NSIDRC Journal Article Alert — January 30, 2009
Prepared by the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center at Georgetown University.
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Other Infant Death
1. Turlington A, Hodgman JE, Barton L
Decreasing trend in postneonatal mortality
J Perinatol. 2008 Mar;28(3):188-91. Epub 2008 Jan 24
USC Division of Newborn Medicine, Department of Pediatrics, Women's and Children's Hospital, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
OBJECTIVE: The objective was to evaluate the postneonatal mortality rate at our institution from 1999 to 2006 as a follow-up to a previous report from our hospital covering 1993 to 1998 and to investigate the causes of death in infants dying in the postneonatal period. STUDY DESIGN: We identified all infant deaths before discharge from the nursery aged > or =28 days. Clinical data for all cases and autopsy records where available were reviewed and the cause of death was determined for each infant. RESULT: Total nursery deaths for the 7 years were 211, of which 14 (6.6%) occurred after the neonatal period. This represents a decreasing trend from the 12% reported in 1993 to 1998. Causes of death were the complications of prematurity and congenital defects. The five infants whose cause of death was the complications of prematurity had chronic lung disease, four had abdominal surgery for perforation and resection and two had intraventricular hemorrhage (IVH) Gr IV. All infants had multiple organ failure by the time of death and the final event was infection and/or renal failure. The nine congenital defects included two trisomy 21 with complications, one CHARGE association with heart defects, one hypertrophic cardiomyopathy and two others with multiple congenital heart defects. Of the three remaining infants, the anomalies included one with hydranencephaly, one with caudal regression and one with multiple vascular liver tumors. CONCLUSION: Along with the general decrease in infant mortality, postneonatal mortality is decreasing as a percentage of nursery deaths. The causes of death include complications of prematurity and congenital defects.
Bereavement
1. Chan MF, Lou FL, Arthur DG, Cao FL, Wu LH, Li P, Sagara-Rosemeyer M, Chung LY, Lui L
Investigating factors associate to nurses' attitudes towards perinatal bereavement care
J Clin Nurs. 2008 Feb;17(4):509-18
School of Nursing, Hong Kong Polytechnic University, Hong Kong SAR, China. hsmfchan@inet.polyu.edu.hk
AIM: The purpose of this study was to explore nurses' attitudes towards perinatal bereavement care and to identify factors associate with such attitudes. BACKGROUND: Caring for and supporting parents whose infant has died is extremely demanding, difficult and stressful. It is likely that the attitude of nursing staff can influence recovery from a pregnancy loss and nurses with positive attitude to bereavement care can help bereaved parents to cope during their grieving period. METHOD: Data were collected through a structured questionnaire; 334 nurses were recruited (63% response rate) from the Obstetrics and Gynaecology unit in five hospitals in Hong Kong during May-August 2006. Outcome measures including attitudes towards perinatal bereavement care, importance on hospital policy and training support for bereavement care. RESULTS: Majority of nurses in this study held a positive attitude towards bereavement care. Results showed that only 39.3% (n = 130) of nurses had bereavement related training. By contrast, about 89.8% of nurses (n = 300) showed they need to be equipped with relevant knowledge, skills and understanding in the care and support of bereaved parents and more than 88.0% (n = 296) would share experiences with colleagues and seek support when feeling under stress. Regression model showed that age, past experience in handling grieving parents and nurses' perceived attitudes to hospital policy and training provided for bereavement cares were factors associate with nurses' attitudes towards perinatal bereavement care. CONCLUSIONS: Hong Kong nurses emphasized their need for increased knowledge and experience, improved communication skills and greater support from team members and the hospital for perinatal bereavement care. RELEVANCE TO CLINICAL PRACTICE: These findings may be used for health policy makers and nursing educators to ensure delivery of sensitive bereavement care in perinatal settings and to enhance nursing school curricula respectively.
Miscarriage/Stillbirth/Prenatal Issues
1. Kist WJ, Janssen NG, Kalk JJ, Hague WM, Dekker GA, de Vries JI
Thrombophilias and adverse pregnancy outcome - A confounded problem!
Thromb Haemost. 2008 Jan;99(1):77-85
Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, The Netherlands.
It was the objective of this study to analyse the influence of confounders, such as ethnicity, severity of illness and method of testing, in articles concerning the still moot relationship of thrombophilias to adverse pregnancy outcome (APO). Relevant case-control studies were identified using Medline and EMBASE databases between 1966 and 2006. Search terms were recurrent fetal loss, intrauterine fetal death, preeclampsia, HELLP-syndrome, eclampsia, fetal growth restriction, abruptio placentae, combined with maternal thrombophilias. Data was extracted from the articles per subgroup of APO regardless of confounder. These subgroups were tested if they fulfilled the heterogeneity testing criterion (I(2) > 35%) to weigh the influence of the confounder. Confounders were selected and examined with Mantel-Haenszel method. Increased thrombophilia prevalence was confirmed in most adverse pregnancy outcomes. Ethnicity, genetic testing only and severity of illness were confounders in the various forms of APO. Stronger relationships between factor V Leiden and severity of disease were found in 2(nd) and 3(rd) trimester than 1(st) trimester recurrent fetal loss, in preeclampsia with: blood pressure > or =160/110 mmHg than > or =140/90 mmHg; proteinuria > or =5 grams per day than <5 grams; onset before than after 28 weeks, in fetal growth restriction <3(rd) percentile than <5(th), than <10(th), and in earlier occurrence of abruptio placentae than 3(rd) trimester. In conclusion, reports on the prevalence of maternal thrombophilias and APO are influenced by various confounders, which are not always appropriately analysed. The differences we have identified reflect the differential impact of these confounders. These data emphasise the importance of more uniform research.
2. Wilson RE, Alio AP, Kirby RS, Salihu HM
Young maternal age and risk of intrapartum stillbirth
Arch Gynecol Obstet. 2008 Sep;278(3):231-6. Epub 2008 Jan 24
Department of Epidemiology and Biostatistics, University of South Florida, Tampa, FL, USA.
OBJECTIVES: To determine the risk of intrapartum stillbirth among teen mothers. METHODS: The Missouri maternally linked data containing births from 1978 to 1997 were analyzed. The study group (teen mothers) was sub-divided into younger (<15 years) and older (15-19 years) teenagers. Women aged 20-24 were the referent category. We used Kaplan-Meier product-limit estimator to calculate the cumulative probability of death for each group and the Cox Proportional Hazards Regression models to obtain adjusted hazards ratios. RESULTS: The rate of antepartum and intrapartum stillbirth among teenagers was 3.8 per 1,000 and 1.0 per 1,000, respectively, compared to 3.5 per 1,000 and 0.8 per 1,000 among the reference group. The adjusted risk of intrapartum stillbirth was more than 4 times as high among younger teens (adjusted hazard ratio [AHR] 4.3 [95% CI 4.0-4.7]) and 50% higher among older teens (AHR 1.5 [95% CI 1.2-1.8]). The risk of intrapartum stillbirth occurred in a dose-dependent fashion, with risk increasing as maternal age decreased (P < 0.01). CONCLUSION: Teenagers are at an increased risk of stillbirth, with the greatest risk disparity occurring intrapartum, especially among younger teens. This new information is potentially useful for targeting intervention measures aimed at improving in utero fetal survival among pregnant women at the lower extreme of the maternal age spectrum.
3. Toth B, Nieuwland R, Kern M, Rogenhofer N, Berkmans R, Rank A, Lohse P, Friese K, Thaler CJ Am J
Systemic changes in haemostatic balance are not associated with increased levels of circulating microparticles in women with recurrent spontaneous abortion
Reprod Immunol. 2008 Feb;59(2):159-66
Department of Obstetrics and Gynecology-Grosshadern, Ludwig-Maximilians-University, Munich, Germany. bettina.toth@med.uni-muenchen.de
PROBLEM: Placental fibrin deposits in patients wih recurrent spontaneous abortion (RSA) indicate an exaggerated haemostatic response. This 'hypercoagulability' may involve pro-coagulant factors such as circulating microparticles (MPs). We investigated the relationship between circulating pro-coagulant MPs and systemic coagulation in RSA patients. METHOD OF STUDY: Platelet- and endothelial cell-derived microparticles (PMPs, EMPs) were evaluated by flow cytometry in RSA patients (n = 51) and compared to controls (n = 24) using annexin V (total numbers of MP), and antibodies against CD61, CD63 and CD62P (PMP), as well as CD144 and CD62E (EMP). Prothrombin fragment 1 + 2 (F(1+2)) and thrombin generation were determined to assess the pro-coagulant potential of MP. RESULTS: Numbers of annexin V-binding MP were nearly similar in RSA patients and controls. However, a subgroup of ten RSA patients (10/51; 20%) presented with MP concentrations >10,000 x 10(6)/L, compared to only one women out of the control group (1/24; 4%; P = 0.038). Neither PMP and EMP nor F(1+2) and thrombin generation differed significantly within the study population. CONCLUSION: The present study shows that circulating MPs are not directly associated with the extent of systemic coagulation activation in RSA patients. We hypothesize that increased numbers of circulating MPs either are only indirectly associated with coagulation during pregnancy of RSA patients, or affect abortion via mechanisms independently from hypercoagulation.
4. Zammiti W, Mtiraoui N, Mahjoub T
Lack of consistent association between endothelial nitric oxide synthase gene polymorphisms, homocysteine levels and recurrent pregnancy loss in tunisian women
Am J Reprod Immunol. 2008 Feb;59(2):139-45
Research Unit of Biology and Genetics of Cancer, Haematological and Autoimmune Diseases, Faculty of Pharmacy of Monastir, Monastir University, Monastir, Tunisia. zammiti_pharmacie@yahoo.fr
PROBLEM: Polymorphisms of the endothelial nitric oxide synthase (eNOS) gene have been associated with reduced vascular NO production or increased level of homocysteine, and evaluated as risk factors for recurrent pregnancy loss (RPL). Therefore, in this case-control study, we aimed to determine the effects of some eNOS functional polymorphisms: the 27-bp intron 4 repeat, the 894G/T of exon 7, and the promoter substitution -786T/C, in women with RPL. METHOD OF STUDY: We genotyped 350 patients with RPL and 200 healthy women by polymerase chain reaction (PCR) and restriction fragment length polymorphism-PCR (RFLP-PCR). The homocysteine total plasma concentrations (tHcy) were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS: None of the eNOS polymorphisms-related alleles, genotypes, and haplotypes were associated with RPL. The tHcy were similar between patients and controls; no significant association between tHcy levels and eNOS genotypes could be evidenced. CONCLUSION: The present study identified a lack of association between eNOS gene polymorphisms, the risk of RPL and tHcy levels.
5. Carp HJ
Intravenous immunoglobulin: effect on infertility and recurrent pregnancy loss
Isr Med Assoc J. 2007 Dec;9(12):877-80
Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel. carp@netvision.net.il
6. Lancet. 2008 Jan 19;371(9608):215-27
Comment in:
* Lancet. 2008 Jan 19;371(9608):186-7
* Lancet. 2008 May 24;371(9626):1751-2
Effect of maternal multiple micronutrient supplementation on fetal loss and infant death in Indonesia: a double-blind cluster-randomised trial.
Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) Study Group, Shankar AH, Jahari AB, Sebayang SK, Aditiawarman, Apriatni M, Harefa B, Muadz H, Soesbandoro SD, Tjiong R, Fachry A, Shankar AV, Atmarita, Prihatini S, Sofia G.
Helen Keller International, Jakarta, Indonesia; Johns Hopkins University, Baltimore, MD, USA.
BACKGROUND: Maternal nutrient supplementation in developing countries is generally restricted to provision of iron and folic acid (IFA). Change in practice toward supplementation with multiple micronutrients (MMN) has been hindered by little evidence of the effects of MMN on fetal loss and infant death. We assessed the effect of maternal supplementation with MMN, compared with IFA, on fetal loss and infant death in the setting of routine prenatal care services. METHODS: In a double-blind cluster-randomised trial in Lombok, Indonesia, we randomly assigned 262 midwives to distribute IFA (n=15 ,86) or MMN (n=15,804) supplements to 31 290 pregnant women through government prenatal care services that were strengthened by training and community-based advocacy. Women obtained supplements, to be taken daily, every month from enrolment to 90 days post partum. The primary outcome was early infant mortality (deaths until 90 days post partum). Secondary outcomes were neonatal mortality, fetal loss (abortions and stillbirths), and low birthweight. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN34151616. FINDINGS: Infants of women consuming MMN supplements had an 18% reduction in early infant mortality compared with those of women given IFA (35.5 deaths per 1000 livebirths vs 43 per 1000; relative risk [RR] 0.82, 95% CI 0.70-0.95, p=0.010). Infants whose mothers were undernourished (mid upper arm circumference <23.5 cm) or anaemic (haemoglobin <110 g/L) at enrolment had a reduction in early infant mortality of 25% (RR 0.75, 0.62-0.90, p=0.0021) and 38% (RR 0.62, 0.49-0.78, p<0.0001), respectively. Combined fetal loss and neonatal deaths were reduced by 11% (RR 0.89, 0.81-1.00, p=0.045), with significant effects in undernourished (RR 0.85, 0.73-0.98, p=0.022) or anaemic (RR 0.71, 0.58-0.87, p=0.0010) women. A cohort of 11 101 infants weighed within 1 h of birth showed a 14% (RR 0.86, 0.73-1.01, p=0.060) decreased risk of low birthweight for those in the MMN group, with a 33% (RR 0.67, 0.51-0.89, p=0.0062) decrease for infants of women anaemic at enrolment. INTERPRETATION: Maternal MMN supplementation, as compared with IFA, can reduce early infant mortality, especially in undernourished and anaemic women. Maternal MMN supplementation might therefore be an important part of overall strengthening of prenatal-care programmes.
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