied in detail are humans. Extensive evidence from humans shows that conditions experienced during early development have profound effects on metabolism and later-life health as well as reproductive outcomes such as age at menopause. For example low birth weight is related to a wide range of outcomes including higher risk of diabetesLoxodonta africana)Here we use a unique longitudinal (born 1941–2014) dataset of Asian elephants employed in the Myanmar timber industry with life histories approximating wild rather than zoo animals2223242728i) measured the stress level variation in reproductive-aged females, we then characterised “high stress” and “low stress” periods using the physiological marker of faecal glucocorticoid metabolites, rather than proxies such as climatic season or exposure to workload. Based upon these newly defined variables marking poor and more amenable birth conditions, we then (ii) linked this to differences in reproductive ageing rates of daughters, and (iii) finally added all those effects up to quantify consequences on lifetime reproductive performance. We hypothesise that being born at the time of year in which elephants are most stressed could be associated with long-term effects on the reproductive success of females and their pattern of reproductive senescence3In this study, we first . This ‘high stress season’ corresponds to return to work after the annual 3-month rest period and overlaps with the monsoon season (late June-October). These results corroborate our findings showing that birth rates across several decades have consistently been at their lowest during these months and that any resulting calves have lower survival prospects to independenceOur analyses reveal first a clear pattern of seasonal variation in maternal stress levels. We analysed glucocorticoid metabolite concentration in non-invasively collected fecal samples from non-pregnant non-lactating reproductive-aged (17–55 years) females  for a complete annual monsoon cycle  shown to2(d.f.=1) = 6.07, P = 0.014, 2(d.f.=1) = 8.96, P = 0.0028, 2(d.f.=1) = 0.03, P = 0.863). This is also the case for the effect of maternal age  = 8.79, P = 0.0030, 2(d.f.=1) = 0.22, P = 0.636). Furthermore, interactions between birth order and birth season and maternal age and birth season did not improve the fit of models and were therefore discarded (likelihood ratio tests for models with and without the interaction term for birth order and birth season Χ2(d.f.=1) = 1.76, P = 0.184 and for the interaction between maternal age and birth season Χ2(d.f.=1) = 0.276, P = 0.599). This suggests that the effect of birth season on female reproductive pattern in adulthood is unlikely to be confounded by only certain type of mothers  reproducing at the first place during the high stress season, leading to their daughters showing lower performance in adulthood. Notably, when we repeated these analyses based on “high stress” conception season, there was no significant interaction between conception season and age on reproduction (likelihood ratio test for models with and without interaction between conception season and stress Χ2(d.f.=1) = 0.253, P = 0.615 Second, birth during this ‘high stress’ season has a strong effect on age-related female reproductive success. In general, females had low probabilities of reproducing between 5–16 years, followed by a steep increase to age 24 and a slow decline . However2(d.f.=1) = 7.98, P = 0.005). This difference does not appear to be attributable to differences in failure to reproduce at all in a lifetime (effect of birth season Χ2(d.f.=1) = 1.37, P = 0.24). Rather, it is due to the faster decline in reproduction from the age of 24 among females born in the ‘high stress’ season, with the probability of reproduction declining by 2.2% during each 3-year period in ‘high stress’-born females, compared to only 0.73% in those born in the rest of the year.Initially, ‘high stress’-born females have somewhat higher probability of reproducing at the peak age of 24 (mean ± SE = 0.46 ± 0.064) than those born at other times of year (0.34 ± 0.024), but this was not statistically significant . However, due to their faster reproductive senescence, females born in the ‘high stress’ season had 15.9% fewer calves in their lifetime than those born in the rest of the year . Our additional analyses show that individuals conceived in the “high stress” season (and experiencing it again 12 months into gestation) do not experience a difference in the pattern of reproductive senescence similarly as those born during the “high stress” season do. This supports the idea that the window in development in which the effect of “high stress” season occurs may be later in pregnancy, in collaboration of studies e.g. in humans that have reported the largest effect of poor prenatal developmental conditions on outcomes such as glucose tolerance during later rather than earlier stages of pregnancy, although other effects such as coronary heart disease and obesity are associated with early gestation exposureRecent experimental studies on rodent models have focused on determining the windows during development that are most sensitive to environmental disturbances and lead to downstream effects on different outcomes. Such studies have shown, for example, that exposure to maternal stress early in gestation in lab rats has no or little effect on offspring hypersensitivity to glucocorticoidsRegardless of the mechanism, our key conclusion is that annually fluctuating conditions linked to time of birth appear to be associated with reproductive rate decades later and are an important source of variability in this population. Such findings are of interest in the light of findings from another long-lived aseasonal breeder, humans, showing significant differences between individuals in longevityMore generally, our results suggest that improving developmental conditions could delay reproductive ageing in a species as long-lived as humans, but with a different pattern of reproductive ageing that appears not to include menopauseOur results are also of interest in the light of recent literature on the potential benefits of poor early life conditions in certain situations. For example, prenatal caloric restriction has been found to be correlated with changes in metabolic phenotype such as altered metabolism of glucose and insulin as well as changes in body composition such as central adiposity and reduced muscle mass1153in situ captive elephants of 16,000in utero, with the possibility of high resource availability months falling at different stages of development3128Asian elephants are recognised as endangeredMyanmar has the largest remaining population of captive elephants worldwide numbering approximately 5,000 individuals. In Myanmar, elephant draught power has been utilised extensively in timber harvesting for over a century57For our analyses, we utilise a unique and extensive demographic dataset detailing the life histories of the timber elephant population of Myanmar for nearly a century. These data have been compiled using the elephant logbooks and annual extraction reports archived and maintained by the Extraction Department of Myanma Timber Enterprise. The state ownership of thousands of elephants makes it possible to compile and transfer data of all registered elephants from the individual based-logbooks to a database. The data recorded for each individual include: registration number and name; origin (wild-caught or captive-born); date and place of birth if captive-born or place and time of capture if wild-caught; mother’s registration number and name if captive-born; year; dates and identities of all calves born; date of death or last known date alive; and cause of death. The elephants have never been culled, released or sold and are kept through their lives even if they are unable to work or reproduce, ensuring that our sample is not biased towards the most healthy or reproductive individuals. Only basic veterinary care is available , and the survival of the elephants is close to survival rates observed in wild populations20This study uses only records of captive-born mothers and their offspring because precise date and place of birth are known for these individuals and because methods of capture are associated with reduced later fitness in wild-captured elephants606121 = 55.18, P < 0.001). These months will therefore be characterised as the high stress season in further analyses.In order to determine the high stress months in reproductive-aged female elephants, and to investigate the association between birth in the high stress season and reproductive senescence, we collected longitudinal faecal sample data for within-individual hormone variation analysis (glucocorticoid metabolite concentration). We took samples on a monthly basis for 12 months from 37 female MTE elephants aged 17-55 from December 2011 to November 2012. We used non-pregnant rather than pregnant females to measure the variation in glucocorticoid metabolites experienced by potential mothers, rather than pregnant individuals whose hormone profiles are likely to be affected by pregnancy. Furthermore as cows are only determined to be pregnant using visual and behavioural cues, they could be at different stages of pregnancy when diagnosed, thus preventing any characterisation of the conditions that their foetuses would have experienced around conception. We also tested the variation of these metabolites in other age and sex classesFirst, we characterised curves of age-specific reproductive rate in order to determine when senescence begins. We analysed reproductive senescence by implementing logistic regression models as generalised linear mixed effect models to predict the probability of reproduction  for each 3-year observation period in an elephants life from the earliest recorded reproductive age (5 years) onwards, sample sizes for each age bin ranged from 1,078 in the earliest (age 5–7 years) to 38 in the last (age 47–49 years)  and GLMMs were implemented using the package lme4 .For all models, we restricted our dataset to individuals for which all variables were available, leading to a total of 6,483 elephant-three-year observations from 1,078 elephants, among which 1,127 reproduction events were recorded. Of these elephants, 832 did not die before the end of the study period (see above for treatment of censoring in the models). We used precisely known ages at last observation to account for differences between censored and dead individuals according toWe determined the shape of the age function by comparing candidate GLMMs using AIC. First, we fitted a null model without age terms and models with linear, quadratic and cubic age terms . We thenThe best-supported final model describing age-related variation in reproduction included two age thresholds  at 15 anTo determine the lifetime fitness consequences of birth season, we investigated the effect of birth season on (a) probability of reproduction throughout life and (b) the total number of calves born to a female in her lifetime. First, we used GLMMs with a binomial error structure with a binary response variable to investigate whether or not a female ever reproduced, where 0 = produced no offspring across life and 1 = produced at least one offspring. Next, we used GLMMs with a Poisson error structure to analyse data on lifetime reproductive success. In each model, we were chiefly interested in the binary explanatory variable of whether the focal females was born in the high stress season  or not (0). We controlled for cohort effects (birth decade as a factor with 5 levels), age at last sighting (modelled as a linear and quadratic term), whether an individual was censored or not (a binary variable where 0 = not censored and 1 = censored) and random terms to take into account individual variation  and regional variation (region as a factor with 10 levels) in all models. We used the full dataset (n = 1078) in both models .How to cite this article: Mumby, H. S. et al. Elephants born in the high stress season have faster reproductive ageing. Sci. Rep.5, 13946; doi: 10.1038/srep13946 (2015).


Teenage pregnant women are at risk of having low birth weight and preterm birth babies. The additional psychosocial interventions are thought to improve these outcomes for teenage pregnancy. However, the effect of additional psychosocial intervention programs on those is uncertain. The aim of this meta-analysis is to assess the effects of additional psychosocial interventions for teenage pregnancy on low birth weight and preterm birth outcomes.Search strategy: Relevant studies were identified from Medline, CINAHL, and Scopus since initiation to November 2013.Selection criteria: Randomized controlled trials investigating the effect of any psychosocial intervention on low birth weight and preterm birth were included.Data collection and analysis: Two reviewers independently assessed the quality of each study and extracted outcomes including rate of low birth weight, preterm birth rate, mean gestational age at delivery and mean birth weight. Standardized mean difference and DerSimonian-Laird method were applied for pooling continuous and dichotomous outcomes, respectively.The five studies with 712 teenage pregnant women were included. Compared with routine antenatal care, the psychosocial intervention significantly reduced risk of low birth weight by 40% . For the preterm birth, the psychosocial intervention reduced risk of preterm birth by 33% with no statistical significance . The pooled result for birth weight showed that our infants in the intervention group are slightly heavier than those of control group with statistical significance . Gestational age at delivery of intervention group was slightly increased than those of control group with no statistical significance .The additional psychosocial support to teenage pregnant women can improve pregnancy outcomes including low birth weight and birth weight. The variation in the intervention and risk of bias within included studies may limit this conclusion.


It is found that the lattice structure and crystalline morphology of CaCO3 can be tailed by the electric field applied to the solution during its crystallization. The calcite structure with cubic-like morphology can be obtained generally without electric field, and the vaterite structure with the morphology of nanorod is formed under the high electric field. The vaterite nanorods can be piled up to the petaliform layers. Both the nanorod and the petaliform layer can have mesocrystal structures which are piled up by much fine units of the rods with the size of several nanometers. Beautiful rose-like nanoflowers can be self-arranged by the petaliform layers. These structures can have potential application as carrier for medicine to involve into metabolism of living cell.The role of electric field is investigated in determining the structure, morphology, and crystallographic characteristics of CaCO Electric field is ubiquitous in nature. It causes the phenomena as great as thunder and lightning or even as fine as the electrostatic interaction among atoms or molecules. It was proposed that the earliest organic compound to biomolecule was produced in the ancient sea on the earth under high electric field, i.e., thunder and lightning . The car3 is one of the standard model systems because of its abundance in nature, participation in the formation of a certain geologic structure as Karst cave, association with biological calcium metabolism, its important industrial applications. Crystallization and morphological control of CaCO3 have attracted extensive attention for decades [3 nanostructures synthesized under the high electric field from solution is investigated and found that they are much different from those without electric field.CaCO decades –23. Much2  was dissolved in 10 ml absolute ethanol  and then transferred into a syringe as injecta. 2.76 gK2CO3  was dissolved in 200-ml deionized water in a stainless steel vessel as a base solution. The vessel was linked to the ground of high voltage power serving as a counter electrode. The syringe was fixed on the ejector jet pump. The syringe nozzle was linked to a perfusion tube, which the other end was fixed on an entry needle. The entry needle simultaneously served as an electrode, to which a high electric field of 0–1000 kV/m can be applied, and the distance to the counter electrode is 10–25 cm in our laboratory systems. The injecta solution was injected into the base solution which was stirred quickly by magnetic stirrer. In our experiments, 0 and 8 kV were employed and perfusion flow was fixed at 80 μl/min. After the completion of the perfusion, obtained white slurry was filtered and washed several times by deionized water. Through the vacuum drying, the white as-prepared powders were checked by the X-ray diffraction , field emission scanning electron microscopy , and transmission electron microscopy .The synthesis system is illustrated in Fig. 3 has three anhydrous crystallographic polymorphs: vaterite (the least stable), aragonite, and calcite (the most stable). Vaterite particles do not show well-defined morphologies and usually aggregate into spherical particles. The vaterite form can crystallize in either an orthorhombic or a hexagonal structure. With the aids of surfactants and/or templates, hollow vaterite spheres, micro floret, hexagonal prism vaterite crystalline powders, etc. could be synthesized. There is seldom aragonite in nature. It may be associated with the activity of the creatures on the earth. Among the three polymorphs of CaCO3, calcite would be crystallized generally from the solution without outside disturbance because it is the most thermodynamic stable phase.CaCO3, two comparable experiments have been done. In our study, both the precipitation of CaCO3 chemical reactions under 8 kV (~800 kV/mm) electrical field and that under electrical field free (0 kV/mm) were completed in our instrument as described above and named as electric field (EF) sample and electric free (NE) sample, respectively. The XRD patterns are shown in Fig. To clear investigate the effect of electric field on the crystallization of CaCO3 can be identified by the Raman spectrum, and the fine distinction on phase structures can be distinguished [3 crystals [−1 overlap, but vaterite has double peaks whereas calcite has mono one. The most intense Raman bands are observed in the low frequency region (50–400 cm−1), which corresponds to the lattice mode vibrations. In these bands, the characteristic peaks of calcite are strong and narrow, whereas the vaterite bands are large and overlap at 150 and 281 cm−1 with calcite. The modes of wide band around 110 and 300 cm−1 are the characteristic vibration of vaterite lattice as shown as Fig. The vibrational spectroscopy as Raman spectroscopy is sensitive to the structural transformation; the distortions and defects of lattice cell at the molecular level can be detected . It is anguished . It is acrystals –29. Figucrystals , 29. TheThe microstructures of EF sample by SEM are shown in Fig. The microstructures of NE sample are shown in Fig. In order to study the characteristics of the crystallization under the electric field, more details of the sample EF was observed by TEM. Figure It is amazing when we check the SEAD of the sample. A series of perfect hexagonal single crystal diffraction pattern is revealed in Fig. 3 under the electric field are described in Fig. 3 from solution under electric field is illustrated in Fig. Polarized hydroxyapatite ceramics was used to study the effect of surface electric field on crystallization of calcite. It was found the oriented growth of calcite crystals with the rhombohedra {10.4} plane parallel to the polarized hydroxyapatite substrates on both negatively and positively charged surfaces due to the electrostatic force applied to the precipitated ions which accumulated on the surface of the substrates . The eleTo understand the transition between different polymorphs further, density functional theory (DFT) methods can enable itself as an extremely powerful tool for elucidating the energy changing of different polymorphs under electric field , 34. The3 from solution. The calcite structure with cubic-like morphology can be obtained usually during deposition from solution. On the other hand, the vaterite structure with morphology of nanorod is formed under the high electric field. During crystallization of vaterites nanostructures from solutions, the electric field splits the titrant to nano-beams and provides an electrical field to make ions orientation in solution and thus changes the crystallization characteristics of the precipitations. Both calculation and experiments confirmed that the electric field is propitious to the crystallization of vaterite during deposition from solution. The vaterite nanorods we synthesized under high electric field can be self-arranged into beautiful rose-like nanoflowers. The petal of rose-like nanoflowers is detected as mesocrystal, in which crystalline structures are constructed and/or transformed from larger units instead of single ions. Therefore, crystals can be assembled from nanoscopic building units in an almost perfect three-dimensional orientation to form so-called mesocrystals, exhibiting well-faceted outer surfaces.The electric field can be one of the most important facts to determine the polymorphs and morphology of the materials during their synthesis and their crystallization. It is found that the lattice structure and crystalline morphology can be tailed by the electric field which applied to the reaction system during deposition of CaCO


Teen childbearing has potential negative health, economic, and social consequences for mother and child. Repeat teen childbearing further constrains the mother’s education and employment possibilities. Rates of preterm and low birth weight are higher in teens with a repeat birth, compared with first births.To assess patterns of repeat childbearing and postpartum contraceptive use among teens, CDC analyzed natality data from the National Vital Statistics System (NVSS) and the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2007–2010.Based on 2010 NVSS data from all 50 states and the District of Columbia, of more than 367,000 births to teens aged 15–19 years, 18.3% were repeat births. The percentage of teen births that represented repeat births decreased by 6.2% between 2007 and 2010. Disparities in repeat teen births exist by race/ethnicity, with the highest percentages found among American Indian/Alaska Natives (21.6%), Hispanics (20.9%), and non-Hispanic blacks (20.4%) and lowest among non-Hispanic whites (14.8%). Wide geographic disparities in the percentage of teen births that were repeat births also exist, ranging from 22% in Texas to 10% in New Hampshire. PRAMS data from 16 reporting areas (15 states and New York City) indicate that 91.2% of teen mothers used a contraceptive method 2–6 months after giving birth, but only 22.4% of teen mothers used the most effective methods. Teens with a previous live birth were significantly more likely to use the most effective methods postpartum compared with those with no prior live birth . Non-Hispanic white and Hispanic teens were significantly more likely to use the most effective methods than non-Hispanic black teens . The percentage of teens reporting postpartum use of the most effective methods varied greatly geographically across the PRAMS reporting areas, ranging from 50.3% in Colorado to 7.2% in New York State.Although the prevalence of repeat teen birth has declined in recent years, nearly one in five teen births is a repeat birth. Large disparities exist in repeat teen births and use of the most effective contraceptive methods postpartum, which was reported by fewer than one out of four teen mothers.Evidence-based approaches are needed to reduce repeat teen childbearing. These include linking pregnant and parenting teens to home visiting and similar programs that address a broad range of needs, and offering postpartum contraception to teens, including long-acting methods of reversible contraception. Healthy People 2020 objective for reducing teen pregnancy rates  poses greater challenges because additional births might further constrain the mother’s ability to attend school and obtain job experience . CloselyGiven that most pregnant teens come into contact with the health-care system while receiving prenatal care , opportuTo assess patterns of repeat teen childbearing and postpartum contraceptive use, CDC analyzed data from the natality files of the National Vital Statistics System (NVSS), and the Pregnancy Risk Assessment Monitoring System (PRAMS). Specific research questions included the following:What number and percentage of teen births are repeat births?What are patterns of repeat teen births by race/ethnicity, by state, and over time?What are current patterns of postpartum contraceptive use among teen mothers, by sociodemographic characteristics and by state?U.S. natality files are compiled annually by CDC’s National Center for Health Statistics and include demographic information such as maternal age, race, and Hispanic origin for all births in the United States in all states and the District of Columbia. This report includes national and state-specific data for 2007–2010  . PRAMS cnow to keep from getting pregnant?” If the response was no, the mother was asked the reason from a list of response choices, with instructions to “check all that apply.” If the response was yes, respondents were asked to check all applicable responses to the question, “What kind of birth control are you or your husband or partner using now to keep from getting pregnant?” Contraceptive methods were categorized by level of effectiveness for pregnancy prevention based on the percentage of females who experience pregnancy during the first year of typical use and coded in a manner consistent with previous analyses of contraceptive use as most effective (<1%), moderately effective (6%–12%), and less effective (≥18%) , birth control patch, and vaginal ring; and less effective included condom, diaphragm, cervical cap, contraceptive sponge, rhythm method, and withdrawal during typical use. Although the diaphragm has been categorized elsewhere as moderately effective during typical use  . Only thical use , for thiWeighted prevalences were calculated using statistical software to account for the complex sampling design and nonresponse. Weighted results were calculated for female teens aged <20 years whose pregnancy resulted in a live birth. The sample included teen mothers who recently had delivered their first child and were at risk for having a second birth, as well as teen mothers who recently had delivered a subsequent child and were at risk for having a third or higher order birth. Analyses examining the typical use effectiveness of contraceptive methods and reasons for nonuse of contraception excluded teen mothers who were not at risk for pregnancy, either because they currently were pregnant or were not sexually active. The prevalence of self-reported contraceptive use postpartum was estimated by select demographic characteristics and reasons for not using contraception were characterized.In 2010, among 364,859 births to teens aged 15–19 years, 66,761 (18.3%) represented repeat births. The vast majority (85.7%) of repeat births were for a second child , but some teens (12.6%) were giving birth to a third child , and a few births (1.7%) were for a fourth to sixth child . The percentage of teen births that represented repeat births decreased gradually over the observation period, from 19.5% in 2007 to 18.3% in 2010, for a 6.2% decline over the 4-year period.The prevalence of repeat teen births varied by race/ethnicity, with the highest prevalence in 2010 among American Indian/Alaska Natives (21.6%), followed by Hispanics (20.9%), non-Hispanic blacks (20.4%), Asian or Pacific Islanders (17.6%), and non-Hispanic whites (14.8%). The prevalence of repeat teen births also varied by state . The higAmong postpartum teen mothers from the participating PRAMS reporting areas, 8.0% were not sexually active , 1.3% were pregnant (CI = 0.9%–1.9%), and 90.7% were sexually active (CI = 89.4%–91.9%). Teen mothers with a repeat birth were as likely as teen mothers with a first birth to report the birth was unintended , and to report using contraception in the prepregnancy period before the birth .Of teen mothers who were sexually active, 91.2% reported using postpartum contraception after the most recent birth. Among sexually active teen mothers, 22.4% used the most effective birth control methods, 54.2% used moderately effective methods, 14.5% used less effective methods, and 8.8% used no method . Teens wPostpartum use of effective contraception among teen mothers also varied markedly by location . Of the Among teen mothers who used contraception postpartum, more than one out of every five respondents reported using long-acting reversible contraception (LARC), with 18.2% reporting intrauterine device use and 3.3% reporting implant use . Use of Among the 9% of sexually active teen mothers who did not use birth control after their most recent birth, the most frequently cited reasons for nonuse included not wanting to use birth control (36.0% [CI = 28.7%–44.0%]), husband/partner objections (21.7% [CI = 15.9%–28.9%]), not being able to pay for birth control (20.0% [CI = 14.5%–26.8%]), and wanting to get pregnant (17.6% [CI = 12.1%–24.9%]).This report documents that nearly one in five teen births in 2010 was a repeat birth. The percentage of teen births that were repeat births has decreased 6.2%, from 19.5% in 2007 to 18.3% in 2010. The prevalence of repeat teen births varied by race/ethnicity, and mirrored racial/ethnic disparities in the overall teen birth rates with Hispanics, non-Hispanic blacks, and American Indian/Alaska Natives experiencing the highest rates  who reported use of a method of birth control at last sex . More thAnother way to reduce repeat teen pregnancy is to engage pregnant and parenting teens in programs that are effective in reducing repeat teen births. Several studies have shown that home visiting can help reduce repeat teen pregnancy ,13. The §Efforts to support pregnant and parenting teens should include counseling about birth spacing and contraception and, among women wishing to delay or avoid future pregnancies, the importance of sustaining contraceptive use over time, in accordance with recommendations from professional organizations such as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists ,10. LARCThe wide geographic variation in use of the most effective contraceptive methods among the PRAMS reporting areas included in this analysis could be explained by a number of factors, such as environmental support for contraception, that should be explored further. Research should attempt to identify how some states successfully overcame barriers to use of the most effective method postpartum. Moreover, further research should investigate reasons for lower rates of use of the most effective contraceptive methods among non-Hispanic black teens.The findings in this report are subject to at least five limitations. First, respondents from PRAMS were interviewed in the period shortly after giving birth; later follow-up is needed to better understand longer-term use of postpartum contraception and determinants of repeat teen childbearing. Second, the PRAMS data do not include information about the consistency and correctness of contraceptive use, which are particularly important determinants of the effectiveness of user-dependent methods of contraception such as condoms and pills. Third, because only 16 PRAMS reporting areas were included in this analysis, results might not be generalizable to other states. Fourth, the years covered by the analysis span from 2007 to 2010, and averaging estimates over these 4 years could mask temporal trends in contraceptive use given continued declines observed in teen birth rates. States with data only for 2007 and 2008 also might have experienced substantial improvements in later years. Finally, the data sources used for these analyses permitted examination only of repeat births among teens rather than repeat pregnancies; because miscarriages, stillbirths, and abortions were not included, the prevalence of repeat pregnancy likely is higher than repeat births.Having more than one child during the teen years might pose greater challenges than having one child. Rates of preterm and low birth weight are higher among repeat teen births than among first births.Nearly one in five teen births  is a repeat birth.Many teens are taking actions to prevent repeat pregnancies and births. Most (91%) sexually active teen mothers are using contraception in the postpartum period, but only 22% are using the most effective methods.Postpartum contraceptive use varies by the number of previous births, race/ethnicity, and geographic location. The geographic variation suggests that barriers might exist to accessing contraception, including the most effective methods of reversible contraception.What can be done to help reduce repeat teen births?– Work with teens during pregnancy at prenatal visits.– Provide broader support and link pregnant and parenting teens to sources of educational, economic, and social support that should continue after the child is born.– Counsel teens about abstinence and contraception as a way to prevent pregnancy, and promote condom use to prevent pregnancy and sexually transmitted infections, including human immunodeficiency virus.– Encourage providers to offer postpartum contraception to teens.http://www.hhs.gov/ash/oah/oah-initiatives/paf.Information for those working with pregnant and parenting teens is available from the U.S. Department of Health and Human Services’ Office of Adolescent Health’s Pregnancy Assistance Fund Resource and Training Center at http://mchb.hrsa.gov/programs/homevisiting.The Maternal and Child Health Bureau of the Health Resources and Services Administration is helping state and local agencies deliver evidence-based home visiting programs. Additional information is available at http://www.cdc.gov/vitalsigns.Additional information is available at The findings in this report suggest that many teen mothers are taking steps in the postpartum period to prevent repeat pregnancy. Previous research has shown that these efforts can be supported by linking pregnant and parenting teens to home visiting programs and other sources of support, as well as health care that includes counseling about and provision of contraception ,9,16.


Dengue is a mosquito-borne disease that is common in many tropical and subtropical areas. Dengue infections can occur at any age and time in the lifespan, including during pregnancy. Few large scale studies have been conducted to determine the risk of preterm birth (PTB) and low birthweight (LBW) for infants born to women who had symptomatic dengue infection during pregnancy.This study is a retrospective cohort study using medical records from 1992–2010 from pregnant women who attended a public regional referral hospital in western French Guiana. Exposed pregnancies were those with laboratory confirmed cases of dengue fever during pregnancy. Each of the 86 exposed infants was matched to the three unexposed births that immediately followed them to form a stratum. Conditional logistic regression was used to analyze these matched strata. Three groups were examined: all infants regardless of gestational age, only infants> = 17 weeks of gestational age and their strata, and only infants> = 22 weeks of age and their strata. Odds ratios were adjusted (aOR) for maternal age, maternal ethnicity, maternal gravidity, interpregnancy interval and maternal anemia. There was an increased risk of PTB among women with symptomatic dengue; , aOR 17 weeks: 1.89 , aOR 22 weeks: 1.41 ) but this risk was only statistically significant when all infants were examined . Adjusted results for LBW were similar, with an increased risk in the exposed group , aOR 17 weeks: 1.67 , aOR 22 weeks: 1.43 ) which was only statistically significant when all infants were examined .Symptomatic dengue infection during pregnancy may increase the risk of PTB and LBW for infants. More research is needed to confirm these results and to examine the role of dengue fever in miscarriage. Previous studies have reported that dengue fever during pregnancy may be related to preterm birth and low birthweight among infants. However, few studies have used an appropriate control group to compare the risk of these outcomes for infants whose mothers had dengue fever to infants whose mothers did not. We designed this study to provide information on the amount of risk (odds ratios) and the stability of this risk  of being born preterm or with low birthweight to a mother with documented dengue infection during the pregnancy. In this study there was an increased risk among pregnant women with symptomatic dengue to deliver infants who are preterm or low birthweight, but both the amount of risk and the stability of this risk were affected by the inclusion or exclusion of miscarriages  This suggests that women who are pregnant should take extra precautions to avoid dengue infections during pregnancy, since it may cause an early delivery, or the birth of a small infant. Dengue is a mosquito-transmitted viral infection that is common in most tropical and sub-tropical areas. Approximately 390 million dengue virus infections occur each year, and about 500,000 of these require hospitalization The poor birth outcomes of preterm birth and low birthweight are associated with increased morbidity and mortality. By some estimates, 60% of all neonatal deaths occur to infants who are born preterm or low birthweight As this study collected personal information from French citizens, the requirements and recommendations of the Commission Nationale de l'Informatique et des Libertés were followed. The Tulane University Institutional Review Board approved this study as an exempt study for which informed consent was not sought from subjects. Informed consent was not sought for this study as all information was taken from the existing medical record, and data were analyzed anonymously.This study used medical archive data from the Franck Joly Hospital in St. Laurent du Maroni, French Guiana. French Guiana is an overseas department of France, with endemic and epidemic transmission of all four serotypes of dengue, as well as a high fertility rate st 1997, miscarriages of≥17 weeks that occurred at the hospital were recorded in the hospital log books, which previously had only contained information on births≥22 weeks of gestational age. Due to differences in recording miscarriages over time, a sensitivity analysis was conducted. Three levels of inclusion were examined: all fetuses and infants regardless of gestational age and their matches, only fetuses and infants≥17 weeks of gestational age and their matches, and only fetuses and infants≥22 weeks of age and their matches.Unexposed subjects were defined as pregnant women who did not have signs or symptoms of dengue during pregnancy, or who received a negative dengue test result if they were febrile. Unexposed subjects were identified either by using the delivery number of the infant (for fetuses≥22 weeks as determined by ultrasound or≥500 grams), or by using the time of miscarriage of the fetus (for infants <22 weeks of gestation and <500 grams). The three deliveries or miscarriages immediately following the birth of an exposed infant were used as the unexposed matches for the exposed infants. During the time period of this study there were different practices for recording miscarriages. After January 1For the purpose of this study, a confirmed diagnosis of dengue was a symptomatic case of dengue fever accompanied by a positive test result from one of the following methods: IgM detection by ELISA, viral RNA detection via PCR, a positive NS-1 viral antigen test, or a positive viral culture. Test confirmation was conducted by the Pasteur Institute of Guiana, the national reference laboratory for arbovirus infections in French Guiana.The outcome definitions used in this study were as follows: a preterm birth was one <37 weeks of gestational age, including miscarriages. An infant with low birth weight was one born weighing <2,500 grams, irrespective of gestational age. Definitions of live birth, stillbirth, and miscarriage used in this study were based on the French definitions Information relating to dengue virus infection, gestational age, and birthweight was abstracted from patient medical files and the Obstetrics and Gynecology ward log books as well as information used to adjust for potential confounders included maternal age, maternal ethnicity, maternal gravidity, interpregnancy interval, and maternal anemia. Adjustment variables were chosen based on a review of the literature and on the information available in the medical archives.Ethnic information was classified by the investigators, based on information contained in the log books and in the patients' medical file. This information was included as previous studies have indicated that infants with African heritage are at increased risks of poor birth outcomes compared to infants of European heritage th week of gestation were considered. All statistical analyses were done using SAS version 9.2 .Statistical analysis for this study included univariate, bivariate, and multivariable investigations. Analyses included descriptive statistical measures for individual variables and tests of association for each variable with the outcomes under investigation. Conditional logistic regression was used to model multivariate associations, with each exposed infant and the three unexposed infants following it modeled as a matched stratum. For the outcome of preterm birth, only dengue infections occurring until the 37A total of 86 exposed infant records were eligible for use in this study and were included in analysis. A total of 281 unexposed infant records were identified as matches to the exposed births by delivery number or time of birth. Out of the 281 records of unexposed infants,,258 were able to be located in the medical archives, and were matched to the exposed infants. One unexposed infant had information missing for several variables, and was not included in multivariate models. Maternal socio-demographic characteristics in the total study sample reflected the larger population of St. Laurent du Maroni, although differences between the exposed and unexposed groups were seen Out of the 344 infants included in this sample, 10.5% were born preterm, 13.4% were low birthweight, and 3.8% were stillbirths. Stillbirths were more common among exposed pregnancies than among unexposed pregnancies, regardless of the inclusion or exclusion of miscarriages in the subject population . Of the Among the 86 dengue-exposed pregnancies, 53.5% of dengue infections occurred in the third trimester, 34.9% in the second trimester, and 11.3% in the first trimester . The medUnadjusted odds ratios for preterm birth resulted in point estimates that showed an increased risk of preterm birth for women who had symptomatic dengue infections during pregnancy. Odds ratio point estimates ranged from 1.92 for all infants regardless of gestational age to 1.28 for models including infants≥22 weeks and their matches . HoweverUnadjusted odds ratios for low birthweight births showed point estimates that indicated increased risk for infants whose mothers had symptomatic dengue infection during pregnancy. Unadjusted point estimates ranged from 2.06 for all infants regardless of gestational age to 1.62 for models restricted to infants≥22 weeks of gestational age and their strata. Only the odds ratio including all infants regardless of gestational age reached statistical significance in unadjusted models  . After aThis study found increases in the risk of preterm birth and low birthweight for infants whose mothers had symptomatic dengue during pregnancy. To our knowledge, the present study is the largest and most epidemiologically sophisticated analysis using individual level data to examine the relationship between dengue fever during pregnancy and poor birth outcomes. This study is also among the first to have examined both the magnitude and variation in the risk of poor birth outcomes while adjusting associations for confounders. Previous research on dengue during pregnancy has generally been in the form of case reports and case series, which sometimes have suggested higher numbers of preterm and low birthweight infants among women with dengue during pregnancy In the present study, the largest odds ratios and those that had significant confidence intervals were obtained when the outcomes of interest were examined using the entire population of infants. However, the group containing all infants is also subject to diagnostic bias. Miscarriages <17 weeks of gestational age are more likely to be reported among women who were already at the hospital with dengue symptoms when they miscarried. This diagnostic bias is expected to decrease as gestational age increases and as the miscarriages approach the gestational age of 22 weeks, the age at which mandatory reporting of fetal death begins. The differences in results between these categories suggest that the models including all infants and the models including infants≥17 weeks of gestational age were influenced by the inclusion of the 4 miscarriages at <22 weeks of gestation in the dengue-exposed group. In a recent study by Tan et al., women who had miscarriages at <22 weeks of gestation were more likely to have a positive NS-1 or IgM test for dengue Symptomatic dengue infection results in a number of physiologic changes, some of which might result in the initiation of early labor. The immune response to dengue could promote preterm birth by inducing placental inflammation and trophoblast apoptosis, production of inflammatory cytokines and chemokines, or fever Interestingly, while the overall study population resembled that of St. Laurent du Maroni, the exposed and unexposed groups differed in regard to ethnicity. Women of non-African descent were overrepresented among women who had dengue during pregnancy (82.35% of the exposed). This may indicate that particular populations are more likely to suffer from symptomatic dengue during pregnancy, or may simply indicate a greater willingness or ability of these women to seek medical treatment The data used in this study were limited by several constraints. All information used in this study was abstracted from the existing medical record in the archives of the Franck Joly Hospital and was limited by the accuracy and completeness of the medical records. Most importantly, this study was limited by the number of dengue fever cases in the medical record, leading to a lower than desired sample size of exposed pregnancies. While there were few missing data among the variables used in this study, there were other possible confounders that were not examined due to complete absence of the data, in particular, maternal education or socioeconomic status and maternal housing. The time period of this study (1992–2010) encompasses a period with great changes in dengue diagnosis methods. It is difficult to predict how this may have impacted the ascertainment of exposure over time, as all of the diagnosis methods that were used to determine exposure  have benefits and detriments This study considered infants as exposed only if their mothers had a symptomatic dengue infection during pregnancy. A large proportion of all dengue infections are asymptomatic, with as many as 90% of all dengue infections occurring without symptoms Aedes mosquitoes to pregnant women in areas where dengue is endemic Despite these limitations, the findings of the present study have great clinical significance for areas with dengue transmission. If dengue infection during pregnancy increases the risk of preterm birth and low birthweight by 40%, then implementation of mosquito avoidance measures during pregnancy should help to lower the risk. The Centers for Disease Control already recommends that pregnant women stay indoors during peak mosquito activity, wear protective clothing, and use insect repellant on clothing and sparingly on skin Findings from this study also suggest several possible areas of future research. A larger study examining the outcomes of preterm birth and low birthweight is necessary in order to confirm the results of the present study and to allow for more precise confidence intervals. Additional research on the effects of asymptomatic dengue infection on poor birth outcomes, as well as more research on the possible biologic mechanisms linking preterm labor and dengue, are needed i to clarify the relationship between dengue and poor birth outcomes.Checklist S1STROBE Checklist.(DOC)Click here for additional data file.