NSIDRC Journal Article Alert — October 3, 2008

Prepared by the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss 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 Resource Center 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.

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Sudden Infant Death

1. Randall B, Wilson AL; Regional Infant and Child Mortality Review Committee.Collaborators (11) The 2007 annual report of the Regional Infant and Child Mortality Review Committee S D Med. 2008 Aug;61(8):287-9, 291, 293

Randall B, Wilson A, Bailey B, Elliot M, Byrne-Olson C, Luther J, Haight M, Burger V, Sideras J, Cressman C, Blake J.

The mission of the Regional Infant and Child Mortality Review Committee (RICMRC) is to review infant and child deaths so that information can be transformed into action to protect young lives. The 2007 review area includes South Dakota's Minnehaha, Turner, Lincoln, Moody, Lake, McCook, Union, Hansen, Miner and Brookings counties. Although there were no deaths in 2007 that met the criteria of the Sudden Infant Death Syndrome (SIDS) in our region, there were three infant deaths associated with unsafe sleeping environments (including adult co-sleeping) that either caused or potentially may have caused these infants' deaths. We need to continue to promote the "Back to Sleep" campaign message of not only placing infants to sleep on their backs, but also making sure infants are put down to sleep on safe, firm sleeping surfaces and that they are appropriately dressed for the ambient temperature. Parents need to be aware of the potential hazards of co-sleeping with their infants. Compared to nine such deaths in 2006, only four deaths in 2007 involved motor-vehicle crashes, none of which were alcohol related. Two drowning deaths illustrated the rapidity in which even momentary caregiver distractions can lead to deaths in children in and around water. Since 1997 the Regional Infant and Child Mortality Review Committee (RICMRC) has sought to achieve its mission to "review infant and child deaths so that information can be transformed into action to protect young lives." For 2007, the committee reviewed 25 deaths from Minnehaha, Turner, Lincoln, Moody, Lake, McCook, Union, Hansen, Miner and Brookings counties that met the following criteria: Children under the age of 18 dying subsequent to hospital discharge following delivery. Children who either died in these counties from causes sustained in them, or residents who died elsewhere from causes sustained in the 10-county region. The report that follows reviews the committee's activities for 2007. No deaths meeting the criteria for Sudden Infant Death Syndrome (SIDS) occurred in the review region. The committee has observed a stable decline in the number of deaths due to the SIDS as compared to the eight SIDS or possible SIDS deaths occurring in 1999. Unfortunately, however, there were three infant deaths in SIDS-like settings where asphyxia could not be excluded. Although the committee strives to be consistent year to year in its investigation protocols, we have noticed that the number of deaths classified as "undetermined" has been increasing over the last few years (starting in 1997: 1, 2, 1, 0, 2, 1, 2, 0, 5, 4, 5). Although it is possible that deaths certified as SIDS in earlier years may now be classified as undetermined due to asphyxial risks, we may also be seeing an increase in infants sleeping in unsafe environments. Our data may be mirroring a national trend amongst death investigators to increasingly recognize asphyxial risks in infant death scenes. Infants co-sleeping with adults (two deaths in 2007) may represent a risk factor not as frequently seen as in prior years. We will watch this trend closely in the future. The Committee strenuously advocates that the Back to Sleep message include placing infants on their back to sleep, avoiding soft bedding for infants, making parents aware of the potential hazards of co-sleeping with young infants, and eliminating both pre- and post-delivery fetal/infant cigarette smoke exposure. a decrease in youth motor-vehicle crash deaths to four versus the nine seen in 2006.2 Three of those dying in motor-vehicle crashes in 2007 were not wearing seat belts. The committee continues to feel that some of these deaths could have been prevented had these children been wearing a seat belt. Compared to four alcohol-related motor-vehicle crash fatalities in 2006, no deaths in 2007 were alcohol related. The committee, however, is painfully aware that even one crash involving multiple occupants can rapidly skew the apparent improvements in 2007 in the wrong direction. In 2007, two youths, both with disabilities, drown. One drown in a bath tub and the other in an outdoor pool. It is unfortunate that these deaths bring home the message that even the smallest, momentary lapses in supervision of these children can have fatal consequences. Fortunately, the child and infant homicide rate in our region is very low. Unfortunately, however, one infant did die as a result of being assaulted and shaken by one of its parents. There remains a need for the community at large, and the medical community specifically, to address issues of parental anger management, particularly when caregiver frustration is directed at children.

2. Chen A, Feresu SA, Fernandez C, Rogan WJ Maternal Obesity and the Risk of Infant Death in the United States Epidemiology. 2008 Sep 20. [Epub ahead of print]

From the aDepartment of Preventive Medicine and Public Health, Creighton University School of Medicine,bDepartment of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE. cDepartment of Pediatrics, Creighton University School of Medicine, Omaha, NE; and dEpidemiology Branch, Department of Health and Human Services, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC.

BACKGROUND: Maternal obesity (defined as prepregnancy body mass index [BMI] >/=30 kg/m ) is associated with increased risk of neonatal death. Its association with infant death, postneonatal death, and cause-specific infant death is less well-characterized. METHODS:: We studied the association between maternal obesity and the risk of infant death by using 1988 US National Maternal and Infant Health Survey data. A case-control analysis of 4265 infant deaths and 7293 controls was conducted using SUDAAN software. Self-reported prepregnancy BMI and weight gain were used in the primary analysis, whereas weight variables in medical records were used in a subset of 4308 women. RESULTS:: Compared with normal weight women (prepregnancy BMI =18.5-24.9 kg/m ) who gained 0.30 to 0.44 kg/wk during pregnancy, obese women had increased risk of neonatal death and overall infant death. For obese women who had weight gain during pregnancy of <0.15, 0.15 to 0.29, 0.30 to 0.44, and >/=0.45 kg/wk, the adjusted odds ratios of infant death were 1.75 (95% confidence interval = 1.28-2.39), 1.42 (1.07-1.89), 1.59 (1.00-2.51), and 2.87 (1.98-4.16), respectively. Nonobese women with very low weight gain during pregnancy also had a higher risk of infant death. The subset with weight information from medical records had similar results for recorded prepregnancy BMI and weight gain. Maternal obesity was associated with neonatal death from pregnancy complications or disorders relating to short gestation and unspecified low birth weight. CONCLUSIONS:: Maternal obesity is associated with increased overall risk of infant death, mainly neonatal death.

3. Oken E Excess Gestational Weight Gain Amplifies Risks Among Obese Mothers Epidemiology. 2008 Sep 20. [Epub ahead of print]

From the Harvard University, Boston, Massachusetts.

In this issue ofEpidemiology, Chen et al report that obese mothers who gained the most weight during pregnancy had elevated risk for infant mortality. Other outcomes related to excess maternal weight or weight gain not only cause complications around the time of birth but also confer elevated chronic disease risk for both mother and child. There is good reason to believe that constraining gestational weight gain within an optimal range will minimize adverse outcomes. Revised gestational weight gain guidelines are needed, especially for obese women.

Miscarriage/Stillbirth/Prenatal Issues

1. Brown S Miscarriage and its associations Semin Reprod Med. 2008 Sep;26(5):391-400. Epub 2008 Sep 29

Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont 05401, USA. sabrown@uvm.edu.

Despite many years of study, abnormal chromosome number remains the most common and well-documented cause of miscarriage. Nonchromosomal factors that have been associated with miscarriage are many and include endocrine abnormalities, anatomic abnormalities, inherited and acquired thrombophilia, environmental exposures, immunologic factors, and others. This article attempts to provide a brief overview and critique of the frequently reported factors. In addition, we call attention to the fact that, to be most helpful, modern studies of miscarriage need to provide details about the sonographically determined gestational age and fetal anatomic development prior to or at the time of pregnancy loss. Such information will be critical in helping to sort out which miscarriage-associated factors are more relevant at which stage of fetal development.

2. Wiser A, Hershko-Klement A, Fishman A, Nachasch N, Fejgin M Gestational diabetes insipidus and intrauterine fetal death of monochorionic twins J Perinatol. 2008 Oct;28(10):712-4

Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Sava,, Israel. wiserniv@netvision.net.il

Gestational diabetes insipidus (GDI) is a rare disorder. The onset is usually in the third trimester of pregnancy. We present a 24-year-old primigravida in her 35th week of a monochorionic-diamniotic twin pregnancy. The patient presented with intrauterine death of both twins accompanied by HELLP syndrome, hypernatremia and hemoconcentration. Urine osmolality below that of the plasma suggested GDI. 1-deamino-8D-arginine vasopressin (dDAVP) treatment was started with a quick response. GDI is probably the result of excessive activity of placental vasopressinase. In cases of liver dysfunction, the clearance rate of vasopressinase decreases, explaining the association of GDI with acute fatty liver and HELLP syndrome. Alert to this diagnosis, its evaluation and treatment is important.

3. Satpathy HK, Fleming A, Frey D, Barsoom M, Satpathy C, Khandalavala J Maternal obesity and pregnancy Postgrad Med. 2008 Sep 15;120(3):E01-9

Department of OB-GYN, Creighton University Medical Center, Omaha, NE, 68105, USA.

Obesity is a global health problem that is increasing in prevalence. The World Health Organization characterizes obesity as a pandemic issue, with a higher prevalence in females than males. Thus, many pregnant patients are seen with high body mass index (BMI). Obesity during pregnancy is considered a high-risk state because it is associated with many complications. Compared with normal-weight patients, obese patients have a higher prevalence of infertility. Once they conceive, they have higher rate of early miscarriage and congenital anomalies, including neural tube defects. Besides the coexistence of preexisting diabetes mellitus and chronic hypertension, obese women are more likely to have pregnancy-induced hypertension, gestational diabetes, thromboembolism, macrosomia, and spontaneous intrauterine demises in the latter half of pregnancy. Obese women also require instrument or Cesarean section delivery more often than average-weight women. Following Cesarean section delivery, obese women have a higher incidence of wound infection and disruption. Irrespective of the delivery mode, children born to obese mothers have a higher incidence of macrosomia and associated shoulder dystocia, which can be highly unpredictable. In addition to being large at birth, children born to obese mothers are also more susceptible to obesity in adolescence and adulthood. Prevention is the best way to prevent this problem. As pregnancy is the worst time to lose weight, women with a high BMI should be encouraged to lose weight prior to conceiving. During preconception counseling, they should be educated about the complications associated with high a BMI. Obese women should also be screened for hypertension and diabetes mellitus. In early pregnancy, besides being watchful about the higher association of miscarriage, obese women should be screened with ultrasound for congenital anomalies around 18 to 22 weeks. The ultrasound should be repeated close to term to check on the estimated fetal weight to rule out macrosomia. Obese pregnant women are screened for gestational diabetes around 24 to 28 weeks. During the second half of pregnancy, one needs to closely watch for signs and symptoms of pregnancy-induced hypertension. Once in labor, an early anesthesia consultation is highly recommended irrespective of delivery mode. When Cesarean section is performed, many obstetricians prefer an incision above the pannus to avoid skin infection. However, the incision should be decided upon the discretion of the surgeon. Peripartum, special attention is given to avoid thromboembolism by using compression stockings and early ambulation.

4. Vinceti M, Malagoli C, Teggi S, Fabbi S, Goldoni C, De Girolamo G, Ferrari P, Astolfi G, Rivieri F, Bergomi M Adverse pregnancy outcomes in a population exposed to the emissions of a municipal waste incinerator Sci Total Environ. 2008 Sep 26. [Epub ahead of print]

CREAGEN-Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Public Health Sciences, University of Modena and Reggio Emilia, Modena, Italy.

Some contaminants emitted by municipal waste incinerators are believed to adversely affect reproductive health in the exposed populations; yet only limited and conflicting epidemiologic evidence on this issue has been provided so far. In this study we analyzed rates of spontaneous abortion and prevalence at birth of congenital anomalies in women residing or working near the municipal solid waste incinerator of Modena, northern Italy, during the 2003-2006 period and who experienced higher levels of exposure to polychlorinated dibenzo-p-dioxins and dibenzofurans, compared to the remaining municipal population. In women residing in two areas close to the incinerator plant with increasing exposure to dioxins, we did not detect an excess risk of miscarriage (relative risk [RR] 1.00, 95% confidence interval [CI] 0.65-1.48) and of birth defects (RR 0.64, 95% CI 0.20-1.55), nor did any indication of dose-response relation emerge. Among female workers employed in the factories located in the exposed areas, we did not observe a higher risk of spontaneous abortion (RR 1.04, 95% CI 0.38-2.30); however, an increase in prevalence of birth defects was noted (RR 2.26), although this risk estimate was statistically very unstable (95% CI 0.57-6.14). Overall, the study results provide little evidence of an excess risk of adverse pregnancy outcomes in women exposed to emissions from a modern municipal solid waste incinerator.

5. Onakewhor JU, Ohiosimuan O, Onyiriuka AN Salvaging twin 2 after abortion of twin 1: a case report Niger J Clin Pract. 2008 Jun;11(2):155-7

Department of Obstetrics and Gynecology, University ofBenin Teaching Hospital, Benin City, Nigeria. jonakewhor@yahoo.com.

We present intentional delayed delivery of twin 2 after a spontaneous membrane rupture and abortion oftwin1 in a dichorionic twin pregnancy at 14 weeks. As signs of infection were missing, we adopted a conservative (not expectant) management. The pregnancy was prolonged to 35 weeks' gestation. In the absence of additional risk factors, the role of conservative management of multiple pregnancies after loss of one fetus in prolonging the pregnancy to fetal viability in resource-poor setting is highlighted. The gained gestational age of 20 weeks and 4 days (144 days in all), for the remaining fetus and the healthy mother and child pair after delivery at 35 weeks are discussed. The perinatal, economic and psychological implications are highlighted. The importance of good clinical assessment in the diagnosis of cervical incompetence and using ultrasound scan as a complimentary instrument is emphasized.

6. Zou G, Zhang J, Li XW, He L, He G, Duan T Quantitative fluorescent polymerase chain reaction to detect chromosomal anomalies in spontaneous abortion Int J Gynaecol Obstet. 2008 Sep 22. [Epub ahead of print]

Shanghai First Maternity and Infant Hospital of Tongji University, Shanghai, China.

OBJECTIVES: To evaluate the value of short tandem repeats (microsatellites) in the study of numerical chromosomal anomalies in spontaneous abortion. METHOD: Multiplex quantitative fluorescent polymerase chain reaction (QF-PCR) was carried out on 61 spontaneous abortion samples and 48 controls using microsatellite markers from 8 chromosomes where aneuploids are commonly found. RESULTS: Of the 61 samples, 65.6% were successfully karyotyped, and the call rate of the QF-PCR was 98.3%. The correspondence between PCR and karyotyping was 95%. The success rate of karyotyping in the inevitable abortion group was 79.6%, higher than for the missed abortion group (8.3%), P<0.001. The call rate of QF-PCR showed no difference between these 2 groups (100% vs 91.7%, P=0.197). CONCLUSION: Microsatellite-based QF-PCR is a helpful and reliable tool to diagnose numerical chromosomal anomalies in spontaneous abortion. It also provides a diagnosis for necrotic tissue.

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