Support for parents experiencing perinatal loss.

Grief following perinatal loss is just as debilitating as that following the death of an older person and may not be completely resolved for years. The physician''s role in assisting parents following perinatal loss is one of a sympathetic listener and compassionate informant, but each category of perinatal loss--miscarriage, stillbirth, neonatal death and sudden infant death syndrome--requires a somewhat different approach. To be of assistance, physicians must understand the normal process of grief and the differences between the reactions of mothers, fathers and siblings. The advent of liberal attitudes to family visiting in perinatal units has helped parents better understand perinatal illness, and appropriate management in the event of perinatal death can greatly benefit the family.     

Multi-fetal pregnancy reduction does not influence perinatal results in twin pregnancies.

The objective of this study was to compare perinatal results in multifetal pregnancies where the reduction to twins was performed with non-reduced twin pregnancies. Perinatal results in 99 sets of twins after transabdominal multifetal pregnancy reduction of triple and higher-order multiple pregnancies performed in a single center were compared with a control group consisting of 151 twin pregnancies conceived in the same time period after infertility treatment, which were not a result of reduction. The main outcome measures were length of pregnancies, weight of the newborns, percentage of miscarriages and the mode of the delivery were analyzed. No significant difference could be found at a 5% level of significance regarding the average duration of pregnancy or average weight of the twins. Fisher test on 5% significance level did not ascertain any significant difference in the probability of miscarriage between the group with reduction (5.26%) and the group without reduction (12.84%). At a 5% level of statistical significance, no significant difference in probability of perinatal death of the fetus or delivery of a stillborn fetus was found. The percentage of cesarean sections did not differ significantly in both groups. The analysis of both groups demonstrated that reduction of multifetal pregnancies to twins may not influence perinatal results in comparison to twin pregnancies where reduction was not performed.     

Psychobiological and evolutionary perspectives on coping and health characteristics following loss: a twin study.

An analysis of coping, grief and health characteristics is reported for a bereaved monozygotic (MZ) and dizygotic (DZ) same-sex twin sample. The data were examined with reference to psychobiological and evolutionary perspectives on behavior. A Coping Scale, included as part of a comprehensive Twin Loss Survey (TLS), assessed coping with daily responsibilities and activities 1-2 months before the co-twin's death, 1-2 months following the co-twin's death and currently. A Grief Intensity Scale obtained judgments of grief 1-2 months following the loss, and currently. Information on physical symptoms was available from the Somatization Scale of the Grief Experience Inventory. Psychobiological and evolutionary perspectives specified hypotheses for two twin groups: one model was specified to reflect bereavement experiences immediately following loss of the co-twin (retrospective twin group); a second model represented present bereavement response (current twin group). Consistent with psychobiological theory, twins' social closeness showed a positive association with grief intensity which, in turn, affected somatic symptoms and coping efficacy in predicted directions. With respect to evolutionary psychological theory, the effect of zygosity on current grief implicated correlates of genetic relatedness as factors in the bereavement process.     

Factors affecting pregnancy loss for single and twin pregnancies in a high-producing dairy herd

Our objective was to determine the magnitude of, and factors affecting, pregnancy loss for lactating Holstein cows on a commercial dairy farm when diagnosed with twin (n = 98) or single (n = 518) pregnancies using transrectal ultrasonography. Pregnancy losses were assessed with records of non-viable embryos at first pregnancy examination and embryo losses between the first (25-40 d after AI) and second (48 and 82 d after AI) post-breeding pregnancy examinations. Among cows diagnosed with single pregnancies, 3.7% were diagnosed with a non-viable embryo at first pregnancy examination, and 4.6% of those diagnosed with a viable embryo underwent pregnancy loss by the second examination. A total of 11.2% of cows diagnosed with twins experienced a single embryo reduction, whereas 13.3% lost both embryos. Overall, the total proportion of cows experiencing pregnancy loss or experiencing embryo reduction was greater for cows diagnosed with twin than single pregnancies (odds ratio; OR = 3.6), resulting in an embryo survival rate of 91.9% for cows diagnosed with single compared to 75.5% for cows diagnosed with twin pregnancies. Season of breeding and milk production were associated with pregnancy loss for single pregnancies, whereas CL number was associated negatively with embryo reduction and pregnancy loss for twin pregnancies. The risk of twinning and double ovulation among pregnant cows increased with days in milk (DIM), and the risk of double ovulation was greater for cows diagnosed with ovarian cysts and lacking a CL at initiation of an Ovsynch protocol. We concluded that in this herd, embryo reduction and pregnancy loss during early gestation was greater for lactating Holstein cows diagnosed with twin compared to single pregnancies. In addition, cows diagnosed with ovarian cysts and lacking a CL had an increased risk for double ovulation.     

Contribution of twin pregnancy to perinatal mortality and fetal growth retardation; reversal of growth retardation after birth.

A survey of factors associated with perinatal mortality in 511 twins and fetal growth retardation and its reversal in 262 twins is presented. The incidence of stillbirth was almost 50% higher in twins than in singletons and the neonatal mortality was six times as high. Eighty percent of the neonatal deaths occurred in infants born prior to or at 30 weeks of gestation; 93% of the deaths were in infants weighing less than 1500 g and 75% occurred within 48 hours of birth. Fetal malnutrition was the main cause of stillbirth, and respiratory distress syndrome and asphyxia neonatorum were the main causes of neonatal death. One quarter of the twins had fetal growth retardation, a prevalence 10 times that in singletons. In almost all, the growth retardation was reversed by high-energy feedings. Although twins represented only 1% of all pregnancies and 2% of live births, they composed 12% of infants with early neonatal death and 17% of growth-retarded infants. A program is suggested for reduction of twin mortality and morbidity.     

Happy families: a twin study of humour.

The objective of this study was to estimate how much of an individual's appreciation of humour is influenced by genetic factors, the shared environment or the individual's unique environment. A population-based classical twin study of 127 pairs of female twins (71 monozygous (MZ) and 56 dizygous (DZ) pairs) aged 20-75 from the St Thomas' UK Adult Twin Registry elicited responses to five 'Far Side' Larson cartoons on a scale of 0-10. Within both MZ and DZ twin pairs, the tetrachoric correlations of responses to all five cartoons were significantly greater than zero. Furthermore, the correlations for MZ and DZ twins were of similar magnitude and in some cases the DZ correlation was greater than that of the MZ twins. This pattern of correlations suggests that shared environment rather then genetic effects contributes to cartoon appreciation. Multivariate model-fitting confirmed that these data were best explained by a model that allowed for the contribution of the shared environment and random environmental factors, but not genetic effects. However, there did not appear to be a general humour factor underlying responses to all five cartoons and no effect of age was seen. The shared environment, rather than genetic factors, explains the familial aggregation of humour appreciation as assessed by the specific 'off the wall' cognitive type of cartoons used in this study.     

Support after perinatal death: a study of support and counselling after perinatal bereavement.

After an earlier study into the practical aspects of the management of perinatal death, a counselling service was introduced for parents whose baby had died in the perinatal period. The service was monitored, and the parents who received the service were compared with a group that did not. Fifty families were allocated randomly either to the counselling (supported) group or to the contrast group, who received routine hospital care. Assessment was carried out at six and 14 months after the death, using a semi-structured interview and two self-rating scales (the general health questionnaire and the Leeds scales). Two of 16 mothers in the supported group showed psychiatric disorder at six months, compared with 10 of 19 in the contrast group (p less than 0.01, Fisher''s exact test). There was no significant difference between the two groups at 14 months, when 80% of all the women studied had recovered psychiatric symptoms. Socially isolated women and those who marital relations lacked intimacy had a higher incidence of psychiatric symptoms at six months. Early pregnancy (within six months) was associated with a higher incidence of psychiatric symptoms in the unsupported group. The duration of bereavement reaction after perinatal death was appreciably shortened by support and counselling.     

Time trends in twin perinatal mortality in northern England, 1982-94. Northern Region Perinatal Mortality Survey Steering Group.

The dynamics of perinatal mortality rates (PNMR) and causes of death in twin pregnancies over 13 years in the Northern Region of the National Health Service in England is described. All twin perinatal deaths occurring between 1982-1994 were identified from the Northern Region Perinatal Mortality Survey. The twinning rate increased from 9.9 per 1000 maternities in 1982 to 12.0 in 1994. There was a total of 10,734 twin pregnancies and of these 421 resulted in 530 perinatal deaths. The perinatal mortality rate in twins significantly decreased over time (1982-87, 55.4 per 1000; 1988-94, 44.4 per 1000; P = 0.01). The PNMR was significantly higher for twins from like-sexed than from unlike-sexed pairs (53.5 and 34.4 per 1000 respectively, P < 0.001). Despite no improvement in birthweight distribution in the twin population, birthweight-specific perinatal mortality rates for both like and unlike-sexed twins decreased for each birthweight category in 1988-94 compared with 1982-87. Twins with very low birthweight (< 1500 g) comprised 69%, and preterm twins (< 37 completed weeks of gestation) 74.9% of all twin perinatal deaths. The major immediate cause of early neonatal death was pulmonary immaturity (63%); antepartum anoxia caused 76.9% of antenatal deaths. Unexplained preterm labour and intrauterine death were the leading obstetric factors underlying death in twins. Despite a decrease over the 13 years, the perinatal mortality rate in twins in the Northern Region remains high. Continued monitoring of trends in twinning and mortality rates is needed to inform health care planning.     

Specialized perinatal care: impact on perinatal mortality.

A neonatal intensive care unit was established at one hospital in 1972 when the neonatal mortality was 7.6 and the perinatal mortality 20.9 per 1000 deliveries. In 1973, with full operation of that unit and partial introduction of a high-risk pregnancy unit for fetal monitoring, the rates decreased to 6.4 and 14.9, respectively. With full operation of both units the rates decreased further, to 3.4 and 9.0 in 1974 and 3.8 and 8.9 in 1975. The frequency of cesarean section was 10.1% in 1972-73 and 11.6% in 1974-75. It is concluded that the centralization of obstetric and neonatal care, together with the development of qualified medical and nursing teams, had a major impact in reducing perinatal mortality, and that the frequency of cesarean section was not affected by the introduction of fetal monitoring, although the indications for this precedure became more specific.     

Hypertensive disease in twin pregnancies: a review.

Reports over the past seventy years show that twin gestations lead to an increased risk of hypertensive disorders. Numerous studies discuss the incidence of hypertensive disease in twin versus singleton gestations, as well as effects of parity, race, age, income level, smoking, zygosity and heritability on this condition. The range of relative risk of gestational hypertension, preeclampsia and eclampsia for twin compared to singleton gestations is 1.2 to 2.7, 2.8 to 4.4 and 3.4 to 5.1 respectively. Parity, African-American ethnicity, and young maternal age are all factors that increase the relative risk of acquiring hypertensive disease to 4.0, 1.8 and 1.5 in mothers of twin gestations. Factors such as maternal smoking, income level and zygosity have a negligible effect on the relative risk of acquiring hypertensive disease in twin gestations. In addition to twin mothers exhibiting a higher incidence of hypertensive disease compared to their singleton counterparts, they also exhibit an earlier onset of hypertensive disease at both 35 and 37 weeks of gestation comparatively. Uric acid levels measured at 30-31 weeks of gestation in twin mothers predicted the onset of preeclampsia with a sensitivity of 73% and a specificity of 74%. The range of risks presented in the literature is wide and the therapies avocated are diverse. We therefore decided to summarize the risks in a comparative fashion and to review current therapeutic strategies for the convenience of clinicians who confront increasing numbers of multiple pregnancies. The tables bring all recent published risks together in the first comparative analysis in which the data has been converted to relative risks and confidence intervals. Because the literature is relatively silent on specific management of hypertensive disease in twin pregnancies, general management recommendations for singleton gestations should be used by practitioners caring over twin gestations.     

Causal models of reading disability: a twin study.

The genetic and environmental relationships among measures of phoneme awareness, naming speed, Intelligence Quotient (IQ), and reading performance were investigated in 623 identical and fraternal twin pairs tested in the Colorado Learning Disabilities Research Center. A Cholesky decomposition analysis of these measures provided evidence supporting the double deficit hypothesis that difficulties in phonological processing and naming speed both contribute to reading disability. Additionally, the model revealed marginally significant genetic and significant non-shared environmental relationships between IQ and reading independent of naming speed and phoneme awareness. Thus a more complete causal model of reading disability should include IQ as well as measures of phonological processing and naming speed.     

Predictors of non-response to a questionnaire survey of a volunteer twin panel: findings from the Australian 1989 twin cohort.

Questionnaire surveys, while more economical, typically achieve poorer response rates than interview surveys. We used data from a national volunteer cohort of young adult twins, who were scheduled for assessment by questionnaire in 1989 and by interview in 1996-2000, to identify predictors of questionnaire non-response. Out of a total of 8536 twins, 5058 completed the questionnaire survey (59% response rate), and 6255 completed a telephone interview survey conducted a decade later (73% response rate). Multinomial logit models were fitted to the interview data to identify socioeconomic, psychiatric and health behavior correlates of non-response in the earlier questionnaire survey. Male gender, education below University level, and being a dizygotic rather than monozygotic twin, all predicted reduced likelihood of participating in the questionnaire survey. Associations between questionnaire response status and psychiatric history and health behavior variables were modest, with history of alcohol dependence and childhood conduct disorder predicting decreased probability of returning a questionnaire, and history of smoking and heavy drinking more weakly associated with non-response. Body-mass index showed no association with questionnaire non-response. Despite a poor response rate to the self-report questionnaire survey, we found only limited sampling biases for most variables. While not appropriate for studies where socioeconomic variables are critical, it appears that survey by questionnaire, with questionnaire administration by telephone to non-responders, will represent a viable strategy for gene-mapping studies requiring that large numbers of relatives be screened.     

Collaborative survey of perinatal loss in planned and unplanned home births. Northern Region Perinatal Mortality Survey Coordinating Group.

OBJECTIVE: To document the outcome of planned and unplanned births outside hospital. DESIGN: Confidential review of every pregnancy ending in stillbirth or neonatal death in which plans had been made for home delivery, irrespective of where delivery eventually occurred. The review was part of a sustained collaborative survey of all perinatal deaths. SETTING: Northern Regional Health Authority area. SUBJECTS: All 558,691 registered births to women normally resident in the former Northern Regional Health Authority area during 1981-94. MAIN OUTCOME MEASURE: Perinatal death. RESULTS: The estimated perinatal mortality during 1981-94 among women booked for a home birth was 14 deaths in 2888 births. This was less than half that among all women in the region. Only three of the 14 women delivered outside hospital. Independent review suggested that two of the 14 deaths might have been averted by different management. Both births occurred in hospital, and in only one was management before admission of the mother judged inappropriate. Perinatal loss to the 64 women who booked for hospital delivery but delivered outside and to the 67 women who delivered outside hospital without ever making arrangements to receive professional care during labour accounted for the high perinatal mortality (134 deaths in 3466 deliveries) among all births outside hospital. CONCLUSIONS: The perinatal hazard associated with planned home birth in the few women who exercised this option (< 1%) was low and mostly unavoidable. Health authorities purchasing maternity care need to address the much greater hazard associated with unplanned delivery outside hospital.