Poor Obstetric Outcome in Subsequent Pregnancies in Women With Prior Fetal Death

A comprehensive assessment of care competence and maternal experience of first antenatal care visits in Mexico: Insights from the baseline survey of an observational cohort study

BACKGROUND

Comprehensive antenatal care (ANC) must prioritize competent, evidence-based medical attention to ensure a positive experience and value for its users. Unfortunately, there is scarce evidence of implementing this holistic approach to ANC in low- and middle-income countries, leading to gaps in quality and accountability. This study assessed care competence, women's experiences during the first ANC visit, and the factors associated with these care attributes.

METHODS AND FINDINGS

The study analyzed cross-sectional baseline data from the maternal eCohort study conducted in Mexico from August to December 2023. The study adapted the Quality Evidence for Health System Transformation (QuEST) network questionnaires to the Mexican context and validated them through expert group and cognitive interviews with women. Pregnant women aged 18 to 49 who had their first ANC visit with a family physician were enrolled in 48 primary clinics of the Instituto Mexicano del Seguro Social across 8 states. Care competence and women's experiences with care were the primary outcomes. The statistical analysis comprised descriptive statistics, multivariable linear and Poisson regressions. A total of 1,390 pregnant women were included in the study. During their first ANC visit, women received only 67.7% of necessary clinical actions on average, and 52% rated their ANC experience as fair or poor. Women with previous pregnancies (adjusted regression coefficient [aCoef.] -3.55; (95% confidence intervals [95% CIs]): -4.88, -2.22, p < 0.001), at risk of depression (aCoef. -3.02; 95% CIs: -5.61, -0.43, p = 0.023), those with warning signs (aCoef. -2.84; 95% CIs: -4.65, -1.03, p = 0.003), common pregnancy discomforts (aCoef. -1.91; 95% CIs: -3.81, -0.02, p = 0.048), or those who had a visit duration of less than 20 minutes (<15 minutes: aCoef. -7.58; 95% CIs: -10.21, -4.95, p < 0.001 and 15 to 19 minutes: aCoef. -2.73; 95% CIs: -4.79, -0.67, p = 0.010) and received ANC in the West and Southeast regions (aCoef. -5.15; 95% CIs: -7.64, -2.66, p < 0.001 and aCoef. -5.33; 95% CIs: -7.85, -2.82, p < 0.001, respectively) had a higher probability of experiencing poorer care competence. Higher care competence (adjusted prevalence ratio [aPR] 1.004; 95% CIs:1.002, 1.005, p < 0.001) and receiving care in a small clinic (aPR 1.19; 95% CIs: 1.06, 1.34, p = 0.003) compared to a medium-sized clinic were associated with a better first ANC visit experience, while common pregnancy discomforts (aPR 0.94; 95% CIs: 0.89, 0.98, p = 0.005) and shorter visit length (aPR 0.94; 95% CIs: 0.88, 0.99, p = 0.039) were associated with lower women's experience. The primary limitation of the study is that participants' responses may be influenced by social desirability bias, leading them to provide socially acceptable responses.

CONCLUSIONS

We found important gaps in adherence to ANC standards and that care competence during the first ANC visit is an important predictor of positive user experience. To inform quality improvement efforts, IMSS should institutionalize the routine monitoring of ANC competencies and ANC user experience. This will help identify poorly performing facilities and providers and address gaps in the provision of evidence-based and women-centered care.

A Systematic Review to Guide Future Efforts in the Determination of Genetic Causes of Pregnancy Loss

Background: Pregnancy loss is the most common obstetric complication occurring in almost 30% of conceptions overall and in 12–14% of clinically recognized pregnancies. Pregnancy loss has strong genetic underpinnings, and despite this consensus, our understanding of its genetic causes remains limited. We conducted a systematic review of genetic factors in pregnancy loss to identify strategies to guide future research.

Methods: To synthesize data from population-based association studies on genetics of pregnancy loss, we searched PubMed for relevant articles published between 01/01/2000-01/01/2020. We excluded review articles, case studies, studies with limited sample sizes to detect associations (N &lt; 4), descriptive studies, commentaries, and studies with non-genetic etiologies. Studies were classified based on developmental periods in gestation to synthesize data across various developmental epochs.

Results: Our search yielded 580 potential titles with 107 (18%) eligible after title/abstract review. Of these, 54 (50%) were selected for systematic review after full-text review. These studies examined either early pregnancy loss (n = 9 [17%]), pregnancy loss &gt;20 weeks' gestation (n = 10 [18%]), recurrent pregnancy loss (n = 32 [59%]), unclassified pregnancy loss (n = 3 [4%]) as their primary outcomes. Multiple genetic pathways that are essential for embryonic/fetal survival as well as human development were identified.

Conclusion: Several genetic pathways may play a role in pregnancy loss across developmental periods in gestation. Systematic evaluation of pregnancy loss across developmental epochs, utilizing whole genome sequencing in families may further elucidate causal genetic mechanisms and identify other pathways critical for embryonic/fetal survival.

16th International Congress on Antiphospholipid Antibodies Task Force Report on Obstetric Antiphospholipid Syndrome

Obstetric antiphospholipid syndrome (APS) remains a clinical challenge for practitioners, with several controversial points that have not been answered so far. This Obstetric APS Task Force met on the 16th International Congress on Antiphospholipid Antibodies in Manchester, England, to discuss about treatment, diagnostic and clinical aspects of the disease. This report will address evidence-based medicine related to obstetric APS, including limitations on our current management, the relationship between antibodies against domain 1 of β2GPI and obstetric morbidity, hydroxychloroquine use in patients with obstetric APS and factors associated with thrombosis after obstetric APS. Finally, future directions for better understanding this complex condition are also reported by the Task Force coordinators.

ACOG Committee Opinion No. 743: Low-Dose Aspirin Use During Pregnancy

Low-dose aspirin has been used during pregnancy, most commonly to prevent or delay the onset of preeclampsia. The American College of Obstetricians and Gynecologists issued the Hypertension in Pregnancy Task Force Report recommending daily low-dose aspirin beginning in the late first trimester for women with a history of early-onset preeclampsia and preterm delivery at less than 34 0/7 weeks of gestation, or for women with more than one prior pregnancy complicated by preeclampsia. The U.S. Preventive Services Task Force published a similar guideline, although the list of indications for low-dose aspirin use was more expansive. Daily low-dose aspirin use in pregnancy is considered safe and is associated with a low likelihood of serious maternal, or fetal complications, or both, related to use. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine support the U.S. Preventive Services Task Force guideline criteria for prevention of preeclampsia. Low-dose aspirin (81 mg/day) prophylaxis is recommended in women at high risk of preeclampsia and should be initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks) and continued daily until delivery. Low-dose aspirin prophylaxis should be considered for women with more than one of several moderate risk factors for preeclampsia. Women at risk of preeclampsia are defined based on the presence of one or more high-risk factors (history of preeclampsia, multifetal gestation, renal disease, autoimmune disease, type 1 or type 2 diabetes, and chronic hypertension) or more than one of several moderate-risk factors (first pregnancy, maternal age of 35 years or older, a body mass index greater than 30, family history of preeclampsia, sociodemographic characteristics, and personal history factors). In the absence of high risk factors for preeclampsia, current evidence does not support the use of prophylactic low-dose aspirin for the prevention of early pregnancy loss, fetal growth restriction, stillbirth, or preterm birth.

Subsequent pregnancy outcomes following second trimester miscarriage-A prospective cohort study

OBJECTIVES

Pregnancy after second-trimester miscarriage represents as clinical challenge. This study sought to determine the rates of recurrence, preterm birth and live births in a cohort of 185 women with previous second-trimester miscarriage. We hypothesized that there would be a higher rate of second-trimester miscarriage and preterm birth in subsequent pregnancy after second trimester miscarriage. The primary objectives of this study were to establish rates of second-trimester miscarriage, preterm birth and live births in this cohort. Secondary objectives were to examine medical and surgical interventions, in addition to other pregnancy outcomes and complications.

STUDY DESIGN

This was a prospective cohort study carried out in a tertiary referral center in southern Ireland with over 8000 deliveries per year. 175 women were followed up. Inclusion criteria were an ultrasound confirmed second-trimester miscarriage between June 2009 and June 2013 and subsequently having a pregnancy between July 2009 and January 2016. Fifty-five women did not become pregnant during the study period and were excluded. Ten women were excluded for missing data.

RESULTS

Between July 2009 and January 2016, 110 women became pregnant following a previous second-trimester miscarriage. In total, 81 babies were born to 77 mothers. The recurrence rate of second-trimester miscarriage was 6.3% (7/110) and the preterm birth rate was also 6.3% (7/110). The cesarean section rate was 45%. Including those who experienced first or second trimester miscarriage, 47% (78/155) of those who were followed up did not go on to have a live infant.

CONCLUSIONS

Women experiencing second-trimester miscarriage are at increased risk in subsequent pregnancies of recurrence. Second-trimester miscarriage needs to be highlighted as a risk factor for adverse pregnancy outcomes. Greater research into its pathophysiology is required to advance preventative measures.

Molecular investigation of uniparental disomy (UPD) in spontaneous abortions

OBJECTIVE

About 10-15% of all clinically recognized pregnancies end as spontaneous abortions while at least 50% of pregnancies are lost before reaching term gestation. Genetic abnormalities are responsible for ≥50% of all early miscarriages. The aim is to indentify associations between UPD and abortions and regarding UPD as pathogenetic mechanism possibly to understand the role of imprinted genes or recessive mutations in abortions.

STUDY DESIGN

To determine additional factors causing spontaneous abortions we searched for uniparental disomies (UPD) which is known to be associated with distinct birth defects as per the chromosome involved and parental origin. Studies were carried on DNA of 68 cases of first trimester spontaneous abortions and DNA of their parents. We examined tissue from aborted fetuses, especially in the first trimester, with molecular techniques to detect UPD to chromosomes that contain imprinting genes.The inheritance of each region of the chromosome was determined by comparing the genotypes obtained from abortion and parental DNA.

RESULTS

Of the 68 cases of spontaneous abortions investigated, 324% were found to be biparental inheritance or were uninformative in locus that they were examined, 4118% were matUPD, 147% trisomy for a chromosome, 8,8% patUPD and 294% matUPD and trisomy for a certain chromosome. Most cases of UPD found on chromosomes 21 and 14. Many of those are found in combination with chromosomes 13, 20 and 22.

CONCLUSIONS

UPD might be a common finding among spontaneous abortuses. UPD can be a cause of miscarriage if localized to regions of chromosomes with imprinted genes which control embryogenesis and fetal development and or can activate a recessive mutation in genes which are essential for early embryogenesis.

[For a targeted use of aspirin]

The use of low-dose aspirin in pregnancy should remain a highly targeted indication since its long-term safety has not been established and should be restricted to women at high risk of vascular complications. Indications for which the benefit of aspirin has been shown are women with a history of preeclampsia responsible for a premature birth before 34 weeks, those having at least two history of preeclampsia, those with an antiphospholipid syndrome and those with lupus associated with positive antiphospholipid antibodies or renal failure. In all other cases, the level of evidence of the benefit of aspirin is insufficient to recommend its routine prescription.

[Frequency and Maternals risk factors of fœtal intra uterin death at Kamina, Democratic Republic of Congo]

Introduction

La mort fœtale in utero constitue un problème fréquent dans la pratique obstétricale. Les objectifs de cette étude étaient de déterminer la fréquence et d'identifier les facteurs de risque de la mort fœtale in utero à l'Hôpital Général de Référence de Kamina.

Méthodes

L’étude était effectuée en deux temps. En premier lieu, une étude descriptive transversale sur 379 accouchements qui avait permis de déterminer la fréquence de la mort fœtale in utero. La détermination des facteurs de risque était faite à l'aide d'une étude cas-témoins dans laquelle les caractéristiques de 53 morts in utero ont été comparées à 106 témoins constitués des naissances vivantes et à terme.

Résultats

La fréquence de la mort fœtale in utero à l'Hôpital Général de Référence de Kamina était de 13,9%. Après ajustement, l’âge maternel de plus de 35 ans (OR = 6,23; IC= (1,30-29,80)), l'antécédent de mort fœtale in utero (OR = 3,13; IC= (1,06-9,27)) et la maladie au cours de la grossesse (OR = 31,6, IC= (7,66-130,71)) ont été retenus comme facteurs significativement associés à l'augmentation de la survenue de la mort fœtale. L'instruction élevée de la mère (OR = 0,11; IC= IC= [0,03-0,42]) et la résidence à Kamina (OR = 0,23; IC= (0,08-0,62)) diminuaient ce risque.

Conclusion

La fréquence de la mort fœtale in utero était de 13,9%. L’âge maternel avancé l'antécédent de mort in utero et la maladie au cours de la grossesse étaient associés à la mort fœtale in utero mais par contre, l'instruction élevée de la femme et la résidence à Kamina diminuaient le risque. La surveillance des gestantes à risque, le dépistage et la prise en charge des maladies pendant la grossesse s'avèrent nécessaires dans la perspective de réduire la fréquence de la mort fœtale in utero dans notre milieu.

Evaluation of chromosomal abnormalities and common trombophilic mutations in cases with recurrent miscarriage

BACKGROUND

Recurrent miscarriage (RM) is a frequent obstetric problem. Its' pathophysiology is poorly understood. Infections, genetic, endocrine, anatomic and immunologic problems have been suggested as causes for RM.

OBJECTIVE

To evaluate the frequency of chromosomal abnormalities and 3 common thrombophilic mutations in couples with RM.

METHODS

A retrospective data collection was performed for the results of the cytogenetic analysis of the couples and Methylenetetrahydrofolate Reductase (MTHFR) C677T, Factor V Leiden (FVL) G1691A and Prothrombin (PTm) G20210A mutations of the mother in 142 couples suffering from RM.

RESULTS

Prevalence of FVL, MTHFR, and PTm gene mutations were similar between cases shaving 2 or ≥3 abortions (P=0.528; P=0.233; P=0.375). In patients with FVL, MTHFR and PTm gene mutations, the OR's of having ≥3 abortions when compared to having 2 abortions were 1.515 (95% CI: 0.414-5.552), 0.573 (95% CI: 0.228-1.441), and 2.848 (95% CI: 0.355-22.871). All cases with PTm mutation had ≥3 abortions and all abortions occurred between 6-8 gestational weeks.

CONCLUSION

Chromosomal abnormalities and thrombophilic mutations (especially PTm) seem to have an important role in RM. Additional larger studies involving investigation of more genes that may have a role in pregnancy are needed to assess this association.

Fetal growth restriction and the risk of perinatal mortality-case studies from the multicentre PORTO study

Background

Intrauterine growth restriction (IUGR) is the single largest contributing factor to perinatal mortality in non-anomalous fetuses. Advances in antenatal and neonatal critical care have resulted in a reduction in neonatal deaths over the past decades, while stillbirth rates have remained unchanged. Antenatal detection rates of fetal growth failure are low, and these pregnancies carry a high risk of perinatal death.

Methods

The Prospective Observational Trial to Optimize Paediatric Health in IUGR (PORTO) Study recruited 1,200 ultrasound-dated singleton IUGR pregnancies, defined as EFW <10^th centile, between 24⁺⁰ and 36⁺⁶ weeks gestation. All recruited fetuses underwent serial sonographic assessment of fetal weight and multi-vessel Doppler studies until birth. Perinatal outcomes were recorded for all pregnancies. Case records of the perinatal deaths from this prospectively recruited IUGR cohort were reviewed, their pregnancy details and outcome were analysed descriptively and compared to the entire cohort.

Results

Of 1,116 non-anomalous singleton infants with EFW <10^th centile, 6 resulted in perinatal deaths including 3 stillbirths and 3 early neonatal deaths. Perinatal deaths occurred between 24⁺⁶ and 35⁺⁰ weeks gestation corresponding to birthweights ranging from 460 to 2260 grams. Perinatal deaths occurred more commonly in pregnancies with severe growth restriction (EFW <3^rd centile) and associated abnormal Doppler findings resulting in earlier gestational ages at delivery and lower birthweights. All of the described pregnancies were complicated by either significant maternal comorbidities, e.g. hypertension, systemic lupus erythematosus (SLE) or diabetes, or poor obstetric histories, e.g. prior perinatal death, mid-trimester or recurrent pregnancy loss. Five of the 6 mortalities occurred in women of non-Irish ethnic backgrounds. All perinatal deaths showed abnormalities on placental histopathological evaluation.

Conclusions

The PNMR in this cohort of prenatally identified IUGR cases was 5.4/1,000 and compares favourably to the overall national rate of 4.1/1,000 births, which can be attributed to increased surveillance and timely delivery. Despite antenatal recognition of IUGR and associated maternal risk factors, not all perinatal deaths can be prevented.

Comparative incidence of pregnancy outcomes in treated obstetric antiphospholipid syndrome: the NOH-APS observational study

Among women with pure obstetric APS, late pregnancy complications are more frequent in cases of prior fetal loss. Late pregnancy complications are more frequent among women treated for pure obstetric APS than among nontreated controls.

Comparative incidence of pregnancy outcomes in thrombophilia-positive women from the NOH-APS observational study

Fetal death is more frequent in women with prior abortions carrying F5 rs6025 or F2 rs1799963 polymorphisms vs nonthrombophilic women. Pregnancy complications are less frequent in LMWH-treated thrombophilic women with fetal loss vs untreated nonthrombophilic women.

Previous stillbirth, late preterm, and early-term birth

Subsequent pregnancies are emotionally traumatic for families with previous stillbirths. Such pregnancies have a 2- to 10-fold increase in the risk for stillbirth as well as an increased probability of other adverse obstetrical outcomes. These medical risks as well as anxiety on the part of families and care providers contribute to an increase in late preterm and early-term birth. However, delivery before 39 weeks' gestation has not been proven to reduce the risk of recurrent stillbirth or adverse pregnancy outcomes in women with previous stillbirths. This work reviews data regarding the optimal timing of delivery in subsequent pregnancies after previous stillbirth, as well as for patients at risk from stillbirth in general. Management recommendations from current data are presented and knowledge gaps are highlighted.

Cytogenetic analysis of 355 cases of fetal loss in different trimesters

OBJECTIVE

We estimated the success rates of cytogenetic analyses in different tissue samples after intrauterine fetal deaths and analyzed the value of cytogenetic testing for determining the causes.

METHODS

Women with intrauterine fetal deaths (occurring at > 10 weeks of gestation) were offered either invasive testing before medical induction of labor, or solid tissue biopsy diagnosis after delivery.

RESULTS

A total cohort of 355 intrauterine fetal deaths was studied. During antepartum examinations, invasive procedures included amniocentesis (AMC), chorionic villus sampling (CVS) and umbilical cord (UBC) sampling. During postpartum examinations, samples were taken from unfixed specimens of fetal skin, placenta and other tissues. Chromosomal abnormalities were observed in 22 fetal deaths for which cytogenetic analyses were successful. Logistic regression analysis identified antepartum invasive sampling [P = 0.000, odds ratio (OR) 31.125, 95% confidence interval (CI) 14.265-67.908] to be associated with a high cytogenetic success rate and older age with fetal deaths (P = 0.104, OR 0.487, 95% CI 0.204-1.160) not to be associated with a high chromosomal abnormality. In the patients with recurrent pregnancy loss, the chromosomal abnormality rate of 18.6% of spontaneous abortions has not been significantly more than that of fetal deaths 11.5% (P = 0.437).

CONCLUSION

Parents should be counseled on all aspects of cytogenetic analysis after fetal death. Antepartum testing after pregnancy loss is recommended.

Still births--eight years experience at Aga Khan University Hospital Karachi, Pakistan

OBJECTIVES

To examine the possible etiological causes of still births during 8 years of clinical experience at a tertiary referral center, The Aga Khan University Hospital Karachi Pakistan. In addition, to compare demographic and medical risk factors along with analysis of cause of fetal death in different groups.

MATERIAL AND METHODS

This was a retrospective cohort study, conducted at the Aga Khan University Karachi, Pakistan over a period of 8-year period between January 2000 and January 2008. We reviewed 287 medical records of all women who had intrauterine fetal demise during study time period.

RESULTS

The prevalence of still births at our institution was 6.6 +/- 2.1 per 1000 total births. Congenital anomalies, maternal hypertension, and fetal growth restrictions were the three main causes of still births. About half of still births were among unbooked pregnant women. More than 90% of occurred during the ante natal period while 10% were intrapartum. Majority of stillborns were in macerated state when delivered.

CONCLUSION

Most of still births were due to known causes such as hypertension, congenital anomalies, and fetal growth restriction. Improvement in the management of hypertension and diagnosis of congenital anomalies is necessary. Results of the analysis urge on the need for antenatal care and compliance for follow-ups.

Recurrence of stillbirth in sibships: Population-based cohort study

Knowledge of stillbirth recurrence risk is of clinical interest and may give etiological insight. The authors studied "gestational age-" and "weight-by-gestation-specific" stillbirth recurrence, and evaluated time trends in a population-based cohort study from the Medical Birth Registry of Norway, from 1967 to 2004. Singleton births, including stillbirths from 20 weeks' gestation, were linked to their mothers by national identification numbers. Stillbirth rates in second pregnancies among mothers with (N = 5,091) and without (N = 562,057; the reference group) a stillbirth in first pregnancies were compared across 4 gestational age and 3 weight-by-gestation groups. A remarkable symmetric pattern of gestational age-specific recurrence of stillbirth was found, with highest odds of stillbirth in the same age group. The adjusted odds ratio values associated with preterm stillbirth recurrence were high, for example, 25.7 (95% confidence interval: 19.8, 33.3) for stillbirth at 20-27 weeks' gestation (73/1,511 vs. 1,021/562,057), while lower for term stillbirth: adjusted odds ratio = 2.3 (95% confidence interval: 1.2, 4.7) (9/1,844 vs. 1,021/538,499). The proportion of second early stillbirths in the population attributable to previous early stillbirth was 6.4%, compared with 0.5% for second term stillbirth. Over time, recurrence of early stillbirth decreased, whereas that of mid/late stillbirth did not change significantly. A symmetric pattern of recurring stillbirth in similar weight-by-gestation groups was not found.

Idiopathic recurrent pregnancy loss recurs at similar gestational ages

OBJECTIVE

To determine whether a correlation exists between gestational ages of idiopathic recurrent pregnancy loss (iRPL).

STUDY DESIGN

Cohort of women with iRPL who had an initial loss (qualifying pregnancy [QP]) with precise documentation of gestational age. Outcomes in the immediate next pregnancy (index pregnancy [IP]) were compared between preembryonic (group I), embryonic (group II), or fetal (group III) losses in the QP.

RESULTS

Three hundred thirty-four women met inclusion criteria. In their IP, group I had 41% preembryonic, 28% embryonic, and 10% fetal losses. Group II had 14% preembryonic, 53% embryonic, and 9% fetal losses. Group III had 19% preembryonic, 23% embroyonic, and 29% fetal loses. Correlation coefficient for type of loss among the QPs and IPs was 0.14, P = .009.

CONCLUSIONS

Women with iRPL tend to have losses recur in the same gestational age period. Causes for RPL may be gestational age specific and should guide further investigations into causes.

Recurrence risk of stillbirth in a second pregnancy

OBJECTIVE

To examine the risk of recurrence of stillbirth in a second pregnancy.

DESIGN

Retrospective cohort study.

SETTING

Scotland, UK.

POPULATION

All women who delivered their first and second pregnancies in Scotland between 1981 and 2005.

METHODS

All women delivering for the first time between 1981 and 2000 were linked to records of their second pregnancy using routinely collected data from the Scottish Morbidity Returns. Women who had an intrauterine death in their first pregnancy formed the exposed cohort, whereas those who had a live birth formed the unexposed cohort.

MAIN OUTCOME MEASURE

Stillbirth in a second pregnancy.

RESULTS

After adjusting for confounding factors, the odds of recurrence of stillbirth in a second pregnancy were found to be 1.94 (99% CI 1.29-2.92) compared with women who had had a live birth in their first pregnancy. Other factors associated with recurrence of stillbirth in a second pregnancy included placental abruption (adjusted OR 1.96; 99% CI 1.60-2.41), preterm delivery (adjusted OR 7.45; 99% CI 5.91-9.39) and low birthweight (adjusted OR 6.69; 99% CI 5.31-8.42). A Bayesian analysis using minimally informative normal priors found the risk of recurrence of stillbirth in a second pregnancy to be 1.59 (99% CI 1.10-2.33).

CONCLUSIONS

Women who have stillbirth in their first pregnancy have a higher risk of recurrence in their next pregnancy.

Male sex and pre-existing diabetes are independent risk factors for stillbirth

AIM

To determine whether the risk of stillbirth is associated with male fetal sex, fetal growth and maternal factors in an Australian population.

METHODS

A retrospective secondary data analysis of 16 445 singleton births was performed using a tertiary referral centre obstetric database (1995-1999). Univariate and multiple logistic regression analyses were performed.

RESULTS

Stillbirth complicated 1% of the pregnancies in the study population, and 59% of stillbirths were associated with a male fetus. Significant characteristics associated with stillbirth were intrauterine growth restriction (IUGR), birth defects, gestational age, Aboriginal ethnicity, previous stillbirth, parity greater than three and placental abruption. Male stillbirths were more likely to occur at a later gestation (median gestation 30.5 weeks, range 20-43 weeks) compared to females (median 25 weeks, range 20-40 weeks), P = 0.01. Sixty per cent of IUGR fetuses were female (P < 0.001). Male sex (odds ratio (OR) 1.5, confidence interval (CI) 1.01, 2.17, P = 0.04) and maternal type 1 diabetes (OR 4.7, CI 1.58, 14.19, P = 0.006) were independently associated with stillbirth.

CONCLUSION

Male fetal sex and pre-existing diabetes are independent risk factors for stillbirth. Diabetes remains a significant risk for stillbirth even with contemporary monitoring and clinical management. Those diabetic pregnancies where the fetus is male require appropriate monitoring and timely interventions to achieve an optimal outcome.

Thromboprophylaxis and pregnancy outcomes in asymptomatic women with inherited thrombophilias

OBJECTIVE

Our objective was to evaluate the effect of thromboprophylaxis on pregnancy outcomes in asymptomatic women with inherited thrombophilias.

STUDY DESIGN

This was a retrospective cohort study of asymptomatic pregnant women with inherited thrombophilias. Medical records were reviewed for pregnancy events, diagnosis of thrombophilias, and management in subsequent pregnancies. Outcomes in women who were and were not treated with thromboprophylaxis were compared using Fisher's exact test and logistic regression.

RESULTS

Fifty-three women had 75 pregnancies subsequent to their diagnosis of thrombophilia. Women treated with heparin had similar rates of live births (86% vs 82%; P = .8, Fisher's exact test) as those not treated. The odds ratio of live birth in all pregnancies for women treated with heparin was compared with untreated women and was 1.9 (95% confidence interval, 0.5-6.3).

CONCLUSION

Pregnancy outcomes are often good in asymptomatic women with thrombophilias in the absence of treatment. Treatment of these women during pregnancy should be considered investigational.

Fetal death persists through recurrent pregnancies in mice following Ljungan virus infection

OBJECTIVES

Laboratory mice infected with Ljungan virus (LV) early in pregnancy suffer from perinatal death. Here we investigate the persistence of that effect through the outcome of consecutive pregnancies in LV-infected mice.

STUDY DESIGN

CD-1 mice were infected while pregnant and their adult female offspring were followed in parallel with uninfected control mice during repeated pregnancies. Three mating attempts resulted in two or three pregnancies per dam. The outcome of the last pregnancy was carefully monitored.

RESULTS

Both the dams infected as adults and their adult female offspring suffered perinatal deaths during the last pregnancy which occurred approximately 6 months after the original LV exposure and acute infection. The non-infected control animals experienced no perinatal death.

CONCLUSIONS

Perinatal death persists across recurrent pregnancies in this mouse model of LV infection, both in animals infected as adults and in females exposed to the virus in utero. This implies that LV persists in mice long after initial infection, and is maintained in a quiescent state but can remain pathogenic in later pregnancies.

The clinical content of preconception care: reproductive history

A history of previous birth of a low birthweight infant, previous cesarean sections, multiple previous spontaneous abortions, prior stillbirth, or uterine anomaly identifies women at increased risk for recurrent abortion, preterm birth, or stillbirth. We review the evidence for the potential benefit of reproductive history in identifying strategies for evaluation and treatment to prevent recurrent adverse pregnancy outcome. We offer evidence-based recommendations for management of women with these histories.

Genetics of pregnancy loss

Pregnancy loss is a common problem in reproductive-aged women. Although most cases of pregnancy loss are sporadic, some couples experience recurrent pregnancy loss, a challenging clinical dilemma. A variety of possible etiologies have been described for both sporadic and recurrent pregnancy loss. This review focuses on the genetic abnormalities that may contribute to this clinical problem and delineates strategies for genetic evaluation and clinical management in subsequent pregnancies.

Second-trimester loss and subsequent pregnancy outcomes: What is the real risk?

OBJECTIVE

This study was performed to determine whether second-trimester pregnancy loss was associated with an increased risk for spontaneous preterm birth or recurrent second-trimester loss in a subsequent pregnancy.

STUDY DESIGN

A retrospective cohort study was conducted. Patients with a second-trimester pregnancy loss (n = 38), a spontaneous preterm birth (n = 76), and a full term delivery (n = 76) were identified from 2002 to 2005 (index pregnancy). Computerized medical records were used to obtain demographic and obstetrical histories.

RESULTS

Frequencies of subsequent second-trimester loss were 27%, 3%, and 1% in the second-trimester loss, spontaneous preterm birth, and full-term delivery cohorts, respectively. Frequencies of subsequent spontaneous preterm birth were 33%, 39.5%, and 9% in the same 3 cohorts. Patients with a prior second-trimester loss were 10.8 times more likely to have recurrent second-trimester loss or spontaneous preterm birth, compared with those with prior full-term delivery (confidence interval 3.6 to 32.1, P < .0001).

CONCLUSION

Patients with a prior second-trimester loss are at significantly increased risk for spontaneous preterm birth and recurrent second-trimester loss in their next pregnancy.

Stillbirth recurrence in a population of relatively low-risk mothers

We sought to estimate the risk of stillbirth recurrence among relatively low-risk women, a group defined as maternal age <35 years; absence of congenital anomalies; gestational age range of 20-44 weeks inclusive; singleton births; and non-smokers. The Missouri maternally linked data containing births from 1978 to 1997 were used for the study. We identified the study group (low-risk gravidae who experienced a stillbirth in the first pregnancy) and a comparison group (low-risk gravidae who delivered a live birth in their first pregnancy) and compared the stillbirth risks in the second pregnancy between both groups. Analysis was based on 261 384 women with information on first and second pregnancies [1050 (0.5%) women with stillbirth]. Of the 947 cases of stillbirth in the second pregnancy, 20 cases occurred in women with a history of stillbirth (stillbirth rate 19.0 per 1000 births) and 927 in the comparison group (stillbirth rate 3.6 per 1000 births; P<0.001). The adjusted risk of stillbirth was almost six times higher in women with a prior stillbirth (hazard ratio [HR] 5.8, [95% CI 3.7, 9.0]). Analysis by stillbirth subtype in the second pregnancy showed that history of stillbirth conferred greater risk for subsequent early (fetal deaths between 20 and 28 weeks) (HR 10.3, [95% CI 6.1, 17.2]) than late stillbirths (fetal deaths at >or=29 weeks) (HR 2.5, [95% CI 1.0, 6.0]); and for intrapartum (HR 12.2, [95% CI 4.5, 33.3]) than antepartum (HR 4.2, [95% CI 2.3, 7.7]) stillbirths. Among relatively low-risk women, history of stillbirth was associated with increased recurrence, with substantial heterogeneity by timing of stillbirth.

Outcome of the subsequent pregnancy after a first loss in women with the factor V Leiden or prothrombin 20210A mutations

BACKGROUND

The factor V Leiden (FVL) and prothrombin 20210A (PTm) mutations are associated with single late pregnancy loss and recurrent early pregnancy loss. The prognosis after an initial loss in women with thrombophilia is uncertain.

OBJECTIVE

To assess the pregnancy outcome of the second pregnancy after a first loss in women with and without either FVL or PTm mutations.

METHODS

We selected women with a first pregnancy loss out of two family cohorts of first degree relatives of probands with FVL or PTm mutations and a history of documented venous thromboembolism or premature atherosclerosis.

RESULTS

Ninety-three women had had a first pregnancy loss and became pregnant a second time. Their risk of loss of the subsequent pregnancy was higher than in 825 women with a successful first pregnancy [25 vs. 12%, relative risk (RR) 2.0, 95% CI 1.4-3.0]. The live birth rate of the second pregnancy after an early first loss ( 12 weeks), the live birth rates were 68% (95% CI 46-85) and 80% (95% CI 49-94) for carriers and non-carriers, respectively (RR 0.9, 95% CI 0.5-1.3).

CONCLUSIONS

Women with a first pregnancy loss have a 2-fold increased risk of loss of the subsequent pregnancy, regardless of their carrier status. More importantly, the outcome of the second pregnancy is rather favorable in absolute terms, even for those with thrombophilia and a late loss, which raises concern regarding the risks and presumed benefits of anticoagulant therapy in these women.

Fetal Death

The death of a formed fetus is one of the most emotionally devastating events for parents and clinicians. With improved care for conditions such as RhD alloimmunization, diabetes, and preeclampsia, the rate of fetal death in the United States decreased substantially in the mid twentieth century. However, the past several decades have seen much greater reductions in neonatal death rates than in fetal death rates. As such, fetal death remains a significant and understudied problem that now accounts for almost 50% of all perinatal deaths. The availability of prostaglandins has greatly facilitated delivery options for patients with fetal death. Risk factors for fetal death include African American race, advanced maternal age, obesity, smoking, prior fetal death, maternal diseases, and fetal growth impairment. There are numerous causes of fetal death, including genetic conditions, infections, placental abnormalities, and fetal-maternal hemorrhage. Many cases of fetal death do not undergo adequate evaluation for possible causes. Perinatal autopsy and placental examination are perhaps the most valuable tests for the evaluation of fetal death. Antenatal surveillance and emotional support are the mainstays of subsequent pregnancy management. Outcomes may be improved in women with diabetes, hypertension, red cell alloimmunization, and antiphospholipid syndrome. However, there is considerable room for further reduction in the fetal death rate.

Preconception Counseling for Women With Thrombophilia

Inherited thrombophilias are a heterogeneous group of coagulation disorders that predispose individuals to thromboembolic events. This group of conditions is the major risk factor for thromboembolism during pregnancy and the puerperium. In addition, thrombophilias have been associated with several adverse obstetric events, including pregnancy loss, preeclampsia, placental abruption, and intrauterine growth restriction. An increased risk for these obstetric complications has prompted many authorities to recommend screening and treating pregnant women for thrombophilias. Optimal obstetric management, however, is controversial as thrombophilias are common and many affected individuals are asymptomatic. Indeed, pregnancy outcome in most women with thrombophilias is normal. The most commonly identified inherited thrombophilias are the factor V Leiden and prothrombin G20210A gene mutations. More rare thrombophilias include protein C and S deficiencies, antithrombin III deficiency. Although relatively common, the association between hyperhomocysteinemia and associated mutations (such as the C677 T methylenetetrahydro-folate reductase) and obstetric complications is controversial.

Prophylaxis and treatment of thrombophilia in pregnancy

PURPOSE OF REVIEW

This review addresses the prophylaxis and treatment of thrombophilia in pregnancy, which is associated with increased risk of venous thromboembolism and placental vascular complications.

RECENT FINDINGS

Topics include preventing deep vein thrombosis recurrence in pregnant women with constitutional thrombophilias, using prophylactic heparins throughout pregnancy and postpartum anticoagulants. Cases of thrombosis still occur in the postpartum period and other therapeutics should be tested. Primary prophylaxis is acceptable for high-risk thrombophilias. Early pregnancy losses (before the 10th week) are not associated with constitutional thrombophilias. The natural prognosis of embryonic losses associated with current thrombogenic polymorphisms is good, unlike fetal losses associated with the same thrombophilias: in this case, a prophylactic low-molecular-weight heparin given from the beginning of the 8th week is more efficient than low-dose aspirin. Data are lacking on the prevention of severe preeclampsia, placental abruption, or intrauterine growth restriction in women with constitutional thrombophilias; preliminary results indicate that low-molecular-weight heparin may have some preventive effect. Specific studies are needed.

SUMMARY

Recent studies have shown the limits of available procedures for women with constitutional thrombophilia and have helped define the clinical situations in thrombophilia-related placental insufficiency in which prophylactic low-molecular-weight heparin may be indicated.

Stillbirth and Bereavement: Guidelines for Stillbirth Investigation

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Is Race a Determinant of Stillbirth Recurrence?

BACKGROUND

A history of stillbirth may result in an increased risk for recurrence, although information regarding this remains scanty. It is also uncertain whether race is a determinant of stillbirth recurrence given that the risk of stillbirth varies across racial and ethnic populations.

METHODS

The Missouri maternally linked cohort data set containing births from 1978 through 1997 was used. We identified the study group (women who experienced a stillbirth in the first pregnancy) and a comparison group (women who delivered a live birth in their first pregnancy) and compared the outcome (stillbirth) in the second pregnancy between the 2 groups.

RESULTS

We analyzed 404,180 women with information on first and second pregnancies (1,979 [0.5%] in the study arm, and 402,201 [99.5%] in the comparison arm). Of the 1,929 cases of stillbirths in the second pregnancy, 45 cases occurred in mothers with a history of stillbirth (stillbirth rate = 22.7/1000) and 1,884 in the comparison group (stillbirth rate 4.7/1,000, P < .001). The adjusted risk of stillbirth was almost 5-fold as high in women with a prior stillbirth (odds ratio 4.7, 95% confidence interval 3.3-6.6). Analysis across racial groups revealed that whites had lower absolute risk for stillbirth recurrence than African Americans (19.1/1,000 compared with 35.9/1,000, P < .05). The elevated stillbirth recurrence risk was confirmed after adjusting for potential confounders (odds ratio 2.6, 95% confidence interval 1.2-5.7).

CONCLUSION

History of stillbirth is associated with a 5-fold increase for subsequent stillbirth. The recurrence of stillbirth is almost tripled in African Americans as compared with whites.

LEVEL OF EVIDENCE

II-2.

Etiology and prevention of stillbirth

OBJECTIVE

This is a systematic review of the literature on the causes of stillbirth and clinical opinion regarding strategies for its prevention.

STUDY DESIGN

We reviewed the causes of stillbirth by performing a Medline search limited to articles in English published in core clinical journals from January 1, 1995, to January 1, 2005. Articles before this date were included if they added historical information relevant to the topic. A total of 1445 articles obtained, 113 were the basis of this review and chosen based on the criterion that stillbirth or fetal death was central to the article.

RESULTS

Fifteen risk factors for stillbirths were identified and the prevalence of these conditions and associated risks are presented The most prevalent risk factors for stillbirth are prepregnancy obesity, socioeconomic factors, and advanced maternal age. Biologic markers associated with increased stillbirth risk are also reviewed, and strategies for its prevention identified.

CONCLUSION

Identification of risk factors for stillbirth assists the clinician in performing a risk assessment for each patient. Unexplained stillbirths and stillbirths related to growth restriction are the 2 categories of death that contribute the most to late fetal losses. Late pregnancy is associated with an increasing risk of stillbirth, and clinicians should have a low threshold to evaluate fetal growth. The value of antepartum testing is related to the underlying risk of stillbirth and, although the strategy of antepartum testing in patients with increased risk will decrease the risk of late fetal loss, it is of necessity associated with higher intervention rates.