Significant Increase In Perinatal Mortality Research Articles

Management and perinatal outcome of selective intrauterine growth restriction in monochorionic pregnancies

Introduction Selective intrauterine growth restriction (sIUGR) is a complication observed in about 10–15% of all monochorionic (MC) pregnancies, causing a significant increase in perinatal mortality and morbidity. Objective To evaluate clinical management options and perinatal outcomes of sIUGR in MC pregnancies monitored in a single tertiary center. Methods A retrospective study was performed on 55-MC pregnancies with sIUGR between January 2012 and May 2018 at the Fetal Medicine Unit of La Paz Hospital. Cases were classified according to the umbilical artery (UA) Doppler pattern as type I (positive end-diastolic flow; n = 25), type II [persistently absent or reversed end-diastolic flow (AREDF); n = 5] and type III [intermittently absent or reversed end-diastolic flow (iAREDF); n = 25]. Types II and III were then merged together as severe sIUGR cases. Subsequently, two possible approaches were considered: expectant management (EM) with elective preterm delivery in case of fetal deterioration, or in-utero therapy via fetoscopic laser photocoagulation (FLP) of intertwin anastomosis or selective umbilical cord occlusion (CO) of the growth-restricted fetus. Results Gestational age (GA) at diagnosis was progressively lower with each type. Severe sIUGR cases delivered significantly earlier than type I, showing lower birth weights and higher intertwin biometric discordance. Unintended fetal demise occurred in 14% (6/25) of severe sIUGR pregnancies as opposed to 0% (0/19) in type I, p = .028. A significantly higher proportion of twins was admitted in NICU in severe cases when compared to type I [87% (33/38) versus 47% (18/38), p < .001]. In addition, brain damage at birth was also found to be more prevalent in this group [21% (8/38) versus 11% (4/38), p = .346], especially in the larger twin, when comparing any short-term neurological sequel [30% (7/23) versus 0% (0/19), p = .011] or specifically periventricular leukomalacia [PVL; 22% (5/23) versus 0% (0/19), p = .053]. Although the overall mortality rate was significantly higher in severe sIUGR that underwent CO instead of EM [58% (7/12) versus 11% (4/36), p = .002], NICU admissions were higher in the latter [94% (17/18) versus 40% (2/5), p = .021]. Neurological sequels at birth were similar in both groups [39% (7/18) versus 40% (2/5), p = 1.000], similarly when considering only the larger twin for any brain lesion [28% (5/18) versus 40% (2/5), p = .621] or just PVL [22% (4/18) versus 20% (1/5), p = 1.000]. Conclusion Given the good prognosis of type I sIUGR, expectant management is the first approach to consider. However, due to the poorer clinical evolution of types II and III sIUGR, the decision-making is challenging and needs to be individualized depending on the UA Doppler pattern, GA at diagnosis, severity of growth restriction and biometric discordance, technical issues and parents’ preferences.

Neonatal and Long-Term Consequences of Fetal Growth Restriction.

Background: Fetal Growth Restriction (FGR) is one of the most common noxious ante-natal conditions in humans, inducing a substantial proportion of preterm delivery and leading to a si-gnificant increase in perinatal mortality, neurological handicaps and chronic diseases in adulthood. This review summarizes the current knowledge about the postnatal consequences of FGR, with a par-ticular emphasis on the long-term consequences on respiratory, cardiovascular and neurological struc-tures and functions.Result and Conclusion: FGR represents a global health challenge, and efforts are urgently needed to improve our understanding of the critical factors leading to FGR and subsequent insults to the deve-loping organs.

Conséquences maternelles et néonatales des accouchements inopinés extrahospitaliers

Know the impact of the unplanned deliveries in a town of medium size, the characteristics of these women and maternal and neonatal risks. This was a retrospective study conducted between January 2002 and December 2009. Unexpected delivery was defined as any delivery taking place outside of a non-elective way maternity. Each unexpected delivery was matched at nearest delivery of equivalent term, at the CHU maternity, with an onset of spontaneous labour. Ninety-four women gave birth unexpectedly for a total of 48,721 births (incidence of 0.19%). There was a significant difference between cases and controls for parity (1.8 versus 0.9), the lack of follow-up of pregnancy (21.3% versus 1.1%), tobacco (57.4% versus 25.5%), the socio-economic level, the type of feeding (artificial: 61.7% versus 30.6%), the home-hospital distance and obstetric follow-up. We found a significant increase in perinatal mortality (6.4% versus 1%) and stay in Neonatal ICU (19.1% versus 9.2%). The main neonatal morbidity was hypothermia. It is difficult to target a population at risk because the type of these women is non-specific. Prevention of unplanned deliveries and their morbidities through information of patients on the grounds of urgent consultation and support of the newborn to limit hypothermia.

Effects of in utero and lactational exposure to triphenyltin chloride on pregnancy outcome and postnatal development in rat offspring

The organotin compound (OTC) triphenyltin (TPT) is used extensively as a herbicide, pesticide and fungicide in agriculture as well as, together with tributyltin (TBT), in marine antifouling paints. We studied the effects of in utero exposure to 2 or 6 mg triphenyltinchloride (TPTCl)/kg b.w. on pregnancy outcome and postnatal development in rat offspring. Gravid Wistar rats were treated per gavage from gestational day 6 until the end of lactation. In the 6 mg TPTCl dose group gestational mortality in dams as well as an increased incidence of anticipated and delayed parturition was observed. Furthermore, treatment resulted in a significant increase in perinatal mortality, a decrease in lactational body weight gain as well as in delayed physical maturation of offspring. Similarily, exposure to 2 mg TPTCl/kg b.w. resulted in a significant increase in perinatal mortality and in delayed eye opening. Lactational body weight gain and other landmarks of physical maturation were unaffected in the low dose group. We conclude, that in utero exposure to TPTCl at the described dose levels severely affected pregnancy outcome and perinatal survival of offspring. These results were unexpected, as in two earlier studies with pubertal rats TPTCl at the same dose levels no signs of general toxicity were observed.

Preterm birth in rural Malawi: high incidence in ultrasound-dated population

Preterm birth is the major cause of neonatal death, and has an incidence in industrialized countries of 7%. We have found a high incidence (25-30%) previously in a population of anaemic, pregnant women in southern Malawi, studied with ultrasound dating. Cohort study of 512 unselected pregnant women in rural communities in Malawi. All had ultrasound fetal measurements before 24 weeks. 20.3% of women delivered before 37 completed weeks of pregnancy. Babies born before 37 completed weeks but after 32 weeks (16%) were twice as likely to die as babies born at term (6.9 versus 3.4%) but this difference did not achieve statistical significance. For those born between 24 and 33 weeks gestation (4.4%) there was a highly significant increase in perinatal mortality (75%) (p <0 .000001). This population has a very high rate of preterm birth, which is probably infection-related. It may be representative of many rural populations in sub-Saharan Africa. Tackling the problem of neonatal mortality in low income countries will require effective methods to prevent preterm birth.

Apport pronostique du Doppler de l’isthme aortique fœtal dans la prise en charge du retard de croissance intra-utérin: Étude prospective longitudinale

Our purpose was to determine whether the use of aortic isthmus Doppler waveform analysis in growth restricted fetuses delivered at 28 to 38 weeks predicts perinatal outcomes.Prospective longitudinal study including singleton non-malformed euploid fetuses with accurate dating and diagnosed as growth restricted (abdominal circumference<10th percentile) and who were followed up at our institution and delivered<10 days after the last Doppler. Timing of delivery was collegial. Perinatal mortality and morbidity outcomes were compared in cases with anterograde blood flow versus retrograde net blood flow in aortic isthmus. Relative risk (RR) were calculated with 95% CI and P<0,05 was considered significant.Thirty-two cases were considered for analysis: growth-restricted foetuses with anterograde blood flow (n=26) versus retrograde net blood (n=6). Maternal demographic characteristics in the two groups were similar and exceptions made of femur length average values for fetal biometrics were not significantly different. Doppler velocimetry results at the uterine, umbilical and cerebral arteries were similar in the two groups. Gestational age at delivery and birth weight were similar in both groups (respectively (239.65 20.1 vs. 247.3 16.4 (days) (p=0.349) and 1748.8 gr 468.7 vs. 1933.3 gr 468.7 (p=0.408)). There was a statistically significant increase in perinatal mortality in retrograde net blood flow group: 8.66 [IC 95% 2.03 - 36.84]. An interesting finding was that neonates with aortic isthmus retrograde net blood flow were more frequently born by cesarean delivery because of a suspected fetal compromise RR=3.22 CI 95% [1.29-8].In our study Doppler identification of aortic isthmus retrograde net blood flow in growth-restricted fetuses was associated with an increase of perinatal death.

Effects of prenatal exposure to manganese on postnatal development and behavior in mice:: Influence of maternal restraint

Manganese (Mn) is an essential trace element whose deficiency and excess have been reported to cause central nervous system (CNS) disturbances. On the other hand, during pregnancy, maternal stress has been shown to enhance the developmental toxicity of a number of metals. In this study, the maternal toxicity and developmental effects of a concurrent exposure to Mn and restraint stress were evaluated in mice. Pregnant animals were divided into three groups and received subcutaneous injections of manganese chloride tetrahydrate (MnCl 2·4H 2O) at 0, 1 and 2 mg/kg/day on Gestation Days 6–18. Each group was divided into two subgroups. Mice in one subgroup were subjected to restraint for 2 h/day on Days 6–18 of gestation. Pregnant mice were allowed to deliver, and pups were evaluated for physical and neuromotor maturation. Subsequently, adult mice were also evaluated for activity and learning. A significant increase in perinatal mortality was observed at 2 mg/kg/day Mn. A delay in some developmental landmarks (eye opening, testes descent) due to Mn exposure (2 mg/kg/day) was also seen in both restrained and unrestrained animals. No differences in motor resistance and coordination, or in learning at the passive avoidance test, were noted in adult mice. At the current Mn doses, combined exposure to Mn and stress during the prenatal period did not produce long-lasting effects on adult mice.

Recent information on iodine deficiency in New Zealand sheep flocks

Aims. To determine the value of pasture iodine, serum thyroxine (T4) and tri-iodothyronine (T3) concentrations and thyroid (g) to body weight (kg) ratios in lambs as criteria to predict and diagnose increased litter size and decreased perinatal mortality in response to iodine supplementation. Methods. Results from ten iodine response trials in ewes using an oil-based intramuscular iodine preparation were reviewed along with results from investigations into goitre on five farms in the Manawatu. Results. In two trials, litter size was increased by 14% and 21% in iodine-treated ewes. In only three of the 10 trials was there a significant reduction in perinatal mortality in iodine-treated ewes. Conclusions. Pasture iodine and serum thyroxine (T4) and tri-iodothyronine (T3) concentrations appeared to be unhelpful in predicting the occurrence of increased litter size and reduced perinatal mortality in response to iodine supplementation. New-born lambs from ewes not supplemented with iodine, that had a mean thyroid weight (g) to body weight (kg) ratio of 0.40 g/kg or greater, generally had a significant increase in perinatal mortality compared to lambs from iodine-supplemented ewes.

Acardia: Predictive risk factors for the co‐twin's survival

This study aimed to find factors in acardiac pregnancies that could be used to predict survival rates of the pump fetus. Five cases of acardia at Monash Medical Centre were found, and all case reports available in the literature from 1960 to 1991 (184 cases) were collected and analyzed. Acardia is more common in nulliparous women and in monoamniotic monochorionic pregnancy. The acardiac fetus usually has a two-vessel umbilical cord and is most likely to develop structures supplied by the lower aortic branches. Delivery is more often preterm (mean gestation = 31.1 weeks) than normal twins. The overall perinatal mortality for the pump fetus is 35% in twins and 45% in triplets. Factors associated with a statistically significant increase in perinatal mortality for the pump fetus include delivery before 32 weeks gestation, acardiacus anceps form of acardia, and the presence of arms, ears, larynx, trachea, pancreas, kidney, or small intestine in the acardiac fetus. Active intervention in these pregnancies is reasonable.

A retrospective study on the effects of steroid administration and prolongation of the latent phase in patients with preterm premature rupture of the membranes

To address the issues of whether corticosteroid treatment and prolongation of the latent phase improve the outcome of pregnancy in patients with preterm premature rupture of the membranes, we studied 96 patients with premature rupture of the membranes who were delivered of infants of adequate weight for gestational age with birth weights between 751 and 2000 gm and who had a latent period longer than 48 hours. Of these 96 infants, 53 received treatment with steroids and tocolytic agents and 43 received no treatment. We found a significant decrease in perinatal mortality and in the incidence of moderate and severe hyaline membrane disease in infants whose mothers received glucocorticoids. The protective effect of glucocorticoid therapy was limited to infants with a birth weight between 751 and 1000 gm or with a gestational age of 27 to 28 weeks. We also found a significant increase in perinatal mortality, mainly due to infection, when the latent phase was prolonged for >7 days, regardless of the type of management.

Maternal weight and pregnancy complications

The effect of obesity alone was investigated among 16,858 women who were delivered of their infants within a 12-month period. Complete analysis was possible for 9667 patients who were divided into four weight categories and separated into two groups, with and without complications. Perinatal mortality, infant size, and the primary cesarean delivery rate were calculated for each group. Among 2597 women with antenatal complications, there was a significant increase in perinatal mortality (p less than 0.001), primary cesarean delivery (p less than 0.02), and mean infant birth weight (p less than 0.01) in the obese and the morbidly obese gravid women. Among 7070 women without antenatal complications there was a significant increase in primary cesarean delivery (p less than 0.001) and mean infant birth weight (p less than 0.01) but not perinatal mortality in the obese and the morbidly obese gravid women. Obesity alone does not appear to affect the perinatal mortality rate but it increases the likelihood of cesarean delivery in the morbidly obese patient.

The interrelationship of maternal smoking and increased perinatal mortality with other risk factors. Further analysis of the Ontario Perinatal Mortality Study, 1960-1961.

Increased perinatal mortality among smokers' babies has been observed in many but not in all studies, with a statistically significant difference in some. This paper explores the hypothesis that maternal smoking may interact with other risk factors, so that a dose-related increase in perinatal mortality may be enhance or masked depending upon the presence or absence of these factors. Data are from the Ontario Perinatal Mortality Study of all single b irths in 10 teaching hospitals in Ontario in 1960-1961 a total of 51,490 births, including 701 fetal deaths and 655 early neonatal deaths. Perinatal mortality increased significantly with smoking, and was also affected by such factors as maternal age, parity, hospital status, previous pregnancy history, hemoglobin level, and others. Smoking frequencies also varied by many of these characteristics. Perinatal mortality was therefore analyzed by the amount smoked during pregnancy within subgroups of these antecedent risk factors. When smoking and other risk factors were cross-tabulated among 52 data subgroups, only the light smokers (less than 1 pack per day) under age 20 had lower perinatal mortality rates than their nonsmoking counterparts. In almost all subgroups the mortality increase with smoking was dose-related, but not in a simple, linear way. The increased risk of perinatal mortality associated with light smoking among young, low-parity, non-anemic mothers was less than 10 percent. At the other extreme, mothers of high parity, public hospital status, with previous low birthweight births, or with hemoglobin less than 11 gm had increased perinatal mortality risks of 70-100 percent when they were heavy smokers. The failure of some studies to find a significant increase in perinatal mortality with maternal smoking may be due to selection of study populations from the end of the spectrum where light smoking is associated with only a slight increase in perinatal risk. Other studies may select higher risk populations, where the influence of smoking on mortality is stronger. Depending on the magnitude of the difference, the amount smoked, and the size of the study, results might or might not be statistically significant.

PREGNANCY OUTCOME AND WEIGHT OF INFANTS BORN TO WOMEN WITH SICKLE CELL TRAIT

A significant increase in perinatal mortality in association with anoxic stress has been reported among Nigerian women with sickle cell trait (AS). Moreover, a significantly lower mean birth weight was reported for infants born to American black AS mothers, although this retrospective survey provided no data concerning parity, or sex and gestational age of the newborn infants. A prospective study has been carried out on the outcome of pregnancy and distribution of birth weights of infants delivered by 73 AS women compared with a control group of AA women matched for race, age, parity and sex of their offspring. 67 (92%) of the pregnant AS women delivered infants at term (>37 weeks). The mean ± S. D. birth weights of term infants with uncomplicated gestation in relation to parity was: primipara, male 3.30 kg ± .42, female 2.77 kg ± .28; multipara, male 3.28 kg ± .54, female 3.25 kg ± .26. Eight (11%) of the infants were born at or before 37 weeks gestation or weighed less than 2. 5 kg at birth. The distribution of birth weights and proportion of low birth weights does not differ significantly from the data from infants born to AA mothers. Five AS mothers had preeclampsia, and 4 had diabetes. There was no increased incidence of urinary tract infections or fetal wastage. These findings do not support the impression that there may be definable pathological correlates of childbearing in AS women.

Effect of maternal sickle-cell trait on perinatal mortality.

Possession of the sickle-cell trait (Hb AS) by the African mother has been shown to be associated with a significant increase in perinatal mortality when there is anoxic stress. This observation should be taken into consideration in the management of labour of both the indigenous and immigrant mothers at risk. The findings do not influence the proposed explanations for the maintenance of high frequencies of the haemoglobin S gene in areas of endemic malaria.