BackgroundThe usefulness of C-reactive protein (CRP) as a non-specific marker of inflammation during pregnancy and lactation is unclear in impoverished populations where co-existing infections and vitamin deficiencies are common.MethodsThis cross-sectional study in Panama recruited 120 pregnant and 99 lactating Ngäbe-Buglé women from 14 communities in rural Panama. Obstetric history, indoor wood smoke exposure, fieldwork, BMI, vitamins A, B12, D, and folic acid, and inflammation markers (CRP, neutrophil/lymphocyte ratio (NLR), plateletcrit and cytokines) were measured. Multiple regressions explored both associations of CRP with other inflammatory markers and associations of CRP and elevated CRP based on trimester-specific cut-offs with maternal factors, infections and vitamin deficiencies.ResultsCRP was higher in pregnancy (51.4 ± 4.7 nmol/L) than lactation (27.8 ± 3.5 nmol/L) and was elevated above trimester specific cut-offs in 21% of pregnant and 30% of lactating women. Vitamin deficiencies were common (vitamin A 29.6%; vitamin D 68.5%; vitamin B12 68%; folic acid 25.5%) and over 50% of women had two or more concurrent deficiencies as well as multiple infections. Multiple regression models highlighted differences in variables associated with CRP between pregnancy and lactation. In pregnancy, CRP was positively associated with greater indoor wood smoke exposure, caries and hookworm and negatively associated with Ascaris and vaginal Lactobacillus and Bacteroides/Gardnerella scores. Consistent with this, greater wood smoke exposure, caries as well as higher diplococcal infection score increased the odds of trimester-elevated CRP concentrations whereas longer gestational age lowered the likelihood of a trimester-elevated CRP. During lactation, folic acid deficiency was associated with higher CRP whereas parity, number of eosinophils and Mobiluncus score were associated with lower CRP. Also, a higher BMI and Trichomonas vaginalis score increased the likelihood of an elevated CRP whereas higher parity and number of eosinophils were associated with lower likelihood of an elevated CRP.ConclusionsInfections both raise and lower CRP concentrations in pregnant and lactating mothers. Only folic acid deficiency during lactation was associated with higher CRP concentrations. Caution is required when interpreting CRP concentrations in pregnant and lactating women who have co-existing nutrient deficiencies and multiple infections.Electronic supplementary materialThe online version of this article (doi:10.1186/s40249-017-0307-1) contains supplementary material, which is available to authorized users.

Abstract. Interrelationships among bacteria, protozoa, helminths, and ectoparasites were explored in a cross-sectional survey of 213 pregnant and 99 lactating indigenous women. Prevalences in pregnancy and lactation, respectively, were: vaginitis (89.2%; 46.8%), vaginal trichomoniasis (75.3%; 91.1%), bacterial vaginosis (BV; 60.6%; 63.3%), hookworm (56.6%; 47.8%), asymptomatic bacteriuria/urinary tract infection (AB/UTI; 56.2%; 36.2%), cervicitis (33.3%; 6.3%), vaginal yeast (24.9%; 11.4%), Ascaris (32.5%; 17.4%), vaginal diplococci (20.4%; 31.6%), caries (19.7%; 18.2%), scabies (17.4%; 8.1%), and Trichuris (12.5%; 8.7%). Multiple regressions revealed positive associations during pregnancy (trichomoniasis and AB/UTI; diplococci and Ascaris) and lactation (yeast and scabies). Negative associations were detected in pregnancy (BV and trichomoniasis; hookworm and diplococci) and lactation (BV and yeast). Vaginal Lactobacillus reduced odds of diplococci in pregnancy and lactation, but increased Ascaris eggs per gram (epg) and odds of trichomoniasis in pregnancy and yeast in lactation. These associations raised a concern that treatment of one condition may increase the risk of another.

Conclusion: MINDI were bi-directionally associated with blood pressure indicators. In this MINDI cohort, infections, nutrients and cytokines both raised, and lowered BP indices. The presence of eMAP identified pregnant women at risk of hypertension whereas low PP was associated with lower SFH. Therefore, MAP and PP may help in detecting women at risk of adverse pregnancy outcomes in settings with limited access to technology.

Background In absence of ultrasound, symphysis-fundal height (SFH) can assess maternal-fetal well-being as it is associated with gestational age, fetal weight and amniotic fluid volume. However, other modifiers of SFH, including maternal infections, nutrient deficiencies and inflammation (MINDI), have not been widely explored. Objectives Our objectives were two-fold: 1) to assess prevalence of low SFH in indigenous Panamanian women using both PAHO and INTERGROWTH-21 standards and 2) to explore associations of SFH with maternal health indicators: infections (oral, skin, urogenital, nematode infections), nutrient deficiencies [protein and iron indicators (ferritin, serum iron, serum transferrin receptor, hepcidin), folate, vitamins A, D, B12] and inflammation [leukocytes, C-reactive protein, cytokines]. Methods For this cross-sectional study, low-SFH-for-gestational-age was assessed using PAHO and INTERGROWTH < 10th centile in 174 women ≥16 weeks’ gestation. Bootstrapping selected MINDI variables for inclusion in multivariable fractional polynomial (MFP) logistic regressions for low-SFH. Associations of MINDI variables with hepcidin were also investigated. Results Prevalence of low-SFH was 8% using PAHO, but using INTERGROWTH, 50.6% had SFH < 10th centile, including 37.9% <3rd centile. Both PAHO-SFH < 10% and INTERGROWTH-SFH < 3rd centiles were associated with higher hepcidin (OR 1.12, p = 0.008 and OR = 3.04. p = 0.001, respectively) and with lower TNF-α (OR = 0.73, p = 0.012 and OR = 0.93, p = 0.015, respectively). Wood smoke exposure increased the odds of PAHO-SFH < 10th centile (OR = 1.19, p = 0.009) whereas higher BMI decreased the odds of INTERGROWTH-SFH < 3rd centile (OR = 0.87, p = 0.012). Lower pulse pressure (OR = 0.90, p = 0.009) and lower inflammatory responses [lower lymphocytes (OR = 0.21, p = 0.026), IL-17 (OR = 0.89, p = 0.011)] distinguished SFH < 3rd centile from SFH 3–10 using INTERGROWTH-21standards. The MFP regression for hepcidin controlling for SFH (Adj R2 = 0.40, p = 0.001) revealed associations with indicators of inflammation (CRP, p < 0.0001; IL-17, p = 0.012), acidic urinary pH (p = 0.008) and higher intake of supplements (p = 0.035). Conclusion Associations of low SFH with MINDI variables, including hepcidin, highlight its potential for early detection of multicausal in-utero growth faltering. LAY SUMMARY Symphysis-fundal height (SFH) is a measure of maternal-fetal well-being and is commonly used when sonography is not available to assess gestational age and the health of fetal-maternal unit. This simple non-invasive indicator uses a tape measure to measure the distance between the symphysis pubis and the highest point of the growing uterus. This distance was compared with two international standards: PAHO and INTERGROWTH. Using PAHO, 8% of women had low SFH (<10th centile for gestational age), but using INTERGROWTH standards, more than half of the women had low SFH with 37.5% having very low SFH (below the 3rd centile for gestational age). A SFH < 3rd centile was associated with higher hepcidin, a protein that decreases iron availability in blood as a defense against infections. In our study, low SFH was also associated with indicators of inflammation, malnutrition and a lower maternal blood pressure. This study supports the use of SFH in remote areas to identify pregnant women at risk of a poor pregnancy outcomes.

Background: Multi-dimensional monitoring evaluation and learning strategies are needed to address the complex set of factors that affect early child development in marginalized populations, but few studies have explored their effectiveness. Objective: To compare improvement of health and development of children 0-3 years between intervention communities (IC) and control communities (CC) from peripheral settlements of Lima. Sequential interventions included: (1) home and community gardens, (2) conscious nutrition, and (3) parenting workshops following the International Child Development Program (ICDP). Methods: Interventions were delivered by community health promoters (CHPs) using a "step-by-step" learning system. Both IC and CC were monitored before the interventions began, at 8 and 12 months (n = 113 IC and 127 CC children). Data were collected on household characteristics, diet, food security, health indicators (history of diarrhea and respiratory infections, hemoglobin, intestinal parasites, anthropometry), caregiver-child interactions and stress, and achievement of Pan-American Health Organization age-specific developmental milestones. Stepwise multiple logistic regressions were used to determine if the interventions affected food insecurity, as well as motor, social/cognitive and language delays. Results: At baseline, 2.6% were categorized as "suspected developmental delay" and 14.2% were on "alert for development delay." Food insecurity, diarrhea and González-Fernández et al. Multi-Sectoral Intervention for Child Development respiratory infections were lowered following the interventions. Through the "step-by-step" approach, caregivers in IC gained skills in gardening, conscious nutrition and parenting that reduced the risk of food insecurity [Adjusted Risk Ratio = 0.20 (95% CI: 0.08-0.51)] and language delay [0.39 (0.19-0.82)] but not motor or social/cognitive delay. Use of a multiple micronutrient supplement decreased the risk of motor delay [0.12 (0.03-0.56)], but more pets were associated with higher risk of motor [3.24 (1.47-7.14)] and social/cognitive delay [2.72 (1.33-5.55)], and of food insecurity [1.73 (1.13-2.66)]. Conclusion: The combined interventions delivered by CHPs helped to mitigate the impact of adversity on food insecurity and language delay. Additional improvements may have been detected if the interventions had continued for a longer time. Our results indicate that control of infections and pets may be needed to achieve measurable results for motor and social/cognitive development. Continuous monitoring facilitated adjusting implementation strategies and achieving positive developmental outcomes.