NSIDRC Journal Article Alert — July 10, 2009
Prepared by the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center at Georgetown University.
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Sudden Infant Death
1. Blood-Siegfried J
The role of infection and inflammation in sudden infant death syndrome
Immunopharmacol Immunotoxicol. 2009 Apr 2. [Epub ahead of print]
Duke University, School of Nursing, box 3322, Durham, 27710 United States
Sudden Infant Death Syndrome (SIDS) is the most common cause of post-neonatal mortality in the developed world. The exact cause of SIDS is likely to be multifactorial involving a critical developmental period, a vulnerable infant, and one or more triggers. Many SIDS infants have a history of viral illness preceding death. Prone sleep position, one of the leading risk factors, can increase airway temperature, as well as stimulate bacterial colonization and bacterial toxin production. Markers of infection and inflammation are often found on autopsy along with microbial isolates. Although the causal link between infection and SIDS is not conclusive, there is evidence that an infectious insult could be a likely trigger of SIDS in some infants.
2. Richardson HL, Walker AM, Horne RS
Minimizing the Risks of Sudden Infant Death Syndrome: To Swaddle or Not to Swaddle?
J Pediatr. 2009 Jun 19. [Epub ahead of print]
From the Ritchie Centre for Baby Health Research, Monash Institute of Medical Research, Monash University, Melbourne (H.R., A.W., R.H.), Victoria, Australia.
OBJECTIVE: To evaluate the effects of swaddling on infant arousability, particularly the progression of subcortical activation (SCA) to full cortical arousal (CA), because impaired arousal may contribute to sudden infant death syndrome. STUDY DESIGN: Healthy term infants, who were routinely swaddled (n = 15) or unswaddled (n = 12) at home, were studied with daytime polysomnography at 3 to 4 weeks and 3 months after birth. When both swaddled and unswaddled, arousability was assessed with a pulsatile jet of air at the nostrils. RESULTS: Larger increases in overall arousal thresholds (SCA plus CA) with swaddling were observed in infants who were easiest to arouse when unswaddled. Swaddling did not alter SCA or CA frequencies of routinely swaddled infants at either age. In infants who were naïve to swaddling, arousal thresholds were increased and CA frequency decreased during swaddled quiet sleep at 3 months. CONCLUSIONS: This study provides a scientific basis for assessing the safety of swaddling in infant care practice. The decreased cortical arousals observed in infants unfamiliar with swaddling may correspond to the increased risk of sudden infant death syndrome for inexperienced prone sleepers.
3. Graham J, Hendrix S, Schwalberg R
Evaluating the SIDS diagnosis process utilized by coroners in Mississippi
J Forensic Nurs. 2009;5(2):59-63.
Health Services Chief Nurse, Mississippi State Department of Health, Jackson, Mississippi 39215-1700, USA. Juanita.Graham@msdh.state.ms.us
To assess the consistency of Mississippi coroners' practices in identifying Sudden Infant Death Syndrome (SIDS) cases, coroners were surveyed about diagnostic protocols. Findings were compared with published Centers for Disease Control guidelines and Mississippi law. One-third of coroners report they sometimes or never perform investigations at the place of infant death. The agency responsible for transferring the infant and the turn-around time for autopsy reports also varies. This study demonstrates inconsistency in SIDS diagnostic protocols among Mississippi coroners.
4. Ball H
Airway covering during bed-sharing
Child Care Health Dev. 2009 Jun 15. [Epub ahead of print]
Parent-Infant Sleep Lab and Medical Anthropology Research Group, Department of Anthropology, Durham University, Durham, UK.
Background Parent-infant bed-sharing is a common practice in Western post-industrial nations with up to 50% of infants sleeping with their parents at some point during early infancy. However, researchers have claimed that infants may be at risk of suffocation or sudden infant death syndrome related to airway covering or compression in the bed-sharing environment. To further understand the role of airway covering and compression in creating risks for bed-sharing infants, we report here on a sleep-lab trial of two infant sleep conditions. Methods In a sleep-lab environment 20 infants aged 2-3 months old slept in their parents' bed, and in a cot by the bed, on adjacent nights. Infants' oxygen saturation and heart rate were monitored physiologically while infant and parental behaviours were recorded via ceiling-mounted infra-red cameras. Infants served as their own controls. Continuous 8-h recordings were obtained for covering of infant external airways, levels of infant oxygen saturation, infant heart rate, evidence of parental compression/overlying of infant, circumstances leading up to potential infant airway obstruction, and parental awareness of and responses to infant airway covering. Results The majority of infants (14/20) spent some part of the bed night with their airways (both mouth and nose) covered, compared with 2/20 on the cot night; however, no consistent effect on either oxygen saturation levels or heart rate was revealed, even during prolonged bouts of airway covering. All cases of airway covering were initiated by parents; 70% were terminated by parents, the remainder by infants. Seven bouts of potential compression were observed with parental limbs resting across infant bodies for lengthy periods, however, in only two cases was the full weight of a parental limb resting on an infant, both events lasting less than 15 s, both being terminated by infant movement. Conclusion Although numerous authors have suggested that bed-sharing infants face risks because of airway covering by bed-clothes or parental bodies, the present trial does not lend support to this hypothesis.
Other Infant Death
1. Lavezzi AM, Corna M, Mingrone R, Matturri L
Study of the human hypoglossal nucleus: Normal development and morpho-functional alterations in sudden unexplained late fetal and infant death
Brain Dev. 2009 Jun 22. [Epub ahead of print]
"Lino Rossi" Research Center for the Study and Prevention of Unexpected Perinatal Death and SIDS - Department of Surgical, Reconstructive and Diagnostic Sciences, University of Milan, Via della Commenda, 19, 20122 Milan, Italy.
This study evaluated the development and the involvement in sudden perinatal and infant death of the medullary hypoglossal nucleus, a nucleus that, besides to coordinate swallowing, chewing and vocalization, takes part in inspiration. Through histological, morphometrical and immunohistochemical methods in 65 cases of perinatal and infant victims (29 stillbirths, 7 newborns and 29 infants), who died of both unknown and known cause, the authors observed developmental anomalies of the hypoglossal nucleus (HGN) in high percentage of sudden unexplained fetal and infant deaths. In particular, HGN hypoplasia, hyperplasia, positive expression of somatostatin and absence of interneurons were frequently found particularly in infant deaths, with a significant correlation with maternal smoking.
Miscarriage/Stillbirth/Prenatal Issues
1. Zareen N, Naqvi S, Majid N, Fatima H
Perinatal outcome in high risk pregnancies
J Coll Physicians Surg Pak. 2009 Jul;19(7):432-5
Department of Obstetrics and Gynaecology, Hamdard University Hospital, Karachi.
Objective: To determine the perinatal outcome of high risk pregnancies, in terms of perinatal mortality, Apgar score, birth weight and neonatal complications in first week after birth. Study Design: Cohort study. Place and Duration of Study: Obstetric Department of Sir Syed Trust Hospital, Karachi, from January to December 2007. Methodology: All antenatal patients attending the Outpatient Department were interviewed, after informed consent. Those who fulfilled the required criteria were grouped in 2 categories; high risk (group A cases) and low risk (group B control) pregnancies according to the risk factors identified in the history. All singleton pregnancies from 28th weeks of gestation till delivery were included in the study. All pregnant women, who had multiple pregnancies or congenital malformations were excluded. Patients were followed till delivery and neonatal outcome was assessed in both the groups. Outcome measures were recorded. Results: There were a total of 282 patients studied. The number of patients in group A were 162 and in group B, 120. Anaemia 98 (60.49%), pregnancy induced hypertension 24 (14.8%) and preterm labour 26 (16%) were identified as the major risk factors in group A. There were 12 (7.40%) stillbirths and 5 (3.08%) early neonatal deaths in group A, while there was 1 (0.84%) stillbirth and no neonatal death in group B (p=0.004, RR=1.72). There were 58 (35.80%) neonates with low birth weight in group A, while the same were only 4 (3.33%) in group B, which was statistically significant (p=0.001, RR=1.98). Poor Apgar score of </= 7 at 1 minute was observed in 6 (4%) and at 5 min was observed in 5 (3.33%), while none of the neonates in group B was born with Apgar score of less </= 7 at 1 or 5 minute (p=0.036, RR=1.83; p=0.068, tR=1.82 respectively). Meconium aspiration syndrome was observed in 7 (4.3%) cases in group A, and 2 (1.66%) in group B, which was statistically insignificant. Complication rate among the neonates was statistically not significant between the two groups. Conclusion: Perinatal mortality was twice as high in high risk group compared to low risk group. However, the complications in the neonates were statistically insignificant between the two groups.
2. Which approach for first trimester miscarriage?
Drug Ther Bull. 2009 Jul;47(7):77-80
Around 15% of all known pregnancies miscarry during the first trimester.1 Historically, first trimester miscarriage was managed surgically to remove all retained products of conception, with the aim of minimising the likelihood of blood loss and infection from retained tissue.2,3 Nowadays, medical management (use of drugs such as mifepristone and misoprostol) and expectant management (i.e. allowing the miscarriage to conclude naturally) have become alternatives to a surgical procedure for managing women with early miscarriage. Here, we review the evidence on these three methods to assess the benefits and disadvantages of each.
3. Headley E, Gordon A, Jeffery H
Reclassification of unexplained stillbirths using clinical practice guidelines
Aust N Z J Obstet Gynaecol. 2009 Jun;49(3):285-9
Department of Neonatal Medicine, Royal Prince Alfred Hospital, New South Wales, Sydney.
BACKGROUND: Twenty-eight per cent of stillbirths in Australia remain unexplained. A clinical practice guideline (CPG) produced by the Perinatal Society of Australia and New Zealand (PSANZ) Perinatal Mortality Special Interest Group is in use to assist clinicians in the investigation and audit of perinatal deaths. AIMS: To describe in a tertiary hospital using the PSANZ stillbirth investigation guidelines: (i) the distribution and classification of stillbirths, and (ii) the compliance with suggested stillbirth core investigations. METHODS: Retrospective cohort of all stillbirths delivered between November 2005 and March 2008. Stillbirths were defined as no sign of life on delivery at > or = 20 weeks gestation or 400 g birthweight if gestation is unknown. Data were collected via the hospital Perinatal Mortality Audit Committee (PMAC). Cause of death was classified by the PSANZ Perinatal Death Classification. RESULTS: There were 86 stillbirths (rate 7.2 per 1000 births). The percentage of unexplained stillbirths was 34% and 13% before and after CPG investigations, respectively. Unexplained stillbirths had the highest compliance with the recommended investigations. The initial cause of death documented on the death certificate was changed by the PMAC in 19 cases. The investigations most likely to prompt a change in the cause of death classification were autopsy and placental pathology. CONCLUSIONS: The percentage of unexplained stillbirths is lower than the national average in a hospital using the Perinatal Mortality Audit Guidelines. However, overall compliance is low, suggesting a targeted approach to investigation is used by clinicians despite a policy that aims to be non-selective. Autopsy and placental examination are the most useful investigations in assisting formal classification of cause of death.
4. Moon KS, Richter KS, Levy MJ, Widra EA
Does dilation and curettage versus expectant management for spontaneous abortion in patients undergoing in vitro fertilization affect subsequent endometrial development?
Fertil Steril. 2009 Jun 26. [Epub ahead of print]
Department of Obstetrics and Gynecology, Georgetown University Hospital, Washington, D.C.
In in vitro fertilization patients, treatment of spontaneous abortion with dilation and curettage (D&C) versus expectant management has no long-term effect on subsequent endometrial development, as measured by change in endometrial thickness. A transient reduction in endometrial thickness was found within the first 6 months after D&C, which is a novel finding, but it is likely to have little or no effect on pregnancy rates given the small absolute effect on endometrial thickness.
5. Fertl KI, Beyer R, Geissner E, Rauchfuß M
Women with a History of Pregnancy Loss or Abortion in a Behavioural Medicine Hospital - an Exploratory Field Study
Psychother Psychosom Med Psychol. 2009 Jun 24. [Epub ahead of print]
1Medizinisch-Psychosomatische Klinik Roseneck, Prien am Chiemsee.
OBJECTIVE: Gaining insights into the frequencies of negative obstetric histories in inpatients of a behavioural medicine hospital and the extent of their current psychological burdens. METHOD: We acquired sociodemografic, obstetric and psychological (psychopathology, coping patterns, and attribution styles) data of 117 inpatients by means of standardized questionnaires and interviews. RESULTS: Eighteen percent of the women exhibited a negative obstetric history (spontaneous, medically indicated or voluntary abortion) that dated back an average of 16 years. These women suffered more often from somatoform disorders and showed higher depression scores as well as other distinctive problems regarding their psychological wellbeing and their attributional and coping styles. Women who had undergone voluntary abortions showed a particular pattern of psychological distress. Those women who still felt psychological burden of pregnancy loss or abortion were younger and had fewer children. CONCLUSIONS: Almost one fifth of this inpatient sample in a behavioural medicine hospital exhibited a negative obstetric history and one third of these women still were affected psychologically. Clinicians therefore need to include obstetric data when taking a woman's psychiatric history, in particular with regard to depression, in order to be able to include this issue in their treatment plan, even if the pregnancy loss or abortion dates back many years.
6. Rubio C, Buendía P, Rodrigo L, Mercader A, Mateu E, Peinado V, Delgado A, Milán M, Mir P, Simón C, Remohí J, Pellicer A
Prognostic factors for preimplantation genetic screening in repeated pregnancy loss
Reprod Biomed Online. 2009 May;18(5):687-93
Instituto Universitario-IVI, Valencia, Spain. c.rubio@ivi.es
The objective of this study was to identify specific subgroups of recurrent pregnancy loss (RPL) patients of unknown aetiology in whom the selection of chromosomally normal embryos for transfer improves reproductive outcome in preimplantation genetic screening (PGS). A total of 428 PGS cycles were included and chromosomes 13, 15, 16, 18, 21, 22, X and Y were evaluated. In RPL patients < or =37 years, a lower incidence of chromosomal abnormalities (P = 0.0004) and miscarriages (P = 0.0283) was observed, and there were significantly higher pregnancy (P < 0.0384) and implantation (P < 0.0434) rates than in patients >37 years. In the former subset, results showed: (i) significantly higher implantation rates (P = 0.0411) in couples that had experienced a previous aneuploid miscarriage; (ii) similar aneuploidy, pregnancy and implantation rates in couples suffering previous miscarriages during fertility treatments and in those with previous spontaneous pregnancies; (iii) no miscarriages after PGS in couples in whom a fluorescence in-situ hybridization assay showed the male partner's sperm to be abnormal; and (iv) lower implantation rates in couples with > or =5 previous miscarriages, associated with a lower percentage of chromosomally abnormal embryos. It is concluded that PGS is to be strongly recommended when RPL is associated with miscarriages during infertility treatments, chromosomopathy in a previous miscarriage, up to five previous miscarriages and a high incidence of chromosomal abnormalities in spermatozoa.
7. Flenady V, Frøen JF, Pinar H, Torabi R, Saastad E, Guyon G, Russell L, Charles A, Harrison C, Chauke L, Pattinson R, Koshy R, Bahrin S, Gardener G, Day K, Petersson K, Gordon A, Gilshenan K
An evaluation of classification systems for stillbirth
BMC Pregnancy Childbirth. 2009 Jun 19;9:24
Mater Mothers' Research Centre, Mater Health Services, Brisbane, Australia. Vicki.flenady@mater.org.au
BACKGROUND: Audit and classification of stillbirths is an essential part of clinical practice and a crucial step towards stillbirth prevention. Due to the limitations of the ICD system and lack of an international approach to an acceptable solution, numerous disparate classification systems have emerged. We assessed the performance of six contemporary systems to inform the development of an internationally accepted approach. METHODS: We evaluated the following systems: Amended Aberdeen, Extended Wigglesworth; PSANZ-PDC, ReCoDe, Tulip and CODAC. Nine teams from 7 countries applied the classification systems to cohorts of stillbirths from their regions using 857 stillbirth cases. The main outcome measures were: the ability to retain the important information about the death using the InfoKeep rating; the ease of use according to the Ease rating (both measures used a five-point scale with a score <2 considered unsatisfactory); inter-observer agreement and the proportion of unexplained stillbirths. A randomly selected subset of 100 stillbirths was used to assess inter-observer agreement. RESULTS: InfoKeep scores were significantly different across the classifications (p < or = 0.01) due to low scores for Wigglesworth and Aberdeen. CODAC received the highest mean (SD) score of 3.40 (0.73) followed by PSANZ-PDC, ReCoDe and Tulip [2.77 (1.00), 2.36 (1.21), 1.92 (1.24) respectively]. Wigglesworth and Aberdeen resulted in a high proportion of unexplained stillbirths and CODAC and Tulip the lowest. While Ease scores were different (p < or = 0.01), all systems received satisfactory scores; CODAC received the highest score. Aberdeen and Wigglesworth showed poor agreement with kappas of 0.35 and 0.25 respectively. Tulip performed best with a kappa of 0.74. The remainder had good to fair agreement. CONCLUSION: The Extended Wigglesworth and Amended Aberdeen systems cannot be recommended for classification of stillbirths. Overall, CODAC performed best with PSANZ-PDC and ReCoDe performing well. Tulip was shown to have the best agreement and a low proportion of unexplained stillbirths. The virtues of these systems need to be considered in the development of an international solution to classification of stillbirths. Further studies are required on the performance of classification systems in the context of developing countries. Suboptimal agreement highlights the importance of instituting measures to ensure consistency for any classification system.
8. Kidron D, Bernheim J, Aviram R
Placental Findings Contributing to Fetal Death, a Study of 120 Stillbirths between 23 and 40 Weeks Gestation
Placenta. 2009 Jun 15. [Epub ahead of print]
Department of Pathology, Meir Medical Center, Kfar Sava and Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Unit of Perinatal Pathology, Meir Medical Center, Kfar Sava and Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Meir Medical Center, Kfar Sava and Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel.
BACKGROUND: Intrauterine fetal death is an agonizing, often unpredictable event. Autopsies of stillborn fetuses, including placentas, are performed to clarify the cause of death. Autopsy results are not always easily understood by the patients or their healthcare providers. OBJECTIVE: To evaluate placental causes of death in stillbirths based on autopsy and placental findings that are related to maternal underperfusion, fetal underperfusion, or inflammatory etiologies in hierarchical order. METHODS: Retrospective review of 120 autopsy reports of singleton stillborn fetuses and placentas from 23 to 40 weeks of gestation. RESULTS: Among the placental causes of death there were 54(51%) cases with direct cause or major contributor to death in the etiology of maternal vascular supply abnormalities, 28(26%) cases in the etiology of fetal vascular supply abnormalities and 13(12%) in the etiology of inflammatory lesions. Maternal vascular supply abnormalities were more common in preterm stillbirths and fetal vascular supply abnormalities were more common among term stillbirths. In 88% of stillbirths, the direct cause or a major contributor to death was found in the placentas. The incidence of unexplained death was 8%. CONCLUSIONS: Pathological analysis of the placenta is essential for clarifying causes of stillbirths. Using specific simplified categories for abnormal placental findings may increase the benefits of the autopsy report.
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