NSIDRC Journal Article Alert — December 4, 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. Krous HF, Haas E, Hampton CF, Chadwick AE, Stanley C, Langston C
Pulmonary arterial medial smooth muscle thickness in sudden infant death syndrome: an analysis of subsets of 73 cases
Forensic Sci Med Pathol. 2009 Nov 28. [Epub ahead of print]
Department of Pathology, Rady Children's Hospital-San Diego, 3020 Children's Way, MC5007, San Diego, CA, 92123, USA, hkrous@rchsd.org.
Previous studies addressing pulmonary artery morphology have compared cases of sudden infant death syndrome (SIDS) to controls but none have compared demographic profiles, exposure to potentially hypoxic risk factors and other pathologic variables in SIDS cases grouped according to pulmonary artery medial smooth muscle thickness. Aims: To compare the relative medial thickness (RMT) in alveolar wall arteries (AW) in SIDS cases with that in age-matched controls and 2. Compare demographic, clinical, and pathologic characteristics among three subsets of SIDS cases based upon alveolar wall (AW) RMT. Retrospective morphometric planimetry of all muscularized arteries in standardized right apical lung sections in 73 SIDS cases divided into three groups based on increasing AW RMT as well as 19 controls age-matched to 19 of the SIDS cases. SIDS and age-matched control cases did not differ with respect to AW RMT or other demographic variables. The SIDS group with the thickest AW RMT had significantly more males and premature birth than the other groups, but the groups did not differ for known clinical risk factors that would potentially expose them to hypoxia. Pathologic variables, including pulmonary inflammation, gastric aspiration, intra-alveolar siderophages, cardiac valve circumferences, and heart and liver weights, were not different between groups. Age was not significantly correlated with RMT of alveolar wall and pre-acinar arteries but was significant at p = .018 for small intra-acinar arteries. The groups were different for RMT of small pre-acinar and intra-acinar arteries, which increased with increasing AW RMT. Statistical differences should not necessarily be equated with clinical importance, however future research incorporating more quantified historical data is recommended.
Other Infant Death
1. Li L, Zhang Y, Zielke RH, Ping Y, Fowler DR
Observations on increased accidental asphyxia deaths in infancy while cosleeping in the state of Maryland
Am J Forensic Med Pathol. 2009 Dec;30(4):318-21
Key Laboratory of Evidence Science, China University of Political Science and Law, Beijing, China. Ling001@aol.com
The Office of the Chief Medical Examiner (OCME) has recorded a significant increase of accidental asphyxia deaths in infancy associated with cosleeping in the state of Maryland in 2003. A total of 102 infants died suddenly and unexpectedly during 2003 in the state of Maryland. Of the 102 infants, 46 (45%) were found cosleeping. The frequency of cosleeping among these 102 infants was 28% (29/102) for black infants and 15% (15/102) for white infants. Ten of the 46 cosleeping infant deaths (20%) were determined to be the result of accidental asphyxia, and 28 cosleeping infant deaths (59%) were classified as "undetermined" because the possibility of asphyxia due to overlay while cosleeping could not be ruled out. Only 21 cases were determined to be Sudden Infant Death Syndrome (SIDS), which is consistent with the continuous decline of SIDS death in Maryland since 1994. The age of asphyxiated cosleeping infants ranged from 15 days to 9 months. Nine out of the 10 asphyxia deaths were black infants. The most common sleeping location of the asphyxia infants was on a couch/sofa, followed by an adult bed. Crib availability was documented in all of the cosleeping cases. A majority (61%) of the cosleeping infants (28/46) had an available crib or bassinet at home and 9 out of 10 asphyxiated cosleeping infants had a crib at home at the time of the incident. This report focuses on the detailed scene investigation findings of infant victims who died of asphyxia while cosleeping. The shift of diagnosis in sudden infant death investigation is also addressed.
Bereavement
1. Moon Fai C, Gordon Arthur D
Nurses' attitudes towards perinatal bereavement care
J Adv Nurs. 2009 Dec;65(12):2532-41
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Aim. This paper is a report of a study conducted to explore the factors associated with nurses and midwives' attitudes towards perinatal bereavement care. Background. Caring for and supporting parents whose infant has died is extremely demanding, difficult and stressful. In some situations nurses may experience personal failure, feel helpless, and need to distance themselves from bereaved parents because they feel unable to deal with the enormity of the parental feelings of loss. Method. A correlational questionnaire study using convenience sampling was carried out in Singapore in 2007 with 185 nurses/midwives in one obstetrics and gynaecology unit. Results. Regression models showed that nurses/midwives with religious beliefs and those with more positive attitudes to the importance of hospital policy and training for bereavement care were statistically significantly more likely to have a positive attitude towards perinatal bereavement care. Nurses emphasized their need for increased knowledge and training on how to cope with bereaved parents and requested greater support from team members and the hospital. Conclusion. Bereavement counselling education and preceptorship supervision are recommended to reduce this stressful experience, increase the confidence and expertise of novices, and lead to increased quality of care for bereaved parents.
2. Kersting A, Ohrmann P, Pedersen A, Kroker K, Samberg D, Bauer J, Kugel H, Koelkebeck K, Steinhard J, Heindel W, Arolt V, Suslow T
Neural activation underlying acute grief in women after the loss of an unborn child
Am J Psychiatry. 2009 Dec;166(12):1402-10. Epub 2009 Nov 2.
Department of Psychiatry, University of Muenster, Albert-Schweitzer-Str. 11, D-48149 Muenster, Germany. patricia.ohrmann@ukmuenster.de.
OBJECTIVE: The traumatic loss of an unborn child by induced termination of pregnancy because of fetal malformation is a major life event that causes intense maternal grief. Increasing evidence supports the hypothesis that the same neural structures involved in the experience of physical pain are involved in the experience of social pain and loss. METHOD: To investigate neural activation patterns related to acute grief, the authors conducted a functional MRI study of 12 post-termination women and 12 noninduced women who delivered a healthy child. Brain activation was measured while participants viewed pictures of happy baby, happy adult, and neutral adult faces. RESULTS: Relative to comparison women, post-termination women showed greater activation in the middle and posterior cingulate gyrus, the inferior frontal gyrus, the middle temporal gyrus, the thalamus, and the brainstem in response to viewing happy baby faces. Functional connectivity between the cingulate gyrus and the thalamus during the processing of happy baby faces was significantly stronger in post-termination women. CONCLUSIONS: Overall, acute grief after the loss of an unborn child was closely related to the activation of the physical pain network encompassing the cingulate gyrus, the inferior frontal gyrus, the thalamus, and the brainstem. To the authors' knowledge, the stronger functional thalamocingulate connectivity in post-termination women is the first in vivo demonstration of an involvement of the neural maternal attachment network in grief after the loss of an unborn child.
3. [No authors listed]
Coping with loss. A look at grief and the grieving process
Mayo Clin Womens Healthsource. 2009 Dec;13(12):1-2
Miscarriage/Stillbirth/Prenatal Issues
1. Sidebotham P, Blair P, Evason Coombe C, Edmond M, Heckstall-Smith E, Fleming P
Responding to Unexpected Infant Deaths: Experience in One English Region
Arch Dis Child. 2009 Nov 29. [Epub ahead of print]
University of Warwick, United Kingdom.
New national procedures for responding to the unexpected death of a child in England require a joint agency approach to investigate each death and support the bereaved family. As part of a wider population-based study of sudden unexpected deaths in infancy (SUDI) we evaluated the implementation of this approach. METHODS: A process evaluation using a population-based study of all unexpected deaths from birth to 2 years in the South West of England between January 2003 and December 2006. Local police and health professionals followed a standardised approach to the investigation of each death, supported by the research team set up to facilitate this joint approach as well as collect data for a wider research project. RESULTS: We were notified of 155/157 SUDI, with a median time to notification of 2 hours. Initial multi-agency discussions took place in 93.5% of cases. A joint home visit by police officers with health professionals was carried out in 117 cases, 75% within 24 hours of the death. Time to notification and interview reduced during the 4 years of the study. Autopsies were conducted on all cases, the median time to autopsy being 3 days. At the conclusion of the investigation, a local multi-agency case discussion was held in 88% of cases. The median time for the whole process (including family support) was 5 months. CONCLUSIONS: This study has demonstrated that with appropriate protocols and support, the joint agency approach to the investigation of unexpected infant deaths can be successfully implemented.
2. Qureshi NS
Treatment options for threatened miscarriage
Maturitas. 2009 Nov 26. [Epub ahead of print]
Birmingham Women's Hospital, Metchely Park Road, Edgbaston, Birmingham B15 2TG, UK.
Threatened miscarriage, as demonstrated by vaginal bleeding with or without abdominal cramps, is a common complication of pregnancy. It occurs in about 20% of recognised pregnancies. Risk of miscarriage is increased in older women and those with a history of miscarriage. Low serum levels of progesterone or human chorionic gonadotrophin (hCG) are a risk factor for miscarriage. Other risk factors include heavy bleeding, early gestational age and an empty gestational sac of >15-17mm diameter. Clinical history and examination, maternal serum biochemistry and ultrasound findings provide valuable information about the prognosis and are important to establish in order to determine potential treatment options. Although bed rest is the most common choice of treatment, there is little evidence of its value. Other options include luteal support with progesterone, dydrogesterone or hCG. There is some evidence from clinical studies indicating that progesterone or dydrogesterone may reduce the rate of miscarriage, although further data from double-blind, randomised-controlled trials are necessary to confirm efficacy.
3. Saraswat L, Bhattacharya S, Maheshwari A, Bhattacharya S
Maternal and perinatal outcome in women with threatened miscarriage in the first trimester: a systematic review
BJOG. 2009 Nov 26. [Epub ahead of print]
Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Aberdeen, UK.
Background Threatened miscarriage is a common complication in the first trimester of pregnancy and is often associated with anxiety regarding pregnancy outcome. Objective We undertook a systematic review to explore the effects of threatened miscarriage in the first trimester on maternal and perinatal outcomes. Search strategy An electronic literature search using MEDLINE and EMBASE, and bibliographies of retrieved primary articles. No language restrictions were applied. Selection criteria All studies analysing outcomes of first-trimester bleeding where viability was confirmed on ultrasound or the pregnancy continued beyond viability. Data collection and analysis Two review authors independently selected studies and extracted data on study characteristics, quality and accuracy. Meta-analysis was performed using Review Manager software Main outcome measures The outcome was broadly categorised into maternal and perinatal outcomes. The chief maternal outcomes included pre-eclampsia/eclampsia or pregnancy-induced hypertension, antepartum haemorrhage, preterm prelabour rupture of membranes (PPROM) and mode of delivery. The perinatal outcomes evaluated were preterm delivery, low birthweight, intrauterine growth restriction, perinatal mortality, indicators of perinatal morbidity (Apgar scores and neonatal unit admission) and presence of congenital anomalies. Main results Fourteen studies met the inclusion criteria. Women with threatened miscarriage had a significantly higher incidence of antepartum haemorrhage due to placenta praevia [odds ratio (OR) 1.62, 95% CI 1.19, 2.22] or antepartum haemorrhage of unknown origin (OR 2.47, 95% CI 1.52, 4.02) when compared with those without first-trimester bleeding. They were more likely to experience PPROM (OR 1.78, 95% CI 1.28, 2.48), preterm delivery (OR 2.05, 95% CI 1.76, 2.4) and to have babies with intrauterine growth restriction (OR 1.54, 95% CI 1.18, 2.00). First-trimester bleeding was associated with significantly higher rates of perinatal mortality (OR 2.15, 95% CI 1.41, 3.27) and low-birthweight babies (OR 1.83, 95% CI 1.48, 2.28). Authors' conclusions Threatened miscarriage in the first trimester is associated with increased incidence of adverse maternal and perinatal outcome.
4. Kharazmi E, Fallah M, Luoto R
Miscarriage and risk of cardiovascular disease
Acta Obstet Gynecol Scand. 2009 Nov 30. [Epub ahead of print]
Tampere School of Public Health, University of Tampere, Tampere, Finland.
Abstract In a nationally representative sample (the Health 2000 Survey) comprising 3,937 Finnish women aged 30-99 years, we examined the association of miscarriage (assessed by questionnaire) with risk of cardiovascular disease (assessed by physician's examination and linkages to hospital discharge and drug reimbursement registers). We considered age, smoking, body mass index, waist/hip ratio, physical activity, education, number of previous pregnancies, blood pressure, and fasting blood glucose and cholesterol as potentially confounding factors in the analysis. In women 50-74 years of age who had experienced pregnancy, history of miscarriage tended to be associated with a higher risk of myocardial infarction (age-adjusted odds ratio (OR): 2.1, 95% confidence interval (CI): 1.0-4.3), and the risk increased significantly with the number of miscarriages (age-adjusted OR per miscarriage: 1.4, 95% CI: 1.1-1.8). These results suggest that women who experience repeated miscarriages may be at an increased risk of cardiovascular disease later in life.
5. Rasmussen S, Irgens LM, Skjaerven R, Melve KK
Prior adverse pregnancy outcome and the risk of stillbirth
Obstet Gynecol. 2009 Dec;114(6):1259-70
Medical Birth Registry of Norway, The Norwegian Institute of Public Health, Bergen, Norway. Svein.Rasmussen@mfr.uib.no
OBJECTIVE: To estimate whether a history of fetal growth restriction, abruptio placentae, preeclampsia, or live preterm birth is associated with excess risk of stillbirth in a subsequent pregnancy. We also estimated the maternal and paternal contributions to such effects. METHODS: This was a population-based cohort study from 1967 to 2005. Pairs of first and second, second and third, third and fourth, and fourth and fifth births were identified among all births from the Medical Birth Registry of Norway; 747,221 pairs with the same parents, 51,708 with the same mother and different father, and 65,602 with the same father and different mother. The associations of gestational age categories (22-27, 28-32, 33-36, and at or above 37 weeks), small for gestational age (SGA), preeclampsia, and abruptio placenta in the first pregnancy with stillbirth and late abortion in the second were assessed by odds ratios (ORs) obtained by logistic regression. RESULTS: The baseline rate of stillbirth during the study period was 1.0% of all births from 16 weeks of gestation. After births with gestational age 22-27, 28-32, and 33-36 weeks of gestation, stillbirth was six, three and two times more likely to occur than after a term birth (OR 5.7, 95% confidence interval [CI] 4.2-7.6; OR 2.6, 95% CI 2.1-3.3; and OR 1.7, 95% CI 1.5-1.9, respectively). Odds ratios of stillbirth subsequent to pregnancies with SGA, preeclampsia, and abruptio placentae were 1.7 (95% CI 1.6-1.9), 1.6 (95% CI 1.5-1.9), and 2.8 (95% CI 2.2-3.5), respectively, and increased with severity of the conditions. Gestational age below 33 weeks with preeclampsia or SGA carried 6-9 and 6-13-fold effects on later stillbirth, respectively. Men who fathered a pregnancy with preterm preeclampsia were significantly more likely to father a stillbirth in another woman (OR 2.4, 95% CI 1.1-5.5). CONCLUSION: Live preterm birth, fetal growth restriction, preeclampsia, and abruptio placenta are strongly associated with later stillbirth. LEVEL OF EVIDENCE: II.
6. Murphy F, Philpin S
Early miscarriage as 'matter out of place': An ethnographic study of nursing practice in a hospital gynaecological unit
Int J Nurs Stud. 2009 Nov 19. [Epub ahead of print]
School of Health Science, Swansea University, United Kingdom.
BACKGROUND: Early miscarriage has been conceptualised as loss and bereavement where nurses are urged to provide sympathetic, psychological care for women. However, the reality of women's experience is also about blood, 'dirt' and failure which are under explored in the literature. OBJECTIVE: To explore the management and care of women having an early miscarriage within a hospital setting. DESIGN: A qualitative, ethnographic study. SETTING: A gynaecological unit consisting of an early pregnancy clinic and two gynaecological wards in a general hospital in an urban area of Wales, United Kingdom. PARTICIPANTS: The first group was a purposive, volunteer sample of eight women who had experienced an early miscarriage and were admitted to hospital for active management of their miscarriage. The second was a purposive, volunteer sample of 16 hospital health professionals actively involved in the care of women having an early miscarriage. This included 10 nurses, three doctors and three ultrasonographers. METHODS: Three main methods were employed. Firstly, 20 months participant observation working alongside gynaecological nurses in a gynaecological unit. Secondly, documentary analysis of key documents such as nursing care plans. Finally, in-depth interviews with women who had experienced early miscarriage and hospital health professionals involved in their care. RESULTS: Three key categories emerged; 'first signs and confirmation', 'losing the baby' and 'the aftermath'. 'First signs' relates to the women's experiences when first realising that their pregnancy is under threat. 'Losing the baby' further explores women's accounts of their experience and the 'aftermath' relates to the long term impact of miscarriage on them and their lives. This paper focuses on the women's experiences of the physical manifestations of miscarriage in 'losing the baby'. Drawing on anthropological literature and the concepts of dirt and pollution, it is argued that miscarriage for both women and health professionals can be considered as ambiguous and that miscarriage and the early passage of the foetus can be seen as 'matter out of place'. CONCLUSION: This exploration of how women were managed in a hospital setting reinforced the notion of the ambiguous nature of miscarriage and supports the position that miscarriage may be considered as atypical bereavement. Furthermore, an analysis is offered of the significance of the vaginal blood loss as polluting and gives insights into how nurses manage this ambiguity.
7. Silingardi E, Santunione AL, Rivasi F, Gasser B, Zago S, Garagnani L
Unexpected intrauterine fetal death in parvovirus B19 fetal infection
Am J Forensic Med Pathol. 2009 Dec;30(4):394-7
Department of Legal Medicine, University of Modena and Reggio Emilia, Modena, Italy. enrico.silingardi@unimore.it
Parvovirus B19 infection during pregnancy can be transmitted to the fetus through the placenta. The consequences for the health of the fetus are very variable and can be very serious. They include intrauterine fetal death (IUFD) and miscarriage, which can lead to medico-forensic questions. For the most part, cases of IUFD take place during the second trimester of gestation and present an anatomopathologic picture characteristic of fetal infection with hydrops, placental edema, serous effusion, and erythroblastosis with nuclear inclusions. Endocardial fibroelastosis, medullar and thymic hypoplasia, and hepatic hemosiderosis are frequently present. In the third trimester, the cases are less frequent, not accompanied by hydrops, and can depend more on placental compromise than on direct infection of the fetus. We present 5 cases of IUFD resulting from parvovirus B19 and we discuss the pathogenetic and anatomopathologic aspects and obstetric liability. In 4 cases, the IUFD took place suddenly, in the absence of symptoms, in women who had not previously shown any symptom of the viral infection. In one case, the patient was hospitalized following an ultrasound diagnosis of fetal hydrops and IUFD took place 5 days after admission. Of these cases 3 were verified in the second trimester and 2 in the third trimester. Only the cases of the second trimester and one of the 2 cases of the third trimester presented the characteristic aspects of fetal infection. The other case of third trimester was characterized by placental involvement.
8. 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 Dec;62(6):365-70. Epub 2009 Oct 11
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.
9. Jin LP, Chen QY, Zhang T, Guo PF, Li DJ
The CD4+CD25 bright regulatory T cells and CTLA-4 expression in peripheral and decidual lymphocytes are down-regulated in human miscarriage
Clin Immunol. 2009 Dec;133(3):402-10. Epub 2009 Sep 18
Laboratory for Reproductive Immunology, Hospital and Institute of Obstetrics and Gynecology, Fudan University Shanghai Medical College, Shanghai 200011, China.
The present study was undertaken to analyze the changes in the proportion of CD4(+)CD25(bright) regulatory T (Treg) cells and the expression of costimulatory molecules, CTLA-4 and CD28, in the peripheral blood and deciduas in the setting of non-pregnancy, normal early pregnancy and miscarriage. In this study, we showed that CD4(+)CD25(bright) T cells significantly increased in the peripheral of normal pregnancy compared to that of non-pregnancy. The proportions of CD4(+)CD25(bright) T cells in both peripheral blood and deciduas were significantly lower in miscarriage than that of normal pregnancy. CD4(+)CD25(bright) T cells were characterized by high-level FoxP3 expression and low-level CD69 expression. An increase in the CD28 mRNA expression was accompanied by a decrease in the CTLA-4 mRNA expression in decidual tissues from human miscarriage. The ratios of CTLA-4(+)/CD28(+) in miscarriage were significantly lower than that of the normal pregnancy both in the peripheral and in deciduas. The ratio of CTLA-4(+)/CD28(+) in CD4(+)CD25(bright) T cells was significantly higher than that of the CD4(+)CD25(dim) T cells both in normal pregnancy and in miscarriage. The decidual T cells in the miscarriage appeared higher in responsiveness and IL-2 and IFN-gamma production in comparison with the decidual T cells in the early pregnancy. These results above suggest that CD4(+)CD25(bright) Treg cells might play a role in the maintenance of pregnancy via up-regulation of CTLA-4 expression. The down-regulation of Treg cells and their functions, and the imbalance of positive and negative regulators of costimulatory signals might lead to an abnormal immune milieu, which confer susceptibility to pregnancy loss.
10. Völker HU, Demmer P, Gattenlöhner S
Idiopathic intrauterine myocardial infarction without malformations of the heart or coronary vessels as a cause of stillbirth
Int J Gynaecol Obstet. 2009 Dec;107(3):251-2. Epub 2009 Sep 9
Institute of Pathology, University of Würzburg, Würzburg, Germany. ullrich.voelker@mail.uni-wuerzburg.de
11. de Vienne CM, Creveuil C, Dreyfus M
Does young maternal age increase the risk of adverse obstetric, fetal and neonatal outcomes: a cohort study
Eur J Obstet Gynecol Reprod Biol. 2009 Dec;147(2):151-6. Epub 2009 Sep 4
Department of Obstetrics and Gynecology, University Hospital of Caen, France.
OBJECTIVE: To determine whether young maternal age is associated with increased risks of adverse obstetric, fetal and perinatal outcomes. STUDY DESIGN: Register-based study using the data from a computerized database of a University Hospital for the years 1994-2001. The study population included 8514 primiparous women aged less than 31 who delivered a singleton infant. Using maternal age as a continuous variable, crude and adjusted relative risks (RRs) were estimated for each maternal and perinatal outcome. RESULTS: Crude and adjusted RRs of anaemia during pregnancy and fetal death consistently increased with younger maternal age. After adjustment for confounding factors, RRs (95% confidence interval) of fetal death and anaemia were respectively 1.37 (1.09-1.70) and 1.27 (1.15-1.40) for a 16-year-old compared to a 20-year-old mother. Younger mothers had significantly decreased risks of obstetric complications (preeclampsia, caesarean section, operative vaginal delivery and post-partum haemorrhage). Higher prevalence of prematurity and low birth weight in infants born to teenagers were not attributable to young maternal age after adjustment for confounding factors. CONCLUSION: In our population, younger maternal age was significantly and consistently associated to greater risks of fetal death and anaemia and to lower risks of adverse obstetric outcomes.
12. Monien S, Kadecki O, Baumgarten S, Salama A, Dörner T, Kiesewetter H
Use of heparin in women with early and late miscarriages with and without thrombophilia
Clin Appl Thromb Hemost. 2009 Dec;15(6):636-44. Epub 2009 Aug 9
Department of Hemostaseology, Institute of Transfusion Medicine, Charité University Hospital Berlin, Berlin, Germany. silke.monien@charite.de
OBJECTIVE: In women with a history of recurrent miscarriage, the risk of miscarriage in a subsequent pregnancy is about 30% to 40%. In patients with thrombophilia, the risk is even higher. Placental thrombosis has been found in women with unexplained recurrent miscarriage independent of thrombophilia. In addition, proinflammatory changes, for example, altered Th1 to Th2 cytokine ratio and complement activation, have been repeatedly demonstrated in these women. Because of the fact that heparin has both anticoagulative and anti-inflammatory effects, the current study evaluated the efficacy of low-molecular-weight heparin (LMWH) in unexplained abortions. STUDY DESIGN: A total of 164 women with unexplained early and late miscarriages presented in our hemostaseological clinic for thrombophilia screening. For these 164 women, 82 subsequent pregnancies in 79 patients were treated with subcutaneous LMWH independently of thrombophilia. In 54/82 unselected pregnancies, 100 mg aspirin was administered in addition to LMWH. Two patients were excluded due to termination of pregnancy. RESULTS: Overall, 83.8% (67/80) of pregnancies resulted in live births. In 22/79 women (27.8%), thrombophilia markers were positive. Most noteworthy, patients with thrombophilia markers had live births at a similar frequency as patients without those parameters. No severe side effects of LMWH were seen. CONCLUSIONS: Our data support the notion that LMWH is efficacious in patients with recurrent abortions and thrombophilia. We demonstrated the same effect of LMWH in women with unexplained abortions without thrombophilia. The potential mechanism of action of LMWH in early and late abortions warrants further study.
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