Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services?

Objective To test the hypothesis that suboptimal factors in perinatal care services resulting in perinatal deaths were more common among immigrant mothers from the Horn of Africa, when compared with Swedish mothers.
Design A perinatal audit, comparing cases of perinatal deaths among children of African immigrants residing in Sweden, with a stratified sample of cases among native Swedish women.
Population and setting Sixty-three cases of perinatal deaths among immigrant east African women delivered in Swedish hospitals in 1990–1996, and 126 cases of perinatal deaths among native Swedish women. Time of death and type of hospital were stratified.
Main outcome measures Suboptimal factors in perinatal care services, categorised as maternal, medical care and communication.
Results The rate of suboptimal factors likely to result in potentially avoidable perinatal death was significantly higher among African immigrants. In the group of antenatal deaths, the odds ratio (OR) was 6.2 (95% CI 1.9–20); the OR for intrapartal deaths was 13 (95% CI 1.1–166); and the OR for neonatal deaths was 18 (95% CI 3.3–100), when compared with Swedish mothers. The most common factors were delay in seeking health care, mothers refusing caesarean sections, insufficient surveillance of intrauterine growth restriction (IUGR), inadequate medication, misinterpretation of cardiotocography (CTG) and interpersonal miscommunication.
Conclusions Suboptimal factors in perinatal care likely to result in perinatal death were significantly more common among east African than native Swedish mothers, affording insight into socio-cultural differences in pregnancy strategies, but also the suboptimal performance of certain health care routines in the Swedish perinatal care system.     

Is fetal gender significant in the perinatal outcome of pregnancies complicated by placental abruption?

Seventy cases of placental abruption were studied. These occurred in 12,800 deliveries, an incidence of 4.8 per 1000. There were more female infants (34-56%) compared with males (27-44%). Sixteen infants were stillborn and one baby died in the neonatal period. Thirteen of the perinatal deaths occurred in male infants. We speculate that a higher metabolic rate in male infants may account for this sex difference.     

Does minor trauma in pregnancy affect perinatal outcome?

Purpose

To investigate pregnancy outcome after minor trauma and to identify risk factors at admission that may predict adverse pregnancy outcome.

Methods

A retrospective study held between January-2005 and December-2011. Pregnant women at 23 weeks or more, who were admitted due to minor trauma, were included. A standard protocol was applied: physical examination, lab tests and a fetal heart rate monitoring (FHRM) and tocometer for 1 h. In cases of symptomatic women, abnormal FHRM or presence of uterine contractions, the length of monitoring was extended. All women were admitted for 24 h of observation. The primary outcome was a composite adverse outcome that included at least one of the following: placental abruption, preterm birth and birthweight <2,500 g. To investigate pregnancy outcome and identify risk factors that may predict pregnancy outcome, matched (1:2) non-trauma controls were included. Risk factors examined included maternal obstetric variables, complaints at admission, clinical findings, lab test results, FHRM and tocometer findings.

Results

A total of 512 women with minor trauma and 1,024 non-trauma controls were included. Composite outcome occurred in 48 (9.4 %) and 131 (12.9 %) of the study and the control groups, respectively (p = 0.04; OR 0.71; 95 % CI, 0.5–0.99). None of the parameters examined at admission predicted the occurrence of the composite outcome.

Conclusion

Pregnant women after minor trauma have a favorable pregnancy outcome. None of the parameters examined at admission were predictive of adverse outcome. Extensive evaluation at admission and observation for 24 h are probably unnecessary following minor trauma, particularly for asymptomatic women.     

Antenatal corticosteroids and perinatal outcomes in infants born at 23–25 weeks of gestation

Objectives: To evaluate the perinatal results of infants born between 23 and 25.6 weeks of gestation.

Methods: Medical charts of all women giving birth prematurely (23–25.6 w) from January 2005 to December 2011 were retrospectively reviewed. Cases of malformed infants or deliveries elsewhere were excluded.

Results: 198 infants were included. Chorioamnionitis occurred in 86 (43.4%) of the whole group: 26 (86.7%) in the 23-week; 35 (53.8%) in the 24-week and 25 (24.3%) in the 25-week groups. Foetal maturation with antenatal corticosteroids was complete in 119 cases (60.1%): 4 (13.3%) in the 23-week; 35 (53.8%) in the 24-week and 80 (77.7%) in the 25-week groups. Foetal death at birth occurred in 22 cases (11%) and 61 newborns (30.8%) died in the neonatal period. Of the 106 survivors with 2 years complete follow-up, 45 infants (42.4%) did not present sequelae; 16 infants (15.1%) had severe sequelae. A 66.6% (4) of infants born at 23 weeks of gestation did not present sequelae compared with a 32.3% (11) at 24 weeks and 45.4% (30) at 25 weeks.

Conclusions: The chorioamnionitis rate was higher when gestational age was lower. The foetal maturation rate was higher when gestational age was higher. A low severe sequelae rate was observed in the whole series, particularly in the 23-week group where the rate was lower than expected; however, these results could have been influenced by the small size of the 23-week group.     

Thiol/disulfide homeostasis in predicting adverse perinatal outcomes at 24–28 weeks of pregnancy in gestational diabetes

Objective: The main aim of this study was to investigate thiol/disulfide homeostasis at 24–28 weeks of pregnancy and to evaluate whether it is predictive for adverse perinatal outcomes or not in gestational diabetes mellitus (GDM).

Methods: A total of 110 pregnant women at 24–28 weeks of pregnancy (74 GDM patients and 36 age- and BMI-matched healthy pregnant women) were enrolled in this prospective case–control study. Thiol/disulfide homeostasis was evaluated with a novel spectrophotometric method to determine if there is an association with adverse perinatal outcomes in GDM, by using logistic regression analysis.

Results: GDM patients, with decreased native thiol levels at 24–28 weeks (OR: 4.890, 95% CI: 1.355–5.764, p?=?0.015) and with higher pre-pregnancy BMI (OR: 1.280, 95% CI: 1.072–1.528, p?=?0.006), were found to be at increased risk of adverse perinatal outcomes in GDM. There were no statistically significant differences in thiol/disulfide homeostasis between diet- and insulin-treated GDM subgroups. Additionally, 1-h and 2-h glucose levels on 100?g OGTT were found to be predictive for the insulin need in achieving good glycemic control in GDM (OR: 1.022, 95% CI: 1.005–1.038, p?=?0.010 and OR: 1.019, 95% CI: 1.004–1.035, p?=?0.015).

Conclusions: GDM patients, with decreased native thiol levels at 24–28 weeks of pregnancy and with higher pre-pregnancy BMI, have an increased risk of possible adverse perinatal outcomes. Also, increased 1-h and 2-h glucose levels on 100?g OGTT can predict the need for insulin treatment for GDM.     

Prevention of perinatal herpes: prophylactic antiviral therapy?

So what is the take-home message from these studies? The first question, about fetal and neonatal safety, appears to be answered positively. With more than 1,812 infants reported to have been exposed to varying amounts and duration of maternal acyclovir suppression, there has not been any apparent, short-term adverse fetal or neonatal effect. Use of acyclovir in infants, even in those that are premature, is very well tolerated, with a wide margin of safety. In addition, the pharmacokinetics studies by Frenkel et al and Kimberlin et al, as well as the animal studies, suggest that maternal use of acyclovir may actually provide a prophylactic and therapeutic benefit to an infant who is exposed to HSV. The second question, as to whether acyclovir suppression would simply change symptomatic outbreaks into asymptomatic ones, also appears to have some answers. The information provided by Wald et al indicated that acyclovir suppression actually decreases asymptomatic shedding, along with decreasing clinical recurrences. Because asymptomatic shedding seems to be similar in pregnant and nonpregnant patients, it would be reasonable to assume that asymptomatic shedding also would be decreased at delivery in pregnant women with HSV infection. This supposition is supported by the data from the randomized trials and cohort studies that demonstrated a lower than expected asymptomatic shedding rate. As yet, however, there has been no randomized trial in pregnant women that has had an adequate sample size to confirm this on a statistically significant basis. The third question, whether acyclovir suppression would lower the frequency of symptomatic recurrences at parturition, reducing the need for cesarean in these patients, has answers as well, although they may not be as clear cut as one would like. Women who experience their first genital herpes outbreak while they are pregnant seem to benefit from acyclovir suppression, with both a decrease in the risk of clinical recurrences at delivery and a decreased need for cesarean delivery. This is well documented by a randomized trial and other cohort studies. Acyclovir's efficacy in patients who have a history of genital herpes infections antedating their pregnancy is less clear. The data appear to indicate a clinically important decrease in the likelihood of symptomatic reactivations at the time of delivery, although the sample sizes in the randomized studies have been too small to draw a statistically significant conclusion one way or the other. Unfortunately, a definitive trial for this group of women may never be done. Assuming a 13% recurrence risk at the time of delivery and a 50% decrease in recurrences with the use of acyclovir, 652 women would have to complete the study to achieve a power of 80%. Conducting the study at the largest, single institution, prenatal center in the United States, Scott et al were only able to enroll 222 women during a period of 6 years. Likewise, Brocklehurst et al terminated their trial early because of recruitment difficulties. They enrolled only 63 women during a period of 4 years using two different sites in the United Kingdom. Unless a multicenter trial is conducted or a meta-analysis performed on the available data, we will probably have to be content with the data as it now stands. With valacyclovir and famciclovir now available, it is unlikely that any further work will be done with acyclovir. Information from the valacyclovir trials, however, may reach statistical significance because of changes in the study design that will allow smaller sample sizes to reach adequate power. Famciclovir treatment holds promise because of its longer intracellular half-life, but until concerns about potential mutagenicity are resolved and more information on its efficacy for suppressive therapy becomes available, it should not be considered for maternal suppressive therapy. Acyclovir appears to be effective, at least in some cohorts, and is probably safe for the fetus. (AB     

A systematic review of concepts related to women’s empowerment in the perinatal period and their associations with perinatal depressive symptoms and premature birth

Background

The perinatal period, which we here define as pregnancy and the first year postpartum, is a time in women’s lives that involves significant physiological and psychosocial change and adjustment, including changes in their social status and decision-making power. Supporting women’s empowerment at this particular time in their lives may be an attractive opportunity to create benefits for maternal and infant health outcomes such as reductions in perinatal depressive symptoms and premature birth rates. Thus, we here systematically review and critically discuss the literature that investigates the effects of empowerment, empowerment-related concepts and empowerment interventions on reductions in perinatal depressive symptoms, preterm birth (PTB), and low birthweight (LBW).

Methods

For this systematic review, we conducted a literature search in PsychInfo, PubMed, and CINAHL without setting limits for date of publication, language, study design, or maternal age. The search resulted in 27 articles reporting on 25 independent studies including a total of 17,795 women.

Results

The majority of studies found that, for the most part, measures of empowerment and interventions supporting empowerment are associated with reduced perinatal depressive symptoms and PTB/LBW rates. However, findings are equivocal and a small portion of studies found no significant association between empowerment-related concepts and perinatal depressive symptoms and PTB or LBW.

Conclusion

This small body of work suggests, for the most part, that empowerment-related concepts may be protective for perinatal depressive symptoms and PTB/LBW. We recommend that future theory-driven and integrative work should include an assessment of different facets of empowerment, obtain direct measures of empowerment, and address the relevance of important confounders, including for example, ethnicity and socioeconomic status.

     

Association between method of delivery and puerperal infectious complications in the perinatal database of Baden-Württemberg 1998-2001

The strongest argument against caesarean delivery relates to maternal complications. Evidence supporting this for elective operations is controversial. The perinatal database 1998-2001 of the German state of Baden-Württemberg was studied to assess the maternal obstetrical risk associated with caesarean delivery with regard to puerperal infectious complications. For statistical analysis the chi2 test, Fisher's exact test, Mantel-Haenszel statistics and relative risks were used to describe the risk of exposure. Surgical delivery was associated with a significantly higher risk of infectious disorders (p < 0.0001). There was a significantly higher risk of septicaemia in the group undergoing caesarean compared to vaginal delivery (p < 0.0001), for pregnancies with and without risk factors of infection, and also for caesarean delivery prior to labour and rupture of membranes (ROM) and singleton gestations (RR 8.56; 95% CI 4.4-16.65, stratum without risks). The rate of wound disorders was found to be significantly increased in the case of surgical delivery (p < 0.0001). After exclusion of pregnancies with risk factors for infectious complications and multi-fetal gestation, a significantly higher risk was also found for caesarean delivery prior to labour and ROM versus vaginal delivery (RR 16.97; 95% CI 14.16-20.34). Caesarean delivery significantly increased the likelihood that a woman would experience fever in puerperium (p < 0.0001), for pregnancies with and without ante- or perinatal risk factors for infectious complications, and also when caesarean delivery prior to labour and ROM and singletons in the cephalic presentation were considered separately (RR 11.03; 95% CI 9.39-12.96; stratum without risks). Considering the obstetrical challenge of how more women can deliver with fewer complications, reducing unnecessary caesarean delivery still seems to be an appropriate approach.     

Anxiety in the perinatal period: antenatal and postnatal influences and women’s experience of care

Objective: To examine the characteristics of women with antenatal or postnatal anxiety and to investigate aspects of their care that may be associated with it. Background: Positive outcomes following childbirth are associated with good physical and mental health during pregnancy and following childbirth. Although a degree of anxiety is normal in pregnancy, for some women it can become a serious problem. Methods: This study used data on 5332 women from a 2010 national maternity survey which asked about antenatal and postnatal health and well-being three months after childbirth. Women self-identified as experiencing anxiety and other problems during pregnancy and the postnatal period. Results: Antenatal anxiety was reported by 14% of women and postnatal anxiety by 5% of women. Antenatal anxiety was associated with younger age, Black and Minority Ethnic status, single parenthood, living in a disadvantaged area, having an unwanted pregnancy and long-term health problems. Of these factors, only long-term mental health problems were associated with anxiety in the postnatal period. In the logistic regression models long-term mental health problems dominated the findings. Significant differences in the perceptions of the care experienced were evident in the responses from women with anxiety both antenatally and postnatally. Conclusions: This study shows that antenatal and postnatal anxiety are influenced by health and social factors. Asking women about their current physical and psychological health and past history during pregnancy and following up on their well-being in the postnatal period is an essential element in planning and providing care to meet their needs.     

Predictive factors of perinatal mortality in transfused fetuses due to maternal alloimmunization: what really matters?

Introduction: Alloimmunization is the main cause of fetal anemia. There are not many consistent analyses associating antenatal parameters to perinatal mortality in transfused fetuses due to maternal alloimmunization. The study aimed to determine the prognostic variables related to perinatal death. Material and Methods: A cohort study analyzed 128 fetuses treated with intrauterine transfusion (IUT), until the early neonatal period. Perinatal mortality was associated with prognostic conditions related to prematurity, severity of fetal anemia and IUT procedure by univariated logistic regression. Multiple logistic regression was used to compute the odds ratio (OR) for adjusting the hemoglobin deficit at the last IUT, gestational age at birth, complications of IUT, antenatal corticosteroid and hydrops. Results: Perinatal mortality rate found in this study was 18.1%. The hemoglobin deficit at the last IUT (OR: 1.26, 95% CI: 1.04–1.53), gestational age at birth (OR: 0.53, 95% CI: 0.38–0.74) and the presence of transfusional complications (OR: 5.43, 95% CI: 142–20.76) were significant in predicting fetal death. Conclusion: Perinatal mortality prediction in transfused fetuses is not associated only to severity of anemia, but also to the risks of IUT and prematurity.     

Does the presence of a funnel increase the risk of adverse perinatal outcome in a patient with a short cervix?

OBJECTIVE: This study was undertaken to determine whether the presence of a dilated internal os (funneling or beaking) alters the outcome of patients with a short cervix documented by transvaginal ultrasound in the second trimester. STUDY DESIGN: Between January 1998 and May 2004, all singleton pregnancies with a short cervix (< or =2.5 cm) and no funnel between 16 and 24 weeks' gestational age were identified by query and review of the Lehigh Valley Perinatal Ultrasound Database. These no funnel patients were compared with patients with a short cervix and funnel matched in accordance with cervical length and risk factors. Multiple variables of perinatal outcome were identified and compared between the Funnel and No Funnel groups. Correlations between cervical measurements and gestational age at birth were analyzed. RESULTS: Of the 279 patients with a short cervix identified, 82 were singleton with a T-shaped cervix and no funnel and 82 patients matched with a typical Y-shaped funnel. There was no difference between groups with respect to maternal demographics, previous preterm birth (28.1% No Funnel group vs 36.5% Funnel group, P = .3), prior cervical surgery (24.3% vs 22.0 %, P = .8), gestational age at entry (20.5 +/- 2.1 vs 21.1 +/- 2.4 weeks, P = .1), and cervical length (1.9 +/- 0.4 vs 1.8 +/- 0.5 cm , P = .1). The No Funnel group had significantly less readmissions for preterm labor (43.2% vs 67.1 %, P = .004), chorioamnionitis (2.4% vs 23.2 %, P = .0002), abruption (1.2% vs 13.4 %, P = .007), preterm rupture of membranes (6.1% vs 23.4%, P = .002), and cerclage placement (23.2% vs 43 %, P = .008). The neonates in the no funnel group delivered later (36.2% +/- 4.6 vs 33.8 +/- 5.4 weeks , P = .003), and had less morbidity and mortality (17.1% vs 37.8 %, P = .02) compared with the Funnel group. The width and depth of the funnel did not correlate with perinatal outcome. Cervical length ( R(2) = 0.07, P = .02) and cervical funneling as a categorical variable ( r = 0.3, P = .0002) did correlate with earlier delivery. CONCLUSION: The disruption of the internal os, as documented by funneling, is a significant risk factor for adverse perinatal outcome (ie, preterm labor, chorioamnionitis, abruption, rupture of the membranes, and serious neonatal morbidity and mortality). Cervical funneling is best measured as a categorical variable (present or absent).     

Does chorionicity or zygosity predict adverse perinatal outcomes in twins?

OBJECTIVE: The purpose of this study was to evaluate chorionicity and zygosity as risk factors for adverse perinatal outcomes in twins. STUDY DESIGN: A population-based, retrospective cohort study was conducted of all twin deliveries in Nova Scotia, Canada, from 1988 to 1997. Chorionicity was established by histologic examination. Zygosity was determined by chorionicity, sex, and infant blood group. Three groups were established: monochorionic/monozygotic twins, dichorionic/dizygotic twins, and dichorionic/majority monozygotic twins. RESULTS: Outcomes from 1008 twin pregnancies were analyzed. Monochorionic/monozygotic twins had lower mean birth weights compared with dichorionic/dizygotic twins. Rates of perinatal mortality of at least 1 twin were significantly higher among monochorionic/monozygotic twins relative to dichorionic/dizygotic twins (relative risk, 2.5; 95% CI, 1.1-2.5). Dichorionic/majority monozygotic twins had similar perinatal outcomes compared with dichorionic/dizygotic twins. CONCLUSION: Monochorionicity increases the risk of adverse perinatal outcome, whereas the effect of zygosity is less clear. Because chorionicity can be determined by prenatal ultrasound scanning, this information should be considered in the prenatal care of twin pregnancies.     

Can fetal left ventricular modified myocardial performance index predict adverse perinatal outcomes in intrahepatic cholestasis of pregnancy?

Objective: To investigate fetal left ventricular function using the left ventricular modified myocardial performance index (mod-MPI) and E wave/A wave peak velocity (E/A) ratio, and to explore the success of mod-MPI in the prediction of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy (ICP).

Methods: Forty-one ICP cases were compared with 41 gestational age-matched healthy controls. Opening and closing clicks of the mitral and aortic valves were used to define the three time periods [ejection time (ET), isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT)], which were employed in the calculation of mod-MPI [mod-MPI?=?(ICT?+?IRT)/ET]. The E/A ratio was calculated as well.

Results: Fetal left ventricular mod-MPI values were significantly higher in the ICP group compared to controls (0.56?±?0.09 versus 0.37?±?0.04, p?p?=?0.011). The optimal cutoff level for mod-MPI in prediction of adverse perinatal outcomes was >0.48 [sensitivity: 81.8%, specificity: 67.6%, area under the curve (AUC): 0.750, 95% CI: 0.613–0.887, p?=?0.008].

Conclusions: Fetuses of ICP cases have significant left ventricular dysfunction. Mod-MPI can be used in the prediction of adverse perinatal outcomes in ICP.     

Effect of therapeutic hypothermia on myocardial dysfunction in term neonates with perinatal asphyxia – a randomized controlled trial

Objective: To evaluate the effect of therapeutic hypothermia on myocardial dysfunction in term neonates with perinatal asphyxia.

Material and methods: This randomized controlled trial (RCT) conducted in a tertiary care teaching hospital, south India included 120 newborns with perinatal asphyxia that were randomized to two groups (therapeutic hypothermia and normothermia). Cardiac enzyme profile changes between groups were assessed at 0, 24, 72?h CPK-MB and troponin I levels were estimated by immune inhibition and quantitative immunochromatography methods, respectively. Electrocardiography (ECG) and Echocardiography (ECHO) were done at 0 and 72?h to evaluate the cardiac function and pulmonary hypertension. Neurodevelopment was assessed at 6 months of age in both groups using Developmental Assessment Scales for Indian Infants.

Results: The median values of CPK-MB in the normothermia and hypothermia groups at 0, 24, and 72?h were 198, 127, and 92?IU/L and 202, 111 and 64?IU/L, respectively. The median values of troponin I in normothermia and hypothermia groups at 0, 24, and 72?hrs were 2.45, 1.53, and 0.9?ng/mL and 1.97, 0.93, and 0.01?ng/mL, respectively. ECG and ECHO findings also suggest lesser myocardial dysfunction in therapeutic hypothermia group compared with the normothermia group.

Conclusions: Therapeutic hypothermia significantly decreases the myocardial damage in term asphyxiated neonates.     

Cesarean delivery and perinatal mortality rates in Japan, 2007–2011

Abstract

Objective: Cesarean delivery (CD) rates are increasing dramatically in developed countries. In this study, we examined the relationship between CD rates and perinatal mortality (PM) rates in all 47 prefectures in Japan.

Methods: The CD rates were derived from a national obstetrics facility survey conducted by the Japan Association of Obstetricians and Gynecologists (JAOG), which included 94.1% of all childbirths in Japan during the 5-year period from 2007 to 2011. The PM rates were based on vital statistics during the same period.

Results: During the 5-year period from 2007 to 2011, the CD rates compiled for the 47 prefectures in Japan increased significantly in each successive year, whereas PM rates decreased significantly in each successive year. However, no statistically significant correlation between CD and PM rates was detected.

Conclusion: There is a lack of evidence for a significant correlation between recently increasing CD rates and decreasing PM rates in Japan.