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NSIDRC Journal Article Alert — May 15, 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.
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Other Infant Death
1. Peters C, Becher JC, Lyon AJ, Midgley P
Who is blaming the baby?
Arch Dis Child. 2009 May 7. [Epub ahead of print]
Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, United Kingdom.
Sudden unexplained collapse within the first 12 hours of life is a rare but recognised event. Over a 2-year period 5 infants, previously assessed as healthy, were found collapsed in our maternity unit in the care of their primiparous mothers. Two were found prone on their mother's chest, two were in their mother's bed. The outcomes were poor with four neonatal deaths and one death aged 18 months. The rate of sudden unexplained neonatal collapse was 0.4 per 1000 live births. No cause for collapse was identified despite extensive investigations, which included post mortem in all the neonatal deaths. One infant, however, showed widespread antenatal brain damage at post mortem. We postulate that some infants with an underlying vulnerability may maladapt to extrauterine life following an hypoxic stressor possibly caused by positional airway obstruction.
Miscarriage/Stillbirth/Prenatal Issues
1. Measey MA, Tursan d'Espaignet E, Charles A, Douglass C
Unexplained fetal death: Are women with a history of fetal loss at higher risk?
Aust N Z J Obstet Gynaecol. 2009 Apr;49(2):151-7
Telethon Institute for Child Health Research, Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia.
Aims: To identify factors, including the loss of a previous pregnancy before 20 weeks gestation, which are associated with increased risk of singleton antepartum unexplained fetal death (UFD) in Western Australia (WA) using information recorded in routine data collections. Methods: All fetal deaths in WA from 1990 to 1999 that underwent thorough post-mortem investigations were classified using the Perinatal Society of Australia and New Zealand Perinatal Death Classification System. All UFDs were selected as cases and unmatched controls were randomly drawn from all live births in WA occurring during the study period. Demographic and clinical information on cases and controls was obtained from the WA Midwives' Notification System. Multivariable logistic regression was carried out to determine the independent effect of risk factors and calculate odds ratios. Results: Almost one quarter (22%) of stillbirths were unexplained. Primigravid and primiparous women with a history of pregnancy loss before 20 weeks were at higher risk of UFD than multiparous women who had not experienced any loss. Women with a history of fetal death (after 20 weeks) had the highest risk of UFD. Conclusion: The current practice of closely monitoring pregnant women with a history of fetal loss or death should continue as this study suggests they may have a higher risk of poor obstetric outcome. Larger studies are needed to confirm the association between previous pregnancy loss and UFD.
2. Winer N, Resche-Rigon M, Morin C, Ville Y, Rozenberg P
Is induced abortion with misoprostol a risk factor for late abortion or preterm delivery in subsequent pregnancies?
Eur J Obstet Gynecol Reprod Biol. 2009 May 6. [Epub ahead of print]
Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire, Nantes, France.
OBJECTIVE: To examine whether a first or second trimester induced abortion with misoprostol influences the risk of late abortion or preterm delivery in subsequent pregnancies. STUDY DESIGN: Case-control study in a teaching hospital from January 2005 to June 2006. The cases had singleton pregnancies delivered at 16-36 weeks of gestation after spontaneous late abortions, preterm labor or preterm premature rupture of membrane, or induction of labor for preterm premature rupture of membrane before 37 weeks. The control group was composed of the two consecutive spontaneous singleton deliveries at >/=37 weeks of gestation after each new case (ratio 2/1). The principal outcome measure was late abortion or preterm delivery. The association between late abortion or preterm delivery and a previous induced abortion with misoprostol was first assessed with the Cochran-Mantel-Haenszel chi-square test. Conditional logistic regression models adapted for clustered data were then further used to quantify the effect size, measured by estimated odds ratios (ORs) with their 95% confidence intervals (95% CI). RESULTS: The study included 245 cases and 490 controls. There was no significant difference in mean maternal age, number of pregnancies, parity, smoking, or history of first trimester miscarriage between cases and controls. However, a history of late abortion or previous preterm delivery was significantly more frequent among cases than controls. Forty (16.3%) cases and 56 (11.5%) controls had a history of cervical ripening with misoprostol before vacuum curettage or evacuation, or of medical abortion by misoprostol alone or with mifepristone (OR 1.51, 95% CI: 0.95-2.39; p=0.08). After adjustment for maternal age and number of pregnancies with a multivariable conditional regression model, the adjusted OR was estimated at 1.33 (95% CI: 0.81-2.17; p=0.25). CONCLUSION: Despite the need for prudence, these results provide some reassurance that induced abortion with misoprostol during the first or second trimester of pregnancy is safe for subsequent pregnancies.
3. Trabucco E, Acone G, Marenna A, Pierantoni R, Cacciola G, Chioccarelli T, Mackie K, Fasano S, Colacurci N, Meccariello R, Cobellis G, Cobellis L
Endocannabinoid System in First Trimester Placenta: Low FAAH and High CB1 Expression Characterize Spontaneous Miscarriage
Placenta. 2009 May 4. [Epub ahead of print]
Dipartimento di Scienze Ginecologiche, Ostetriche e della Riproduzione, II Università degli Studi di Napoli, Largo Madonna delle Grazie 1, 80138 Naples, Italy.
Anandamide (AEA) and 2-arachidonoylglycerol (2-AG) were the first endocannabinoids to be characterized, that bind two G protein-coupled receptors, CB1 and CB2. AEA synthesized by multiple pathways, including NAPE-specific phospholipase D (NAPE-PLD) and degraded by the fatty acid amide hydrolase (FAAH). AEA levels are critical in regulating embryo development and the "window" of implantation. We examined the expression of nape-pld mRNA, CB1 and FAAH in human placenta hypothesizing that their altered signaling may contribute to spontaneous miscarriage. First trimester placentas from women with spontaneous miscarriage (group 1) were matched with placentas from women who underwent termination (group 2). Nape-pld expression was analyzed by RT-PCR; CB1 and FAAH expression by Western blot and immunohistochemistry. Nape-pld mRNA expression was higher in group 2 than in group 1. Western blot analysis revealed higher CB1 expression and lower or absent FAAH in group 1 than in group 2. Immunohistochemistry confirmed CB1 and FAAH signals in group 1 and group 2 placentas, respectively. Human placenta contains the enzymes to synthesize AEA. Moreover, placental tissue represents a target for endocannabinoids whose activity may regulate pregnancy outcome. In particular, very low or absent FAAH and high CB1 levels correspond with spontaneous miscarriage.
4. O'Donoghue K, Rutherford M, Engineer N, Wimalasundera R, Cowan F, Fisk N
Transfusional fetal complications after single intrauterine death in monochorionic multiple pregnancy are reduced but not prevented by vascular occlusion
BJOG. 2009 May;116(6):804-12.
Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, London, UK.
Objective To document co-twin death/pregnancy loss and brain injury after single intrauterine death (sIUD) in monochorionic pregnancies. Design A total of 135 pregnancies with sIUD were reviewed for co-twin IUD, miscarriage and abnormal antenatal and postnatal neuro-imaging. Setting A tertiary referral fetal medicine unit from 2000 to 2007. Population or Sample All cases referred with a single fetal death in monochorionic pregnancy, including those where sIUD was spontaneous or occurred after fetoscopic laser treatment, or resulted from selective termination by cord occlusion with bipolar diathermy or intrafetal vascular ablation with interstitial laser. Methods Clinical details and ultrasound findings of the study population were retrieved from ultrasound and institutional databases. Delivery and neonatal outcome data were obtained from discharge summaries supplemented by individual chart review. Main outcome measures Co-twin death or pregnancy loss and neurologic injury assessed on antenatal ultrasound and MR-imaging. Results A total of 81 sIUDs resulted from vascular occlusive feticide (diathermy or interstitial laser), 22 followed placental laser and 32 were spontaneous. In 22 pregnancies (16.8%), the co-twin died in utero and eight pregnancies miscarried (6.1%). Antenatal magnetic resonance (MR) imaging in 76/91 (83.5%) continuing pregnancies detected antenatal brain injury in five (6.6%). Three infants (two not scanned antenatally) had abnormalities detected postnatally. Brain abnormality was detected less often after procedure related (2.6%, 2/77) than spontaneous sIUD (22.2%, 6/27, P = 0.003) and after early compared with late gestation sIUD (3.6%, 4/111 versus 20.0%, 4/20; P = 0.02). Conclusions We confirm substantial co-twin loss (22.9%) after monochorionic sIUD, but a low risk of antenatally acquired MRI-identified brain injury, suggesting this risk has been overestimated. Procedures restricting inter-twin transfusion reduce, but do not negate risk of brain injury.
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Loss Resource Center
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