Aetiology of late fetal death in Maputo

BACKGROUND

To study the etiology of late fetal death in Maputo.

PATIENTS

Stillbirths (n = 163) in Maputo were compared to 207 live births.

RESULTS

A probable cause of fetal death could be determined in 112 cases (69%). Hypertension was the most common factor associated with stillbirth and occurred in 14% of the fetal deaths, followed by abruption of the placenta (13%), syphilis (8%), clinical intra-uterine infection (6%), malaria (4%), fetal malformation (4%), umbilical cord complications (4%) and anaemia (4%). Mothers of stillborns and referent mothers differed in the following parameters: fetal weight, gestational age, numbers of previous stillbirths, haemoglobin, packed cell volume (p < 0.001), age, number of pregnancies (p < 0.01), parity, number of live children and skinfold thickness (p < 0.05). In the stillborn cases where no probable cause of fetal death was established, newborn weight was significantly lower and estimated gestational age significantly shorter (p < 0.001), number of previous pregnancies and number of previous stillbirths were significantly larger (p < 0.05) than in the referent group, but otherwise no significant differences were found. In two randomly selected sub-groups, 28 mothers with stillbirth without probable diagnoses, and in 24 referent mothers, selected serum proteins and acute-phase reactants were determined. There were no statistically significant differences in the mean values of haptoglobin, pre-albumin, retinol-binding protein and alpha 1-antitrypsin in the two subgroups. The stillbirth subgroup had significantly higher mean values of C-reactive protein and serum orosomucoid than the referent group (p < 0.01).

CONCLUSION

Signs of maternal illness were present in one third of the mothers with stillbirth, and half of them required medical care. In one third there was no final diagnosis, but these mothers showed significantly higher mean values of acute phase reactants, suggesting low-grade infection.

Infant care in rural Malawi. A prospective study of morbidity and growth in relation to environmental factors

In connection with the introduction of piped surface water delivered by community taps in a rural area of Malawi, 46 infants were studied prospectively during a 10-month period to monitor infant care and health. Compared with the reference population, newborn infants generally weighed less and were shorter. Breastfeeding was universal and appeared adequate for catch-up in weight during the 1st 3 months. Growth faltering occurred from the age of 3 months when the prevalence of infectious diseases gradually increased and suitable supplementary foods were lacking. Babies were given highly contaminated water from the 1st days of life, but, in spite of this, diarrhoea was infrequent during the 1st 5 months when respiratory tract infections and episodes of fever were the most common symptoms of disease. Diarrhoea became a problem from the age of 5-6 months. No differences in morbidity or growth patterns were observed between infants using piped and traditional water sources. Thus, the quality of drinking water seemed to have no substantial effect on the health of the studied infants during the 1st months of life.

Feeding and nutritional problems in children with cerebral palsy and myelomeningocoele

This study was undertaken to characterize the food intake, current feeding situation and nutritional status of children with cerebral palsy and myelomeningocoele. Thirty children with cerebral palsy and 14 with myelomeningocoele were investigated. The children with cerebral palsy were subgrouped into those with diplegia (11 children), dystonia (10 children), hemiplegia (6 children) and ataxia (3 children). Information was obtained from medical records, current dietary recording and clinical and anthropometric examinations. Feeding problems, low energy intake and wasting were frequent among the children with cerebral palsy, particularly those with the dystonic form. Children with myelomeningocoele gave the impression of being overnourished, despite a seemingly relatively low energy intake. It is clear that nutritional and feeding aspects should receive particular attention in the habilitation of children with various disabilities.

Interactions of vitamins A and E and retinol-binding protein in healthy Swedish children--evidence of thresholds of essentiality and toxicity

The serum levels of vitamins A and E and retinol-binding protein (RBP) were determined and their relationships investigated in 144 healthy Swedish children between the ages of 1 month and 16 years. The median level for vitamin A was 540 micrograms l-1 (range 181-1720 micrograms l-1); for vitamin E 6.8 mg l-1 (range 1.0-14.0 mg l-1) and for RBP 0.030 g l-1 (0.018-0.045 g l-1). Retinol-binding protein levels rose steeply in relation to vitamin A levels of up to approximately 800 micrograms l-1. However, RBP levels remained constant when vitamin A levels were between 800 and 1600 micrograms l-1 but displayed a further steep rise for vitamin A levels above this range. Fourteen individuals had levels that did not follow this pattern but fell rather neatly below the correlation line. These individuals were also found to have significantly higher mean levels of acute phase reactants than the rest of the study group, suggesting the possibility of subclinical infection or inflammation in these subjects. Vitamins A and E showed an inverse curvilinear relationship. This is the first report of an interaction between vitamins A and E and RBP in healthy Swedish children. The study demonstrates that a linear one-to-one relationship between RBP and vitamin A may not be of regular occurrence as previously assumed. The pattern described suggests the existence of thresholds of essentiality and toxicity in the interaction between the two vitamins and RBP.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of smoking on maternal glucose metabolism

Maternal smoking, studied in late pregnancy, was found to be associated with lower blood glucose values, both during fasting and after an intravenous glucose load. As a correlation between blood glucose levels and infant birth weight has been reported, it is possible that smoking during pregnancy might reduce fetal growth through an effect on maternal glucose metabolism.

Plasma-free amino acid concentrations during ketamine anesthesia in the rhesus monkey: a short methodological study

The effect of ketamine anesthesia on the pattern of free amino acids in plasma was investigated in four healthy non-pregnant rhesus monkeys. Blood samples were collected at intervals during a period of 150 min both with and without anesthesia. Repeated measures analysis of variance, with time and ketamine/control as trial factors, was used. In only four amino acids were any changes with time or with ketamine treatment observed, the rest remaining unchanged. Ketamine anesthesia seemed to reduce the concentrations of several amino acids, but the findings were not conclusive.

Low concentrations of sodium and magnesium in erythrocytes from cystic fibrosis heterozygotes

The concentrations of electrolytes and trace elements in erythrocytes were determined in eight children with cystic fibrosis (CF) and the parents of four of the children and compared with age- and sex-matched healthy controls. The children with CF had significantly lower median erythrocyte concentrations of sodium, magnesium and zinc and a higher median concentration of calcium than both the healthy control children and the parents of the CF children. Although the sodium and magnesium median values were higher in CF parents than in CF children they were nevertheless significantly lower than in adult controls. These data indicate a system for heterozygote detection.

Amino acid transport across the placenta measured by positron emission tomography and analyzed by compartment modelling

The materno-fetal transfer of methionine in the Rhesus monkey was investigated using positron emission tomography, a non-invasive in vivo tracer technique based on short-lived radionuclides. A bolus dose of [11CH3]-l-methionine was administered intravenously and the radioactivity concentrations in the placenta, the fetus and the maternal arterial blood were measured as functions of time and fitted to an equation derived from a four compartment model of the feto-placental complex. Rate constants were calculated describing maternal placental blood flow, the transfer of [11CH3]-l-methionine to the placental tissue and the fetus. The transfer rate of methionine to the fetus was estimated as 0.8-1.5 nmol/min/g placenta and was similar to the transfer to the placental tissue. An approximate blood flow through the intervillous space of 128 ml/min was found. The correlation between placental transfer to the fetus and the maternal blood flow in the intervillous space was low.

Increased plasma and erythrocyte selenium concentrations but decreased erythrocyte glutathione peroxidase activity after selenium supplementation in children with Down syndrome

An investigation was made of the activity of glutathione peroxidase (GSH-Px) in erythrocytes and the levels of selenium in plasma and erythrocytes before, during and after selenium supplementation in children with Down syndrome (DS). This subject is of interest since it has been suggested that selenium supplementation could enhance the GSH-Px activity in erythrocytes, probably leading to improved protection against oxygen radicals, which might cause damage by lipid peroxidation, especially in the brain. Forty-eight children with DS were treated with selenium-rich yeast tablets (10 micrograms/kg body weight/day) for 6 months. The supplementation was well tolerated and no side effects were observed. Selenium supplementation resulted in increased concentrations of selenium both in plasma and erythrocytes, but decreased GSH-Px-activity in erythrocytes. Plasma and erythrocyte selenium levels but almost regained the initial values 12 months after termination of the supplementation. Erythrocyte GSH-Px activity, on the other hand, remained reduced and did not return to the presupplementation levels. Until we gain more knowledge about the biological functions of selenium in man and the role of oxygen metabolism in the development of presenile dementia in DS, universal selenium supplementation in DS patients cannot be recommended.

A study of antenatal care at village level in rural Tanzania

Antenatal care is an acknowledged measure for the reduction of maternal and perinatal mortality. In the rural village of Ilula, Tanzania, the possible impact of antenatal care on mortality was studied longitudinally on the basis of the 707 women delivered in the study period. Ninety-five percent of the antenatal records were available. Anemia, malaria and anticipated obstetric problems were the most frequent reasons for interventions. Among the women from the area who were delivered in hospital, 90% had been referred there. No relationship was found between the number of antenatal visits and the pregnancy outcome, but perinatal mortality was correlated to a low birth weight. Even with a mean attendance rate of six visits and full coverage by antenatal care maternal and perinatal mortality remains high.

Selected trace elements and proteins in serum of apparently healthy newborn infants of mothers who smoked during pregnancy

The serum concentrations of selected trace elements and proteins in cord blood from 17 newborn infants whose mothers were habitual smokers were compared with values from 22 infants of non-smoking mothers. All the mothers were healthy with normal pregnancies and deliveries. Cigarette smoke exposure was verified by determinations of nicotine, cotinine and thiocyanate concentrations in cord blood. Infants of smoking mothers had a slightly lower mean birth weight (3490 +/- 430 g) than control infants (3780 +/- 460 g). Infants of smokers had lower serum iron (p = 0.05) and prealbumin (p less than 0.05), but higher serum copper (p less than 0.05) and ceruloplasmin (p less than 0.01) levels than the controls. Infants of smoking mothers tended to have higher levels of the acute-phase reactants alpha-2-macroglobulin and orosomucoid, but lower levels of albumin, transferrin and retinol-binding-protein, although differences were not statistically significant.

Placental hormones and maternal glucose metabolism. A study of fetal growth in normal pregnancy

The interrelations between three placental hormones (oestradiol, progesterone and hPL), maternal glucose metabolism, maternal anthropometry and fetal growth were studied in a sample of 52 carefully selected pregnant women. A relation was found between infant birthweight and both fasting blood glucose and t1/2 of glucose of an intravenous glucose tolerance test at week 37 of pregnancy. The serum concentrations of the placental hormones were not significantly related to the glucose variables. The correlation between birthweight and the maternal levels of hPL in late pregnancy (r = 0.60) persisted when fasting blood glucose and t1/2 of glucose were taken into account. Maternal fat mass was found to explain more of the variation in basal insulin levels around week 37 than did the placental hormones.

Maternal weight, weight gain and birthweight at term in the rural Tanzanian village of Ilula

In an area-based study in a rural Tanzanian village, the relations of maternal weight and weight gain during pregnancy to birthweight were analysed for 331 term deliveries. The distribution of body-mass index, used as an indicator of maternal nutritional status, was similar to the pattern seen in Sweden, although mean maternal height (156 cm) was 9 cm below that of Swedish women. Mean initial weight measured at week 14 was 53 kg and total pregnancy weight gain was 6 kg. Women weighing greater than or equal to 60 kg in early pregnancy gained less weight (0.16 kg/week) than those weighing less than 50 kg (0.22 kg/week). Birthweight was correlated both with maternal weight in early pregnancy and with weight gain during pregnancy, but only 10% of the variation in birthweight was explained by these maternal factors. Mean maternal weight 24 h postpartum was equal to the weight at 14 weeks of pregnancy, implying, on the average, no net weight gain. Women with a positive net weight gain had heavier babies than women with a negative net weight gain. Maternal anthropometric characteristics are important underlying determinants of intrauterine growth and birthweight, but they explain only a minor part of the variation and are of little value for screening purposes in individual women.

A prospective area-based study of the outcome of pregnancy in rural Tanzania

A prospective area-based study on the outcome of pregnancy was carried out in the rural village of Ilula in Tanzania. A coverage of 99% (n = 719) regarding the ultimate outcome for mother and child was achieved, including deliveries that took place in hospital (9%), at the dispensary (67%) and at home (23%). There were four maternal deaths (6/1,000). The mean birth weight for singletons was 3,070 g and the low birth weight (less than 2,500 g) rate 13%. From a gestational age of 37 weeks onwards there was a definite slowing of fetal growth. Perinatal mortality rate was 82 per 1,000 born, half of the deaths occurring in low birth weight babies. Twinning occurred in 3.5% and the mean length of gestation at delivery for these pregnancies was 35.5 weeks. Twins constituted 6.8% of newborns but accounted for 23.0% of perinatal losses, making twin pregnancy a major contributor to perinatal mortality. Post-term pregnancies carried no significant increase in mortality. It is concluded that reliable area-based data on the outcome of pregnancy in Tanzania can be obtained at village level, with good coverage of the study population, by properly instructed and motivated local staff with moderate supervisory support.

Maternal glucose metabolism and infant birth weight: a study in healthy pregnant women

An intravenous glucose tolerance test (IVGTT) with serum insulin determinations was performed at week 37 of pregnancy in 52 healthy primiparae, selected to provide an increased variation in infant birth weight. A significant relationship was found between infant birth weight and both fasting blood glucose and t1/2 of glucose. Infant skinfold thickness, however, was not correlated independently to any of the parameters of the IVGTT. There was a significant correlation between maternal lean body mass and glucose metabolism, but this could not fully explain the relation between lean body mass and infant birth weight. Maternal fat mass was not significantly correlated to infant birth weight, though it was correlated with serum insulin levels. In the investigated population, fasting blood glucose, t1/2 of glucose, and maternal lean body mass accounted for 27% of the variation in infant birth weight.

Childhood mortality in relation to nutritional status and water supply--a prospective study from rural Malawi

In connection with the introduction of an improved method of water supply in rural Malawi, the nutritional status, morbidity, and mortality among 1,178 children under five were studied during three rainy and three dry seasons. Data were collected at fortnightly home interviews. Nutritional assessment was made twice a year. One hundred and thirty-seven of the children died during the study period, and the probability of dying before the age of five was estimated to 270 per 1,000 children. The mortality risk was related to weight for height (p less than 0.001) and height for age (p less than 0.01) as well as to upper arm circumference (p less than 0.001) and triceps skinfold (p less than 0.05). Mortality among children living in households using the new, piped-water supply tended to be lower than mortality for those using traditional water sources, although the difference was not statistically significant (relative risk 0.4, 95% confidence interval 0.1-1.3).

Serum albumin, retinol-binding protein, thyroxin-binding prealbumin and acute phase reactants as indicators of undernutrition in children with undue susceptibility to acute infections

This study was conducted in order to test the usefulness of measuring the concentrations of selected serum proteins and acute phase reactants in assessing the nutritional status of children with undue susceptibility to acute infections. The concentrations of serum proteins were determined by an immunodiffusion technique in 28 children with undue susceptibility to infections and were compared with those in healthy children. The patients were grouped according to the clinical pattern, i.e. into children with mainly upper respiratory tract infections, with frequent middle ear infections and with lower respiratory tract infections. The total group and all three subgroups of patients had not only significantly lower (p less than 0.001 or p less than 0.01) mean serum levels of albumin and retinol-binding protein, but also of the acute phase reactants alpha 2-macroglobulin and ceruloplasmin (p less than 0.01) than the controls. No differences were observed between the patients and the controls in respect of the acute phase reactant orosomucoid. This study indicates that the concentrations of albumin and RBP along with selected acute phase reactants are rapidly influenced by altered nutritional status in children with undue susceptibility to acute infections.

Serum selenium is related to low-density lipoproteins in healthy children but not in children with diabetes

The serum concentrations of selenium in 13 healthy children and 27 children with type 1 diabetes mellitus were evaluated in relation to serum lipoprotein and apolipoprotein concentrations. In healthy children a correlation was found between serum selenium and both serum cholesterol (r = 0.56; p less than 0.05) and serum triglycerides (r = 0.56; less than 0.05) and their low-density lipoprotein (LDL) + very low-density lipoprotein (VLDL) fractions (r = 0.60 and 0.56 respectively; p less than 0.05), but not their high-density lipoprotein fractions. Associations were also found between selenium and apolipoproteins, especially A II and C II (r = 0.57; p less than 0.05). In diabetic children serum selenium was significantly correlated with apolipoproteins A II and Apo C II, but not with any lipoprotein or lipid or any of their fractions. This study supports the hypothesis that serum selenium is an integral part of the defence system against degradation products associated with LDL and VLDL in young healthy humans. These associations were not found in diabetes, which might suggest that the defence system against lipid peroxidation is less effective in this disease.

Maternal fat stores and fat accretion during pregnancy in relation to infant birthweight

Maternal fat stores and fat accretion during pregnancy were estimated from body weight and skinfold thicknesses and by the factorial method in a sample of 56 Swedish women in their second pregnancies who gave birth to singletons at term. Prepregnancy lean body mass, and not fat mass, were strongly correlated with infant birthweight. Total weight gain was significantly correlated with infant birthweight. A wide range of maternal fat accretion during pregnancy was observed, and the amount of fat accumulated was related to the total weight gain. In spite of this, maternal fat accretion during pregnancy was found to have little bearing on the infant birthweight at term.

Energy intake and physical activity during pregnancy in relation to maternal fat accretion and infant birthweight

During the second pregnancy of 56 Swedish women resulting in a term birth, energy intake and physical activity were measured for 3 days at weeks 17 and 33. The values were related to maternal lean body mass, pregnancy weight gain, maternal fat accretion and infant birthweight by multiple linear regression analyses. A significant regression coefficient was found for energy intake at week 17 on maternal fat accretion. Energy intake was not significantly correlated with infant birthweight, not even when physical activity and maternal lean body mass were taken into account. Thus in a well-nourished Swedish population, energy intake is positively related to maternal fat accretion but not to the birthweight of term infants.

Child health and household water supply: a longitudinal study of growth and its environmental determinants in rural Malawi

The growth of 1029 children under 5 years of age, in rural Malawi, was studied during 1 year before and 1 year after the introduction of a piped water supply system. The study was performed to evaluate the effect of socio-economic and environmental factors, especially water supply, on growth. In general, the first 2 years of life were highly liable to nutritional impairment. The seasonal variation of growth rate was most pronounced in children under 2 years. It was found that crowding, measured both as population density and as members per household, had a negative impact on the growth of younger children. In households utilizing piped water, children did not display significantly better growth when compared with children in households using traditional water sources. Although clean water in itself is vital, it was not enough to improve the growth of young children under the conditions that we have studied. It is suggested that, when providing an improved water supply, sanitation and hygiene education are necessary additions. Other ways of reducing recurrent infections, in combination with effective nutrition during and after episodes of disease, should also be given increased consideration in order to improve growth.