NSIDRC Journal Article Alert — January 18, 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.
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Miscarriage/Stillbirth/Prenatal Issues
1: Huang L, Sauve R, Birkett N, Fergusson D, van Walraven C.
Maternal age and risk of stillbirth: a systematic review.
CMAJ. 2008 Jan 15;178(2):165-72.
Health Surveillance and Epidemiology Division, Centre for
Health Promotion, Public Health Agency of Canada, Ottawa, Ont.
BACKGROUND: The number of women who delay childbirth to their
late 30s and beyond has increased significantly over the past
several decades. Studies regarding the relation between older
maternal age and the risk of stillbirth have yielded inconsistent
conclusions. In this systematic review we explored whether
older maternal age is associated with an increased risk of
stillbirth. METHODS: We searched MEDLINE, EMBASE and the Cochrane
Database of Systematic Reviews for all relevant articles (original
studies and systematic reviews) published up to Dec. 31, 2006.
We included all cohort and case-control studies that measured
the association between maternal age and risk of stillbirth.
Two reviewers independently abstracted data from all included
studies using a standardized data abstraction form. Methodologic
and statistical heterogeneities were reviewed and tested. RESULTS:
We identified 913 unique citations, of which 31 retrospective
cohort and 6 case-control studies met our inclusion criteria.
In 24 (77%) of the 31 cohort studies and all 6 of the case-control
studies, we found that greater maternal age was significantly
associated with an increased risk of stillbirth; relative risks
varied from 1.20 to 4.53 for older versus younger women. In
the 14 studies that presented adjusted relative risk, we found
no extensive change in the direction or magnitude of the relative
risk after adjustment. We did not calculate a pooled relative
risk because of the extreme methodologic heterogeneity among
the individual studies. INTERPRETATION: Women with advanced
maternal age have an increased risk of stillbirth. However,
the magnitude and mechanisms of the increased risk are not
clear, and prospective studies are warranted.
2: Baud D, Regan L, Greub G.
Emerging role of Chlamydia and Chlamydia-like organisms in
adverse pregnancy outcomes.
Curr Opin Infect Dis. 2008 Feb;21(1):70-76.
aCenter for Research on Intracellular Bacteria (CRIB), Institute
of Microbiology, University Hospital Center and University
of Lausanne, Lausanne, Switzerland bDepartment of Obstetrics
and Gynecology, Imperial College London, St Mary’s Hospital,
London, UK.
PURPOSE OF THE REVIEW: This review considers the roles of
Chlamydia spp. and newly identified Chlamydia-like organisms
in miscarriage, stillbirths and preterm labour in both animals
and humans. RECENT FINDINGS: The cause of miscarriage, stillbirth
and preterm labour often remains unexplained. Intracellular
bacteria that grow either poorly or not at all on media used
routinely to detect human pathogens could be the aetiological
agents of these obstetrical conditions. There is growing evidence
that Chlamydia trachomatis, Chlamydophila abortus, Chlamydophila
psittaci and Chlamydophila pneumoniae infections may result
in adverse pregnancy outcomes in humans and/or animals. Waddlia,
a Chlamydia-like organism first isolated from an aborted bovine,
has emerged as an agent of abortion in cattle. Recently, Waddlia
was also implicated in human foetal death. Moreover, Parachlamydia
acanthamoebae is also abortigenic in ruminants. Whether additional
novel Chlamydia-like organisms, such as Protochlamydia amoebophila,
Neochlamydia hartmanellae, Criblamydia sequanensis, Rhabdochlamydia
crassificans and Simkania negevensis, are involved in foetal
loss or premature delivery remains to be determined. SUMMARY:
This review provides an update on the consequences of chlamydial
infection during pregnancy and summarizes current evidence
suggesting that some Chlamydia-related organisms are probably
emerging obstetrical pathogens.
3: Bowen ME, Ray WA, Arbogast PG, Ding H, Cooper WO.
Increasing exposure to angiotensin-converting enzyme inhibitors
in pregnancy.
Am J Obstet Gynecol. 2008 Jan 11 [Epub ahead of print]
Department of Pediatrics, Vanderbilt University School of
Medicine, Nashville, TN.
OBJECTIVE: The objective of the study was to identify angiotensin-converting
enzyme (ACE) inhibitor prescription-filling trends in pregnant
women. STUDY DESIGN: This was a retrospective cohort study
in women continuously enrolled in Tennessee Medicaid during
pregnancy who delivered a live infant or had a fetal death
between 1986-2003 (n = 262,179). RESULTS: ACE inhibitor exposures
increased more than 4-fold: from 11.2 per 10,000 pregnancies
in 1986-1988 to 58.9 per 10,000 pregnancies by 2003 (adjusted
risk ratio [RR], 4.49; 95% confidence interval [CI], 2.78-7.25).
Exposures in the second and third trimesters nearly tripled
(RR, 2.88; 95% CI, 1.45-5.75) and did not decrease following
a US Food and Drug Administration black box warning against
such use in 1992. Exposures were most common among women 35
years of age or older. CONCLUSION: Despite evidence of fetal
complications associated with ACE inhibitor use during pregnancy,
the number of pregnant women with pregnancy-related ACE inhibitor
exposures increased steadily between 1986-2003. Better methods
are needed to reduce fetal exposure to potentially teratogenic
prescribed medications.
4: Salihu HM, Sharma PP, Getahun D, Hedayatzadeh M, Peters
S, Kirby RS, Alio AP, Gaafer-Ahmed H.
Prenatal tobacco use and risk of stillbirth: A case-control
and bidirectional case-crossover study.
Nicotine Tob Res. 2008 Jan;10(1):159-66.
UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ.
We sought to estimate the association between prenatal smoking
and stillbirth in a longitudinal cohort using two study designs:
a case-control study and a bidirectional case-crossover study.
The analysis was conducted using the Missouri maternally linked
cohort dataset from 1978 through 1997. In the case-control
study, each mother contributed only one birth to the analysis.
For the bidirectional crossover design, analysis was restricted
to women who gave birth to at least one stillbirth, and the
controls comprised all live births before and after the stillbirth.
The independent association between prenatal smoking and stillbirth
was computed using nonconditional (case-control design) and
conditional (bidirectional case-crossover design) logistic
regression. Prenatal smoking decreased from 29.7% in 1978 to
21.2% by 1997 (p<.001). The absolute risk of stillbirth
was greater among smokers (7.7/1000) than nonsmokers (5.3/1000),
p<.001. In the case-control design, the risk of stillbirth
was 34% greater among smokers than nonsmokers (OR = 1.34, 95%
CI 1.26-1.43). For each 10-unit increase in the number of cigarettes
consumed per day prenatally, the likelihood of stillbirth rose
by about 14% (p<.001). In the bidirectional case-crossover
design, the association between stillbirth and smoking during
pregnancy was confirmed, although the magnitude of the relationship
was smaller (OR = 1.20, 95% CI 1.03-1.39). In conclusion, we
found prenatal smoking to be a risk factor for stillbirth even
after minimizing the influence of known and unknown sources
of confounding as well as changes in temporal trend in prenatal
smoking.
5: Brown CA, Sohani SB, Khan KS, Lilford RJ, Mukhwana W.
Antenatal care and perinatal outcomes in Kwale district, Kenya.
BMC Pregnancy Childbirth. 2008 Jan 10;8(1):2 [Epub ahead of
print]
ABSTRACT: Background The importance of antenatal care (ANC)
for improving perinatal outcomes is well established. However
access to ANC in Kenya has hardly changed in the past 20 years.
This study aims to identify the determinants of attending ANC
and the association between attendance and behavioural and
perinatal outcomes (live births and healthy birthweight) for
women in the Kwale region of Kenya. Method A Cohort survey
of 1,562 perinatal outcomes (response rate 100%) during 2004-05
in the catchment areas for five Ministry of Health dispensaries
in two divisions of the Kwale region. The associations between
background and behavioural decisions on ANC attendance and
perinatal outcomes were explored using univariate analysis
and multivariate logistic regression models with backwards-stepwise
elimination. The outputs from these analyses were reported
as odds ratios (OR) with 95% confidence intervals (CI). Results
Only 32% (506/1,562) of women reported having any ANC. Women
with secondary education or above (adjusted OR 1.83; 95% CI
1.06-3.15) were more likely to attend for ANC, while those
living further than 5km from a dispensary were less likely
to attend (OR 0.29; 95% CI 0.22-0.39). Paradoxically, however,
the number of ANC visits increased with distance from the dispensary
(OR 1.46; 95% CI 1.33-1.60). Women attending ANC at least twice
were more likely to have a live birth (vs. stillbirth) in both
multivariate models. Women attending for two ANC visits (but
not more than two) were more likely to have a healthy weight
baby (OR 4.39; 95% CI 1.36-14.15). Conclusions The low attendance
for ANC, combined with a positive relationship between attendance
and perinatal outcomes for the women in the Kwale region highlight
the need for further research to understand reasons for attendance
and non-attendance and also for strategies to be put in place
to improve attendance for ANC.
6: Heinig J, Müller V, Schmitz R, Lohse K, Klockenbusch
W, Steinhard J.
Sonographic assessment of the extra-abdominal fetal small bowel
in gastroschisis: a retrospective longitudinal study in relation
to prenatal complications.
Prenat Diagn. 2008 Jan 10 [Epub ahead of print]
Department of Obstetrics and Gynecology, University of Münster,
Münster, Germany.
OBJECTIVE: An explorative retrospective study following a
case-series of fetuses with isolated gastroschisis, to evaluate
if small-bowel dilatation may be indicative for emerging obstetric
complications. The secondary aim was to establish preliminary
normative curves for the external diameter and wall thickness
of eventerated fetal small bowel in gastroschisis during the
second and third trimester of pregnancy. METHODS AND MATERIALS:
Fourteen fetuses with isolated gastroschisis were followed
at a single center. Repeated ultrasound examinations for fetal
surveillance with measurement of fetal small-bowel diameter
and wall thickness over the course of pregnancy until delivery
were performed. RESULTS: Longitudinal data analysis showed
significantly increasing bowel diameter and wall thickness
of eventerated small bowel with advancing gestation. Dilatation
of small bowel more than 25 mm in the third trimester of pregnancy
was associated with an increased risk of short-term prenatal
complications as fetal distress or intrauterine fetal death
(PPV 100%; 95% CI: 29.2-100%, NPV 100%; 95% CI: 71.5-100%).
CONCLUSIONS: Dilatation of the extra-abdominal fetal small
bowel in the third trimester may allow identifying fetuses
with increased risk of fetal distress requiring closer monitoring
of fetal well-being or delivery in a short interval to prevent
impending fetal death. Copyright (c) 2008 John Wiley & Sons,
Ltd.
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