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1. Conference
proceedings
The 2007 ISA Conference in
Birmingham in November was a great success.
Visit the ISA website (
www.stillbirthalliance.org
) and follow the link on the first page to access the Conference
Proceedings, General Assembly minutes and summaries of the scientific
meetings. These include a workshop on the definition of stillbirth,
protocols and investigations and classification systems.
2.
Overviews/Guidelines
Stillbirth. Gordon, C. Smith, S. Fretts,
R. (2007). The Lancet 370(9600): 1715-25
Stillbirths
account for 60% of all deaths during the period roughly defined as
starting 20 to 28 weeks prior to birth and 7 to 28 days after birth and
75% of all are potentially preventable losses. The rates of stillbirth
have slightly increased recently in England and Wales and the causes are
unknown.
This article aims to provide an overview of the causes
of stillbirth and to summarize present practice and future strategies to
reduce the number of stillbirths. The authors found that a systematic
approach to classification of stillbirths is a crucial step in design of
prevention strategies. A definitive classification system will continue
to be difficult until the unexplained causes for stillbirth can be
identified and risk factors can be isolated from actual causes.
Future work on population-based screening for stillbirth should be
preceded by high-quality, non-interventional prospective new methods of
risk assessment in an unselected population.
Pregnancy Loss and the Death of a
Baby: Guidelines for Professionals. SANDS UK.
The Sands
Guidelines are an essential benchmark for good practice when caring for
parents who have a childbearing loss at any stage during pregnancy, at
birth or shortly afterwards. This new edition of the Guidelines is
comprehensive and is rooted in principles of informed choice and of
parent-centred, individual care. It is based on research, on discussions
with many different health professionals and on parents’ perspectives.
To obtain a copy, visit www.fundraisingforsands.org where
copies for U.K. addresses can be purchased (£16.99) or email fundraising@uk-sands.org to find
out postage rates for your
country.
Understanding the Basics of
Stillbirth. An ISA wikipedia article.
The ISA Parent Advisory
Committee collaborated to write a short article about stillbirth for
Wikipedia and for the ISA website. These parent leaders from New
Zealand, Australia, Norway, England, and the US were led by Vicki
Culling, Sands NZ and Ros Richardson, SIDS and Kids
Australia.
This article gives a layman's overview of stillbirth
(a medical portion will be added soon) which addresses some of the key
choices parents should have when their baby dies. From creating memories
to autopsy and funeral, the importance of saying hello before saying
goodbye is emphasized. Involvement of all family members is encouraged
and a discussion of the natural grief response is also included. To read
the entire article visit : www.stillbirthalliance.org and follow the link on the first page.
3. Risk
factors/Causes
Reddy, U. (2007). “Prediction and
Prevention of Recurrent Stillbirth”. Obstetrics and Gynecology. 110 (5):
1151-1164
Stillbirth is one of the most common poor pregnancy
outcomes in the United States. This study looked at whether it is more
likely to occur in future pregnancies in women who have had one
previously. According to this study, a woman who has had a stillbirth is
2 – 10 times more likely to have another stillbirth if they have another
pregnancy. It concludes that growth restricted infants, maternal race,
and previous preterm and small for gestational age births are risk
factors for future stillbirths and pregnancy complications.
Redecha, P., R. Tilley, et al. (2007).
"Tissue factor: a link between C5a and neutrophil activation in
antiphospholipid antibody induced fetal injury." Blood Rev 110(7):
2423-31.
It is believed that antiphospholipid
antibodies (aPL) could lead to fetal loss due to clotting of placental
vessels. In a study using a mouse model of aPL antibody-induced
pregnancy loss, Redecha and others found that inflammation can affect
the development of the fetus. The authors found that either blocking or
genetically reducing tissue factor (TF), an inflammation producing
factor, prevented inflammation caused by aPL and pregnancy loss in mice.
This may assist in developing a new therapy to prevent pregnancy loss in
antiphospholipid syndrome.
Cundy, T., G. Gamble, et al.
(2007). "Differing causes of pregnancy loss in type 1 and type 2
diabetes." Diabetes Care 30(10): 2603-7.
Cundy and
others carried out a study to compare the differences in causes of
pregnancy loss in women with type 1 and 2 diabetes. The information was
collected over a 20-year-period from 1986 – 2005 from a single center
with a high rate of type 2 diabetes. The study found that while the
rates of pregnancy loss were similar, the causes of losses differed with
losses from Type 1 diabetes mostly due to congenital abnormalities and
prematurity, while for type 2 diabetes was more frequently associated
with stillbirth and chorioamnionitis. The authors suggest that other
conditions present in diabetes type 2 such as obesity, add to the risk
of stillbirth.
Bagga, R., N. Aggarwal, et al. (2007).
"Pregnancy complicated by severe chronic hypertension: a 10- year
analysis from a developing country." Hypertension in pregnancy 26(2):
139-49.
The objective of this study by Bagga et al was
to assess pregnancy outcome in patients with severe high blood pressure
(severe chronic hypertension). They looked at data from a north Indian
hospital from 1995-2004 and compared those findings with women who
presented with mild chronic hypertension to the pregnancy clinic. The
results suggest that preeclampsia (a condition in pregnancy where the
patient has high blood pressure and fluid retention), premature delivery
and death of the baby around the time of birth, was increased in
patients with long term hypertension when compared with those with mild
hypertension. Overall, women generally came to the clinic in their third
trimester of pregnancy, which made it difficult to see whether they had
high blood pressure before the pregnancy. Poor outcomes and problems
were more likely to occur in patients with severe chronic hypertension
rather than those with mild hypertension.
Silverman, J.
G., J. Gupta, et al. (2007). "Intimate partner violence and unwanted
pregnancy, miscarriage, induced abortion, and stillbirth among a
national sample of Bangladeshi women." Bjog 114(10):
1246-52.
This study, using the 2004 MEASURE Bangladesh
Demographic Health Survey, presented results suggesting that violence
within couples is extremely common in Bangladesh. It links this violence
to unwanted pregnancy and higher rates of pregnancy loss such as
miscarriage, induced abortion and stillbirth. The study recommends
investigating causes for these links to improve health for mothers and
their babies.
Kwak-Kim, J., S. K. Lee, et al. (2007).
"Elevated Th1/Th2 cell ratios in a pregnant woman with a history of RSA,
secondary Sjogren's syndrome and rheumatoid arthritis complicated with
one fetal demise of twin pregnancy." American journal of Reproductive
Immunology 58(4): 325-9.
Women with a history of miscarriage
and repeated failure of artificial insemination have been found to have
high levels of Th1/Th2 cytokine producing CD3(+) and CD4(+) cell ratios
(immune cells). In this case report, levels of these cells were found to
be increased 3 weeks before the loss of a twin during pregnancy, and
continued to get worse after. Due to this it is believed that the
placenta is not a factor in the Th1/Th2 immune response.
Pusl, T. and U. Beuers (2007). "Intrahepatic
cholestasis of pregnancy." Orphanet J Rare Dis 2:
26.
Intrahepatic cholestasis of pregnancy (ICP) is a disorder
characterised by itching starting in second or third trimester,
increased levels of liver enzymes and bile acid levels, and relief of
signs and symptoms (without assistance) within 2 – 3 weeks after
delivery. ICP increases the risk of premature delivery, slowing of fetal
heartbeat, fetal distress and stillbirth. Genetic, hormonal and
environmental factors are thought to contribute to ICP. The bile acid
ursodeoxycholic acid (10-20 mg/kg/d) is today regarded as the first
treatment for ICP. Delivery of the baby has been recommended in the 38th
week of pregnancy when lung maturity has been established.
Chigbu, C. O. and G. C. Iloabachie (2007). "The burden of
caesarean section refusal in a developing country setting." Bjog
114(10): 1261-5.
A study in 2 Nigerian hospitals including 62
women who declined caesarean sections was undertaken to investigate the
frequency, causes and outcomes of choosing not to have a caesarean
section. Information was gained via questionnaire and delivery outcomes
were compared with woman who accepted caesarean section. Results show
that there is a high level of caesarean section refusal in south-eastern
Nigeria relating to fear of death, economic reasons, desire to
experience vaginal delivery and inadequate counselling. The risk of poor
outcomes, including mortality for mothers and babies are higher for
women who decline caesarean sections in south-eastern
Nigeria.
Lansky, S., S. V. Subramanian, et al. (2007). "Higher
perinatal mortality in National Public Health System hospitals in Belo
Horizonte, Brazil, 1999: a compositional or contextual effect?" Bjog
114(10): 1240-5.
Brazillian authors Lansky and others
(2007) found that hospitals contracted to the National Public Health
System in Brazil are more likely to influence the risk of death of
babies around the time of birth. As most babies in Brazil are born in
public hospitals this is considered an urgent priority to assist in
reducing the rate of newborn and infant mortality.
Sibley, L.
M., T. A. Sipe, et al. (2007). "Traditional birth attendant training for
improving health behaviours and pregnancy outcomes." Cochrane Database
Syst Rev(3): CD005460.
Plain language summary extracted from
the Cochrane Library:
“Traditional birth attendant training for
improving health behaviours and pregnancy outcomes
In the
developing world, many women give birth at home assisted by family
members or traditional birth attendants (TBAs). TBAs lack formal
training and governments and other organizations have conducted training
programs to improve their skills. There is disagreement that these
training programs are effective. This review included four studies and
examined the effect of TBA training on TBA behaviour and on pregnancy
outcomes. We conclude that the potential of TBA training to decrease
newborn death is promising, when combined with improved health services.
The number of studies, however, is insufficient to provide the necessary
evidence for TBA training effectiveness”.
4.
Investigation/audit/classification
Please refer to:
Item 1. Conference proceedings for
abstracts and meeting summaries from the International Stillbirtth
Alliance 2008 Conference.
Item 2. Overviews/
Guidelines
5. Bereavement
Please refer to:
Item 1. Conference proceedings for
abstracts and meeting summaries from the International Stillbirtth
Alliance 2008 Conference; and
Item 2. Overviews/ Guidelines
6.
Intervention/Prevention
Crombleholme, T. M., D. Shera, et
al. (2007). "A prospective, randomized, multicenter trial of
amnioreduction vs selective fetoscopic laser photocoagulation for the
treatment of severe twin-twin transfusion syndrome." Am J Obstet Gynecol
197(4): 396 e1-9.
This article compares the use of fetal
laser therapy known as selective fetoscopic laser photocoagulation
(SFLP) (a procedure which seals the blood vessels that connect the
babies in the womb) and AR (serial amnioreduction) (repeated removal of
amniotic fluid) in pregnancies complicated with severe twin-twin
transfusion syndrome (TTTS). TTTS is a life threatening problem of
placental blood circulation which can occur in identical twins. While
there was no conclusion as to which therapy works better, the study
found that cardiomyopathy (a disease affecting the heart muscle) seems
to be important in the survival of twins with
TTTS.
Zhang, X., R. Platt, et
al. (2007). “The use of customised versus population-based birthweight
standards in predicting perinatal mortality.” BJOG 114(4):
474-7.
In a correspondence to the authors of the article
“The use of customised versus population-based birthweight standards in
predicting perinatal mortality” by Zhang et al, McCowan et al suggested
that the paper in question contained misleading information for clinicians. Both McCowan et al and
Gardosi et al question the conclusion by Zhang stating that ‘the large
increase in perinatal mortality risk among infants classified as SGA
based on customised standards is largely an artefact due to inclusion of
more preterm births’. The
consensus of both letters is that customised centiles identify an
increased proportion of preterm babies as SGA as they are at increased
risk of perinatal mortality, and this is an important advantage of
customised over population centiles. In addition, both letters
question the correctness of adjusting for gestational age when
calculating the adjusted odds of stillbirth, due to the fact that
gestational age is not a cause of
stillbirth.
References:
Gardosi, J., Clausson, B., Francis, A. (2007). “The use of
customised versus population-based birthweight standards in predicting
perinatal mortality.” BJOG 114 (10): 1301-2.
McCowan, L., Groom, K.,
Stewart, A. (2007). “The use of customised versus population-based
birthweight standards in predicting perinatal mortality.” BJOG 114(10):
1302-3.
Mahomed, K., Bhutta Z,
Middleton P. (2007). "Zinc supplementation for improving pregnancy and
infant outcome." Cochrane Database Syst Rev(2):
CD000230.
Plain language summary extracted form the Cochrane
Library:
“Taking zinc during pregnancy helps to slightly reduce
preterm births, but does not help prevent other problems such as low
birthweight babies
Many women of childbearing age may have mild
to moderate zinc deficiency. Low zinc levels may cause preterm birth or
they may prolong labour. It is also possible that zinc deficiency may
affect infant growth as well. The review of 17 trials, involving over
9000 women and their babies, found that although zinc supplementation
has a small effect on reducing preterm births, it does not help to
prevent low birthweight babies. Finding ways to improve women's overall
nutritional status, particularly in low-income areas, will do more to
improve the health of mothers and babies than supplementing pregnant
women with zinc”.
Fauveau,
V. (2007). "New indicator of quality of emergency obstetric and newborn
care." Lancet 370(9595): 1310.
The Lancet, Volume 370,
issue 9595 October 2007 includes a published letter by Vincent Fauveau
of the United Nations describing a new system of care for women and
babies during pregnancy. A new indicator – ‘the intrapartum case
fatality rate’ will be included in the new WHO guidelines on monitoring
the availability and use of obstetric services. Its aim is to address
the quality of care of the unborn or newborn baby, instead of just the
mother in emergency obstetric care The intrapartum case fatality rate is
the number of deliveries that result in stillbirth and deaths of
newborns which occur during the first 24 hours after birth). The author
outlines 3 main difficulties in collecting the
information:
- identification, reporting and recording of
very early neonatal deaths, as some woman only stay in the facility for
6 or 12 hours after the delivery. He suggests perhaps making the
definition of early neonatal deaths to those which happen within the
first 6 – 12 hours after birth.
- to make sure it is the quality of
obstetric care given and not risks due to the babies small size, he
proposes that data should only be used on babies weighing 2500g or more
(or 2000g where babies are all small).
- instead of identifying stillbirths by
presence of heart beats able to be heard at the beginning of labour, he
suggests examination of the fetus for freshness and absence of signs of
deterioration.
It is hoped people interested in this topic
will act as a team with each other and exchange information.
Duke, C. W., C. J. Alverson, et al. (2007). "Fetal death
certificates as a source of surveillance data for stillbirths with birth
defects." Public Health Rep 122(5): 664-9.
The quality of
data sources is important so that up to date and correct information is
available. This is demonstrated in the article by Duke and others (2007)
which examines whether fetal death certificates (FDC) and information on
the Metropolitan Atlanta Congenital Defects Program (MACDP) have the
same information. It was found that the majority of FDC’s were
identified within the MACDP’s and that stillbirth, birth defects and
autopsies were more likely to be issued an FDC.
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