Epidemiology of Pregnancy Complications Through the Lens of Immunological Memory.

In the fifteen minutes it takes to read this short commentary, more than 400 babies will have been born too early, another 300 expecting mothers will develop preeclampsia, and 75 unborn third trimester fetuses will have died in utero (stillbirth). Given the lack of meaningful progress in understanding the physiological changes that occur to allow a healthy, full term pregnancy, it is perhaps not surprising that effective therapies against these great obstetrical syndromes that include prematurity, preeclampsia, and stillbirth remain elusive. Meanwhile, pregnancy complications remain the leading cause of infant and childhood mortality under age five. Does it have to be this way? What more can we collectively, as a biomedical community, or individually, as clinicians who care for women and newborn babies at high risk for pregnancy complications, do to protect individuals in these extremely vulnerable developmental windows? The problem of pregnancy complications and neonatal mortality is extraordinarily complex, with multiple unique, but complementary perspectives from scientific, epidemiological and public health viewpoints. Herein, we discuss the epidemiology of pregnancy complications, focusing on how the outcome of prior pregnancy impacts the risk of complication in the next pregnancy - and how the fundamental immunological principle of memory may promote this adaptive response.

Reproductive Characteristics and Pregnancy Outcomes in Hidden Celiac Disease Autoimmunity.

INTRODUCTION: Untreated symptomatic celiac disease (CD) adversely affects female reproduction; however, the effect of hidden CD autoimmunity is uncertain. METHODS: We identified women who were not previously diagnosed with CD and tested positive for tissue transglutaminase and endomysial antibodies between 2006 and 2011 in a community-based retrospective cohort study. We evaluated (i) the rate of adverse pregnancy outcomes and medical complications of pregnancy in successful singleton deliveries and (ii) reproductive characteristics in seropositive women without a clinical diagnosis of CD and age-matched seronegative women. RESULTS: Among 17,888 women whose serum samples were tested for CD autoimmunity, 215 seropositive and 415 seronegative women were included. We reviewed 231 and 509 live singleton deliveries of 117 seropositive and 250 seronegative mothers, respectively. Menarche and menopausal age, gravidity, parity, and age at first child were similar in seropositive and seronegative women. CD seropositivity was not associated with an increased risk of maternal pregnancy complications. Maternal seropositivity was associated with small for gestational age in boys (OR 3.77, 95% CI: 1.47-9.71; P = 0.006), but not in girls (OR 0.57, 95% CI: 0.15-2.17; P = 0.41). CD serum positivity was not associated with prematurity, small for gestational age (birth weight <10th percentile), or 5-minute Apgar score of less than 7. DISCUSSION: Although underpowered, the present study did not show any difference in reproductive characteristics or rates of adverse pregnancy outcomes in women with and without CD autoimmunity, except for birth weight in male offspring. Larger studies are needed to determine the effects of CD autoimmunity on female reproduction.

The impact of previous live births on peripheral and uterine natural killer cells in patients with recurrent miscarriage.

BACKGROUND: Peripheral and uterine natural killer cells (pNK and uNK cells) are key players in the establishment and maintenance of pregnancy and are disturbed in patients with recurrent miscarriage (RM). Different immunologic risk factors have been proposed between patients with primary RM (pRM, no previous live birth) and secondary RM (sRM, ≥ 1 previous live birth). However, so far, the study populations mainly consisted of small subgroups. Therefore, we aimed to analyse pNK and uNK cells in a large, well defined study population within a prospective study. METHODS: In total, n = 575 RM patients (n = 393 pRM, n = 182 sRM) were screened according to a standard protocol for established risk factors as well as pNK and uNK cells. Peripheral blood levels of CD45+CD3-CD56+CD16+ NK cells were determined by flow cytometry and uterine CD56+ NK cells by immunohistochemistry in mid-luteal non-pregnant RM patients. Exclusion of patients with ≥1 established risk factor revealed n = 248 idiopathic RM patients (iRM, n = 167 primary iRM (ipRM), n = 81 secondary iRM (isRM)). RESULTS: Patients with pRM and ipRM showed significant higher absolute numbers and percentages of pNK cells compared to sRM and isRM patients (pRM/ipRM vs sRM/isRM, mean ± SD /µl: 239.1 ± 118.7/244.9 ± 112.9 vs 205.1 ± 107.9/206.0 ± 105.6, p = 0.004/ p = 0.009; mean ± SD %: 12.4 ± 5.5/12.8 ± 5.4 vs 11.1 ± 4.6/11.1 ± 4.3, p = 0.001; p = 0.002). Only patients with isRM showed significantly higher uNK levels compared to patients with ipRM (mean ± SD /mm2 288.4 ± 239.3 vs 218.2 ± 184.5, p = 0.044). CONCLUSIONS: The demonstrated differences in pNK and uNK cells in RM patients depending on previous live birth might indicate differences in NK cell recruitment and potentially different underlying immune disorders between pRM and sRM. As there is an overlap in the distribution of the NK cell results, further studies with focus on NK cell function are needed in order to clearly identify RM patients with distinct immune abnormalities. The clinical relevance of our findings should be interpreted cautiously until specificity and sensitivity are further evaluated.

Blood lymphocyte subpopulations in healthy water buffaloes (Bubalus bubalis, Mediterranean lineage): Reference intervals and influence of age and reproductive history.

There is an increasing interest toward infectious diseases and mechanisms of immune response of water buffaloes, mainly because of the growing economic impact of this species and of its high-quality milk. However, little is known about the immune system of these animals in physiological conditions. Recently, a wide number of antibodies cross reacting with buffalo antigens has been validated for use in flow cytometry (FC), allowing detailed characterization of the lymphocytic population in this species. The aim of the present study was to describe the lymphocyte subpopulations in a large number of healthy water buffaloes, providing reference intervals (RIs), and to assess whether the composition of blood lymphocyte population significantly varied with age and reproductive history. Our final aim was to lay the ground for future studies evaluating the role of host immune response in water buffaloes. One-hundred-twelve healthy buffaloes from four different herds in the South of Italy were included in the study. All animals had been vaccinated for Infectious Bovine Rhinotracheitis (IBR), Salmonellosis, Colibacillosis and Clostridiosis, and all herds were certified Brucellosis- and Tuberculosis-free. Venous blood collected into EDTA tubes was processed for FC, and the percentage of cells staining positive for the following antibodies was recorded: CD3, CD4, CD8, CD21, TCR-δ-N24, WC1-N2, WC1-N3 and WC1-N4. Absolute concentration of each lymphoid subclass was then calculated, based on automated White Blood Cell (WBC) Count. Reference Intervals were calculated according to official guidelines and are listed in the manuscript. The composition of the lymphocyte population varied with age and reproductive history, with animals <2-years-old and heifers having higher concentration of most of the subclasses. The present study provides RIs for the main lymphocytic subclasses in healthy water buffaloes, highlighting gross differences between young and old animals. Establishment of age-specific RIs is recommended in water buffaloes. The data we present may be useful as a basis for further studies concerning mechanisms of immune response toward infectious agents in water buffaloes.

Increased HLA-G Expression in Term Placenta of Women with a History of Recurrent Miscarriage Despite Their Genetic Predisposition to Decreased HLA-G Levels.

Human leukocyte antigen (HLA)-G is an immune modulating molecule that is present on fetal extravillous trophoblasts at the fetal-maternal interface. Single nucleotide polymorphisms (SNPs) in the 3 prime untranslated region (3'UTR) of the HLA-G gene can affect the level of HLA-G expression, which may be altered in women with recurrent miscarriages (RM). This case-control study included 23 women with a medical history of three or more consecutive miscarriages who delivered a child after uncomplicated pregnancy, and 46 controls with uncomplicated pregnancy. Genomic DNA was isolated to sequence the 3'UTR of HLA-G. Tissue from term placentas was processed to quantify the HLA-G protein and mRNA levels. The women with a history of RM had a lower frequency of the HLA-G 3'UTR 14-bp del/del genotype as compared to controls (Odds ratio (OR) 0.28; p = 0.039), which has previously been related to higher soluble HLA-G levels. Yet, HLA-G protein (OR 6.67; p = 0.006) and mRNA (OR 6.33; p = 0.010) expression was increased in term placentas of women with a history of RM as compared to controls. In conclusion, during a successful pregnancy, HLA-G expression is elevated in term placentas from women with a history of RM as compared to controls, despite a genetic predisposition that is associated with decreased HLA-G levels. These findings suggest that HLA-G upregulation could be a compensatory mechanism in the occurrence of RM to achieve an ongoing pregnancy.

Monitoring mRNA transcription of genes involved in early pregnancy from endometrium and peripheral blood mononuclear cells of pregnant pigs with different parity.

The reproductive success of mammals is largely dependent on the interaction between maternal and foetal interfaces during early pregnancy. Particularly, immune cells which reside at the maternal endometrium can modulate the conception and placental vascularization. In this study, we analysed the transcription of genes involved in early pregnancy from endometrium and peripheral blood mononuclear cells (PBMCs) of pregnant pigs with different parity. Briefly, three groups of female pigs were divided based on parity (0, 2 and 5) and each group was artificially inseminated. Within 30 days of gestation, the total RNA was isolated from the endometrium and PBMCs of sacrificed experimental pigs and the expression patterns of genes involved in early pregnancy were monitored by quantitative real-time RT-PCR. Results indicated absence of correlation between increased parity and the expression of vascular endothelial growth factor (VEGF) and hypoxia-inducible factor 1-α (HIF-1α) mRNA in endometrium among the groups of pigs analysed. Yet, the mRNA levels of Fas, Fas ligand (FasL) and tumour necrosis factor-α (TNF-α) in the endometrium of parity 5 sows were much higher than those of pregnant gilts (parity 0), and the mRNA ratios of both TNF-α:interleukin-4 (IL-4) and IFN-γ (interferon-γ):interleukin-10 (IL-10) in PBMCs of pregnant pigs were augmented with increasing parity. Furthermore, the mRNA levels of TNF-α and IFN-γ in PBMCs of pregnant pigs were inversely correlated with litter size. These combined results may demonstrate that increased parity of pregnant pigs leads to enhance Th1-prone immunity within the maternal-foetal interface during early pregnancy.

Comparison of hepatitis B viral loads and viral antigen levels in child-bearing age women with and without pregnancy.

BACKGROUND: Pregnancy is a unique physiological condition with the cellular immune functions compromised at some extents to allow the mature of growing fetus. Whether pregnancy may influence the replication of hepatitis B virus (HBV) is less studied. The present study aimed to investigate the influence of pregnancy on the replication of HBV and expression of viral antigens by comparing the levels of HBV DNA and viral antigens in pregnant and non-pregnant women. METHODS: A total of 727 HBsAg-positive serum samples, collected from 214 pregnant women and 513 non-pregnant women of childbearing age, were included. Based on the pregnancy status, subjects were divided into four groups: nulliparous (n = 158), pregnant (n = 214), 7-12 months postpartum (n = 170), and 2-5 years postpartum (n = 185). The levels of hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) were quantitatively measured with microparticle enzyme immunoassay. HBV DNA levels were detected by fluorescent real-time PCR. RESULTS: The median ages of four groups were 25.0, 25.3, 26.2 and 29.3 years, respectively (p < 0.01). HBeAg-positive proportions were 34.2, 33.6, 35.3 and 29.2%, respectively (p = 0.624). HBV DNA levels in HBeAg-positive women were higher than those in HBeAg-negative women (7.88 vs 2.62 log IU/ml, p < 0.001). HBV DNA levels in the four groups with positive HBeAg were 7.8, 7.7, 8.0 and 8.0 log IU/ml, respectively (p = 0.057), while HBsAg titers were 4.4, 4.5, 4.6 and 4.8 log IU/ml (p = 0.086) and HBeAg titers were 3.1, 3.0, 3.1 and 3.0 log S/CO (p = 0.198). In the four groups with negative HBeAg, HBV DNA levels were 2.3, 2.6, 2.5 and 2.8 log IU/ml, respectively (p = 0.085), while HBsAg titers were 3.1, 3.3, 3.3 and 3.0 log IU/ml (p = 0.06). CONCLUSIONS: Serum levels of HBV DNA and viral antigens showed no significant changes in nulliparous, pregnant, and postpartum women, regardless of the HBeAg status. The results indicate that pregnancy has little influence on the replication of HBV and the expression of viral antigens.

Parity and Risk of Thyroid Autoimmunity Based on the NHANES (2001-2002, 2007-2008, 2009-2010, and 2011-2012).

Context: Autoimmune thyroid disease is more common in women than in men. Fetal microchimerism has been implicated as a potential explanation for this disparity. Objective: The objective of this study was to evaluate the relationship between parity and thyroid autoimmunity in the US population. Design, Setting, Patients: The National Health and Nutrition Examination Survey was used to identify females with antithyroperoxidase (TPOAb) and antithyroglobulin antibody (TgAb) measurements and parity data. Subjects (n = 4864) were categorized as never pregnant (n = 909) or previously pregnant (n = 3955). The association of parity with thyroid autoantibodies was examined both qualitatively and quantitatively. Thyroid autoimmunity was defined as TPOAb and/or TgAb titers above the reference limits. Results: Previous pregnancy carried an odds ratio (OR) of 1.55 [95% confidence interval (CI): 1.26 to 1.91] for thyroid autoimmunity compared with never pregnant. Number of pregnancies was associated with thyroid autoimmunity: OR = 1.37 (95% CI: 1.02 to 1.84); 1.4 (95% CI: 1.08 to 1.81); 1.52 (95% CI: 1.18 to 1.96); and 1.73 (95% CI: 1.38 to 2.18) for 1, 2, 3, and ≥4 pregnancies, respectively. Because ever-pregnant women differed in several variables-age, race, smoking status, history of thyroid disease, and urinary iodine level-from never-pregnant women (P < 0.001), a multivariate regression analysis was performed, which showed no association of pregnancy with thyroid autoimmunity. The association was further examined utilizing an age-matched analysis, which confirmed the absence of an association between thyroid autoimmunity and parity. Conclusion: Although we initially observed a strong association between parity and thyroid autoimmunity, after controlling for age and other variables, we were unable to identify an association.

Effect of APOE ε4 allele on survival and fertility in an adverse environment.

BACKGROUND: The apolipoprotein-ε4 allele (APOE-ε4) is strongly associated with detrimental outcomes in affluent populations including atherosclerotic disease, Alzheimer's disease, and reduced lifespan. Despite these detrimental outcomes, population frequencies of APOE-ε4 are high. We hypothesize that the high frequency of APOE-ε4 was maintained because of beneficial effects during evolution when infectious pathogens were more prevalent and a major cause of mortality. We examined a rural Ghanaian population with a high pathogen exposure for selective advantages of APOE-ε4, to survival and or fertility. METHODS AND FINDINGS: This rural Ghanaian population (n = 4311) has high levels of mortality from widespread infectious diseases which are the main cause of death. We examined whether APOE-ε4 was associated with survival (total follow-up time was 30,262 years) and fertility after stratifying by exposure to high or low pathogen levels. Households drawing water from open wells and rivers were classified as exposed to high pathogen levels while low pathogen exposure was classified as those drawing water from borehole wells. We found a non-significant, but positive survival benefit, i.e. the hazard ratio per APOE-ε4 allele was 0.80 (95% confidence interval: 0.69 to 1.05), adjusted for sex, tribe, and socioeconomic status. Among women aged 40 years and older (n = 842), APOE-ε4 was not associated with the lifetime number of children. However, APOE-ε4 was associated with higher fertility in women exposed to high pathogen levels. Compared with women not carrying an APOE-ε4 allele, those carrying one APOE-ε4 allele had on average one more child and those carrying two APOE-ε4 alleles had 3.5 more children (p = 0.018). CONCLUSIONS: Contrary to affluent modern-day populations, APOE-ε4 did not carry a survival disadvantage in this rural Ghanaian population. Moreover, APOE-ε4 promotes fertility in highly infectious environments. Our findings suggest that APOE-ε4 may be considered as evolutionarily adaptive. Its adverse associations in affluent modern populations with later onset diseases of aging further characterize APOE-ε4 as an example of antagonistic pleiotropy.

Exposures influencing total IgA level in colostrum.

Immunoglobulin A (IgA) is a predominant immunoglobulin present in human breast milk and is known to play an important role in infant gut immunity maturation. Breast milk composition varies between populations, but the environmental and maternal factors responsible for these variations are still unclear. We examined the relationship between different exposures and levels of IgA in colostrum. The objective of this study was to examine whether exposures analysed influence levels of IgA in colostrum. The present study used 294 colostrum samples from the MecMilk International cohort, collected from women residing in London, Moscow and Verona. Samples were analysed in automated Abbott Architect Analyser. We found an inverse correlation between time postpartum and colostrum total IgA level (r=-0.49, P<0.001). Adjusting for maternal parity, smoking, fresh fruit and fish consumption and allergen sensitization, multiple regression model showed that IgA levels were influenced by colostrum collection time (P<0.0001) and country of collection (P<0.01). Mode of delivery influence did not appear to be significant in univariate comparisons, once adjusted for the above maternal characteristics it showed a significant influence on total IgA (P=0.01). We conclude that the concentration of IgA in colostrum drops rapidly after birth and future studies should always consider this factor in analysis. IgA concentration varied significantly between countries, with the highest level detected in Moscow and lowest in Verona. Mode of delivery effect should be confirmed on larger cohorts. Further work is needed to determine ways to correct for IgA decline over time in colostrum, and to find the cause of variations in IgA levels between the countries.

Parity influences the severity of ACPA-negative early rheumatoid arthritis: a cohort study based on the Swedish EIRA material.

BACKGROUND: In women with rheumatoid arthritis (RA) it has been observed that during pregnancy a majority of patients experience amelioration, but after delivery a relapse of the disease is common. However, there are few studies, with diverging results, addressing the effect of parity on the severity of RA over time. Our aim was to explore the impact of parity, with stratification for anti-citrullinated protein antibody (ACPA) status as well as for onset during reproductive age or not. METHODS: Female RA cases aged 18-70 years were recruited for the Epidemiological Investigation of Rheumatoid Arthritis (EIRA). Information on disease severity (the health assessment questionnaire (HAQ) and the disease activity score 28 (DAS28)) was retrieved from the Swedish Rheumatology Quality Register at inclusion and 3, 6, 12 and 24 months after diagnosis. Mixed models were used to compare mean DAS28 and HAQ scores over time in parous and nulliparous women. Mean differences at individual follow-up visits were compared using analysis of covariance. The odds of having DAS28 or HAQ above the median in parous verus nulliparous women were estimated in logistic regression models. RESULTS: A total of 1237 female cases (mean age 51 years, 65 % ACPA-positive) were included. ACPA-negative parous women, aged 18-44 years, had on average 1.17 units higher DAS28 (p < 0.001) and 0.43 units higher HAQ score (p < 0.001) compared to nulliparous women during the follow-up time, adjusted for age. In this subgroup, the average DAS28 and HAQ scores were significantly higher in parous women at all follow-up time points. Younger parous ACPA-negative women were significantly more likely to have DAS28 and HAQ values above the median compared to nulliparous women at all follow-up visits. No association between parity and severity of ACPA-positive disease was observed. CONCLUSIONS: Parity was a predictor of a more severe RA among ACPA-negative younger women, which might indicate that immunomodulatory changes during and after pregnancy affect RA severity, in particular for the ACPA-negative RA phenotype.

Antibodies against human platelet alloantigens and human leucocyte antigen class 1 in Saudi Arabian multiparous women and multi-transfused patients.

OBJECTIVES: To determine the frequency of alloimmunization against human platelet antigens (HPAs) and human leucocyte antigen class 1 (HLA1) in multiparous women and multi-transfused patients.   METHODS: This prospective study was conducted between January and August 2013, on 50 multiparous women with no history of previous blood transfusion recruited from the Obstetrics and Gynecology Clinic, and 50 patients, who received multiple platelet transfusions, recruited from the Hematology/Oncology Ward, King Khalid University Hospital, Riyadh, Saudi Arabia. RESULTS: The frequency of alloimmunization among multiparous pregnant women was 76%, as follows: 16% against HLA1 only, 8% against HPAs only, 52% against both HPAs and HLA1 antigens. In multi-transfused patients, the rate of alloimmunization was 42% as follows: 2% against HLA1 only, 22% against HPAs only, 18% against both HPAs and HLA1 antigens. The frequency of alloimmunization increases with the number of pregnancies, but not with the number of platelet transfusions. CONCLUSION: Alloimmunization against HPAs and HLA1 is very common among Saudi multiparous women and multi-transfused patients, which encourages the search for the extent of the possible complications in the fetus and newborn and in multitransfused patients and how to prevent their occurrence.

Effects of Pregnancy-associated Malaria on T Cell Cytokines in Cameroonian Women.

Although Th17 cells subsets improve immunity against extra and intracellular pathogens, and in modulating Th1 and other immune responses, its role on pregnancy-associated malaria (PAM) is unknown. This study aims to investigate the effects of PAM on Th1 (IFN-γ, TNF-α), IL-10 family (IL-10, IL-19, IL-22), Th17 (IL-17A, IL-23) cytokines and on CXCL-10 chemokine profiles in pregnant women. Between 2010 and 2011, venous blood specimens from 107 volunteer pregnant Cameroonian women was used to determine parasitaemia microscopically and haemoglobin levels using HemoCue analyzer. Plasma levels of the biomarkers were determined by ELISA. Parasitaemia was higher in women with low haemoglobin levels, parity and mother's age. IL-10 and CXCL-10 plasma levels were higher in the malaria infected and in anaemic women while IFN-γ and IL-17A levels were higher in malaria non-infected and in non-anaemic women. Parasitaemia correlated positively with IL-10 and CXCL-10 levels but inversely with IFN-γ and IL-17A. Haemoglobin levels were higher in women with low IL-10 and CXCL-10 levels, and in group with high IFN-γ, IL-17A and IL-23 levels. Only IL-10 levels associated negatively with parity. Positive correlations were observed between Th17 (IL-17A) and Th1 (IFN-γ, TNF-α), IL-10 family (IL-19 and IL-22) and Th17 (IL-23) cytokines. Multivariate analysis showed association between: mother's age and IFN-γ levels, parasitaemia and IL-10 and CXCL-10 levels and haemoglobin levels, gestational age and IL-17A levels. In conclusion, during PAM, CXCL-10 and IL-10 responses are implicated in the pathogenesis while Th17 and Th1 immune responses, via IL-17A and IFN-γ might play protective roles.

Phenotypic and genetic relationships of bovine natural antibodies binding keyhole limpet hemocyanin in plasma and milk.

To improve the health status (resilience) of dairy cows, levels of natural antibodies (NAb) might be useful. The objective of the present study was to compare levels and to estimate genetic parameters for NAb measured in milk and plasma samples. Titers of NAb IgM and IgG isotype-binding keyhole limpet hemocyanin of 2,919 cows, in both plasma and milk, were measured using ELISA. Analysis revealed that NAb levels in milk significantly increased with parity, whereas they remained constant in plasma. Moderate positive phenotypic correlations were found between NAb levels in milk and in plasma: 0.18 for IgG and 0.40 for IgM. This indicates that NAb from milk and plasma might reflect different aspects of dairy cow health status. However, high genetic correlations were found for NAb in milk and plasma: 0.81 for IgG and 0.79 for IgM. Heritabilities (SE in parentheses) for NAb measured in plasma [0.15 (0.05) for IgG and 0.25 (0.06) for IgM] were higher than heritabilities of NAb measured in milk [0.08 (0.03) for IgG and 0.23 (0.05) for IgM]. Our results indicate that NAb measured in milk and plasma are heritable and likely have a common genetic background, suggesting that NAb levels measured in milk might be useful for genetic improvement of disease resistance.

Elevated plasma haptoglobin concentrations following parturition are associated with elevated leukocyte responses and decreased subsequent reproductive efficiency in multiparous Holstein dairy cows.

The objectives were to describe the relationship between the intensity of the acute phase response and the metabolic status and leukocyte responses of early postpartum, multiparous cows and determine if subsequent reproductive performance was impaired in cows with a greater acute phase response. Peripheral blood was collected from 240 Holstein cows, 2-8 days in milk and 2nd-8th parity from 8 dairies in Western TX and Eastern NM across 5 days (n=6 cows/dairy/day). Plasma concentrations of haptoglobin were measured and cows were classified as Low (1st quartile), Moderate (2nd and 3rd quartiles), or High (4th quartile) responders. Metabolic measurements included: plasma glucose, urea nitrogen, non-esterified fatty acids and ß-hydroxybutyrate concentrations. Leukocyte response measurements included: total leukocyte counts and differentials, neutrophil surface expression of L-selectin, neutrophil oxidative burst capacity when co-cultured with an environmental Escherichia coli, as well as the secretion of tumor necrosis factor-α and interferon-γ when diluted whole blood were co-cultured with lipopolysaccharide and phytohemagglutinin-P, respectively. All data are reported as Low, Moderate, and High haptoglobin responders. Plasma haptoglobin concentrations ranged from below the limit of detection to 8.4 µg/mL, 8.5 to 458 µg/mL, and 459 to 1757 µg/mL. The High cows had more severe neutropenia (3.45, 3.31, and 2.23 ± 0.31 × 10(6)cells/mL; P=0.013) Additionally, the innate leukocyte responses of the High cows were stimulated as evident by increased secretion of tumor necrosis factor-α (568, 565, and 730 ± 73.4 pg/mL; P=0.003), surface expression of L-selectin on neutrophils (70.8, 71.9, and 119.8 ± 7.9 geometric mean fluorescence intensity; P=0.001), and greater neutrophil oxidative burst capacity (37.9, 40.4, and 47.9 ± 0.31 geometric mean fluorescence intensity; P=0.002). In contrast, the secretion of the T-lymphocyte derived cytokine, interferon-γ, was suppressed in both the Moderate and High cows when compared with Low cows (718, 408, and 322 ± 92.2 pg/mL; P=0.01). Haptoglobin class had an overall effect on days to conception (P=0.039). The number of days in milk for 75% of the cows in each haptoglobin class to conceive increased from 123 d in the Low group, 139 d in the Moderate group, and 183 d in the High group. These data indicate that a stronger acute phase response during the early postpartum period that is characterized by an activated innate immune system and a suppressed mitogen-induced interferon-γ secretion resulted in impaired reproductive efficiency, and this response was consistent across the large commercial dairy herds sampled.

Caesarean section rates in Mozambique

Background: The Caesarean section (C-section) rate is used as an indicator for availability and utilization of life-saving obstetric services. The purpose of the present study was to explore changes in C-section rates between 1995 and 2011 by area, place of delivery and maternal socioeconomic factors in Mozambique. Methods: Cross-sectional data from the Demographic and Health Surveys conducted in Mozambique in 1997, 2003 and 2011 were used, including women having a live birth within 3 years prior to the survey. Descriptive statistics and logistic regressions were used to identify factors associated with having a C-section. Results: The C-section rate decreased slightly from 2.5 % in 1995­1997 to 2.1 % in 2001­2003 and then increased to 4.7 % in 2009­2011. In 2009­2011, C-section rates ranged in urban areas from 4.6 % in the northern region to 12.2 % in the southern region and in rural areas from 1.6 % in the northern region to 3.9 % in the southern region. 12.3 % of the richest women had had a C-section, compared to 1.7 % of the poorest women. C-sections were the most common at public hospitals (12.6 % in 2009­2011), but C-sections at health centers increased from the second to the third period. The likelihood of having a C-section was associated with living in urban areas and in the southern region, having a formal education and living in a rich household, even adjusting for age and parity (and study periods). The strongest relationship was for the richest household wealth quintile [OR (95 % CI): 9.8 (6.3­15.3)]. The highest rate (20.6 %) was found among the richest women giving birth at public hospitals in the southern region in 2009­2011. Conclusion: In Mozambique, underuse of C-section was likely among the poor and in rural areas, but overuse in the most advantaged groups seemed to be emerging.

Parity and the risk of developing rheumatoid arthritis: results from the Swedish Epidemiological Investigation of Rheumatoid Arthritis study.

OBJECTIVE: To study the impact of parity history on the risk of antibodies to citrullinated peptide antigens (ACPA) positive and ACPA-negative rheumatoid arthritis (RA), in different age-groups. METHOD: Data from a population-based case-control study of female incident RA cases were analysed (2035 cases and 2911 controls, aged 18-70 years ). Parity history was assessed through a questionnaire. Parous women were compared with nulliparous, by calculating odds ratios (ORs) with 95% confidence interval (CI). RESULTS: Parity was associated with an increased risk of ACPA-negative RA in women aged 18-44 years (OR=2.1, 95% CI 1.4 to 3.2), but not in those aged 45-70 years (OR=0.9, 95% CI 0.7 to 1.3). Among young women, an increased risk of ACPA-negative RA was found in those who gave birth during the year of symptom onset (OR=2.6, 95% CI 1.4 to 4.8) and who were at a young age at first birth (<23) (OR=2.5, 95% CI 1.5 to 4.1). Parity and the postpartum period were not associated with ACPA-positive RA, but older age at first birth was weakly associated with a decreased risk. CONCLUSIONS: The increased risk of ACPA-negative RA in parous women of reproductive age seemed to be associated with an increased postpartum risk and with young age at first birth. Further research is needed to explore the biological mechanisms behind our findings.

Antenatal rubella immunity in Ireland.

The objective of the study was to identify those women attending for antenatal care who would have benefited from prepregnancy rubella vaccination. It was a population-based observational study of women who delivered a baby weighing < or = 500 g in 2009 in the Republic of Ireland. The woman's age, parity, nationality and rubella immunity status were analysed using data collected by the National Perinatal Reporting System. Of the 74,810 women delivered, the rubella status was known in 96.7% (n = 72,333). Of these, 6.4% (n = 4,665) women were not immune. Rubella seronegativity was 8.0% (n = 2425) in primiparous women compared with 5.2% (n = 2239) in multiparous women (p < 0.001), 14.7% (n = 10653) in women < 25 years old compared with 5.0% (n = 3083) in women < or = 25 years old (p < 0.001), and 11.4% (n = 780) in women born outside the 27 European Union (EU27) countries compared with 5.9% (n = 3886) in women born inside the EU27 countries (p < 0.001). Based on our findings we recommend that to prevent Congenital Rubella Syndrome, the health services in Ireland should focus on women who are young, nulliparous and born outside the EU.

Complement activation in primiparous women from a malaria endemic area is associated with reduced birthweight.

The hallmark of placental malaria (PM) due to Plasmodium falciparum infection is the accumulation of mature-stage parasites, monocytes and macrophages in the maternal vascular bed of the placenta. The mechanisms leading to morbidity and mortality in PM are incompletely understood. However, an inflammatory response in the placenta has been related to both severe anemia in the mother and low birthweight (<2500 g) in the newborn. In this study we analyzed whether complement activation as a mediator of inflammation could contribute to poor pregnancy outcome in PM. The concentrations of the soluble terminal complement complex (TCC) were measured as an indicator of complement activation in placental, cord and peripheral blood samples from 146 women from a malaria endemic area. Placental and cord plasma samples of primiparous women, a group vulnerable to PM, showed significantly higher levels of TCC than multiparous women. Additionally, in women with malaria history during pregnancy or placental infection by P. falciparum at delivery, the TCC levels in the corresponding placental and cord plasma samples were significantly higher than in the malaria negative group. In multiple regression analysis parity was shown to be the main determinant of TCC levels. Placental plasma samples corresponding to babies weighing less than 2700 g had significantly higher levels of TCC than babies carrying more weight. In conclusion, both primiparity and P. falciparum infection were related to a local increase of complement activation in the placentas. Association between reduced birthweight and higher levels of TCC in placental blood suggests a role for complement activation in influencing the pregnancy outcome in malaria exposed women.

Pathology consultation on transfusion-related acute lung injury (TRALI).

Transfusion-related acute lung injury (TRALI) is a serious condition characterized by respiratory distress, hypoxia, and bilateral pulmonary infiltrates, which occur within 6 hours of transfusion. Several theories have been proposed to explain the underlying pathologic mechanisms of TRALI. Immune-mediated TRALI accounts for over 80% of reported cases and is mediated by donor antibodies to HLAs and/or human neutrophil antigens (HNA). Immune-mediated TRALI is most commonly associated with donor plasma transfusion or other blood products from multiparous women, which has led many countries to reduce or exclude women from donating high-volume plasma products. This policy change has resulted in a decrease in the incidence of TRALI and highlighted the importance of nonimmune-mediated TRALI, which is thought to be caused by bioreactive lipids and other biologic response modifiers that accumulate during storage of blood products. When TRALI is suspected, clinical consultation with a transfusion medicine specialist helps differentiate it from other transfusion reactions with similar characteristics.