NSIDRC Journal Article Alert — November 7, 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.
Other Infant Death
1. Pasupathy D, Wood AM, Pell JP, Fleming M, Smith GC Time trend in the risk of delivery-related perinatal and neonatal death associated with breech presentation at term Int J Epidemiol. 2008 Oct 31. [Epub ahead of print]
Department of Obstetrics and Gynaecology, Cambridge University, Cambridge CB2 2QQ, UK.
BACKGROUND: To determine the factors associated with the risk of delivery-related perinatal and neonatal death among term infants presenting by the breech and the effect of changes in the mode of delivery on the overall rates of perinatal and neonatal mortality associated with breech presentation. METHODS: We studied 32 776 singleton term infants presenting breech excluding anomalous and antepartum losses in Scotland between 1985 and 2004, using linked Scottish national registries of pregnancy outcome data and perinatal death data. The event was delivery-related perinatal and neonatal death (i.e. intrauterine fetal death during labour or death of infant in the first 4 weeks of life), subdivided according to intrapartum anoxia or mechanical cause of death. Analysis was by multivariate logistic regression. RESULTS: During the study period, the risk of delivery-related perinatal and neonatal death decreased by 72% (95% CI -1% to 93%), due to a 90% (95% CI 33-99%) reduction in anoxic or mechanical deaths. Both intrapartum (OR 0.16, 95% CI 0.02-0.75) and planned (OR 0.01, 95% CI 0.00-0.09) caesarean delivery were protective against anoxic or mechanical deaths and increased use of planned caesarean delivery accounted for 16% of the decline in anoxic and mechanical deaths over the study period. CONCLUSION: Increased use of planned caesarean delivery only partly explains the decline in delivery-related perinatal and neonatal death between 1985 and 2004 in Scotland.
2. Miller JL, Harman C, Weiner C, Baschat AA Perinatal outcomes after second trimester detection of amniotic fluid viral genome in asymptomatic patients J Perinat Med. 2008 Oct 28. [Epub ahead of print]
1Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center, Baltimore, MD, USA.
Abstract Objective: Symptomatic fetal viral infection can affect placental and fetal development and may lead to non-immune hydrops or fetal death. All infections are not detectable by clinical history or ultrasound and a background positivity rate exists in asymptomatic patients. We investigated if intraamniotic presence of viral genome at the time of genetic amniocentesis in asypmtomatic patients affects perinatal outcome. Study design: Six-hundred and eighty-six pregnancies referred for second trimester genetic amniocentesis with a normal ultrasound and fetal karyotype had amniotic fluid multiplex polymerase chain reaction for adeno-, cytomegalo-, Ebstein-Barr-, entero- and parvovirus. Forty asymptomatic patients that were positive for viral genome were matched 2:1 with negative controls. Perinatal outcomes were compared between these groups. Results: Pregnancy complications and perinatal outcomes were similar in the two groups. Conclusion: Asymptomatic fetal viral infection at the time of second trimester amniocentesis does not increase the risk for adverse perinatal outcome.
Miscarriage/Stillbirth/Prenatal Issues
1. Shannon MS, Edwards MB, Long F, Taylor KM, Bagger JP, De Swiet M Anticoagulant management of pregnancy following heart valve replacement in the United Kingdom, 1986-2002 J Heart Valve Dis. 2008 Sep;17(5):526-32
Department of Haematology, St. George's Hospital, London. mshannon@sgul.ac.uk
BACKGROUND AND AIM OF THE STUDY: Patients with mechanical heart valves require anticoagulation which is associated with significant maternal mortality (1-4%) and fetal complications (31%) in pregnancy. The study aim was to identify anticoagulant protocols and outcomes for pregnant women undergoing heart valve replacement (HVR) in the United Kingdom. METHODS: Women aged between 18 and 45 years and registered with the United Kingdom Heart Valve Registry (UKHVR) each completed a questionnaire, and their obstetric notes were reviewed. The data analyzed included valve type (mechanical, bioprosthetic, homograft), valve site (mitral, aortic, tricuspid, pulmonary), anticoagulation at confirmation of pregnancy, between 6-12 weeks and from 12 weeks to term, delivery, maternal and fetal outcomes, and cause of death. The summary statistics and a descriptive review of the findings are reported. RESULTS: Of 2,532 women eligible for the study, 922 responded. Among these women, 72 became pregnant, with 60 pregnancies in the mechanical valve (MV) group and 45 in the tissue valve (TV) group. Three anticoagulation regimes were used during early pregnancy: unfractionated heparin (UFH), low-molecular-weight heparin (LMWH) or warfarin. All women received warfarin in the second trimester and heparin for delivery. Live births were recorded in 30% of MV pregnancies and in 60% of TV pregnancies. Miscarriage rates differed markedly (37% MV versus 2% TV). Fetal outcome was poorest in the warfarin-only group, with embryopathy occurring at a dose level of 6 mg. The maternal outcomes did not differ significantly among groups. High-dose heparin during the first trimester and for delivery was effective for the majority of mechanical valves. CONCLUSION: The study results illustrate the diverse and uncertain manner in which UKHVR patients are managed during pregnancy. A national notification system would record much-needed prospective information on anticoagulation and pregnancy outcomes, thus aiding evidence-based management.
2. Baruch S, Kaufman DJ, Hudson KL Preimplantation genetic screening: a survey of in vitro fertilization clinics Genet Med. 2008 Sep;10(9):685-90
From the Genetics and Public Policy Center, Berman Institute of Bioethics, Johns Hopkins University, Washington DC, USA. sbaruch2@jhu.edu
PURPOSE: The purpose of this study was to determine which US in vitro fertilization clinics provide preimplantation genetic screening for aneuploidy in treating infertility, and to explore clinic directors' attitudes toward this technique. METHODS: Online survey included 415 US assisted reproductive technology clinics. The survey had a valid response rate of 45% or 186 clinics. RESULTS: Nearly 68% of US in vitro fertilization clinics responding to the survey provided preimplantation genetic screening in an effort to increase success rates of fertility treatment. More than half of these in vitro fertilization clinics (56%) provided preimplantation genetic screening for advanced maternal age and the same percentage provided preimplantation genetic screening to treat repeated in vitro fertilization failure, whereas 66% provided preimplantation genetic screening to treat women with repeated miscarriage. Opinions of the effectiveness of preimplantation genetic screening for these indications varied widely, even among those providing it. Most directors (85%) of clinics providing preimplantation genetic screening believed that more data are needed to determine whether and to whom it should be offered. CONCLUSIONS: Despite the lack of data supporting the use of preimplantation genetic screening for recurrent pregnancy loss, in vitro fertilization failure, and advanced maternal age, a majority of in vitro fertilization clinics in the United States offer preimplantation genetic screening for these purposes. There is significant support among clinic directors for more research into the effectiveness of preimplantation genetic screening and for professional guidelines in this area.
3. Bottomley C, Daemen A, Mukri F, Papageorghiou AT, Kirk E, Pexsters A, De Moor B, Timmerman D, Bourne T Functional linear discriminant analysis: a new longitudinal approach to the assessment of embryonic growth Hum Reprod. 2008 Oct 31. [Epub ahead of print]
Early Pregnancy and Gynaecology Ultrasound Unit, Department of Obstetrics and Gynaecology, St George's University of London, Third Floor Lanesborough Wing, Cranmer Terrace, London SW17 0RE, UK.
BACKGROUND Functional linear discriminant analysis (FLDA) is a new growth assessment technique using serial measurements to discriminate between normal and abnormal fetal growth. We used FLDA to assess and compare growth in live pregnancies destined to miscarry with those remaining viable. METHODS This was a prospective cohort study of women with ultrasound scans on at least two separate occasions showing live pregnancies. Serial crown-rump length (CRL), mean gestational sac diameter and mean yolk sac diameter measurements were recorded. The ability of FLDA to predict subsequent miscarriage was compared with that of a single CRL measurement. RESULTS Of 521 included pregnancies, 493 (94.6%) remained viable at 14 weeks and 28 (5.4%) miscarried. The CRL growth rate was significantly lower in those that miscarried (one-sample t-test, P = 2.638E-22). The sensitivity of FLDA in predicting miscarriage from serial CRL measurements was 60.7% and specificity was 93.1% [positive predictive value (PPV) 33.3%, negative predictive value (NPV) 97.7%]. This was significantly better for predicting miscarriage than a single CRL observation of more than 2SD below that expected (sensitivity 53.6%, specificity 72.2%, PPV 9.9%, NPV 96.5%). CONCLUSIONS FLDA discriminates between normal and abnormal growth to predict miscarriage with high specificity. FLDA predicts miscarriage better than a
4. De Geyter C, Steimann S, Müller B, Kränzlin ME, Meier C Pattern of Thyroid Function During Early Pregnancy in Women Diagnosed with Subclinical Hypothyroidism and Treated with l-Thyroxine is Similar to That in Euthyroid Controls Thyroid. 2008 Nov 2. [Epub ahead of print]
1 Division of Gynecological Endocrinology and Reproductive Medicine at the Women's Hospital, Basel, Switzerland ., 2 Division of Endocrinology, Diabetes and Clinical Nutrition at the Department of Internal Medicine, University Hospital Basel , Basel, Switzerland .
Background: Subclinical hypothyroidism (SCH) is associated with a higher miscarriage rate. It is unclear how the thyroid function in SCH differs from that in euthyroidism during early pregnancy. We intended to determine the regulation of thyroid function in women with SCH receiving constant l-thyroxine (T(4)) replacement during early pregnancy as compared to euthyroid controls. Methods: This was a prospective cohort study with weekly serum sampling in eight women in early pregnancy with SCH and eight euthyroid women from week 5 to week 12 of pregnancy. Thyroid function was assessed before pregnancy. Women with SCH were treated with T(4) (50 mug daily) and continued on an unchanged dose until week 12. The following parameters were measured weekly: thyrotropin (TSH), thyroglobulin, thyroxine, triiodothyronine, free thyroxine (FT(4)), free triiodothyronine (FT(3)), estradiol, progesterone, human chorionic gonadotropin, and prolactin. Results: Although the pregestational levels of TSH were significantly higher among women with SCH as compared to euthyroid controls, the self-limited estrogen-induced increment of TSH during early pregnancy was similar in both groups. Conclusions: Although both SCH and ovarian hyperstimulation were associated with an intermediate rise in TSH, the pattern of thyroid function followed similar changes as in euthyroid controls and is unlikely to cause the higher miscarriage rate observed in SCH.
5. Bettio D, Venci A, Levi Setti PE Chromosomal abnormalities in miscarriages after different assisted reproduction procedures Placenta. 2008 Oct;29 Suppl B:126-8
Cytogenetic and Medical Genetic Laboratory, Operative Unit of Clinical Investigations, IRCCS Humanitas Clinical Institute, Via Manzoni, 56, 20089 Rozzano, Milan, Italy. daniela.bettio@humanistas.it
About 10-15% of all recognised pregnancies end in spontaneous abortion and around 60% of these show a chromosomal abnormality. The finding of an abnormal karyotype allows one to avoid unnecessary and controversial testing and treatment, providing accurate reproductive and genetic counselling to the couple. Consequently, chromosome study of products of conception (POC) is routinely performed in our Institute, starting from 2002. Cytogenetic analysis on spontaneous metaphases, obtained using direct method, was successfully performed on a total of 277 cases: 133 from patients who underwent assisted reproductive technology (ART) and 144 samples from infertile couples that had natural conceptions (NC). An abnormal karyotype was observed in 84 (63.2%) cases after ART and in 103 (71.5%) after NC demonstrating that the ART group doesn't seem subjected to a higher cytogenetic risk due to the application of technical procedures and higher than the expected risk in the fertile population. Moreover we did not observe a significant difference in the incidence of chromosome anomalies between intracytoplasmic sperm injection (ICSI) (61.5%) and in vitro fertilisation (IVF) (54.5%). However, in the ICSI with testicular sperm extraction (ICSI-TESE) group, 80% of the cases were abnormal with 50% showing triploid/tetraploid karyotypes. Chromosomal abnormalities were present in 54.5% of miscarriages which occurred after ICSI with cryo-preserved oocytes (cryo-ICSI) and in 85.7% after intra-uterine insemination (IUI). To our knowledge this study analysed the largest number of POCs after ART and NC in an infertile population. Moreover, for the first time the cytogenetic results of POC from different ART procedures were included.
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