Classification of perinatal mortality

A classification based upon pathophysiological mechanisms has been applied to perinatal mortality. The approximate relevance of each group was: fetal insufficiency 40%, respiratory failure 30%, developmental abnormality 20%, and the specific mechanisms 10%. Secondary subclassification of each category according to the maturity of the gestation emphasizes the importance of prematurity in the total perinatal mortality (66%) and the relevance of each pathophysiological mechanism in each phase of maturity. The principal mechanism in the mature group is fetal insufficiency and in the premature group, particularly between 20 and 28 weeks, it is neonatal respiratory failure. Perinatal death due to developmental abnormalities occurs most frequently in the mature infant and due to specific mechanisms in the premature infant, particularly between 29 and 36 weeks. It is suggested that greater emphasis should be placed on perinatal mortality rather than the separate consideration of stillbirth and neonatal mortality.     

The Antepartum Assessment of Fetal Well-being

Modern obstetrics is concerned with the health and well-being of both the mother and the unborn child. During the first two thirds of this century there was a pronounced decrease in maternal mortality and morbidity related to pregnancy. More recently, using the techniques of amniocentesis, antepartum fetal heart rate testing and ultrasound, obstetricians have been able to more accurately assess the health of a fetus. This knowledge has resulted in decreased perinatal mortality and morbidity and, when rigorously applied, a decrease in fetal loss.     

Combating iodine deficiency disorders to achieve millennium development goal 4 in India: reduction in infant mortality rate

In severe iodine deficient areas, iodine deficiency has been documented to be an important etiological factor leading to poor fetal growth and development. Iodine is essential for physical growth and development of the central nervous system of the fetus. Iodine deficiency in pregnant mothers leads to increased incidence of infertility and abortions, perinatal mortality and infant child mortality. The clinical iodine supplementation trials have documented adverse health consequences due to iodine deficiency. Evidence from observational studies concludes that prevention of iodine deficiency can lead to reduction in infant mortality rate and facilitate to achieve millennium development goal-4.     

Labour: when to worry.

To ensure an optimum result in pregnancy it is essential that the physician be alert in the antenatal period to recognize those women and their babies who are at risk during labour. Premature labour, with its attendant risk of respiratory distress syndrome in the newborn, continues to be an important factor in perinatal morbidity and mortality. Early recognition of predisposing factors and the judicious use of myometrial inhibiting agents have helped to reduce the incidence of fetal prematurity in these cases. A long interval between rupture of the membranes and delivery continues to be a danger to both mother and fetus. Delivery is recommended when gestation is beyond 36 weeks or when there are signs of incipient infection, and once labour has begun antibiotics should be used prophylactically. Failure of labour to progress should be recognized and managed aggressively in its early stages. Amniotomy and oxytocin infusion have reduced considerably the incidence of prolonged labour and its risks to both mother and fetus. The role of intrapartum monitoring of the fetal heart rate, measurement of the pH in the fetus''s scalp blood and assessment of amniotic fluid is discussed, as is the monitoring of maternal well-being.     

Perinatal outcome of pregnancies in women aged 40 and over

Perinatal outcome of pregnancies at forty and over was analyzed starting from the diagnosis of pregnancy to seven days following delivery. Retrospectively, pre-gestational health and reproduction status were dealt with, as well as the course of pregnancy, deliveries, and newborn children (study group). The control group was composed of pregnant women aged 20 to 29, who were identical to study group in terms of parity. Statistical data processing was done by means of chi2-test, and contingency 2 x 2 tables. The difference was significant if p < 0.05. Out of 2,099 diagnosed wanted pregnancies at forty and over, 415 (19.8%) had a miscarriage, in 33 (1.6%) an artificial abortion was performed after determining the fetus karyotype and 1,651 (78.2%) of pregnant women delivered. In 66.2% of pregnancies the fetus karyotype was determined and in 33 (2.5%) fetuses chromosomal abnormalities were found Incidence of deliveries at 40 and over is 1.38%, which is a 35.6-percent increase in the last ten years. Nullipara and pluripara had an increase, and multipara had a decrease. Pre-gestational health and reproduction status in study group is lower than in control group. Complications during pregnancy: threatened abortion, EPH gestosis, placenta praevia, gestational diabetes, late fetal death are more frequent than in control group (p < 0.05). In intrapartal terms, more frequent were induction of delivery, meconium-stained amniotic fluid, fetal distress, operative vaginal deliveries, and Cesarean section (p < 0.05). In neonatal outcome there are more premature infant, there are more VLBW, LBW, SGA, newborn with low Apgar index values, and the total perinatal death is greater than in the control group (p < 0.05). In perinatal terms, (from the diagnosis to the seventh day following delivery) 1,617 children survived (77.0%), meaning that perinatal loss was 482 (23.0%). Authors conclude that pregnancy at 40 and over is a high-risk pregnancy. There is a high risk of pre-gestational and gestational complications, and perinatal loss is high. Therefore, those pregnancies are not desirable from the medical point of view.     

The development of cortisol metabolism in the perinatal period in the guinea-pig

Cortisol metabolism appears to be active soon after birth in guineapigs. Indeed, plasma cortisol half-life measured in three day-old animals resembles that of adult guinea-pigs (48 min). The metabolic clearance rate (MCR) of plasma cortisol as measured by continuous infusions of ³H-cortisol in fetal and newborn guinea-pigs remained very low, increasing slowly and regularly during the perinatal period without abrupt change at birth. Whole cortisol MCR in fetus is presented as the resultant of the concomitant actions of three factors: transfer to the mother, fetal irreversible removal rate and placental metabolism. True fetal cortisol MCR could be dissociated from total cortisol MCR measured in fetus by comparing the ratios of other measured parameters in maternal and fetal plasmas. Until ten days post partum, cortisol MCR varied independently of body weight growth and reflected the maturation of catabolizing hepatic enzymes.     

Fetal circulatory responses to oxygen lack.

The knowledge on fetal and neonatal circulatory physiology accumulated by basic scientists and clinicians over the years has contributed considerably to the recent decline of perinatal morbidity and mortality. This review will summarize the peculiarities of the fetal circulation, the distribution of organ blood flow during normoxemia, and that during oxygen lack caused by various experimental perturbations. Furthermore, the relation between oxygen delivery and tissue metabolism during oxygen lack as well as evidence to support a new concept will be presented along with the principal cardiovascular mechanisms involved. Finally, blood flow and oxygen delivery to the principal fetal organs will be examined and discussed in relation to organ function. The fetal circulatory response to hypoxemia and asphyxia is a centralization of blood flow in favour of the brain, heart, and adrenals and at the expense of almost all peripheral organs, particularly of the lungs, carcass, skin and scalp. This response is qualitatively similar but quantitatively different under various experimental conditions. However, at the nadir of severe acute asphyxia the circulatory centralization cannot be maintained. Then there is circulatory decentralization, and the fetus will experience severe brain damage if not expire unless immediate resuscitation occurs. Future work in this field will have to concentrate on the important questions, what factors determine this collapse of circulatory compensating mechanisms in the fetus, how does it relate to neuronal damage, and how can the fetal brain be pharmacologically protected against the adverse effects of asphyxia.     

Pregnancy and viral infections: Mechanisms of fetal damage,diagnosis and prevention of neonatal adverse outcomes from cytomegalovirus to SARS-CoV-2 and Zika virus

Some maternal infections, contracted before or during pregnancy, can be transmitted to the fetus, during gestation (congenital infection), during labor and childbirth (perinatal infection) and through breastfeeding (postnatal infection). The agents responsible for these infections can be viruses, bacteria, protozoa, fungi. Among the viruses most frequently responsible for congenital infections are Cytomegalovirus (CMV), Herpes simplex 1–2, Herpes virus 6, Varicella zoster. Moreover Hepatitis B and C virus, HIV, Parvovirus B19 and non-polio Enteroviruses when contracted during pregnancy may involve the fetus or newborn at birth. Recently, new viruses have emerged, SARS-Cov-2 and Zika virus, of which we do not yet fully know the characteristics and pathogenic power when contracted during pregnancy.Viral infections in pregnancy can damage the fetus (spontaneous abortion, fetal death, intrauterine growth retardation) or the newborn (congenital anomalies, organ diseases with sequelae of different severity). Some risk factors specifically influence the incidence of transmission to the fetus: the timing of the infection in pregnancy, the order of the infection, primary or reinfection or chronic, the duration of membrane rupture, type of delivery, socio-economic conditions and breastfeeding. Frequently infected neonates, symptomatic at birth, have worse outcomes than asymptomatic. Many asymptomatic babies develop long term neurosensory outcomes.The way in which the virus interacts with the maternal immune system, the maternal-fetal interface and the placenta explain these results and also the differences that are observed from time to time in the fetal?neonatal outcomes of maternal infections. The maternal immune system undergoes functional adaptation during pregnancy, once thought as physiological immunosuppression. This adaptation, crucial for generating a balance between maternal immunity and fetus, is necessary to promote and support the pregnancy itself and the growth of the fetus. When this adaptation is upset by the viral infection, the balance is broken, and the infection can spread and lead to the adverse outcomes previously described. In this review we will describe the main viral harmful infections in pregnancy and the potential mechanisms of the damages on the fetus and newborn.     

Does routine ultrasound scanning improve outcome in pregnancy? Meta-analysis of various outcome measures.

OBJECTIVE--To evaluate the effectiveness of routine ultrasound scanning in pregnancy by a meta-analysis of various outcome measures. DESIGN--Meta-analysis of randomised controlled trials evaluating the effect of routine ultrasound scanning on perinatal mortality and morbidity. Live birth rate (that is, live births per pregnancy) is included as a measure of pregnancy outcome in addition to the conventional perinatal mortality. SUBJECTS--15,935 pregnancies (7992 in which routine ultrasound scanning was used and 7943 controls with selective scanning) from four randomised controlled trials. MAIN OUTCOME MEASURES--Perinatal mortality, live birth rate, rate of miscarriage, Apgar score < 7 at 1 minute, and number of induced labours. RESULTS--The live birth rate was identical in both screening and control groups (odds ratio = 0.99; 95% confidence interval 0.88 to 1.12) although the perinatal mortality was significantly lower in the group who had routine ultrasonography (0.64, 0.43 to 0.97). Differences in perinatal morbidity between the two groups as measured by the proportion of newborn babies with Apgar score < 7 at 1 minute were not significant (1.05; 0.93 to 1.19). CONCLUSION--Routine ultrasound scanning does not improve the outcome of pregnancy in terms of an increased number of live births or of reduced perinatal morbidity. Routine ultrasound scanning may be effective and useful as a screening for malformation. Its use for this purpose, however, should be made explicit and take into account the risk of false positive diagnosis in addition to ethical issues.     

Delayed surgical treatment for a traumatic bilateral cervical facet joint dislocation using a posterior-anterior approach: a case report

Introduction

Advanced abdominal (extrauterine) pregnancy is a rare condition with high maternal and fetal morbidity and mortality. Because the placentation in advanced abdominal pregnancy is presumed to be inadequate, advanced abdominal pregnancy can be complicated by pre-eclampsia, which is another condition with high maternal and perinatal morbidity and mortality. Diagnosis and management of advanced abdominal pregnancy is difficult.

Case presentation

We present the case of a 33-year-old African woman in her first pregnancy who had a full-term advanced abdominal pregnancy and developed gross ascites post-operatively. The patient was successfully managed; both the patient and her baby are apparently doing well.

Conclusion

Because most diagnoses of advanced abdominal pregnancy are missed pre-operatively, even with the use of sonography, the cornerstones of successful management seem to be quick intra-operative recognition, surgical skill, ready access to blood products, meticulous post-operative care and thorough assessment of the newborn.     

Fetal and neonatal breathing movements in man after betamethasone.

Nineteen women in the last trimester of pregnancy were treated with betamethasone 12 mg daily for three consecutive days. The fetal breathing movements were monitored by an ultrasonic method before and after the treatment and the patterns of movements were compared to those in controls. In seven treated cases the recording of breathing was performed also in the neonatal period. Betamethasone in the given dose, which causes pronounced alterations in the fetal corticosteroid balance, does not influence the pattern of breathing movements in the fetus and newborn. Although corticosteroids are known to affect several functions of CNS, the maturation of mechanisms regulating breathing movements in the perinatal period is apparently not accelerated by betamethasone.     

Peripheral Blood Mononuclear Cell Traffic Plays a Crucial Role in Mother-to-Infant Transmission of Hepatitis B Virus

The role of peripheral blood mononuclear cells (PBMCs) in HBV intrauterine infection is not fully defined. Particularly the origin of PBMCs in HBV-infected neonates remains to be addressed. We carried out a population-based nested case-control study by enrolling 312 HBsAg-positive mothers and their babies. PBMC HBV DNA as well as serum HBsAg and HBV DNA was tested in cohort entry samples. Totally, 45.5% (142/312) of the newborns were found to be infected with HBV in perinatal transmission. 119 mother-infant pairs were identified to be different in the genetic profile of maternal and fetal PBMCs by AS-PCR and hemi-nested PCR. Among them, 57.1% (68/119) of the maternal PBMCs in index cases were positive for HBV DNA while 83.8% (57/68) of the HBV DNA positive maternal PBMCs passed the placental barrier and entered the fetus. Furthermore, maternal PBMC HBV infection was significantly associated with newborn infants HBV infection. PBMC traffic from mother to fetus resulted in a 9.5-fold increased risk of HBV infection in PBMC HBV DNA positive newborn infants. These data indicate that maternal PBMCs infected with HBV contribute to HBV intrauterine infection of newborn infants via PBMC traffic from mother to fetus.     

Prospective cohort study of factors influencing the relative weights of the placenta and the newborn infant.

OBJECTIVES: To determine the demographic, environmental, and medical factors that influence the relative weights of the newborn infant and the placenta and compare this ratio with other factors known to predispose to adult ill health. DESIGN: Prospective cohort study. SETTING: The tertiary referral centre for perinatal care in Perth, Western Australia. SUBJECTS: 2507 pregnant women who delivered a single live infant at term. MAIN OUTCOME MEASURES: Placental weight, birth weight, and the ratio of placental weight to birth weight. RESULTS: By multiple regression analysis the placental weight to birthweight ratio was significantly and positively associated with gestational age, female sex, Asian parentage, increasing maternal body mass index, increased maternal weight at booking, lower socioeconomic status, maternal anaemia, and increasing number of cigarettes smoked daily. There were no consistent relations between the placental weight to birthweight ratio and measures of newborn size. CONCLUSIONS: The ratio of placental weight to birth weight is not an accurate marker of fetal growth. In its role as a predictor of adult disease the ratio may be acting as a surrogate for other factors which are already known to influence health and may act before or after birth. Determining the role that relative growth rates of the fetus and placenta have in predisposing to adult disease requires prospective study to account for the many confounding variables which complicate this hypothesis.     

Angiotensin receptors, autoimmunity, and preeclampsia

Preeclampsia is a pregnancy-induced hypertensive disorder that causes substantial maternal and fetal morbidity and mortality. Despite being a leading cause of maternal death and a major contributor to maternal and perinatal morbidity, the mechanisms responsible for the pathogenesis of preeclampsia are poorly understood. Recent studies indicate that women with preeclampsia have autoantibodies that activate the angiotensin receptor, AT1, and that autoantibody-mediated receptor activation contributes to pathophysiology associated with preeclampsia. The research reviewed here raises the intriguing possibility that preeclampsia may be a pregnancy-induced autoimmune disease.     

Cardiac functional stress imaging: A sequential approach with stress echo and cardiovascular magnetic resonance

Background

An adequate placental perfusion is crucial for the normal growth and well being of the fetus and newborn. The blood flow through the placenta can be compromised in a variety of clinical situations, always causing important damage to the gestation. Our objective is to identify significant predictors for adverse neonatal outcome in severe fetal compromise.

Methods

Consecutive premature fetuses at between 25 and 32 weeks with severe placental insufficiency were examined prospectively. Inclusion criteria were: (i) singletons (ii) normal anatomy; (iii) abnormal umbilical artery Doppler pulsatility index (PI); (iv) abnormal cerebroplacental ratio; (v) middle cerebral artery (MCA) PI < - 2SD ("brain sparing"); (vi) last Doppler examination performed within 24 hours prior to delivery. All 46 patients that met criteria and started the study were followed to the end. We considered as independent potential predicting variables: absent or reversed end diastolic flow in umbilical artery, abnormal ductus venosus S/A ratio, absent or reversed flow during atrial contraction in the ductus venosus and birth weight Z score. Outcome parameters were: neonatal mortality and severe neonatal morbidity.

Results

Backward stepwise logistic regression analysis was used to determine the optimal model for the prediction of neonatal mortality and severe neonatal morbidity. In this analysis birth weight Z score index showed the strongest association OR = 1,87 [1,17-2,99] with all neonatal outcome, all other independent variables were excluded for the optimal model. There was no mortality for the group with normal birth weight Z score.

Conclusion

Our study suggests that birth weight Z score is the strongest predictor of adverse neonatal outcome in severe placental insufficiencies. Such use of Z scores, allowing to get rid of gestational age or sex covariates could be extended to estimated fetal weight and might help in making important decisions in the management of compromised pregnancies.     

Perinatal mortality and adverse pregnancy outcomes in a low‐income rural population of women who smoke

We describe adverse pregnancy outcomes, including congenital anomalies, fetal, neonatal, and infant mortality among a Missouri population of low‐income, rural mothers who participated in two randomized smoking cessation trials. In the Baby BEEP (BB) trial, 695 rural women were recruited from 21 WIC clinics with 650 women's pregnancy outcomes known (93.5% retention rate). Following the BB trial, 298 women who had a live infant after November 2004 were recruited again into and completed the Baby Beep for Kids (BBK) trial. Simple statistics describing the population and perinatal and postneonatal mortality rates were calculated. Of the adverse pregnancy outcomes (n = 79), 29% were spontaneous abortions of less than 20 weeks' gestation, 23% were premature births, and 49% were identified birth defects. The perinatal mortality rate was 15.9 per 1000 births (BB study) compared with 8.6 per 1000 births (state of Missouri) and 8.5 per 1000 births (United States). The postneonatal infant mortality rate was 13.4 per 1000 live births (BBK) compared with 2.1 per 1000 live births (United States). The health disparity in this population of impoverished, rural, pregnant women who smoke, particularly in regard to perinatal and infant deaths, warrants attention. Birth Defects Research (Part A), 2012. © 2012 Wiley Periodicals, Inc.     

Sterol and bile acid metabolism during development. 1. Studies on the gallbladder and intestinal bile acids of newborn and fetal rabbit

Bile acid composition and content in the intestine and gallbladder of newborn and fetal rabbits were investigated. Unlike the circumstances in adult rabbits, the bile acids were conjugated with both taurine and glycine. The major bile acids of the fetus and newborn rabbit were cholic acid, chenodeoxycholic acid, and deoxycholic acid. This is different from the known bile acid composition of adult rabbits, in which deoxycholic acid is the major bile acid (> 80%). The proportion of chenodeoxycholic acid was higher in the fetal than in the newborn tissues. The total bile acid pool in the newborn was higher than in the fetus. In the fetus, large proportions of bile acids (60.9%) were associated with the gallbladder fraction, whereas in the newborn the bulk of the bile acids were found with the intestinal fraction (64.4%),     

Risk factors for perinatal mortality in Canada

A population-based computer record-linkage study of infant births and deaths in 1978 and 1979 in eight Canadian provinces (Quebec and Newfoundland were excluded) was undertaken to permit analysis of perinatal mortality in relation to maternal and infant characteristics. Perinatal mortality rates were significantly higher in nonurban than in urban areas (p < 0.05). A logistic regression model was used to assess the effects on perinatal mortality of variables reported on birth and stillbirth records. This model included length of gestation, infant''s birth weight and sex, number of previous births and number of previous stillbirths as well as an interaction term for length of gestation and birth weight. For early-neonatal mortality, odds ratios over 8 were observed for birth weight less than 2500 g or gestation less than 35 weeks. About 75% of early-neonatal mortality was attributable to low birth weight or fetal immaturity. Greater emphasis should be placed on the prevention of low birth weight.     

Bilateral fetal uropathy: what is the outlook?

OBJECTIVE--To assess the morbidity and mortality associated with a prenatal diagnosis of bilateral fetal uropathy. DESIGN--Retrospective study. SETTING--Departments of radiology, paediatric surgery, obstetrics, and pathology in two teaching hospitals that serve as referral centres for the Yorkshire region. PATIENTS--126 Cases of fetal uropathy were referred either prenatally or postnatally from hospitals in Yorkshire between August 1982 and December 1987. The disease was bilateral in 54 cases and unilateral in 72 cases. In 14 cases bilateral fetal uropathy was associated with coexistent disease. INTERVENTIONS--All cases were managed individually by an obstetrician after discussion with the radiologists and paediatric surgeons. Babies who survived were treated prophylactically with antibiotics after delivery and were operated on if appropriate. END POINT--Assessment of prognosis for long term renal function for each baby referred between August 1982 and December 1987: follow up ranged from six months to five years. MEASUREMENTS AND MAIN RESULTS--Of the 54 fetuses with bilateral fetal uropathy, 13 were terminated as the prenatal findings of ultrasonography were considered to be incompatible with long term survival. Ten of the liveborn babies died, five of renal or pulmonary insufficiency, or both, and five of associated congenital anomalies. Thirty one infants survived to follow up; four of these had serious coexistent disease and two had impaired renal function. Thus the overall mortality was 43% and the morbidity rate 19%. The renal anomaly was associated with other serious disease in 14 cases (26%) compared with two (3%) of the 72 cases of unilateral fetal uropathy. All but two of the 27 infants with isolated bilateral urinary tract disease had excellent prospects for survival. CONCLUSION--Although bilateral fetal uropathy is associated with a high morbidity rate and mortality, careful prenatal assessment can help to identify fetuses with a poor prognosis. The outlook for a fetus with isolated renal disease if treated promptly after delivery is excellent and compares favourably with that reported after prenatal surgical intervention.