Management of pregnancy complications in women of advanced maternal age

The average age of women at childbirth in high resource obstetric settings has been increasing steadily for approximately 30 years. Women aged 35 years or over have an increased risk of gestational hypertensive disease, gestational diabetes, placenta praevia, placental abruption, perinatal death, preterm labour, fetal macrosomia and fetal growth restriction. Unsurprisingly, rates of obstetric intervention are higher among older women. Of particular concern is the increased risk of antepartum stillbirth at term in women of advanced maternal age. In all maternal age groups, the risk of stillbirth is higher among nulliparous women than among multiparous women. Women of advanced maternal age (>40 years) should be given low dose aspirin in the presence of an additional risk factor for pre-eclampsia and offered serial ultrasounds for fetal growth and wellbeing. Given the increased risk of antepartum stillbirth, induction of labour from 39 weeks’ gestation should be discussed with woman.     

Racial and ethnic disparities in United States: stillbirth rates: trends, risk factors, and research needs

As with most adverse health outcomes, there has been long standing and persistent racial and ethnic disparity for stillbirth in the United States. In 2005, the stillbirth rate (fetal deaths ≥ 20 weeks' gestation per 1000 fetal deaths and live births) for non-Hispanic blacks was 11.13 compared with 4.79 for non-Hispanic whites. Rates were intermediate for American Indian or Alaska Natives (6.17) and Hispanics (5.44). There is racial disparity for both early (< 28 weeks' gestation) and late stillbirths. We review available data regarding risk factors for stillbirth with a focus on those factors that are more prevalent in certain racial/ethnic groups and those factors that appear to have a more profound effect in certain racial/ethnic groups. Although many factors, including genetics, environment, stress, social issues, access to and quality of medical care and behavior, contribute to racial disparity in stillbirth, the reasons for the disparity remain unclear. Knowledge gaps and recommendations for further research and interventions intended to reduce racial disparity in stillbirth are highlighted.     

Repeated pregnancy in a woman with uterine prolapse from a rural area in Nepal

Pelvic organ prolapse is common in rural women in Nepal. Pregnancy in a woman with pelvic organ prolapse is uncommon and rarely continues beyond the second trimester. If it proceeds after that, the uterus usually ascends with progression of pregnancy and becomes abdominal, leaving little trace of prolapse. Pregnancy continuing to term with uterine prolapse is very rare. The case reported here is of a pregnant woman from a remote district in Nepal who had nine pregnancies and at 38 weeks of pregnancy presented at the district hospital with severe uterine prolapse, a large cervical ulcer and the baby's foot protruding from the cervix. Air transport was the only means of reaching the nearest hospital with emergency obstetric care, 200km away. The baby was delivered stillborn at the airport by the auxiliary nurse-midwife who accompanied her. Her husband was counselled for and had a vasectomy. The woman was fitted with a ring pessary but could not afford to go to the nearest town for surgery for the prolapse. People in remote areas of Nepal often seek medical advice very late. This and the lack of education, low utilisation of family planning services, and lack of skilled birth attendance and safe delivery centres at local level contribute to high maternal morbidity and mortality.     

Understanding perinatal mortality

Various assessments of health are used to promote comprehensive, formulated worldwide policies for improvement of delivery of care. Perinatal mortality is one measure of global perinatal health. In this review, we clarify the definition of perinatal mortality and discuss the recent trends, backgrounds, contributing factors, and practical management strategies. The wide differences in perinatal mortality between developing and developed countries are well recognized. Of equal concern are the potentially avoidable perinatal deaths that occur in developed countries; the varying perinatal mortality rates between developed countries indicate that they are not yet at an irreducible minimum. To that effect, international health policies should include the unique circumstances of developed countries, and effective practices should be better shared amongst developed countries. The international goal for improving the perinatal mortality rate, in addition to improving public health and access to good care for all pregnant women, is to develop a unified and multifaceted approach as considerably more can be achieved.     

Stillbirth and early neonatal mortality in rural Central Africa

Objective

To develop a prospective perinatal registry that characterizes all deliveries, differentiates between stillbirths and early neonatal deaths (ENDs), and determines the ratio of fresh to macerated stillbirths in the northwest Democratic Republic of Congo.

Method

Birth outcomes were obtained from 4 rural health districts.

Results

A total of 8230 women consented, END rate was 32 deaths per 1000 live births, and stillbirth rate was 33 deaths per 1000 deliveries. The majority (75%) of ENDs and stillbirths occurred in neonates weighing 1500 g or more. Odds of stillbirth and END increased in mothers who were single or who did not receive prenatal care, and among premature, low birth weight, or male infants. The ratio of fresh to macerated stillbirths was 4:1.

Conclusion

Neonates weighing 1500 g or more at birth represent a group with a high likelihood of survival in remote areas, making them potentially amenable to targeted intervention packages. The ratio of fresh to macerated stillbirths was approximately 10-fold higher than expected, suggesting a more prominent role for improved intrapartum obstetric interventions.     

Mortality patterns among very preterm babies: a comparative analysis of two European regions in France and England

OBJECTIVE: To explore the differences in outcome of very preterm pregnancies between two geographically defined populations in Europe with similar socioeconomic characteristics and healthcare provision but different organisational arrangements for perinatal care. DESIGN: Prospective cohort study. SETTING: Nord Pas-de-Calais (NPC), France, and Trent, UK. PARTICIPANTS: All pregnancy outcomes 22(+0) to 32(+6) weeks' gestational age for resident mothers. OUTCOME MEASURES: Mortality patterns (antepartum death, intrapartum death, labour ward death and neonatal unit death) among very preterm babies were analysed by region. Multinomial logistic regression was used to model regional differences for a variety of pregnancy outcomes and to adjust for regional differences in the organisation of perinatal care. RESULTS: Delivery of very preterm infants was significantly higher in Trent compared with NPC (1.9% v 1.5% of all births, respectively (p<0.001)). Stillbirth rate was significantly higher in NPC than in Trent (23.0%, 95% CI 20.0% to 26.5% v 14.4%, 95% CI 12.3% to 16.6%, respectively (p<0.001)) and survival to discharge was higher in Trent than in NPC (74.6%, 95% CI 71.9% to 77.1% v 66.7%, 95% CI 63.3% to 69.9%, respectively (p<0.001)). Probability of intrapartum and labour ward death in NPC was more than five times higher than Trent (relative risk 5.3, 95% CI 2.2 to 13.1 (p<0.001)). CONCLUSION: The high rate of very preterm deliveries and the larger proportion of these infants recorded as live born in Trent appear to be the cause of the excess neonatal mortality seen in the routine statistics. Information about very preterm babies (not usually included in routine statistics) is vital to avoid inappropriate interpretation of international perinatal and infant data. This study highlights the importance of including deaths before transfer to neonatal care and emphasises the need to include the outcome of all pregnancies in a population in any comparative analysis.     

Peripartum and intrapartum assessment of the fetus

Perinatal death or cerebral palsy are devastating outcomes of pregnancy for families. In an attempt to prevent these outcomes fetal wellbeing is assessed by a variety of means in the antenatal and intrapartum settings. In this review, the most common means to confirm fetal wellbeing, the rationale for their use and evidence of their efficacy in each of these settings are discussed. With respect to labour, the indications for continuous electronic fetal monitoring are presented, together with a guide to interpretation of cardiotocograph (CTG) or fetal blood samples (FBS).     

Pregnancy Loss and Distress Among U.S. Women

Although pregnancy loss—especially miscarriage—is a relatively common experience among reproductive‐aged women, much of our understanding about the experience has come from small clinic‐based or other nonrepresentative samples. We compared fertility‐specific distress among a national sample of 1,284 women who have ever experienced a stillbirth or miscarriage. We found that commitment/attachment to pregnancy that ended in loss as well as current childbearing contexts and attitudes were associated with distress following pregnancy loss. Practitioners working with women or couples who have experienced pregnancy loss should be aware of the importance of characteristics associated with higher distress, such as whether the pregnancy had been planned, recency of the loss, no subsequent live births, having a medical explanation for the loss, a history of infertility, current childbearing desires, importance of motherhood, and locus of control over fertility.