Most authors believe that the optimal treatment for pulmonary hydatid cyst is surgery. Albendazole has been used as a prophylactic measure for reducing recurrence rate but there are some controversies about this strategy. Some researchers have described the increased risk of spontaneous rupture of cysts following albendazole treatment. In this case report, we present a case of spontaneous rupture of pulmonary hydatid cyst with fatal outcome that may be the adverse cause of albendazole. Hydatid cyst is an endemic disease in Iran and other Middle East countries. The lung is the second most common organ after liver that is involved in this parasitic disease. Although there are some controversies about the optimal therapeutic strategy for patients with pulmonary hydatid cyst, most of the investigators believe that surgery is the best therapy. Albendazole has been used as a prophylactic drug before surgery for reducing recurrence or as a definitive medical therapy in patients with this disease. Some physician uses this drug as a sole treatment for pulmonary hydatid cyst especially in patients who are not a good candidate for surgery –3. On thA 43-years-old man was admitted to the emergency room due to severe cough, fever, vomiting and copious sputum production. Physical examination at arrival revealed tachypnea and bilaterally diminished breath sounds. Nine months before this event, the patient was visited by a physician due to right flank pain and based on the detection of a large cystic lesion on liver sonography, the diagnosis of hydatid cyst was made. At that time bilateral pulmonary hydatid cysts were discovered on chest X-ray that was approved by CT scan .Thoracotomy and resection of the pulmonary cyst were planned for treating the lung cysts and preoperative albendazole was begun with the dose of 400 mg twice daily. But patient postponed the surgery by himself and used albendazole for about 70 days. Two weeks after discontinuing albendazole there was an attack of a cough, fever and salty tasting sputum; however after 24 hours and following accentuation of symptoms he was referred to the emergency room. Initial chest X-ray showed a ruptured left lung cyst .Antibiotics  were administered intravenously in conjunction with dexamethasone and albendazole that was begun orally. In spite of these treatments respiratory distress worsened and due to severe dyspnea and diagnosis of respiratory insufficiency and empyema the patient was admitted to ICU. At this time chest x-ray revealed severe infiltration and pneumonitis in right lung that was probably due to flooding of the left cyst content after its rupture in to right lung  . After tHydatid cyst is an endemic disease in Iran and other Middle East countries. The liver is the most common location of the cyst and the lung is the second most common organ that is involved in this disease . Most auBenzimidazole anthelmintic drugs such as albendazole have been used as a prophylactic drug before surgery for reducing recurrence rate or even as a definitive medical treatment in patients that are not a good candidate for surgery due to widespread involvement or intolerance to surgery . TherapeIn our patient, one of the pulmonary cysts ruptured following treatment with albendazole that resulted in pulmonary insufficiency and death. Probably the main explanation for this event was chemical pneumonitis that was induced by the highly allergic content of cyst which affected both lungs, although on chest x-ray right lung was affected more intensely. As mentioned before the therapeutic response of pulmonary hydatid cyst is unpredictable and in this patient, only one of three cysts ruptured following albendazole treatment but this event terminated with a grave outcome for the patient. Anaphylactic shock and even sudden death have been reported after rupturing of pulmonary hydatid cyst , althougUsluer et al. in their experimental study showed that tensile strength of cuticular membrane of pulmonary hydatid cysts would be decreased following administration of albendazole  and we aAccording to increased incidence of pulmonary hydatid cyst rupture following albendazole therapy and not fully recognized effect of the drug in reducing recurrence rate, it is probable that the best-justified policy in the treatment of pulmonary hydatid cyst is immediate surgical evacuation without any further albendazole prophylaxis.Albendazole has been used as a prophylactic treatment before surgery in patients with pulmonary hydatid cyst for reducing recurrence rate. This drug can cause spontaneous rupture of cysts with some unpredictable complications. Although rupture of cyst can occur in the absence of albendazole treatment we believe that this drug is a potential cause and more investigations are needed to prove it clinically. Therefore, we believe early surgical treatment even without albendazole prophylaxis provides an acceptable strategy for treating these patients.


In 1952, the Japanese Society for Hygiene had once passed a resolution at its 22nd symposium on population control, recommending the suppression of population growth based on the idea of cultivating a healthier population in the area of eugenics. Over half a century has now passed since this recommendation; Japan is witnessing an aging of the population (it is estimated that over 65-year-olds made up 27.7% of the population in 2017) and a decline in the birth rate  at a rate that is unparalleled in the world; Japan is faced with a “super-aging” society with low birth rate. In 2017, the Society passed a resolution to encourage all scientists to engage in academic researches to address the issue of the declining birth rate that Japan is currently facing. In this commentary, the Society hereby declares that the entire text of the 1952 proposal is revoked and the ideas relating to eugenics is rejected. Since the Society has set up a working group on the issue in 2016, there have been three symposiums, and working group committee members began publishing a series of articles in the Society’s Japanese language journal. This commentary primarily provides an overview of the findings from the published articles, which will form the scientific basis for the Society’s declaration. The areas we covered here included the following: (1) improving the social and work environment to balance between the personal and professional life; (2) proactive education on reproductive health; (3) children’s health begins with nutritional management in women of reproductive age; (4) workplace environment and occupational health; (5) workplace measures to counter the declining birth rate; (6) research into the effect of environmental chemicals on sexual maturity, reproductive function, and the children of next generation; and (7) comprehensive research into the relationship among contemporary society, parental stress, and healthy child-rearing. Based on the seven topics, we will set out a declaration to address Japan’s aging society with low birth rate. According to the 50th anniversary of the Japanese Society for Hygiene, even before, the issue of an aging society with low birth rate had surfaced in Japan; the Society had already passed a resolution at its 22nd symposium on population control in 1952 to deliver the following proposal to the Ministry of Health and Welfare authorities:“...the decline in mortality rates [...] is further accelerating the process of overpopulation in Japan. What this means for the future population is a decline in the amount of nutrition they will each receive, weaker physical health, and an increase in cases of tuberculosis and other diseases... Therefore, the most important thing that the government needs to do [...], in the aim of maintaining people’s heath from a public health stance, is to direct people to adjust the number of births [...] consciously. The Society [...] sincerely hopes that the government’s targets (for promoting the use of birth control) will be modified along the lines of cultivating a healthier population. This concludes our proposal.”An additional resolution sets out that “in setting up (cooperating organizations to ensure the effective dissemination of birth control), the Society would like to be seen as a leading body because it has been interested in this issue for a number of years and has carried out considerable research.”In other words, even after the new constitution, setting out fundamental human rights had been enacted; the Society was recommending birth control and the suppression of population growth based on the idea of cultivating a healthier population in the area of eugenics.Over half a century has now passed since this recommendation; Japan is witnessing an aging of the population (it is estimated that over 65-year-olds made up 27.7% of the population in 2017) and a decline in the birth rate  at a rate that is unparalleled in the world; Japan is faced with a “super-aging” society with low birth rate. Against such a backdrop, the Japanese Society for Hygiene passed a resolution at its 2017 annual general meeting to encourage all scientists to engage in academic researches to address the issue of the declining birth rate that Japan is currently facing.It cannot be overlooked that the 1952 resolution  was a proposal based on eugenics. The resolution set out the need for a perspective on eugenic protection, arguing that the Ministry of Health and Welfare is setting birth control targets that just emphasized the protection of maternal health which could lead to serious misunderstandings and also constitute a basis for committing the error of reverse selection. The Japanese Society for Hygiene does not advocate human rights violations based on eugenics, such as the forced sterilizations that occurred under the old Eugenic Protection Law (1948–1996). The Society, therefore, hereby declares that the entire text of the 1952 proposal is revoked and the ideas relating to eugenics is rejected.Before making a declaration, the Society has set up a working group on strategies to address the declining birth rate, made up of members of the Society. Since the 2016 annual general meeting, there have been three symposiums and side events on the topic, and these events have enabled the Society to conduct discourse from a range of different angles. Working group committee members also began publishing a series of articles on the topic in the Japanese Journal of Society for Hygiene  in January 2018. This paper primarily provides an overview of the findings from the symposiums and published articles, which will form the scientific basis for the Society’s declaration on the issue of Japan’s aging society with low birth rate.In recent years in Japan, changes in the social and economic environment as well as in individual values, such as an increase in young people and on low incomes, have meant that a growing number of people either never marry or marry for the first time at a later age . FurtherIt is a woman’s fundamental human right to choose and determine (the right to self-determination) whether to marry, whether to have children, when to have children, how many children to have, and how much of a gap to leave between each child. To consider and come to a decision on this, women need accurate information . FertiliThe Developmental Origins of Health and Disease (DOHaD) hypothesis, whereby a woman of reproductive age being underweight creates a state of starvation in the intrauterine environment and causes an epigenetic modification of the fetus, has become a topic of interest in recent years . UnderweOn the issue of the health of women of childbearing age, and from the perspective of safeguarding fertility, it is essential to promote research in overwork and other areas of occupational health. Occupational health professionals should be trained particularly on mental health issues before and during pregnancy . FurtherWorkplace structures that provide a choice of working styles for women wanting to conceive or give birth and for couples with children also need to be extended to non-permanent staff and some small medium enterprises. It is recommended that measures are put in place to create a workplace environment that enables both parents to continue working. These measures include securing regular employment for men and women, replacing long working hours with efficient working systems, giving both men and women the option of childcare leave, shorter working hours or home teleworking, providing a nursery or using babysitters, and providing workplace support to enable couples to undergo infertility treatment alongside their work . Many woThe third biggest reason women cite for not having their intended number of children is simply the inability to do so, representing 23.5% . ScientiWomen experience a huge burden by giving birth and becoming a mother, with plenty of mothers suffering from stress and anxiety. In particular, women who are pregnant or bringing up children tend to tire more easily, both physically and mentally, and are more prone to feeling isolated or stressed compared with before having children. Stress can be a causal factor in a wide range of illnesses. It is widely accepted that psychological stress affects the development and exacerbation of allergic disorders. In particular, parental psychological stress can also affect allergic reactions in infants who have a close relationship with their parents –39. It iThe time has come to give serious thought as to how best to protect the health of the children of the next generation amid the rapid decline in the working age population that is the backbone of Japan’s economic foundation Fig. . Approxi


Sci., 2014, 5, 3486–3492.Correction for ‘Carbon nanotube–vitrimer composite for facile and efficient photo-welding of epoxy’ by Yang Yang  All instances of “15.2 W cmThe Royal Society of Chemistry apologises for these errors and any consequent inconvenience to authors and readers.


We recruited 1296 mothers in their first trimester from the Affiliated Obstetrics and Gynecology Hospital of Nanjing Medical University between May 2014 and September 2015 to investigate the associations of maternal, perinatal and postnatal factors with the eruption timing of the first primary tooth (ETFPT) in a Chinese population. We collected maternal demographic information and clinical data during the perinatal and postnatal period, and oral examinations of the infants were performed by a doctor at 6, 9 and 12 months of age. Multiple regression analysis was used to identify significant explanatory variables for ETFPT. The mean age at eruption of the first primary tooth for all the infants was 6.82 ± 1.90 months. After adjustment for confounders, higher maternal childbearing age , female sex , and low birth weight  were significantly associated with delayed eruption of the first primary tooth, while macrosomia  was significantly associated with earlier eruption of the first primary tooth. Maternal childbearing age, infant sex and infant birth weight were significant determinants of ETFPT. Teeth are formed in the upper and lower jaw through mutual, subtle and sophisticated interactions between the dental epithelium and oral ectomesenchyme involving the expression of several tooth-related genes1. Primary tooth eruption is a complex and highly regulated process in which teeth enter the mouth and become visible during a certain time period. In most infants, the first primary tooth to erupt is the central mandibular incisor, which erupts between 2 and 15 months of age2. The complete primary dentition erupts from 10 to 33 months depending on the position and type of tooth3.The formation and development of human primary teeth begins at the end of the fifth week of gestation4. Furthermore, genome-wide association studies (GWAS) have identified some candidate genes associated with tooth development, such as KCNJ2, EDA, HOXB2, RAD51L1, IGF2BP1, HMGA2 and MSRB35. There are ethnicity- and sex-related differences in the timing of primary tooth eruption6. However, external environmental factors also make significant contributions to the timing of the primary tooth eruption. Maternal exposure to tobacco during pregnancy8, infant birth weight10, birth length11, nutritional state at birth and at postnatal timepoints12, gestational age13, method of infant feeding14 and socioeconomic situation15 have been reported to be significant determinants of the eruption of primary teeth. Delayed tooth eruption has been reported in premature infants16 with small gestational age and low birth weight and in those with systemic disorders, such as hypothyroidism17, while accelerated tooth eruption has been observed in children whose mothers smoked during pregnancy8 as well as in those with childhood obesity18 and diabetes mellitus19.Variations in the eruption timing of the first primary tooth (ETFPT) are considered multifactorial. Eruption is under strong genetic control, and the estimates of narrow-sense heritability are over 70%22. Most of the studies focused only on factors within a defined period of time and based their findings on evidence from small cohorts, while some studies focused on the whole pregnancy. A prospective cohort study in Turkey23 found that growth parameters and feeding patterns may be determinants of the timing of tooth eruption. The GUSTO cohort study in Singapore24 found that infant weight gain from birth to 3 months, ethnicity and maternal childbearing age were associated with the timing of the eruption of the first tooth. A study from the Southampton Women’s Survey25 found that maternal smoking and socioeconomic status were associated with tooth eruption. Taken together, these cohort studies25 were based on relatively large populations and focused on comprehensive data, including maternal, perinatal and postnatal data; in contrast, their results are not entirely consistent.Although several studies have examined the factors influencing tooth eruption, their results are inconsistent27. Importantly, other factors, including socioeconomic factors, nutritional status, maternal educational levels and overall maternal health vary from country to country28. In the United States, primary tooth eruption timing differs among American Indian, Black and White children29. The GUSTO cohort study in Singapore24 found that compared to Chinese children, Malay and Indian children experienced significantly delayed tooth eruption. Meanwhile, primary tooth eruption timing differs between Indian children in Singapore24 and in India31. However, there is a lack of population data for residents in Nanjing of China. Therefore, our study aimed to evaluate the relationships between maternal, perinatal and postnatal factors and ETFPT of infants in a large cohort of Chinese mothers in Nanjing, China.There is definite evidence that children in different geographic regions have different eruption timing of the primary teethThe demographic and clinical characteristics of 1109 mother-child pairs are shown in Table p < 0.05). Interestingly, the first eruption peak for both females and males was 6 months, and the second peak was 8 months  , female infants , and low infant birth weight  were significantly associated with delayed ETFPT, while macrosomia  was significantly associated with earlier ETFPT  in the ETFPT between Chinese children in Nanjing, China, and Singapore. The mean ETFPT of all the infants in our study was 6.82 ± 1.90 months, while in the GUSTO study in Singapore, the mean ETFPT of the Chinese children was 7.80 ± 2.20 months. Similarly, the mean ETFPT of Indian children was 8.15 ± 1.69 months in a major city in North India30 and 9.50 ± 2.70 months in Singapore24. Meanwhile, another study in India reported that the mean ETFPT of Indian children in Bhopal was 11.40 ± 3.43 months31. Although differences in tooth eruption timing between shared ancestry populations in different countries/communities do exist, the reasons may include nutrition, socioeconomic status, climate, and environmental factors, such as the fluoride content in drinking water30. Common environmental toxins can also affect tooth development in human embryos32. However, for any one factor, the results are inconsistent and inconclusive. The tooth eruption timing reported in this study differs from those reported in longitudinal studies in other countries34, suggesting that population-level differences in the ETFPT may exist. The ETFPT is ethnicity and community dependent. Since the current standards of primary teeth eruption timing are based mainly on Western populations, our data can be used as a reference for future clinical studies in Nanjing of China.Comparing our study with the GUSTO study24, which previously uncovered an association between higher maternal childbearing age and earlier ETFPT in infants. Previous work has demonstrated a similar relationship between maternal childbearing age and child growth parameters in which increased maternal childbearing age was associated with taller stature in children - on average, children of mothers who were older than 30 years at childbirth were 1.5 cm taller than those of mothers who were younger than 30 years35. The mechanisms underlying these differences are unclear but may include ethnic or population history differences and environmental and/or genetic factors. Additionally, the literature suggests that factors such as ethnicity or population history may influence tooth formation and eruption36.Furthermore, our study showed that maternal childbearing age as a continuous variable have no statistics significance, however as a ordinal variable that increasing maternal childbearing age is associated with delayed ETFPT in infants. This finding disagrees with the results of the GUSTO study in Singapore24 did not find a sex-related difference; however, in the present study, we found a sex difference in the ETFPT, which was earlier in males. Our results align with previous studies that found that the primary teeth erupt earlier in males than in females40. The reason for the differences in the timing of tooth eruption between males and females is poorly understood. We hypothesize that the earlier onset of the primary dentition is related to differences in sexual maturity and may be partially attributed to environmental and/or genetic influences on growth41.The GUSTO study in Singapore42. Birth weight has been used as a marker of intrauterine nutritional environment, with low birth weight indicating poor fetal nutrition. Additionally, children who have experienced nutritional deficiencies show delayed primary teeth eruption43. Interestingly, we found that the first primary tooth eruption occurred earlier in infants with macrosomia, while it was delayed in infants with low birth weight; these findings are consistent with studies that focused on other populations45. Even when chronological age was adjusted for prematurity, infants with low birth weight have been shown to have greater likelihood of delayed ETFPT46.Previous studies have also suggested that the timing of primary tooth eruption is significantly related to general somatic growth and nutritional status18. Similarly, the GUSTO study in Singapore24 reported that earlier tooth eruption was associated with infant weight gain from birth to 3 months. Additionally, our study demonstrated that macrosomia is associated with earlier eruption of the primary teeth. Because birth weight is related to pregnancy and perinatal nutritional status and conditions, the findings of this study also suggest that primary tooth eruption may be an indicator of the nutritional status of the mother during pregnancy. As a result, we proposed that adequate nutrition during pregnancy and early life may prevent delayed ETFPT in infants.According to previous research, there was an association between the earlier eruption of permanent teeth and childhood obesity7. Reports indicate that only 2.4% of the women in China are tobacco smokers47, and most women who do smoke quit after they became pregnant48. Few mothers in China actively smoke during pregnancy, but secondhand smoke exposure still exists. However, we did not find an association between ETFPT and the mother’s exposure to secondhand smoke during pregnancy. Additionally, some previous studies have noted an association between breast feeding and the timing of the eruption of primary teeth, finding that children who were not breast fed had delayed tooth eruption49. The effect of breast feeding was also examined in this study, but we found that neither the breast feeding model nor the duration of breast feeding were significantly related to the ETFPT, which agreed with another report50.Previous studies have also found that children born to mothers who smoked during pregnancy had an earlier ETFPTOur study has a number of strengths. First, our participants were drawn from a systematic screening of pregnant women in a population-based, large study performed in Nanjing, China. Moreover, the relatively large sample size in this study provided good statistical power. There are also several limitations to this study. First, it used information from a cohort based on only one hospital in one city. The annual delivery rate of Nanjing babies in this hospital was about 20%. Therefore, the results should be considered with caution. Second, some reported risk factors for ETFPT, such as sociodemographic and socioeconomic characteristics, were not considered for adjustment in this study due to the high percentage of missing data. Third, the data on the timing of tooth eruption were reported by the mothers and are thus subject to error. To further explore the link between primary tooth eruption and other postnatal factors, further studies are ongoing. In particular, future studies will explore the association between the eruption timing of primary teeth and the development of subsequent dental caries, which has received little attention in the literature.Higher maternal childbearing age, female sex in infants and low infant birth weight were significantly associated with delayed ETFPT, while macrosomia was significantly associated with earlier ETFPT.Considering the limitations of this study, no associations were observed between other maternal, perinatal or postnatal factors and ETFPT.The ETFPT differs depending on infants’ ethnicity and community, likely in response to variation in environmental, developmental and genetic factors.Based on this study’s findings, the following conclusions can be drawn:This study was conducted according to the guidelines in the Declaration of Helsinki, and all procedures involving human subjects were approved by the Institutional Review Board of Nanjing Maternity and Child Health Care Institute. A total of 1296 singleton pregnant women in their first trimester were recruited between May 2014 and September 2015. The inclusion criteria included women who intended to give birth at the Affiliated Obstetrics and Gynecology Hospital of Nanjing Medical University and planned to reside in Nanjing, China, for the 5 years after being recruited into this study. The exclusion criteria included women who had chronic diseases requiring medication  and those who abused alcohol or substances. All participants signed written free informed consent forms for themselves and their children.Maternal general demographic information regarding childbearing age, prepregnancy BMI, pregnancy tobacco exposure, parity, personal health and family history of disease were collected from a detailed questionnaire. The clinical data of the women during pregnancy, including gestational age and delivery method, were extracted from hospital laboratory records.2. The World Health Organization (WHO) criteria were used to classify the women’s BMIs into four groups: underweight (<18.5 kg/m2), normal (18.5–23.9 kg/m2), overweight (24–27.9 kg/m2), and obese (>28.0 kg/m2). The infants’ gestational age at birth was divided into two groups: low gestational age, which was less than 37 weeks, and normal gestational age, which was at least 37 weeks.The maternal childbearing age of the participants was divided into three groups: <25 years, 25–35 years, >35 years. BMI was calculated as weight (kg)/height (m)Perinatal details, such as infant sex and birth weight, were also obtained. Infant birth weight was divided into three groups: low birth weight (<2500 g), normal birth weight (2500–4000 g), and macrosomia (>4000 g).51.Questionnaires regarding child factors, including feeding mode  and duration of breast feeding were collected at subsequent return visits. All oral examinations of the infants were performed at 6, 9, and 12 months of age by one experienced senior dentist. Meanwhile, a licensed dental assistant checked and recorded the data for each child. Training and calibration sessions were done before the oral examinations. Kappa was used to assess the intra-examiner reliability and the inter-examiner reliability. To this end, test-retest was done in first 20 samples for the observers and in 50 cases selected randomly, oral examinations were completed by the two examiners. The agreement between test and retest was 100% and the agreement between the dentist and the dental assistant was also excellent (Kappa = 1). The examinations were performed under natural light in a dental chair. At each visit, the mothers were asked the age or date at which the child’s first primary tooth erupted. The aim of the oral examinations was to ascertain the eruption of the child’s first primary tooth and its eruption mode. The eruption of a tooth was defined as the appearance of any part of the tooth piercing the gum by using Federation Dentaire Internationale (FDI) standardsOf the total 1296 singleton pregnant women, 45 were excluded because of prediagnosed diabetes, alcohol or substance abuse, and 1251 live-born infants were delivered. During the 6-, 9-, and 12-month return visits, 40, 53 and 49 patients dropped out because of loss to follow-up, personal reasons, inconvenience and other factors. After 12 months of oral examinations, sufficient information was available for 1109 mother-child pairs to perform further analysis (Fig. p < 0.05 was considered statistically significant.Maternal, perinatal and postnatal information was collected to identify potential determinants of ETFPT Table . Descrip


In this study, LDECs were cultured from rabbit lacrimal duct tissues, and the barrier function of LEDCs was examined in vitro via transepithelial electrical resistance (TER) measurement, with or without interleukin (IL)-6 and/or rebamipide. For the in vivo examination, benzalkonium chloride (BAC) was injected into the rabbit lacrimal ducts, followed by the application of rebamipide or a placebo vehicle alone. The results of the in vitro examination revealed a significant decrease in TER in the group treated with IL-6 alone compared with the placebo-vehicle group (p < 0.05) and the group treated with IL-6 and rebamipide (p < 0.01). The results of the in vivo examination revealed that the infiltration of neutrophils under the basement membrane and the disruption of tight junction proteins with BAC injection and rebamipide attenuates the disturbance of tissue construction. These results suggest that rebamipide protects LDECs via an anti-inflammatory effect and preserves the barrier function of those cells.Nasolacrimal duct obstruction (NLDO) is thought to be due to inflammation and fibrosis of lacrimal duct epithelial cells (LDECs). Here we investigated the effect of rebamipide, a drug that is used for the protection of the mucosa and the treatment of gastritis and gastroduodenal ulcers, on LDECs, both  The common symptoms of NLDO include epiphora, discharges and dacryocystitis, an infection or inflammation of the lacrimal sac. Lacrimal stent intubation or dacryocystorhinostomy improves the symptoms, but these treatments are accompanied by surgical stress.It has been theorized that inflammation and age-related fibrosis of the lacrimal-duct epithelium are involved in the pathology of idiopathic nasolacrimal duct obstruction (NLDO)2, and that IL-6 is also involved in congenital NLDO (CNLDO)3. Thus, the suppression of the level of inflammatory cytokines in tears is considered to be a key factor in the development of new methods for the treatment of NLDO.It has recently been reported that various tear cytokines, such as interleukin (IL)-2, IL-6, and IL-10, are involved in the pathology of primary acquired nasolacrimal duct obstruction (PANDO)®; Otsuka Pharmaceutical Co., Ltd, Tokyo, Japan) for the treatment of dry eye. We previously reported that rebamipide has an anti-inflammatory effect and enhances the barrier function of cultured human corneal epithelial cells (CECs)4. In a previous study by Mimura et al., it was reported that the postoperative administration of rebamipide increases the rate of surgical success in patients who undergo lacrimal stent intubation for the treatment of PANDO5. However, the exact mechanism for the anatomical success in that study was not revealed.Rebamipide, an oral drug that is used for the protection of the mucosa and the treatment of gastritis and gastroduodenal ulcers, is currently marketed in Japan as an ophthalmic suspension , both The animals used in this study were male adult Japanese white rabbits (body-weight range: 3.5–3.99 kg), and all animals were treated in accordance with the ARVO Statement for the Use of Animals in Ophthalmic and Vision Research. All experimental procedures were approved by the Committee for Animal Research at Kyoto Prefectural University of Medicine, Kyoto, Japan.in vitro examination, rabbits were first sacrificed with an intravenous injection of pentobarbital. Next, lacrimal tissue samples were obtained, and LDECs were collected from those samples via the use of Dispase II . First, the collected LDECs were then cultured on 6-well dishes with keratinocyte serum free medium , BEGM™ Bronchial Epithelial Cell Growth Medium , and 8% fetal bovine serum (Thermo Fisher Scientific). The cells were then subcultured on 24-well Transwell Permeable Supports  until cell confluence was achieved. The transepithelial electrical resistance (TER) in the cells was then measured post confluence in 3 groups: Group A ; Group B ; Group C  (n = 4 each) at 0-, 24-, and 72-hours after stimulation.For the Second, the LDECs were subcultured on 24-well dishes until cell confluence was achieved. The cells were stimulated with 1% benzalkonium chloride (BAC) with 2-mM rebamipide or the vehicle for 72-hours and fixed in 4% paraformaldehyde, and investigated with immunohistochemistry. As a control, the cells were incubated with medium (n = 2 each).in vivo, and whether rebamipide might prevent the damage of epithelium with BAC treatment. For the in vivo examination, the rabbits were first placed under general anesthesia via the injection of a cocktail containing ketamine and xylazine. Next, an LDEC damage model was created by injecting 250 µl of 1% BAC into the rabbit’s lacrimal duct once daily for 3 consecutive days. After verification that the LEDC damage model was successfully created, 250 μl of 2% rebamipide ophthalmic solution  or the vehicle of rebamipide was injected (n = 3 each) simultaneously with the injection of 1% BAC. As a control, phosphate buffered saline (PBS) was injected into the lacrimal duct of 3 rabbits.We next investigated whether BAC affected the nasolacrimal duct epithelium ® O.C.T.; Sakura® Finetek Japan Co., Ltd., Tokyo, Japan). The tissue was then cut into 7-um sections, fixed in 4% paraformaldehyde, and investigated with histological examination and immunohistochemistry (n = 3 each). The thickness of the LDECs was then measured via the results of the histological examinations by another investigator, and the measurements were compared between the 3 groups.Next, lacrimal duct tissue was obtained and embedded in optimal cutting temperature compound  containing 4′,6 diamidino-2-phenylindole.Immunohistochemistry staining was performed with mouse antibodies to zonula occludens (ZO) protein ZO-1, claudin (CLDN)1, and CLDN7  overnight at 4 °C. Next, the sections were incubated with a secondary antibody  for 1 hour at room temperature, and then mounted with VectashieldFor SEM analysis, the obtained tissue samples that were first fixed in 0.1 mol phosphate buffered 2% glutaraldehyde, then subsequently post-fixed in 2% osmium tetroxide for 2 hours in an ice bath. The specimens were then dehydrated in a graded ethanol and dried by frozen t-butyl alcohol in a vacuum. The freeze-dried specimens then underwent SEM examination  after being coated with an osmium plasma ion coater device.Statistical analysis of the data was performed and basic descriptive statistics were calculated on all of the gathered data, with the values reported as mean ± SD. Results were compared among three groups by Bonferroni correction. A p value of <0.05 was considered statistically significant.in vitro  and Group C (p < 0.01).We first investigated the effect of rebamipide on the barrier function of rabbit LDECs that were successfully cultured tro Fig. . The celp C Fig. . At 0- ain vivo   Fig. .Figure 2Immunohistological examination findings confirmed the expression of tight junction proteins ZO-1, CLDN1, and CLDN7 between the epithelial cells in the control group and in the 1% BAC and rebamipide injected group, yet disruption in the 1% BAC and vehicle of rebamipide injected group Fig. .Figure 3Analysis of the SEM images revealed healthy microvilli on the surface of the LDECs in the group injected with 1% BAC and rebamipide, similar to the findings observed in the control group. On the other hand, healthy microvilli were not observed accompanied with a disruption of the LDECs in the group injected with 1% BAC and the vehicle of rebamipide Fig. .Figure 4in vitro and established a rabbit lacrimal-duct-damage model with BAC in vivo. Our findings revealed that rebamipide attenuates the IL-6-induced decrease of barrier function between rabbit LDECs in vitro, and that it has protective effects on rabbit LDECs in a BAC-induced lacrimal-duct-damage model that disrupts the tight junctions between the cells in vivo. These results suggest that rebamipide suppresses the inflammatory-induced barrier function damage and helps to maintain the LDEC structure, thus protecting against tissue disruption.In this study, we successfully cultivated LDECs et al.6.Although numerous clinical research and anatomy-related studies focusing on lacrimal ducts have previously been performed, there have been few published basic-research reports on the related cell biology. In this present study, we were able to successfully cultivate LDECs until confluence, and subculture the LDECs using the method previously described by Xie 2, and that IL-6, specifically, is increased in the tear fluid of patients with CNLDO3. As the findings in several previous reports have suggested that IL-6 attenuates the barrier function between cells8, our results revealed that IL-6 induced barrier dysfunction of cultured LDECs. In this present study, our findings suggest that the anti-inflammatory effect of rebamipide can maintain intercellular barrier function by suppressing IL-6 inflammation. Based on these results, anti-inflammatory drugs might possibly be one key element in the treatment of lacrimal-duct disease.Inflammation is thought to be a pathology of NLDO, and it has been reported that several inflammatory cytokines, such as IL-2, IL-6, IL-10, vascular endothelial growth factor, and fibroblast growth factor 2, are increased in the tear fluid of patients with PANDO9. Via the injection of BAC, we were able to successfully create a rabbit lacrimal duct damage model. Histological examination revealed obvious disruption of LDECs with the injection of 1% or more BAC. Thus, 1% was selected as the appropriate percentage of BAC to create the lacrimal duct damage model 20. It has also been reported that rebamipide helps to maintain the microvilli of CECs and CjECs against N-acetylcysteine21 and the barrier function between CECs4.It has been reported that rebamipide was first developed as a gastroprotective drug due to its ability to increase gastric mucus production22, the same as in rabbit LDECs. In this present study, we found that rebamipide also helps to maintain the microvilli of LDECs. In regard to lacrimal duct disease, it has been reported that rebamipide clinically improved postoperative results after tube intubation for PANDO5, however, the specific underlying mechanisms for that improvement are still unknown. In this present study, our findings showed that rebamipide improves the disruption of barrier function of LDECs, thus suggesting that its use post-surgery might improve surgical outcomes.Moreover, it has been reported that human LDECs are faced with microvilliin vitro, and that pre-administered rebamipide suppressed BAC-induced cell damage in vivo. Although rebamipide already has a long and well-recognized history of being applied for the treatment of corneal and gastro-intestinal diseases, maybe it can possibility now be repositioned as an effective drug for the protection of LDECs as well.In summary, the findings in this study show that rebamipide has a protective effect against inflammatory cytokines that helps to recover the barrier function of LDECs Supplementary Information


Background/Aims: IntraUterine (IUGR) and ExtraUterine Growth Restriction (EUGR) may induce reprogramming mechanisms, finalized to survive before and after birth. Nutritional factors and other environmental signals could regulate gene expression through epigenetic modification, but the molecular mechanisms involved are not yet well understood. Epigenetic mechanisms could be considered as a bridge between environmental stimuli and long lasting phenotype, acquired during the intrauterine life and the first weeks of life. Our aim was to investigate the relationship between growth patterns, nutritional determinants, and epigenetic pathways.Methods: We enrolled 38 newborns admitted to Neonatal Intensive Care Unit (NICU) at University Hospital of Pisa. Gestational age at birth was <34 weeks and post-menstrual age (PMA) was 36–42 weeks at discharge. We excluded infants with malformations or clinical syndromes. EUGR was defined as the reduction in weight z score between birth and discharge >1 SD. We also evaluated DNA methylation of Imprinting Centre 1 (IC1) at birth and at discharge.Results: We observed a decrease in SD of weight and head circumference mainly during the first weeks of life. We found a correlation between EUGR for weight and for head circumference and an increased IC1 methylation . We observed a relationship between reduced protein and lipid intake and IC1 hypermethylation .Conclusion: IC1 hypermethylation could be a reprogramming mechanism to promote a catch-up growth, by means of an increased Insulin-like growth factor 2 (IGF2) expression, that may have potential effects on metabolic homeostasis later in life. Extrauterine growth restriction is still a serious problem in very low birth weight preterm infants (VLBW), since the gradual improvement in neonatal intensive care has allowed the survival of newborns with an increasingly low weight and gestational age and major necessity of optimal nutrition , 2. In VIn many studies EUGR was defined as growth parameters  ≤ 10th percentile (z-score < -1.28) for post-menstrual age (PMA) at discharge . HoweverNutritional factors and other environmental signals could regulate gene expression through epigenetic modification –14, but Obesity and subsequent metabolic disease in adolescent and adulthood have been associated with adverse intrauterine events in the so-called “Developmental Origins of Health and Disease (DOHaD)” , even ifAn overexpression of IGF2 is also caused by a hypermethylation of its imprinting control region IC1. An important study regarding IGF2/H19 IC1 DNA methylation in human models was conduced by Huang et al. . They shOther studies underlined the relationship between IGF2/H19 IC1 DNA methylation and the development of overweight/obesity. St. Pierre et al.  showed tThe aim of our study was to investigate the relationship between growth patterns, nutritional determinants, and epigenetic mechanisms.We enrolled 38 newborns admitted to NICU at University Hospital of Pisa  from January 2016 to July 2016. Inclusion criteria were: gestational age (GA) at birth <34 weeks and post-menstrual age (PMA) between 36 and 42 weeks at discharge. We excluded infants with congenital malformations or clinical syndromes.We recorded several variables categorized as prenatal, neonatal, auxological, nutritional, and epigenetic factors Table .Among prenatal factors, we considered z-score of weight and head circumference at birth, during the hospital stay and at discharge, using 2013 Fenton growth chart for preterm infants . The useParenteral and enteral feeding was evaluated daily considering the amount of fluids (ml/kg/day), macronutrients (g/kg/day), macroelements (mg or mEq/kg/day) assumed by the newborns. Other infusions  received were considered in the daily fluid intake.The epigenetic analysis was performed on peripheral blood samples in EDTA, collected in two different timepoints (at birth and at discharge). All our evaluations are part of the normal care given to preterm infants and for the evaluation of IC1 methylation we used a small amount of samples, remained after the determination of blood count and/or the cross-tests. DNA extraction was performed using QIAsymphony . Methylation level was evaluated through methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) on one imprinting control region (ICR) on 11p15. MS-MLPA was performed on genomic DNA with SALSA MS-MLPA kit ME030-c3 .t-test for continuous variables and with Odds Ratio (OR) for qualitative variables. Data with skewed distributions were analyzed with a parametric test (Mann-Whitney test). The correlation between two continuous variables was evaluated by linear regression and scatter plots. Values of p < 0.05 were considered statistically significant. Informed consent was collected from neonates' parents for data analysis and blood exams.Statistical analysis was performed using STATA 12 . The distribution of data was tested with the Shapiro-Wilk's test. Comparisons between groups were made by Student's We observed a decrease in SD of weight and head circumference mainly during the first 28 days of life. From 1 month of life to discharge, z-score remained almost unchanged, except for few cases  was 71% and the incidence of EUGR for head circumference (hc) was 50%. Among these EUGR infants, we observed that 30% showed EUGR >2 SD for weight and 37% EUGR >2 SD for head circumference Figures .Among the prenatal and neonatal factors considered, we observed that several factors  were more frequently associated to EUGRw, even if the difference is not significant Table . All ourT-test showed that infants with EUGRw have received a lower protein intake than newborns without EUGRw (EUGRw 2.56 ± 0.05 g/kg/day vs. notEUGRw 2.86 ± 0.06 g/kg/day *p = 0.005). Furthermore, a low lipid intake had also an important role in postnatal growth restriction (t-test: EUGRw 2.03 ± 0.06 g/kg/day vs. notEUGRw 2.38 ± 0.09 g/kg/day *p = 0.005). The different intake of protein and lipid has been observed retrospectively and it is due to the different severity of the clinical conditions.Among all nutritional factors considered Table , the ana*p = 0.009; r2 0.17; Coef −0.05 [95% CI −0.09 to −0.001] *p = 0.043; r2 0.11, respectively; Figures Among all nutritional factors considered Table , we obseRegarding the epigenetic analysis we considered first the correlation between IC1 DNA methylation and weight and head circumference at birth and we did not find any significant correlation.p = 0.018 and p = 0.0028, respectively), respect to newborns without EUGR.Evaluating the methylation levels between birth and discharge, we observed a dynamic trend. An increased methylation of IC1 at discharge, at least 5% over birth values, was found in 47.3% of our cases. We have considered the IC1 hypermethylation in relation with growth patterns, by Fisher's exact test, and we have found significant correlations. Most of the patients with EUGRw and EUGRhc showed an increased IC1 methylation (>5%) from birth to discharge (We observed an elevated incidence of EUGR for weight (EUGRw = 71%) and of EUGR for head circumference (EUGRhc = 50%).Considering weight and head circumference of the infants weekly , it was An appropriate nutrition is known to be fundamental to promote growth and could be crucial for improvement of postnatal growth –37. In oThe effect of nutrition on neonatal growth could be associated with epigenetic mechanism as we observed in our data regarding the correlation between methylation and the protein and lipid intake. Some authors underlined the relationship between reduced protein intake and DNA methylation –41. GongWe found only a negative weak association between protein and lipid intake and IC1 methylation and these data should be evaluated on a larger case series .Regarding the results on epigenetic analysis and auxological parameters, Huang's study showed that a greater IGF2/H19 IC1 DNA methylation was associated with greater subcutaneous fat measures . SecondlWe considered first the correlation between IC1 methylation and weight and head circumference at birth and we did not find any significant correlation . We obsePostnatal head growth restriction is a relatively common condition in preterm neonates and head circumference correlates with brain volume. Different reports have described an association between reduced head size and neurodevelopmental outcome , 43. It We could consider IC1 hypermethylation, associated to reduce nutritional intake in several human and animal models, as a reprogramming mechanism to promote a catch-up growth, by means of an increase of IGF2 expression. In fact in our study infants with EUGRw and/or EUGRhc had an increase of IC1 methylation from birth to discharge. According to this hypothesis, IC1 methylation could be used as a marker of reduced growth and may guides us to prevent severe EUGR. A persistent IC1 hypermethylation since early life could be responsible for an altered metabolic setting, leading to metabolic and cardiovascular complications in the adult life . Our stuThe protocol was approved by the Ethical committee of the University Hospital of Pisa. All subjects gave written informed consent in accordance with the Declaration of Helsinki.MT designed the study, carried out the initial analyses, drafted the initial manuscript, revised it, and approved the final manuscript as submitted. FM carried out the initial analyses, drafted the initial manuscript, and approved the final manuscript as submitted. AM and CC performed genetic analyses, reviewed, and approved the final manuscript as submitted. FL and MC critically reviewed statistical analyses, drafted the initial manuscript, revised it, and approved the final manuscript as submitted. PG conceptualized and designed the study, drafted the initial manuscript, coordinated and supervised data collection, and approved the final manuscript as submitted. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Preeclampsia is a common cause of preterm birth and neonatal morbidity, but its relationship with neonatal respiratory distress syndrome (RDS) remains controversial. We conducted a retrospective cohort study with data from very-low-birth-weight (VLBW) infants born in 1997–2014 from the database of the Premature Baby Foundation of Taiwan to evaluate the relationship between maternal preeclampsia and neonatal RDS. In total, 13,490 VLBW infants were enrolled, including 2200 (16.3%) infants born to preeclamptic mothers. The mean (standard deviation) gestational ages were 30.7 (2.5) weeks in the preeclamptic group and 28.6 (2.9) weeks in the control (non-preeclamptic) group. Severe RDS was defined according to the surfactant therapy requirement. The incidence of severe RDS was lower in infants exposed to maternal preeclampsia than in controls . However, after adjustment for confounders, the OR for severe RDS development in the preeclampsia group was 1.16 . Other factors, such as gestational age, birth weight, female sex, and antenatal receipt of two or more steroid doses were significantly protective against RDS in multivariate regression analysis. This study revealed that maternal preeclampsia slightly increases the risk of severe RDS in VLBW infants. This syndrome poses a great challenge for obstetricians and neonatologists because the optimal timing for delivery is a dilemma. In most cases, preeclampsia occurs at the late preterm or term stage, but about 12% of affected women develop early-onset preeclampsia (at <34 weeks of gestation)2. The etiology of early-onset preeclampsia differs from that of late-onset preeclampsia; abnormal placentation and spiral artery remodeling lead to intrauterine growth restriction and a greater probability of preterm birth5. The rates of perinatal death and severe neonatal morbidity are much higher in association with early-onset relative to late-onset preeclampsia2.Preeclampsia is a systemic syndrome that occurs in 5–10% of pregnant women and is a leading cause of maternal and neonatal morbidity and mortality18. Shah et al.12 found a lower incidence of RDS in preterm  infants born to preeclamptic mother than in a control group. In contrast, Tagliaferro et al.18 found in a cohort study that the risk of severe RDS was increased in extremely premature  infants exposed to preeclampsia. Thus, this study aimed to analyze the relationship between maternal preeclampsia and the development of RDS in very-low-birth-weight (VLBW) infants in a large cohort.Respiratory distress syndrome (RDS) is among the most common complications of preterm delivery. Preterm RDS is secondary to surfactant insufficiency, and its incidence is usually related inversely to gestational age (GA). The literature contains conflicting information on the effect of preeclampsia per se on RDSP < 0.001; Table In total, 13,490 VLBW infants, including 2,200 (16.3%) cases born to mothers with preeclampsia, were enrolled in this study. The mean (standard deviation) GAs were 30.7 (2.5) weeks in the preeclamptic group and 28.6 (2.9) weeks in the control group (odds ratio (OR), 1.30; 95% confidence interval (CI), 1.28–1.32; In a multivariate logistic regression analysis including GA, birth weight, infant sex, SGA, and antenatal steroid use as potential confounders, preeclampsia was associated with an insignificantly increased risk of RDS (adjusted odds ratio (aOR), 1.12; 95% CI, 0.98–1.29; Table Given the uneven distribution of baseline SGA between the preeclampsia and control groups, and the possible interaction between preeclampsia and SGA in the effect on RDS, we performed a subgroup analysis with stratification by SGA. No significant association between preeclampsia and severe RDS was found in the SGA or non-SGA subgroup (OR (95% CI), 1.12 0.94–1.34) and 1.15 (0.95–1.40), respectively; Table –1.34 andIn this cohort study of VLBW infants, the incidences of RDS and severe RDS were lower in infants whose mothers had preeclampsia; we infer that more protective factors were present in the preeclampsia group than in the control group. This assumption was verified by those of the multivariate analysis, which showed that maternal preeclampsia increased the risk of severe RDS, but not RDS, after adjustment for confounding factors. The high incidence or diagnostic rate of RDS of any grade in very preterm infants in our sample may have obscured a difference in RDS risk between the preeclampsia and control groups. The need for surfactant use, which was generally regarded as rescue therapy in Taiwan during our study period (1997–2014), may more objectively represent the presence and the severity of RDS. GA, birth weight, female sex, and antenatal receipt of two or more doses of steroids were protective factors against RDS in this study.12. Those previous studies promoted the belief that maternal preeclampsia accelerates fetal lung maturation. Some trial results also supported the enhancement of biochemical lung maturation profile by chronic in utero stress, possibly via increased fetal cortisol production9. The most recent study to support such a protective effect of preeclampsia on RDS was a large cohort study conducted in the Netherlands10. However, that study was conducted to examine the outcomes of late-onset preeclampsia . Our preeclampsia group contained mainly early-onset preeclampsia cases, with a different pathogenesis and worse neonatal outcomes relative to late-onset preeclampsia2.Our findings are contrary to previous findings that preeclampsia is a protective factor against RDS13. Even more, preeclampsia was associated with an increased risk of neonatal RDS in several studies, consistent with our findings19. In a large national cohort study conducted in the United States, which included 156,681 infants born to mothers with preeclampsia, the greater probability of RDS was found in the preeclamptic group compared to the non-preeclamptic group (6.6% vs. 1.9%)17. Another recent single-center cohort study including infants born at 23–28 gestational weeks also revealed that preeclampsia increased the risk of severe RDS18. Preeclampsia is characterized by an imbalanced maternal angiogenic state, resulting in generalized endothelial dysfunction, increased levels of maternal antiangiogenic factor soluble fms-like tyrosine kinase-1 (sFlt-1), and decreased free circulating levels of the angiogenic factors vascular endothelial growth factor (VEGF) and placental growth factor23. VEGF is important for normal lung vasculature24 and surfactant protein production27. sFlt-1, an antagonist of VEGF, can impede VEGF signaling and lead to impaired surfactant production. RDS is secondary to surfactant insufficiency, and low VEGF concentrations have been associated with RDS severity in preterm infants31. Similarly, high sFlt-1 and/or low VEGF levels have been observed in neonatal cord blood and tracheal aspirates from infants born to preeclamptic mothers36. Higher sFlt-1 concentrations have also been noted in amniotic fluid from preeclamptic mother34. Wang et al.16 demonstrated that preeclampsia was correlated with a higher maternal circulating sFlt-1 level and an increased risk of neonatal RDS. All of these findings imply that preeclampsia creates not only a stressful intrauterine environment, but also an unfavorable state for fetal lung surfactant production. A study of infants born prematurely to mothers with severe preeclampsia or amniotic infection found that non-surviving infants exposed to preeclampsia had a higher proportion of accelerated morphologic lung maturation than non-surviving infants exposed to amniotic infection (40% vs. 5%). However, the remaining survivors in the preeclampsia group needed more respiratory support after the first 24 hours, indicating greater surfactant insufficiency37.On the other hand, accumulating data indicate the absence of a protective effect of maternal preeclampsia on the fetal respiratory system40. In this study, the incidence of SGA in the preeclamptic group was very high, perhaps due to the application of inclusion criteria according to birth weight instead of GA, and thus the enrollment of more SGA infants. Although the association between preeclampsia and severe RDS was insignificant in our subgroup analysis, the trend of increased risk was consistent in both groups. This finding indicates that preeclampsia and SGA do not interact significantly in affecting RDS. In the whole-sample multiple regression analysis, 95% CIs for the association of preeclampsia with severe RDS were very close to 1, which may explain the failure to detect a significant difference in the subgroup analysis in this small sample.In the present study, baseline characteristics showed a high degree of heterogeneity between the preeclampsia and control groups. Infants born to preeclamptic mothers had significantly greater birth weights and GAs, and the female predominance and SGA proportion were greater in this group than in the control group. SGA status is a common complication of preeclampsia, with a widely ranging incidence of 13.36–52%41. Amorim et al.42 reported that antenatal corticosteroid therapy could reduce the risk of RDS in the presence of severe preeclampsia at 26–34 weeks of gestation. Our study revealed a weak positive association between preeclampsia and severe RDS, with other covariates also contributing to neonatal RDS development. Thus, the relationship between preeclampsia and RDS could be divergent if all confounding factors are not taken into consideration. This situation may reasonably explain the discrepant results obtained in previous studies, given the small sample and examination of different potentially confounding factors.Birth weight and GA are known to correlate negatively with RDS; male sex also contributes to an increased RDS risk15.The main strength of our study was the examination of a large cohort of VLBW neonates; the mean gestational age was 30 weeks, which indicated that most mothers with preeclampsia had the early-onset form of this condition. We also excluded mother with histories of chronic hypertension, which may alter the pathogenesis and effects relative to those of maternal preeclampsia alone. Another large cohort study of infants delivered at >23 gestational weeks’ (average 37 weeks’) revealed an increased risk of RDS in the presence of maternal hypertensive disorder, and different neonatal outcomes among cases of maternal gestational hypertension, mild chronic hypertension, and mild preeclampsiaOur study has some limitations. First, the reliability of our data depends on the accuracy of pediatricians’ records, but the large sample size minimizes the potential effect of this factor. Second, maternal comorbidity, body mass index, and severity of preeclampsia were not recorded in the neonatal-oriented registration database. Third, the type and total dosage of antenatal steroids, and the interval between their use and delivery, were not recorded in the database. Additionally, RDS diagnoses were based on physicians’ subjective interpretations of clinical and chest X-ray data, which may cause bias. For this reason, we took surfactant usage as an objective indicator of severe RDS.In this population-based cohort study of VLBW infants, we found early-onset maternal preeclampsia slightly increased the risk of severe RDS compare with preterm delivery of other causes, whereas GA, birth weight, SGA, female sex and antenatal use of two or more doses of steroids were prominent protective factors that decreased the risk of RDS.43. The data collected included antenatal and perinatal histories, delivery mode, neonatal histories including diagnoses, complications during hospitalization, and clinical outcomes at discharge. Patient information received by the database coordinator was cross checked with the national birth registry. The exclusion criteria were congenital anomalies, chromosomal anomalies, and maternal chronic hypertension with or without preeclampsia. The cases were divided into the preeclampsia and control (non-preeclampsia) groups. Preeclampsia was defined as diastolic blood pressure ≥90 mm Hg with proteinuria ≥1+ (30 mg/dl) on dipstick testing or non-dependent edema during pregnancy44.This study was based on data on all VLBW infants born from 1997 to 2014 in all 22 neonatal departments in Taiwan, registered in the database of the Premature Baby Foundation of Taiwan. VLBW was defined as birth body weight <1500 gWritten informed consent was obtained from included subjects’ parents or legal guardians. The study was approved by the Institutional Review Boards of eight participating hospitals , and Joint Institutional Review Board for the other participating hospitals. All research was performed in accordance with relevant guidelines and regulations.45.RDS was diagnosed by neonatologists in charge of the infants’ care according to clinical symptoms and signs, chest X-ray findings, and arterial blood gas findings. Mainstream surfactant therapy was used as a rescue treatment rather than a prophylactic during the study collection period in Taiwan. Thus, we defined severe RDS according to the requirement for surfactant therapy. Antenatal steroid usage was defined as the receipt of any type of steroid prior to delivery to accelerate fetal lung maturation. SGA status was defined as birth body weight <10th percentile for gestational aget-test were used to compare the distributions of categorical and continuous variables, respectively, between groups. A multivariate logistic regression model was used to analyze the association between maternal preeclampsia and RDS risk, with adjustment for potential confounders. The confounders included demographic and clinical variables that differed between the preeclampsia and control groups in univariate analysis. aORs with 95% CIs were calculated to assess the magnitudes of the associations between various factors and RDS risk. Significance was determined by two- tailed P < 0.05. The association between preeclampsia and RDS was further examined in a subgroup analysis stratified according to SGA.The chi-squared test and Student’s


Evidence shows that negative childbirth experiences may lead to undesirable effects including failure to breastfeed, reduced love for the baby, emotional upsets, post-traumatic disorders and depression among mothers. Understanding childbirth experiences and their meaning could be important in planning individualized care for mothers. The purpose of this study was to explore childbirth experiences and their meaning among postnatal mothers.A phenomenological qualitative study was conducted at Mbale Regional Referral Hospital among 25 postnatal mothers within two months after birth using semi-structured interviews and focus group discussions and data was thematically analyzed.The severity, duration and patterns of labour pains were a major concern by almost all women. Women had divergent feelings of yes and no need of biomedical pain relief administration during childbirth. Mothers were socially orientated to regard labour pains as a normal phenomenon regardless of their nature. The health providers’ attitudes, care and support gave positive and negative birth experiences. The Physical and psychosocial support provided comfort, consolation and encouragement to the mothers while inappropriate care, poor communication and compromised privacy contributed to the mothers’ negative childbirth experiences. The type of birth affected the interpretations of the birth experiences. Women who gave birth vaginally, thought they were strong and brave, determined and self-confident; and were respected by members of their communities. On the contrary, the women who gave birth by operation were culturally considered bewitched, weak and failures.Childbirth experiences were unique; elicited unique feelings, responses and challenges to individual mothers. The findings may be useful in designing interventions that focus on individualized care to meet individual needs and expectations of mothers during childbirth. Childbirth experiences are the women’s personal feelings and interpretations of birth processes. Birth experiences to some women have meant hard work, exciting lovely event and to others it is a stressful, exhausting and unpredictable experience. Negative experiences have been associated with poor support and care, fear, excessive pain, discomfort and undesirable outcomes. Participating in making decisions regarding childbirth care and being supported by healthcare providers gives a positive memory and increases the woman’s confidence and love for the baby and better adjustment to motherhood. Understanding the women’s childbirth experiences and their meaning is important in providing socially acceptable individualized care during and after birth. In Uganda, few studies on childbirth experiences of mothers and their meanings have been done. This study explored childbirth experiences and their meanings among women within two months after giving birth. Twelve women were interviewed one on one and thirteen women in two groups of seven and six in Mbale Regional Referral Hospital, in the Eastern part of Uganda. The women reported unique experiences of labour pains, they had social orientation on labour and gave different views on pain management during birth. Negative and positive attitudes and care by service providers were described and the social support from the significant others was noted as a source of comfort and encouragement. The personal women’s and society’s interpretations of birth experiences focused on the type of birth undergone. The vaginal birth meant braveness to some mothers and caesarean birth was associated with witchcraft and weakness of a woman. In conclusion, the individual mothers had unique childbirth experiences that required service provider’s understanding and personalized care.Childbirth is a significant event in a woman’s life and a transition to motherhood. Childbirth experiences are the subjective psychological and physiological processes, influenced by the social and environmental factors . Birth eChildbirth experiences could be both positive and negative. Negative experiences are characterized by fear, excessive pain, poor support and care, discomfort and undesirable outcomes –8. The nUnderstanding the women’s childbirth experiences and their meaning is crucial in the provision of individualized and culturally sensitive care during and after childbirth –17. A nuA phenomenological qualitative research design was used. Phenomenological qualitative research is an approach that describes life experiences and gives them meaning . The desPurposive sampling was used to recruit participants. Purposive sampling allows a researcher to get rich information to a particular research question . The resTo build the credibility and better understanding of the childbirth experiences two methods of data collection were used; the semi-structured interviews (SSI) and the focus group discussions (FGDs).. A semi-structured interview guide with open ended questions and probes were used to explore and understand better the issues as they emerged [Twelve (12) semi-structured interviews with postnatal mothers were conducted in Luganda and English by the first author at YCC in a quiet room adjacent to the clinic. The saturation was reached with 12 interviews where the answers from mothers seemed to repeat information gained earlier with little new information . A semi- emerged  and elicTwo FGDs with postnatal mothers were conducted. The discussion groups included 6 and 7 postnatal mothers. The first author moderated the discussions and notes and non-verbal clues were taken by the assistant, the clinic midwife who was not involved during the participants’ recruitment process. The FGD guide used centered on the mothers’ childbirth experiences and their meanings. The discussions were held in Luganda, the local language of instruction in schools, spoken and preferred by all participants and all the discussions were audio recorded with permission from participants. The discussions lasted between 60 and 80 min.Thematic analysis guided the analysis of data. All the audio recorded interviews and discussions were transcribed verbatim and were translated from Luganda to English. The English translated transcripts were reviewed and edited to ensure correct interpretation of the mothers’ accounts. The analysis procedure included familiarization with the material through careful reading of sentence by sentence for many times, identification of the codes, searching for subcategories, formulation, revision and interpretation of themes. Phrases and sentences related to the mothers’ experiences of childbirth were coded in the margin of the transcript sheets. The coding was predominantly close to the text using mothers’ own descriptions. The codes with similar content were then brought together into sub-categories and themes. The authors discussed and reflected on the interpretations of the mothers’ descriptions of their childbirth experiences and agreed on the themes. Anonymous quotes were used to illustrate the facts..Qualitative researchers suggest the use of credibility, transferability, dependability and conformability as methods to ensure trustworthiness in qualitative studies , 25. Then = 7), teachers (n = 6), business women (n = 6), students (n = 2), a journalist, an administrator, a peasant and health information assistant (n = 1). They were between 18 and 33 years of age, 88% (n = 22) were married; 88% (n = 22)gave birth in the health facilities and 12% delivered at their homes or from the traditional birth attendant. Their parity ranged from one to five and the majority were Christians (Born again (32%), Protestants (24%), Catholics (12%), the rest were Moslems (32%).The 25 women who were interviewed about their childbirth experiences described themselves as housewives  themes emerged. These included the Childbirth experiences  and the Meaning attached to childbirth experiences . The Women reported diverse trends in their birth experiences that provided the differences and the basis for emphasis. Numbers were used to identify participants during group discussions instead of names for privacy purposes and fictive names are used in the presentation of quotes.This is the 4thborn, other children never pained me like this one,…contractions were very strong and I reached a point when I did not understand well, they just lifted me up on to the bed. ….I just found myself delivered. After delivering, my senses came back The memory of labour pains remained in the minds of almost all women and formed the basis for their stories. The women’s birth pain experiences were viewed and expressed in terms of intensity, duration and patterns. The severe labour pains to some women were characterized by the temporary moments of confusion and loss of understanding as one mother expressed:Labour for my last born was hard, because the pains were much and later the contractions stopped. …..later the midwives put on a drip for contractions .Rose who experienced abnormal labour patterns also said:…the contractions pained me for 3 days… I went back, they examined me … I was still not ready. I walked and walked …. I went back at 6.00pm .Some womenexperienced labour for a long duration and its effects were reported with dismay, frustration and loss of hope as one mother explained:My attendants told me, contractions pain but you must be strong, and when time comes for the baby to come out, the baby itself will force you” .“The labour pain aspect of childbirth is one dimension that is given attention in various ways. In this study, the women were socially oriented to view labour pains as a normal phenomenon regardless of intensity, duration and varying patterns. This psychological care in preparation for birth provided consolation, hope and encouragement as narratives below indicate:“Getting much pain happens and is human and normal to a woman, but it is God who gives you the life and energy” .Next time I deliver, I would not want to have too much labour pains like the ones I went through. If that medicine was there, I would feel like having such a drug to reduce the pain .Labour pain management elicited mixed feelings from participants. Some women believed childbirth is natural and therefore should be left to take the natural course, while others felt it was necessary to reduce on the birth pains through medication if it was possible. According to the women’s descriptions, none of them received biomedical painkillers during birth and one mother explained:“I think no need of medicine, because it is natural. I think even if they give you some medicine for pain, contractions would still come because the baby has to come out. I think the drugs cannot reduce those pains…every other woman goes through that” .Some women doubted as to whether medicine could have an effect on a natural process like labour pains as they had no prior knowledge to the interventionbirths, majority of women had given birth from the Regional Referral Hospital apart from one woman who had delivered from a private maternity centre. The women’s comments generally centred on the attitude of service providers, the interpersonal communication, the physical and psychological support and how the labour complications were managed. For those who felt good about their labour experiences described them in form of the good reception and attention given to them, the physical and psychological support through counseling; being listened to and having been given appropriate management to the complications as some mothers narrated:The midwives were good…. even when they were attending to other people, when I would also call her (musawo) meaning a health care provider, also come and help me, She would not shout at me, would say let me come, I am hearing. I used to hear that they shout at people but for me they never shouted at me. .The experiences of women regarding care and support received in the health facilities varied from positive by some mothers to negative and non-satisfying by others. Regarding institutional The midwives welcomed me well, examined me … delivery time had not reached. I told them, basawo, I am sick, (HIV positive) they said you have done a good thing to tell us…, they said don’t fear. Some hide and do not tell us. ….when the time reaches you will push well and in case something wrong happens, we will help you. When time came, the midwife helped me to climb the bed. After delivery, I bled a lot … quickly they ran and gave me an injection and blood stopped. … weighed the baby, wrote treatment and gave the syrup for the baby .Another one said:…. I called her that I feel like something pushing me, she never bothered. She said, “Keep quiet, for you, you are making yourself tired for nothing, you are not going to deliver now”. I forced to deliver myself, what can I do? (Voice tone lowered) I said that if I relax I would lose my baby…. When the midwife reached, the baby was out and a lot of water (liquor) had poured on the baby. She (midwife) got annoyed, quarreled…. She cut the baby’s cord from that water yet I normally see midwives cut the cord from the mother’s abdomen. I felt too bad.As some mothers expressed their birth experiences with confidence and trust in service providers, to others it was a moment of reflection on the sadness, suffering and agony they went through. The women described experiences of non- caring attitude, limited technical care and support; quarreling and being rough to them. Rose,one of the mothers that was cared for by the morning and evening ward staff described her experience with the midwife of the 2nd shift:… the midwife told me to push. I tried to push and push, she was even slapping me telling me to push. The old woman (attendant) had given the midwife some money, now she was on my “bamper” (on my neck). “I have told you to push the baby with slaps”The practices reflected by some health care providers were unethical and violated the rights of the clients as one mother who was slapped during the time she pushed her baby narrated:….now you are under stress and you feel like… they have to do it (operation) immediately. “They take you in the theatre room, you again spend some good time there when they are still organizing. It was too bad, ….now even you feel stress is coming back again , you try to console yourself , you control…As you wait, you are naked, you are exposed there… (laughed while shaking her head)… you know how funny it is. ..you are nude. It was not good, privacy was not enough”. .Giving birth by caesarean was a hurdle. One mother who was taken to the theatre for the caesarean birth experienced delay to be operated as theatre was unready causing her stress and anxiety. This was heighted by being left exposed naked, a factor that compromised her privacy as she lamented:….. the doctor told me, Irene, with you, you are just going for an operation. …I had to break down… because I was like what has gone wrong? ... why not me to deliver like other women? ….they are telling me I am going for an operation but they are not telling me the cause! Doctor Just told me, the baby was big. He then used some medical language that I did not understand. She did not convince me as to why I should have an operation… they were talking alone! .Many women were giving birth for the first time and as such needed more information regarding labour and its proceedings. Women noted limited effective communication and sharing of information by the service providers. The non-involvement of a mother in decision-making regarding her care resulted in a number of unanswered questions as one woman explained:The mothers according to their narratives appreciated the presence, proximity, the physical and psychological support from their birth companions that were basically family members  and friends. Physically, the women were supported by giving them food and drinks like tea, they were supported to walk around before reaching second stage of labour and their backs were rubbed to provide relief during contractions by their birth companions.Attendants (birth companions)helped me to get tea to drink, they kept around, and during that time when I could get the contractions, they could support me at the back, rub it, I could get some relief of about one minute.Eseza a 23 year old mother of 3 recounted:“At that time when I broke down,… my sister in law and mother in law were there for me. They tried to counsel and consoled me but still it wasn’t an easy moment”Irene, a 26 year old primepara, who was supported through counselling by a relative before a caesarean birth recalled:My husband was not near, had feared and moved away. I never wanted him to be near because when you are in labour the face changes, you may say that it is this one who brought the problems and get annoyed with him (laughed) .The male partners were involved in intrapartum care of their spouses at different times and in various ways. Although their  physical presence was registered at the hospital, their participation in real care was minimal. One mother whose husband was in hospital but at a distance from the maternity unit commented:When I came back to the labour ward they told me “the baby has reached you push”, I was not feeling any energy. ….my husband helped me, held me and he never feared. When the baby was coming out, he told me that “bambi” (meaning my friend) push more,the head is coming, add in more effort. … I felt good, I liked it so much because he gave me support,and he was there .Another mother whose husband fully participated in the processes of the birth of their baby by being present at the side of his partner and providing physical and psychological support during the pushing time gave her story:It is hard when you are going for a cesarean birth, you are always worried. …… you are not sure of what is going to happen there….. in such situation the mother is not sure of the baby’s survival and her own wellbeing; or she might come out with complications. Yah…it is like you are going for trouble when you are seeing (mother laughed) .Childbirth is a moment of unpredictable “next” in terms of the outcome of the baby and mother both to those who give birth normally and by caesarean birth. In this study, these experiences were worsened by giving birth by a caesarean resulting into mothers’ fear, anxiety and loss of hope for survival as one woman recalled:The doctor told me, “Irene, with you, you are just going for an operation at 10am”. ….I had to break down, I did not know … “if others can push normally, why not me?” At 10 a.m I refused the operation. I told them I don’t want, give me time ……I had feared the theatre because with me I knew whoever goes to theatre, does not come back. They just die like that. I imagined very many thingsThe situation can be more terrifying to those who are giving birth for the first time. Irene, a first time mother had refused a caesarean birth for fear of losing her life in theatre until all hope of delivering normally was lost.“... I forced to deliver myself”….in that difficulty situation I went through, I got scared, I feared the midwives of the main hospital (government). I feared too much, I said next time when I deliver, at least I go to private but not go back to main hospital. .Multidimensional sources of fear were reported in this study. One mother who experienced excessive bleeding and a retained placenta regretted the decision she had made of delivering at home: “being with aunt alone I feared, I felt my life was going and regretted not having been in hospital”. The mistreatment of women by health care providers was sofrightening that one mother vowed never again to deliver in that hospital as she expressed it:The negative stories (the past experiences by other mothers) about the institutional care were noted to be far reaching and a source of childbirth fears regarding the place of delivery. One mother who presumed and perceived hospital care negatively resorted to practices that undermine the quality of birth outcomes as she gave birth at the TBA’s home and gave her account:“I refused going to hospital. I had no appetite of going there. What I hear threatened me. I hear in the hospital they don’t care about you, you care for yourself. ……..You are seeing this one is complaining, that one grumbling, another one is dying, I avoided such things. I said at least, for me let me die from here (TBA’s) and those other ones die there in hospital” .things to do with childbirth, it is God’s grace and others affirmed:You must believe in yourself and believe in God. ….for me during birth, I said yes I will do it… I became firm and pushed the baby. Believing in yourself helps you to push the baby .It’s not an easy thing but when you are determined, God can be by your side, yah then you will get a child” .“The individual women interviewed had varying personal interpretations of their birth experiences. The sense made out of it was determined by what preoccupied the woman at that time of labour, the transpirations of the day and the outcomes. The supremacy of God in the event of childbirth was strongly expressed by many women but in union with self-belief and determination of an individual. The women were convinced that God had to be in control for a successful birth. One woman said; ….As some women believed childbirth had a strong bearing on one’s personal effort put in during labour, to others birthing without complications was perceived and directly associated with “being strong and brave” as accounts below indicated:.... people used to consider me as a weak person and thought I would not manage to give birth by myself… but I demonstrated that I am strong, …I pushed the baby without any problem others when they start to push, they push and even die. I had to push and I saw the baby; then what I concluded is that i am brave because it is not easy there”“….. Anna, a 28-year-old first time mother also added:When women were asked to comment on how society perceived the different birth experiences they had gone through, the responses were cross cutting despite mothers being from different tribal and cultural backgrounds. The socio- cultural interpretations were mainly bent on the type of birth a woman went through. A mother was considered a strong woman if she gave birth well  and the operated were regarded bewitched, failures or weak women.The Gisu’s themselves think that when you go for an operation, …. you are bewitched. …you are unable to have children, unable to be a real housewife; … not a good house woman to make a child for somebody.Caroline, who had 3 consecutive operations said:Culturally, to the illiterate, they assume whoever goes for an operation failed to push. You are a weak woman. So, they were insulting me “eeeh she had just fattened, but you see, she failed to push the baby”.Irene, a first- time mother who delivered by caesarean birth was insulted by the community members as she explained:The study explored and presents the childbirth experiences among postnatal mothers and the meaning attributed to such experiences. The themes that emerged majorly focused on childbirth pains and management, institutional care and support, social support, childbirth fears and the meaning attributed to their childbirth experiences.The intensity of labour pains, the duration and patterns gave women different birth experiences and responses. The varied experiences were a reflection that each labour and birth a woman goes through is a unique experience even to women who have given birth before .This calThe women’s experiences of care and support varied from positive to negative and non-satisfying. The majority of women had given birth from the Regional Referral Hospital apart from one woman who had given birth from a private maternity centre. The needs and expectations of mothers in labour may seem to be many, however from this study it became apparent that giving attention and listening to women; good interpersonal communication and involving them in their care plans were key; the provision of physical and psychological support and competence in the management of complications were all paramount. The extent to which care met the individual expectations of mothers influenced the individual comments which were either reflective of a positive or negative birth experience. The women who received attention, good care and support expressed comfort and contentment of the hospital services and built high degree of confidence in the service providers and themselves. In a study done in Australia, women who were under supportive midwives felt contented with their childbirth experiences as opposed to those who were not and felt frustrated . SimilarSupport from family members  and friends was strongly noted during this study. Escorting women to the birth places, provision of food and other requirements; rubbing the back, helping the mother to move to and forth were among the physical support given. Psychologically, they were supported through consolation and counseling and orientation on labour pains before or during labour. Social support in this study was strongly noted as a source of comfort, encouragement and hope to the mothers as strongly supported in other studies .The presence of the male partner in the labour ward and his proximity to the spouse was appreciated by some women while others felt comfortable when their spouses were at a distance for fear of shifting blame to their male partners as trouble causers. Such divergent views and feelings about the men’s availability in labour wards have been cited in  in whichThe fears of childbirth reported in this study were majorly associated with the uncertainties of birth outcomes especially women who underwent an operation for they were not sure of the lives of the baby and self; or whether it would result in complications. Similarly, Corbett and Callister  found ouThe non-satisfying childbirth experience due to the negative attitudes and practices of the health care providers frightened women and as such they vowed never again to give birth in the public hospitals. Furthermore, the stories the mothers heard from other women about the care and the practices of health care providers in hospital, caused some women to resist moving to hospital with the eventual decision to give birth with the TBA. This puts a woman further at risk and undermines the quality of the outcomes of labour given the limited level of knowledge and skills of the traditional birth attendant .AlthoughThe meaning of the childbirth experiences captured was two folded. The first one was – the mother’s personal interpretation of her own birth experience and two was how other people in the community interpreted the birth experience she went through. The women drew personal meanings and lessons of their birth experiences mainly from the nature of labour pains they had, the treatment by the service providers, the complications experienced and the labour outcomes. According to their accounts, women felt it was important and safer to deliver in a hospital especially those who had given birth at home and those who got complications like severe bleeding.Such lessons learnt could be helpful to a woman to subsequently make rational decisions regarding the birthing place. On the contrary, in a study done among Hmong women of Vietnam, majority of participants preferred a home birth for fear of loss of control over birth care decisions, limited comfort and loss of the placenta for cultural rituals .FindingsThe cultural and social interpretations of childbirth experiences were the perceived meanings of childbirth by other people. Given the fact that these mothers were living in the same communities, it was speculated that the participants knew or had heard what people say about their birth experiences. According to the accounts of mothers, the majority of meanings were drawn from the type of birth one underwent. Culturally, every woman is expected to be strong, endure with pain and give birth vaginally. So, if a woman gave birth by caesarean, she would be considered bewitched, failed to push (a failure), weak and a woman not good to make a housewife. These findings might be so because in many African cultures, what goes wrong is thought to be an influence of evil spirits. They also believe in big number of children yet a mother, who is operated right from the first child, can safely produce four. Such interpretations may cause loss of self-esteem leading to poor adjustment to motherhood . UnderstChildbirth experiences were got from mothers of parity five and below despite trying hard to look for those ones with parity above five. These possibly would have given different stories regarding childbirth. Literature from Africa on childbirth experiences and their meaning to mothers was limited giving a narrow point of reference when discussing the results in regard to the African context. Therefore, we recommend that subsequent similar or related studies look at settings like Latin America for a broader and closer contextual comparison. The socio cultural interpretations of the childbirth experiences may not fully reflect the views of all the other people in the studied community given the narrow source of the views.Childbirth experiences were unique and elicited unique feelings, responses and challenges to individual mothers, thus the need for the proper assessment and understanding of women for personalized care. It is important to note that pain management during labour is a necessity and a right of a woman to experience a pain free labour and birth for a positive childbirth outcome for those who embrace it. Creating a good birthing environment with the health care providers that are competent, compassionate and supportive to their clients, builds a sense of trust, and confidence in them and their services and the institution at large which promotes the general wellbeing of a woman at birth. Understanding the societal perceptions of childbirth experiences provides a basis for identifying and designing interventions to support the victimized mothers and the communities to understand childbirth.Childbirth experiences: Is an individual woman’s life event that incorporates interrelated subjective psychological and physiological processes, influenced by social, environmental, organizational and policy contexts [contexts .Childbirth: In this study, childbirth referred to labour and birth.Experiences: the personal lived through encounter of the phenomenon.Mothers: women who had been pregnant and delivered.Meaning: were the individual and subjective interpretations of a situation or a happening (her childbirth experiences) by the mother.Postpartum period: Is the period from one hour following the delivery of the placenta up to six weeks . However, in this study the postpartum period referred to the period from one hour after the birth of the placenta up to eight weeks or two months.