NSIDRC Journal Article Alert — August 1, 2008

Prepared by the National Sudden Infant Death Resource Center at Georgetown University.

This journal article alert provides selected items added to the National Library of Medicine’s PubMed database in the last week.

Past issues of NSIDRC journal alerts are available at http://www.sidscenter.org.
Availability of full-text journal articles is often limited to subscribers or through inter-library loan. Please see your local library for copies of these articles, or view PubMed's How to Get the Journal Article for more details.

Miscarriage/Stillbirth/Prenatal Issues

1. Das B, Sengupta S
HbE genotypes and fertility: a study on a Tibeto-Burmese population in Upper Assam, India
Ann Hum Biol. 2008 Jul-Aug;35(4):422-31

Department of Anthropology, University of Dibrugarh, Dibrugarh, 786 004 Assam, India. bd_das2002@yahoo.co.in

BACKGROUND: The north-eastern states of India in general and the state of Assam in particular appear to be areas with a very high incidence of HbE, with the highest frequency of the allele observed among the Kachari population. AIM: In the present study a Tibeto-Burmese speaking population of Assam, India has been studied with regard to haemoglobin E (HbE) and to examine the role of different HbE genotypes on fertility. SUBJECTS AND METHODS: Detailed reproductive histories and socio-economic data were collected from 159 unrelated Mishing (a Tibeto-Burmese population) couples initially. Haemoglobin typing was done by restriction digestion to detect wild type (HbA/HbA), heterozygotes (HbA/HbE) and homozygotes (HbE/HbE). RESULTS AND CONCLUSION: The HbE gene frequency for the total 318 individuals was 0.4623. The results suggest that HbE homozygosity is associated with a higher pregnancy rate. Mothers homozygous for HbE also have more live births in spite of having more spontaneous abortions. The study shows that HbE homozygous women may be getting an advantage up to the point of conception but beyond that various factors come into play to increase miscarriage and infant mortality and that the socio-economic factor is one important reason behind this.

2. Scifres CM, Macones GA
Antenatal testing-benefits and costs
Semin Perinatol. 2008 Aug;32(4):318-21

Washington University, St. Louis, MO.

Antenatal testing is a common component of care for the high-risk pregnancy. The goals of antenatal testing include the prevention of stillbirth and the detection of the hypoxic fetus to allow intervention before acidosis and long-term damage. Data regarding the efficacy of antenatal testing are limited by a lack of randomized controlled trials. The majority of available data hinge on observational studies with the inherent potential for bias. There is also a paucity of data comparing the various testing modalities and addressing the issue of the optimal timing of initiation of testing. As well, data are limited regarding the various conditions most likely to benefit from testing and the frequency with which testing should be performed. The issue of cost relating to antenatal testing is an important one. Central to the issue of estimating cost is an understanding of the efficacy of the test. Given our current limitations, we have significant difficulty accurately estimating the cost of antenatal testing; however, rough estimates of cost are made.

3. Fretts RC, Duru UA
New indications for antepartum testing: making the case for antepartum surveillance or timed delivery for women of advanced maternal age
Semin Perinatol. 2008 Aug;32(4):312-7

Harvard Vanguard Medical Associates, Brigham and Women's Hospital and Newton Wellesley Hospital, Wellesley, MA.

Maternal age is an independent risk factor for stillbirth; a moderate number of these occur in normally formed babies near term. For a woman 40 years of age or older giving birth, her risk of having a chromosomal anomaly is 1/66. What is not appreciated is that even without medical risk factors, her risk of having a stillbirth after 37 weeks of gestation is 1/116. This article reviews the risks and benefits of the strategy of antepartum testing and timed delivery and discusses the limitations of the available data in this field.

4. Frøen JF, Tveit JV, Saastad E, Børdahl PE, Stray-Pedersen B, Heazell AE, Flenady V, Fretts RC
Management of decreased fetal movements
Semin Perinatol. 2008 Aug;32(4):307-11

Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.; Brigham and Women's Hospital, Div. of Maternal-Fetal Medicine, Harvard Medical School, Boston, MA.

Maternal perception of decreased fetal activity is a common complaint, and one of the most frequent causes of unplanned visits in pregnancy. No proposed definitions of decreased fetal movements have ever been proven to be superior to a subjective maternal perception in terms of identifying a population at risk. Women presenting with decreased fetal movements do have higher risk of stillbirth, fetal growth restriction, fetal distress, preterm birth, and other associated outcomes. Yet, little research has been conducted to identify optimal management, and no randomized controlled trials have been performed. The strong associations with adverse outcome suggest that adequate management should include the exclusion of both acute and chronic conditions associated with decreased fetal movements. We propose guidelines for management of decreased fetal movements that include both a nonstress test and an ultrasound scan and report findings in 3014 cases of decreased fetal movements.

5. Weeks JW
Antepartum testing for women with previous stillbirth
Semin Perinatol. 2008 Aug;32(4):301-6

University of Louisville School of Medicine, Louisville, KY.

Women with past histories of stillbirth have been referred for antepartum surveillance since the inception of electronic fetal monitoring. However, this approach was originally based on mid-twentieth century perinatal studies that noted an increase in adverse outcomes in pregnancies subsequent to stillbirth. When these landmark studies were done, Rh immune globulin, ultrasonography, and other important medical advances had not yet occurred. This article discusses whether women who have suffered a past stillbirth remain at increased risk for perinatal mortality and morbidity in future pregnancies and whether antepartum fetal surveillance can reduce the risk of recurrent stillbirth.

6. Divon MY, Feldman-Leidner N
Postdates and antenatal testing
Semin Perinatol. 2008 Aug;32(4):295-300

Department of Obstetrics and Gynecology, Lenox Hill Hospital, New York, NY.

The standard definition of a prolonged pregnancy is 42 completed weeks of gestation. The incidence of prolonged pregnancy varies depending on the criteria used to define gestational age at birth. It is estimated that 4 to 19% of pregnancies reach or exceed 42 weeks gestation. Several studies that have used very large computerized databases of well-dated pregnancies provided insights into the incidence and nature of adverse perinatal outcome such as an increased fetal and neonatal mortality as well as increased fetal and maternal morbidity in prolonged pregnancy. Fetal surveillance may be used in an attempt to observe the prolonged pregnancy while awaiting the onset of spontaneous labor. This article reviews the different methodologies and protocols for fetal surveillance in prolonged pregnancies. On the one hand, false-positive tests commonly lead to unnecessary interventions that are potentially hazardous to the gravida. On the other hand, to date, no program of fetal testing has been shown to completely eliminate the risk of stillbirth.

7. Freeman RK
Antepartum testing in patients with hypertensive disorders in pregnancy
Semin Perinatol. 2008 Aug;32(4):271-3

University of California at Irvine, Long Beach Memorial Medical Center, and Miller Children's Hospital, Long Beach, CA.

Antepartum fetal testing in pregnant patients with hypertensive disorders may be beneficial in preventing stillbirth and hypoxic sequelae in the fetus. The highest risk patients in this category are those with intrauterine growth restriction, superimposed preeclampsia, associated medical complications such as diabetes, systemic lupus erythematosis, chronic renal disease, or history of a prior stillbirth. The current recommended method of primary testing is a twice weekly modified biophysical profile with either a full BPP or a contraction stress test for backup evaluation of those patients with lack of reactivity or decreased amniotic fluid volume on a modified biophysical profile. Even uncomplicated patients with chronic hypertension or pregnancy-induced hypertension carry an increased risk of perinatal mortality and for these patients testing should begin at 33 to 34 weeks gestation. Patients with complications of intrauterine growth restriction, preeclampsia, diabetes, systemic lupus erythematosis, or chronic renal disease should have antepartum testing begin when intervention for fetal indications is judged to be appropriate, usually beginning at about 26 weeks gestation. Doppler velocimetry may be helpful in further evaluation of those patients in the early third trimester with abnormal primary testing.

8. Nageotte MP
Semin Perinatol. 2008 Aug;32(4):269-70
Antenatal testing: diabetes mellitus

Department of Obstetrics and Gynecology, University of California, Irvine, CA.

Diabetes complicating pregnancy is a problem for which fetal surveillance testing is considered to be the standard of care. In response to the unacceptable frequency of stillbirth in such pregnancies, fetal testing historically was first introduced to manage women whose pregnancies were complicated by diabetes. Essentially all forms of antepartum testing have been used to assess fetal well-being during the third trimester of pregnant diabetics. The contraction stress test became established as the "gold standard," yet other testing protocols have been used successfully. It is clear that control of diabetes throughout gestation, not just in the later stages, is more important for optimal outcome than is a specific form of fetal testing. Biweekly testing has become the standard and with well-controlled diabetics, allowing the gestation to continue until the onset of spontaneous labor, even when the gestation exceeds 40 weeks, is appropriate management with normal testing.

9. Salihu HM
Epidemiology of stillbirth and fetal central nervous system injury
Semin Perinatol. 2008 Aug;32(4):232-8

Department of Obstetrics and Gynecology, and Department of Epidemiology and Biostatistics, University of South Florida, Tampa, FL.

The epidemiology of stillbirth and fetal central nervous system (CNS) injury is described with some emphasis on maternal and feto-placental risk factors. To maximize utility of the discussion and because it also represents the classical manifestation of fetal CNS injury, we have selected cerebral palsy (CP) to illustrate the epidemiologic aspects of injury to the fetal CNS in general. While trends in stillbirth rates have modestly decreased over time, those of CP seem to be increasing. Interestingly, both stillbirth and CP share traditional as well as emerging risk factors lending credence to the hypothesis that fetuses that would previously have been stillborn are increasingly surviving albeit with some form of morbidity. The existence of shared risk factors also suggests that in some cases of stillbirth fetal CNS injury precedes the in utero fetal demise. Pregnant women bearing these risk indicators represent potential candidates for appropriate and tailored protocols for antenatal fetal testing.

10. Fetters T, Vonthanak S, Picardo C, Rathavy T
Abortion-related complications in Cambodia.
BJOG. 2008 Jul;115(8):957-68; discussion 968

Research Evaluation, Ipas, Chapel Hill, NC, USA. fetterst@ipas.org.

INTRODUCTION: Although termination of pregnancy (termination) has been legal in the Kingdom of Cambodia since 1997, a number of barriers to safe termination services persist and many women continue to induce their own terminations or seek unsafe services that result in complications requiring 'post-abortion' care. OBJECTIVE: To describe the complications of miscarriage and failed terminations and document the magnitude of the resulting morbidity in the Cambodian public sector. DESIGN: Cross-sectional descriptive study. SETTING: Public sector hospitals and health centres. SAMPLE: Stratified multistage sampling design included all hospitals (n = 71), 14% of eligible high-level health centres (n = 58) and 22% of eligible low-level health centres (n = 57). METHODS: Data collectors used a standardised questionnaire to record information on diagnosis, reproductive history and treatment from 629 women seeking care for termination or miscarriage-related complications in study facilities over a 3-week period. MAIN OUTCOME MEASURES: Annual estimate of cases, clinical symptoms, severity distribution of morbidity, ratio of complications to live births and incidence of abortion complications for Cambodian public health facilities. RESULTS: In 2005, an estimated 31,579 women with complications of miscarriage or terminations were treated in Cambodian government facilities; 80% of these women sought care at a health centre. Forty percent of all women seeking care for complications either reported or showed strong clinical evidence of prior attempted terminations. Nearly 17% of these women were in the second trimester of pregnancy and 42% of them presented with high severity complications. The annual incidence of termination and miscarriage complications (abortion complications) was 867 per 100,000 women of reproductive age. The projected ratio of complications was 93 per 1000 live births. CONCLUSIONS: To reduce maternal morbidity in Cambodia, women must be encouraged to seek safe termination services or seek postabortion care without delay. Additionally, providers need further training, and facilities greater commitment, to provide safe terminations and care for complications of unsafe terminations and miscarriage.

11. Wiggans GR, Cole JB, Thornton LL
Multiparity evaluation of calving ease and stillbirth with separate genetic effects by parity
J Dairy Sci. 2008 Aug;91(8):3173-8

Animal Improvement Programs Laboratory, Agricultural Research Service, USDA, Beltsville, MD 20705-2350, USA. George.Wiggans@ars.usda.gov.

Evaluations that analyze first and later parities as correlated traits were developed separately for calving ease (CE) from over 15 million calving records of Holsteins, Brown Swiss, and Holstein-Brown Swiss crossbreds and for stillbirth (SB) from 7.4 million of the Holstein CE records. Calving ease was measured on a scale of 1 (no difficulty) to 5 (difficult birth); SB status was designated as live or dead within 48 h. Scores for CE and SB were transformed separately for each trait by parity (first or later) and calf sex (male or female) and converted to a unit standard deviation scale. For variance component estimation, Holstein data were selected for the 2,968 bulls with the most records as sire or maternal grandsire (MGS). Six samples were selected by herd; samples ranged in size from 97,756 to 146,138 records. A multiparity sire-MGS model was used to calculate evaluations separately for CE and for SB with first and later parities as correlated traits. Fixed effects were year-season, calf sex, and sire and MGS birth years; random effects were herd-year interaction, sire, and MGS. For later parities, sex effects were separated by parity. The genetic correlation between first and later parities was 0.79 for sire and 0.81 for MGS for CE, and 0.83 for sire and 0.74 for MGS for SB. For national CE evaluations, which also include Brown Swiss, a fixed effect for breed was added to the model. Correlations between solutions on the underlying scale from the January 2008 USDA CE evaluation with those from the multiparity analysis for CE were 0.89 and 0.91 for first- and later-parity sire effects and 0.71 and 0.88 for first- and later-parity MGS effects; the larger value for later parity reflects that later parities comprised 64% of the data. Corresponding correlations for SB were 0.81 and 0.82 for first- and later-parity sire effects and 0.46 and 0.83 for first- and later-parity MGS effects, respectively. Correlations were higher when only bulls with a multiparity reliability of >65% were included. The multiparity analysis accounted for genetic differences in calving performance between first and later parities. Evaluations should become more stable as the portion of a bull's observations from different parities changes over his lifetime. Accuracy of the net merit index can be improved by adjusting weights to use evaluations for separate parities optimally.

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