NSIDRC Journal Article Alert — July 17, 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.
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.

Sudden Infant Death

1. Lavezzi AM, Corna M, Matturri L, Santoro F

Neuropathology of the Guillain-Mollaret Triangle (Dentato-Rubro-Olivary Network) in Sudden Unexplained Perinatal Death and SIDS

Open Neurol J. 2009 Jun 30;3:48-53

Department of Surgical, Reconstructive and Diagnostic Sciences - "Lino Rossi" Research Center for the study and prevention of unexpected perinatal death and SIDS, University of Milan, Italy.

The present study was undertaken to evaluate the possible alterations of the triangle of Guillain and Mollaret (G-Mt), a neuronal brainstem/cerebellum network (from the dentate nucleus to red nucleus and inferior olivary nucleus) already known for its involvement in the pathogenesis of the palatal myoclonus, in sudden unexplained perinatal and infant death. In 44 cases of perinatal and infant death victims, aged from 26 gestational weeks to 10 months of life, we investigated, besides the histological morphology of the three nuclei, the c-fos and apoptotic expression, as well as the possible effects elicited by maternal cigarette smoking.A significant increase of lesions (hypoplasia and/or increased c-fos and apoptotic neuronal immunopositivity) of the three nuclei was found in unexplained death victims, compared with age-matched controls. These alterations were related to maternal cigarette smoking habit.We postulated that the G-Mt is an important network involved in the pathogenesis of a wide spectrum of pathological manifestations and that maternal smoking during pregnancy can exert an adverse influence on this complex, even leading to sudden death in vulnerable periods of perinatal or infant development.

Miscarriage/Stillbirth/Prenatal Issues

1. Turton P, Badenhorst W, Pawlby S, White S, Hughes P

Psychological vulnerability in children next-born after stillbirth: a case-control follow-up study

J Child Psychol Psychiatry. 2009 Jul 9. [Epub ahead of print]

Division of Mental Health, St George's University of London, UK.

Background: Case studies and anecdotal accounts suggest that perinatal loss may impact upon other children in the family, including those born subsequent to loss. However, there is a dearth of systematically collected quantitative data on this potentially vulnerable group. Methods: Case-controlled follow-up of 52 mothers with history of stillbirth with their next-born children aged 6-8 years, and 51 control mother-child dyads. Previously reported baseline data included maternal antenatal and postnatal psychological assessment, and infant security of attachment at 12 months. Follow-up assessments included maternal psychiatric and socio-demographic data, mother and teacher-rated scales of the child's strengths and difficulties, child IQ, observer-rated mother-child interaction and maternal reports of child health. Results: There were no significant between-group differences in child cognitive or health assessments, or in teacher-rated child difficulties. However, mothers with history of stillbirth (the index group) reported increased child difficulties, in particular peer problems, and more adverse interaction was observed in respect of higher levels of maternal criticism of the child's actions, more overall controlling behaviour by the mother, a less harmonious emotional atmosphere and a lower level of maternal engagement with the child. Some of these effects appeared to be mediated by maternal perinatal psychological symptoms and family breakdown. Conclusions: This study provides no evidence to suggest that siblings born after stillbirth are clinically at risk but does lend empirical support to clinical reports that such children are seen by their mothers as having problems and that they are exposed to less optimal interaction with their mothers. Possible interpretations of these findings are discussed in the context of theoretical accounts of 'replacement child' and 'vulnerable child' syndromes.

2. Erez O, Romero R, Vaisbuch E, Mazaki-Tovi S, Kusanovic JP, Chaiworapongsa T, Than NG, Gotsch F, Kim CJ, Mittal P, Edwin S, Pacora P, Kim SK, Yeo L, Mazor M, Hassan SS

Maternal anti-protein Z antibodies in pregnancies complicated by pre-eclampsia, SGA and fetal death

J Matern Fetal Neonatal Med. 2009 Jul 7:1-10. [Epub ahead of print]

Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, USA.

Objective. Low maternal plasma protein Z (PZ) concentrations were reported in patients with pre-eclampsia (PE), a small for gestational age (SGA) neonate, and a fetal demise (FD). Anti-protein Z antibodies (APZ-AB) have been proposed as a possible underlying mechanism leading to low plasma PZ concentrations. The objective of this study was to determine the maternal plasma concentration of APZ-AB in women with a normal pregnancy, and patients with PE, an SGA neonate or a FD. Study design. A cross-sectional study included women in the following groups: (1) non-pregnant women (n = 45); and pregnant women with: (2) normal pregnancies (n = 70); (3) PE (n = 123); (4) SGA neonates (n = 51); and (5) a FD (n = 51). Plasma concentrations of anti-protein Z IgM and IgG antibodies were measured by ELISA. Elevated APZ-AB was defined as >75th, 90th and 95th percentile of the normal pregnancy group. Non-parametric statistics were used for analyses. Results. (1) Patients with an SGA neonate had a higher median maternal plasma IgG APZ-AB concentration than women with normal pregnancies (p < 0.001), and patients with PE (p < 0.001) or with a FD (p = 0.001). (2) The proportion of patients with a maternal plasma IgM APZ-AB concentration >90th percentile was higher in the SGA group than in the PE group (p = 0.01). (3) Patients with PE maternal plasma IgM APZ-AB concentration >90th percentile had a higher rate of villous thrombosis (p = 0.03) and persistent muscularisation of basal plate arteries (p = 0.01) than those with IgM APZ-AB concentration <90th percentile; and (5) Patients with FD and maternal plasma IgM APZ-AB concentration >90th percentile had a higher rate of umbilical phlebitis and arteritis than those with IgM APZ-AB concentration <90th percentile (p = 0.003). Conclusions. (1) Patients with SGA neonates have a higher median plasma concentration of IgG APZ-AB than normal pregnant women, or patients with PE or FD; and (2) maternal plasma IgM APZ-AB concentration >90th percentile was associated with vascular placental lesions in patients with PE, but not in those with an SGA neonate, suggesting that in a subset of patients, these antibodies can be associated with abnormal placentation and pregnancy complications.

3. Chi CC, Lee CW, Wojnarowska F, Kirtschig G

Safety of topical corticosteroids in pregnancy

Cochrane Database Syst Rev. 2009 Jul 8;(3):CD007346

Department of Dermatology, Chang Gung Memorial Hospital-Chiayi, Chang Gung University College of Medicine, 6, Sec West, Chia-Pu Road, Putz, Chiayi, Taiwan, 61363.

BACKGROUND: Topical corticosteroids are the most frequently prescribed dermatological treatment and are frequently used by pregnant women with skin conditions. However, little is known about their safety in pregnancy. OBJECTIVES: To assess the effects of topical corticosteroids on pregnancy outcomes. SEARCH STRATEGY: On 5th May 2009 we searched the Cochrane Skin Group Specialised Register, the Cochrane Pregnancy and Childbirth Group Specialised Register, CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (from 2003), and EMBASE (from 2005). We searched LILACS, CINAHL, British Nursing Index, SCI-EXPANDED, BIOSIS Previews, Conference Papers Index, and Conference Proceedings Citation Index-Science from inception to May 2009. We scanned the bibliographies of the included studies, published reviews, and articles that had cited the included studies. Pharmaceutical companies that have introduced an original topical corticosteroid product were contacted. SELECTION CRITERIA: Randomised controlled trials and cohort studies of topical corticosteroids in pregnant women, and case-control studies comparing maternal exposure to topical corticosteroids between cases and controls were included where outcomes were those we had pre-specified. Outcomes included mode of delivery, congenital abnormality, birthweight, preterm delivery, stillbirth, and low Apgar score. DATA COLLECTION AND ANALYSIS: Two authors independently applied selection criteria, extracted data, and assessed the quality of the included studies. A third author was available for resolving differences of opinion. MAIN RESULTS: Seven studies, including 2 cohort and 5 case-control studies, of 659,675 participants were included. We did not undertake a meta-analysis due to considerable methodological heterogeneity. The available data was limited and mainly on orofacial cleft. Most studies did not find significant associations between topical corticosteroids and pregnancy outcomes including mode of delivery, congenital abnormality, preterm delivery, and stillbirth. One study found a significant association between first trimester topical corticosteroid use and orofacial cleft, and another found a significant association between very potent topical corticosteroids and low birthweight. Nevertheless, all the studies had drawbacks, and the quality of evidence was low to very low. AUTHORS' CONCLUSIONS: Currently limited and inconclusive data are unable to detect an association between topical corticosteroids and congenital abnormality, preterm delivery, or stillbirth. The current evidence shows no statistically significant difference between pregnant women who use and those who do not use topical corticosteroids. However, there does appear to be an association of very potent topical corticosteroids with low birthweight. Cohort studies with comprehensive outcome measures, assessment of effects of corticosteroid potency and dose, application methods, and reasons for giving them, and a very large sample size are needed.

4. Salihu HM, Mbah AK, Alio AP, Lynch O, Wathington D, Kornosky JL

Maternal prepregnancy underweight and risk of early and late stillbirth in black and white gravidas

J Natl Med Assoc. 2009 Jun;101(6):582-7

Department of Obstetrics and Gynecology, The Chiles Center for Healthy Mothers and Babies, University of South Florida, 3111 E Fletcher Ave, Tampa, FL 33613, USA. hamisu.salihu@gmail.com

OBJECTIVE: The association between underweight and stillbirth remains poorly defined, especially across racial/ethnic sub-populations. We investigate the association of pre-pregnancy underweight on the risk for early and late stillbirth among black and white mothers. METHODS: We conducted analysis on the Missouri maternally linked data files covering the period 1989-1997 inclusive. Using body mass index (BMI), we categorized mothers as underweight (BMI <18.5) and normal weight (BMI = 18.5-24.9). By applying logistic regression modeling with adjustment for intracluster correlation, we estimated the risk for total, early (-28 weeks of gestation), and late stillbirth (>28 weeks of gestation) among black and white mothers. RESULTS: A total of 1808 cases of stillbirth were registered. The rate of stillbirth among white mothers was 3.7 per 1000, while the rate among blacks was 7.1 per 1000. Underweight black mothers had comparable risk for total (OR, 0.9; 95% CI, 0.7-1.2), early (OR, 1.1; 95% CI, 0.8-1.5), and late stillbirth (OR, 0.8; 95% CI, 0.5-1.2) as compared to their normal-weight counterparts. By contrast, underweight white gravidas had a 30% reduced likelihood (OR, 0.7; 95% CI, 0.6-0.9) for late stillbirth as compared to normal-weight white mothers. However, the risks for total and early stillbirth among underweight white mothers were similar to those of normal-weight white mothers. CONCLUSION: Low prepregnancy BMI has similar effects on fetal survival in both blacks and whites except for late stillbirth. The underweight white survival advantage over blacks in late pregnancy could probably be due to greater access for identified white at-risk groups to effective obstetrical interventions as previously reported.

5. Chan MF, Lou FL, Cao FL, Li P, Liu L, Wu LH

Investigating factors associated with nurses' attitudes towards perinatal bereavement care: a study in Shandong and Hong Kong

J Clin Nurs. 2009 Aug;18(16):2344-54

Alice Lee Centre for Nursing Studies, National University of Singapore, 7 Engineering Drive 1, Singapore. nurcmf@nus.edu.sg

AIMS: To explore nurses' attitudes towards perinatal bereavement care and to identify factors associated with these attitudes. BACKGROUND: It is likely that the attitude of nursing staff can influence recovery from a pregnancy loss and that nurses with positive attitudes to bereavement care can help bereaved parents to cope during their grieving period. DESIGN: Survey. METHOD: Data were collected through a structured questionnaire; 657 nurses were recruited from Obstetrics and Gynaecology units in Hong Kong and Shandong during 2006. Outcome measures included attitudes towards perinatal bereavement care, importance of hospital policy and training support for bereavement care. RESULTS: The majority of nurses in this study had a positive attitude to bereavement care. Results show that only 21.6% (n = 141) of the nurses surveyed had bereavement-related training. In contrast, about 89.8% (n = 300) believed they needed to be equipped with relevant knowledge, skills and understanding in the care and support of bereaved parents and more than 88.5% (n = 592) would share their experiences with their colleagues and seek support when feeling under stress. A regression model showed that age, past experience in handling grieving parents, recent ranking and nurses' perceived attitudes to hospital policy and training provided for bereavement care were the factors associated with nurses' attitudes to perinatal bereavement care. CONCLUSIONS: Nurses in both cities emphasised 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 by nursing educators to educate their students on issues related to delivery of sensitive bereavement care in perinatal settings and to enhance nursing school curricula.

6. Gardosi J, Francis A

Adverse pregnancy outcome and association with small for gestational age birthweight by customized and population-based percentiles

Am J Obstet Gynecol. 2009 Jul;201(1):28.e1-8

West Midlands Perinatal Institute, Birmingham, England, UK. jason.gardosi@pi.nhs.uk

OBJECTIVE: The objective of the study was to investigate the association between pregnancy complications and small for gestational age (SGA) birthweight, comparing SGA based on the customized growth potential with SGA based on the birthweight standard of the same population. STUDY DESIGN: This was a retrospective analysis of a database from a US multicenter study. Pregnancy complications included threatened preterm labor, antepartum hemorrhage, pregnancy-induced hypertension, preeclampsia, stillbirth, and early neonatal death. RESULTS: Compared with SGA by the birthweight standard, SGA by customized growth potential showed higher risk for each of the 6 adverse indicators. A third of the SGA group was small by customized centiles but not by population-based centiles, yet was strongly associated with each of the pregnancy complications studied. This subgroup of unrecognized SGA babies included 26% preterm deliveries. In contrast, a subgroup that was SGA by the population standard but not by the customized standard (17.2%), was not associated with any of the indicators of adverse outcome. CONCLUSION: SGA defined by customized growth potential improves the differentiation between physiologically and pathologically small babies.

7. 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.

8. Vahter M

Effects of Arsenic on Maternal and Fetal Health

Annu Rev Nutr. 2009 Jun 12. [Epub ahead of print]

Institute of Environmental Medicine, Karolinska Institutet, SE 171 77 Stockholm, Sweden; email: Marie.Vahter@ki.se.

Arsenic, which is commonly found in drinking water, is a potent toxicant, but little is known about its effects on maternal health. Arsenic's modes of action include enzyme inhibition and oxidative stress as well as immune, endocrine, and epigenetic effects. A couple of studies reported increased blood pressure and anemia during pregnancy. Susceptibility to arsenic is dependent on the biomethylation, which occurs via onecarbon metabolism. Methylarsonic acid and dimethylarsinic acid are main metabolites in urine, and elevated methylarsonic acid is considered a general risk factor. Arsenic easily passes the placenta, and a few human studies indicate a moderately increased risk of impaired fetal growth and increased fetal and infant mortality. The fetus and infant are probably partly protected by the increased methylation of arsenic during pregnancy and lactation; the infant is also protected by low arsenic excretion in breast milk. Early-life exposure may induce changes that will become apparent much later in life. Expected final online publication date for the Annual Review of Nutrition Volume 29 is July 17, 2009. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.

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Please see your local library for copies of these articles, or view PubMed's How to Get the Journal Article for more details. Sudden Infant Death 1. Lavezzi AM, Corna M, Matturri L, Santoro F Neuropathology of the Guillain-Mollaret Triangle (Dentato-Rubro-Olivary Network) in Sudden Unexplained Perinatal Death and SIDS Open Neurol J. 2009 Jun 30;3:48-53 Department of Surgical, Reconstructive and Diagnostic Sciences - "Lino Rossi" Research Center for the study and prevention of unexpected perinatal death and SIDS, University of Milan, Italy. The present study was undertaken to evaluate the possible alterations of the triangle of Guillain and Mollaret (G-Mt), a neuronal brainstem/cerebellum network (from the dentate nucleus to red nucleus and inferior olivary nucleus) already known for its involvement in the pathogenesis of the palatal myoclonus, in sudden unexplained perinatal and infant death. In 44 cases of perinatal and infant death victims, aged from 26 gestational weeks to 10 months of life, we investigated, besides the histological morphology of the three nuclei, the c-fos and apoptotic expression, as well as the possible effects elicited by maternal cigarette smoking.A significant increase of lesions (hypoplasia and/or increased c-fos and apoptotic neuronal immunopositivity) of the three nuclei was found in unexplained death victims, compared with age-matched controls. These alterations were related to maternal cigarette smoking habit.We postulated that the G-Mt is an important network involved in the pathogenesis of a wide spectrum of pathological manifestations and that maternal smoking during pregnancy can exert an adverse influence on this complex, even leading to sudden death in vulnerable periods of perinatal or infant development. Miscarriage/Stillbirth/Prenatal Issues 1. Turton P, Badenhorst W, Pawlby S, White S, Hughes P Psychological vulnerability in children next-born after stillbirth: a case-control follow-up study J Child Psychol Psychiatry. 2009 Jul 9. [Epub ahead of print] Division of Mental Health, St George's University of London, UK. Background: Case studies and anecdotal accounts suggest that perinatal loss may impact upon other children in the family, including those born subsequent to loss. However, there is a dearth of systematically collected quantitative data on this potentially vulnerable group. Methods: Case-controlled follow-up of 52 mothers with history of stillbirth with their next-born children aged 6-8 years, and 51 control mother-child dyads. Previously reported baseline data included maternal antenatal and postnatal psychological assessment, and infant security of attachment at 12 months. Follow-up assessments included maternal psychiatric and socio-demographic data, mother and teacher-rated scales of the child's strengths and difficulties, child IQ, observer-rated mother-child interaction and maternal reports of child health. Results: There were no significant between-group differences in child cognitive or health assessments, or in teacher-rated child difficulties. However, mothers with history of stillbirth (the index group) reported increased child difficulties, in particular peer problems, and more adverse interaction was observed in respect of higher levels of maternal criticism of the child's actions, more overall controlling behaviour by the mother, a less harmonious emotional atmosphere and a lower level of maternal engagement with the child. Some of these effects appeared to be mediated by maternal perinatal psychological symptoms and family breakdown. Conclusions: This study provides no evidence to suggest that siblings born after stillbirth are clinically at risk but does lend empirical support to clinical reports that such children are seen by their mothers as having problems and that they are exposed to less optimal interaction with their mothers. Possible interpretations of these findings are discussed in the context of theoretical accounts of 'replacement child' and 'vulnerable child' syndromes. 2. Erez O, Romero R, Vaisbuch E, Mazaki-Tovi S, Kusanovic JP, Chaiworapongsa T, Than NG, Gotsch F, Kim CJ, Mittal P, Edwin S, Pacora P, Kim SK, Yeo L, Mazor M, Hassan SS Maternal anti-protein Z antibodies in pregnancies complicated by pre-eclampsia, SGA and fetal death J Matern Fetal Neonatal Med. 2009 Jul 7:1-10. [Epub ahead of print] Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, USA. Objective. Low maternal plasma protein Z (PZ) concentrations were reported in patients with pre-eclampsia (PE), a small for gestational age (SGA) neonate, and a fetal demise (FD). Anti-protein Z antibodies (APZ-AB) have been proposed as a possible underlying mechanism leading to low plasma PZ concentrations. The objective of this study was to determine the maternal plasma concentration of APZ-AB in women with a normal pregnancy, and patients with PE, an SGA neonate or a FD. Study design. A cross-sectional study included women in the following groups: (1) non-pregnant women (n = 45); and pregnant women with: (2) normal pregnancies (n = 70); (3) PE (n = 123); (4) SGA neonates (n = 51); and (5) a FD (n = 51). Plasma concentrations of anti-protein Z IgM and IgG antibodies were measured by ELISA. Elevated APZ-AB was defined as >75th, 90th and 95th percentile of the normal pregnancy group. Non-parametric statistics were used for analyses. Results. (1) Patients with an SGA neonate had a higher median maternal plasma IgG APZ-AB concentration than women with normal pregnancies (p < 0.001), and patients with PE (p < 0.001) or with a FD (p = 0.001). (2) The proportion of patients with a maternal plasma IgM APZ-AB concentration >90th percentile was higher in the SGA group than in the PE group (p = 0.01). (3) Patients with PE maternal plasma IgM APZ-AB concentration >90th percentile had a higher rate of villous thrombosis (p = 0.03) and persistent muscularisation of basal plate arteries (p = 0.01) than those with IgM APZ-AB concentration <90th percentile; and (5) Patients with FD and maternal plasma IgM APZ-AB concentration >90th percentile had a higher rate of umbilical phlebitis and arteritis than those with IgM APZ-AB concentration <90th percentile (p = 0.003). Conclusions. (1) Patients with SGA neonates have a higher median plasma concentration of IgG APZ-AB than normal pregnant women, or patients with PE or FD; and (2) maternal plasma IgM APZ-AB concentration >90th percentile was associated with vascular placental lesions in patients with PE, but not in those with an SGA neonate, suggesting that in a subset of patients, these antibodies can be associated with abnormal placentation and pregnancy complications. 3. Chi CC, Lee CW, Wojnarowska F, Kirtschig G Safety of topical corticosteroids in pregnancy Cochrane Database Syst Rev. 2009 Jul 8;(3):CD007346 Department of Dermatology, Chang Gung Memorial Hospital-Chiayi, Chang Gung University College of Medicine, 6, Sec West, Chia-Pu Road, Putz, Chiayi, Taiwan, 61363. BACKGROUND: Topical corticosteroids are the most frequently prescribed dermatological treatment and are frequently used by pregnant women with skin conditions. However, little is known about their safety in pregnancy. OBJECTIVES: To assess the effects of topical corticosteroids on pregnancy outcomes. SEARCH STRATEGY: On 5th May 2009 we searched the Cochrane Skin Group Specialised Register, the Cochrane Pregnancy and Childbirth Group Specialised Register, CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (from 2003), and EMBASE (from 2005). We searched LILACS, CINAHL, British Nursing Index, SCI-EXPANDED, BIOSIS Previews, Conference Papers Index, and Conference Proceedings Citation Index-Science from inception to May 2009. We scanned the bibliographies of the included studies, published reviews, and articles that had cited the included studies. Pharmaceutical companies that have introduced an original topical corticosteroid product were contacted. SELECTION CRITERIA: Randomised controlled trials and cohort studies of topical corticosteroids in pregnant women, and case-control studies comparing maternal exposure to topical corticosteroids between cases and controls were included where outcomes were those we had pre-specified. Outcomes included mode of delivery, congenital abnormality, birthweight, preterm delivery, stillbirth, and low Apgar score. DATA COLLECTION AND ANALYSIS: Two authors independently applied selection criteria, extracted data, and assessed the quality of the included studies. A third author was available for resolving differences of opinion. MAIN RESULTS: Seven studies, including 2 cohort and 5 case-control studies, of 659,675 participants were included. We did not undertake a meta-analysis due to considerable methodological heterogeneity. The available data was limited and mainly on orofacial cleft. Most studies did not find significant associations between topical corticosteroids and pregnancy outcomes including mode of delivery, congenital abnormality, preterm delivery, and stillbirth. One study found a significant association between first trimester topical corticosteroid use and orofacial cleft, and another found a significant association between very potent topical corticosteroids and low birthweight. Nevertheless, all the studies had drawbacks, and the quality of evidence was low to very low. AUTHORS' CONCLUSIONS: Currently limited and inconclusive data are unable to detect an association between topical corticosteroids and congenital abnormality, preterm delivery, or stillbirth. The current evidence shows no statistically significant difference between pregnant women who use and those who do not use topical corticosteroids. However, there does appear to be an association of very potent topical corticosteroids with low birthweight. Cohort studies with comprehensive outcome measures, assessment of effects of corticosteroid potency and dose, application methods, and reasons for giving them, and a very large sample size are needed. 4. Salihu HM, Mbah AK, Alio AP, Lynch O, Wathington D, Kornosky JL Maternal prepregnancy underweight and risk of early and late stillbirth in black and white gravidas J Natl Med Assoc. 2009 Jun;101(6):582-7 Department of Obstetrics and Gynecology, The Chiles Center for Healthy Mothers and Babies, University of South Florida, 3111 E Fletcher Ave, Tampa, FL 33613, USA. hamisu.salihu@gmail.com OBJECTIVE: The association between underweight and stillbirth remains poorly defined, especially across racial/ethnic sub-populations. We investigate the association of pre-pregnancy underweight on the risk for early and late stillbirth among black and white mothers. METHODS: We conducted analysis on the Missouri maternally linked data files covering the period 1989-1997 inclusive. Using body mass index (BMI), we categorized mothers as underweight (BMI <18.5) and normal weight (BMI = 18.5-24.9). By applying logistic regression modeling with adjustment for intracluster correlation, we estimated the risk for total, early (-28 weeks of gestation), and late stillbirth (>28 weeks of gestation) among black and white mothers. RESULTS: A total of 1808 cases of stillbirth were registered. The rate of stillbirth among white mothers was 3.7 per 1000, while the rate among blacks was 7.1 per 1000. Underweight black mothers had comparable risk for total (OR, 0.9; 95% CI, 0.7-1.2), early (OR, 1.1; 95% CI, 0.8-1.5), and late stillbirth (OR, 0.8; 95% CI, 0.5-1.2) as compared to their normal-weight counterparts. By contrast, underweight white gravidas had a 30% reduced likelihood (OR, 0.7; 95% CI, 0.6-0.9) for late stillbirth as compared to normal-weight white mothers. However, the risks for total and early stillbirth among underweight white mothers were similar to those of normal-weight white mothers. CONCLUSION: Low prepregnancy BMI has similar effects on fetal survival in both blacks and whites except for late stillbirth. The underweight white survival advantage over blacks in late pregnancy could probably be due to greater access for identified white at-risk groups to effective obstetrical interventions as previously reported. 5. Chan MF, Lou FL, Cao FL, Li P, Liu L, Wu LH Investigating factors associated with nurses' attitudes towards perinatal bereavement care: a study in Shandong and Hong Kong J Clin Nurs. 2009 Aug;18(16):2344-54 Alice Lee Centre for Nursing Studies, National University of Singapore, 7 Engineering Drive 1, Singapore. nurcmf@nus.edu.sg AIMS: To explore nurses' attitudes towards perinatal bereavement care and to identify factors associated with these attitudes. BACKGROUND: It is likely that the attitude of nursing staff can influence recovery from a pregnancy loss and that nurses with positive attitudes to bereavement care can help bereaved parents to cope during their grieving period. DESIGN: Survey. METHOD: Data were collected through a structured questionnaire; 657 nurses were recruited from Obstetrics and Gynaecology units in Hong Kong and Shandong during 2006. Outcome measures included attitudes towards perinatal bereavement care, importance of hospital policy and training support for bereavement care. RESULTS: The majority of nurses in this study had a positive attitude to bereavement care. Results show that only 21.6% (n = 141) of the nurses surveyed had bereavement-related training. In contrast, about 89.8% (n = 300) believed they needed to be equipped with relevant knowledge, skills and understanding in the care and support of bereaved parents and more than 88.5% (n = 592) would share their experiences with their colleagues and seek support when feeling under stress. A regression model showed that age, past experience in handling grieving parents, recent ranking and nurses' perceived attitudes to hospital policy and training provided for bereavement care were the factors associated with nurses' attitudes to perinatal bereavement care. CONCLUSIONS: Nurses in both cities emphasised 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 by nursing educators to educate their students on issues related to delivery of sensitive bereavement care in perinatal settings and to enhance nursing school curricula. 6. Gardosi J, Francis A Adverse pregnancy outcome and association with small for gestational age birthweight by customized and population-based percentiles Am J Obstet Gynecol. 2009 Jul;201(1):28.e1-8 West Midlands Perinatal Institute, Birmingham, England, UK. jason.gardosi@pi.nhs.uk OBJECTIVE: The objective of the study was to investigate the association between pregnancy complications and small for gestational age (SGA) birthweight, comparing SGA based on the customized growth potential with SGA based on the birthweight standard of the same population. STUDY DESIGN: This was a retrospective analysis of a database from a US multicenter study. Pregnancy complications included threatened preterm labor, antepartum hemorrhage, pregnancy-induced hypertension, preeclampsia, stillbirth, and early neonatal death. RESULTS: Compared with SGA by the birthweight standard, SGA by customized growth potential showed higher risk for each of the 6 adverse indicators. A third of the SGA group was small by customized centiles but not by population-based centiles, yet was strongly associated with each of the pregnancy complications studied. This subgroup of unrecognized SGA babies included 26% preterm deliveries. In contrast, a subgroup that was SGA by the population standard but not by the customized standard (17.2%), was not associated with any of the indicators of adverse outcome. CONCLUSION: SGA defined by customized growth potential improves the differentiation between physiologically and pathologically small babies. 7. 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. 8. Vahter M Effects of Arsenic on Maternal and Fetal Health Annu Rev Nutr. 2009 Jun 12. [Epub ahead of print] Institute of Environmental Medicine, Karolinska Institutet, SE 171 77 Stockholm, Sweden; email: Marie.Vahter@ki.se. Arsenic, which is commonly found in drinking water, is a potent toxicant, but little is known about its effects on maternal health. Arsenic's modes of action include enzyme inhibition and oxidative stress as well as immune, endocrine, and epigenetic effects. A couple of studies reported increased blood pressure and anemia during pregnancy. Susceptibility to arsenic is dependent on the biomethylation, which occurs via onecarbon metabolism. Methylarsonic acid and dimethylarsinic acid are main metabolites in urine, and elevated methylarsonic acid is considered a general risk factor. Arsenic easily passes the placenta, and a few human studies indicate a moderately increased risk of impaired fetal growth and increased fetal and infant mortality. The fetus and infant are probably partly protected by the increased methylation of arsenic during pregnancy and lactation; the infant is also protected by low arsenic excretion in breast milk. Early-life exposure may induce changes that will become apparent much later in life. Expected final online publication date for the Annual Review of Nutrition Volume 29 is July 17, 2009. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates. Prepared by the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center Georgetown University 2115 Wisconsin Avenue, N.W., Suite 601 Washington, DC 20007 (866) 866-7437 toll free (202) 687-7466 local (202) 784-9777 fax info@sidscenter.org http://www.sidscenter.org
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