NSIDRC Journal Article Alert — December 5, 2008

Prepared by the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center at Georgetown University.

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Sudden Infant Death

1. Laskey AL, Haberkorn KL, Applegate KE, Catellier MJ
Postmortem Skeletal Survey Practice in Pediatric Forensic Autopsies: A
National Survey*
J Forensic Sci. 2008 Nov 21

Department of Pediatrics, Riley Hospital for Children, Children's
Health Services Research, Indiana University School of Medicine, 410
West 10th Street, Suite 1020, Indianapolis, IN 46202.

Recommendations for the evaluation of an unexplained death in infancy
include a postmortem skeletal survey (PMSS) to exclude skeletal
trauma. Objectives of this study were to assess adherence to these
recommendations in forensic autopsies in children equal to or less
than 36 months of age, and what factors influence the use or nonuse of
the PMSS. We surveyed pathologists who were members of the American
Academy of Forensic Sciences. The survey included practice
characteristics about where, when, and how PMSS were done. Nearly all
respondents (99.6%) indicated they performed PMSS at least some of the
time; however, almost a third did not use PMSS for all suspected
Sudden Infant Death Syndrome (SIDS), abuse, unsafe sleep, or
undetermined causes of death. Despite evidence that "babygrams" are
inappropriate in a SIDS workup, 30% of pathologists use them
preferentially. Despite SIDS being a diagnosis of exclusion that
requires a PMSS, almost 10% of pathologists do not order a PMSS.
Future research is necessary to reduce barriers to this important
component of the pediatric forensic autopsy.

2. Sperhake JP, Zimmermann I, Püschel K
Current recommendations on infants' sleeping position are being
followed-initial results of a population-based sentinel study on risk
factors for SIDS, 1996-2006, in Hamburg, Germany
Int J Legal Med. 2008 Nov 19. [Epub ahead of print]

Department of Legal Medicine, University Medical Center
Hamburg-Eppendorf, Butenfeld 34, 22529, Hamburg, Germany,
sperhake@uke.de.

Sudden infant death syndrome (SIDS) is a target for public health care
in Germany. The aim of this study was to monitor data on risk-related
behavior in the population of Hamburg, Germany, in order to respond to
changes quickly and to estimate the effectiveness of prevention
activities. Data have been gathered using the sentinel system with
repeated surveys (1996, 1998, 2001, and 2006) in pediatric practices,
thus allowing an estimate of the prevalence of risk factors in an
urban population, both transversally and vertically. From 1996 to
2007, the SIDS rate in Hamburg fell from 0.9/1,000 live births to 0.1.
The prevalence of infants sleeping prone declined from 8.1% in 1996 to
3.5% in 2006. In this small subgroup, up to 81.7% (2006) of the
caretakers were well aware of the risk of sleeping prone. The
prevalence of infants sleeping on their sides fell from 55.3% in 1998
to 10.6% in 2006. The sentinel setting is suitable for gathering
risk-related data on SIDS. Despite the fact that, so far, no
nationwide back-to-sleep campaign has been instituted in Germany,
local campaigns have proved successful in reducing prone sleeping for
infants. Moreover, the substantial reduction of side sleeping within a
short time span going along with a reduced SIDS rate is an indicator
of the effectiveness of prevention activities on a local basis.

3. Matturri L, Mauri M, Elena Ferrero M, Lavezzi AM
Unexpected Perinatal Loss versus Sids-a Common Neuropathologic Entity
Open Neurol J. 2008;2:45-50. Epub 2008 Sep 5

Lino Rossi" Research Center for the study and prevention of unexpected
perinatal death and SIDS, University of Milan, Italy.

Objective: To evaluate the involvement of alterations of the central
autonomic nervous system, particularly of the brainstem and
cerebellum, in a wide set of victims of sudden and unexplained
perinatal and infant death.Material and Methods: The study population
consisted of 63 stillbirths, 28 neonatal deaths and 140 suspected
SIDS. The victims were subjected to in-depth anatomopathological
examination following appropriate guidelines. The protocol included,
in particular, the histological evaluation on serial sections of the
cardiorespiratory autonomic nervous system.Results: A diagnosis of
"unexplained death" was established for 217 of the 231 victims (59
stillbirths, 28 newborns and 130 SIDS). In a very high percentage of
these deaths (84%) we observed one or more anomalies of the nuclei
and/or structures of the brainstem and cerebellum related to vital
functions.Conclusion: Unexpected perinatal loss should not be regarded
as a separate entity from SIDS, given the common neuropathological
substrates.

Other Infant Death

1. Barnes GL
Perspectives of African-American Women on Infant Mortality
Soc Work Health Care. 2008;47(3):293-305

Twice as many African-American infants die each year when compared to
White infants. This study explores the lived experiences of
African-American women to identify factors related to this racial gap
in infant mortality. Thirteen African-American women from two Virginia
towns participated in either a focus group or in-depth interviews.
Content and interpretive analysis revealed several themes.
Participants indicated that the experiences of stress and racism are
constant factors in African-American women's lives and are inseparable
from their pregnancy experiences. Participants noted the importance of
social support and the health care provider–client relationship
for positive pregnancy outcomes.

Bereavement

1. Cartwright P, Read S
Working with practitioners to develop training in peri-natal loss and
bereavement: Evaluating three workshops
Nurse Educ Pract. 2005 Sep;5(5):266-73

Wolstanton Medical Centre, Newcastle-under-Lyme PCT, UK.

Peri-natal loss is as profound as any other bereavement [Chambers,
H.M., Chan, F.J., 2000. Support for women/families after peri-natal
death. (Cochrane Review). Issue 1. The Cochrane Library, Oxford,
Update Software], is commonplace, and its traumatic potential has long
been overlooked by clinicians and researchers [Spechard, 1997.
Traumatic death in pregnancy: the significance of meaning and
attachment. In: Figley, C.R., Bride, B., Mazza, N., (Eds.), Death and
Trauma: The Traumatology of Grieving. Taylor and Francis, London,
1997, pp. 67-98]. Previous miscarriage, stillbirth or neonatal death
is implicated in post-natal depression and behaviour management
difficulties after the birth of subsequent children. The involvement
of the health visitor in supporting grieving parents may be crucial to
medium and long-term family health [Hill, C., 1997. Evaluating the
quality of after death care. Nursing Standard 12(8), 38-39]. However,
service provision for such families appears to be inconsistent and
depends on the skills, confidence and time constraints of individual
practitioners, with little in the way of guidance and support in this
sensitive area of care [Dent, A., Condon, L., Blair, P., Flemming, P.,
1996. A study of bereavement care after a sudden and unexpected death.
Archives of disease in childhood, 74, 552-526]. This paper outlines
the development and evaluation of a series of workshops around
peri-natal loss initially offered to health visitors in North
Staffordshire (UK), and then expanded to incorporate midwives. The
authors formally evaluated the three workshops (and their impact)
retrospectively, and implemented the findings to further develop the
workshops, thus ensuring relevance to professional practice. The
rationale behind the introduction of the workshops and the contents
are introduced; approaches to the evaluation process described;
presentation of the findings offered; followed by a discussion of the
key issues.

2. Mitchell M.
Nurse Educ Pract. 2005 Mar;5(2):78-83
Preparing student midwives to care for bereaved parents

Faculty of Health and Social Care, School of Maternal and Child
Health, University of the West of England, Blackberry Hill, Stapleton
BS16 1DD, UK.

Caring for bereaved parents after the death of a baby is emotionally
challenging for midwives. There is a lack of discussion and debate in
the literature of how student midwives are prepared to undertake this
role. This article describes the way student midwives undertaking 3
year and 18 month courses, in one university in the UK, are prepared
to care for bereaved parents and their evaluation of this preparation.
Verbal feedback and student's comments in the form of reflective
writing formed the basis of the evaluation. Evaluation of the
preparation included a focus on the use of the support group the
Stillbirth and Neonatal Death Society, as this aspect has received
little attention in the literature. In the analysis of the student
feedback five main themes emerged. These were dealing with death and
bereaved families, anxieties and fears, teaching strategies, user
representation and preparedness for practice. Teaching about death is
challenging and there is a need to share how educators undertake this
task and to learn from each other. It is hoped that this discussion
will stimulate a debate surrounding this issue.

Miscarriage/Stillbirth/Prenatal Issues

1. Dingle K, Alati R, Clavarino A, Najman JM, Williams GM
Pregnancy loss and psychiatric disorders in young women: an Australian
birth cohort study
Br J Psychiatry. 2008 Dec;193(6):455-60

Level 2, Public Health Building, School of Population Health,
University of Queensland, Herston Road, Herston, QLD 4006, Australia.
s4002827@student.uq.edu.au.

BACKGROUND: Recent evidence has linked induced abortion with later
adverse psychiatric outcomes in young women. AIMS: To examine whether
abortion or miscarriage are associated with subsequent psychiatric and
substance use disorders. METHOD: A sample (n=1223) of women from a
cohort born between 1981 and 1984 in Australia were assessed at 21
years for psychiatric and substance use disorders and lifetime
pregnancy histories. RESULTS: Young women reporting a pregnancy loss
had nearly three times the odds of experiencing a lifetime illicit
drug disorder (excluding cannabis): abortion odds ratio (OR)=3.6 (95%
CI 2.0-6.7) and miscarriage OR=2.6 (95% CI 1.2-5.4). Abortion was
associated with alcohol use disorder (OR=2.1, 95% CI 1.3-3.5) and
12-month depression (OR=1.9, 95% CI 1.1-3.1). CONCLUSIONS: These
findings add to the growing body of evidence suggesting that pregnancy
loss per se, whether abortion or miscarriage, increases the risk of a
range of substance use disorders and affective disorders in young
women.

2. Catov JM, Newman AB, Sutton-Tyrrell K, Harris TB, Tylavsky F,
Visser M, Ayonayon HN, Ness RB; for the health ABC study
Parity and Cardiovascular Disease Risk among Older Women: How Do
Pregnancy Complications Mediate the Association?
Ann Epidemiol. 2008 Dec;18(12):873-879

Departments of Obstetrics, Gynecology & Reproductive Sciences,
Pittsburgh, PA; Department of Epidemiology, Pittsburgh, PA.

PURPOSE: To determine whether parity is associated with increased risk
of cardiovascular disease (CVD) after accounting for perinatal
complications. METHODS: CVD prevalence, number of births, and a
history of preeclampsia, term low birth weight, preterm or stillbirth
were evaluated among 540 women (mean age, 80 years; 47% black)
enrolled in the Pittsburgh, PA site of the Health, Aging and Body
Composition Study. Biomarkers were measured and CVD status was
determined by self-report and hospital records. RESULTS: Nulliparous
women (n = 89) had lower CVD prevalence compared with parous women
(18.0% vs. 30.2%). Parous women without perinatal complications of
interest (n = 321) had higher statin use compared with nulliparas, a
trend accompanied by lower high-density lipoprotein (HDL) and higher
triglycerides among women with perinatal complications (n = 130).
After adjustment, parous women with no complicated births had a
1.95-fold (95% confidence interval [CI], 1.03-3.7) higher CVD
prevalence compared to nulliparas. Among women with one or more
pregnancy complications, CVD prevalence was 2.67 times (CI, 1.34-5.33)
higher. Women with five or more births had the highest CVD prevalence
(odds ratio [OR], 2.60; CI, 1.17-5.76) that was attenuated to 2.27
(1.00-5.15) after adjustment for complications of interest.
CONCLUSIONS: History of pregnancy complications and higher statin use
accounted for some but not all of the excess CVD prevalence among
older parous women.

3. Cacciatore J, Rådestad I, Frederik Frøen J
Effects of contact with stillborn babies on maternal anxiety and depression
Birth. 2008 Dec;35(4):313-20

College of Human Services, Arizona State University, Phoenix, Arizona, USA.

Background: Some guidelines encourage mothers to see and hold their
babies after stillbirth, which might be traumatizing. The study
objective was to investigate the effects of women seeing and holding
their stillborn baby on the risk of anxiety and depression in a
subsequent pregnancy and in the long term. Methods: Thirty-seven
organizations recruited women who had experienced stillbirth (N =
2,292 of whom 286 reported being pregnant). Anxiety and depressive
symptoms were assessed by using the 25-item Hopkins Symptom Check
List. Results: Among nonpregnant women, seeing and holding their
stillborn baby were associated with lower anxiety symptoms (OR 0.68,
95% CI 0.49-0.95) and a tendency toward fewer symptoms of depression
(OR 0.72, 95% CI 0.51-1.02), compared with pregnant women.
Participants who were pregnant also had less depressive symptomatology
(OR 0.57, 95% CI 0.43-0.75), but more symptoms of anxiety if they had
seen and held their baby (OR 3.79, 95% CI 1.42-10.1). Conclusions:
Seeing and holding the baby are associated with fewer anxiety and
depressive symptoms among mothers of stillborn babies than not doing
so, although this beneficial effect may be temporarily reversed during
a subsequent pregnancy.

4. Wisborg K, Barklin A, Henriksen T, Hedegaard M
Author response to: Psychological stress during pregnancy and
stillbirth: no convincing evidence of an association
BJOG. 2008 Nov;115(12):1585-6

Perinatal Epidemiology Research Unit, Department of Obstetrics and
Paediatrics, Aarhus University Hospital, Aarhus N, Denmark.

5. Mikkelsen S
Psychological stress during pregnancy and stillbirth: no convincing
evidence of an association
BJOG. 2008 Nov;115(12):1584-5

Department of Occupational Medicine, Copenhagen University Hospital,
Glostrup, Denmark.

6. Leung T, Leung T, Sahota D, Chan O, Chan L, Fung T, Lau T
Trends in maternal obesity and associated risks of adverse pregnancy
outcomes in a population of Chinese women
BJOG. 2008 Nov;115(12):1529-37

Department of Obstetrics and Gynaecology, The Chinese University of
Hong Kong, Hong Kong, China.

Objective To assess the effect of increasing body mass index (BMI) on
pregnancy outcome in a population of Chinese women. Design A
retrospective study. Setting A university teaching hospital.
Population Women delivering singleton babies between 1995 and 2005 who
sought antenatal care before 20 weeks of gestation. Methods A total of
29 303 women were categorised into six BMI groups according to WHO's
classification. Univariate, multivariate and logistic regression
analysis were performed to compare obstetric and perinatal outcomes
between BMI groups. Main outcome measures Incidences of caesarean
delivery, pre-eclampsia, gestational diabetes, preterm delivery, small
for gestational age (SGA) and large for gestational age (LGA),
perinatal death, and the respective odd ratios in reference to the
normal group with BMI >/= 18.5 kg/m(2) and <23 kg/m(2). Results The
median BMI increased with increasing maternal age, parity, gestation
at the first visit, but decreased with year of delivery (P < 0.001).
Concerning the obstetric outcomes, increasing BMI was associated with
increasing incidence of caesarean section, pre-eclampsia, gestational
diabetes, preterm delivery, LGA, as well as SGA according to
customised growth standards (P < 0.001). The odds ratios for most of
these adverse outcomes are higher than those reported in Caucasian
population. Increasing BMI was not associated with the rate of
stillbirth, neonatal death or shoulder dystocia. Conclusion Increasing
BMI is associated with increased risks of adverse obstetric outcomes.
The impacts of high BMI on pre-eclampsia, gestational diabetes and
preterm delivery in Chinese women might be stronger than that in
Caucasian. Hence, it may be appropriate to use a lower BMI cutoff for
defining overweight in Chinese.

7. Hvas AM, Ingerslev J, Salvig JD
Scand J Clin Lab Invest. 2008 Nov 21:1-7. [Epub ahead of print]
Thrombophilia risk factors are associated with intrauterine foetal
death and pregnancy-related venous thromboembolism

Center for Haemophilia and Thrombosis, Department of Clinical
Biochemistry, Aarhus University Hospital, Skejby, Denmark.

Pregnancy in healthy women is accompanied by hypercoagulable changes
that may interact with thrombophilia risk factors and threaten
pregnancy. However, the literature on this issue is conflicting. In
investigating the relationship between pregnancy-associated
complications and the presence of thrombophilia risk factors, we
studied the records of 414 women who had been examined for inherited
and acquired thrombophilia in the period 1996 to 2006 because of
pregnancy-associated complications. Of a total of 885 pregnancies
among the women, 397 were recorded as foetal loss/intrauterine foetal
death during the first (62 %), second (25 %) or third trimester (13
%). One-hundred-and-two (25 %) women had had a thromboembolic event
during one of their pregnancies, and 98 (24 %) had had pre-eclampsia
on at least one occasion. Intrauterine growth restriction was found in
105 (25 %) of the women, and 29 (7 %) suffered placental abruption. We
found that 120 (29 %) women had at least one thrombophilia risk
factor. Factor V Leiden heterozygosity was the most common
thrombophilia factor (n = 52), mostly linked with the risk of venous
thromboembolism during pregnancy or postpartum and to foetal death
during the second or third trimester. Fifty-three (13 %) women had
antiphospholipid antibodies (lupus anticoagulant and/or
anti-beta2-glycoprotein 1 antibodies) mainly associated with the risk
of spontaneous abortion during the first trimester. In conclusion,
thrombophilia was found to be considerably more common in women with
pregnancy-associated complications in comparison with the general
population, and most frequently in conjunction with venous
thromboembolism during pregnancy and the postpartum period.

8. Riggs R, Mayer J, Dowling-Lacey D, Chi TF, Jones E, Oehninger S
Does storage time influence postthaw survival and pregnancy outcome?
An analysis of 11,768 cryopreserved human embryos
Fertil Steril. 2008 Nov 20. [Epub ahead of print]

The Jones Institute for Reproductive Medicine, Department of
Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk,
Virginia.

OBJECTIVE: To evaluate the impact of cryopreservation storage duration
on embryo survival, implantation competence, and pregnancy outcome.
DESIGN: Retrospective study. SETTING: Academic tertiary-referral
infertility center. PATIENT(S): In vitro fertilization patients and
recipients of oocyte donation cycles who had cryopreserved embryos and
underwent at least one thaw cycle from 1986 to 2007. INTERVENTION(S):
None. MAIN OUTCOME MEASURE(S): Postthaw survival proportion and
implantation, clinical pregnancy, miscarriage, and live birth rates.
RESULT(S): Length of storage time did not have a significant effect on
postthaw survival for IVF or oocyte donation cycles, or for embryos
frozen at the pronuclear or cleavage stages. There was no significant
impact of the duration of storage on clinical pregnancy, miscarriage,
implantation, or live birth rate, whether from IVF or oocyte donation
cycles. Logistic regression analysis demonstrated that the length of
storage time or developmental stage at freezing were not predictive of
embryo survival or pregnancy outcome. Only oocyte age, survival
proportion, and number of transferred embryos were positive predictors
of pregnancy outcome. CONCLUSION(S): Cryostorage duration did not
adversely affect postthaw survival or pregnancy outcome in IVF or
oocyte donation patients.

9. Topalidou M, Effraimidou S, Farmakiotis D, Papadakis E, Papaioannou
G, Korantzis I, Garipidou V
Low protein Z levels, but not the intron F G79A polymorphism, are
associated with unexplained pregnancy loss
Thromb Res. 2008 Nov 19. [Epub ahead of print]

Haemostasis Unit, Department of Haematology, "Papageorgiou" General
Hospital, Thessaloniki, Greece.

INTRODUCTION: The present case-control study was designed in order to
investigate the association between plasma protein Z (PZ) levels, the
intron F G79A polymorphism and unexplained pregnancy loss. MATERIALS
AND METHODS: 51 women with at least two consecutive or three
non-consecutive fetal losses between the 8th and 12th week of
gestation and 47 apparently healthy parous women of reproductive age
with no history of pregnancy loss (controls) were enrolled. Allele
frequencies of the PZ intron F G79A polymorphism and PZ levels were
measured. RESULTS: PZ levels (mg/L) were significantly lower in cases
(mean+/-S.D. 1.28+/-0.56) than controls (1.97+/-0.76, p<0.001) and in
carriers of the A allele (1.46+/-0.62), compared to GG homozygous
subjects (1.72+/-0.81, p=0.044). A higher proportion of cases (41.2%)
were PZ-deficient (<1 mg/L), compared to controls (10.6%, p=0.001). No
significant difference in the frequency of at least one A allele
carriers was observed between cases (39.2%) and controls (40.4%).
CONCLUSION(S): It is possible that low PZ levels are a novel risk
factor for unexplained recurrent miscarriage or fetal death. The
presence of the F 79A allele is associated with significantly lower PZ
levels, but, in the present study, was unrelated to unexplained early
pregnancy loss.

10. Salim R, Czarnowicki T, Nachum Z, Shalev E
The impact of close surveillance on pregnancy outcome among women with
a prior history of antepartum complications attributed to thrombosis:
a cohort study
Reprod Biol Endocrinol. 2008 Nov 21;6(1):55. [Epub ahead of print]

ABSTRACT: BACKGROUND: There is limited evidence, so far, as to the
optimal management of women with a prior obstetric history of
antepartum complications attributed to thrombosis. We aimed to
investigate the contribution of close antepartum surveillance on
pregnancy outcome among women with prior antepartum complications
attributed to thrombosis. METHODS: The study was conducted on all
women who were delivered, conceived and delivered again between
January 2000 and January 2006 at a university teaching hospital. Women
included were managed in previous pregnancy at a low risk setting and
had unpredicted antepartum complications occurring at a gestational
age of 23 weeks or more. Antepartum complications considered were
intrauterine fetal death, neonates who were small for gestational age,
severe pre-eclampsia and placental abruption. All women were tested
for the presence of thrombophilia after delivery. In the following
pregnancy, only women found to have any thrombophilia (thrombophilic
group) were treated with enoxaparin. Both the thrombophilic group and
the non-thrombophilic group (tested negatively for thrombophilia) were
managed and observed closely at our high-risk pregnancy clinic.
RESULTS: Ninety-seven women, who conceived at least once after the
diagnosis of the relevant antepartum complications, were included in
this study. Forty-nine had any thrombophilia and 48 tested negatively.
Composite antepartum complications (all antepartum complications
considered) were reduced significantly after close antepartum
surveillance in both groups. Mean birth weight and mean gestational
age improved significantly and were comparable between the groups.
CONCLUSION: Close antepartum surveillance may contribute to
improvement in the perinatal outcomes of women with prior antepartum
complications attributed to thrombosis.

11. Pasupathy D, Dacey A, Cook E, Charnock-Jones DS, White IR, Smith GC
Study protocol. A prospective cohort study of unselected primiparous
women: the pregnancy outcome prediction study
BMC Pregnancy Childbirth. 2008 Nov 19;8(1):51. [Epub ahead of print]

ABSTRACT: BACKGROUND: There have been dramatic changes in the approach
to screening for aneuploidy over the last 20 years. However, the
approach to screening for other complications of pregnancy such as
intra-uterine growth restriction, pre-eclampsia and stillbirth remains
largely unchanged. Randomised controlled trials of routine application
of high tech screening methods to the general population have
generally failed to show improvement in outcome. We have previously
reviewed this and concluded it was due, in large part, to poor
performance of screening tests. Here, we report a study design where
the primary aim is to generate clinically useful methods to screen
women to assess their risk of adverse pregnancy outcome.
Methods/design: We report the design of a prospective cohort study of
unselected primiparous women recruited at the time of their first
ultrasound scan. Participation involves serial phlebotomy and
obstetric ultrasound at the dating ultrasound scan (typically 10-14
weeks), 20 weeks, 28 weeks and 36 weeks gestation. In addition,
maternal demographic details are obtained; maternal and paternal
height are measured and maternal weight is serially measured during
the pregnancy; maternal, paternal and offspring DNA are collected;
and, samples of placenta and membranes are collected at birth. Data
will be analysed as a prospective cohort study, a case-cohort study,
and a nested case-control study. DISCUSSION: The study is expected to
provide a resource for the identification of novel biomarkers for
adverse pregnancy outcome and to evaluate the performance of
biomarkers and serial ultrasonography in providing clinically useful
prediction of risk.