FHR monitoring and perinatal mortality in high-risk pregnancies.

The aim of the study was to evaluate the effect of the introduction of fetal heart rate monitoring on perinatal mortality rates in high-risk pregnancies. Results were compared with the perinatal mortality rates published previously from our clinics. The study group consisted of 2165 high-risk pregnant patients. The perinatal mortality rate in the study group was 28.6%, and the corrected rate 15.9%. The rates were significantly lower in comparison with the total perinatal mortality rates in former years. We are convinced that fetal heart-rate monitoring resulted in a significant decrease in the perinatal mortality rate. Although the increased use of fetal monitoring cannot reduce perinatal mortality resulting from problems such as genetic disorders, this study shows improved outcomes for many high-risk conditions, in particular postmature pregnancies.     

The risk of perinatal mortality with each week of expectant management in obese pregnancies

Introduction: The risk of stillbirth associated with maternal obesity increases with gestational age; however, it is unclear if earlier delivery reduces the overall perinatal mortality rate. Our objective was to compare the risk of perinatal mortality associated with each additional week of expectant management to that of immediate delivery.

Methods: This was a retrospective cohort study of singleton non-anomalous births in Texas between 2006 and 2011. Analyses were stratified based on maternal pre-pregnancy BMI class. For each BMI class, we calculated the rate of neonatal death and stillbirth at each week of gestation from 34 to 41 weeks. A composite risk of perinatal mortality associated with 1 week of expectant management was estimated combining the stillbirth rate of the current week and the neonatal death rate of the following week. This was compared with the rate of neonatal death of the current week.

Results: After all exclusions, 2,149,771 births remained for analysis. In the normal weight group, stillbirth risk increased from 0.8 per 10,000 births at 34 weeks to 5.7 per 10,000 births at 42 weeks, whereas the neonatal death risk decreased from 76.5 per 10,000 births at 34 weeks to 30.4 per 10,000 births at 42 weeks, there were no differences between expectant management and delivery for any gestational week. In the obese group, stillbirth risk increased from 1.8 per 10,000 births at 34 weeks to 10.5 per 10,000 births at 42 weeks, whereas the neonatal death risk decreased from 67.7 per 10,000 births at 34 weeks to 26.2 per 10,000 births at 42 weeks, the perinatal mortality risk favored delivery at 39 weeks (RR: 1.17; 99% CI: 1.01–1.36) and not thereafter. In contrast, in the morbidly obese group, stillbirth risk increased from 8.8 per 10,000 births at 34 weeks to 83.7 per 10,000 births at 42 weeks, whereas the neonatal death risk decreased from 63.6 per 10,000 births at 34 weeks to 15.5 per 10,000 births at 42 weeks, the perinatal mortality risk favored delivery from 38 weeks (RR: 1.53; 99% CI: 1.16–2.02) through 41 weeks (RR: 5.39; 99% CI: 1.83–15.88).

Conclusion: The findings reported here suggest that delivery by 38 weeks in gestation minimizes perinatal mortality in pregnancies complicated by maternal morbid obesity.     

Persistence of perinatal mortality due to congenital malformations in resource-poor settings

Every year, half a million babies are born with malformations, one-third of these life-threatening. The present study aims at analysing trends of perinatal mortality (PM) due to major congenital malformations (MCM) at a rural institute, for preventive possibilities. Records of all perinatal deaths due to MCM over 24 years were analysed. Perinatal deaths (PD) due to MCM were 346; overall 8.3% of PD (287 (82.94%) stillbirths; 59 (17.06%) neonatal deaths). There was a decreasing trend of contribution of MCM to PM: 9.52% in Block A to 6.95% in Block H; 26.87% of PD were due to nervous system anomalies: 3.76% in Block A to 2.02% in Block H. PM due to congenital heart disease increased from 0.87% in Block A to 6.94% in Block H. It is essential that a system exists to diagnose MCM at a gestation when abortion is possible. Research for prevention of anomalies needs to be continued.     

The effect of a perinatal center on perinatal mortality.

The evolution of a perinatal center over the past 12 years was reviewed. Factors in obstetric practices, maternal morbidity, and perinatal mortality were evaluated. The reduction in conditions leading to uteroplacental insufficiency (toxemia, hypertension, high parity) has been the most significant result. This in turn has led to a decrease in deaths from abruption, asphyxia, and respiratory distress syndrome (RDS). The practice of referring high-risk mothers to a perinatal center for delivery can continue to reduce perinatal mortality significantly.     

The problem of multiple pregnancies

A meeting of experts on the subject of multiple pregnancies was held on 25 November 2005 at the invitation of the Bertarelli Foundation, Switzerland. Swiss law on reproductive medicine prohibits the selection of embryos, a situation that not only reduces the success rate of IVF, but also makes it virtually impossible to achieve a further reduction in multiple pregnancy rates resulting from IVF. The medical profession, the couples affected and the general public need to be better informed about this restrictive law. Furthermore, it is a little known fact that a considerable number of multiple pregnancies are due to simple ovulation induction.     

Delayed interval delivery in twin pregnancies in the United States: Impact on perinatal mortality and morbidity

OBJECTIVE: To estimate the incidence of delayed interval delivery in twin pregnancies in the United States and evaluate the impact of delayed delivery on perinatal outcomes. STUDY DESIGN: A population-based retrospective cohort study was performed using the U.S. "matched multiple birth" file (1995 to 1998), restricting our analysis to twin sets in which the first twin was delivered vaginally at 22 to 28 weeks (n = 4257). Outcomes examined included perinatal and infant mortality and small-for-gestational-age births. Outcomes of second twins in pregnancies that underwent delayed interval delivery of 1, 2, 3, and >/=4 weeks were compared with those in which both twins were delivered contemporaneously. RESULTS: In this cohort, 6.1% (n = 258) of twins had delayed delivery (>/=1 week) of the second twin. Decreases in perinatal and infant mortality were observed only when the first twin was delivered at 22 to 23 weeks and when the delivery interval was /=4 weeks or when the first twin was delivered at 24 to 28 weeks (regardless of delivery interval), there was no benefit in perinatal or infant mortality. Delayed delivery of >/=4 weeks was associated with increased risk of small-for-gestational-age birth in the second twin, regardless of gestational age at delivery of the first. CONCLUSION: When a first twin was delivered at 22 to 23 weeks, delayed delivery of the second twin was associated with reduced perinatal and infant mortality of the second twin if the interval was less than 3 weeks. Delayed delivery of the second twin when the first was delivered at >/=24 weeks had no benefit on mortality.     

Impact of prior perinatal loss on subsequent pregnancies

OBJECTIVE: To evaluate the influence of previous perinatal loss on depressive symptoms, pregnancy-specific anxiety, and prenatal attachment for parents during subsequent pregnancies. DESIGN: Cross-sectional, survey design. PARTICIPANTS: Forty expectant couples who experienced a prior perinatal loss. Measures: Influence of loss (Impact of Event Scale [IES]), depressive symptoms (Center for Epidemiologic Studies-Depression Scale [CES-D]), pregnancy-specific anxiety (Pregnancy Outcome Questionnaire [POQ]), and prenatal attachment (Prenatal Attachment Inventory [PAI]). RESULTS: Mothers reported higher levels of depressive symptoms, pregnancy-specific anxiety, and prenatal attachment than fathers did. Forty-five percent of mothers and 23% of fathers had CES-D scores greater than or equal to 16 indicating high risk for depression. Eighty-eight percent of mothers and 90% of fathers reported elevated stress related to the prior loss (IES scores greater than or equal to 19). The impact of the previous perinatal loss was moderately correlated with depressive symptoms as well as pregnancy-specific anxiety. There was no relationship between the psychological distress in pregnancy after perinatal loss and prenatal attachment. CONCLUSIONS: The extent to which the impact of the prior loss increased parents' stress in the current pregnancy influenced their psychological distress. These findings should heighten awareness of the mixture of hope and fear expectant parents experience during pregnancies subsequent to perinatal loss.     

The hidden mortality of monochorionic twin pregnancies

In an ultrasound screening study at 10 to 14 weeks of gestation for measurement of fetal nuchal translucency thickness there were 102 monochorionic and 365 dichorionic twin pregnancies. In the monochorionic compared with the dichorionic pregnancies there was a higher rate of fetal loss before 24 weeks of gestation (12.2% versus 1.8%), perinatal mortality (2.8% versus 1.6%), prevalence of delivery before 32 weeks (9.2% versus 5.5%), and prevalence of birthweight below the 5th centile in both twins (7.5% versus 1.7%). However, the proportion of pregnancies with a birthweight discordancy of more than 25% was similar in the two groups (11.3% versus 12.1%).