NSIDRC Journal Article Alert — July 24, 2009

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

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.

Sudden Infant Death

1. Eron NB, Dygert KM, Squillace C, Webster NJ, Andrianos A, Crockett EG, Consenstein L

The Physician's Role in Reducing SIDS

Health Promot Pract. 2009 Jul 20 [Epub ahead of print]

Despite a sustained public education campaign aimed at reducing the risks of sudden infant death syndrome (SIDS), it remains one of the leading causes of infant death. This study aims to determine physicians' knowledge of SIDS and whether physicians are discussing how to reduce the risk of SIDS with parents. A cross-sectional survey is sent to 912 pediatricians, family practitioners, and obstetrician-gynecologists in Central New York State. The response rate is 23.5%. Almost all respondents (99.5%) agree that certain measures can be taken to reduce the risks of SIDS, but 30.3% incorrectly state that the safest sleep position is something other than on the back. Although 97.6% agree that it is important to discuss SIDS with parents, 30% admit to not discussing this information. To continue to decrease the SIDS rate, physicians must take responsibility for educating themselves and parents about safe sleep practices and other SIDS risk factors.

2. Parekh B

The Mechanism of Dead-in-bed Syndrome and other Sudden Unexplained Nocturnal Deaths

Curr Diabetes Rev. 2009 Aug 1. [Epub ahead of print]

Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK. bp258@cam.ac.uk.

The mechanism of dead-in-bed syndrome (DBS), a rare but devastating condition that mainly affects young type 1 diabetes patients, remains mysterious. A new theory is proposed to explain this syndrome. This theory suggests that repeated episodes of hypoglycaemia-induced adaptation in orexin-A neurons cause (i) defective awakening and (ii) hypotonia of upper airway muscles during sleep. Consequently, due to the combined effect of these factors, long-term exposure of intermittent hypoxia occurs, leading to a combination of factors - such as depression of ventilation, increase in sympathetic tone, fluctuations in intrathoracic pressure and cardiac arrhythmias - these in conjunction with an underlying cardiovascular pathology (genetically inherited or acquired) cause cardio-respiratory failure and thus sudden death during sleep. This mechanism can be generalized to explain other cases of sudden unexplained nocturnal deaths including sudden infant deaths (SIDs).

Other Infant Death

1. Blabey MH, Gessner BD

Infant bed-sharing practices and associated risk factors among births and infant deaths in Alaska

Public Health Rep. 2009 Jul-Aug;124(4):527-34.

Alaska Division of Public Health, Anchorage, AK 99524-0249, USA. Margaret.Blabey@alaska.gov

OBJECTIVE: The Alaska Division of Public Health has stated that infants may safely share a bed for sleeping if this occurs with a nonsmoking, unimpaired caregiver on a standard, adult, non-water mattress. Because this policy is contrary to recent national recommendations that discourage any bed sharing, we examined 13 years of Alaskan infant deaths that occurred while bed sharing to assess the contribution of known risk factors. METHODS: We examined vital records, medical records, autopsy reports, and first responder reports for 93% of Alaskan infant deaths that occurred between 1992 and 2004. We examined deaths while bed sharing for risk factors including sleeping with a non-caregiver, prone position, maternal tobacco use, impairment of a bed-sharing partner, and an unsafe sleep surface. We used Pregnancy Risk Assessment Monitoring System data to describe bed-sharing practices among all live births in Alaska during 1996-2003. RESULTS: Thirteen percent (n=126) of deaths occurred while bed sharing; 99% of these had at least one associated risk factor, including maternal tobacco use (75%) and sleeping with an impaired person (43%). Frequent bed sharing was reported for 38% of Alaskan infants. Among these, 60% of mothers reported no risk factors; the remaining 40% reported substance use, smoking, high levels of alcohol use, or most often placing their infant prone for sleeping. CONCLUSIONS: Almost all bed-sharing deaths occurred in association with other risk factors despite the finding that most women reporting frequent bed sharing had no risk factors; this suggests that bed sharing alone does not increase the risk of infant death.

Miscarriage/Stillbirth/Prenatal Issues

1. Scarpellini F, Sbracia M

Use of granulocyte colony-stimulating factor for the treatment of unexplained recurrent miscarriage: a randomised controlled trial

Hum Reprod. 2009 Jul 17. [Epub ahead of print]

Hungaria Center for Endocrinology and Reproductive Medicine (CERM), 00198 Rome, Italy.

BACKGROUND Recurrent miscarriage (RM) is defined as the occurrence of three or more clinically detectable pregnancy losses in the first trimester. In most cases of RM, its aetiology remains unexplained. Granulocyte colony-stimulating factor (G-CSF), a cytokine, and its receptor are expressed in placental tissue. To investigate the effectiveness of G-CSF in preventing embryo demise, we administered G-CSF to women with RM. METHODS A randomised controlled trial in women with RM treated with G-CSF or placebo was conducted in one private reproductive medicine clinic. Sixty-eight women with unexplained primary RM, all with at least four consecutive miscarriages and negative for all clinical investigations, were selected. Patients were randomized for s.c. treatment with G-CSF (n = 35) (1 microg/kg/day) starting on the sixth day after ovulation, or with placebo (n = 33). Patients were randomized using a computer-generated randomization number sequence. Pregnancy outcome (delivery of a healthy baby without major or minor malformations) was the primary outcome measure. RESULTS In the group treated with G-CSF, 29 out of 35 (82.8%) women delivered a healthy baby, whereas in the placebo group, this figure was only 16 out of 33 (48.5%) (P = 0.0061, odds ratio = 5.1; 95% confidence interval 1.5-18.4). Significantly higher beta-hCG levels were found in gestation weeks 5-9 in women treated with G-CSF versus placebo (P < 0.001). CONCLUSIONS Our data show that G-CSF may be effective in the treatment of unexplained RM. However, further studies are needed to confirm the effectiveness of this treatment in women with unexplained RM, refractory to conventional treatment. The study was registered with a ICMJE recognized registry, the Clinical Trial.gov Protocol Registry System, with the number NCT00772122.

2. Shokry M, Shahin AY, Fathalla MM, Shaaban OM

Oral misoprostol reduces vaginal bleeding following surgical evacuation for first trimester spontaneous abortion

Int J Gynaecol Obstet. 2009 Jul 17. [Epub ahead of print]

Department of Obstetrics and Gynecology, Women's Health Centre, Assiut University, Assiut, Egypt.

OBJECTIVE: To assess the effectiveness and tolerability of misoprostol to reduce the amount and duration of vaginal bleeding following surgical evacuation for first trimester spontaneous abortion. METHODS: A total of 160 patients who underwent surgical evacuation for first trimester spontaneous abortion between 8 and 12 weeks of pregnancy were randomized into 2 groups to receive either 200 microg of oral misoprostol immediately after evacuation followed every 6 hours for 48 hours or no misoprostol. Pain scores, duration and amount of bleeding, and endometrial thickness were assessed over 10 days. RESULTS: Women who received misoprostol had significantly fewer bleeding days after evacuation (4.11+/-2.69 vs 5.89+/-3.06; P<0.001), fewer patients reported vaginal bleeding lasting 10 days or more (3.8% vs 15.0%; P=0.014), and endometrial thickness 10 days after evacuation was less (6.25+/-2.38 vs 7.23+/-1.94; P=0.05). Pain scores were comparable in both groups (1.54+/-0.65 vs 1.63+/-0.83; P=0.40) after 10 days. CONCLUSION: Oral misoprostol is effective in reducing the prevalence and amount of vaginal bleeding after surgical evacuation for first trimester spontaneous abortion.

3. Einarson A, Choi J, Einarson TR, Koren G

Rates of spontaneous and therapeutic abortions following use of antidepressants in pregnancy: results from a large prospective database

J Obstet Gynaecol Can. 2009 May;31(5):452-6

The Motherisk Program, The Hospital for Sick Children, Toronto ON.

Objective: The use of antidepressants during pregnancy remains a controversial issue, and there is little information on the risk of spontaneous abortions following antidepressant exposure in early pregnancy. We sought to examine whether use of antidepressants increases the rates of spontaneous abortion (SA) and therapeutic abortion (TA) in women exposed in early pregnancy. Methods: In a cohort of women who contacted the Motherisk program during pregnancy, we compared two groups of women, one exposed and the other not exposed to antidepressants during pregnancy, and calculated the associated rates of SA and TA. Results: Among 937 women exposed to antidepressants prior to and during early pregnancy, there were 122 SAs (13.0%) including three ectopic pregnancies, and in the comparison group there were 75 SAs (8.0%) and no ectopic pregnancies. The relative risk was 1.63 (95% CI 1.24-2.14). Three-fold more women reported a TA in the exposed group, 26 (2.4%) compared to 8 (0.7%) in the non-exposed group (RR 3.25; 95% CI 1.48-7.14). A sub-analysis revealed that in both groups, of 338 women with a prior SA, 58 (17.2%) reported having a SA in the current pregnancy, compared with 61/652 (9.4%) with no prior SA (chi square = 12.09, P lt; 0.001). In the antidepressant group, the incidence was 20.7%, and in the non-exposed group, it was 13.3%. Logistic regression confirmed that only antidepressant exposure and prior SA were significantly associated with current SA. Conclusion: Exposure to antidepressants in the first trimester of pregnancy appears to be associated with a small but statistically significant increased risk of SA and decision to terminate a pregnancy. The risk for SA is further elevated with a history of previous SA. However, any underlying depression must be taken into consideration when evaluating these results.

4. Low YS, Adams T, Clement-Jones M

Uterine rupture during the mid-trimester management of intrauterine fetal death

J Obstet Gynaecol. 2009 Jul;29(5):443

Department of Obstetrics and Gynaecology, Liverpool Women Hospital, Liverpool, UK. shannielys@hotmail.co.uk

Prepared by the
National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center
Georgetown University
2115 Wisconsin Avenue, N.W., Suite 601
Washington, DC 20007
(866) 866-7437 toll free
(202) 687-7466 local
(202) 784-9777 fax
info@sidscenter.org
http://www.sidscenter.org


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	Center Resources Bereavement Support Bibliographies Child Care and SIDS Definitions En Español First Responders For Families Infant Mortality Journal Alerts MCH Alert Multimedia Pregnancy Loss Professional Resources Safe Sleep Environment Statistics Training Toolkit Partner SIDS/ID Centers National SIDS & Infant Death Program Support Center / First Candle National SIDS & Infant Death Project IMPACT National Center for Cultural Competence SIDS/ID Project For more information on maternal and child health topics, visit the MCH Library	NSIDRC Journal Article Alert — July 24, 2009 Prepared by the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center at Georgetown University. 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. Sudden Infant Death 1. Eron NB, Dygert KM, Squillace C, Webster NJ, Andrianos A, Crockett EG, Consenstein L The Physician's Role in Reducing SIDS Health Promot Pract. 2009 Jul 20 [Epub ahead of print] Despite a sustained public education campaign aimed at reducing the risks of sudden infant death syndrome (SIDS), it remains one of the leading causes of infant death. This study aims to determine physicians' knowledge of SIDS and whether physicians are discussing how to reduce the risk of SIDS with parents. A cross-sectional survey is sent to 912 pediatricians, family practitioners, and obstetrician-gynecologists in Central New York State. The response rate is 23.5%. Almost all respondents (99.5%) agree that certain measures can be taken to reduce the risks of SIDS, but 30.3% incorrectly state that the safest sleep position is something other than on the back. Although 97.6% agree that it is important to discuss SIDS with parents, 30% admit to not discussing this information. To continue to decrease the SIDS rate, physicians must take responsibility for educating themselves and parents about safe sleep practices and other SIDS risk factors. 2. Parekh B The Mechanism of Dead-in-bed Syndrome and other Sudden Unexplained Nocturnal Deaths Curr Diabetes Rev. 2009 Aug 1. [Epub ahead of print] Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK. bp258@cam.ac.uk. The mechanism of dead-in-bed syndrome (DBS), a rare but devastating condition that mainly affects young type 1 diabetes patients, remains mysterious. A new theory is proposed to explain this syndrome. This theory suggests that repeated episodes of hypoglycaemia-induced adaptation in orexin-A neurons cause (i) defective awakening and (ii) hypotonia of upper airway muscles during sleep. Consequently, due to the combined effect of these factors, long-term exposure of intermittent hypoxia occurs, leading to a combination of factors - such as depression of ventilation, increase in sympathetic tone, fluctuations in intrathoracic pressure and cardiac arrhythmias - these in conjunction with an underlying cardiovascular pathology (genetically inherited or acquired) cause cardio-respiratory failure and thus sudden death during sleep. This mechanism can be generalized to explain other cases of sudden unexplained nocturnal deaths including sudden infant deaths (SIDs). Other Infant Death 1. Blabey MH, Gessner BD Infant bed-sharing practices and associated risk factors among births and infant deaths in Alaska Public Health Rep. 2009 Jul-Aug;124(4):527-34. Alaska Division of Public Health, Anchorage, AK 99524-0249, USA. Margaret.Blabey@alaska.gov OBJECTIVE: The Alaska Division of Public Health has stated that infants may safely share a bed for sleeping if this occurs with a nonsmoking, unimpaired caregiver on a standard, adult, non-water mattress. Because this policy is contrary to recent national recommendations that discourage any bed sharing, we examined 13 years of Alaskan infant deaths that occurred while bed sharing to assess the contribution of known risk factors. METHODS: We examined vital records, medical records, autopsy reports, and first responder reports for 93% of Alaskan infant deaths that occurred between 1992 and 2004. We examined deaths while bed sharing for risk factors including sleeping with a non-caregiver, prone position, maternal tobacco use, impairment of a bed-sharing partner, and an unsafe sleep surface. We used Pregnancy Risk Assessment Monitoring System data to describe bed-sharing practices among all live births in Alaska during 1996-2003. RESULTS: Thirteen percent (n=126) of deaths occurred while bed sharing; 99% of these had at least one associated risk factor, including maternal tobacco use (75%) and sleeping with an impaired person (43%). Frequent bed sharing was reported for 38% of Alaskan infants. Among these, 60% of mothers reported no risk factors; the remaining 40% reported substance use, smoking, high levels of alcohol use, or most often placing their infant prone for sleeping. CONCLUSIONS: Almost all bed-sharing deaths occurred in association with other risk factors despite the finding that most women reporting frequent bed sharing had no risk factors; this suggests that bed sharing alone does not increase the risk of infant death. Miscarriage/Stillbirth/Prenatal Issues 1. Scarpellini F, Sbracia M Use of granulocyte colony-stimulating factor for the treatment of unexplained recurrent miscarriage: a randomised controlled trial Hum Reprod. 2009 Jul 17. [Epub ahead of print] Hungaria Center for Endocrinology and Reproductive Medicine (CERM), 00198 Rome, Italy. BACKGROUND Recurrent miscarriage (RM) is defined as the occurrence of three or more clinically detectable pregnancy losses in the first trimester. In most cases of RM, its aetiology remains unexplained. Granulocyte colony-stimulating factor (G-CSF), a cytokine, and its receptor are expressed in placental tissue. To investigate the effectiveness of G-CSF in preventing embryo demise, we administered G-CSF to women with RM. METHODS A randomised controlled trial in women with RM treated with G-CSF or placebo was conducted in one private reproductive medicine clinic. Sixty-eight women with unexplained primary RM, all with at least four consecutive miscarriages and negative for all clinical investigations, were selected. Patients were randomized for s.c. treatment with G-CSF (n = 35) (1 microg/kg/day) starting on the sixth day after ovulation, or with placebo (n = 33). Patients were randomized using a computer-generated randomization number sequence. Pregnancy outcome (delivery of a healthy baby without major or minor malformations) was the primary outcome measure. RESULTS In the group treated with G-CSF, 29 out of 35 (82.8%) women delivered a healthy baby, whereas in the placebo group, this figure was only 16 out of 33 (48.5%) (P = 0.0061, odds ratio = 5.1; 95% confidence interval 1.5-18.4). Significantly higher beta-hCG levels were found in gestation weeks 5-9 in women treated with G-CSF versus placebo (P < 0.001). CONCLUSIONS Our data show that G-CSF may be effective in the treatment of unexplained RM. However, further studies are needed to confirm the effectiveness of this treatment in women with unexplained RM, refractory to conventional treatment. The study was registered with a ICMJE recognized registry, the Clinical Trial.gov Protocol Registry System, with the number NCT00772122. 2. Shokry M, Shahin AY, Fathalla MM, Shaaban OM Oral misoprostol reduces vaginal bleeding following surgical evacuation for first trimester spontaneous abortion Int J Gynaecol Obstet. 2009 Jul 17. [Epub ahead of print] Department of Obstetrics and Gynecology, Women's Health Centre, Assiut University, Assiut, Egypt. OBJECTIVE: To assess the effectiveness and tolerability of misoprostol to reduce the amount and duration of vaginal bleeding following surgical evacuation for first trimester spontaneous abortion. METHODS: A total of 160 patients who underwent surgical evacuation for first trimester spontaneous abortion between 8 and 12 weeks of pregnancy were randomized into 2 groups to receive either 200 microg of oral misoprostol immediately after evacuation followed every 6 hours for 48 hours or no misoprostol. Pain scores, duration and amount of bleeding, and endometrial thickness were assessed over 10 days. RESULTS: Women who received misoprostol had significantly fewer bleeding days after evacuation (4.11+/-2.69 vs 5.89+/-3.06; P<0.001), fewer patients reported vaginal bleeding lasting 10 days or more (3.8% vs 15.0%; P=0.014), and endometrial thickness 10 days after evacuation was less (6.25+/-2.38 vs 7.23+/-1.94; P=0.05). Pain scores were comparable in both groups (1.54+/-0.65 vs 1.63+/-0.83; P=0.40) after 10 days. CONCLUSION: Oral misoprostol is effective in reducing the prevalence and amount of vaginal bleeding after surgical evacuation for first trimester spontaneous abortion. 3. Einarson A, Choi J, Einarson TR, Koren G Rates of spontaneous and therapeutic abortions following use of antidepressants in pregnancy: results from a large prospective database J Obstet Gynaecol Can. 2009 May;31(5):452-6 The Motherisk Program, The Hospital for Sick Children, Toronto ON. Objective: The use of antidepressants during pregnancy remains a controversial issue, and there is little information on the risk of spontaneous abortions following antidepressant exposure in early pregnancy. We sought to examine whether use of antidepressants increases the rates of spontaneous abortion (SA) and therapeutic abortion (TA) in women exposed in early pregnancy. Methods: In a cohort of women who contacted the Motherisk program during pregnancy, we compared two groups of women, one exposed and the other not exposed to antidepressants during pregnancy, and calculated the associated rates of SA and TA. Results: Among 937 women exposed to antidepressants prior to and during early pregnancy, there were 122 SAs (13.0%) including three ectopic pregnancies, and in the comparison group there were 75 SAs (8.0%) and no ectopic pregnancies. The relative risk was 1.63 (95% CI 1.24-2.14). Three-fold more women reported a TA in the exposed group, 26 (2.4%) compared to 8 (0.7%) in the non-exposed group (RR 3.25; 95% CI 1.48-7.14). A sub-analysis revealed that in both groups, of 338 women with a prior SA, 58 (17.2%) reported having a SA in the current pregnancy, compared with 61/652 (9.4%) with no prior SA (chi square = 12.09, P lt; 0.001). In the antidepressant group, the incidence was 20.7%, and in the non-exposed group, it was 13.3%. Logistic regression confirmed that only antidepressant exposure and prior SA were significantly associated with current SA. Conclusion: Exposure to antidepressants in the first trimester of pregnancy appears to be associated with a small but statistically significant increased risk of SA and decision to terminate a pregnancy. The risk for SA is further elevated with a history of previous SA. However, any underlying depression must be taken into consideration when evaluating these results. 4. Low YS, Adams T, Clement-Jones M Uterine rupture during the mid-trimester management of intrauterine fetal death J Obstet Gynaecol. 2009 Jul;29(5):443 Department of Obstetrics and Gynaecology, Liverpool Women Hospital, Liverpool, UK. shannielys@hotmail.co.uk Prepared by the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center Georgetown University 2115 Wisconsin Avenue, N.W., Suite 601 Washington, DC 20007 (866) 866-7437 toll free (202) 687-7466 local (202) 784-9777 fax info@sidscenter.org http://www.sidscenter.org
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NSIDRC Journal Article Alert — July 24, 2009

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