Absence of association of inherited thrombophilia with unexplained third-trimester intrauterine fetal death

OBJECTIVE: The purpose of this study was to investigate the alleged association between thrombophilia and unexplained third-trimester stillbirth. STUDY DESIGN: Case subjects were 37 women with a history of a third-trimester unexplained stillbirth. Control subjects were 46 volunteers, group-matched for ethnic origin, with no history of stillbirth, recurrent fetal loss, or thromboembolism. The pathology report of 34/37 placentas of case subjects was reviewed. RESULTS: The prevalence of at least 1 inherited thrombophilia among case subjects was 37.8% compared with 41.3% among control subjects. (OR = 0.87; 95%CI, 0.32-2.29). There was no significant difference between the groups with respect to the prevalence of any single inherited thrombophilia. There was, however, a significantly higher prevalence of antiphospholipid antibodies among case subjects compared with control subjects: 47.2% vs 8.7%, respectively (OR = 9.4; 95%CI, 2.5-42.3). No significant difference was noted in the prevalence of thrombopilia among subjects with or without placental infarcts. CONCLUSION: We did not find an association between unexplained third-trimester intrauterine fetal death and inherited thrombophilia; however, we did find such an association with antiphospholipid antibodies.     

Amphetamine abuse in pregnancy: the impact on obstetric outcome

Objective To determine whether pregnant women with amphetamine abuse developed more obstetric complications than non-drug abuser pregnant women. Materials and methods A retrospective case control study was undertaken. Pregnant women with amphetamine abuse who delivered between January 2002 and December 2003 were compared to control pregnant women. Results Pregnant women who abused amphetamine were more likely to develop anemia, preterm delivery, thick meconium stained amniotic fluid, and delivered small for gestational age neonates. However, cephalopelvic disproportion was less frequently found in the amphetamine abuse group. Conclusion Pregnant women who abuse amphetamine experience more obstetric complications than the non-drug abuser. This information may be useful to medical personnel who are caregivers of these pregnant women to provide adequate perinatal care.     

First presentation of polymyositis postpartum following intrauterine fetal death

We present a case of polymyositis (PM) following intrauterine fetal death. The first presentation of PM in the patient was during postpartum. The patient was referred to our hospital because of a fever of unknown cause 13 d after delivery of dead fetus at 32 weeks’ gestation. PM was diagnosed based on the increased serum creatine phosphokinase level, typical electromyogram findings and characteristic muscle biopsy findings. Received: 15 December 1999 / Accepted: 15 February 2000     

Association between small for gestational age and intrauterine fetal death: comparing a customized South Korean growth standard versus a population-based fetal growth chart

Objective: To determine if a customized growth standard developed for an ethnically homogeneous South Korean population is better at identifying (SGA) fetuses at risk for intra-uterine fetal death (IUFD), compared with a current population based-growth standard.

Study design: A retrospective cohort study comparing the identification of SGA fetuses at risk for IUFD using a customized versus a population based-chart. The association between a SGA infant defined as a birth weight <10th percentile using the South Korean population chart versus the customized chart and IUFD were compared. Intrauterine fetal death was defined as fetal demise occurring after 20 weeks gestation. Statistical analyses including OR, 95% confidence interval (CI), and screening accuracy using each chart were performed.

Results: The customized singleton chart identified 11 (8.2%) of the SGA pregnancies detected by the population chart and classified 15 additional fetuses as SGA. Those identified as SGA using the customized chart had an OR for IUFD that was approximately 15 times as high as those identified using the population chart. The customized chart also showed a higher sensitivity and specificity for identifying SGA pregnancies at risk for IUFD.

Conclusion: In this ethnically homogenous population, the customized growth chart showed improved discrimination in identifying SGA pregnancies at risk for fetal death than the population-based growth chart.     

Cell-free fetal DNA and adverse outcome in low risk pregnancies

Objective

To analyze in a large prospective cohort study of low risk pregnancies whether cell-free fetal (cff) DNA in maternal plasma of the second trimester might be associated with the development of preeclampsia, preterm delivery, and small for gestational age.

Study design

A subset of a large prospective cohort study in serological RhD negative pregnant women with RHD positive fetuses was used. Cff DNA was determined through the detection of RHD specific sequences with real-time PCR.

Results

In 611 pregnancies, rates of 7.2% preeclampsia, 1.6% preterm birth ≤32, 2.9% ≤34, and 12.4% ≤37 weeks of gestation, 5.7% of small for gestational age <5th percentile, and 8.2% <10th percentile were observed. For none of these risk groups an association with cff DNA could be established.

Conclusion

Cff DNA in maternal plasma of the second trimester was not found to be a marker for an adverse pregnancy outcome in low risk pregnancies.     

Intrauterine fetal death

Sadly, intrauterine fetal death is a common occurrence and one that all labour ward personnel should be trained to manage. Recent advances have improved the likelihood of identifying a cause. The key to this is a logical and methodical approach to investigation. Postmortem examination remains a critical aspect of investigation and labour ward teams require a clear understanding of the legal aspects of this. Sympathetic and supportive care of parents should respect parental wishes and allow choice wherever possible. However, maternal safety should also be a central aspect of this care.     

Eating disorder that was diagnosed before pregnancy and pregnancy outcome

OBJECTIVE: The purpose of this study was to determine the association of an eating disorder that was diagnosed before pregnancy and a preterm delivery and/or the delivery of a low-birth-weight or small-for-gestational-age infant. STUDY DESIGN: This was a register-based follow-up study. We included 302 women who were hospitalized with an eating disorder before pregnancy who were delivered of 504 children and 900 control subjects who were delivered of 1552 children. The association of eating disorders, birth weight, and gestational age was assessed by bivariate and multivariate analyses. RESULTS: The risk of a low-birth-weight infant was twice as high in women with a previous eating disorder compared with women with no such disorder (odds ratio, 2.2; 95% CI, 1.4-3.2). The risk of preterm delivery and a small-for-gestational-age infant was increased to 70% and 80% (odds ratio, 1.7 [95% CI, 1.1-2.6]; odds ratio, 1.8 [95% CI, 1.3-2.4]), respectively. CONCLUSION: Women who were hospitalized for an eating disorder that was diagnosed before pregnancy were at increased risk of impaired pregnancy outcome.     

Obstetric outcomes subsequent to intrauterine death in the first pregnancy

Objective  To compare obstetric outcomes in the pregnancy subsequent to intrauterine death with that following live birth in first pregnancy.
Design  Retrospective cohort study.
Setting  Grampian region of Scotland, UK.
Population  All women who had their first and second deliveries in Grampian between 1976 and 2006.
Methods  All women delivering for the first time between 1976 and 2002 had follow up until 2006 to study their next pregnancy. Those women who had an intrauterine death in their first pregnancy formed the exposed cohort, while those who had a live birth formed the unexposed cohort.
Main outcome measures  Maternal and neonatal outcomes in the second pregnancy, including pre-eclampsia, placental abruption, induction of labour, instrumental delivery, caesarean delivery, malpresentation, prematurity, low birthweight and stillbirth.
Results  The exposed cohort ( n = 364) was at increased risk of pre-eclampsia (OR 3.1, 95% CI 1.7–5.7); placental abruption (OR 9.4, 95% CI 4.5–19.7); induction of labour (OR 3.2, 95% CI 2.4–4.2); instrumental delivery (OR 2.0, 95% CI 1.4–3.0); elective (OR 3.1, 95% CI 2–4.8) and emergency caesarean deliveries (OR 2.1, 95% CI 1.5–3.0); and prematurity (OR 2.8, 95% CI 1.9–4.2), low birthweight (OR 2.8, 95% CI 1.7–4.5) and malpresentation (OR 2.8, 95% CI 2.0–3.9) of the infant as compared with the unexposed cohort ( n = 33 715). The adjusted odds ratio for stillbirth was 1.2 and 95% CI 0.4–3.4.
Conclusion  While the majority of women with a previous stillbirth have a live birth in the subsequent pregnancy, they are a high-risk group with an increased incidence of adverse maternal and neonatal outcomes.     

Stillbirth rates in Peruvian populations at high altitude

OBJECTIVE: To compare the stillbirth rates in 4 cities at different altitudes in Peru. METHODS: The stillbirth rates from a sample of 22,662 births recorded in the Perinatal Information System database were analyzed between 2005 and 2006 for the cities of Lima (150 m), Huancayo (3280 m), Cuzco (3430 m), and Puno (3850 m). RESULTS: Stillbirths were higher at high altitude (>3000 m) (OR 4.82; CI, 3.05-7.72) compared with low altitude. The effect of altitude was observed after controlling for socioeconomic (OR 4.29; CI, 2.61-6.93), demographic and biological (OR 4.18; CI, 2.65-6.77), maternal health care (OR 4.72; CI, 2.96-7.61), and fetal factors (OR 3.96; CI, 2.48-6.45). Inhabitants from the southern Andes demonstrated a protective effect on stillbirth rate compared with the central Andes, which may be due to an ancestry effect with longer multigenerational residence in the southern Andes population. CONCLUSION: Stillbirth rate is higher at high altitude compared with low altitude.     

Intrauterine fetal death of one twin of diamnionic twins is associated with adverse perinatal outcome of the co-twin

Objective: To determine whether intrauterine fetal death (IUFD) of one twin of diamnionic twins after 22 weeks of gestation is associated with adverse perinatal outcome to the co-twin. Method: A retrospective case-control study (n?=?4070), including all twin births delivered between the years 1988 and 2010, was conducted. Perinatal outcome of the co-twin in diamnionic pregnancies complicated by IUFD were compared with the first twin from a pair of live-born diamnionic twins. A multiple logistic regression model was constructed to determine the association between IUFD of one twin and postpartum death (PPD) of the co-twin while controlling for confounders such as gestational age. Results: Pregnancies complicated with IUFD of a co-twin (n?=?116) had higher rates of adverse perinatal outcomes such as PPD (9.5% vs. 2.3%, p?<?0.001), low Apgar scores (<7) at 1 and 5?min (30.2% vs. 10.6%, p?<?0.001 and 6.9% vs. 1.8%, p?<?0.001, respectively), lower birth weight (1953?±?746?g vs. 2299?±?559?g), and higher rates of preterm birth before 34 weeks of gestation (38.8% vs. 16.4%, p?<?0.001). Using a multivariate analysis with PPD as the outcome variable, mortality was attributed to gestational age (adjusted OR?=?0.58; 95% CI 0.5–0.6, p?<?0.001) and not to the IUFD per se (adjusted OR?=?1.3, 95% CI 0.5–3.3, p?=?0.552). Conclusion: Intrauterine fetal death of one twin (of diamnionic twins) is associated with adverse perinatal outcome of the co-twin mainly due to prematurity.     

A piece in the puzzle of intrauterine fetal death: Pathological findings in placentas from term and preterm intrauterine fetal death pregnancies

Objective.?To compare pathological findings of placentas from term and preterm pregnancies complicated by intrauterine fetal death (IUFD).

Study design.?A retrospective cohort study was conducted including deliveries complicated by IUFD. A comparison was made between placentas from term and preterm (<37 weeks' gestation) pregnancies complicated by IUFD. A second analysis was undertaken comparing IUFD placentas delivered before and after 34 weeks' gestation. Uteroplacental insufficiency was defined when one or more of the following pathological features were found: placental infarct, poor vascularity of the chorionic villi, intravascular thrombi and vascular occlusion.

Results.?During the study period, 849 placentas of IUFD were examined. Gross and microscopic pathological finding were noted. When comparing gross and microscopic findings in term and preterm (<37 weeks) IUFD placentas, higher rates of calcifications, tissue congestion and cellular metaplasia were found in term vs. preterm placentas. Significantly increased rates of poor tissue vascularity, placental vascular occlusion and uteroplacental insufficiency were demonstrated in preterm IUFD placentas. When comparing pathological findings in IUFD placentas delivered before and after 34 weeks' gestation, higher rates of abnormal cord insertion, calcifications, tissue congestion, infarcts and intravascular thrombi as well as poor tissue vascularity and placental vascular occlusion were demonstrated in IUFD placentas delivered before 34 weeks. Regardless of gestational age at the time of IUFD in more than 90% of placentas vascular wall thickening was found. A third of both term and preterm placentas demonstrated histological chorioamionitis.

Conclusions.?A vast majority of IUFD placentas reveal numerous pathological findings that reflect uteroplacental insufficiency and abnormal blood supply. Different characteristics were noted in term and preterm placentas of pregnancies complicated by IUFD. Better definition of causes and associated placental pathological findings of IUFD might aid clinicians in counseling such patients regarding the reason and risk of recurrence in subsequent pregnancies.     

Clinical strategies for improving the detection of fetal growth restriction

The single most important condition affecting the viable fetus is intrauterine growth retardation (IUGR). IUGR is a common condition, affecting about 10% to 15% of the general maternity population. Despite its importance and relatively high prevalence, IUGR detection is poor. This article will focus on how to improve on IUGR detection.     

Women with endometriosis at first pregnancy have an increased risk of adverse obstetric outcome

Objective: To evaluate pregnancy, delivery and neonatal outcome in singleton primiparous versus multiparous women with/without endometriosis.

Methods: Multicentric, observational and cohort study on a group of Caucasian pregnant women (n?=?2239) interviewed during their hospitalization for delivery in five Italian Gynecologic and Obstetric Units (Siena, Rome, Padua, Varese and Florence).

Results: Primiparous women with endometriosis (n?=?219) showed significantly higher risk of small for gestational age fetuses (OR: 2.72, 95% CI 1.46–5.06), gestational diabetes (OR: 2.13, 95% CI 1.32–3.44), preterm premature rupture of membranes (OR: 2.93, 95% CI 1.24–6.87) and preterm birth (OR: 2.24, 95% CI 1.46–3.44), and were hospitalized for a longer period of time (p?n?=?1331). Multiparous women with endometriosis (n?=?97) delivered significantly more often small for gestational age fetuses (OR: 2.93, 95% CI 1.28–6.67) than control group (n?=?592). Newborns of primiparous women with endometriosis needed more frequently intensive care (p?=?0.05) and were hospitalized for a longer period of time (p?Conclusions: Women with endometriosis at first pregnancy have an increased risk of impaired obstetric outcome, while a reduced number of complications occur in the successive gestation. Therefore, it is worthy for obstetricians to increase the surveillance in nulliparous women with endometriosis during pregnancy.     

Clinicopathological evaluation of 59 cases of fetal death

OBJECTIVE: The purpose of this study has been assessing the determinants of stillbirth among the newborns of the Verona University Obstetrics Department. MATERIALS AND METHODS: A total of 59 stillbirth cases, observed between January 2000 and June 2006, were retrospectively studied. WHO definition for stillbirth was adopted as the inclusion criterion. Clinical files, feto-maternal laboratory data, feto-placental pathology findings as well as delivery mode and circumstances were all systematically reviewed. RESULTS: The 59 observed cases correspond to an incidence of 9.8 stillbirths/year, which, considering the institutional delivery rate, correspond to 5.4 cases per 1000 births. Frequent relevant conditions associated with stillbirth were intrauterine growth restriction (15.2%), congenital fetal anomalies (13.5%), various maternal diseases (21.0%); no cause of fetal demise could be found in 10/59 (17.0%) cases, which were classified as unexplained. Most deliveries were successfully induced with prostaglandins except 11 cases (19.0%) which required a C-section due to severe maternal conditions associated with the fetal loss. CONCLUSION: Thorough investigation of each individual stillbirth case, by means of an integrated study protocol, along with the Pathologist's close collaboration, allows identification of a likely cause in the majority of cases. Better knowledge of unexpected fetal loss is the premise for better parental counselling and for prevention of recurrences.     

Low first-trimester hemoglobin and low birth weight, preterm birth and small for gestational age newborns.

OBJECTIVE: To examine the relationship between first-trimester hemoglobin (Hb) concentration and risk of low birth weight (LBW), preterm birth and small for gestational age (SGA). METHODS: Data were obtained from a population-based prenatal care program in China. A total of 88,149 women who delivered during 1995-2000 and had their Hb measured in the first trimester were selected as study subjects. RESULTS: The prevalence of anemia (Hb<110 g/L) was 22.1% in the first trimester. The risk of LBW, preterm birth and SGA was increased steadily with the decrease of first-trimester Hb concentration. After controlling for confounding factors, women with Hb 80-99 g/L had significantly higher risk for LBW (OR=1.44, 95% CI 1.17-1.78), preterm birth (OR=1.34, 95% CI 1.16-1.55) and SGA (OR=1.13, 95% CI 0.98-1.31) than women with Hb 100-119 g/L. No elevated risk was noted for women with Hb> or =120 g/L. CONCLUSION: Low first-trimester Hb concentration increases the risk of LBW, preterm birth and SGA.