OBJECTIVE:To evaluate the association between maternal HIV infection and preeclampsia. We hypothesized that maternal HIV infection would be associated with a lower risk of preeclampsia, potentially due to HIV-related immunomodulatory effects. METHODS:We combined participants from one observational cohort and two randomized trials conducted at the same facilities in Lusaka, Zambia between 2015 and 2022. The exposure of interest was maternal HIV infection, and the primary outcome was preeclampsia, defined as 1) new-onset (at or after 20 weeks of gestation) hypertension (systolic blood pressure [BP] 140 mm Hg or higher or diastolic BP 90 mm Hg or higher) with concurrent proteinuria (1+ or higher), 2) new onset proteinuria (1+ or higher) in participants with chronic hypertension in the absence of urinary tract infection, or 3) diagnosis of severe preeclampsia. We defined severe preeclampsia as 1) new-onset severe-range BP (systolic 160 mm Hg or higher or diastolic 110 mm Hg or higher), 2) eclamptic seizure, or 3) clinician-initiated preterm delivery (before 37 weeks of gestation) for preeclampsia. Using marginal standardization (parametric g-formula), we estimated the risk of preeclampsia associated with HIV infection. Antiretroviral therapy (ART) exposure and HIV disease severity (viral load, CD4 counts) were assessed as effect modifiers. RESULTS:Of 4,078 women included in the combined cohort, 186 (4.6%) were diagnosed with preeclampsia, including 43 (2.7%) of 1,590 women with HIV infection and 143 (5.8%) of 2,488 women without HIV infection. Of those with HIV infection, 73.2% were on prepregnancy ART, and 56.7% had an undetectable viral load at study enrollment (median 15 weeks). In analyses standardizing for maternal age, nulliparity, and calendar time of enrollment, HIV infection was associated with lower preeclampsia risk (relative risk 0.42; 95% CI, 0.26-0.59; risk difference -3.5%; 95% CI, -4.9 to -2.1). This reduced risk persisted when stratifying by prepregnancy ART exposure, detectable viral load, and CD4 count at enrollment; findings were similar when applying the more stringent definition of severe preeclampsia. CONCLUSION:In this well-phenotyped cohort, women with HIV infection were less likely to have preeclampsia compared with those without HIV infection.

(Abstracted from JAMA 2024;332:649–657) Gestational age (GA) is critical for guiding obstetric decisions related to antenatal care and delivery. In high-income countries, GA is typically measured via fetal biometry using high-resolution ultrasound machines operated by credentialed sonographers.

( Int J Gynaecol Obstet . 2026 Mar;172(3):1791–1793. doi: 10.1002/ijgo.70484) Obesity affects nearly 1 in 3 pregnancies and significantly elevates the risk of hypertensive disorders, which are major contributors to maternal illness and death. Accurate blood pressure (BP) monitoring is essential for managing these risks. However, traditional arm cuff methods often perform poorly in individuals with larger arm circumferences, particularly when compared with intra-arterial monitoring (A-line), which is considered the clinical gold standard. Despite its accuracy, the invasive nature and potential complications of A-line monitoring make it impractical for routine obstetric use.

Importance:Accurate assessment of gestational age (GA) is essential to good pregnancy care but often requires ultrasonography, which may not be available in low-resource settings. This study developed a deep learning artificial intelligence (AI) model to estimate GA from blind ultrasonography sweeps and incorporated it into the software of a low-cost, battery-powered device. Objective:To evaluate GA estimation accuracy of an AI-enabled ultrasonography tool when used by novice users with no prior training in sonography. Design, Setting, and Participants:This prospective diagnostic accuracy study enrolled 400 individuals with viable, single, nonanomalous, first-trimester pregnancies in Lusaka, Zambia, and Chapel Hill, North Carolina. Credentialed sonographers established the "ground truth" GA via transvaginal crown-rump length measurement. At random follow-up visits throughout gestation, including a primary evaluation window from 14 0/7 weeks' to 27 6/7 weeks' gestation, novice users obtained blind sweeps of the maternal abdomen using the AI-enabled device (index test) and credentialed sonographers performed fetal biometry with a high-specification machine (study standard). Main Outcomes and Measures:The primary outcome was the mean absolute error (MAE) of the index test and study standard, which was calculated by comparing each method's estimate to the previously established GA and considered equivalent if the difference fell within a prespecified margin of ±2 days. Results:In the primary evaluation window, the AI-enabled device met criteria for equivalence to the study standard, with an MAE (SE) of 3.2 (0.1) days vs 3.0 (0.1) days (difference, 0.2 days [95% CI, -0.1 to 0.5]). Additionally, the percentage of assessments within 7 days of the ground truth GA was comparable (90.7% for the index test vs 92.5% for the study standard). Performance was consistent in prespecified subgroups, including the Zambia and North Carolina cohorts and those with high body mass index. Conclusions and Relevance:Between 14 and 27 weeks' gestation, novice users with no prior training in ultrasonography estimated GA as accurately with the low-cost, point-of-care AI tool as credentialed sonographers performing standard biometry on high-specification machines. These findings have immediate implications for obstetrical care in low-resource settings, advancing the World Health Organization goal of ultrasonography estimation of GA for all pregnant people. Trial Registration:ClinicalTrials.gov Identifier: NCT05433519.

In low resource settings, twins often go undiagnosed until delivery. We sought to create a low-cost ultrasound tool for diagnosis and assessment of twins in settings where trained sonographers are scarce. We collected blind ultrasound sweeps (∼10 second cines in cranio-caudal and lateral directions) from pregnant people in North Carolina. The cohort was randomly divided at the patient level into discreet training/tuning (80%) and testing (20%) datasets. We built deep learning AI models to diagnose twins and estimate their gestational age (GA). We also explored assessment of chorionicity. From Feb 2020 thru March 2023, 16,557 pregnancies contributed 30,106 studies containing blind sweeps. Of these, 490 pregnancies (1,215 studies) were twins. To evaluate twin diagnosis, we restricted the test set to studies ≥14 weeks GA (3,163 pregnancies; 5,424 studies). Among the 87% of studies in which the model could make a prediction, the area under the receiver operating curve (AUC-ROC) was 99.4% (sens: 98.1%; spec: 98.2%). To evaluate twin GA estimation, we restricted the test set to twin pregnancies whose GA had previously been established by early CRL or IVF (92 pregnancies; 185 scans). The model made a prediction in all studies with a mean absolute error of 4.6 ±0.3 days vs 4.5 ±0.3 days for biometry (difference, 0.1 days; 95% CI: -0.6, 0.8). To evaluate chorionicity assessment, we limited the test set to twins with scans performed < 24 weeks (67 pregnancies, 93 scans). Among the 73% of studies in which the model could make a prediction, AUC-ROC was 87.1% (sens: 82.6%; spec: 82.2%). AI-assisted ultrasound, which can be deployed on low-cost point-of-care devices, can diagnose twins and assess their gestational age with high performance. Preliminary results for chorionicity assessment are encouraging but more training data from earlier GA are needed. These results presage a future where all patients carrying twins – not just those in rich countries – can access the diagnostic benefits of sonography.

OBJECTIVE:Low-cost devices have made obstetric sonography possible in settings where it was previously unfeasible, but ensuring quality and consistency at scale remains a challenge. In the present study, we sought to create a tool to reduce substandard fetal biometry measurement while minimizing care disruption. METHODS:We developed a deep learning artificial intelligence (AI) model to estimate gestational age (GA) in the second and third trimester from fly-to cineloops-brief videos acquired during routine ultrasound biometry-and evaluated its performance in comparison to expert sonographer measurement. We then introduced random error into fetal biometry measurements and analyzed the ability of the AI model to flag grossly inaccurate measurements such as those that might be obtained by a novice. RESULTS:The mean absolute error (MAE) of our model (±standard error) was 3.87 ± 0.07 days, compared to 4.80 ± 0.10 days for expert biometry (difference -0.92 days; 95% CI: -1.10 to -0.76). Based on simulated novice biometry with average absolute error of 7.5%, our model reliably detected cases where novice biometry differed from expert biometry by 10 days or more, with an area under the receiver operating characteristics curve of 0.93 (95% CI: 0.92, 0.95), sensitivity of 81.0% (95% CI: 77.9, 83.8), and specificity of 89.9% (95% CI: 88.1, 91.5). These results held across a range of sensitivity analyses, including where the model was provided suboptimal truncated fly-to cineloops. CONCLUSIONS:Our AI model estimated GA more accurately than expert biometry. Because fly-to cineloop videos can be obtained without any change to sonographer workflow, the model represents a no-cost guardrail that could be incorporated into both low-cost and commercial ultrasound devices to prevent reporting of most gross GA estimation errors.

Postpartum depression (PPD) affects nearly 20% of postpartum women in Sub-Saharan Africa (SSA), where HIV prevalence is high. Depression is associated with worse HIV outcomes in non-pregnant adults and mental health disorders may worsen HIV outcomes for postpartum women and their infants. PPD is effectively treated with psychosocial or pharmacologic interventions; however, few studies have evaluated the acceptability of treatment modalities in SSA. We analyzed interviews with 23 postpartum women with HIV to assess the acceptability of two depression treatments provided in the context of a randomized trial. Most participants expressed acceptability of treatment randomization and study visit procedures. Participants shared perceptions of high treatment efficacy of their assigned intervention. They reported ongoing HIV and mental health stigma in their communities and emphasized the importance of social support from clinic staff. Our findings suggest a full-scale trial of PPD treatment will be acceptable among women with HIV in Zambia.

BACKGROUND:Data on long-term neurodevelopmental outcomes of normocephalic children (born with normal head circumference) exposed to Zika virus in utero are scarce. We aimed to compare neurodevelopmental outcomes in normocephalic children up to age 48 months with and without Zika virus exposure in utero. METHODS:In this prospective cohort study, we included infants from two cohorts of normocephalic children born in León and Managua, Nicaragua during the 2016 Zika epidemic. In León, all women pregnant during the two enrolment periods were eligible. In Managua, mother-child pairs were included from three districts in the municipality of Managua: all women who became pregnant before June 15, 2016, and had a due date of Sept 15, 2016 or later were eligible. Infants were serologically classified as Zika virus-exposed or Zika virus-unexposed in utero and were followed up prospectively until age 48 months. At 36 months and 48 months of age, the Mullen Scales of Early Learning (MSEL) assessment was administered. Primary outcomes were MSEL early learning composite (ELC) scores at 30-48 months in León and 36-48 months in Managua. We used an inverse probability weighting generalised estimating equations model to assess the effect of Zika virus exposure on individual MSEL cognitive domain scores and ELC scores, adjusted for maternal education and age, poverty status, and infant sex. FINDINGS:The initial enrolment period for the León cohort was between Jan 31 and April 5, 2017 and the second was between Aug 30, 2017, and Feb 22, 2018. The enrolment period for the Managua cohort was between Oct 24, 2019, and May 5, 2020. 478 mothers (482 infants) from the León cohort and 615 mothers (609 infants) from the Managua cohort were enrolled, of whom 622 children (303 from the León cohort; 319 from the Managua cohort) were included in the final analysis; four children had microcephaly at birth and thus were excluded from analyses, two from each cohort. 33 (11%) of 303 children enrolled in León and 219 (69%) of 319 children enrolled in Managua were exposed to Zika virus in utero. In both cohorts, no significant differences were identified in adjusted mean ELC scores between Zika virus-exposed and unexposed infants at 36 months (between-group difference 1·2 points [95% CI -4·2 to 6·5] in the León cohort; 2·8 [-2·4 to 8·1] in the Managua cohort) or at 48 months (-0·9 [-10·8 to 8·8] in the León cohort; 0·1 [-5·1 to 5·2] in the Managua cohort). No differences in ELC scores between Zika virus-exposed and unexposed infants exceeded 6 points at any time between 30 months and 48 months in León or between 36 months and 48 months in Managua, which was considered clinically significant in other settings. INTERPRETATION:We found no significant differences in neurodevelopmental scores between normocephalic children with in-utero Zika virus exposure and Zika virus-unexposed children at age 36 months or 48 months. These findings are promising, supporting typical neurodevelopment in Zika virus-exposed normocephalic children, although additional follow-up and research is warranted. FUNDING:National Institute of Child Health and Development, National Institute of Allergy and Infectious Diseases, and Fogarty International Center. TRANSLATION:For the Spanish translation of the abstract see Supplementary Materials section.

ObjectiveTo evaluate the accuracy of two portable ultrasound machines (PUM) in assessing fetal biometry and estimated gestational age (EGA).MethodsThis was a secondary analysis of data from the Fetal Age Machine Learning Initiative, an observational study of pregnant women in the USA and Zambia. Each participant underwent ultrasound assessment by an experienced sonographer using both a high-specification ultrasound machine (HSUM) and a PUM (Butterfly iQ or Clarius C3) to measure fetal biometry and calculate EGA at each visit. By comparing paired PUM and HSUM scans, we estimated agreement between individual biometry measurements and aggregate gestational age estimates by reporting mean difference, intraclass correlation coefficient (ICC) and Bland-Altman plots, adjusting for trend.ResultsBetween April and December 2021, 818 participants contributed 1386 paired PUM-HSUM ultrasound investigations, of which 991 PUM scans were obtained using the Butterfly iQ device and 395 using the Clarius C3 device. Gestational age at scan ranged from 7 to 38 weeks. Compared with HSUM, the Butterfly iQ PUM had a mean difference of -0.20 (95% CI, -0.60 to 0.20) days in the first trimester and -0.68 (95% CI, -0.93 to -0.44) days in the second/third trimesters. Compared with HSUM, the Clarius C3 PUM had a mean difference of -0.47 (95% CI, -1.11 to 0.18) days in the first trimester and -1.67 (95% CI, -2.10 to -1.25) days in the second/third trimesters. ICCs were 0.989 or greater throughout. Increasing gestational age was associated with increasing error and absolute error in EGA and fetal biometry. Both PUM devices demonstrated a modest trend toward underestimation of EGA with advancing gestational age in second/third-trimester scans, compared with HSUM.ConclusionThe Butterfly iQ and Clarius C3 PUM devices were highly accurate in performing fetal biometry in a diverse population from the USA and Zambia. (c) 2023 International Society of Ultrasound in Obstetrics and Gynecology.

2023 is the 60th year of publication of FIGO's journal, the International Journal of Gynecology and Obstetrics (IJGO), and to mark this anniversary we have invited five of IJGO's former and current Editors to reflect on their time with the journal. We have also compiled a special collection of seminal paper from the past 60 years, "60 years of IJGO"—all papers in this collection are free to access for a limited period. We hope that you find this editorial interesting and informative—as ever, we welcome any general feedback, suggestions, or any proposals of special issues and supplements, at [email protected]. FIGO was founded in 1954 in Geneva, and in 1960 the concept of a FIGO journal was put forth. Professor Howard Taylor of New York, the fourth President of FIGO, made the statement that "Nothing could be more important for the Federation's prestige than a journal of its own", and in 1963 the first edition of the International Journal of Gynecology and Obstetrics was published as a quarterly publication, with Professor Giuseppe Tesauro of Naples, Italy as the Editor. One of the early decisions was whether the language of publication should be French or English. The compromise during the early years was to publish in English with French abstracts. During this time there were two recurring problems—attracting quality submissions, and the financing of the journal. Societies were encouraged to subscribe to the journal, but relatively few did. However, by 1968, when Professor Tesauro retired as Editor, the journal had achieved international recognition. In 1968, Professor Harold Kaminetzky was appointed as the second Editor and the journal office moved to his department in Newark, New Jersey. IJGO became a bimonthly publication with Elsevier as the publisher, an arrangement that continued for many years. During Professor Kaminetzky's editorship an editorial board was appointed, and the peer review process was expanded to handle the increasing number of manuscripts being submitted for consideration for publication. In 1985 Professor Kaminetzky joined the staff of the American College of Obstetricians and Gynecologists in Washington DC, and had to relinquish the editorship of the journal. Professor John Sciarra of Northwestern University Medical School was appointed the third Editor of IJGO, and the editorial office moved to his department in Chicago, Illinois. The journal became a monthly publication in 1989, with an increasing number of quality manuscripts being submitted from countries in every continent. The Managing Editor of the Chicago office was Ms Kelley Williams, and since this predated the days of electronic publication, all manuscripts were submitted as typed hard copy; correspondence was by typewritten letter and postal mail, often with long delays. Despite these problems, in the 1990s the time from submission to publication was between 30 and 40 weeks, comparable to other journals at that time. Some notable events during Professor Sciarra's editorship were the triennial publication of the World Report on Women's Health, the triennial publication of the FIGO Report on Gynecologic Cancer, and the initiation of the annual award for the best paper from a low-resource country. This annual award has proved to be very popular and appreciated. The international scope of the journal was expanded in 1991, with an arrangement with an Italian publisher to publish selected articles in Italian, and in 1998 with the publication of IJGO—India, and in 2000 with IJGO—China. One notable manuscript appeared in the March 2002 issue of the journal recording the first human uterine transplantation; this was given front-page coverage by The New York Times and was featured in Time magazine.1 Professor Sciarra's editorship of IJGO continued until 2006, when Professor Timothy Johnson of Ann Arbor, Michigan, a senior member of the editorial board, was appointed the fourth Editor, and the editorial office moved to its present home at FIGO House in London, England. I was lucky enough to learn at the feet of a master when Professor Jack Sciarra asked me to join his IJGO editorial team in 1995. Our paths had first crossed when we served as ACOG representatives on the Carnegie Corporation of New York's Ghana Postgraduate Training Programme in Obstetrics and Gynecology External Advisory Board. In addition to learning the editorial ropes, I got to co-edit a new section of the journal—"Contemporary Issues in Women's Health"—envisioned by former Editor Harold Kaminetzky. Together with Sabaratnam Arulkumaran, and subsequently Richard Adanu, we enhanced the journal's focus on real-life, up-to-the-moment women's health issues. The day I inherited the mantle of Editor-in-Chief in 2007 was a landmark for IJGO: the editorial office moved to London, in space shared with the FIGO secretariat, and simultaneously the journal moved to an electronic submission and publication system. Clare Addington directed the new London editorial office professionally at every step, and our goal of expanding the global reach of both authors and reviewers was successfully achieved. I was able to edit the journal from my base in Ann Arbor, Michigan, and the growth we hoped to encourage has continued with the journal's ongoing success. We continued accepting clinical articles reflecting the broad interests of FIGO's constituent societies, but also recognized our role as FIGO's official journal, publishing articles of public health, social, and policy importance in both obstetrics and gynecology and women's health. The impact and impact factor of the journal both increased. We also established important goals of diversity and equity in our author and reviewer bases and adopted important publication policies. One example I am most proud of is the policy requiring that local co-authors be included on all papers from low- and middle-income countries, supporting FIGO's priority of capacity building, as well as preventing the co-opting of research databases and opportunities by high-income countries.2 Submissions increased, publication time decreased, and the global diversity of submissions, authors, and reviewers increased—especially in Africa, the Middle East, and Asia. Latin America and the former Soviet Union remained challenges for soliciting submissions. The hard work of Clare Addington and the editorial office staff made our goal of seeing the transformation of the editorial office into the current FIGO Publications office a reality. I was also proud when a student and mentee of mine, Professor Richard Adanu, succeeded me as Editor-in-Chief in 2014, the first person from the Global South to hold this position. In 2020–2021, the online submission and online publication format of IJGO afforded a special opportunity when Editor-in-Chief Michael Geary asked me to coordinate fast-track review of COVID-related articles, allowing this topical research to be published online as promptly as possible. IJGO was among the first journals to publish important articles on the impact of the pandemic on women's health and obstetric and gynecologic practice. Between February 25, 2020, and February 10, 2021, IJGO received over 230 submissions relating to COVID-19, of which 100 were published by March 2021. We identified a small team of highly dedicated reviewers and editors who were able to commit to rapid peer review turnaround while maintaining rigorous standards, and we were delighted to achieve a turnaround of under 1 week from submission to first decision on average, and under 24 days to final decision. The IJGO editorial team worked closely with copyeditors and Wiley's production department to fast-track the copyediting and typesetting of accepted papers, averaging under 5 days between acceptance and online publication.3 We agreed with our partner publisher, Wiley, that all articles should be free to access so that the latest research and knowledge could be disseminated as widely as possible, and we grouped these together in our COVID-19 Virtual Issue, which currently remains free for all to access.4, 5 IJGO is a truly international journal, both in name and in practice. The journal continues to attract submissions from all regions of the world, and our reviewers are similarly international. Analysis of submitted manuscripts and published papers over the years has demonstrated that we have been successful in maintaining a similar regional distribution for both the submitted manuscripts and published papers. This shows that no particular region of the world receives preferential treatment in the publication of submitted manuscripts. The import of the international nature of IJGO gained full recognition during my tenure as Editor-in-Chief, when the Editorial Board took the decision to introduce regional representation. This led to the selection of additional Associate Editors representing different regions of the world. Since IJGO is the official publication of FIGO, it is imperative that we maintain this international outlook. IJGO therefore highlights the best science from the different countries that are members of FIGO. IJGO is also very interested in capacity building among authors and researchers, especially those from low- and middle-income countries who have limited access to resources for their career development. At each of the FIGO Congresses held in recent times, IJGO has had a session focusing on improving scientific writing skills and increasing authors' chances of getting published. These sessions have covered the ethics of publishing, basic research methods, and tips on how to navigate the peer review process. In the spirit of true partnership, a number of these sessions were held together with the British Journal of Obstetrics and Gynecology and Obstetrics and Gynecology ("the Green Journal"). The educational role that scientific journals ought to play in developing new researchers is sometimes overlooked, so IJGO must continue to play a leading role in this, and to serve as a convening point where different journals come together to work on raising the next generation of researchers. IJGO has become a highly respected women's health journal throughout the world. This has been achieved through the hard work of all the different Editors and Editorial Board members over the years. The partnership between the journal and the FIGO expert committees, which results in widely read and widely downloaded publications on practice guidance among other topics, has been a major contributor to this achievement. IJGO must continue working closely with the FIGO committees so that the journal serves as the home for all FIGO guidance and expert statements. I joined IJGO in 2017 as the Public Health Obstetric Consultant, and was honored to become the first Deputy Editor-in-Chief—and the first female Deputy Editor-in-Chief—in 2021. Since then, I have witnessed expansion of the Editorial Board to ensure greater global representation. This expansion has brought increased diversity in perspectives and expertise to the journal, enhancing the quality and breadth of published research. IJGO has also forged partnerships with the World Association for Trainees in Obstetrics and Gynecology, welcoming two Associate Editors from this global organization. This collaboration brings fresh perspectives and insights from trainees and young researchers, ensuring that IJGO remains at the forefront of emerging trends and developments in the field. It is clear to me that IJGO's commitment to supporting and promoting burgeoning researchers remains unwavering. With increased training initiatives for junior researchers and editors, IJGO is actively investing in the professional growth and development of the next generation, further enhancing the journal's editorial capabilities and the quality of published content. In addition to the aforementioned positive changes, IJGO continues to place a strong emphasis on promoting researchers from low- and middle-income countries (LMICs). Recognizing the importance of equitable access to scientific publishing and the valuable contributions made by researchers from diverse backgrounds, IJGO has implemented initiatives to support and amplify the voices of researchers from LMICs. Finally, at a time when women's access to full-scope reproductive rights increasingly appears to be challenged, IJGO stands as a journal dedicated to advocating for women's rights and highlighting researchers who actively support women's health. With an unwavering commitment to progress, IJGO continues to amplify the voices of those who champion comprehensive reproductive healthcare. I am nothing but honored and proud to be a part of IJGO. I was honored to be appointed as Editor-in-Chief for IJGO when I succeeded Richard Adanu in January 2021. Richard increased the success and profile of our journal during his tenure, and I enjoyed working with and learning from him. I initially became a member of the IJGO Editorial Board in 2015 when I was working in Toronto, and I acted as the North American representative on the board. I was also part of the team of Associate Editors working on the Contemporary Issues in Women's Health section of the journal from 2017. In late 2017 I moved home to work in Ireland. When I was appointed as Editor-in-Chief I had several key goals. My initial aim was to extend and broaden the readership of the journal, in other words to "widen the circle of friends" of IJGO. My clear objective was to continue the great work of my predecessors and to continue to encourage the next generation of researchers, in both clinical and academic research. I believe that one of the key strategies of the journal has been to support researchers from low- and middle-income countries, and this is an approach that must continue into the future. IJGO has come a long way since its inception in 1963. It has a very wide reach, across all continents of the globe. It has provided a forum for all types of researchers, from those starting out in their careers to those who are at the very highest level of research expertise. It has facilitated publication of research from very small units, with minimal or no funding, to those affiliated with premier universities of the highest ranking. Most importantly, it has provided a voice for women and children by publishing work that has had a direct impact on patient care. My second goal was to enhance our impact factor. The journal has traditionally performed very well and the impact factor has increased steadily over time, standing at 2.216 at the time of my appointment. Our target was to increase this to 3.0 within 3 years, and possibly to further increase towards 5.0 within 5 years. At the outset, my third goal to increase the Editorial Board membership was approved by FIGO, and I am pleased to say that we now have two board members from each of the five FIGO geographical regions. I also wanted to ensure gender balance, and I am pleased to say that we now have equal gender membership on our board. FIGO also supported my proposal to appoint a first Deputy Editor-in-Chief, and I was delighted when Elizabeth Stringer was appointed to this role in 2020. As a team, we are also enthusiastic about supporting the next generation of academic trainees. Our proposal to appoint trainee editors was again met with resounding approval by our board and by FIGO. We appointed two WATOG representatives, Goknur Topçu and Priyankur Roy, again ensuring gender balance. Both have been wonderful additions to our board. Through significant teamwork and tremendous support from Amy Goggins (Head of Publishing) and her team, the journal has expanded hugely over the last 3 years. The number of submissions has dramatically increased from around 1300 papers per year to around 2000 or more new submissions each year. We have increased the number of special issues and supplements published in IJGO, too. Our ability to be really nimble, flexible, and responsive during the pandemic allowed the journal to publish breaking research around COVID-19 very quickly and ahead of our competitor journals. I am particularly grateful to Timothy Johnson, Richard Adanu, and the IJGO editorial office team for their sterling work during this unprecedented time. As a result of all of this, our impact factor rose to 3.561 in 2020, and further to 4.447 in 2021. 2021 saw a general trend of journal impact factors increasing rapidly due to a change in the calculation algorithm, followed by a moderate drop, and in 2022 the journal's impact factor has leveled off to 3.8. A better marker of our progress perhaps is our improved ranking among the 85 main journals in our specialty of Obstetrics & Gynecology, to 21/85 in 2022. We will work to improve this further over time. In 2022 we introduced the concept of a cascade journal, and partnered with the journal Reproductive, Female and Child Health. This project will inevitably take time to develop, but the early signs are that this is a positive step for our journal. We have a clear goal to increase the number of open access articles published in IJGO so that our authors are assured of the widest possible circulation, and so that readers do not face barriers to accessing important research and reviews. IJGO now publishes all guidance papers from FIGO's committees open access, and the proportion of open access publications in the journal has increased significantly year on year, from 8% in 2019 to 30% in 2023 year-to-date. Over the past few years, research integrity has become a major focus for all of us involved in medical research. Sadly, this has also proved to be an issue in Obstetrics & Gynecology, and all of the major OBGYN journals are grappling with this problem—IJGO is no exception. As the volume of published medical research articles continues to expand, so too do the occurrences of errors and outright research and publication misconduct. It is important for all stakeholders in medical research to take an active role in identifying possible errors, misconduct, and manipulation of the publication process. To combat this, IJGO appointed Pat Dicker to our Editorial Board in 2022 as Research Integrity Editor. We have also recruited additional colleagues with forensic expertise to conduct research integrity reviews, and to review any "flagged" publications as they are brought to our attention. We have been instrumental in coordinating an ad hoc group of journal editors in the fields of obstetrics, gynecology, women's health, and related topics. We started to meet monthly in September 2022, to collectively focus on the problem of manuscripts with flawed or fabricated data, or other types of misconduct. Although our initial focus has been on randomized controlled trials and systematic reviews with or without meta-analysis, the principles apply across all methodologies. A joint editorial captures the work that has been done in this area, and this has been jointly published in IJGO, BJOG, AJOG MFM, and ANZJOG.6 We have agreed updates to our various author guidelines and new submission checking processes—particularly for RCTs—which will be common to all journals that have participated in the process. We have collaborated closely with COPE. As a group of editors, we are committed to making significant progress in this area and our aim is to improve the trustworthiness of published data in women's health research. Over the next few years, our goal is to build on the great work done by our predecessors and by our current team. I look forward to continuing to work with the journal's editorial team, our Editorial Board, my colleagues at FIGO, and all of my colleagues and friends associated with IJGO. The fact that IJGO is the academic/journal arm of FIGO is incredibly important, and it maintains that essence of being part of the global voice for women's health. We will remain true to our mission and vision whilst striving for further improvements and successes.

This paper describes SimNorth, an unsupervised learning approach for classifying non-standard fetal ultrasound images. SimNorth utilizes a deep feature learning model with a novel contrastive loss function to project images with similar characteristics closer together in an embedding space while pushing apart those with different image features. We then use non-linear dimensionality reduction via t-SNE and apply standard clustering algorithms such as k-means and dbscan in 2D embedding space to identify clusters containing similar fetal structures. We compare SimNorth to other unsupervised learning techniques (such as Autoencoders, MoCo, and SimCLR) and demonstrate its superior performance based on cluster purity measures.

Knowledge regarding the frequency of ocular abnormalities and abnormal visual function in children exposed to Zika virus (ZIKV) in utero but born without congenital Zika syndrome (CZS) is limited. We hypothesized that children exposed to ZIKV in utero born without CZS may have visual impairments in early childhood. We performed ophthalmic examination between 16 and 21 months of age and neurodevelopment assessment at 24 months of age with the Mullen Scales of Early Learning test (MSEL) on children enrolled in a cohort born to women pregnant during and shortly after the ZIKV epidemic in Nicaragua (2016–2017). ZIKV exposure status was defined based on maternal and infant serological testing. Visual impairment was defined as abnormal if the child had an abnormal ophthalmic exam and/or low visual reception score in the MSEL assessment. Of 124 children included in the analysis, 24 (19.4%) were classified as ZIKV-exposed and 100 (80.6%) unexposed according to maternal or cord blood serology. Ophthalmic examination showed that visual acuity did not differ significantly between groups, thus, 17.4% of ZIKV-exposed and 5.2% of unexposed had abnormal visual function ( p = 0.07) and 12.5% of the ZIKV-exposed and 2% of the unexposed had abnormal contrast testing ( p = 0.05). Low MSEL visual reception score was 3.2-fold higher in ZIKV-exposed than unexposed children, but not statistically significant (OR 3.2, CI: 0.8–14.0; p = 0.10). Visual impairment (a composite measure of visual function or low MESL visual reception score) was present in more ZIKV-exposed than in unexposed children (OR 3.7, CI: 1.2, 11.0; p = 0.02). However, the limited sample size warrants future investigations to fully assess the impact of in utero ZIKV exposure on ocular structures and visual function in early childhood, even in apparently healthy children.

Objective: To understand the dynamics of Zika virus (ZIKV)-specific antibody immunity in children born to mothers in a flavivirus-endemic region during and after the emergence of ZIKV in the Americas. Methods: We performed serologic testing for ZIKV cross-reactive and type-specific IgG in two longitudinal cohorts, which enrolled pregnant women and their children (PW1 and PW2) after the beginning of the ZIKV epidemic in Nicaragua. Quarterly samples from children over their first two years of life and maternal blood samples at birth and at the end of the two-year follow-up period were studied. Results: Most mothers in this dengue-endemic area were flavivirus-immune at enrollment. ZIKV-specific IgG (anti-ZIKV EDIII IgG) was detected in 82 of 102 (80.4%) mothers in cohort PW1 and 89 of 134 (66.4%) mothers in cohort PW2, consistent with extensive transmission observed in Nicaragua during 2016. ZIKV-reactive IgG decayed to undetectable levels by 6–9 months in infants, whereas these antibodies were maintained in mothers at the year two time point. Interestingly, a greater contribution to ZIKV immunity by IgG3 was observed in babies born soon after ZIKV transmission. Finally, 43 of 343 (13%) children exhibited persistent or increasing ZIKV-reactive IgG at ≥9 months, with 10 of 30 (33%) tested demonstrating serologic evidence of incident dengue infection. Conclusions: These data inform our understanding of protective and pathogenic immunity to potential flavivirus infections in early life in areas where multiple flaviviruses co-circulate, particularly considering the immune interactions between ZIKV and dengue and the future possibility of ZIKV vaccination in women of childbearing potential. This study also shows the benefits of cord blood sampling for serologic surveillance of infectious diseases in resource-limited settings.

Objective To compare the performance of mid upper arm circumference (MUAC) and body mass index (BMI) for prediction of small for gestational age (SGA) in Zambia. Methods This is a secondary analysis of an ongoing clinical cohort that included women with a single gestation and MUAC measured before 24 weeks of pregnancy. We assessed relationships between maternal MUAC and birth weight centile using regression. The performance of MUAC and BMI to predict SGA was compared using receiver operating characteristic curves and the effect of maternal HIV was investigated in sub-group analyses. Results Of 1117 participants, 847 (75%) were HIV-negative (HIV-) and 270 (24%) were HIV-positive (HIV+). Seventy-four (7%) delivered severe SGA infants (<3rd centile), of whom 56 (76%) were HIV- and 18 (24%) were HIV+ (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.58-1.75). MUAC was associated with higher birth weight centile (+1.2 centile points, 95% CI 0.7-1.6; P < 0.001); this relationship was stronger among HIV+ women (+1.7 centile points, 95% CI 0.8-2.6; P < 0.001) than HIV- women (+0.9 centile points, 95% CI 0.4-1.4; P = 0.001). The discriminatory power was similar, albeit poor (area under the curve [AUC] < 0.7), between MUAC and BMI for the prediction of SGA. In stratified analysis, MUAC and BMI showed excellent discrimination predicting severe SGA among HIV+ (AUC 0.83 and 0.81, respectively) but not among HIV- women (AUC 0.64 and 0.63, respectively). Conclusion Maternal HIV infection increased the discrimination of both early pregnancy MUAC and BMI for prediction of severe SGA in Zambia. Clinical Trial Number (NCT02738892).

ObjectiveTo measure maternal/fetal SARS-CoV-2 antibody levels. MethodsA prospective observational study of eligible parturients admitted to the hospital for infant delivery was conducted between April and September 2020. SARS-CoV-2 antibody levels were measured in maternal and umbilical cord specimens using an in-house ELISA based on the receptor-binding domain (RBD) of the spike protein. Among SARS-CoV-2 seropositive patients, spike RBD antibody isotypes (IgG, IgM, and IgA) and ACE2 inhibiting antibodies were measured. ResultsIn total, 402 mothers were enrolled and spike RBD antibodies in 388 pregnancies were measured (336 maternal and 52 cord specimens). Of them, 19 were positive (15 maternal, 4 cord) resulting in a seroprevalence estimate of 4.8% (95% confidence interval 2.9-7.4). Of the 15 positive maternal specimens, all had cord blood tested. Of the 15 paired specimens, 14 (93.3%) were concordant. Four of the 15 pairs were from symptomatic mothers, and all four showed high spike-ACE2 blocking antibody levels, compared to only 3 of 11 (27.3%) from asymptomatic mothers. ConclusionA variable antibody response to SARS-CoV-2 in pregnancy among asymptomatic infections compared to symptomatic infections was found, the significance of which is unknown. Although transfer of transplacental neutralizing antibodies occurred, additional research is needed to determine how long maternal antibodies can protect the infant against SARS-CoV-2 infection.

Objectives: In the spring of 2020, Chatham County of North Carolina became a COVID-19 rural epicenter for SARS-CoV-2 infection. During this time seroprevalence of SARS-CoV-2 among adults in Chatham County was as high as 9%.5 The objective of this study was to measure the incidence of SARS-CoV-2 viral infection among pregnant patients seeking care at two rural federally qualified health centers in Chatham County. Methods: This was a retrospective cohort study of mothers and neonates who (1) received prenatal care at the above-mentioned medical clinics between March 2020 and July 2020 and (2) received nasopharyngeal SARS-CoV-2 PCR testing as a part of their prenatal care. Data were collected from outpatient and inpatient records beginning at first prenatal visit until first postpartum visit. Neonatal data were collected from time of birth until first well child visit. Descriptive Statistics are reported. Results: Fifty-one patients who received prenatal care at the study sites were tested for SARS-CoV-2. Hospital records were available from 48 deliveries. A total of 17 (33%) of 51 women tested positive for SARS-CoV-2 virus. Eleven patients had positive tests at prenatal testing; 3 tested positive at delivery, and 3 tested positive during the postpartum period, within 6 weeks of delivery. Two out of the three neonates born to mothers who tested positive at delivery were tested at 24-48 hours of life and neither tested positive. Two of three infants tested after hospital discharge but prior to the first well child visit had positive test results. Race/ethnicity were as follows: Hispanic/Latina (90.0%), Non-Hispanic white (2.0%), Black/African American (3.9%) and Asian (3.9%). Thirty-five women (68.6%) were identified as having no insurance, 10 women (19.6%) had Medicaid or other federal or state supported program, and 5 (9.8%) had private insurance. Conclusions: One-third of this cohort of pregnant patients in a rural setting in a COVID pandemic hotspot in NC tested positive for SARs-CoV-2 infection, significantly higher than the population seroprevalence at the time.

Background Fetal ultrasound is an important component of antenatal care, but shortage of adequately trained healthcare workers has limited its adoption in low-to-middle-income countries. This study investigated the use of artificial intelligence for fetal ultrasound in under-resourced settings. Methods Blind sweep ultrasounds, consisting of six freehand ultrasound sweeps, were collected by sonographers in the USA and Zambia, and novice operators in Zambia. We developed artificial intelligence (AI) models that used blind sweeps to predict gestational age (GA) and fetal malpresentation. AI GA estimates and standard fetal biometry estimates were compared to a previously established ground truth, and evaluated for difference in absolute error. Fetal malpresentation (non-cephalic vs cephalic) was compared to sonographer assessment. On-device AI model run-times were benchmarked on Android mobile phones. Results Here we show that GA estimation accuracy of the AI model is non-inferior to standard fetal biometry estimates (error difference −1.4 ± 4.5 days, 95% CI −1.8, −0.9, n = 406). Non-inferiority is maintained when blind sweeps are acquired by novice operators performing only two of six sweep motion types. Fetal malpresentation AUC-ROC is 0.977 (95% CI, 0.949, 1.00, n = 613), sonographers and novices have similar AUC-ROC. Software run-times on mobile phones for both diagnostic models are less than 3 s after completion of a sweep. Conclusions The gestational age model is non-inferior to the clinical standard and the fetal malpresentation model has high AUC-ROCs across operators and devices. Our AI models are able to run on-device, without internet connectivity, and provide feedback scores to assist in upleveling the capabilities of lightly trained ultrasound operators in low resource settings.

BACKGROUND Ultrasound is indispensable to gestational age estimation and thus to quality obstetrical care, yet high equipment cost and the need for trained sonographers limit its use in low-resource settings. METHODS From September 2018 through June 2021, we recruited 4695 pregnant volunteers in North Carolina and Zambia and obtained blind ultrasound sweeps (cineloop videos) of the gravid abdomen alongside standard fetal biometry. We trained a neural network to estimate gestational age from the sweeps and, in three test data sets, assessed the performance of the artificial intelligence (AI) model and biometry against previously established gestational age. RESULTS In our main test set, the mean absolute error (MAE) (±SE) was 3.9±0.12 days for the model versus 4.7±0.15 days for biometry (difference, -0.8 days; 95% confidence interval [CI], -1.1 to -0.5; P<0.001). The results were similar in North Carolina (difference, -0.6 days; 95% CI, -0.9 to -0.2) and Zambia (-1.0 days; 95% CI, -1.5 to -0.5). Findings were supported in the test set of women who conceived by in vitro fertilization (MAE of 2.8±0.28 vs. 3.6±0.53 days for the model vs. biometry; difference, -0.8 days; 95% CI, -1.7 to 0.2) and in the set of women from whom sweeps were collected by untrained users with low-cost, battery-powered devices (MAE of 4.9±0.29 vs. 5.4±0.28 days for the model vs. biometry; difference, -0.6; 95% CI, -1.3 to 0.1). CONCLUSIONS When provided blindly obtained ultrasound sweeps of the gravid abdomen, our AI model estimated gestational age with accuracy similar to that of trained sonographers conducting standard fetal biometry. Model performance appears to extend to blind sweeps collected by untrained providers in Zambia using low-cost devices. (Funded by the Bill and Melinda Gates Foundation.).

Objective To evaluate the effect of HIV co-infection on non-treponemal titers during pregnancy in women with syphilis. Methods This is a secondary analysis of pregnant women with syphilis in the prospective, observational Zambian Preterm Birth Prevention Study (ZAPPS). Treponemal (Treponema pallidum particle agglutination) and non-treponemal (rapid plasma reagin; RPR) testing were performed on serum biospecimens, resulting in 47 participants with serologically confirmed syphilis (27 HIV-positive, 20 HIV-negative). The primary outcome, achievement of RPR titer seroreduction during pregnancy, was analyzed by logistic regression. Secondary outcomes included overall titer reduction, seroreduction rate, serologic cure, and adverse pregnancy outcomes. Results Seroreduction of RPR titer occurred in 78% (21/27) of women with HIV versus 45% (9/20) of women without (adjusted odds ratio 4.66; 95% confidence interval [CI] 1.14 - 19.08). Overall RPR titer reduction, rate of seroreduction per week, and the proportion achieving serologic cure each trended higher among women with HIV compared with those without HIV. There was a trend toward decreased stillbirth incidence in participants achieving seroreduction (odds ratio 0.15, 95% CI 0.01-1.58). Conclusion HIV co-infection in this cohort of Zambian women with syphilis was associated with greater odds of RPR titer seroreduction during pregnancy. Pregnant women with syphilis and HIV may not be at increased risk for a delayed syphilis treatment response compared with women without HIV.