Genes upregulated in the amnion at labour are bivalently marked by activating and repressive histone modifications.

Inflammatory genes are expressed increasingly in the foetal membranes at late gestation triggering birth. Here we have examined whether epigenetic histone modifications contribute to the upregulation of proinflammatory genes in the amnion in late pregnancy and at labour. Amnion samples were collected from early pregnancy, at term in the absence of labour and after spontaneous birth. The expression of the labour-associated proinflammatory genes PTGS2, BMP2 and NAMPT was determined by reverse transcription-coupled quantitative real-time PCR (qRT-PCR). Chromatin immunoprecipitation (ChIP) and sequential double ChIP were performed to determine the levels and co-occurrence of activating histone-3, lysine-4 trimethylation (H3K4me3) and repressive histone-3, lysine-27 trimethylation (H3K27me3) at the gene promoters. H3K4 methyltransferase, H3K27me3 demethylase and H3K27 methyltransferase expression was determined by qRT-PCR and immunofluorescence confocal microscopy. PTGS2, BMP2 and NAMPT expression was upregulated robustly between early pregnancy and term (P < 0.05). The promoters were marked bivalently by both the H3K4me3 and H3K27me3 modifications. Bivalence was reduced at term by the decrease of the H3K27me3-modified fraction of promoter copies marked by H3K4me3 indicating epigenetic activation. Messenger RNAs encoding the H3K4-specific methyl transferases MLL1,-2,-3,-4, SETD1A,-B and the H3K27me3-specific demethylases KDM6A,-B were expressed increasingly while the H3K27 methyl transferase EZH2 was expressed decreasingly at term. Histone modifying enzyme proteins were detected in amnion epithelial and mesenchymal cells. These results with prototypical proinflammatory genes suggest that nucleosomes at labour-promoting genes are marked bivalently in the amnion, which is shifted towards monovalent H3K4me3 modification at term when the genes are upregulated. Bivalent epigenetic regulation by histone modifying enzymes may control the timing of labour.

Antenatal care for alcohol consumption during pregnancy: pregnant women's reported receipt of care and associated characteristics.

BACKGROUND: Antenatal clinical guidelines recommend that during initial and subsequent antenatal visits all pregnant women: have their alcohol consumption assessed; be advised that it is safest not to consume alcohol during pregnancy and of the potential risks of consumption; and be offered referrals for further support if required. However, the extent to which pregnant women attending public antenatal services receive guideline recommended care at these visits, and the characteristics associated with its receipt, is unknown. The purpose of this study was to examine: 1) pregnant women's reported receipt of guideline recommended care addressing alcohol consumption during pregnancy; 2) characteristics associated with the receipt of care; and 3) pregnant women's acceptability of care. METHODS: From July 2017 - February 2018 a survey (telephone or online) was undertaken with 1363 pregnant women who had recently visited a public antenatal service in one health district in Australia. Receipt and acceptability of recommended care were assessed via descriptive statistics and associations via logistic regression analyses. RESULTS: At the initial antenatal visit, less than two thirds (64.3%) of pregnant women reported that they received an assessment of their alcohol consumption and just over one third (34.9%) received advice and referral appropriate to their self-reported level of alcohol consumption since pregnancy recognition. Less than 10% of women received such care at subsequent antenatal visits. Characteristics that significantly increased the odds of receiving all guideline elements at the initial antenatal visit included: less than university attainment (OR = 1.93; 95% CI:1.12, 3.34), not residing in an advantaged area (OR = 2.11; 95% CI:1.17, 3.79), first pregnancy (OR = 1.91; 95% CI:1.22, 2.99) and regional/rural service location (OR = 2.38; 95% CI:1.26, 4.48); and at subsequent visits: younger age (OR = 0.91; 95% CI:0.84, 0.99) and Aboriginal origin (OR = 3.17; 95% CI:1.22, 8.24). Each of the recommended care elements were highly acceptable to pregnant women (88.3-99.4%). CONCLUSIONS: Although care for alcohol consumption is both recommended by clinical guidelines and highly acceptable to pregnant women, its receipt in public antenatal services is suboptimal. There is a need and an opportunity for interventions to support antenatal care providers to routinely and consistently provide such care to all pregnant women.

A first step to improving maternal mortality in a low-literacy setting; the successful use of singing to improve knowledge regarding antenatal care.

BACKGROUND: Preventable maternal mortality is related to delays in recognizing the problem, transport to a facility, and receiving appropriate care on arrival. Reducing maternal mortality in low-literacy settings is particularly challenging. In the rural villages of Nepal, the maternal mortality rate is among the highest in the world; the reasons include illiteracy and lack of knowledge of the needs of pregnant women. Culturally, singing and dancing are part of Nepalese daily life and present an opportunity to transmit knowledge of antenatal care and care at birth with a view to reducing the first 2 delays. OBJECTIVE: We hypothesized that health messages regarding the importance of antenatal care and skilled birth assistance would be effectively transmitted by songs in the limited literacy environment of rural Nepal. STUDY DESIGN: We randomly grouped 4 rural village development committees comprising 36 villages into 2 (intervention and control) clusters. In the intervention group, local groups were invited to write song lyrics incorporating key health messages regarding antenatal care to accompany popular melodies. The groups presented their songs and dances in a festival organized and judged by the community. The winning songs were performed by the local people in a song and dance progression through the villages, houses, and fields. A wall chart with the key health messages was also provided to each household. Knowledge of household decision makers (senior men and women) was assessed before and after the intervention and at 12 months using a structured questionnaire in all households that also assessed behavior change. RESULTS: Structured interviews were conducted at baseline, immediately postintervention in the control and intervention areas (intervention n = 735 interviews, control n = 775), and at 12 months in the intervention area only (n = 867). Knowledge scores were recorded as the number of correct items out of 36 questions at baseline and postintervention, and of 21 questions at follow-up. Postintervention, test score doubled in the intervention group from a mean of 11.60/36-22.33/36 (P < .001), with no practically significant change in the control population (17.48/36-18.26/36). Improvement was greatest among the most illiterate members of the community (6.8/36-19.8/36, P < .001). At 12 months follow-up, a majority of the participants (63.9%) indicated that they provided information learned from the songs to their neighbors and friends, and 41.3% reported still singing the songs from the intervention. CONCLUSION: The use of songs bypassed the limitations of literacy in communicating health messages that are key to improving maternal care in this low-literacy rural setting within a developing country. The improvements were maintained without further intervention for 12 months. With appropriate sociocultural adaptation to local contexts, this low-cost method of community education may be applicable to improving maternal health knowledge and behavior change in other low-resource and limited literacy settings that may lead to reductions in maternal mortality.

Gamma Interferon-Regulated Chemokines in Leishmania donovani Infection in the Liver.

In the livers of C57BL/6 mice, gamma interferon (IFN-γ) controls intracellular Leishmania donovani infection and the efficacy of antimony (Sb) chemotherapy. Since both responses usually correlate with granulomatous inflammation, we tested six prominently expressed, IFN-γ-regulated chemokines-CXCL9, CXCL10, CXCL13, CXCL16, CCL2, and CCL5-for their roles in (i) mononuclear cell recruitment and granuloma assembly and maturation, (ii) initial control of infection and self-cure, and (iii) responsiveness to Sb treatment. Together, the results for the L. donovani-infected livers of chemokine-deficient mice (CXCR6-/- mice were used as CXCL16-deficient surrogates) indicated that individual IFN-γ-induced chemokines have diverse affects and (i) may be entirely dispensable (CXCL13, CXCL16), (ii) may promote (CXCL10, CCL2, CCL5) or downregulate (CXCL9) initial granuloma assembly, (iii) may enhance (CCL2, CCL5) or hinder (CXCL10) early parasite control, (iv) may promote granuloma maturation (CCL2, CCL5), (v) may exert a granuloma-independent action that enables self-cure (CCL5), and (vi) may have no role in responsiveness to chemotherapy. Despite the near absence of tissue inflammation in early-stage infection, parasite replication could be controlled (in CXCL10-/- mice) and Sb was fully active (in CXCL10-/-, CCL2-/-, and CCL5-/- mice). These results characterize chemokine action in the response to L. donovani and also reemphasize that (i) recruited mononuclear cells and granulomas are not required to control infection or respond to Sb chemotherapy, (ii) granuloma assembly, control of infection, and Sb's efficacy are not invariably linked expressions of the same T cell-dependent, cytokine-mediated antileishmanial mechanism, and (iii) granulomas are not necessarily hallmarks of protective antileishmanial immunity.

Comparison of induction of labour regimes for termination of pregnancy, with and without mifepristone, from 20 to 41 weeks gestation.

AIM: To investigate the efficacy of mifepristone for induction of labour in pregnancies at 20-41 weeks' gestation, by comparing the outcomes of length of labour and duration of admission in women with and without mifepristone pretreatment. METHOD: In this retrospective cohort study, all women who underwent a medical termination of a singleton pregnancy between 20 and 41 weeks gestation for either a fetal abnormality or fetal death in utero between 1 January, 2009 and 1 January, 2014 were identified. Women who went into spontaneous labour, required a primary surgical delivery or had a multiple pregnancy were not included. RESULTS: The total number of women included in the study was 147: 63 in the mifepristone treatment and 84 in the no mifepristone treatment. In the group of women induced after mifepristone pre-treatment there was a 38% reduction in the median duration of labour, with 2.5 h in the group treated with mifepristone versus 4.0 h in women induced without (P = 0.001). We also found a 50% reduction in the number of days admitted to hospital with the length of admission being 1 day versus 2 days (P = 0.005). CONCLUSION: This study supports the hypothesis that in pregnancies greater than 20 weeks, the duration of labour and length of admission are reduced when induction of labour for termination of pregnancy is preceded by treatment with mifepristone.

Granzyme-mediated regulation of host defense in the liver in experimental Leishmania donovani infection.

In the livers of susceptible C57BL/6 (B6) mice infected with Leishmania donovani, CD8(+) T cell mechanisms are required for granuloma assembly, macrophage activation, intracellular parasite killing, and self-cure. Since gene expression of perforin and granzymes A and B (GzmA and GzmB), cytolytic proteins linked to CD8(+) cell effector function, was enhanced in infected liver tissue, B6 mice deficient in these granular proteins were used to gauge host defense roles. Neither perforin nor GzmA was required; however, mice deficient in GzmB (GzmB(-/-), GzmB cluster(-/-), and GzmA×B cluster double knockout [DKO] mice) showed both delayed granuloma assembly and initially impaired control of parasite replication. Since these two defects in B6 mice were limited to early-stage infection, innately resistant 129/Sv mice were also tested. In this genetic setting, expression of both innate and subsequent T (Th1) cell-dependent acquired resistance, including the self-cure phenotype, was entirely derailed in GzmA×B cluster DKO mice. These results, in susceptible B6 mice for GzmB and in resistant 129/Sv mice for GzmA and/or the GzmB cluster, point to granzyme-mediated host defense regulation in the liver in experimental visceral leishmaniasis.

IFN-γ-induced macrophage antileishmanial mechanisms in mice: A role for immunity-related GTPases, Irgm1 and Irgm3, in Leishmania donovani infection in the liver.

In C57BL/6 mice, Leishmania donovani infection in the liver provoked IFN-γ-induced expression of the immunity-related GTPases (IRG), Irgm1 and Irgm3. To gauge the antileishmanial effects of these macrophage factors in the liver, intracellular infection was analyzed in IRG-deficient mice. In early- (but not late-) stage infection, Irgm3(-/-) mice failed to properly control parasite replication, generated little tissue inflammation and were hyporesponsive to pentavalent antimony (Sb) chemotherapy. Observations limited to early-stage infection in Irgm1(-/-) mice demonstrated increased susceptibility and virtually no inflammatory cell recruitment to heavily-parasitized parenchymal foci but an intact response to chemotherapy. In L. donovani infection in the liver, the absence of either Irgm1 or Irgm3 impairs early inflammation and initial resistance; the absence of Irgm3, but not Irgm1, also appears to impair the intracellular efficacy of Sb chemotherapy.

Cutaneous leishmaniasis in North Dakota.

In the United States, autochthonous cutaneous leishmaniasis caused by infection with Leishmania mexicana has been reported from Texas and Oklahoma. Here, we describe a child with 2 new features: cutaneous infection acquired outside of the south-central United States (in North Dakota) and infection caused by Leishmania donovani species complex.

Regulatory actions of Toll-like receptor 2 (TLR2) and TLR4 in Leishmania donovani infection in the liver.

In livers of susceptible but self-curing C57BL/6 mice, intracellular Leishmania donovani infection enhanced Toll-like receptor 4 (TLR4) and TLR2 gene expression. In the liver, infected TLR4(-/-) mice showed reduced gamma interferon (IFN-γ), tumor necrosis factor (TNF), and inducible nitric oxide synthase (iNOS) mRNA expression, higher-level and slowly resolving infection, delayed granuloma formation, and little response to low-dose chemotherapy; in serum, the ratio of IFN-γ to interleukin 10 (IL-10) activity was decreased by 50%. In contrast, in TLR2(-/-) mice, control of liver infection, parasite killing, and granuloma assembly were accelerated and chemotherapy's efficacy enhanced. In livers of infected TLR2(-/-) mice, mRNA expression was not increased for inflammatory cytokines or iNOS or decreased for IL-10; however, the serum IFN-γ/IL-10 ratio was increased 6.5-fold and minimal responses to IL-10 receptor blockade suggested downregulated IL-10. In established infection in wild-type mice, blockading TLR2 induced parasite killing and triggering TLR4 strengthened resistance and promoted chemotherapy's effect. Thus, in experimental L. donovani infection in the liver, TLR4 signaling upregulates and TLR2 signaling downregulates macrophage antileishmanial activity, making both receptors potential therapeutic targets in visceral leishmaniasis for engagement (TLR4) or blockade (TLR2).

Single-dose liposomal amphotericin B for visceral leishmaniasis in India.

BACKGROUND: Some 50% of patients with visceral leishmaniasis (kala-azar) worldwide live in the Indian state of Bihar. Liposomal amphotericin B is an effective treatment when administered in short courses. We wanted to determine whether the efficacy of a single infusion of liposomal amphotericin B was inferior to conventional parenteral therapy, consisting of 15 alternate-day infusions of amphotericin B deoxycholate. METHODS: In this open-label study, we randomly assigned 412 patients in a 3:1 ratio to receive either liposomal amphotericin B (liposomal-therapy group) or amphotericin B deoxycholate (conventional-therapy group). Liposomal amphotericin B (at a dose of 10 mg per kilogram of body weight) was given once, and patients were discharged home 24 hours later. Amphotericin B deoxycholate, which was administered in 15 infusions of 1 mg per kilogram, was given every other day during a 29-day hospitalization. We determined the cure rate 6 months after treatment. RESULTS: A total of 410 patients--304 of 304 patients (100%) in the liposomal-therapy group and 106 of 108 patients (98%) in the conventional-therapy group--had apparent cure responses at day 30. Cure rates at 6 months were similar in the two groups: 95.7% (95% confidence interval [CI], 93.4 to 97.9) in the liposomal-therapy group and 96.3% (95% CI, 92.6 to 99.9) in the conventional-therapy group. Adverse events in the liposomal-therapy group were infusion-related fever or rigors (in 40%) and increased anemia or thrombocytopenia (in 2%); such events in the conventional-therapy group were fever or rigors (in 64%), increased anemia (in 19%), and hypokalemia (in 2%). Nephrotoxicity or hepatotoxicity developed in no more than 1% of patients in each group. CONCLUSIONS: A single infusion of liposomal amphotericin B was not inferior to and was less expensive than conventional therapy with amphotericin B deoxycholate. (ClinicalTrials.gov number, NCT00628719.)

The kinetoplast in the diagnosis of visceral leishmaniasis.

In visceral leishmaniasis (as in all leishmanial infections), microscopic diagnosis is made by observing the intracellular amastigote form, complete with a kinetoplast, in aspirate smears or biopsied tissue. In the 2 clinically-ill patients described here, intracellular inclusions were demonstrated in a bone marrow aspirate or a colon tissue biopsy. Kinetoplasts associated with the inclusions were not identified in the marrow aspirate smear (although the patient was treated for visceral leishmaniasis), but were identified retrospectively in the colonic tissue (although the patient was treated for histoplasmosis). Both cases illustrate the importance to clinical consultants of microscopically observing (or not) an associated kinetoplast when faced with a tissue aspirate or biopsy specimen showing intracellular inclusions.

Fly bites and skin lesion in an asymptomatic traveler returned from Tanzania: Next steps?

A returned traveler had three features suggesting a risk for developing East African human trypanosomiasis - geographical exposure (Tanzania), likely tsetse fly bites and a trypanosomal chancre-like skin lesion. However, the traveler was asymptomatic at the time of presentation, raising the issue of how to proceed clinically.

An implementation intervention to increase the routine provision of antenatal care addressing gestational weight gain: study protocol for a stepped-wedge cluster trial.

BACKGROUND: Weight gain during pregnancy that is outside of recommended levels is associated with a range of adverse outcomes for the mother and child, including gestational diabetes, pre-eclampsia, preterm birth, and obesity. Internationally, 60-80% of pregnant women report gaining weight outside of recommended levels. While guideline recommendations and RCT evidence support the provision of antenatal care that supports healthy gestational weight gain, less than 10% of health professionals routinely weigh pregnant women; discuss weight gain, diet, and physical activity; and provide a referral for additional support. This study aims to determine the effectiveness of an implementation intervention in increasing the provision of recommended gestational weight gain care by maternity services. METHODS: A stepped-wedge controlled trial, with a staggered implementation intervention, will be conducted across maternity services in three health sectors in New South Wales, Australia. The implementation intervention will consist of evidence-based, locally-tailored strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training, and monitoring and feedback. Primary outcome measures will be the proportion of women who report receiving (i) assessment of gestational weight gain; (ii) advice on gestational weight gain, dietary intake, and physical activity; and (iii) offer of referral to a telephone coaching service or local dietetics service. Measurement of outcomes will occur via telephone interviews with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost, cost-consequence, cost-effectiveness, and budget impact of the implementation intervention. Receipt of all care elements, acceptance of referral, weight gain during pregnancy, diet quality, and physical activity will be measured as secondary outcomes. Process measures including acceptability, adoption, fidelity, and reach will be reported. DISCUSSION: This will be the first controlled trial to evaluate the effectiveness of a implementation intervention in improving antenatal care that addresses gestational weight gain. The findings will inform decision-making by maternity services and policy agencies and, if the intervention is demonstrated to be effective, could be applied at scale to benefit the health of women and children across Australia and internationally. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12621000054819 . Registered on 22 January 2021.

A subset of liver NK T cells is activated during Leishmania donovani infection by CD1d-bound lipophosphoglycan.

Natural killer (NK) T cells are activated by synthetic or self-glycolipids and implicated in innate host resistance to a range of viral, bacterial, and protozoan pathogens. Despite the immunogenicity of microbial lipoglycans and their promiscuous binding to CD1d, no pathogen-derived glycolipid antigen presented by this pathway has been identified to date. In the current work, we show increased susceptibility of NK T cell-deficient CD1d(-/-) mice to Leishmania donovani infection and Leishmania-induced CD1d-dependent activation of NK T cells in wild-type animals. The elicited response was Th1 polarized, occurred as early as 2 h after infection, and was independent from IL-12. The Leishmania surface glycoconjugate lipophosphoglycan, as well as related glycoinositol phospholipids, bound with high affinity to CD1d and induced a CD1d-dependent IFNgamma response in naive intrahepatic lymphocytes. Together, these data identify Leishmania surface glycoconjugates as potential glycolipid antigens and suggest an important role for the CD1d-NK T cell immune axis in the early response to visceral Leishmania infection.

Perinatal risk factors for the neonatal abstinence syndrome in infants born to women on methadone maintenance therapy.

BACKGROUND: Neonatal abstinence syndrome (NAS) occurs in more than 50% of infants exposed to intrauterine opiates. Maternal opiate dosing has been investigated with conflicting results. AIMS: The aims of this study were to correlate maternal methadone dose and other risk factors with the development of NAS requiring pharmacological treatment by using easily accessible clinical parameters. METHODS: Retrospective medical record review of data from 228 opioid dependent pregnant women who delivered 232 live-born infants. Logistic regression analysis was performed on maternal, perinatal and neonatal parameters to identify risk factors for NAS requiring treatment. A prediction model was developed and validated on a separate independent cohort of 188 infants. RESULTS: Of the 232 infants, 172 (74%) infants were treated for NAS. The risk of withdrawal increased by 17% per 5 mg increment of the last maternal methadone dose. The risk was lower for younger gestational ages and for those delivered by Caesarean section compared to those delivered by normal vaginal delivery. Through predictive modeling, gestational age, mode of delivery and last methadone dose were established as risk factors for withdrawal. The model was validated by other statistical measures and its diagnostic performance confirmed on the separate independent cohort. CONCLUSIONS: Our data suggests that timing and mode of delivery as well as last maternal methadone dose are significant risk factors for the development of NAS requiring treatment. Based on these clinical parameters, risk stratification for perinatal management of pregnancies associated with opioid dependency and risk prediction for the neonate might now be possible.

Targeting IL-27 and/or IL-10 in Experimental Murine Visceral Leishmaniasis.

Interleukin-10 (IL-10) and interleukin-27 (IL-27) both exert counterregulatory immunodeactivation in visceral Leishmania donovani infection. We studied experimental L. donovani infection in the livers of IL-10-/- and IL-27Rα-/- mice and observed that in IL-27Rα-/-, but not IL-10-/- mice, interferon-gamma (IFN-γ) and tumor necrosis factor (TNF) were required for heightened granulomatous inflammation and accelerated control of intracellular parasite replication. This difference in mechanism, along with residual IL-10 activity in IL-27Rα-/- mice, suggested targeting IL-27 in addition to IL-10 in a macrophage-activating, anti-counterregulatory cytokine treatment strategy. In C57BL/6 wild-type mice with established liver infection, a single injection of anti-IL-27 p28 or anti-IL-10R monoclonal antibody enhanced granuloma assembly, enabled macrophage activation, and induced comparable parasite killing (49-56%). However, anti-IL-27 p28 plus anti-IL-10R combination treatment did not increase leishmanicidal effects. These results suggest that IL-27 and IL-10 may operate in a linked deactivating mechanism and that in this intracellular infection, either IL-27 or IL-10 is a suitable immunotherapeutic target.

The Pretravel Consultation: Recent Updates.

Estimates suggest that 43%-79% of international travelers may develop travel-related illnesses. Most such illnesses are considered mild and self-limited; however, some are life-threatening. The pretravel consultation is aimed at assessing risks for a range of illnesses, communicating these risks, and then providing individualized recommendations and interventions to minimize or manage such risks. The effective consultation is predicated on a well-prepared clinician and motivated traveler, understanding the traveler's perception of, and tolerance for, risk, and providing education applicable to the actual itinerary. Integral to the clinician's preparation is regular review of up-to-date trip-specific recommendations; country-specific information and recommendations are readily available and can now be efficiently accessed. From the infectious diseases perspective, immunizations, malaria chemoprophylaxis, insect repellent use, and travelers' diarrhea and its self-management are cornerstones of the consultation. This review focuses primarily on updating these 4 topics with recently published information relevant to adult travelers.

Case Report: Mucosal Leishmaniasis in New York City.

The six previously reported civilian cases of mucosal leishmaniasis (ML) diagnosed in the United States have all represented imported New World ML. We describe two new patients with ML diagnosed in New York City-a Syrian immigrant with a nasal mass (Leishmania tropica), the first report of Old World ML in the United States, and an American ecologist who worked in Bolivia and had been treated for cutaneous infection 23 years before developing lesions (L. (Viannia) braziliensis) initially of the uvula, soft palate, and posterior pharynx and subsequently the larynx.

Antenatal corticosteroid administration for foetal lung maturation.

Antenatal corticosteroids are an essential component in the management of women at risk for preterm labour. They promote lung maturation and reduce the risk of other preterm neonatal complications. This narrative review discusses the contentious issues and controversies around the optimal use of antenatal corticosteroids and their consequences for both the mother and the neonate. The most recent evidence base is presented.

Are antenatal interventions effective in improving multiple health behaviours among pregnant women? A systematic review protocol.

BACKGROUND: Maternal behaviours in pregnancy associated with adverse pregnancy, birth and health outcomes include tobacco smoking, poor nutrition, alcohol consumption and low physical activity, collectively referred to as the SNAP risk factors. Due to the high prevalence, co-occurrence and possible interactive health effects of such health behaviours in pregnancy, antenatal interventions that support pregnant women to improve multiple SNAP behaviours have a greater potential impact on the health outcomes of women and their children than interventions addressing single behaviours. The objective of this review is to determine the effectiveness of interventions delivered as part of antenatal care that aim to improve multiple SNAP behaviours among pregnant women. METHODS: Seven electronic databases will be searched for potentially eligible studies. Eligible studies will include those where pregnant women are attending antenatal care. Studies that examine the effect of an intervention that addresses multiple SNAP behaviours (≥ 2 behaviours) during pregnancy and are delivered or instigated through antenatal care in a healthcare service will be included. Systematic reviews of randomised controlled trials (RCTs), RCTs, cluster RCTs, stepped-wedge RCTs and non-randomised control trials will be eligible. Studies that include a no-intervention control, wait-list control group, standard/usual care, or another active single behavioural intervention (e.g. addressing one behaviour only) will be considered. Two independent reviewers will conduct study screening, data extraction and risk of bias assessment. Discrepancies will be resolved by consensus or a third reviewer if required. A random effects model will be used to synthesise the results. Alternative synthesis methods will be investigated in instances where a meta-analysis is not appropriate, such as summarising effect estimates, combining P values, vote counting based on direction of effect, or synthesis in narrative form. DISCUSSION: The review will synthesise the evidence on the effect of interventions that address multiple SNAP behaviours in antenatal care and will help researchers, policy-makers and health services to develop and deliver best practice integrated models of antenatal care that have the potential to impact on both the short- and long-term health outcomes for women and their children. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018095315.