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To compare the performance of mid upper arm circumference (MUAC) and body mass index (BMI) for prediction of small for gestational age (SGA) in Zambia.This is a secondary analysis of an ongoing clinical cohort that included women with a single gestation and MUAC measured before 24 weeks of pregnancy. We assessed relationships between maternal MUAC and birth weight centile using regression. The performance of MUAC and BMI to predict SGA was compared using receiver operating characteristic curves and the effect of maternal HIV was investigated in sub-group analyses.Of 1117 participants, 847 (75%) were HIV-negative (HIV-) and 270 (24%) were HIV-positive (HIV+). Seventy-four (7%) delivered severe SGA infants (3rd centile), of whom 56 (76%) were HIV- and 18 (24%) were HIV+ (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.58-1.75). MUAC was associated with higher birth weight centile (+1.2 centile points, 95% CI 0.7-1.6; P 0.001); this relationship was stronger among HIV+ women (+1.7 centile points, 95% CI 0.8-2.6; P 0.001) than HIV- women (+0.9 centile points, 95% CI 0.4-1.4; P = 0.001). The discriminatory power was similar, albeit poor (area under the curve [AUC] 0.7), between MUAC and BMI for the prediction of SGA. In stratified analysis, MUAC and BMI showed excellent discrimination predicting severe SGA among HIV+ (AUC 0.83 and 0.81, respectively) but not among HIV- women (AUC 0.64 and 0.63, respectively).Maternal HIV infection increased the discrimination of both early pregnancy MUAC and BMI for prediction of severe SGA in Zambia.ClinicalTrials.gov (NCT02738892).

Knowledge regarding the frequency of ocular abnormalities and abnormal visual function in children exposed to Zika virus (ZIKV) in utero but born without congenital Zika syndrome (CZS) is limited. We hypothesized that children exposed to ZIKV in utero born without CZS may have visual impairments in early childhood. We performed ophthalmic examination between 16 and 21 months of age and neurodevelopment assessment at 24 months of age with the Mullen Scales of Early Learning test (MSEL) on children enrolled in a cohort born to women pregnant during and shortly after the ZIKV epidemic in Nicaragua (2016–2017). ZIKV exposure status was defined based on maternal and infant serological testing. Visual impairment was defined as abnormal if the child had an abnormal ophthalmic exam and/or low visual reception score in the MSEL assessment. Of 124 children included in the analysis, 24 (19.4%) were classified as ZIKV-exposed and 100 (80.6%) unexposed according to maternal or cord blood serology. Ophthalmic examination showed that visual acuity did not differ significantly between groups, thus, 17.4% of ZIKV-exposed and 5.2% of unexposed had abnormal visual function (p = 0.07) and 12.5% of the ZIKV-exposed and 2% of the unexposed had abnormal contrast testing (p = 0.05). Low MSEL visual reception score was 3.2-fold higher in ZIKV-exposed than unexposed children, but not statistically significant (OR 3.2, CI: 0.8–14.0; p = 0.10). Visual impairment (a composite measure of visual function or low MESL visual reception score) was present in more ZIKV-exposed than in unexposed children (OR 3.7, CI: 1.2, 11.0; p = 0.02). However, the limited sample size warrants future investigations to fully assess the impact of in utero ZIKV exposure on ocular structures and visual function in early childhood, even in apparently healthy children.

To measure maternal/fetal SARS-CoV-2 antibody levels.A prospective observational study of eligible parturients admitted to the hospital for infant delivery was conducted between April and September 2020. SARS-CoV-2 antibody levels were measured in maternal and umbilical cord specimens using an in-house ELISA based on the receptor-binding domain (RBD) of the spike protein. Among SARS-CoV-2 seropositive patients, spike RBD antibody isotypes (IgG, IgM, and IgA) and ACE2 inhibiting antibodies were measured.In total, 402 mothers were enrolled and spike RBD antibodies in 388 pregnancies were measured (336 maternal and 52 cord specimens). Of them, 19 were positive (15 maternal, 4 cord) resulting in a seroprevalence estimate of 4.8% (95% confidence interval 2.9-7.4). Of the 15 positive maternal specimens, all had cord blood tested. Of the 15 paired specimens, 14 (93.3%) were concordant. Four of the 15 pairs were from symptomatic mothers, and all four showed high spike-ACE2 blocking antibody levels, compared to only 3 of 11 (27.3%) from asymptomatic mothers.A variable antibody response to SARS-CoV-2 in pregnancy among asymptomatic infections compared to symptomatic infections was found, the significance of which is unknown. Although transfer of transplacental neutralizing antibodies occurred, additional research is needed to determine how long maternal antibodies can protect the infant against SARS-CoV-2 infection.

Postpartum depression (PPD) is a prevalent and debilitating disease that may affect medication adherence and thus maternal health and vertical transmission among women with HIV. We assessed the feasibility of a trial of interpersonal psychotherapy (IPT) versus antidepressant medication (ADM) to treat PPD and/or anxiety among postpartum women with HIV in Lusaka, Zambia.Between 29 October 2019 and 8 September 2020, we pre-screened women 6-8 weeks after delivery with the Edinburgh Postnatal Depression Scale (EPDS) and diagnosed PPD or anxiety with the Mini International Neuropsychiatric Interview. Consenting participants were randomized 1:1 to up to 11 sessions of IPT or daily self-administered sertraline and followed for 24 weeks. We assessed EPDS score, Clinical Global Impression-Severity of Illness (CGI-S) and medication side effects at each visit and measured maternal HIV viral load at baseline and final study visit. Retention, visit adherence, change in EPDS, CGI-S and log viral load were compared between groups with t-tests and Wilcoxon signed rank tests; we report mean differences, relative risks and 95% confidence intervals. A participant satisfaction survey assessed trial acceptability.78/80 (98%) participants were retained at the final study visit. In the context of the COVID-19 pandemic, visit adherence was greater among women allocated to ADM (9.9 visits, SD 2.2) versus IPT (8.9 visits, SD 2.4; p = 0.06). EPDS scores decreased from baseline to final visit overall, though mean change was greater in the IPT group (-13.8 points, SD 4.7) compared to the ADM group (-11.4 points, SD 5.5; p = 0.04). Both groups showed similar changes in mean log viral load from baseline to final study visit (mean difference -0.43, 95% CI -0.32, 1.18; p = 0.48). In the IPT group, viral load decreased significantly from baseline (0.9 log copies/ml, SD 1.7) to final visit (0.2 log copies/ml, SD 0.9; p = 0.01).This pilot study demonstrates that a trial of two forms of PPD treatment is feasible and acceptable among women with HIV in Zambia. IPT and ADM both improved measures of depression severity; however, a full-scale trial is required to determine whether treatment of PPD and anxiety improves maternal-infant HIV outcomes.

Background Neurodevelopmental outcomes of asymptomatic children exposed to Zika virus (ZIKV) in utero are not well characterized. Methods We prospectively followed 129 newborns without evidence of congenital Zika syndrome (CZS) up to 24 months of age. Participants were classified as ZIKV exposed or ZIKV unexposed. The Mullen Scales of Early Learning (MSEL) was administered in the participants’ homes at 6, 12, 15, 18, 21, and 24 months of age by trained psychologists. Sociodemographic data, medical history, and infant anthropometry at birth were collected at each home visit. Our primary outcome was the Mullen Early Learning Composite Score (ECL) at 24 months of age between our 2 exposure groups. Secondary outcomes were differences in MSEL subscales over time and at 24 months. Results Of 129 infants in whom exposure status could be ascertained, 32 (24.8%) met criteria for in utero ZIKV exposure and 97 (75.2%) did not. There were no differences in maternal age, maternal educational attainment, birthweight, or gestational age at birth between the 2 exposure groups. The adjusted means and standard errors (SEs) for the ELC score between the ZIKV-exposed children compared to ZIKV-unexposed children were 91.4 (SE, 3.1) vs 96.8 (SE, 2.4) at 12 months and 93.3 (SE, 2.9) vs 95.9 (SE, 2.3) at 24 months. In a longitudinal mixed model, infants born to mothers with an incident ZIKV infection (P = .01) and low-birthweight infants (, Children with in utero Zika virus exposure and without congenital Zika syndrome in Nicaragua had lower neurocognitive scores at 24 months. Our study includes multiple evaluations over time and a contemporary nonexposed comparator group of children, which is currently lacking in the literature.

OBJECTIVE To assess plasma and vaginal inflammation in three antenatal groups (HIV-uninfected women, HIV-infected women entering care on preconceptional ART, and HIV-infected women not on preconceptional ART) and whether these measures are associated with spontaneous preterm birth (sPTB). DESIGN Case--control study nested within a pregnancy cohort in Lusaka, Zambia. METHODS We analyzed 11 pro-inflammatory and two anti-inflammatory markers in 207 women with paired plasma and vaginal specimens collected between 16 and 20 gestational weeks. Among 51 HIV-infected women, we repeated the assays in 24-34-week samples. We used confirmatory factor analysis to create inflammation scores and compared them among the three groups. RESULTS At baseline, HIV-infected women not on ART had higher vaginal pro-inflammatory scores than HIV-uninfected women [mean 0.37 (95% CI -0.06 to 0.80) vs. -0.02 (-0.32 to 0.27), P = 0.02]. In repeat testing, women not on preconceptional ART had an increase in vaginal inflammation between the baseline and 24-34-week visits compared with those continuing preconceptional ART [mean 0.62 (95% CI -0.80 to 4.20) vs. -0.07 (-2.78 to 2.11), P = 0.04]. In multivariate analyses, baseline vaginal inflammation predicted sPTB (aOR 1.5; 95% CI 1.0-2.3; P = 0.02). Plasma inflammation did not differ by HIV or ART exposure and was not associated with sPTB. CONCLUSION Women not receiving ART at entry into pregnancy care had more vaginal inflammation than women entering on treatment. They also experienced an increase in vaginal inflammation between the two sampling timepoints, possibly as a consequence of ART initiation. Vaginal (but not systemic) inflammation was associated with sPTB and offers a potential mechanistic insight into this important adverse birth outcome.

BACKGROUND: Ultrasound is indispensable to gestational age estimation and thus to quality obstetrical care, yet high equipment cost and the need for trained sonographers limit its use in low-resource settings. METHODS: From September 2018 through June 2021, we recruited 4695 pregnant volunteers in North Carolina and Zambia and obtained blind ultrasound sweeps (cineloop videos) of the gravid abdomen alongside standard fetal biometry. We trained a neural network to estimate gestational age from the sweeps and, in three test data sets, assessed the performance of the artificial intelligence (AI) model and biometry against previously established gestational age. RESULTS: In our main test set, the mean absolute error (MAE) (±SE) was 3.9±0.12 days for the model versus 4.7±0.15 days for biometry (difference, −0.8 days; 95% confidence interval [CI], −1.1 to −0.5; P

Rickettsiella infection was diagnosed in 4 adult emperor scorpions ( Pandinus imperator) from 2 different collections over a 3-year period. One case had a 2-day history of weakness, failure to lift the tail, or respond to stimulation, with rapid progression to death. The other 3 cases were found dead. There were no gross lesions, but histologically the hemolymphatic vasculature and sinuses, presumed hematopoietic organ, heart, midgut and midgut diverticula, nerves, and skeletal muscle were infiltrated with phagocytic and granular hemocytes with necrosis. Phagocytic hemocytes contained abundant intracellular microorganisms that were Fite’s acid-fast-positive, Macchiavello-positive, variably gram-positive or gram-negative, and Grocott’s methenamine silver-negative. By transmission electron microscopy, hemocytes contained numerous phagocytic vacuoles with small dense bacterial forms (mean 0.603 × 0.163 μm) interspersed with large bacterial forms (mean 1.265 × 0.505 μm) and few intermediary forms with electron-dense nucleoids and membrane-bound crystalline arrays (average 4.72 μm). Transmission electron microscopy findings were consistent with bacteria of the family Coxiellaceae. Based on sequencing the 16S ribosomal RNA gene, the identity was confirmed as Rickettsiella, and phylogenetic analysis of protein-coding genes gidA, rspA, and sucB genes suggested the emperor scorpion pathogen as a new species. This study identifies a novel Rickettsiella causing infection in emperor scorpions and characterizes the unique pathological findings of this disease. We suggest this organism be provisionally named Rickettsiella scorpionisepticum.

A trial of progesterone to prevent preterm birth among HIV-infected Zambian women [Improving Pregnancy Outcomes with Progesterone (IPOP)] found no treatment effect, but the risk of the primary outcome was among the lowest ever documented in women with HIV. In this secondary analysis, we compare the risks of preterm birth (37 weeks), stillbirth, and a composite primary outcome comprising the two in IPOP versus an observational pregnancy cohort [Zambian Preterm Birth Prevention Study (ZAPPS)] in Zambia, to evaluate reasons for the low risk in IPOP.Both studies enrolled women before 24 gestational weeks, during August 2015-September 2017 (ZAPPS) and February 2018-January 2020 (IPOP). We used linear probability and log-binomial regression to estimate risk differences and risk ratios (RR), before and after restriction and standardization with inverse probability weights.The unadjusted risk of composite outcome was 18% in ZAPPS (N = 1450) and 9% in IPOP (N = 791) (RR = 2.0; 95% CI = 1.6, 2.6). After restricting and standardizing the ZAPPS cohort to the distribution of IPOP baseline characteristics, the risk remained higher in ZAPPS (RR = 1.6; 95% CI = 1.0, 2.4). The lower risk of preterm/stillbirth in IPOP was only partially explained by measured risk factors.Possible benefits in IPOP of additional monetary reimbursement, more frequent visits, and group-based care warrant further investigation.

BackgroundUltrasound is indispensable to gestational age estimation, and thus to quality obstetric care, yet high equipment cost and need for trained sonographers limit its use in low-resource settings.MethodsFrom September 2018 through June 2021, we recruited 4,695 pregnant volunteers in North Carolina and Zambia and obtained blind ultrasound sweeps (cineloops) of the gravid abdomen alongside standard fetal biometry. We trained a neural network to estimate gestational age from the sweeps and, in three test sets, assessed performance of the model and biometry against previously established gestational age.ResultsIn our main test set, model mean absolute error (MAE) was 3.9 days (standard error [SE] 0.12) vs. 4.7 days (SE 0.15) for biometry (difference -0.8 days; 95% CI -1.1, -0.5; pConclusionsOur model estimated gestational age more accurately from blindly obtained ultrasound sweeps than did trained sonographers performing fetal biometry. These results presage a future where all pregnant people – not just those in rich countries – can access the diagnostic benefits of sonography.

Objectives To estimate the rate of pregnancy-associated emergency care visits and identify maternal and pregnancy characteristics associated with high utilization of emergency care among pregnant Medicaid recipients in North Carolina. Methods A retrospective cohort study using linked Medicaid hospital claims and birth records of 107,207 pregnant Medicaid recipients who delivered a live-born infant in North Carolina between January 1, 2008 and December 31, 2009. Rates were estimated per 1000 member months of Medicaid coverage. High utilization was defined as ≥ 4 visits. Emergency care visits included encounters in the emergency department or obstetric triage unit during pregnancy that did not result in hospital admission. Results During the study period, 57.5% of pregnant Medicaid recipients sought emergency care at least once during pregnancy. There were 171,909 emergency care visits with an overall rate of 202.3 visits per 1000 member months. Among the subset of pregnant women with Medicaid coverage for the majority of their pregnancy (n = 75,157), 18.1% were high utilizers. High emergency care utilization was associated with young age, black race, lower education, tobacco use, late preterm delivery, multifetal gestation, and having ≥ 1 comorbidity. Threatened labor and abdominal pain were the leading indications for visits. Conclusion Utilization of hospital-based emergency care services was common in this cohort of pregnant Medicaid recipients. Additional research is needed to assess the drivers for accessing care through the emergency department, and to examine differences in pregnancy outcomes and health care costs between high and low utilizers.

Accurate assessment of fetal gestational age (GA) is critical to the clinical management of pregnancy. Industrialized countries rely upon obstetric ultrasound (US) to make this estimate. In low- and middle- income countries, automatic measurement of fetal structures using a low-cost obstetric US may assist in establishing GA without the need for skilled sonographers. In this report, we leverage a large database of obstetric US images acquired, stored and annotated by expert sonographers to train algorithms to classify, segment, and measure several fetal structures: biparietal diameter (BPD), head circumference (HC), crown rump length (CRL), abdominal circumference (AC), and femur length (FL). We present a technique for generating raw images suitable for model training by removing caliper and text annotation and describe a fully automated pipeline for image classification, segmentation, and structure measurement to estimate the GA. The resulting framework achieves an average accuracy of 93% in classification tasks, a mean Intersection over Union accuracy of 0.91 during segmentation tasks, and a mean measurement error of 1.89 centimeters, finally leading to a 1.4 day mean average error in the predicted GA compared to expert sonographer GA estimate using the Hadlock equation.

To evaluate the effect of HIV co-infection on non-treponemal titers during pregnancy in women with syphilis.This is a secondary analysis of pregnant women with syphilis in the prospective, observational Zambian Preterm Birth Prevention Study (ZAPPS). Treponemal (Treponema pallidum particle agglutination) and non-treponemal (rapid plasma reagin; RPR) testing were performed on serum biospecimens, resulting in 47 participants with serologically confirmed syphilis (27 HIV-positive, 20 HIV-negative). The primary outcome, achievement of RPR titer seroreduction during pregnancy, was analyzed by logistic regression. Secondary outcomes included overall titer reduction, seroreduction rate, serologic cure, and adverse pregnancy outcomes.Seroreduction of RPR titer occurred in 78% (21/27) of women with HIV versus 45% (9/20) of women without (adjusted odds ratio 4.66; 95% confidence interval [CI] 1.14 - 19.08). Overall RPR titer reduction, rate of seroreduction per week, and the proportion achieving serologic cure each trended higher among women with HIV compared with those without HIV. There was a trend toward decreased stillbirth incidence in participants achieving seroreduction (odds ratio 0.15, 95% CI 0.01-1.58).HIV co-infection in this cohort of Zambian women with syphilis was associated with greater odds of RPR titer seroreduction during pregnancy. Pregnant women with syphilis and HIV may not be at increased risk for a delayed syphilis treatment response compared with women without HIV.

BackgroundZika virus caused thousands of congenital anomalies during a recent epidemic. Because Zika emerged in areas endemic for dengue and these related flaviviruses elicit cross-reactive antibodies, it is challenging to serologically monitor pregnant women for Zika infection.MethodsA prospective cohort of 253 pregnant women was established in León, Nicaragua. Women were followed during prenatal care through delivery. Serologic specimens were obtained at each visit, and birth outcome was recorded. Established flavivirus serologic methods were adapted to determine Zika seroprevalence, and a stepwise testing algorithm estimated timing of Zika infection in relation to pregnancy.ResultsZika seroprevalence was approximately 59% among women tested. Neutralization testing was highly concordant with Zika NS1 BOB results. Per study algorithm, 21% (40/187) of women were classified as experiencing Incident ZIKV infection during pregnancy. Importantly, the Incident ZIKV group included mostly women pregnant during the 2016 Zika epidemic peak and the only 3 subjects in the cohort with RT-PCR-confirmed infections. Approximately 17% of births had complications; 1.5% (3/194) manifesting clinical criteria of congenital Zika syndrome, one was RT-PCR-confirmed as a case of congenital Zika syndrome. Adverse birth outcome did not correlate with timing of Zika infection.ConclusionsBy leveraging prenatal care systems, we developed a simple algorithm for identifying women who were likely infected by Zika during pregnancy.

Background: Few cohort studies of pregnancy in sub-Saharan Africa use rigorous gestational age dating and clinical phenotyping. As a result, incidence and risk factors of adverse birth outcomes are inadequately characterized. Methods: The Zambian Preterm Birth Prevention Study (ZAPPS) is a prospective observational cohort established to investigate adverse birth outcomes at a referral hospital in urban Lusaka. This report describes ZAPPS phase I, enrolled August 2015 to September 2017. Women were followed through pregnancy and 42 days postpartum. At delivery, study staff assessed neonatal vital status, birthweight, and sex, and assigned a delivery phenotype. Primary outcomes were: (1) preterm birth (PTB; delivery

Each year in the United States, more than 500,000 neonates are born before 37 weeks of gestation. Women who have experienced a previous preterm birth are at high risk of recurrence. A weekly prenatal injection of 17α-hydroxyprogesterone caproate decreases the risk of recurrent preterm birth and is recommended from as early as 16 weeks of gestation in women carrying singleton pregnancies who have a history of spontaneous singleton preterm birth. A commonly used metric for public health program effectiveness is population coverage of an intervention. In the case of 17α-hydroxyprogesterone caproate, population coverage can be defined as the proportion of women who are eligible for 17α-hydroxyprogesterone caproate (ie, previous pregnancy complicated by spontaneous singleton preterm birth) who actually receive the intervention. To receive a full course of 17α-hydroxyprogesterone caproate, women must negotiate a complex series of steps that includes presenting early for prenatal care, being identified as eligible for 17α-hydroxyprogesterone caproate, being offered 17α-hydroxyprogesterone caproate, accepting 17α-hydroxyprogesterone caproate, and adhering to the weekly 17α-hydroxyprogesterone caproate dose schedule. We describe this series of steps as well potential solutions to increase 17α-hydroxyprogesterone caproate coverage.

After the declaration of the Millennium Development Goals in 2000 by the United Nations, many stakeholders allocated financial resources to "global maternal health." Research to expand care and improve delivery of maternal health services has exponentially increased. The present article highlights an overview, namely 10 of the health system, clinical, and technology-based advancements that have occurred in the past three decades in the field of global maternal health. The list of topics has been selected through the cumulative clinical and public health expertise of the authors and is certainly not exhaustive. Rather, the list is intended to provide a mapping of key topics arranged from broad to specific that span from the global policy level to the level of individual care. The list of health system, clinical, and technology-based advancements include: (10) Millennium Development Goals and Sustainable Development Goals; (9) Development of clinical training programs, including the potential for subspecialty development; (8) Prenatal care expansion and potential; (7) Decentralized health systems, including the use of skilled birth attendants; (6) Antiretroviral therapy for HIV; (5) Essential medicines; (4) Vaccines; (3) mHealth/eHealth; (2) Ultrasonography; and (1) Obstetric hemorrhage management. With the Sustainable Development Goals now underway, the field must build upon past successes to sustain maternal and neonatal well-being in the future global health agenda.

Background Several health agencies define microcephaly for surveillance purposes using a single criterion, a percentile or Z-score cut-off for newborn head circumference. This definition, however, conflicts with the reported prevalence of microcephaly even in populations with endemic Zika virus. Objective We explored possible reasons for this conflict, hypothesising that the definition of microcephaly used in some studies may be incompletely described, lacking the additional clinical criteria that clinicians use to make a formal diagnosis. We also explored the potential for misclassification that can result from differences in these definitions, especially when applying a percentile cut-off definition in the presence of the much lower observed prevalence estimates that we believe to be valid. Methods We conducted simulations under a theoretical bimodal distribution of head circumference. For different definitions of microcephaly, we calculated the sensitivity and specificity using varying cut-offs of head circumference. We then calculated and plotted the positive predictive value for each of these definitions by prevalence of microcephaly. Results Simple simulations suggest that if the true prevalence of microcephaly is approximately what is reported in peer-reviewed literature, then relying on cut-off-based definitions may lead to very poor positive predictive value under realistic conditions. Conclusions While a simple head circumference criterion may be used in practice as a screening or surveillance tool, the definition lacks clarification as to what constitutes true pathological microcephaly and may lead to confusion about the true prevalence of microcephaly in Zika-endemic areas, as well as bias in aetiologic studies.

Importance Women in low- and middle-income countries (LMICs) are responsible for the stability of their families. Child survival is directly linked to the health and well-being of their mother. Cancer is the leading cause of morbidity and mortality worldwide, and the incidence and mortality for women from cancer are projected to increase over the coming decades. Gynecologic cancer outcomes are improved when women are cared for by a gynecologic oncologist; however, there are limited specialized providers in LMICs. Increasing interest and involvement from specialists in the United States will improve partnerships abroad and the care of women worldwide. Objective To summarize the importance of global gynecologic oncology care and the current data for US trainees in obstetrics and gynecology to participate in clinical and capacity-building opportunities. Evidence acquisition We performed a PubMed literature search for articles pertaining to the topic of global health education in obstetrics and gynecology and gynecologic oncology specifically. Results Many obstetric and gynecologic residency programs offer international opportunities, but these are less than those in other specialties and are more frequently focused in obstetrics. Many gynecologic oncology fellowship programs offer international experiences for fellows; however, the time and resources required are limited. Several US and international programs are ongoing to improve capacity building for gynecologic oncology in LMICs with local trainees. Conclusions and relevance Training and care in gynecologic oncology care worldwide are improving through efforts at multiple levels. Continued efforts are needed to improve US trainee international education and experience.

Objectives We investigated whether a woman's role in household decision-making was associated with receipt of services to prevent mother-to-child HIV transmission (PMTCT). Methods We conducted a secondary analysis of the PEARL study, an evaluation of PMTCT effectiveness in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Our exposure of interest was the women's role (active vs. not active) in decision-making about her healthcare, large household purchases, children's schooling, and children's healthcare (i.e., four domains). Our primary outcomes were self-reported engagement at three steps in PMTCT: maternal antiretroviral use, infant antiretroviral prophylaxis, and infant HIV testing. Associations found to be significant in univariable logistic regression were included in separate multivariable models. Results From 2008 to 2009, 613 HIV-infected women were surveyed and provided information about their decision-making roles. Of these, 272 (44.4%) women reported antiretroviral use; 281 (45.9%) reported infant antiretroviral prophylaxis; and 194 (31.7%) reported infant HIV testing. Women who reported an active role were more likely to utilize infant HIV testing services, across all four measured domains of decision-making (adjusted odds ratios [AORs] 2.00-2.89 all p

Vaginal dysbiosis has been shown to increase the risk of some adverse birth outcomes. HIV infection may be associated with shifts in the vaginal microbiome. We characterized microbial communities in vaginal swabs collected between 16–20 gestational weeks in the Zambian Preterm Birth Prevention Study to investigate whether HIV and its treatment alter the microbiome in pregnancy. We quantified relative abundance and diversity of bacterial taxa by whole-genome shotgun sequencing and identified community state types (CST) by hierarchical clustering. Associations between exposures—HIV serostatus (HIV+ vs HIV-) and preconceptional ART (ART+ vs ART-)—and microbiome characteristics were tested with rank-sum, and by linear and logistic regression, accounting for sampling by inverse-probability weighting. Of 261 vaginal swabs, 256 (98%) had evaluable sequences; 98 (38%) were from HIV+ participants, 55 (56%) of whom had preconceptional ART exposure. Major CSTs were dominated by: L. crispatus (CST 1; 17%), L.] iners (CST 3; 32%), Gardnerella vaginalis (CST 4-I; 37%), G. vaginalis & Atopobium vaginae (CST 4-II; 5%), and other mixed anaerobes (CST 4-III; 9%). G. vaginalis was present in 95%; mean relative abundance was higher in HIV+ (0.46±0.29) compared to HIV- participants (0.35±0.33; rank-sum p = .01). Shannon diversity was higher in HIV+/ART+ (coeff 0.17; 95%CI (0.01,0.33), p = .04) and HIV+/ART- (coeff 0.37; 95%CI (0.19,0.55), p < .001) participants compared to HIV-. Anaerobe-dominant CSTs were more prevalent in HIV+/ART+ (63%, AOR 3.11; 95%CI: 1.48,6.55, p = .003) and HIV+/ART- (85%, AOR 7.59; 95%CI (2.80,20.6), p < .001) compared to HIV- (45%). Restricting the comparison to 111 women in either CST 3 (L. iners dominance) or CST 1 (L. crispatus dominance), CST 3 frequency was similar in HIV- (63%) and HIV+/ART- participants (67%, AOR 1.31; 95%CI: (0.25,6.90), p = .7), but higher in HIV+/ART+ (89%, AOR 6.44; 95%CI: (1.12,37.0), p = .04). Pregnant women in Zambia, particularly those with HIV, had diverse anaerobe-dominant vaginal microbiota.

Objective To evaluate the association between severity of prior low birth weight (LBW) delivery and adverse perinatal outcomes in the subsequent delivery among an HIV-prevalent urban African population. Methods A retrospective cohort study was conducted among 41 109 women who had undergone two deliveries in Lusaka, Zambia, between February 1, 2006, and May 31, 2013. The relationship between prior LBW delivery (

Background In pregnancy, conditions presenting with hematologic abnormalities, transaminitis, and proteinuria pose diagnostic challenges in pregnancy. Case We present the case of an 18-year-old woman, G1P0, at 33 weeks' gestation with fever of unknown cause, who developed progressively elevated liver enzymes, proteinuria, and thrombocytopenia, due to Epstein–Barr virus (EBV) infection. Conclusion Acute infection with EBV should be included in the differential diagnosis of preeclampsia with severe features, particularly in the setting of fever. Supportive treatment and observation may prevent iatrogenic preterm birth.

There are approximately 284,500 adolescent and adult women living with human immunodeficiency virus (HIV) in the United States. It is estimated that approximately 8500 of these women give birth annually. While the rate of perinatal transmission in the United States has decreased by more than 90% since the early 1990s, potentially preventable HIV transmission events still occur and cause significant morbidity and mortality.The aim of this review was to summarize the current data regarding perinatal HIV transmission timing and risk factors, current management recommendations, and implications of timing of transmission on patient management.Literature review.This review reiterates that the risk of perinatal HIV transmission can be reduced to very low levels by following current recommendations for screening for HIV in all pregnant women and properly treating HIV-infected mothers, as well as using evidence-based labor management practices.Familiarity with the pathogenesis of HIV transmission is important for obstetric care providers to appropriately manage HIV-infected women in pregnancy, intrapartum, and the postpartum period.

With the growing class of CFTR modulator therapy available to more patients and with increasing pregnancies in individuals with CF, there is a growing need to understand the effects of these agents during pregnancy. There are few reports of their continued use in the literature, although it is likely that this is not an uncommon occurrence. We report the uncomplicated and successful pregnancy of a woman treated with lumacaftor/ivacaftor, as well as the clinical course of the infant during the first 9 months of life. We also report drug levels in plasma from the mother, cord blood, breast milk, and infant to estimate fetal and infant drug exposure.

Objective To evaluate whether maternal HIV serostatus and plasma viral load (VL) are associated with midtrimester cervical length (CL). Methods The Zambian Preterm Birth Prevention Study (ZAPPS) is an ongoing prospective cohort that began enrolling in Lusaka in August 2015. Pregnant women undergo ultrasound to determine gestational age and return for CL measurement at 16-28 weeks. We evaluated crude and adjusted associations between dichotomous indicators and short cervix (≤2.5 cm) via logistic regression, and between VL and CL as a continuous variable via linear regression. Results This analysis includes 1171 women enrolled between August 2015 and September 2017. Of 294 (25.1%) HIV-positive women, 275 (93.5%) had viral load performed close to CL measurement; of these, 148 (53.8%) had undetectable virus. Median CL was 3.6 cm (IQR 3.5-4.0) and was similar in HIV-infected (3.7 cm, IQR 3.5-4.0) versus uninfected (3.6 cm, IQR 3.5-4.0) participants (P=0.273). The odds of short CL were similar by HIV serostatus (OR 0.64; P=0.298) and detectable VL among those infected (OR 2.37, P=0.323). We observed no association between log VL and CL via linear regression (-0.12 cm; P=0.732). Conclusion We found no evidence of association between HIV infection and short CL.

OBJECTIVE Cesarean delivery (CD) may be associated with stillbirth in future pregnancies. We investigated prior CD as a risk factor for stillbirth in Lusaka, Zambia. METHODS We conducted a retrospective cohort analysis of women with only one prior pregnancy who delivered between February 1, 2006, and May 31, 2013. We analysed data from the Zambia Electronic Perinatal System. Maternal and infant characteristics were analyzed for association with stillbirth using Pearson's χ2 test or the Wilcoxon rank-sum test. We calculated risk ratios for the relationship between stillbirth (antepartum vs intrapartum) and prior CD, with a log Poisson model to adjust for confounding. RESULTS Of 57 320 women in our cohort, 1933 (3.4%) reported a prior CD. There were 1012 (1.8%) stillbirths in the no prior CD group and 81 (4.2%) in the prior CD group (P

As antiretroviral therapy (ART) expands in resource-limited settings, understanding the impact of ART on pregnancy outcomes is critical. We analyzed women who became pregnant on ART while enrolled in a clinical trial (HPTN 052, ACTG A5208, and ACTG A5175); the majority of women were from Africa, with a median age of 29 years. Eligible women were on ART at conception and had a documented date of a last menstrual period and a pregnancy outcome. The primary outcome was non-live birth (stillbirth; spontaneous abortion; elective termination; or ectopic pregnancy) versus live birth. Preterm birth (

OBJECTIVE: To compare neonatal abstinence syndrome prevalence and characteristics among neonates born to women prescribed buprenorphine and naloxone compared with methadone during pregnancy. METHODS: Retrospective cohort analysis of mother– neonate dyads treated with either buprenorphine and naloxone or methadone during pregnancy. Primary neonatal outcomes included diagnosis of neonatal abstinence syndrome, neonatal abstinence syndrome peak scores, total amount of morphine used to treat neonatal abstinence syndrome (mg), and duration of treatment for neonatal abstinence syndrome (days). Secondary outcomes included head circumference, birth weight, length, preterm birth, neonatal intensive care unit admission, Apgar scores, and overall length of hospitalization. RESULTS: From January 1, 2011, to November 30, 2013, we identified 62 mother–neonate dyads, 31 treated with methadone and 31 treated with buprenorphine and naloxone. Sixteen neonates (51.6%) in the methadone group were diagnosed with neonatal abstinence syndrome compared with eight (25.1%) in the buprenorphine and naloxone group (adjusted odds ratio 2.55, 95% confidence interval [CI] 1.31–4.98, P5.01). The buprenorphine and naloxone-exposed neonates had lower peak neonatal abstinence syndrome scores (9.064.4 compared with 10.763.7, multivariate-adjusted mean difference522.77, 95% CI 24.99 to 20.56, P5.02) and shorter overall hospitalization (5.665.0 compared with 9.867.4 days, multivariate-adjusted mean difference523.90, 95% CI, 27.13 to 20.67, P5.02). We found no other differences in primary or secondary outcomes. CONCLUSION: In a cohort of pregnant patients treated with either methadone or buprenorphine and naloxone in pregnancy, newborns exposed to maternal buprenorphine and naloxone had less frequent neonatal abstinence syndrome. Additionally, neonates exposed to buprenorphine and naloxone had shorter overall hospitalization lengths.

Introduction. Although increasing access to family planning has been an important part of the global development agenda, millions of women continue to face unmet need for contraception.Materials and Methods. We analyzed data from a repeated cross-sectional community survey conducted in Lusaka, Zambia, over an eight-year period. We described prevalence of modern contraceptive use, including long-acting reversible contraception (LARC), among female heads of household aged 16–50 years. We also identified predictors of LARC versus short-term contraceptive use among women using modern methods.Results and Discussion. Twelve survey rounds were completed between November 2004 and September 2011. Among 29,476 eligible respondents, 17,605 (60%) reported using modern contraception. Oral contraceptive pills remained the most popular method over time, but use of LARC increased significantly, from less than 1% in 2004 to 9% by 2011 (p<0.001). Younger women (OR: 0.46, 95% CI: 0.34, 0.61) and women with lower levels of education (OR: 0.70, 95% CI: 0.56, 0.89) were less likely to report LARC use compared to women using short-term modern methods.Conclusions. Population-based assessments of contraceptive use over time can guide programs and policies. To achieve reproductive health equity and reduce unmet contraceptive need, future efforts to increase LARC use should focus on young women and those with less education.

Tusk fractures in Asian (Elephas maximus) and African elephants (Loxodonta africana) can result in damage to the distal end or to longitudinal cracks, potentially progressing to pulpitis. With pulp exposure, endodontic therapy is the treatment of choice, but conservative therapy has sufficed for some elephants. This manuscript describes the use of composite materials as a component of tusk fracture management. A 7-yr-old male Asian elephant fractured the distal end of both tusks with pulp exposure in one. Capping of each tusk with a Kevlar/fiberglass composite prevented further damage, and a modification allowed care of the exposed pulp tissue. A 34-yr-old male African elephant with a longitudinal crack received a carbon fiber/fiberglass composite circumferential wrap to potentially stabilize the crack. Compression of the crack was achieved, but follow-up was truncated due to bacterial pulpitis. Both cases show that composite material allows for lightweight, durable management of tusk fractures with continued radiographic monitoring.

To evaluate if a pilot programme to prevent mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) was associated with changes in early childhood survival at the population level in rural Zambia.Combination antiretroviral regimens were offered to pregnant and breastfeeding, HIV-infected women, irrespective of immunological status, at four rural health facilities. Twenty-four-month HIV-free survival among children born to HIV-infected mothers was determined before and after PMTCT programme implementation using community surveys. Households were randomly selected and women who had given birth in the previous 24 months were asked to participate. Mothers were tested for HIV antibodies and children born to HIV-infected mothers were tested for viral deoxyribonucleic acid. Multivariable models were used to determine factors associated with child HIV infection or death.In the first survey (2008-2009), 335 of 1778 women (18.8%) tested positive for HIV. In the second (2011), 390 of 2386 (16.3%) tested positive. The 24-month HIV-free survival in HIV-exposed children was 0.66 (95% confidence interval, CI: 0.63-0.76) in the first survey and 0.89 (95% CI: 0.83-0.94) in the second. Combination antiretroviral regimen use was associated with a lower risk of HIV infection or death in children (adjusted hazard ratio: 0.33, 95% CI: 0.15-0.73). Maternal knowledge of HIV status, use of HIV tests and use of combination regimens during pregnancy increased between the surveys.The PMTCT programme was associated with an increased HIV-free survival in children born to HIV-infected mothers. Maternal utilization of HIV testing and treatment in the community also increased.Évaluer si un programme pilote pour prévenir la transmission mère-enfant (PTME) du virus de l'immunodéficience humaine (VIH) est associé à des changements en matière de survie du jeune enfant au sein de la population dans les régions rurales de la Zambie.Des thérapies antirétrovirales combinées ont été proposées à des femmes infectées par le VIH, enceintes et allaitantes, indépendamment de leur statut immunologique, dans quatre centres de santé ruraux. La survie sans VIH à 24 mois chez les enfants nés de mères infectées par le VIH a été déterminée avant et après la mise en œuvre du programme PTME à l'aide d'enquêtes communautaires. Les ménages ont été choisis de manière aléatoire, et il a été demandé aux femmes qui avaient accouché au cours des 24 derniers mois, d'y participer. On a testé la présence d'anticorps anti-VIH chez les mères et d'acide désoxyribonucléique viral chez les enfants nés de mères infectées par le VIH. Des modèles à variables multiples ont été utilisés pour déterminer les facteurs associés à l'infection par le VIH ou au décès de l'enfant.Dans la première étude (2008–2009), 335 femmes parmi 1778 (18,8%) ont été testées positives à l'infection par le VIH. Dans la deuxième étude (2011), 390 femmes parmi 2386 (16,3%) ont été testées positives. La survie sans VIH à 24 mois chez les enfants exposés au VIH était de 0,66 (intervalle de confiance de 95%, IC: 0,63–0,76) dans la première étude et de 0,89 (IC de 95%: 0,83–0,94) dans la seconde. La combinaison de la thérapie antirétrovirale était associée à un risque inférieur d'infection par le VIH ou de décès chez les enfants (rapport de risques ajusté: 0,33, IC de 95%: 0,15–0,73). La connaissance du statut VIH des mères, l'utilisation des tests de dépistage du VIH et des traitements combinés pendant la grossesse ont augmenté entre les études.Le programme PTME était associé à une augmentation de la survie sans VIH chez les enfants nés de mères infectées par le VIH. L'utilisation par les mères du dépistage et du traitement contre le VIH a également augmenté au sein de la communauté.Evaluar si un programa piloto para prevenir la transmisión maternoinfantil (PTMI) del virus de la inmunodeficiencia humana (VIH) está asociado a cambios en la supervivencia en la primera infancia a nivel de población en las zonas rurales de Zambia.Se ofreció una combinación de tratamientos antirretrovirales a mujeres embarazadas y lactantes infectadas por el VIH, independientemente de su estado inmunológico, en cuatro centros de salud rurales. Mediante encuestas en la comunidad se determinó una supervivencia sin VIH de veinticuatro meses entre los niños nacidos de madres infectadas por el VIH antes y después de la implementación del programa PTMI. Los hogares se seleccionaron al azar y se pidió que participaran las mujeres que habían dado a luz en los 24 meses anteriores. Las madres se sometieron a una prueba para detectar los anticuerpos contra el VIH y se realizó una prueba del ácido desoxirribonucleico viral a los niños nacidos de madres infectadas con VIH. Se utilizaron modelos multivariables para determinar los factores asociados con la infección o muerte por VIH del niño.En la primera encuesta (2008–2009), 335 de 1778 mujeres (18,8 %) dieron positivo en el VIH. En la segunda (2011), dieron positivo 390 de 2386 (16,3 %). La supervivencia sin VIH de 24 meses en los niños expuestos al VIH fue del 0,66 (intervalo de confianza del 95 %, IC: 0,63–0,76) en la primera encuesta y del 0,89 (IC del 95 %: 0,83–0,94) en la segunda. La combinación de un tratamiento antirretroviral se asoció con un menor riesgo de infección por VIH o muerte en los niños (razón de riesgo ajustada: 0,33, IC del 95 %: 0,15–0,73). El conocimiento de las madres de su estado serológico, el uso de pruebas para el VIH y los tratamientos combinados durante el embarazo aumentaron en el tiempo transcurrido entre las encuestas.El programa PTMI estuvo asociado a un aumento de la supervivencia sin VIH en los niños nacidos de madres infectadas por el VIH. La utilización materna de la prueba y el tratamiento del VIH en la comunidad también aumentó.تقييم ما إذا كان البرنامج التجريبي لتوقي انتقال فيروس العوز المناعي البشري من الأم إلى الطفل مرتبطاً بالتغيرات في البقاء على قيد الحياة في مرحلة الطفولة المبكرة على صعيد السكان في المناطق الريفية في زامبيا.تم تقديم نظم العلاج التوليفي بمضادات الفيروسات القهقرية إلى النساء الحوامل والمرضعات المصابات بعدوى فيروس العوز المناعي البشري، بغض النظر عن حالتهن المناعية، في أربعة مرافق صحية ريفية. وتم تحديد بقاء الأطفال في سن 24 شهراً على قيد الحياة دون الإصابة بفيروس العوز المناعي البشري بين الأطفال الذين ولدوا لأمهات مصابات بعدوى فيروس العوز المناعي البشري قبل تنفيذ برنامج توقي الانتقال من الأم إلى الطفل وبعده باستخدام دراسات استقصائية مجتمعية. وتم اختيار الأسر المعيشية عشوائياً ومطالبة النساء اللاتي ولدن خلال الأربع والعشرين شهراً السابقة بالمشاركة. وتم اختبار الأمهات للكشف عن أضداد فيروس العوز المناعي البشري، وتم اختبار الأطفال الذين ولدوا لأمهات مصابات بفيروس العوز المناعي البشري للكشف عن الحمض الريبي النووي منزوع الأكسجين الفيروسي. وتم استخدام نماذج متعددة المتغيرات لتحديد العوامل المرتبطة بإصابة الطفل بعدوى فيروس العوز المناعي البشري أو وفاته.كانت نتيجة اختبار 335 سيدة من إجمالي 1778 سيدة (18.8 %) في الدراسة الاستقصائية الأولى (من 2008 إلى 2009) إيجابية لفيروس العوز المناعي البشري. وكانت نتيجة اختبار 390 سيدة من إجمالي 2386 سيدة (16.3 %) في الدراسة الاستقصائية الثانية (2011) إيجابية. وكان بقاء الأطفال في سن 24 شهراً على قيد الحياة دون الإصابة بفيروس العوز المناعي البشري في الأطفال المعرضين لفيروس العوز المناعي البشري 0.66 (فاصل الثقة 95 %، فاصل الثقة: 0.63 –0.76) في الدراسة الاستقصائية الأولى و0.89 (فاصل الثقة: 95 %، فاصل الثقة: 0.83 –0.94) في الدراسة الاستقصائية الثانية. وكان استخدام نظام العلاج التوليفي بمضادات الفيروسات القهقرية مرتبطاً بانخفاض مخاطر الإصابة بعدوى فيروس العوز المناعي البشري أو الوفاة في الأطفال (نسبة المخاطر المصححة: 0.33، فاصل الثقة: 95 %، فاصل الثقة: 0.15 –0.73). وازدادت معرفة الأمهات بحالة فيروس العوز المناعي البشري واستخدام اختبارات فيروس العوز المناعي البشري واستخدام نظم العلاج التوليفي أثناء الحمل بين الدراسات الاستقصائية.ارتبط برنامج توقي الانتقال من الأم إلى الطفل بازدياد بقاء الأطفال الذين ولدوا لأمهات مصابات بعدوى فيروس العوز المناعي البشري على قيد الحياة دون الإصابة بفيروس العوز المناعي البشري. وازداد كذلك استخدام الأمهات لاختبارات فيروس العوز المناعي البشري وعلاجه في المجتمع المحلي.评估赞比亚农村防止艾滋病毒（HIV）母婴传播的试点计划（PMTCT）是否在人口水平上与儿童早期存活的改变有关。在四个农村卫生设施，对于处于怀孕和哺乳期并感染艾滋病毒的妇女，无论其免疫状态如何均提供联合抗逆转录病毒治疗方案。使用社区调查确定PMTCT计划实施之前和之后HIV感染母亲生育的孩子中24月无HIV存活情况。随机选择家庭，并要求在之前24个月生育的妇女参与调查。母亲接受HIV抗体检测，HIV感染母亲所生婴儿接受病毒脱氧核糖核酸检测。使用多变量模型确定与儿童HIV感染或死亡相关的因素。在第一次调查中（2008–2009年），1778名妇女中有335名（18.8%）检测HIV阳性。在第二次调查中（2011年），2386名中有390（16.3%）名检测阳性。在第一次调查中HIV暴露儿童中24月无HIV存活率为0.66（95%置信区间，CI：0.63–0.76），在第二次中为0.89（95% CI：0.83–0.94）。使用联合抗逆转录疗法与更低HIV感染或儿童死亡风险相关（校正危险比：0.33，95% CI：0.15–0.73）。在两次调查之间，母亲HIV知识的状态、使用HIV检测和在怀孕期间使用联合治疗方案的情况有所增强。PMTCT计划与HIV感染母亲所生儿童更高的无HIV生存率有关。社区中母亲使用HIV检测和治疗也有增加。Определить, связана ли пилотная программа по предотвращению передачи от матери к ребенку (ППМР) вируса иммунодефицита человека (ВИЧ) с изменениями в уровне выживаемости в раннем детском возрасте в сельских районах Замбии.В четырех сельских медицинских учреждениях беременным и кормящим ВИЧ-инфицированным женщинам предлагалась комбинированная антиретровирусная терапия вне зависимости от их иммунологического статуса. До и после реализации программы ППМР на основе исследований общин были определены уровни 24-месячной выживаемости без ВИЧ среди детей, рожденных от ВИЧ-инфицированных матерей. Домохозяйства выбирались случайным образом, и женщинам, родившим в течение последних 24 месяцев, предлагалось принять участие в исследовании. Матери были протестированы на наличие антител к ВИЧ, а дети, рожденные от ВИЧ-инфицированных матерей, были проверены на наличие ДНК ВИЧ. Для определения факторов, связанных с инфицированием детей ВИЧ или смертью, использовались многопараметрические модели.В первом исследовании (2008–2009 гг.) 335 из 1778 женщин (18,8%) имели положительный результат на ВИЧ. Во втором исследовании (2011 г.) положительный результат показали 390 из 2386 (16,3%) обследованных женщин. Уровень 24-месячной выживаемости без ВИЧ у детей, подверженных ВИЧ, составил 0,66 (95% доверительный интервал, ДИ: 0,63–0,76) в первом исследовании и 0,89 (95% ДИ: 0,83–0,94) – во втором. Применение комбинированной антиретровирусной терапии сопровождалось более низким риском инфицирования ВИЧ или смерти у детей (скорректированное отношение рисков: 0,33, 95% ДИ: 0,15–0,73). Осведомленность матерей о ВИЧ-статусе, использование тестов на ВИЧ и применение комбинированной терапии во время беременности возросло в период между исследованиями.Программа ППМР сопровождалась увеличением выживаемости без ВИЧ у детей, рожденных от ВИЧ-инфицированных матерей. Также увеличилось число матерей в сельских общинах, проходящих проверку и лечение ВИЧ-инфекции.