Lower mesodermal defects: A common cause of fetal and early neonatal death

Among the first 1,130 referrals to the Wisconsin Stillbirth Service Program 17 infants have been recognized to share phenotypic characteristics involving the genital, urinary, lower gastrointestinal, and axial skeletal systems. The pattern of abnormalities identified appears to be limited to structures sharing a common embryologic origin. These features, for the most part, are shown to be non-randomly associated. No clearly definable sub-groups within this population are demonstrable. The pattern of abnormalities is defined to include abnormalities of the following structures as pathogenetically primary features: lumbosacral vertebrae, kidneys, ureters, uterus/fallopian tubes, vagina, bladder, urethra, adrenals, gonads, anorectum, external genitalia, and umbilical arteries. An embryologic mechanism is proposed which explains this non-random association as arising secondary to disruption of structures derived from the lower portion of the primitive intra-embryonic mesoderm. The Lower Mesodermal Defects Sequence appears to be a rather common (and under-recognized) cause of stillbirth and immediate neonatal death. © 1994 Wiley-Liss, Inc.     

Introduction to the special issue: Attachment-based psychoanalytic psychotherapy

Abstract

The unresolved (U) state of mind in parents has been validated by its association with infant attachment disorganization (D), yet all studies show a transmission gap, and a proportion of individuals classified as U have infants who are not D. This paper reports on 31 mothers who showed the characteristic lapses in thinking and reasoning of the unresolved/disorganized state of mind in relation to stillbirth (U_sb), when assessed with the Adult Attachment Interview (AAI) in the pregnancy after stillbirth. Seventeen (55%) of their infants were D at 1 year old. We evaluate social, attachment, and psychiatric variables to establish whether there are differences in U_sb individuals that will predict infant D. In this population of U mothers, social and attachment factors did not predict infant D, but U_sb mothers of non-D infants showed significantly higher levels of depression and of intrusive thoughts on the posttraumatic stress disorder (PTSD) scale in pregnancy, and showed higher levels of intrusive thoughts when the infant was 1 year old. We discuss possible interpretations of these findings.     

Transcervical Foley’s catheter versus Cook balloon for cervical ripening in stillbirth with a scarred uterus: a randomized controlled trial

Objective: To compare the efficacy and safety of the use of transcervical Foley’s catheter versus Cook cervical ripening balloon in pregnant women with stillbirth, unfavorable cervix and scarred uterus.

Design: Randomized controlled study.

Setting: El Minia University Hospital, El Minia, Egypt.

Patients and methods: Two-hundred pregnant women with stillbirth, unfavorable cervix and scarred uterus were recruited into this study. They were randomized into two groups. In group I (n?=?100), cervical ripening was done using Foley’s catheter. In group II (n?=?100), cervical ripening was done using Cook cervical ripening balloon.

Main outcome measures: Balloon insertion to delivery interval, successful ripening rate, cesarean delivery rate, maternal adverse events and maternal satisfaction.

Results: Time from balloon insertion to expulsion and from balloon insertion to delivery was significantly shorter in Foley’s catheter group. However, the difference between the two groups regarding time from balloon insertion to active labor, time from balloon expulsion to delivery, cervical ripening, cesarean section, instrumental delivery, pain score, need for analgesia, hospital stay and maternal satisfaction was not statistically significant.

Conclusions: Foley’s catheter and Cook cervical ripening balloon are comparable regarding efficacy and safety profile when used to ripen the cervix in pregnant women with stillbirth, unfavorable cervix and scarred uterus. However, Foley’s catheter has a shorter induction to delivery interval and is relatively cheaper device.     

Stillbirths and early neonatal mortality in rural Northern Ghana

Objective To calculate perinatal mortality (stillbirth and early neonatal death: END) rates in the Upper East region of Ghana and characterize community‐based stillbirths and END in terms of timing, cause of death, and maternal and infant risk factors. Methods Birth outcomes were obtained from the Navrongo Health and Demographic Surveillance System over a 7‐year period. Results Twenty thousand four hundred and ninty seven pregnant women were registered in the study. The perinatal mortality rate was 39 deaths/1000 deliveries, stillbirth rate 23/1000 deliveries and END rates 16/1000 live births. Most stillbirths were 31 weeks gestation or less. Prematurity, first‐time delivery and multiple gestation all significantly increased the odds of perinatal death. Approximately 70% of END occurred during the first 3 postnatal days, and the most common causes of death were birth asphyxia and injury, infections and prematurity. Conclusion Stillbirths and END remain a significant problem in Navrongo. The main causes of END occur during the first 3 days and may be modifiable with simple targeted perinatal policies.     

Trends in Risk of Pregnancy Loss Among US Women, 1990–2011

Background

Pregnancy loss can have physical and psychological consequences for women and their families. Though a previous study described an increase in the risk of self‐reported pregnancy loss from 1970 to 2000, more recent examinations from population‐based data of US women are lacking.

Methods

We used data from the 1995, 2002, 2006–2010, 2011–2015 National Survey of Family Growth on self‐reported pregnancy loss (miscarriage, stillbirth, ectopic pregnancy) among US women (15–44 years) who reported at least one pregnancy conceived during 1990–2011 that did not result in induced termination (n = 20 012 women; n = 42 526 pregnancies). Trends in the risk of self‐reported pregnancy loss and early pregnancy loss (<12 weeks) were estimated, separately, by year of pregnancy conception (limited to 1990–2011 to ensure a sufficient sample of pregnancies for each year and maternal age group) using log‐Binomial and Poisson models, adjusted for maternal‐ and pregnancy‐related factors.

Results

Among all self‐reported pregnancies, excluding induced terminations, the risk of pregnancy loss was 19.7% and early pregnancy loss was 13.5% during 1990–2011. Risk of pregnancy loss increased by a relative 2% (rate ratio [RR] 1.02, 95% confidence interval [CI] 1.01, 1.02) per year in unadjusted models and 1% per year (RR 1.01, 95% CI 1.00, 1.02) during 1990–2011, after adjustment for maternal characteristics and pregnancy‐related factors. In general, trends were similar for early pregnancy loss.

Conclusion

From 1990 to 2011, risk of self‐reported pregnancy loss increased among US women. Further work is needed to better understand the drivers of this increase in reported pregnancy loss in the US.     

Risk of Cardiovascular Disease Among Postmenopausal Women with Prior Pregnancy Loss: The Women’s Health Initiative

PURPOSE

Metabolic, hormonal, and hemostatic changes associated with pregnancy loss (stillbirth and miscarriage) may contribute to the development of cardiovascular disease (CVD) in adulthood. This study evaluated prospectively the association between a history of pregnancy loss and CVD in a cohort of postmenopausal women.

METHODS

Postmenopausal women (77,701) were evaluated from 1993–1998. Information on baseline reproductive history, sociodemographic, and CVD risk factors were collected. The associations between 1 or 2 or more miscarriages and 1 or more stillbirths with occurrence of CVD were evaluated using multiple logistic regression.

RESULTS

Among 77,701 women in the study sample, 23,538 (30.3%) reported a history of miscarriage; 1,670 (2.2%) reported a history of stillbirth; and 1,673 (2.2%) reported a history of both miscarriage and stillbirth. Multivariable-adjusted odds ratio (OR) for coronary heart disease (CHD) for 1 or more stillbirths was 1.27 (95% CI, 1.07–1.51) compared with no stillbirth; for women with a history of 1 miscarriage, the OR = 1.19 (95% CI, 1.08–1.32); and for 2 or more miscarriages the OR = 1.18 (95% CI, 1.04–1.34) compared with no miscarriage. For ischemic stroke, the multivariable odds ratio for stillbirths and miscarriages was not significant.

CONCLUSIONS

Pregnancy loss was associated with CHD but not ischemic stroke. Women with a history of 1 or more stillbirths or 1 or more miscarriages appear to be at increased risk of future CVD and should be considered candidates for closer surveillance and/or early intervention; research is needed into better understanding the pathophysiologic mechanisms behind the increased risk of CVD associated with pregnancy loss.     

Stillbirth after COVID-19 in Unvaccinated Mothers Can Result from SARS-CoV-2 Placentitis,Placental Insufficiency,and Hypoxic Ischemic Fetal Demise,Not Direct Fetal Infection: Potential Role of Maternal Vaccination in Pregnancy

Stillbirth is a recently recognized complication of COVID-19 in pregnant women. Other congenitally transmitted infections from viruses, bacteria and parasites can cause stillbirth by infecting fetal organs following transplacental transmission of the agent from the maternal bloodstream. However, recent research on pregnant women with COVID-19 having stillbirths indicates that there is another mechanism of stillbirth that can occur in placentas infected with SARS-CoV-2. In these cases, viral infection of the placenta results in SARS-CoV-2 placentitis, a combination of concurrent destructive findings that include increased fibrin deposition which typically reaches the level of massive perivillous fibrin deposition, chronic histiocytic intervillositis and trophoblast necrosis. These three pathological lesions, in some cases together with placental hemorrhage, thrombohematomas and villitis, result in severe and diffuse placental parenchymal destruction. This pathology can involve greater than one-half of the placental volume, averaging 77% in the largest study of 68 cases, effectively rendering the placenta incapable of performing its function of oxygenating the fetus. This destructive placental process can lead to stillbirth and neonatal death via malperfusion and placental insufficiency which is independent of fetal infection. Fetal autopsies show no evidence that direct infection of fetal organs is contributory. Because all mothers examined have been unvaccinated, maternal vaccination may prevent viremia and consequent placental infection.