Background: Vitamin D deficiency during pregnancy is a public health problem in Pakistan and is prevalent among most women of reproductive age in the country. Vitamin D supplementation during pregnancy is suggested to prevent adverse pregnancy outcomes and vitamin D deficiency in both the mother and her newborn. Methods: We conducted a double-blinded, randomised controlled trial in Karachi, Pakistan to evaluate the effect of different doses of vitamin D supplementation during pregnancy on biochemical markers (serum 25(OH)D, calcium, phosphorus and alkaline phosphatase) in women and neonates, and on pregnancy and birth outcomes (gestational diabetes, pre-eclampsia, low birth weight, preterm births and stillbirths). Results: Pregnant women (N=350) in their first trimester were recruited and randomised to three treatment groups of vitamin D supplementation: 4000 IU/day (group A, n=120), 2000 IU/day (group B, n=115) or 400 IU/day (group C, n=115). Women and their newborn in group A had the lowest vitamin D deficiency at endline (endline: 75.9%; neonatal: 64.9%), followed by group B (endline: 84.9%; neonatal: 73.7%) and then the control group (endline: 90.2%; neonatal: 91.8%). Vitamin D deficiency was significantly lower in group A than in group C (p=0.006) among women at endline and lower in both groups A and B than in the control group (p=0.001) in neonates. Within groups, serum 25(OH)D was significantly higher between baseline and endline in group A and between maternal baseline and neonatal levels in groups A and B. Participant serum 25(OH)D levels at the end of the trial were positively correlated with those in intervention group A (4000 IU/day) (β=4.16, 95% CI 1.6 to 6.7, p=0.002), with food group consumption (β=0.95, 95% CI 0.01 to 1.89, p=0.047) and with baseline levels of serum 25(OH)D (β=0.43, 95% CI 0.29 to 0.58, p<0.0001). Conclusion: The evidence provided in our study indicates that vitamin D supplementation of 4000 IU/day was more effective in reducing vitamin D deficiency among pregnant women and in improving serum 25(OH)D levels in mothers and their neonates compared with 2000 IU/day and 400 IU/day. Trial registration number NCT02215213 .

Uterine arteriovenous malformation (AVM) is a rare condition, with few cases reported in the literature. Despite being rare, it is a potentially life-threatening condition in women of child-bearing age. It should be considered in the differential diagnosis of prolonged or irregular vaginal bleeding, which, otherwise, can lead to critical complications ending up in severe morbidity and mortality. This case series describes four cases of young Asian women aged between 33 and 38 years who presented with irregular vaginal bleeding. Trans-abdominal ultrasound of the pelvis showed increased vascularity with multi-directional blood flow in the uterus. Magnetic resonance imaging (MRI) confirmed an arteriovenous malformation in all cases. All cases remained stable through the diagnostic journey. Embolization of the arteriovenous malformation was performed successfully in three cases and one case was managed conservatively on hormones. Later, two of them conceived within a year and had live births at term. The aim of reporting these cases is to share the common presentation of this condition and our experience in making the diagnosis and treatment of such patients. Although a few cases are reported world over, none was reported earlier from Pakistani Asian women.

Background: Preterm birth complications are the leading cause of newborn and under-5 mortality. Over 85% of all preterm births occur in the late preterm period, i.e. between 34 and < 37 weeks of gestation. Antenatal corticosteroids (ACS) prevent mortality and respiratory morbidity when administered to women at high risk of an early preterm birth, i.e. < 34 weeks’ gestation. However, the benefits and risks of ACS in the late preterm period are less clear; both guidelines and practices vary between settings. Emerging evidence suggests that the benefits of ACS may be achievable at lower doses than presently used. This trial aims to determine the efficacy and safety of two ACS regimens compared to placebo, when given to women with a high probability of late preterm birth, in hospitals in low-resource countries. Methods: WHO ACTION III trial is a parallel-group, three-arm, individually randomized, double-blind, placebo-controlled trial of two ACS regimens: dexamethasone phosphate 4 × 6 mg q12h or betamethasone phosphate 4 × 2 mg q 12 h. The trial is being conducted across seven sites in five countries—Bangladesh, India, Kenya, Nigeria, and Pakistan. Eligible women are those with a gestational age between 34 weeks 0 days and 36 weeks 5 days, who have a high probability of preterm birth between 12 h and 7 days (up to 36 weeks 6 days gestation). The primary outcome is a composite of stillbirth or neonatal death within 72 h of birth or use of newborn respiratory support within 72 h of birth or prior to discharge from hospital, whichever is earlier. Secondary outcomes include safety and health utilization measures for both women and newborns. The sample size is 13,500 women. Discussion: This trial will evaluate the benefits and possible harms of ACS when used in women likely to have a late preterm birth. It will also evaluate a lower-dose ACS regimen based on literature from pharmacokinetic studies. The results of this trial will provide robust critical evidence on the safe and appropriate use of ACS in the late preterm period internationally. Trial registration: ISRCTN11434567. Registered on 7 June 2021.

Hackett K, et al. J Glob Health Sci. 2021 Dec;3:e12. https://doi.org/10.35500/jghs.2021.3.e12

Background: The emergence of COVID-19 and its pandemic nature has exacerbated fears worldwide. Pregnant women are considered a vulnerable group during the COVID-19 pandemic because the physiological changes make them more susceptible to infections. Pregnant women are found expressing much of the fear related to their course of pregnancy, the in-utero transmission of the disease, and questions related to infection control in healthcare settings. Hence, the purpose of this paper was to explore the fears faced by pregnant women related to COVID.Methods: It was a cross-sectional survey among 201 pregnant women attending antenatal clinics of Aga Khan University Hospital. The survey tool contains demographic variables and a 7-item scale of “Fear in COVID” which is pre tested in the Iranian population. The survey form was made on google drive and sent to pregnant females on WhatsApp.Results: 201 pregnant women mostly belonging to middle and low socioeconomic class were enrolled. The majority (80%) of women were less than 30 years of age. Only 26 (12.9%) were primigravids, remaining were multigravidas of a different order of pregnancy. 60% of our study population showed high fear scores (27-35) from coronavirus whereas another 30% had moderate fear. No association of study variables was found with fear scores.Conclusions: We found a high level of fear of COVID-19 among the pregnant population with a higher level of anxiety and stress related symptoms. The amount of fear and stress is independent of the trimester or order of pregnancy.

Background: There is limited evidence between contraceptive use, availability of commodities and distance to the facility in developing countries. Distance to the facility is an essential determinant of contraceptive use. Still, women may not seek family planning services from the nearest facility and may be prepared to travel the farthest distance to receive quality family planning services. Methods: We analyzed women's survey data linked to health facility data and applied an alternate specific conditional logit model to examine the distance a woman is prepared to travel and the quality of services offered by facilities in urban areas in Karachi, Pakistan. Results: This study analyzed data from 336 women and 28 facilities and identified that the mean distance to the nearest facility was 0.44 km; the chosen facility was, on average, 5 km away. Women preferred facilities that offered a range of contraceptive methods and additional services provided by female healthcare providers only. Furthermore, on average, women are willing to travel a further 1.7 km for a facility that offers more family planning methods, 1.4 km for a facility that offers additional health services and 11 km for a facility that offers services delivered by female healthcare providers. Conclusions: The findings highlight the quality measures women prioritize over distance and consider essential when choosing a family planning facility.