NSIDRC Journal Article Alert — October 16, 2009
Prepared by the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center at Georgetown University.
These articles have been selected from PubMed, a service of the National Library of Medicine that includes over 19 million citations from MEDLINE and other life science journals for biomedical articles back to 1948. PubMed includes links to full text articles and other related resources.
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Sudden Infant Death
1. Mitchell EA
SIDS: past, present and future
Acta Paediatr. 2009 Nov;98(11):1712-9
Department of Paediatrics, University of Auckland, Auckland, New Zealand. e.mitchell@auckland.ac.nz
Despite the large reduction in SIDS mortality, which occurred in the early 1990s following the 'Back to Sleep' campaigns, SIDS remains the leading cause of death in the postneonatal age group. This paper describes the position in the 1980s, the contribution of the New Zealand Cot Death Study, what should be recommended and the current research priorities. Conclusion: SIDS is preventable. Application of what we currently know could eliminate SIDS. The challenge is to find ways of implementing our knowledge.
Miscarriage/Stillbirth/Prenatal Issues
1. Goodman C, Hur J, Goodman CS, Jeyendran RS, Coulam C
Are Polymorphisms in the ACE and PAI-1 Genes Associated with Recurrent Spontaneous Miscarriages?
Am J Reprod Immunol. 2009 Oct 11. [Epub ahead of print]
CARI Reproductive Institute, Chicago, IL, USA.
Problem To determine whether the ACE D/D genotype or the combination of PAI-1 4G/4G and ACE D/D genotypes may serve as a risk factor for recurrent pregnancy loss. Method of study Buccal swabs were obtained from 120 women experiencing recurrent pregnancy loss and from 84 fertile control women. DNA was extracted from the buccal swab samples using the Qiagen DNA Mini Kit (Qiagen), followed by multiplex polymerase chain reaction (PCR). PCR products were analyzed for the ACE gene polymorphism, which consists of the insertion or deletion (I/D) of a 287-bp fragment in intron 16, and the PAI-1 4G/4G genotype. Results No significant differences in specific ACE gene mutations were observed when patients experiencing recurrent miscarriage were compared with control women. When the frequencies of homozygous mutations for ACE D/D and PAI-I 4G/4G were compared between recurrent aborters and controls, again no significant differences in the prevalence of the combination of these gene mutations were noted. Conclusion Homozygosity for the D allele of the ACE gene and the combination of the D/D genotype with two 4G alleles of the PAI-1 promoter gene are not associated with a significant increase in the risk of recurrent miscarriage.
2. O'sullivan O, Stephen G, Martindale E, Heazell AE
Predicting poor perinatal outcome in women who present with decreased fetal movements
J Obstet Gynaecol. 2009 Nov;29(8):705-10
Department of Obstetrics and Gynaecology, Royal Blackburn Hospital, Blackburn.
Maternal perception of decreased fetal movements (DFM) is associated with increased incidence of stillbirth and intrauterine growth restriction. We hypothesised that clinical assessment of women perceiving DFM may identify patients at highest risk of poor perinatal outcome. This was a retrospective study of 203 patients presenting to the obstetric triage service with DFM. Information on obstetric and past medical history, the current presentation with DFM and the outcome of pregnancy was collected. Using multivariate analysis, odds ratios (OR) and 95% confidence intervals (CI) were calculated for poor pregnancy outcome defined as stillbirth, small for gestational age or pre-term delivery. The rate of stillbirth was increased in women with DFM (OR 2.9). Some 26.6% of women perceiving DFM had a poor perinatal outcome. Women with relevant past obstetric history (OR 2.11), two or more presentations of DFM (OR 1.92), or who measured small-for-dates (OR 19.53) were at increased risk of poor pregnancy outcome. These preliminary data suggest that some features of clinical assessment can identify patients at increased risk of poor perinatal outcome after presentation with DFM. Such patients may be prioritised for detailed assessment of fetal growth and wellbeing.
3. El-Sayed MM, Mohamed SA, Jones MH
J Obstet Gynaecol. 2009 Nov;29(8):681-5
Expectant management of first-trimester miscarriage
Department of Obstetrics and Gynaecology, Darent Valley Hospital, Dartford.
Miscarriage is the most common complication of pregnancy, which creates a significant workload for health-care professionals. For decades, surgical evacuation of the uterus has remained the conventional treatment of first-trimester miscarriage. Recently, non surgical treatments have been introduced with increasing popularity. This review explores the evidence in support of expectant management of first-trimester miscarriage. It is safe, effective and well-tolerated by women. It enhances women's choice and control. It generates significant cost savings compared with the traditional surgical management. Accurate diagnosis, counselling, 24/7 telephone advice and follow-up are among the important aspects of expectant management. More studies are needed to develop methods for identifying miscarriages suitable for expectant management.
4. King K, Smith S, Chapman M, Sacks G
Detailed analysis of peripheral blood natural killer (NK) cells in women with recurrent miscarriage
Hum Reprod. 2009 Oct 9. [Epub ahead of print]
St George Hospital, UNSW and IVF Australia, Sydney, Australia.
BACKGROUND Increased peripheral blood natural killer (NK) cell activity has been associated with unexplained reproductive failure including recurrent (three or more) miscarriages (RM). Studies have reported abnormalities in both numbers (absolute and proportion) and activation. This study assessed numerous NK cell parameters to determine which (if any) are altered in women with RM compared with controls, which parameter best differentiated women with RM from controls, and what NK levels should be considered high. METHODS Luteal-phase blood samples from women with RM (n = 104) and controls (n = 33) were analysed by four-colour flow cytometry. NK cells were analysed as a percentage of lymphocytes, total NK concentration, CD56(Dim) subtype concentration and percentage, activated CD69(+)CD56(Dim) subtype concentration and percentage and CD56(+Bright):CD56(+Dim) subtype ratio. Women with RM were analysed in two subgroups: those positive in >/=1 RM screening tests (karyotype, uterine, antiphospholipid syndrome, thrombophilia) (n = 48) and those who had negative screening tests (n = 56). RESULTS Women with RM had significantly higher NK percentage (P < 0.001), and significantly lower CD56(+Bright):CD56(+Dim) ratio (P < 0.05) than controls. NK percentage was the only significantly higher variable in the RM screening test negative subgroup (P < 0.01). A ROC analysis (AUC = 0.71) found that an NK percentage >18% was highly specific for women with RM (97.0%), and defined 12.5% of women with RM as having high NK percentage, compared with 2.9% of controls. CONCLUSION Women with RM have altered peripheral blood NK parameters. NK cells as a percentage of lymphocytes best discriminated RM and control populations. Women with RM and high NK levels may have an immunological disorder.
5. Smith LF, Ewings PD, Quinlan C
Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial
BMJ. 2009 Oct 8;339:b3827. doi: 10.1136/bmj.b3827
East Somerset Research Consortium, Westlake Surgery, West Coker, Somerset BA22 9AH. research@esrec.nhs.uk
OBJECTIVES: To compare fertility rates after the three methods of managing early miscarriage in women recruited to the MIST (miscarriage treatment) randomised controlled trial. SETTING: Early pregnancy clinics of acute hospitals in the south west region of England. PARTICIPANTS: 1199 women who had had an early miscarriage (<13 weeks) confirmed by scan. INTERVENTION: Expectant, medical, or surgical management. MAIN OUTCOME MEASURES: Self reported pregnancy rates and live birth rates. RESULTS: Of 1199 women recruited to the trial, 1128 consented to follow-up. Of these, 762 women replied giving pregnancy details (68% response rate). Respondents were representative of the trial participants. The live birth rate five years after the index miscarriage was similar in the three management groups: 177/224 (79%, 95% confidence interval 73% to 84%) in the expectant management group, 181/230 (79%, 73% to 84%) in the medical group, and 192/235 (82%, 76% to 86%) in the surgical group. There was also no significant difference according to previous birth history. Older women and those with previous miscarriages were significantly less likely to subsequently give birth. CONCLUSION: Method of miscarriage management does not affect subsequent pregnancy rates with around four in five women giving birth within five years of the index miscarriage. Women can be reassured that long term fertility concerns need not affect their choice of miscarriage management. TRIAL REGISTRATION: National Research Register N0467011677/N0467073587.
6. Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson B, Darmstadt GL
Two million intrapartum-related stillbirths and neonatal deaths: Where, why, and what can be done?
Int J Gynaecol Obstet. 2009 Aug 28. [Epub ahead of print]
Saving Newborn Lives/Save the Children-USA.
BACKGROUND: Intrapartum-related neonatal deaths ("birth asphyxia") are a leading cause of child mortality globally, outnumbering deaths from malaria. Reduction is crucial to meeting the fourth Millennium Development Goal (MDG), and is intimately linked to intrapartum stillbirths as well as maternal health and MDG 5, yet there is a lack of consensus on what works, especially in weak health systems. OBJECTIVE: To clarify terminology for intrapartum-related outcomes; to describe the intrapartum-related global burden; to present current coverage and trends for care at birth; and to outline aims and methods for this comprehensive 7-paper supplement reviewing strategies to reduce intrapartum-related deaths. RESULTS: Birth is a critical time for the mother and fetus with an estimated 1.02 million intrapartum stillbirths, 904000 intrapartum-related neonatal deaths, and around 42% of the 535900 maternal deaths each year. Most of the burden (99%) occurs in low- and middle-income countries. Intrapartum-related neonatal mortality rates are 25-fold higher in the lowest income countries and intrapartum stillbirth rates are up to 50-fold higher. Maternal risk factors and delays in accessing care are critical contributors. The rural poor are at particular risk, and also have the lowest coverage of skilled care at birth. Almost 30000 abstracts were searched and the evidence is evaluated and reported in the 6 subsequent papers. CONCLUSION: Each year the deaths of 2 million babies are linked to complications during birth and the burden is inequitably carried by the poor. Evidence-based strategies are urgently needed to reduce the burden of intrapartum-related deaths particularly in low- and middle-income settings where 60 million women give birth at home.
7. Gleicher N, Ryan E, Weghofer A, Blanco-Mejia S, Barad DH
Miscarriage rates after dehydroepiandrosterone (DHEA) supplementation in women with diminished ovarian reserve: a case control study
Reprod Biol Endocrinol. 2009 Oct 7;7(1):108. [Epub ahead of print]
ABSTRACT: BACKGROUND: Dehydroepinadrosterone (DHEA) supplementation improves pregnancy chances in women with diminished ovarian reserve (DOR), by possibly reducing aneuploidy. Since a large majority of spontaneous miscarriages are associated with aneuploidy, one can speculate that DHEA supplementation may also reduce miscarriage rates. METHODS: We retroactively compared, utilizing two independent statistical models, miscarriage rates in 73 DHEA supplemented pregnancies at two independent North American infertility centers, age-stratified, to miscarriages reported in a national U.S. in vitro fertilization (IVF) data base. RESULTS: After DHEA supplementation the miscarriage rate at both centers was 15.1% (15.0% and 15.2%, respectively). For DHEA supplementation Mantel-Hanszel common odds ratio (and 95% confidence interval), stratified by age, was significantly lower, relative to odds of miscarriage in the general IVF control population [0.49 (0.25 - 0.94; p = 0.04)]. Miscarriage rates after DHEA were significantly lower at all ages but most pronounced above age 35 years. DISCUSSION: Since DOR patients in the literature are reported to experience significantly higher miscarriage rates than average IVF patients, the here observed reduction in miscarriages after DHEA supplementation exceeds, however, all expectations. Miscarriage rates after DHEA not only were lower than in an average national IVF population but were comparable to rates reported in normally fertile populations. Low miscarriage rates, comparable to those of normal fertile women, are statistically impossible to achieve in DOR patients without assumption of a DHEA effect on embryo ploidy. Beyond further investigations in infertile populations, these data, therefore, also suggest the investigations of pre-conception DHEA supplementation in normal fertile populations above age 35 years.
8. Shimada S, Takeda M, Nishihira J, Kaneuchi M, Sakuragi N, Minakami H, Yamada H
A high dose of intravenous immunoglobulin increases CD94 expression on natural killer cells in women with recurrent spontaneous abortion
Am J Reprod Immunol. 2009 Nov;62(5):301-7
Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
PROBLEM: A high dose of intravenous immunoglobulin (HIVIg) therapy is effective in various diseases such as autoimmune diseases, and also is expected to have efficacy in recurrent spontaneous abortion (RSA). The aim of this study was to understand immunological mechanisms of this therapy. METHOD OF STUDY: By flowcytometric analyses, we examined phenotypic changes of a variety of immunological cells including natural killer (NK) cells, cytotoxic T cells, regulatory T cells and macrophages in peripheral blood of RSA women with HIVIg therapy (n = 8). RESULTS: Expression percentages of inhibitory CD94 on NK cells significantly (P = 0.01) increased after the therapy (58.8 +/- 21.4% versus 71.0 +/- 17.6%). CONCLUSION: Mechanisms of possible efficacy of HIVIg therapy for RSA may include enhancement of CD94 expression and subsequent suppression of NK cell cytotoxicity.
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