Induction of fetal demise in advanced pregnancy terminations: report on a funic potassium chloride protocol

Advanced pregnancy termination with uterotonic agents with their inherent risk for occurrence of a live birth and surgical evacuation of a fetus perceived to be vigorous can both be sources of emotional anguish for women. They argue for offering women an option for induction of fetal demise prior to uterine evacuation. We report on our experience with 60 pregnancies in which lethal fetal administration of potassium chloride was performed prior to evacuation of the uterus. We describe a double-bolus technique for funic intravascular injection of potassium chloride to arrest the fetal heart. There were no maternal complications and the procedure was successful in 86.7% (n = 52) of the cases; of the remaining 8 cases, 7 had demise induced by direct fetal cardiac injection, and a live birth occurred in 1 case.

Pregnancy wastage in two tribal communities (Gujars and Bazigars) of Punjab, India

The present report is an attempt to secure adequate data about pregnancy wastage in Gujar and Bazigar females of Punjab. Gujars in general are primarily cattle breeders and shepherds but Gujars of Punjab are farmers, too. In Punjab they mostly occupy the submountainous regions and riverline lowlands. Bazigar is a persian word meaning "he who does Bazi" or any sort of game or play but it is applied only to jugglers and acrobats. Bazigars are a gypsy tribe of vagrant habits. Most of them are now settled in the vicinity of large villages or towns. Analysis of reproductive histories of 250 Gujar females and 360 Bazigar females reveals that in the maternal age group 25-29 years, mothers experienced the least number of abortions and stillbirths. However, beyond this, the risk of pregnancy wastage increases with age. An overall rate of pregnancy wastage is 140.55 and 130.09 per 1000 pregnancies among Gujars and Bazigars of Punjab, respectively.

Why infant very low birthweight rates have failed to decline in the United States vital statistics

BACKGROUND

Very low birthweight (VLBW) rates, i.e. births of < 1500 g, have been long established as the major determinant of outcome for infants. Nevertheless, despite much medical, political and social effort, these rates have not declined during the past 40 years in the US Vital Statistics. To explore the causes of this disturbing finding, trends in low birthweight distribution at a community hospital and the Vital Statistics data were investigated.

METHODS

The weights of livebirths and foetal deaths (27,944 births) at a community hospital during three 5-year periods, 1973-1987, were examined for trends in low birthweight (LBW) distribution, and they were contrasted with the US Vital Statistics.

RESULTS

For white infants weighing 500-999 g the livebirth rates declined from 3.7 per 1000 births in period one to 1.1 per 1000 in period three (70.2%); for white infants 1000-1499 g, livebirths declined from 4.2 to 3.2 per 1000. Hospital white livebirths < 2500 g declined 18.7% from the first to the third period. Among black livebirths the LBW rate also declined from 126.4 per 1000 in period one to 85.4 per 1000 in the third period. Foetal deaths declined from 8.2 per 1000 births to 6.2 per 1000 in period three, a 24.4% decline. However, foetal deaths < 500 g increased 411%, from 3.6% of the total foetal deaths in period one to 18.4% in the third period.

CONCLUSION

Increasing registration of births in the US may have hidden a marked improvement in the VLBW problem. More complete registration of births and changes in the perception of viability appear responsible for the artefact.

A survey of Papua New Guinean parturients at the Port Moresby General Hospital: sociodemographic and reproductive characteristics

A survey of 673 consecutive Papua New Guinea parturients carried out at the Port Moresby General Hospital between May and June 1990 showed that socioeconomic and educational factors played a part in predicting perinatal death. Mothers who have previously experienced a perinatal death are more likely to experience a second one.

Pregnancy termination, perceived control, and perinatal grief

In a group of 30 women who underwent induced delivery after they had been informed of a lethal fetal anomaly, 18 women reported that this was the outcome of a clear decision process and 12 reported that they had no choice. In contrast to findings in other research areas, the experience of having perceived control was not associated with lower grief scores three months after perinatal loss.

Perinatal, infant, and child death rates among the Old Order Amish

The Old Order Amish are a distinct ethnic group with a very high birth rate and patterns of perinatal risk factors quite different from those of the general population. This study reports marital fertility and perinatal, infant, and child death rates for an entire Amish settlement of approximately 10,000 individuals, centered around Geauga County, Ohio. All 6,623 births from 1948 to 1988 listed in a directory of Geauga Settlement Amish households were studied. The childbearing experience of all 475 married women over the age of 44 years was also described. Women aged > 44 years had a median of 8.3 births; 24% of the births were to women aged > 34 years. Despite a higher prevalence of several risk factors for perinatal and infant death among the Amish, neonatal and infant death rates for Geauga Settlement Amish have been very similar to the corresponding rates for white children in rural Ohio and the state as a whole. The beneficial aspects of Amish society that may lessen the impact of perinatal risk factors on mortality merit further study.

Perinatal mortality in eclampsia in relation to drug therapy

Fifty-nine babies were born to eclamptic mothers among 7500 deliveries giving incidence of occurrence of 0.77 percent. The perinatal mortality in eclamptic babies was 32.7%, whereas the total perinatal mortality rate amongst all the deliveries was 10.5%. The mothers were treated within Group I--diazepam, Group II i chlorpromazine (largactil), phenargan and diazepam and Group III--largactil, phethidine and phenargan. The mortality rate was 23.8%, 18.8% and 66.6% respectively. The highest number of still-born i.e. six out of 8 occurred in Group III. Hundred percent still-born was noted in 28-32 weeks of gestation and birth weight less than 1.5 kg irrespective of drug regimes. Iargactil potentiates the respiratory depressant effect of pethidine and may cause high rate of still-birth and death after birth.

[Infant mortality in Europe and Canada: a resolved problem?]

"Tendencies in foetal-infant mortality in countries characterized by very low overall mortality rates should be set forth in terms of health. First with respect to physical health, greater use of technology in reproductive matters is translated by an increase in both survival rates of very low birth weight infants and, in certain countries, in multiple deliveries. Next concerning social health, given the persistence and potential deepening of social inequalities, it is unlikely that overall rates have reached a peak. Several indicators can be developed with vital statistics, including incidence of low and very low birth weight, specific risks by birth weight, and differential risks by social characteristics of the parents. These phenomena can be monitored and, to a certain extent, compared in [Canada and] a large number of European countries." (SUMMARY IN ENG AND SPA)

[[Perinatal mortality rates in single and multiple births, and the effects of maternal age, birthweight, and other factors on the perinatal mortality rates in Japan]]

"The perinatal mortality rate (PMR) was analyzed using... Vital Statistics for 1950-1991 in Japan. Secular changes in the PMRs were analyzed according to sex and single-multiple births. This paper also investigated the effects of maternal age, birth order, gestational age, and birthweight on the PMR." (SUMMARY IN ENG)

Perinatal mortality in caesarean section: a disturbing picture of unfulfilled expectations

Indications for caesarean section had been studied in a 2-year period and the incidences were compared to that of the same 15 years back. Though there are more incidences of caesarean section, still perinatal death is a major concern to all. The study included a total of 291 perinatal deaths of which there were 208 early neonatal deaths and 83 stillbirths over a period of 2 years from January, 1990 to December, 1991. Caesarean section is being increasingly performed for foetal interest, but this study reveals that perinatal mortality is still high though cesarean section rate has increased in recent times.

Electrohysterography during pregnancy: preliminary report

The purpose of this study was to test the ability of uterine electrical activity recorded by electrohysterography (EHG) from abdominal electrodes during pregnancy to provide reliable information about uterine contractions. In this preliminary study, abdominal EHG was used to monitor the uterine contractions of eight women, three of whom were having spontaneous contractions related to preterm labor and five of whom were having medical abortions after intrauterine fetal death. The EHG signal consisting of one electrical burst (EB) correlated with a single episode of mechanical activity (MA) in more than 66% of the recorded contractions. When mechanical or electrical activity identified as artifactual was excluded, the temporal correlation of EBs with MA was found in 89% of the recorded contractions. Furthermore, the electrical bursts detected had temporal and spectral characteristics similar to those described previously. Reliable detection of mechanical activity during early pregnancy remains problematic. Nevertheless, abdominal EHG appears suitable for noninvasive monitoring of pregnancies at risk. Further studies are needed to elucidate the significance of the EHG signal in both normal and abnormal pregnancies. It may eventually be possible to use EHG as an ambulatory monitoring tool for the early diagnosis of preterm labor.

First-trimester transabdominal multifetal pregnancy reduction: a report of two hundred completed cases

OBJECTIVE

Multifetal pregnancy reduction has been proposed as a way to reduce the risk of preterm delivery in women who conceive three or more fetuses. This communication presents the outcome of 200 consecutive multifetal pregnancies in which reduction to a smaller number of fetuses was accomplished.

STUDY DESIGN

All of the procedures were performed in the first trimester by the transabdominal injection of potassium chloride into the thoraces of those fetuses that underwent feticide. All of the pregnancies have been completed and outcome data have been obtained in every case.

RESULTS

At the time of the procedure 88 women had triplets, 89 had quadruplets, 16 had quintuplets, and 7 had from 6 to 9 fetuses. These pregnancies were reduced to 189 sets of twins, 5 sets of triplets, and 6 singletons. Reductions to triplets were done at the patient's request, and reductions to singletons were only done for medical indications. There were no cases of chorioamnionitis or other maternal complications attributable to the procedure. A total of 181 women were delivered of one or more live infants after 24 weeks' gestation, and 19 (9.5%) lost all of their fetuses before that time. The mean gestational age for all women delivered after 24 weeks was 35.7 weeks. The mean gestational age at delivery varied inversely with the initial number of fetuses, from 36.1 weeks for women who presented with triplets to 33.8 weeks for those who had 6 or more fetuses, and this trend was statistically significant. Sixteen of the 19 complete pregnancy losses occurred > 4 weeks after the reduction procedure had been performed. The loss rates were 7.9% for those who presented with 3 or 4 fetuses, 12.5% for those with 5, and 42.9% for those with > or = 6. This trend was statistically significant. Two neonates died in the first week of life and one died at 10 months of age as a consequence of the sequelae of severe prematurity. Only two surviving infants have shown evidence of chronic morbidity related to early delivery, and all of the others are developing normally.

CONCLUSION

The incidence of intrauterine growth retardation was not increased over that anticipated in a population of twins.

Caesarean section rates in an African country

The use of caesarean section (C.S.) has been analysed in the 12 hospitals of the Midlands Province of Zimbabwe during a 2-year period. Maternal mortality rate, perinatal mortality rate, low birthweight rate, percentage of high risk pregnancy, C.S. rate and instrumental delivery rate have been extracted for each hospital. The rate of C.S. delivery varied between 2.2 and 16.8 per 100 deliveries but was not correlated with the number of high-risk pregnancies. Increased use of C.S. was not linked to better perinatal results. An important determinant of the C.S. rate appears to be the physician and the ratio between the rate of instrumental deliveries (ID) and C.S. differentiated the 12 hospitals into two groups. Although there was no difference in the number of high risk patients in these two groups, outcomes were much better in the hospitals with a high ID rate than in the hospitals with a high C.S. rate, suggesting that attitudes of medical staff can influence both the mode of delivery and the perinatal outcome in a developing country.

Perinatal mortality in a northern Nigerian rural community

87 perinatal deaths which occurred out of 1484 births in a rural area of Northern Nigeria over a 9 month period were reviewed. The perinatal mortality rate was 58.6 per 1000 births. Babies born to very young adolescent mothers aged between 10-14 years had the highest perinatal mortality of 375 per 1000 births. Statistically significant relationships were also established between perinatal mortality and parity, educational status of the mother and birth weight. The leading cause of perinatal death was birth trauma which accounted for 48% of all perinatal deaths. Strategies for the reduction of perinatal mortality in the rural community are highlighted.

Maternal and perinatal mortality due to eclampsia

Forty-four mothers with eclampsia and their newborns managed during the year 1988 at the University Hospital of Banaras Hindu University, Varanasi were analyzed. The incidence of eclampsia was 2.2% of all hospital deliveries. Eclampsia was more common in women (below 20 years) and at gestation of 36 weeks and below, and amongst the mothers deprived of antenatal care. The maternal mortality amongst cases of eclampsia was 31.8% and perinatal loss was 38.6%. A relatively high incidence of eclampsia and maternal and perinatal loss was considered to be related to lack of antenatal care and late referral to the hospital. Our findings suggest that more frequent use of properly timed cesarean section can improve the maternal outcome.

Pregnancy loss in Nomadic and settled women in Turkana, Kenya: a prospective study

There have been few investigations of intrauterine mortality in non-Western populations that have used techniques capable of detecting early pregnancy loss. We report here the initial results of a prospective study of fetal loss among the Turkana of northwest Kenya. Over 300 nomadic and settled women provided early morning urine samples for 3 consecutive days. Chorionic gonadotropin (hCG), a marker for pregnancy, and markers of ovarian cyclicity (LH, PdG) were determined with solid-phase enzyme immunoassays. Pregnancy was detected in 11% of nomadic women and in 22% of sedentary women of reproductive age. Follow-up surveys revealed that 45% of all pregnancies among settled women were lost; nearly 70% of pregnancies detected in the first trimester were lost. In contrast, none of the nomadic women experienced fetal loss. Because of the small sample sizes, these results must be interpreted cautiously. Nevertheless, even a conservative estimate of the fetal loss rate among the settled women is high compared with Western experience. Anthropometric data suggest that nutritional stress may contribute to the difference between the two populations. There is also some indication that risk of fetal loss in the settled population is associated with parity. The high rate of loss among the settled women along with the difference between the nomadic and settled samples supports the contentions that there may be substantial variation among populations in intrauterine mortality and that the contribution of fetal loss to fertility differences among populations may be more important than has been suspected.

High perinatal and neonatal mortality in rural India

A prospective study conducted in rural India on pregnant women showed poor utilization of primary health services and very poor maternal care receptivity especially in terms of antenatal care. A very high perinatal mortality rate of 81.3/1000 live births and a neonatal mortality rate of 63.7/1000 live births was observed in the present study. Out of 204 live births, 72.05% of newborn developed complications within 6 weeks of the delivery. Most of the complications were of a minor nature and could be attributed to poor environmental conditions, lack of personal hygiene and ignorance. The study highlights the need for training of grass root level workers for the improvement of perinatal and neonatal care in rural India.

Eclampsia in Enugu, eastern Nigeria

A retrospective analysis of 83 cases of eclampsia managed at the University of Nigeria Teaching Hospital over a ten year period was carried out. Incidence of eclampsia was 1.7/1000 deliveries. Antepartum eclampsia constituted 84% of the cases managed. The incidence of eclampsia among unbooked cases was 14.3/1000 births and of these, the maternal mortality was 15.6% while the incidence of eclampsia for the booked patients was 1.1/1000 births of which the maternal mortality was 7.8%. Selection of high risk cases for hospital confinement, early referral of cases of eclampsia and careful use of drugs to control eclamptic fits are recommended to reduce morbidity and mortality from eclampsia.

Pregnancy outcome and placental weights: their relationship to HIV-1 infection

The relationship between placental characteristics, including weight and inflammation, and pregnancy outcome was examined as part of a case control study looking into the impact of maternal HIV-1 infection on pregnancy outcome. Cases defined as low birth weight (< 2500g) or stillbirth deliveries, were compared to controls defined as mothers who delivered a live born neonate weighing 2500g or more. The mean placental weight and the mean foetal/placental weight ratio were significantly lower in cases (n = 253) than in controls (n = 216) (p < .05). Placental inflammation (chorioamnionitis) was significantly associated with prematurity (p < .001) and with stillbirth (p < .05), maternal HIV-1 antibody being a risk factor for chorioamnionitis in the preterm group. These data support a correlation between placental weight and pregnancy outcome, and suggest that maternal HIV-1 infection is a risk factor for chorioamnionitis in HIV-1 seropositive preterm deliveries.

Agricultural pesticide exposure and perinatal mortality in central Sudan

Hospital- and community-based studies were conducted in central Sudan to investigate the association between pesticide exposure and perinatal mortality. The cases were 197 stillbirths in the hospital and 36 perinatal deaths in the community; the controls were 812 liveborn, normal-birth-weight infants in the hospital, and 1505 liveborn infants who survived for the first 7 days after birth in the community. The odds ratio (OR) of perinatal death associated with pesticide exposure was estimated using multiple logistic regression. There was a consistent and significant association between pesticide exposure and perinatal mortality in the hospital (adjusted OR = 1.9; 95% confidence interval (CI): 1.3-2.8) and the community populations (adjusted OR = 2.7; 95% CI: 1.1-6.4). The OR was significantly higher among women engaged in farming (3.6; 95% CI: 1.6-8.0), but not among women in nonfarming occupations (1.6; 95% CI: 0.8-3.3). The estimated attributable risks of perinatal death owing to pesticide exposure were 22.6% for hospital stillbirths and 15.7% for community perinatal deaths; but among women engaged in farming in the hospital population the attributable risks were substantially higher (34.5%).

Hypertension during pregnancy in Africa and infants' health. A cohort study in an urban setting

The objective of the study was to assess the prevalence of unclassified hypertension during pregnancy and its consequences on infant's health in an African urban setting: Pikine, a suburb of Dakar, Senegal. A cross-sectional study of a random sample of pregnant women and a prospective study, from the inclusion to seven days after delivery, were performed. 886 women attending the prenatal centers were included in the cross-sectional study. 471 pregnant women were included in the follow-up study. The prevalence of DBP > or = 120 mmHg was 0.7%; 5.7% of the women had DBP > or = 95 mmHg. Longitudinal data were available for 425 deliveries. Two spontaneous abortions, 25 stillbirths, and 12 deaths during the early neonatal period were recorded. Among babies living at birth, the percentage of LBW (> or = 2500 g) was 8.5%. The percentages of adverse outcome of pregnancy (death and/or low birth weight) was associated with mothers' diastolic BP: < 85 mmHg: 13%; 85 to 89: 16%; 90 to 94: 9%; DBP > or = 95: 32%, (p < 0.01). Using 95 mmHg as a cutpoint, the relative risk of adverse outcome associated with a DBP > or = 95 mmHg was 2.5 (CI 95%: 1.4-4.3). This risk was significantly increased among women who reported difficult living conditions. Eight percent of the adverse outcomes of pregnancy, 10% of the low birth weights and 8% of the perinatal mortality were found to be associated with DBP > or 95 mmHg.

Syphilis-associated perinatal and infant mortality in rural Malawi

In Mangochi District, a rural area of Malawi, the prevalence of active syphilis was 3.6% among 3591 women who had singleton births and who were negative for human immunodeficiency virus (HIV). Compared with non-syphilitic women, those with active syphilis (positive Venereal Disease Research Laboratory/rapid plasmin reagin tests (titre > or = 1:8) and a reactive microhaemagglutination assay) were more likely to experience stillbirths as well as the early and late neonatal deaths and even postneonatal deaths of their children. Characteristics associated with active syphilis were not very useful in targeting women at high risk of having the condition, which makes universal screening in antenatal programmes the most efficacious way to prevent syphilis-associated morbidity and mortality. The potential for a programme to prevent congenital syphilis in the perinatal, neonatal, and post-neonatal periods is evident. In considering resource allocation to child survival programmes in areas where the prevalence of syphilis is high, officials need to include antenatal syphilis screening, using rapid tests and treatment at the first contact of the mother with the health care system.