Management of subsequent pregnancy after an unexplained stillbirth

Syncytiotrophoblast Markers Are Downregulated in Placentas from Idiopathic Stillbirths

The trophoblast cells are responsible for the transfer of nutrients between the mother and the foetus and play a major role in placental endocrine function by producing and releasing large amounts of hormones and growth factors. Syncytiotrophoblast cells (STB), formed by the fusion of mononuclear cytotrophoblasts (CTB), constitute the interface between the foetus and the mother and are essential for all of these functions. We performed transcriptome analysis of human placental samples from two control groups-live births (LB), and stillbirths (SB) with a clinically recognised cause-and from our study group, idiopathic stillbirths (iSB). We identified 1172 DEGs in iSB, when comparing with the LB group; however, when we compared iSB with the SB group, only 15 and 12 genes were down- and upregulated in iSB, respectively. An assessment of these DEGs identified 15 commonly downregulated genes in iSB. Among these, several syncytiotrophoblast markers, like genes from the PSG and CSH families, as well as ALPP, KISS1, and CRH, were significantly downregulated in placental samples from iSB. The transcriptome analysis revealed underlying differences at a molecular level involving the syncytiotrophoblast. This suggests that defects in the syncytial layer may underlie unexplained stillbirths, therefore offering insights to improve clinical obstetrics practice.

Neonatal and Maternal Outcomes of Pregnancies following Stillbirth

OBJECTIVE

 Prior stillbirth increases risk of subsequent stillbirth but has unclear effect on subsequent liveborn pregnancies. We examined associations between prior stillbirth, adverse neonatal outcomes, and maternal morbidity in subsequent liveborn pregnancies.

STUDY DESIGN

 This is a secondary analysis of a large, National Institutes of Health-funded retrospective cohort study of parturients who delivered a singleton infant at a tertiary-care hospital from January 2002 to March 2013 and had a past medical/obstetric history of diabetic, and/or hypertensive disorders, and/or pregnancy with fetal growth restriction. Our analysis included all multiparous patients from the parent study. The primary outcome was a neonatal morbidity composite (neonatal resuscitation, neonatal birth injury, respiratory distress syndrome, transient tachypnea of the newborn, hypoglycemia, sepsis). Secondary outcomes included a maternal morbidity composite (venous thromboembolism, intensive care unit admission, disseminated intravascular coagulation, sepsis, hysterectomy, pulmonary edema, renal failure, blood transfusion), other maternal/delivery complications, and neonatal intensive care unit (NICU) admission. Outcomes were compared between those with versus without prior stillbirth. Negative binomial regression controlled for maternal comorbidities and delivery year.

RESULTS

 Among 171 and 5,245 multiparous parturients with versus without prior stillbirth, respectively, those with prior stillbirth had higher rates of pregestational diabetes, autoimmune disease, and clotting disorders. After controlling for these differences and delivery year, infants of parturients with prior stillbirth had similar risk of composite neonatal morbidity (adjusted relative ratio [aRR] 1.19; 95% confidence interval [CI] 0.99-1.45) but higher risk of NICU admission (aRR 1.42; 95% CI 1.06-1.91) compared with infants of parturients without prior stillbirth, despite delivering at similar gestational ages. Multiparous patients with prior stillbirth had equal maternal morbidity risk but higher risk of developing preeclampsia with severe features (aRR 2.11; 95% CI 1.19-3.72).

CONCLUSION

 Compared with high-risk multiparous patients without prior stillbirth, those with prior stillbirth have higher risk of NICU admission and preeclampsia with severe features.

KEY POINTS

· Prior stillbirth increases risk in subsequent livebirth for NICU admission and neonatal morbidity.. · Prior stillbirth increased the risk of severe preeclampsia for mothers in subsequent livebirth.. · Additional monitoring of pregnancies of patients with prior history of demise may be warranted..

Parents experiences of pregnancy following perinatal loss: An integrative review

BACKGROUND

Pregnancy following perinatal loss has a profound effect on parents and may contribute to intense psychological distress including grief, post-traumatic stress disorder, anxiety and depression. The subsequent pregnancy may also be perceived as more stressful due to the fear of recurrent loss. Midwives and other health care professionals need to be sensitive and empathetic to the needs of these parents when providing care in a pregnancy subsequent to a loss.

METHODOLOGY

The aim of this integrated literature review was to explore parents' experiences of pregnancy following a previous perinatal loss using a systematic approach. This is presented in a five-stage process that includes problem identification, literature search, data extraction and evaluation, data analysis and presentation of results. A systematic search of seven electronic databases was conducted (Jan 2009 -Jan 2023) to identify relevant primary research which addressed parents' experiences of pregnancy following a previous perinatal loss. Seven papers met the eligibility criteria and were assessed for quality using Crowe's Critical Appraisal Tool (CCAT). Thematic analysis identified two themes.

FINDINGS

The key themes identified from the literature were; the psychosocial needs and challenges faced by previously bereaved parents in subsequent pregnancies; and the need for specialist care and support in a subsequent pregnancy. Psychological needs and challenges included continued grief, depression, anxiety, and disparities in the grief process between men and women. The importance of specialist care with an increased level of support from competent, confident and compassionate health care providers was highlighted.

CONCLUSION

The experience of pregnancy following a perinatal loss can be a complex emotional experience for parents. The review identifies the need for post pregnancy loss debriefing and counselling and care pathways specific to caring for women and their partners in a pregnancy subsequent to a perinatal loss. Care in pregnancy subsequent to loss should be provided by empathetic, competent health care providers and include additional antenatal clinic appointments, pregnancy monitoring and psychological support in order to meet the needs of these expectant parents.

Etiology and evaluation of stillbirth in patients with obesity

OBJECTIVE

Maternal obesity is a risk factor for stillbirth, but whether or not the etiology of stillbirth differs in gravidas with and without obesity is unknown. We categorized stillbirths in a contemporary cohort to test the hypothesis that the etiology of stillbirth is different in gravidas with and without obesity.

METHODS

This retrospective cohort study included all gravidas with a stillbirth ≥20 weeks' gestation between 2010 and 2017 and a normal mid-trimester anatomic survey by ultrasound assessment at a large academic institution. Pregnancies were excluded if delivery data were unavailable, a multifetal gestation was present, or there was an antenatally diagnosed fetal structural or genetic anomaly. Our primary exposure was maternal obesity, defined as a body mass index (BMI) ≥ 30 kg/m² at the time of anatomic survey. Our primary outcome was stillbirth etiology, as classified by the initial causes of fetal death tool from the Stillbirth Collaborative Research Network and includes maternal, obstetric, hematologic, fetal, infectious, placental, other, or unexplained categories. Our secondary outcomes included the evaluation performed on each stillbirth, compliance with the recommended stillbirth evaluation by the American College of Obstetricians and Gynecologists (ACOG), and the percentage of abnormal results for each of the tests ordered for stillbirth evaluation.

RESULTS

Of 118 stillbirths meeting the inclusion criteria, 44 (37.3%) occurred in gravidas with obesity and 74 (62.7%) were in patients without obesity. An obstetric complication was the most commonly identified etiology for stillbirth, found in 40.9% of cases with obesity versus in 29.7% of cases without obesity (aOR 1.09, 95% CI 0.47-2.66). The likelihood of any specific etiology of stillbirth was not significantly different in gravidas of the two weight groups, after controlling for confounders. However, assignment to the unexplained stillbirth category was significantly less common in women with obesity, compared to those without obesity (aOR 0.18, 95% CI 0.05-0.67). There was no difference in testing performed on each stillbirth between the groups. Compliance with the ACOG-recommended diagnostic evaluation for stillbirth was similar in the two groups but was only performed in 10.2% of all cases of stillbirth. Placental pathology was the test most likely to yield an abnormal result in both groups, but the percentage of abnormal results for this and all other tests was the same in the presence and absence of obesity.

CONCLUSION

There is no specific etiology of stillbirth seen in gravidas with obesity, compared to those without obesity, after controlling for maternal confounders. We surmise that the evaluation recommended for stillbirth assessment in the general population is appropriate for stillbirth evaluation in gravidas with obesity. Testing pursued was similar between groups, but compliance with ACOG recommendations for testing after stillbirth was deficient in the cohort. Future work should aim to identify and address barriers to completing the recommended stillbirth evaluation.

Maternal experiences of care following a stillbirth at Steve Biko Academic Hospital, Pretoria, South Africa

Background. Despite improvements in obstetrics and neonatal care, the stillbirth rate remains high (23 per 1 000 births) in South Africa (SA). The occurrence of a stillbirth is a dramatic and often life-changing event for the family involved. The potential consequences include adverse effects on the health of the mother, strain on the relationship of the parents, and strain on the relationship between the parents and their other children. The standard of care in SA follows the Royal College of Obstetricians and Gynaecologists Green-top guidelines.Objectives. To explore maternal experiences of in-patient care received in cases of stillbirth.Methods. A descriptive phenomenological approach was performed in the obstetrics unit at Steve Biko Academic Hospital, Pretoria, SA. Post-discharge interviews were conducted with women who experienced a stillbirth. The healthcare workers in the obstetric unit were also interviewed on the care provided to these patients. Data analysis was performed using the Colaizzi’s method.Results. Data from the interviews with the 30 patients resulted in five themes relating to the maternal experience of stillbirth: ‘broken heart', ‘helping hand’, ‘searching brain’, ‘soul of service’ and ‘fractured system’. Healthcare worker participants emphasised the importance of medical care (the clinical guidelines) rather than maternal care (the psychosocial guidelines).Conclusion. While the medical aspects of the guidelines are adhered to, the psychosocial aspects are not. Consequently, the guidelines require adaptation, especially taking into consideration African cultural practices, and the inclusion of allocated responsibility regarding the application of the psychosocial guidelines, as this is the humanitarian umbilical cord between healthcare workers and those in their care.

Stillbirth and neonatal mortality in a subsequent pregnancy following stillbirth: a population-based cohort study

BACKGROUND

A history of stillbirth is a risk factor for recurrent fetal death in a subsequent pregnancy. Reported risks of recurrent fetal death are often not stratified by gestational age. In subsequent pregnancies increased rates of medical interventions are reported without evidence of perinatal benefit. The aim of this study was to estimate gestational-age specific risks of recurrent stillbirth and to evaluate the effect of obstetrical management on perinatal outcome after previous stillbirth.

METHODS

A retrospective cohort study in the Netherlands was designed that included 252.827 women with two consecutive singleton pregnancies (1^st and 2^nd delivery) between 1999 and 2007. Data was obtained from the national Perinatal Registry and analyzed for pregnancy outcomes. Fetal deaths associated with a congenital anomaly were excluded. The primary outcome was the occurrence of stillbirth in the second pregnancy stratified by gestational age. Secondary outcome was the influence of obstetrical management on perinatal outcome in a subsequent pregnancy.

RESULTS

Of 252.827 first pregnancies, 2.058 pregnancies ended in a stillbirth (8.1 per 1000). After adjusting for confounding factors, women with a prior stillbirth have a two-fold higher risk of recurrence (aOR 1.96, 95% CI 1.07-3.60) compared to women with a live birth in their first pregnancy. The highest risk of recurrence occurred in the group of women with a stillbirth in early gestation between 22 and 28 weeks of gestation (a OR 2.25, 95% CI 0.62-8.15), while after 32 weeks the risk decreased. The risk of neonatal death after 34 weeks of gestation is higher in women with a history of stillbirth (aOR 6.48, 95% CI 2.61-16.1) and the risk of neonatal death increases with expectant obstetric management (aOR 10.0, 95% CI 2.43-41.1).

CONCLUSIONS

A history of stillbirth remains an important risk for recurrent stillbirth especially in early gestation (22-28 weeks). Women with a previous stillbirth should be counselled for elective induction in the subsequent pregnancy at 37-38 weeks of gestation to decrease the risk of perinatal death.

The role of confounding in the association between pregnancy complications and subsequent preterm birth: a cohort study

OBJECTIVE

To estimate the degree of confounding necessary to explain the associations between complications in a first pregnancy and the subsequent risk of preterm birth.

DESIGN

Population-based cohort study.

SETTING

Western Australia.

POPULATION

Women (n = 125 473) who gave birth to their first and second singleton children between 1998 and 2015.

MAIN OUTCOME MEASURES

Relative risk (RR) of a subsequent preterm birth (<37 weeks of gestation) with complications of pre-eclampsia, placental abruption, small-for-gestational age and perinatal death (stillbirth and neonatal death within 28 days of birth). We derived e-values to determine the minimum strength of association for an unmeasured confounding factor to explain away an observed association.

RESULTS

Complications in a first pregnancy were associated with an increased risk of a subsequent preterm birth. Relative risks were significantly higher when the complication was recurrent, with the exception of first-term perinatal death. The association with subsequent preterm birth was strongest when pre-eclampsia was recurrent. The risk of subsequent preterm birth with pre-eclampsia was 11.87 (95% CI 9.52-14.79) times higher after a first term birth with pre-eclampsia, and 64.04 (95% CI 53.58-76.55) times higher after a preterm first birth with pre-eclampsia, than an uncomplicated term birth. The e-values were 23.22 and 127.58, respectively.

CONCLUSIONS

The strong associations between recurrent pre-eclampsia, placental abruption and small-for-gestational age with preterm birth supports the hypothesis of shared underlying causes that persist from pregnancy to pregnancy. High e-values suggest that recurrent confounding is unlikely, as any such unmeasured confounding factor would have to be uncharacteristically large.

TWEETABLE ABSTRACT

First pregnancy complications are associated with a higher risk of subsequent preterm birth, with evidence strongest for pregnancies complicated by pre-eclampsia.

Stillbirth and subsequent pregnancy outcome - a cohort from a large tertiary referral hospital

Objectives This study aimed to assess pregnancy and delivery outcomes in women with a history of stillbirth in a large tertiary referral hospital. Methods This was a retrospective study from Helsinki University Hospital, Finland. The cohort comprised 214 antepartum singleton stillbirths in the period 2003-2015 (case group). Of these, 154 delivered by the end of 2017. Adverse pregnancy outcomes were compared to those in singleton pregnancies of parous women in Finland from the Finnish Medical Birth Register (reference group). Results The rates of adverse pregnancy outcomes were higher among case women for preeclampsia (3.3 vs. 0.9%, P = 0.002), preterm birth (8.5 vs. 3.9%, P = 0.004), small-for-gestational-age (SGA) children (7.8 vs. 2.2%, P < 0.001) and stillbirth (2.7 vs. 0.3%, P < 0.001). There were four preterm recurrent stillbirths. Induction of labor was more common among case women than parous women in the reference group (49.4 vs. 18.3%, P < 0.001). Duration of pregnancy was shorter among case women (38.29 ± 3.20 vs. 39.27 ± 2.52, P < 0.001), and mean birth weight was lower among newborns of the case women (3274 ± 770 vs. 3491 ± 674 g, P < 0.001). Conclusion Although the rates for adverse pregnancy outcomes were higher compared to the parous background population, the overall probability of a favorable outcome was high. The risk of recurrent premature stillbirth in our cohort was higher than that for parous women in general during the study period. No recurrent term stillbirths occurred, however.

Pregnancy decisions after fetal or perinatal death: systematic review of qualitative research

OBJECTIVES

To synthesise the findings of qualitative research exploring parents' experiences, views and decisions about becoming pregnant following a perinatal death or fetal loss.

DESIGN

Systematic review and meta-synthesis of qualitative research.

DATA SOURCES

Medline, Web of Science, CINAHL, PsycINFO, ASSIA, Embase, PUBMED, Scopus and Google Scholar.

ELIGIBILITY CRITERIA

Nine electronic databases were searched using predefined search terms. Articles published in English, in peer-reviewed journals, using qualitative methods to explore the experiences and attitudes of bereaved parents following perinatal or fetal loss, were included.

DATA EXTRACTION AND SYNTHESIS

Qualitative data relating to first-order and second-order constructs were extracted and synthesised across studies using a thematic analysis.

RESULTS

15 studies were included. Four descriptive themes and 10 subthemes were identified. The descriptive themes were: deciding about subsequent pregnancy, diversity of reactions to the event, social network influences, and planning or timing of subsequent pregnancy. The decision to become pregnant after death is complex and varies between individuals and sometimes within couples. Decisions are often made quickly, in the immediate aftermath of a pregnancy loss, but may evolve over time. Bereaved parents may feel isolated from social networks.

CONCLUSIONS

There is an opportunity to support parents to prepare for a pregnancy after a fetal or perinatal loss, and conversations may be welcomed at an early stage. Health professionals may play an important role providing support lacking from usual social networks.

PROSPERO REGISTRATION NUMBER

CRD42018112839.

Bemiparin as a Prophylaxis After an Unexplained Stillbirth: Open-Label Interventional Prospective Study

Stillbirth is a devastating event to the parents, relatives, friends, and families. The role of anticoagulants in the prevention of unexplained stillbirths is uncertain. An open-label interventional prospective cohort study was conducted on 144 women with a history of unexplained stillbirths. The intervention group had a high umbilical artery resistance index (RI) and received bemiparin. The nonintervention group had a normal RI and did not receive any intervention. We measured the adjusted odds ratio (OR) and 95% confidence interval (CI) of the main outcome for these variables using logistic regression analysis. Fresh stillbirth and early neonatal death rates were lower (P = .005, OR = 11.949 and 95% CI = 2.099-68.014) and newborn weight was higher (P = .015, OR = 0.048, 95% CI = 0.004-0.549) in the group that received bemiparin. Bemiparin is effective in decreasing the rate of stillbirth in women with a history of previous unexplained stillbirths.

Care prior to and during subsequent pregnancies following stillbirth for improving outcomes

BACKGROUND

Stillbirth affects at least 2.6 million families worldwide every year and has enduring consequences for parents and health services. Parents entering a subsequent pregnancy following stillbirth face a risk of stillbirth recurrence, alongside increased risks of other adverse pregnancy outcomes and psychosocial challenges. These parents may benefit from a range of interventions to optimise their short- and longer-term medical health and psychosocial well-being.

OBJECTIVES

To assess the effects of different interventions or models of care prior to and during subsequent pregnancies following stillbirth on maternal, fetal, neonatal and family health outcomes, and health service utilisation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (6 June 2018), along with ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 June 2018).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised controlled trials (qRCTs). Trials using a cluster-randomised design were eligible for inclusion, but we found no such reports. We included trials published as abstract only, provided sufficient information was available to allow assessment of trial eligibility and risk of bias. We excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for eligibility and undertook data extraction and 'Risk of bias' assessments. We extracted data from published reports, or sourced data directly from trialists. We checked the data for accuracy and resolved discrepancies by discussion or correspondence with trialists, or both. We conducted an assessment of the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included nine RCTs and one qRCT, and judged them to be at low to moderate risk of bias. Trials were carried out between the years 1964 and 2015 and took place predominantly in high-income countries in Europe. All trials assessed medical interventions; no trials assessed psychosocial interventions or incorporated psychosocial aspects of care. Trials evaluated the use of antiplatelet agents (low-dose aspirin (LDA) or low-molecular-weight heparin (LMWH), or both), third-party leukocyte immunisation, intravenous immunoglobulin, and progestogen. Trial participants were women who were either pregnant or attempting to conceive following a pregnancy loss, fetal death, or adverse outcome in a previous pregnancy.We extracted data for 222 women who had experienced a previous stillbirth of 20 weeks' gestation or more from the broader trial data sets, and included them in this review. Our GRADE assessments of the quality of evidence ranged from very low to low, due largely to serious imprecision in effect estimates as a result of small sample sizes, low numbers of events, and wide confidence intervals (CIs) crossing the line of no effect. Most of the analyses in this review were not sufficiently powered to detect differences in the outcomes assessed. The results presented are therefore largely uncertain.Main comparisonsLMWH versus no treatment/standard care (three RCTs, 123 women, depending on the outcome)It was uncertain whether LMWH reduced the risk of stillbirth (risk ratio (RR) 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), adverse perinatal outcome (RR 0.81, 95% CI 0.20 to 3.32; 2 trials; 77 participants; low-quality evidence), adverse maternal psychological effects (RR 1.00, 95% CI 0.07 to 14.90; 1 trial; 40 participants; very low-quality evidence), perinatal mortality (RR 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), or any preterm birth (< 37 weeks) (RR 1.01, 0.58 to 1.74; 3 trials; 114 participants; low-quality evidence). No neonatal deaths were reported in the trials assessed and no data were available for maternal-infant attachment. There was no clear evidence of a difference between the groups among the remaining secondary outcomes.LDA versus placebo (one RCT, 24 women)It was uncertain whether LDA reduced the risk of stillbirth (RR 0.85, 95% CI 0.06 to 12.01), neonatal death (RR 0.29, 95% CI 0.01 to 6.38), adverse perinatal outcome (RR 0.28, 95% CI 0.03 to 2.34), perinatal mortality, or any preterm birth (< 37 weeks) (both of the latter RR 0.42, 95% CI 0.04 to 4.06; all very low-quality evidence). No data were available for adverse maternal psychological effects or maternal-infant attachment. LDA appeared to be associated with an increase in birthweight (mean difference (MD) 790.00 g, 95% CI 295.03 to 1284.97 g) when compared to placebo, but this result was very unstable due to the extremely small sample size. Whether LDA has any effect on the remaining secondary outcomes was also uncertain.Other comparisonsLDA appeared to be associated with an increase in birthweight when compared to LDA + LMWH (MD -650.00 g, 95% CI -1210.33 to -89.67 g; 1 trial; 29 infants), as did third-party leukocyte immunisation when compared to placebo (MD 1195.00 g, 95% CI 273.35 to 2116.65 g; 1 trial, 4 infants), but these results were again very unstable due to extremely small sample sizes. The effects of the interventions on the remaining outcomes were also uncertain.

AUTHORS' CONCLUSIONS

There is insufficient evidence in this review to inform clinical practice about the effectiveness of interventions to improve care prior to and during subsequent pregnancies following a stillbirth. There is a clear and urgent need for well-designed trials addressing this research question. The evaluation of medical interventions such as LDA, in the specific context of stillbirth prevention (and recurrent stillbirth prevention), is warranted. However, appropriate methodologies to evaluate such therapies need to be determined, particularly where clinical equipoise may be lacking. Careful trial design and multicentre collaboration is necessary to carry out trials that would be sufficiently large to detect differences in statistically rare outcomes such as stillbirth and neonatal death. The evaluation of psychosocial interventions addressing maternal-fetal attachment and parental anxiety and depression is also an urgent priority. In a randomised-trial context, such trials may allocate parents to different forms of support, to determine which have the greatest benefit with the least financial cost. Importantly, consistency in nomenclature and in data collection across all future trials (randomised and non-randomised) may be facilitated by a core outcomes data set for stillbirth research. All future trials should assess short- and longer-term psychosocial outcomes for parents and families, alongside economic costs of interventions.

The Impact of Previous Pregnancy Loss on Lactating Behaviors and Use of Herbal Medicines during Breastfeeding: A Post Hoc Analysis of the Herbal Supplements in Breastfeeding InvesTigation (HaBIT)

Introduction

Complementary and alternative medicines (CAMs) are commonly used among lactating women, despite the poor knowledge of these products and of their safety. Perception of pregnancy- and breastfeeding-related difficulties and consequent use of CAMs may differ in bereaved women, by force of the distress related to previous loss, although no literature evidence is available. This Herbal supplements in Breastfeeding InvesTigation (HaBIT) post hoc analysis explored the impact of previous pregnancy loss on lactating behaviors and on use of CAMs during breastfeeding.

Methods

A web-based survey was conducted among lactating women with no previous alive child, resident in Tuscany (Italy). Data on lactating behavior and on CAMs use were collected and evaluated among women with previous pregnancy loss as compared to control women.

Results

Out of 476 women answering the questionnaire, 233 lactating women with one child were considered. Of them, 80 had history of pregnancy loss. Cesarean birth was significantly more frequent among women with history of pregnancy loss as compared to controls (41% versus 22%; p=0.004). Proportion, length of exclusive breastfeeding, and occurrence of breastfeeding-related complications were comparable among the two cohorts. More than half of women used CAMs during breastfeeding. Use of CAMs was more frequent among women with previous pregnancy loss (54% versus 68%; p=0.050), specifically considering herbal preparations (16% versus 30%; p=0.018). Major advisors for CAMs use were midwives. 18% and 23% of women without and with history of pregnancy loss declared no clear perception on CAMs efficacy and safety.

Conclusion

Overcoming the social taboo of pregnancy loss and training healthcare professionals for an adequate management of the perinatal period are essential for an effective and safe care. Despite the common use and advice on CAMs use during breastfeeding, it is important to acknowledge that limited evidence supports their safety and efficacy during such critical period.

An inactivating mutation in the histone deacetylase SIRT6 causes human perinatal lethality

Ferrer et al. demonstrate that a homozygous inactivating mutation in the histone deacetylase SIRT6 results in severe congenital anomalies and perinatal lethality in four affected fetuses. Human induced pluripotent stem cells derived from D63H homozygous fetuses fail to differentiate into embryoid bodies, functional cardiomyocytes, and neural progenitor cells due to a failure to repress pluripotent genes.

It has been well established that histone and DNA modifications are critical to maintaining the equilibrium between pluripotency and differentiation during early embryogenesis. Mutations in key regulators of DNA methylation have shown that the balance between gene regulation and function is critical during neural development in early years of life. However, there have been no identified cases linking epigenetic regulators to aberrant human development and fetal demise. Here, we demonstrate that a homozygous inactivating mutation in the histone deacetylase SIRT6 results in severe congenital anomalies and perinatal lethality in four affected fetuses. In vitro, the amino acid change at Asp63 to a histidine results in virtually complete loss of H3K9 deacetylase and demyristoylase functions. Functionally, SIRT6 D63H mouse embryonic stem cells (mESCs) fail to repress pluripotent gene expression, direct targets of SIRT6, and exhibit an even more severe phenotype than Sirt6-deficient ESCs when differentiated into embryoid bodies (EBs). When terminally differentiated toward cardiomyocyte lineage, D63H mutant mESCs maintain expression of pluripotent genes and fail to form functional cardiomyocyte foci. Last, human induced pluripotent stem cells (iPSCs) derived from D63H homozygous fetuses fail to differentiate into EBs, functional cardiomyocytes, and neural progenitor cells due to a failure to repress pluripotent genes. Altogether, our study described a germline mutation in SIRT6 as a cause for fetal demise, defining SIRT6 as a key factor in human development and identifying the first mutation in a chromatin factor behind a human syndrome of perinatal lethality.

Pregnancy subsequent to stillbirth: Medical and psychosocial aspects of care

Pregnancy after stillbirth presents unique challenges for families and healthcare providers. Medical surveillance and interventions must be optimized to improve outcomes and provide individualized support for families. A key component of acceptable care is psychosocial support that is delivered in a timely and sensitive manner by care providers with knowledge about the pervasive impact of stillbirth. With the lack of existing evidence to guide care, there is an urgent need for global leadership and research to address knowledge gaps.

Caesarean delivery and subsequent stillbirth or miscarriage: systematic review and meta-analysis

OBJECTIVE

To compare the risk of stillbirth and miscarriage in a subsequent pregnancy in women with a previous caesarean or vaginal delivery.

DESIGN

Systematic review of the published literature including seven databases: CINAHL; the Cochrane library; Embase; Medline; PubMed; SCOPUS and Web of Knowledge from 1945 until November 11(th) 2011, using a detailed search-strategy and cross-checking of reference lists.

STUDY SELECTION

Cohort, case-control and cross-sectional studies examining the association between previous caesarean section and subsequent stillbirth or miscarriage risk. Two assessors screened titles to identify eligible studies, using a standardised data abstraction form and assessed study quality.

DATA SYNTHESIS

11 articles were included for stillbirth, totalling 1,961,829 pregnancies and 7,308 events. Eight eligible articles were included for miscarriage, totalling 147,017 pregnancies and 12,682 events. Pooled estimates across the stillbirth studies were obtained using random-effect models. Among women with a previous caesarean an increase in odds of 1.23 [95% CI 1.08, 1.40] for stillbirth was yielded. Subgroup analyses including unexplained stillbirths yielded an OR of 1.47 [95% CI 1.20, 1.80], an OR of 2.11 [95% CI 1.16, 3.84] for explained stillbirths and an OR of 1.27 [95% CI 0.95, 1.70] for antepartum stillbirths. Only one study reported adjusted estimates in the miscarriage review, therefore results are presented individually.

CONCLUSIONS

Given the recent revision of the National Institute for Health and Clinical Excellence guidelines (NICE), providing women the right to request a caesarean, it is essential to establish whether mode of delivery has an association with subsequent risk of stillbirth or miscarriage. Overall, compared to vaginal delivery, the pooled estimates suggest that caesarean delivery may increase the risk of stillbirth by 23%. Results for the miscarriage review were inconsistent and lack of adjustment for confounding was a major limitation. Higher methodological quality research is required to reliably assess the risk of miscarriage in subsequent pregnancies.

Heavy prenatal alcohol exposure and risk of stillbirth and preterm delivery

We prospectively identified 96 women consuming at least 4 drinks/day during pregnancy by screening 9628 pregnant women. In these women with heavy prenatal alcohol use, there were three stillbirths and one preterm delivery; 98 matched nondrinking women had no stillbirths and two preterm births. Preterm rates did not differ significantly. The stillbirth rate was higher in the exposed group (p = 0.06). Additional investigation showed the stillbirth rate in the exposed population (3.1%) was significantly higher (p = 0.019) than the reported Chilean population rate (0.45%). Our data suggest that heavy alcohol consumption may increase the risk for stillbirth but not preterm delivery.