Mediation of the effect of malaria in pregnancy on stillbirth and neonatal death in an area of low transmission: observational data analysis.
Mediation of the effect of malaria in pregnancy on stillbirth and neonatal death in an area of low transmission: observational data analysis.
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DOI：
10.1186/s12916-017-0863-z
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发表时间：
2017-05-10
期刊：
影响因子：
9.3
通讯作者：
McGready R
中科院分区：
文献类型：
--
作者：
Moore KA;Fowkes FJI;Wiladphaingern J;Wai NS;Paw MK;Pimanpanarak M;Carrara VI;Raksuansak J;Simpson JA;White NJ;Nosten F;McGready R
妊娠期间的疟疾是可以预防的，每年估计有 550 万例死产和新生儿死亡，是由疟疾造成的。在传播率低的地区，妊娠期疟疾的贡献尚未量化，而且孕产妇贫血、小于胎龄状况和早产在介导妊娠期疟疾对死产和新生儿死亡的影响中所起的作用也很少得到阐明。我们分析了泰缅边境产前诊所常规收集的观察数据（1986-2015）。我们使用 Cox 回归和序贯中介分析来确定妊娠期恶性疟和间日疟对产前（子宫内死亡）和产时（分娩期间死亡）死产和新生儿死亡率的影响，以及通过孕产妇贫血、早产和小于胎龄状态的中介作用。在 61,836 名女性中，9350 名（15%）在怀孕期间患有疟疾，526 名（0.8%）有死产。在 9090 名活产单身婴儿中，有 153 名（1.7%）新生儿死亡。恶性疟疾后产前死产的风险增加了 2.24 倍 [95% 置信区间：1.47, 3.41]（42% 由小于胎龄状态和贫血介导），由有症状的恶性疟疾（风险比，HR：2.99 [1.83, 4.89]）而非无症状的恶性疟疾驱动。 （HR：1.35 [0.61，2.96]）。有症状的间日疟疾（24%由小于胎龄状态和贫血介导）后，产前死产的风险增加了 2.21 倍 [1.12, 4.33]，但无症状的间日疟疾则没有增加（HR：0.54 [0.20, 1.45]）。妊娠期恶性疟或间日疟与产时死产之间没有关联（恶性疟 HR：1.03 [0.58，1.83]；间日疟 HR：1.18 [0.66，2.11]）。妊娠期恶性疟和间日疟使新生儿死亡风险分别增加 2.55 倍 [1.54, 4.22] 和 1.98 倍 [1.10, 3.57]（分别为 40% 和 50%，通过小于胎龄状态和早产介导）。预防妊娠期疟疾、预防小于胎龄和孕产妇贫血的新干预措施和现有干预措施，以及提高管理早产儿和小于胎龄新生儿的能力，将减少疟疾流行地区与疟疾相关的死产和新生儿死亡数量。本文的在线版本 (doi:10.1186/s12916-017-0863-z) 包含补充材料，可供授权用户使用。
Malaria in pregnancy is preventable and contributes significantly to the estimated 5.5 million stillbirths and neonatal deaths that occur annually. The contribution of malaria in pregnancy in areas of low transmission has not been quantified, and the roles of maternal anaemia, small-for-gestational-age status, and preterm birth in mediating the effect of malaria in pregnancy on stillbirth and neonatal death are poorly elucidated. We analysed observational data routinely collected at antenatal clinics on the Thai-Myanmar border (1986–2015). We used Cox regression and sequential mediation analysis to determine the effect of falciparum and vivax malaria in pregnancy on antepartum (death in utero) and intrapartum (death during labour) stillbirth and neonatal mortality as well as mediation through maternal anaemia, preterm birth, and small-for-gestational-age status. Of 61,836 women, 9350 (15%) had malaria in pregnancy, and 526 (0.8%) had stillbirths. In a sub-set of 9090 live born singletons followed from birth there were 153 (1.7%) neonatal deaths. The hazard of antepartum stillbirth increased 2.24-fold [95% confidence interval: 1.47, 3.41] following falciparum malaria (42% mediated through small-for-gestational-age status and anaemia), driven by symptomatic falciparum malaria (hazard ratio, HR: 2.99 [1.83, 4.89]) rather than asymptomatic falciparum malaria (HR: 1.35 [0.61, 2.96]). The hazard of antepartum stillbirth increased 2.21-fold [1.12, 4.33] following symptomatic vivax malaria (24% mediated through small-for-gestational-age status and anaemia) but not asymptomatic vivax malaria (HR: 0.54 [0.20, 1.45]). There was no association between falciparum or vivax malaria in pregnancy and intrapartum stillbirth (falciparum HR: 1.03 [0.58, 1.83]; vivax HR: 1.18 [0.66, 2.11]). Falciparum and vivax malaria in pregnancy increased the hazard of neonatal death 2.55-fold [1.54, 4.22] and 1.98-fold [1.10, 3.57], respectively (40% and 50%, respectively, mediated through small-for-gestational-age status and preterm birth). Prevention of malaria in pregnancy, new and existing interventions to prevent small-for-gestational-age status and maternal anaemia, and improved capacity for managing preterm and small-for-gestational-age newborns will reduce the number of malaria-associated stillbirths and neonatal deaths in malaria-endemic areas. The online version of this article (doi:10.1186/s12916-017-0863-z) contains supplementary material, which is available to authorized users.