New Publication: “Maternal-infant transfer of SARS-CoV-2 antibodies following vaccination in pregnancy: A prospective cohort study” published in Vaccine!
September 11th, 2024
A new publication from a team of RID Program collaborators and current team members Dr. Elisabeth McClymont, Dr. Chelsea Elwood and Dr. Deborah Money has been published in Vaccine! This publication, entitled “Maternal-infant transfer of SARS-CoV-2 antibodies following vaccination in pregnancy: A prospective cohort study” describes findings from data collected as part of the COVERED Project’s Immune Sub-Study. The project aimed to understand the impact of receiving SARS-CoV-2 (COVID-19) vaccinations alone and COVID-19 vaccination as well as infection in pregnancy, on the maternal and infant SARS-CoV-2 antibody titers. The data described in this paper were collected through analysis of maternal, umbilical cord and child blood samples as well as breast milk samples, collected at delivery and 4-6 weeks postpartum (no umbilical sample at this instance) for COVID-19 vaccinated pregnancies who delivered at BC Women’s Hospital in Vancouver, BC. Key findings described in the publication include higher antibody concentrations for those with three vaccination doses compared to two doses (if not previously infected with COVID-19), within the three dose population, those that had previously been infected with COVID-19 had higher antibody concentrations than those with no previous infection, and significant correlation between antibody levels in maternal and infant samples which suggests successful transplacental transfer of these antibodies. For more information and to read more about these and other findings, access the publication here!
New Publication: “Antepartum versus postpartum amoxicillin oral challenge in pregnant patients with a reported penicillin allergy: A two-center prospective cohort study” Published in Acta Obstetricia et Gynecologica Scandinavica!
September 10th, 2024
A new publication authored by RID Program team members Dr. Jeffrey Wong, Melissa Watt, Dr. Chelsea Elwood, and Dr. Julie van Schalkwyk has been published in Acta Obstetricia et Gynecologica Scandinavica! This publication, entitled “Antepartum versus postpartum amoxicillin oral challenge in pregnant patients with a reported penicillin allergy: A two-center prospective cohort study” describes findings from data collected from pregnant patients of penicillin allergy delabelling clinics at BC Women’s Hospital in Vancouver, BC and another in Winnipeg, MB. It describes the differences in efficacy, adverse events and patient satisfaction between these two clinics, as the site in BC employed amoxicillin oral challenge (either automatically or after a negative penicillin skin test) to patients during the antepartum period, whereas the Winnipeg site employed only penicillin skin testing during the antepartum period and oral amoxicillin challenge during a follow-up visit in the postpartum period. Key findings from the publication included 98% of patients who recieved an oral amoxicillin challenge passing the challenge (no allergic reaction), 70% of patients from the Winnipeg site being lost to follow-up prior to the postpartum oral amoxicillin challenge being completed, and much higher percentage of patients delabelled from the allergy (97%) at the Vancouver site than at the Winnipeg site (38%). For more information on these and other findings, please click here to access the publication!
New Government of Canada Travel Recommendations for Pregnant Women and People Regarding Outbreaks of Oropouche Virus Disease
September 6th, 2024
Over the past few months, outbreaks of Oropouche Virus Disease (OVD) have occurred in multiple countries throughout South America and the Caribbean. OVD is caused by the Oropouche virus, which is spread mainly through insect bites, with the main vectors being midges, which are a small type of fly, and also potentially some species of mosquitoes. A particular population of concern for the disease is pregnant women and people, as infection in a pregnant person can result in the fetus also becoming infected, and these infections in pregnancy have been linked to serious negative pregnancy and infant outcomes including stillbirth and congenital microcephaly. Although cases of this disease have occurred in the past in the region, much higher case numbers than ever previously seen and new regions and countries being affected including Bolivia, Brazil and Cuba, led the international community including the Government of Canada to begin monitoring the situation. Cases of OVD have also begun to be detected in countries outside of the South America/Caribbean region, due to infected travelers (mainly returning from Cuba) coming back to their home countries. Due to these increased case numbers and particular risks of negative impacts for pregnant women and people, the Government of Canada has released travel recommendations for pregnant women and people going to countries with active outbreaks. For more information click here and to access the full recommendations from the Government of Canada click here.
New Practice Bulletin “Listeriosis in Pregnancy” Authored by RID Program Team Published by the Canadian Medical Association Journal!
August 26th, 2024
In response to the Listeria-related recalls of plant-based milks in Canada from the brands Silk and Great Value in July of 2024, four members of the RID program (Dr. Jeffrey Wong, Dr. Chelsea Elwood, Dr. Deborah Money and Dr. Julie van Schalkwyk), wrote and have now published a new practice bulletin on listeriosis in pregnancy in the Canadian Medical Association Journal (CMAJ). The team of RID Program members aimed to provide key knowledge to clinicians on the treatment and management of infectious listeriosis in pregnancy, to ensure that in case of increased cases in pregnancy due to exposures from the contaminated milk, these will be managed correctly by clinicians. To read the practice bulletin, click here!
New Publication: “Comparison of Maternal and Infant Outcomes in SARS-CoV-2 Infected Pregnancies and Contemporaneous General Population Pregnancies from British Columbia” published in JOGC!
August 6th, 2024
A new publication authored by RID Program team members Winnie Fu, Dr. Elisabeth McClymont, Dr. Chelsea Elwood, Dr. Julie van Schalkwyk, and Dr. Deborah Money as well as other longstanding RID Program collaborators including Dr. Manish Sadarangani and Dr. Laura Sauvé, has been published in the Journal of Obstetrics and Gynaecology Canada (JOGC). This publication, entitled “Comparison of Maternal and Infant Outcomes in SARS-CoV-2 Infected Pregnancies and Contemporaneous General Population Pregnancies From British Columbia” focused on findings from the BC data from the CANCOVID-Preg project, as well as population data on non-COVID-19 infected pregnancies in BC from the BC Perinatal Data Registry of Perinatal Services BC. It describes how SARS-CoV-2 infection in pregnancy affected the maternal and infant outcomes for pregnant women and people in BC compared to non-infected pregnant women and people. Data on maternal (gestational diabetes, pregnancy-induced hypertension, mode of delivery) and infant outcomes (birth outcome, resuscitation at birth, Apgar score at 5 minutes <7, birth weight, NICU admission, preterm birth) was collected on COVID-19 infected and non-infected pregnant women and people in BC, who delivered between March 1st 2020 to March 31st 2021. These data for the two groups were then compared to determine the impact of COVID-19 infection on these outcomes. To access the publication, please click here!
Strong Showing for RID Program at 2024 IDSOG Annual Meeting!
August 1-3rd, 2024
From August 1-3rd, 2024, the Infectious Diseases Society for Obstetrics and Gynecology (IDSGOG) hosted its Annual Meeting in Portland, Oregon USA. This meeting is held every year by IDSOG as an opportunity for a diverse pool of researchers to meet and discuss the latest findings from their various research projects in the field of infectious diseases and obstetrics and gynaecology. This year’s session included a very strong representation of the RID Program team and its research! On the first day of the meeting, Thursday August 1st, 2024, RID Program collaborator Dr. Clara Van Ommen presented a poster on the findings from the placental pathology reports from pregnant women and people infected with COVID-19 in BC that were abstracted as part of the CANCOVID-Preg Project. During this first day of the meeting, Dr. Deborah Money also participated in a “Stump the Professors” case competition, wherein a very unusual/difficult infectious diseases and OBGYN case was presented and a panel of experts needed to confirm the diagnosis, which she did successfully! During the second day of the meeting (Friday, August 2nd, 2024), RID Program clinical research fellow Dr. Jeffrey Wong, presented extensively, including both an oral abstract and poster on the results of his penicillin allergy delabelling in pregnancy research and an additional poster on a scoping review conducted on Hansen’s disease in pregnancy. Finally, on the final day of the meeting (Saturday, August 3rd, 2024) frequent RID Program collaborator Dr. Isabelle Boucoiran presented an oral abstract on CMV infection in pregnancy for women living with and without HIV. Congratulations to all these members of the RID Program team and collaborators on such a successful meeting! For more information on the meeting and the presentations/posters of the RID team, click here!
Congratulations Dr. Mel Krajden on receiving the John G. FitzGerald Award from the Canadian Association for Clinical Microbiology and Infectious Diseases!
July 17th, 2024
The RID Program team would like to offer our sincerest congratulations to Dr. Mel Krajden O.B.C., MD, FRCPC, a longtime and frequent collaborator of the RID Program, who has been awarded the John G. FitzGerald Award from the Canadian Association for Clinical Microbiology and Infectious Diseases (CACMID)! This award is awarded each year by CACMID to a Canadian microbiologist who through their contributions in academia, education and/or clinical practice has significantly advanced the field of medical microbiology. Dr. Krajden’s exemplary and extensive academic, educational and professional background was highlighted as reasoning for him receiving this award. Additionally, his pivotal roles in the $6.8M CIHR-Funded “FOCAL Trial”, the Canadian Hepatitis C Network (CanHepC) project, as well as his other research and expansive publication history were all highlighted in the reasoning for his selection as well. Dr. Krajden has been instrumental in the success of numerous RID Program projects including the NOVA-HIV Project, COVERED Project and its associated Immune Sub-Study, as well as the Canadian Population Serological Survey Utilizing Antenatal Serum Samples Project. Congratulations again to Dr. Krajden on this well-deserved award! To read more on this award and the reasoning behind Dr. Krajden’s selection, click here!
New Publication: “Maternal-infant transfer of SARS-CoV-2 antibodies following vaccination in pregnancy: A prospective cohort study” published in Vaccine!
July 9th, 2024
A new publication authored by RID Program team members Dr. Elisabeth McClymont, Dr. Chelsea Elwood, and Dr. Deborah Money as well as other longstanding RID Program collaborators is currently in press in the journal Vaccine (Journal of the Japanese Society of Vaccinology) and will be published in the upcoming issue of the journal. This publication, entitled “Maternal-infant transfer of SARS-CoV-2 antibodies following vaccination in pregnancy: A prospective cohort study” focused on findings from the first iteration of the COVERED Project’s Immune Sub-Study. It describes how SARS-CoV-2 vaccination in pregnancy, number of doses received, and previous SARS-CoV-2 infection in pregnant individuals affected the antibody concentrations in maternal serum, cord serum, infant serum and maternal breast milk, to determine the impact of these factors on maternal immune response and the transfer of SARS-CoV-2 antibodies across the placenta to the fetus. For more information on this publication and the findings described, please click here to access the publication!
New SOGC Clinical Practice Guideline “Guideline No. 450: Care of Pregnant Women Living with HIV and Interventions to Reduce Perinatal Transmission” in press in JOGC!
May 9th, 2024
On Thursday May 9th 2024, The Journal of Obstetrics and Gynaecology Canada (JOGC) virtually published the new clinical practice guidelines for The Society of Obstetricians and Gynaecologists Canada (SOGC) on the care of pregnant women (and people with a cervix) living with HIV and interventions on how to prevent perinatal HIV transmission. These guidelines are also currently in press, with a planned publication in a future issue of the JOGC. These guidelines were created by a group of four distinguished experts in the field of pregnancy care and reproductive infectious disease, which included RID Program team members Dr. Deborah Money and Dr. Andrea Atkinson! Additionally, longtime RID program collaborator Dr. Isabelle Boucoiran was also one of the authors!
Strong Showing for RID Program at 2024 UBC Department of OBGYN Academic Day!
May 8th, 2024
On Wednesday May 8th 2024, the UBC Department of Obstetrics and Gynaecology hosted the 24th edition of its annual Academic Day. This event is conducted every year to allow trainees from across the department to showcase the research they have been working on, through presentations to their fellow trainees, esteemed faculty members and department staff. This year in particular there was a strong presence of RID Program trainees presenting throughout the day, allowing for RID Program research to be particularly highlighted. The event was also hosted by RID Program leader, Dr. Deborah Money who is also the current head of the UBC Department of OBGYN, and she delivered both opening and closing remarks to the event.
Dr. Deborah Money Presented and Participated in a Q&A Session during Women’s Health-Focused Meeting of the Canadian House of Commons Standing Committee on Health!
May 2nd, 2024
On Thursday May 2nd, 2024, RID Program Leader Dr. Money presented to the Canadian House of Commons Standing Committee on Health in Ottawa, Ontario during their 113th meeting, which was focused on women’s health. She spoke on the importance of women’s heath research, impacts that Canadian research has had in the field of women’s health, the positive advancements in healthcare that can be achieved when women and pregnancy-focused research is prioritized and multiple recommendations on how to improve women’s health research in Canada. Following the presentation session, Dr. Money and the three other researchers present participated in a Q&A session for the MPs of the committee.
Congratulations to RID Program Clinical Research Fellow Dr. Jeffrey Wong on receiving the Best Early Career Presenter Award at the 2024 International Workshop on HIV & Women!
April 16th, 2024
The RID Program would like to send our sincerest congratulations to Clinical Research Fellow Dr. Jeffrey Wong on receiving the Best Early Career Presenter Award at the 14th Annual International Workshop on HIV & Women! This conference, which was held in Washington, D.C. USA on April 12 and 13th, featured numerous presentations from experts in the field of HIV and women’s health. Dr. Jeffrey Wong presented on the topic of “Risk Factors for Preterm Birth in Pregnant Women Living with HIV: A 25-Year Analysis of the British Columbia Perinatal HIV Database”, and for this presentation was presented with this award from the organizers of the workshop! Congratulations again to Dr. Jeffrey Wong!
Congratulations to RID Program Master’s Student Sofia Nicolls on winning the UBC Women+ and Children’s Health Sciences Research Day Poster Competition!
April 16th, 2024
The RID Program would like to congratulate master’s student Sofia Nicolls on winning the research poster competition at the 2024 UBC Women+ and Children’s Health Sciences (WACH) Research Day on Tuesday, April 16th 2024. At this event, Sofia presented on her current project on the incidence and prevalence of Human Papillomavirus (HPV) infection in women living with HIV (WLWH) in BC. This work has been supported by her supervisor, RID Program Leader Dr. Deborah Money, and involves analyzing previous data collected from past HPV in HIV studies conducted by the RID Program to understand these incidence and prevalence rates. Congratulations once again Sofia on this amazing achievement!
New Publication: “Retrospective Cohort Study on the Impact of the COVID-19 Pandemic on Pregnancy Outcomes for Women Living With HIV in British Columbia” published in JAIDS!
April 15th, 2024
A new publication authored by RID Program team members Winnie Fu, Dr. Elisabeth McClymont, Dr. Andrea Atkinson, Arezou Azampanah, Dr. Chelsea Elwood, Dr. Julie van Schalkwyk, and Dr. Deborah Money as well as other collaborators has been published in the Journal of Acquired Immune Deficiency Syndrome (JAIDS). The study found that the COVID-19 pandemic affected pregnant women living with HIV and their infants in BC, including higher rates of preterm birth and higher gestational age at first antenatal encounter during the pandemic. There were 2 cases of perinatal transmission of HIV during the pandemic, compared to none in the 3 years preceding the pandemic. Future pandemic-time guidelines should enhance engagement with communities that have existing social-structural barriers to health. For more information on this study and its findings, please click here to access the publication!
Congratulations to RID Program Clinical Research Fellow Dr. Jeffrey Wong on receiving the 2024 D.A. Boyes Memorial Research Award!
April 2nd, 2024
The RID Program would like to congratulate Clinical Research Fellow Dr. Jeffrey Wong on receiving the 2024 D.A. Boyes Memorial Research Award from the UBC Department of Obstetrics and Gynaecology, for his project “Evaluation of the Universal Maternal Syphilis Screen at Delivery: a collaboration with the British Columbia Centre for Disease Control”. This award has been given by the UBC Department of OBGYN annually since 2017, to honor notable department member Dr. David A. Boyes and to support research in the department of OBGYN. Congratulations once again to Dr. Wong!
Congratulations to RID Program Clinical Research Fellow Dr. Jeffrey Wong on receiving the JAMMI Trainee Published Manuscript Award!
March 13th, 2024
The RID Program would like to congratulate Clinical Research Fellow Dr. Jeff Wong on receiving the JAMMI Trainee Published Manuscript Award for his manuscript “Establishing obstetrics-specific metrics and interventions for antimicrobial stewardship”. This award is given by the Association of Medical Microbiology and Infectious Disease (AMMI) Canada annually to celebrate an extraordinary manuscript published by a trainee in the Journal of the Association of Medical Microbiology and Infectious Disease (JAMMI) Canada. Congratulations once again to Dr. Wong!
Congratulations to RID Program Collaborator Dr. Mark Yudin on receiving the Casey Award for Leadership in Social Justice for the HIV/AIDS Community!
February 28th, 2024
Dr. Mark Yudin, a long-time colleague and principal collaborator of the RID Program, has recently been awarded the Casey Award for Leadership in Social Justice for the HIV/AIDS Community, by the Casey House Hospital in Toronto, for his extensive exemplary work as the head of the Positive Pregnancy Program (P3 Clinic) at St. Michael’s Hospital in Toronto. The P3 Clinic is a program, which was partly modelled after BCWH’s Oaktree Clinic, that has been operating for over 15 years, and works to provide high-quality obstetric and midwifery care for women living with HIV (WLWH) in the greater Toronto area. Congratulations Dr. Yudin and the rest of the P3 Clinic Team!
RID Program 2023 Annual Report is Now Available!
February 21st, 2024
The RID Program’s Annual Report for 2023 is now available to read! Click here to access the report and learn about all of the amazing work completed, conferences attended, new publications and other important accomplishments for the RID Program in 2023, as well as updates on our ongoing research projects.
Dr. Deborah Money appointed as member of the Order of Canada!
January 2nd, 2024
On December 28th 2023, Dr. Deborah Money was named as a new appointee to the Order of Canada along with 77 other individuals by Her Excellency the Right Honourable Mary Simon, Governor General of Canada. Dr. Money was selected due to her significant contributions to the field of women’s health and especially in the area of reproductive infectious disease. Congratulations Dr. Money!
RID Program Leader Dr. Deborah Money interviewed on Global News BC, regarding the currently recruiting COVERED Project, as well as latest insights and guidance on vaccination in pregnancy
December 21st, 2023
Dr. Deborah Money, the leader of the RID Program, was recently interviewed on the Global News BC Morning Show to discuss the RID Program’s COVERED project, a project being conducted across Canada to help broaden our understanding of vaccinations, pregnancy outcomes, and infant outcomes. Additionally, Dr. Money spoke about the latest insights and guidance regarding COVID-19 and Influenza Vaccination for pregnant women and people.
New Paper Published on Findings of RID Program’s COVERED Project: “Reactogenicity, pregnancy outcomes, and SARS-CoV-2 infection following COVID-19 vaccination during pregnancy in Canada: A national prospective cohort study”
October 31st, 2023
A new paper authored by the team behind the RID Program’s COVERED Project has been published in the scientific journal Vaccine, entitled “Reactogenicity, pregnancy outcomes, and SARS-CoV-2 infection following COVID-19 vaccination during pregnancy in Canada: A national prospective cohort study“. The paper describes the findings from data collected from Canadian pregnant women and people from July 2021 to July 2022, to understand various aspects of their experience in pregnancy during the COVID-19 pandemic.
RID Program Leader Dr. Deborah Money Honored with Woman’s Health Champion, Health Leader Award
October 26th, 2023
Dr. Deborah Money, the leader of the RID program, professor of OB/GYN and clinician/scientist in Reproductive Infectious Diseases, was recently honored with the Women’s Health Champion, Health Leader Award at the annual Glow Gala hosted by the BC Women’s Health Foundation (BCWHF) and RBC.
NIH selects Dr. Jeanne Marrazzo as director of the National Institute of Allergy and Infectious Diseases
August 2nd, 2023
Congratulations to Dr. Jeanne Marrazzo who was named Director of the National Institute of Allergy and Infectious Diseases!
Babies’ gut microbiome not influenced by mothers’ vaginal microbiome composition
March 30th, 2023
Frontiers Science News features our latest publication, titled “Maternal vaginal microbiome composition does not affect development of the infant gut microbiome in early life”. This study has one of the largest mother-infant cohort studies to date.
COVID-19 vaccination during pregnancy helps protect newborns, Canadian study suggests
February 8th, 2023
CBC News features Dr. Deborah Money, who comments on the benefit of COVID-19 vaccination in pregnancy, explaining that getting vaccinated during pregnancy is also of “great benefit to the infant” after they’re born.
HSV-2 infection and HPV incidence, persistence, and precancerous lesions in a cohort of HPV-vaccinated women living with HIV
January 26th, 2023
Our recent publication in the International Journal of STD & AIDS assesses the relationship between HSV-2 infection and HPV-related outcomes in quadrivalent HPV-vaccinated (qHPV) women living with HIV (WLWH).
Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis
January 24th, 2023
Check out this recently published prospective meta-analysis, with Dr. Deborah Money as a contributing author, which indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal mortality, severe maternal morbidities and adverse newborn outcomes.
Reproductive Infectious Diseases Team Annual Report 2022
January 15th, 2023
Our Annual Report is here! Read about the work that the RID team has been involved in over the past year.
UBC Q & A With Dr. Deborah Money: Bivalent Vaccines in Pregnancy
November 8th, 2022
With bivalent COVID-19 boosters rolling out across Canada, Dr. Deborah Money answers questions about what people who are pregnant need to know.
The 13th International Workshop on HIV & Women
October 26th, 2022
The 13th International Workshop on HIV & Women is accepting abstract submissions! The deadline for submission is November 4th, 2022.
Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: A sequential, prospective meta-analysis
August 24th, 2022
Data from our CANCOVID-Preg Surveillance project are used in this recent publication from the American Journal of Obstetrics and Gynecology.
CITF News Release: The Omicron Tsunami
July 6th, 2022
Data from our Canadian Antenatal Serosurveillance Study are highlighted in the most recent news release from Canada’s COVID-19 Immunity Task Force (CITF).
Vaginal microbiota associated with oncogenic HPV in a cohort of HPV-vaccinated women living with HIV
July 1st, 2022
Drs. Elisabeth McClymont, Arianne Albert and Deborah Money, along with the CTN 236 HPV in HIV Study Team, have recently been published in the International Journal of STD & AIDS.
Interim Guidance on Monkeypox Exposure for Pregnant People
June 9th, 2022
Drs. Vanessa Poliquin, Andrea Atkinson, Isabelle Boucoiran, Chelsea Elwood, Julie van Schalkwyk, Mark H. Yudin, and Deborah Money released these guidelines on behalf of the SOGC’s Infectious Diseases Committee.
Bloomberg Article: The Risks of Being Pregnant While Infected With Covid
May 26th, 2022
Dr. Deborah Money (school of population and public health; department of obstetrics and gynaecology) discussed a study she led which found that pregnant, unvaccinated people are more vulnerable to severe COVID-19 outcomes.
Association of SARS-CoV-2 Infection During Pregnancy With Maternal and Perinatal Outcomes
May 2nd, 2022
Researchers at the UBC Faculty of Medicine are urging people who are pregnant to remain vigilant based on data from Canada’s first national, peer-reviewed study on COVID-19 in pregnancy.
Pregnant women safely tolerate amoxicillin direct oral challenges
April 27th, 2022
Pregnant women with a history of penicillin allergy safely passed direct oral challenges for amoxicillin without preceding skin testing, according to our study published in The Journal of Allergy and Clinical Immunology: In Practice.
ACOG Today’s Headlines
April 20th, 2022
ACOG Today’s Headlines is a digest of women’s health news selected from thousands of sources. Our recent publication, titled “Safety of Direct Oral Challenge to Amoxicillin in Pregnant Patients at a Canadian Tertiary Hospital” was recently featured as their top news story. To read the article, click here.
Ask a Scientist: Will the COVID-19 vaccine affect my fertility?
March 16th, 2022
Misinformation about COVID-19 vaccines and fertility has been rampant, but the good news is that data from scientific studies around the world have been very reassuring. There is already a tremendous body of evidence telling us that the COVID-19 vaccines do not interfere with fertility or pregnancy.
Pregnancy & COVID-19
January 6, 2022
A new study sheds more light on the impact of COVID-19 on pregnancy and vaccine efficiency. Lead researcher Dr. Deborah Money joins Global’s Andrea Howick with preliminary results.
Misinformation Linking Vaccine to Stillbirths Condemned by Vancouver Coastal Health
November 24, 2021
Online misinformation prompted the health authority to take to social media, dispel frightening rumours. Dr. Anna Wolak says anti-vaccine misinformation is increasingly targeting parents, expectant parents
How scientific evidence evolves: A case study on COVID-19 in pregnancy
November 23, 2021
Growing evidence has led to the continuous evolution of our understanding of COVID-19 in pregnancy.