Malaria and Pregnancy.

Recent identification of local mosquito-borne transmission of malaria in Florida, Texas, and Maryland and increasing travel to malaria-endemic countries raise the likelihood that U.S. obstetricians might encounter a pregnant patient with malaria. Pregnancy increases the risk of becoming infected with malaria and of developing severe disease. Malaria during pregnancy also increases the risk of adverse pregnancy outcomes, including low birth weight, pregnancy loss, and preterm birth; thus, prevention and prompt diagnosis and treatment are essential. Diagnosis can be challenging during pregnancy among persons with partial immunity because placental sequestration of parasite-infected red blood cells can result in lower parasite levels in peripheral blood. Treatment for uncomplicated malaria depends on the expected resistance pattern, which is determined by the specific Plasmodium species identified and where infection was acquired. For severe disease, parenteral artesunate treatment needs to be initiated immediately. Given the dire consequences of malaria in pregnancy, prevention is crucial. For persons born and raised in endemic areas, interventions include use of insecticide-treated bed nets, intermittent preventive treatment, and prompt diagnosis and treatment of illness. U.S. pregnant persons should avoid travel to endemic countries; for unavoidable travel, pregnant travelers should receive chemoprophylaxis and avoid mosquito bites. Although the risk is low to U.S. pregnant persons who are not traveling internationally, avoiding mosquito bites is important, especially for pregnant persons residing in or visiting areas with recent local mosquito-borne transmission.

Trichomoniasis and adverse birth outcomes: a systematic review and meta-analysis.

BACKGROUND: Trichomoniasis commonly affects women of childbearing age and has been linked to several adverse birth outcomes. OBJECTIVE: To elucidate the association between trichomoniasis in pregnant women and adverse birth outcomes, including preterm delivery, prelabour rupture of membranes and low birthweight. SEARCH STRATEGY: MEDLINE, EMBASE and ClinicalTrials.gov were systematically searched in December 2020 without time or language restrictions. SELECTION CRITERIA: Original research studies were included if they assessed at least one of the specified adverse birth outcomes in pregnant women with laboratory-diagnosed trichomoniasis. DATA COLLECTION AND ANALYSIS: Estimates from included articles were either extracted or calculated and then pooled to produce a combined estimate of the association of trichomoniasis with each adverse birth outcome using the random effects model. Heterogeneity was assessed using the I2 statistic and Cochran's Q test. MAIN RESULTS: Literature search produced 1658 publications after removal of duplicates (n = 770), with five additional publications identified by hand search. After screening titles and abstracts for relevance, full text of 84 studies was reviewed and 19 met inclusion criteria for meta-analysis. Significant associations were found between trichomoniasis and preterm delivery (OR 1.27; 95% CI 1.08-1.50), prelabour rupture of membranes (OR 1.87; 95% CI 1.53-2.29) and low birthweight (OR 2.12; 95% CI 1.15-3.91). CONCLUSIONS: Trichomoniasis in pregnant women is associated with preterm delivery, prelabour rupture of membranes and low birthweight. Rigorous studies are needed to determine the impact of universal trichomoniasis screening and treatment during pregnancy on reducing perinatal morbidity. TWEETABLE ABSTRACT: This systematic review and meta-analysis found that in the setting of pregnancy, trichomoniasis is significantly associated with multiple adverse birth outcomes, including preterm delivery, low birthweight, and prelabour rupture of membranes.

Adverse birth outcomes among mothers who received intermittent preventive treatment with Sulphadoxine-Pyrimethamine in the low malaria transmission region.

BACKGROUND: Malaria in pregnancy increases the risk of adverse birth outcomes such as low birth weight (LBW), maternal and foetal anemia. In Tanzania, some areas have attained low malaria transmission. However, data on the burden of preterm delivery, LBW, maternal and foetal anemia following substantial reduction of malaria transmission in recent years is still scarce in these settings. METHODS: A study involving 631 pregnant women was conducted at Mwananyamala referral hospital in Dar es Salaam from April to August, 2018. Study enrollment was done prior to delivery. Structured interview and antenatal clinic cards were used to obtain data including the use of intermittent preventive therapy in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). Infants birth weights were recorded, maternal venous and cord blood were taken for testing of malaria and determination of haemoglobin (Hb) levels. Chi-square test and regression analysis were done to identify risk factors for preterm delivery, LBW, maternal and foetal anemia. RESULTS: The prevalence of malaria among mothers who used at least one dose of IPTp-SP was 0.6% (4/631). Fourteen mothers (2.2%) did not use IPTp-SP and had no malaria infection. The prevalence of maternal anemia, LBW, foetal anemia and preterm delivery was 40.6, 6.5, 5.9 and 9.2% respectively. Participants who were malaria positive had 11 times more risk of LBW compared to those who were negative (AOR, 11; 95%, CI 1.07-132.2; p = 0.04). The risk of delivering babies with LBW was 1.12 times high among mothers who were ≤ 36 weeks of gestation (AOR, 1.12; 95% CI, 0.06-0.25; p = < 0.001). The use of ≥3 doses of IPTp-SP was associated with 83% decrease in risk of LBW compared to those who did not use any dose of IPTp-SP (AOR, 0.17; 95% CI, 0.03-0.88; p = 0.05). Severe anaemia at delivery was associated with seven times increased risk of preterm delivery compared to non-anemic participants (AOR, 6.5; 95% CI, 1.49-28.16; p = 0.013). CONCLUSION: Despite the reduced malaria transmission and use of IPTp-SP, prevalence of preterm delivery, maternal anemia, LBW and foetal anemia is still high in Tanzania. The recommended ≥3 doses of IPTp-SP should continue be provided even in areas with substantial reduction of malaria.

The assessment of gestational age: a comparison of different methods from a malaria pregnancy cohort in sub-Saharan Africa.

BACKGROUND: Determining gestational age in resource-poor settings is challenging because of limited availability of ultrasound technology and late first presentation to antenatal clinic. Last menstrual period (LMP), symphysio-pubis fundal height (SFH) and Ballard Score (BS) at delivery are therefore often used. We assessed the accuracy of LMP, SFH, and BS to estimate gestational age at delivery and preterm birth compared to ultrasound (US) using a large dataset derived from a randomized controlled trial in pregnant malaria patients in four African countries. METHODS: Mean and median gestational age for US, LMP, SFH and BS were calculated for the entire study population and stratified by country. Correlation coefficients were calculated using Pearson's rho, and Bland Altman plots were used to calculate mean differences in findings with 95% limit of agreements. Sensitivity, specificity, positive predictive value and negative predictive value were calculated considering US as reference method to identify term and preterm babies. RESULTS: A total of 1630 women with P. falciparum infection and a gestational age > 24 weeks determined by ultrasound at enrolment were included in the analysis. The mean gestational age at delivery using US was 38.7 weeks (95%CI: 38.6-38.8), by LMP, 38.4 weeks (95%CI: 38.0-38.9), by SFH, 38.3 weeks (95%CI: 38.2-38.5), and by BS 38.0 weeks (95%CI: 37.9-38.1) (p < 0.001). Correlation between US and any of the other three methods was poor to moderate. Sensitivity and specificity to determine prematurity were 0.63 (95%CI 0.50-0.75) and 0.72 (95%CI, 0.66-0.76) for LMP, 0.80 (95%CI 0.74-0.85) and 0.74 (95%CI 0.72-0.76) for SFH and 0.42 (95%CI 0.35-0.49) and 0.77 (95%CI 0.74-0.79) for BS. CONCLUSIONS: In settings with limited access to ultrasound, and in women who had been treated with P. falciparum malaria, SFH may be the most useful antenatal tool to date a pregnancy when women present first in second and third trimester. The Ballard postnatal maturation assessment has a limited role and lacks precision. Improving ultrasound facilities and skills, and early attendance, together with the development of new technologies such as automated image analysis and new postnatal methods to assess gestational age, are essential for the study and management of preterm birth in low-income settings.

Relationships between infection with Plasmodium falciparum during pregnancy, measures of placental malaria, and adverse birth outcomes.

BACKGROUND: Malaria in pregnancy has been associated with maternal morbidity, placental malaria, and adverse birth outcomes. However, data are limited on the relationships between longitudinal measures of malaria during pregnancy, measures of placental malaria, and birth outcomes. METHODS: This is a nested observational study of data from a randomized controlled trial of intermittent preventive therapy during pregnancy among 282 participants with assessment of placental malaria and delivery outcomes. HIV-uninfected pregnant women were enrolled at 12-20 weeks of gestation. Symptomatic malaria during pregnancy was measured using passive surveillance and monthly detection of asymptomatic parasitaemia using loop-mediated isothermal amplification (LAMP). Placental malaria was defined as either the presence of parasites in placental blood by microscopy, detection of parasites in placental blood by LAMP, or histopathologic evidence of parasites or pigment. Adverse birth outcomes assessed included low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA) infants. RESULTS: The 282 women were divided into three groups representing increasing malaria burden during pregnancy. Fifty-two (18.4%) had no episodes of symptomatic malaria or asymptomatic parasitaemia during the pregnancy, 157 (55.7%) had low malaria burden (0-1 episodes of symptomatic malaria and < 50% of samples LAMP+), and 73 (25.9%) had high malaria burden during pregnancy (≥ 2 episodes of symptomatic malaria or ≥ 50% of samples LAMP+). Women with high malaria burden had increased risks of placental malaria by blood microscopy and LAMP [aRR 14.2 (1.80-111.6) and 4.06 (1.73-9.51), respectively], compared to the other two groups combined. Compared with women with no malaria exposure during pregnancy, the risk of placental malaria by histopathology was higher among low and high burden groups [aRR = 3.27 (1.32-8.12) and aRR = 7.07 (2.84-17.6), respectively]. Detection of placental parasites by any method was significantly associated with PTB [aRR 5.64 (1.46-21.8)], and with a trend towards increased risk for LBW and SGA irrespective of the level of malaria burden during pregnancy. CONCLUSION: Higher malaria burden during pregnancy was associated with placental malaria and together with the detection of parasites in the placenta were associated with increased risk for adverse birth outcomes. Trial Registration Current Controlled Trials Identifier NCT02163447.

Fish Parasites: A Growing Concern During Pregnancy.

Intestinal parasitic worms affect more than 2 billion people worldwide according to the World Health Organization. Fish-borne parasitic infections are becoming more common with the increasing popularity of sushi, sashimi, Carpaccio, tartare, gefilte, and ceviche. The ingestion of these parasites can cause serve anemia, malabsorption, severe abdominal pain, nausea, vomiting, strong allergic reactions, and gastric ulcers. Knowledge about fish parasites and pregnancy is limited. A literature search on PubMed and Web of Science used the search terms "fish parasites" OR "diphyllobothrium" OR "anisakiasis" OR "pseudoterranova" OR ("food borne parasites" AND "fish") AND "pregnancy" OR "maternal" OR "fetus" OR "fetal" OR "newborn" OR "neonatal" OR "childbirth." No limit was put on the number of years searched. There were 281 publications identified. The abstracts of all of these publications were read. After exclusion of the articles that were not relevant to pregnancy, pregnancy outcome, and fish parasites, there were 24 articles that became the basis of this review. The pathophysiology, altered maternal immunity related to the infection, limited information about fish-borne parasitic infections and pregnancy, and treatments are discussed. The main impact of a fish-borne parasitic infection on pregnant women is anemia and altered immunity, which may increase the risk of a maternal infection. The primary fetal effects include intrauterine growth restriction and preterm delivery.

Risk factors for malaria and adverse birth outcomes in a prospective cohort of pregnant women resident in a high malaria transmission area of Papua New Guinea.

BACKGROUND: Low birth weight (LBW), anaemia and malaria are common in Papua New Guinean women. METHODS: To identify risk factors for LBW, anaemia and preterm delivery (PTD), pregnant women recruited into a cohort study in Madang, Papua New Guinea, were followed to delivery. RESULTS: Of 470 women enrolled, delivery data were available for 328 (69.7%). By microscopy, 34.4% (113/328) of women had malaria parasitaemia at enrolment and 12.5% (41/328) at delivery; at each time point, PCR detected sub-microscopic parasitaemia in substantially more. Most infections were with Plasmodium falciparum; the remainder being predominantly P. vivax. Anaemia and smoking were associated with lower birth weight, and LBW (16.7%; 51/305) and PTD (21.8%; 63/290) were common. Histopathologically diagnosed chronic placental malaria was associated with LBW (adjusted odds ratio [aOR] 3.3; p=0.048) and PTD (aOR 4.2; p=0.01). Lack of maternal education predisposed to PTD. Sub-microscopic parasitaemia at delivery appeared to increase the risk of LBW. Of the genetic polymorphisms, Southeast Asian ovalocytosis, α(+)-thalassaemia and complement receptor 1 (CR1) deficiency, a CR1 heterozygous genotype was associated with decreased risk of anaemia and substantial but non-significant effects were noted in other comparisons. CONCLUSIONS: In coastal Papua New Guinea, malaria and anaemia are important causes of adverse pregnancy outcomes.

Las representaciones de apego y el estrés en las madres de niños nacidos pretérmino de muy bajo peso a los 2 años / Attachment representations and stress in mothers of very low birth weight preterm infants at two years of age

Introducción: Hay consenso en las investigaciones acerca de los efectos del nacimiento prematuro en las interacciones bebe-cuidador, aumentando los riesgos sobre el apego. Material y métodos: Se estudia a un grupo de 90 niños nacidos pretérmino con muy bajo peso (<1.500 g) seguidos en el Hospital de Cruces (Bizkaia, España) y 96 niños nacidos sanos a término, con edad y características sociodemográficas similares. El objetivo es evaluar, mediante una entrevista semiestructurada (entrevista R de representaciones maternas), el estrés materno y el modelo vincular sobre la base de las representaciones maternas de apego. Resultados: Los niños pretérmino tenían una inmadurez y riesgo biológico de grado medio-severo al nacimiento: EG media 29,9 semanas, PN 1.159,76 g y 57% más de 1 semana de hospitalización en la UCI. Las madres del grupo de los nacidos pretérmino presentaron más estrés durante el primer año de su hijo (61%) comparando con el grupo control (39%), pero no se encuentran diferencias en el modelo vincular o representacional de apego de las madres entre los 2 grupos. Discusión y conclusiones: Se confirma que el nacimiento pretérmino tiene gran influencia sobre el equilibrio emocional materno y la conveniencia de evaluar las reacciones de estrés en los padres y los signos de riesgo para el apego de esta población lo más temprano posible(AU)

Introduction: There is a consensus that prematurity could affect the risk of attachment impairment. Material and methods: We studied 90 very low birth weights preterm children (<1500 g) with follow-ups at Cruces Hospital (Bizkaia) and 96 healthy children born at term with similar age and sociodemographic characteristics. Our objective is to assess maternal stress and link model in accordance to attachment representations of mothers on both groups by using R Interview for Maternal Representations. Results: Preterm infants had a medium-to-severe degree of immaturity and biological risk: mean gestational age of 29.9 weeks and birth weight 1159.76 gr, with 57% staying in the ICU mayor 1 week. Mothers of preterm infants reported higher levels of stress during their first year of life (61%) than controls (39%), but no significant differences were found in link model (attachment representations) between the two groups. Discussion and conclusions: The results confirm that preterm birth has a great influence on maternal emotional responses, and indicate that stress responses in parents and alarm signs for attachment problems should be assessed as early as possible(AU)

Treatment of trichomoniasis in pregnancy and preterm birth: an observational study.

OBJECTIVE: To investigate the association between treatment of maternal trichomoniasis with oral metronidazole and preterm birth. METHODS: We conducted a retrospective cohort study using Medicaid billing data and birth certificate records for 144,737 live births in South Carolina from 1996 through 2002. Cases of trichomoniasis were identified using billing codes. The risk of preterm birth among women with treated vs. untreated trichomoniasis was modeled as a time-varying covariate in Cox proportional hazards regression. Women who were initially diagnosed with trichomoniasis at > or =35 weeks or delivered <2 days after the diagnosis were excluded from the modeling. We also examined the effect of excluding women who gave birth within 14 days following the diagnosis. RESULTS: There were 4274 (3.0%) women diagnosed with trichomoniasis; 3579 women were diagnosed with trichomoniasis prior to 35 weeks gestation and remained pregnant until at least the second day after the diagnosis, and 1436 (40.1%) of these women filled a prescription for oral metronidazole within 14 days. Of treated women, 12.7% delivered prior to 37 weeks compared with 15.3% of women who were not treated within 14 days. In the multivariable proportional hazards regression, treatment appeared to be protective both for women with and without another genitourinary infection at some point during pregnancy (HR = 0.69, 95% CI 0.50, 0.95 in women with another infection; HR = 0.69, 95% CI 0.52, 0.92 in women without another infection). After excluding women who delivered within 14 days of the diagnosis, the hazard ratios remained <1.0 but were no longer statistically significant (HR = 0.84, 95% CI 0.64, 1.11 in women with another infection; HR = 0.96, 95% CI 0.69, 1.32 in women without another infection). CONCLUSIONS: Treatment with oral metronidazole was not associated with increased risk of preterm birth in women diagnosed with trichomoniasis.

Association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth.

OBJECTIVE: To determine the association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth. DESIGN: Multicentre prospective cohort study. SETTING: Ten European centres offering prenatal screening for toxoplasmosis. POPULATION: Deliveries after 23 weeks of gestation in 386 women with singleton pregnancies who seroconverted to toxoplasma infection before 20 weeks of gestation. Deliveries after 36 weeks in 234 women who seroconverted at 20 weeks or later, and tested positive before 37 weeks. METHODS: Comparison of infected and uninfected births, adjusted for parity and country of birth. MAIN OUTCOME MEASURES: Differences in gestational age at birth, birthweight and birthweight centile. RESULTS: Infected babies were born or delivered earlier than uninfected babies: the mean difference for seroconverters before 20 weeks was -5.4 days (95% CI: -1.4, -9.4), and at 20 weeks or more, -2.6 days (95% CI: -0.5, -4.7). Congenital infection was associated with an increased risk of preterm delivery when seroconversion occurred before 20 weeks (OR 4.71; 95% CI: 2.03, 10.9). No significant differences were detected for birthweight or birthweight centile. CONCLUSION: Babies with congenital toxoplasmosis were born earlier than uninfected babies but the mechanism leading to shorter length of gestation is unknown. Congenital infection could precipitate early delivery or prompt caesarean section or induction of delivery. We found no evidence for a significant association between congenital toxoplasmosis and reduced birthweight or small for gestational age birth.

Effects of an experimental Trypanosoma congolense infection on the reproductive performance of West African Dwarf goats.

Thirty-six West African Dwarf (WAD) goats were used to assess the effects of an experimental Trypanosoma congolense infection on their reproductive system. Estrous cycles were synchronised and when confirmed pregnant (n = 31), the does were randomly allocated into control and trypanosome-infected groups. After infection, the animals were carefully observed till parturition. Trypanosome infection caused an increase of rectal temperature, a significant drop in PCV (infected: 23.3 +/- 0.3%; control: 28.5 +/- 0.4%; P < 0.0001) and abortions in 27.8% of the infected does. Kids born from infected does had a lower birth weight than kids born from control goats (0.9 +/- 0.1 kg versus 1.6 +/- 0.1 kg; P < 0.0001). Eight out of 13 kids (61.5%) that were born alive from infected does died during their first week of life. Plasma pregnancy-associated glycoprotein (PAG) and progesterone concentrations were lower in the infected animals than in the controls. In general, PAG concentration in does which aborted dropped before abortion. Our results revealed that artificial T. congolense infection affected reproductive performance of WAD goats with abortions, premature births and perinatal losses being observed. Neither transplacental transmission of T. congolense nor histopathological lesions of the placenta could be demonstrated.

The sick placenta-the role of malaria.

The human placenta is an ideal site for the accumulation of Plasmodium falciparum malaria parasites, and as a consequence serious health problems arise for the mother and her baby. The pathogenesis of placental malaria is only partially understood, but it is clear that it leads to a distinct epidemiological pattern of malaria during pregnancy. The objectives of this review are: (1) To review recent data on the epidemiology of malaria in pregnancy, with emphasis on placental malaria; (2) to describe the pathological changes and immunological factors related to placental malaria; and (3) to discuss briefly the functional consequences of this infection for the mother and her baby. The review attempts to bring together local events at the maternal-fetal interface which encompass immunological and pathological processes which relate to the epidemiological pattern of malaria in pregnancy in areas of both high and low malaria transmission. An integrated understanding of the epidemiological, immunological and pathological processes must be achieved in order to understand how to control malaria in pregnancy. The yearly exposure of at least 50 million pregnancies to malaria infection makes it the commonest and most recurrent parasitic infection directly affecting the placenta. These statistics and our limited understanding of its pathogenesis suggest the research priorities on this subject.