Cara Heuser

Mutations in Complement Regulatory Proteins Predispose to Preeclampsia: A Genetic Analysis of the PROMISSE Cohort

Jane Salmon and colleagues studied 250 pregnant patients with SLE and/or antiphospholipid antibodies and found an association of risk variants in complement regulatory proteins in patients who developed preeclampsia, as well as in preeclampsia patients lacking autoimmune disease.

Idiopathic recurrent pregnancy loss recurs at similar gestational ages

OBJECTIVE To determine whether a correlation exists between gestational ages of idiopathic recurrent pregnancy loss (iRPL). STUDY DESIGN Cohort of women with iRPL who had an initial loss (qualifying pregnancy [QP]) with precise documentation of gestational age. Outcomes in the immediate next pregnancy (index pregnancy [IP]) were compared between preembryonic (group I), embryonic (group II), or fetal (group III) losses in the QP. RESULTS Three hundred thirty-four women met inclusion criteria. In their IP, group I had 41% preembryonic, 28% embryonic, and 10% fetal losses. Group II had 14% preembryonic, 53% embryonic, and 9% fetal losses. Group III had 19% preembryonic, 23% embroyonic, and 29% fetal loses. Correlation coefficient for type of loss among the QPs and IPs was 0.14, P = .009. CONCLUSIONS Women with iRPL tend to have losses recur in the same gestational age period. Causes for RPL may be gestational age specific and should guide further investigations into causes.

Stillbirth workup and delivery management

Evaluation for etiology is vital in cases of stillbirth to facilitate emotional closure and for counseling regarding subsequent pregnancies. Patients should be treated in a sensitive manner and encouraged to allow an evaluation within the boundaries of their cultural and individual values. The most important components of this workup include a complete medical history, autopsy, placental pathology, and karyotype. Other tests that may be valuable include Kliehauer-Betke; antiphospholipid antibodies, parvovirus, and syphilis serology; toxicology; and indirect Coombs. Further testing should be guided by the clinical situation and medical history. Induction of labor using prostaglandins or oxytocin is the most common method of delivery. However, under some circumstances, dilation and evacuation is a safe alternative during the second trimester.

Correlation between stillbirth vital statistics and medical records

OBJECTIVE: Most data regarding conditions associated with or contributing to stillbirth are derived from fetal death certificates. Our purposes were to compare stillbirth data recorded in vital statistics with those in the medical record and to investigate whether diagnostic evaluations differed in tertiary care and community hospitals. METHODS: In this cross-sectional study, fetal death certificate data identified individuals with stillbirths delivering in eight Salt Lake City hospitals from 1998 to 2002. Medical records were reviewed to assess demographics, diagnostic evaluation, and potential causes of stillbirth. Data were compared between death certificates and the medical record by calculation of the &kgr; coefficient for categorical variables or Kendalls &tgr;-b coefficients based on the number of concordant and discordant pairs of observations for continuous variables. Diagnostic tests completed were compared between community and tertiary care hospitals with &khgr;2 or Fisher exact test. RESULTS: Five-hundred fifty-six individuals were identified, and 461 (83%) charts were available for review. Correlation between death certificates and the medical record was nearly perfect for demographic variables (correlation 0.8–0.9) but slight to moderate (correlation 0.2–0.5) for contributing or etiologic factors. Important diagnostic tests performed significantly more often in tertiary care than community hospitals included autopsy (35% compared with 13%, P<.01), karyotype (17% compared with 4%, P<.01), Kleihauer-Betke (22% compared with 13%, P=.01), toxicology screen (13% compared with 2%, P<.01), and complete blood count (95% compared with 90%, P=.03). CONCLUSION: There are important discrepancies between fetal death certificates and medical records. Complete work-up, review of the medical record, and efforts to increase accurate reporting may improve the accuracy of stillbirth vital statistics. Diagnostic evaluation was more extensive in tertiary care hospitals. LEVEL OF EVIDENCE: II

Diagnostic Tests for Evaluation of Stillbirth: Results From the Stillbirth Collaborative Research Network

OBJECTIVE To estimate the usefulness of each diagnostic test in the work-up for potential causes of stillbirth. METHODS A secondary analysis of 512 stillbirths enrolled in the Stillbirth Collaborative Research Network from 2006 to 2008 was performed. The Stillbirth Collaborative Research Network was a multisite, geographically, racially, and ethnically diverse, population-based study of stillbirth in the United States. Participants underwent standardized evaluations that included maternal interview, medical record abstraction, biospecimen collection, fetal autopsy, and placental pathology. Also, most participants had a clinical work-up that included karyotype, toxicology screen, syphilis serology, antibody screen, fetal-maternal hemorrhage testing, and testing for antiphospholipid antibodies as well as testing performed on biospecimens for research purposes. Previously, each participant had been assigned probable and possible causes of death using the Initial Causes of Fetal Death classification system. In this analysis, tests were considered useful if a positive result established (or helped to establish) this cause of death or a negative result excluded a cause of death that was suspected based on the clinical history or other results. RESULTS The usefulness of each test was as follows: placental pathology 64.6% (95% confidence interval [CI] 57.9-72.0), fetal autopsy 42.4% (95% CI 36.9-48.4), genetic testing 11.9% (95% CI 9.1-15.3), testing for antiphospholipid antibodies 11.1% (95% CI 8.4-14.4), fetal-maternal hemorrhage 6.4% (95% CI 4.4-9.1), glucose screen 1.6% (95% CI 0.7-3.1), parvovirus 0.4% (95% CI 0.0-1.4), and syphilis 0.2% (95% CI 0.0-1.1). The utility of the tests varied by clinical presentation, suggesting a customized approach for each patient. CONCLUSION The most useful tests were placental pathology and fetal autopsy followed by genetic testing and testing for antiphospholipid antibodies.OBJECTIVE To estimate the usefulness of each diagnostic test in the work-up for potential causes of stillbirth. METHODS A secondary analysis of 512 stillbirths enrolled in the Stillbirth Collaborative Research Network from 2006 to 2008 was performed. The Stillbirth Collaborative Research Network was a multisite, geographically, racially, and ethnically diverse, population-based study of stillbirth in the United States. Participants underwent standardized evaluations that included maternal interview, medical record abstraction, biospecimen collection, fetal autopsy, and placental pathology. Also, most participants had a clinical work-up that included karyotype, toxicology screen, syphilis serology, antibody screen, fetal-maternal hemorrhage testing, and testing for antiphospholipid antibodies as well as testing performed on biospecimens for research purposes. Previously, each participant had been assigned probable and possible causes of death using the Initial Causes of Fetal Death classification system. In this analysis, tests were considered useful if a positive result established (or helped to establish) this cause of death or a negative result excluded a cause of death that was suspected based on the clinical history or other results. RESULTS The usefulness of each test was as follows: placental pathology 64.6% (95% confidence interval [CI] 57.9-72.0), fetal autopsy 42.4% (95% CI 36.9-48.4), genetic testing 11.9% (95% CI 9.1-15.3), testing for antiphospholipid antibodies 11.1% (95% CI 8.4-14.4), fetal-maternal hemorrhage 6.4% (95% CI 4.4-9.1), glucose screen 1.6% (95% CI 0.7-3.1), parvovirus 0.4% (95% CI 0.0-1.4), and syphilis 0.2% (95% CI 0.0-1.1). The utility of the tests varied by clinical presentation, suggesting a customized approach for each patient. CONCLUSION The most useful tests were placental pathology and fetal autopsy followed by genetic testing and testing for antiphospholipid antibodies.

Radiographic and pathologic evaluation of idiopathic infantile arterial calcification.

BACKGROUND: Idiopathic infantile arterial calcification is a rare disorder that often results in fetal or neonatal demise. Few reports have detailed an early diagnosis, complete antenatal and postnatal imaging, and postmortem findings. CASE: A patient presented at 33 weeks of gestation with hydrops fetalis. Idiopathic infantile arterial calcification was diagnosed using a fetal echocardiogram, and fetal demise occurred shortly thereafter. A complete postmortem evaluation included radiography and pathology. The patients postpartum course was complicated by maternal respiratory distress and pulmonary edema. CONCLUSION: Finding calcified vessels in the context of fetal hydrops should lead one to consider idiopathic infantile arterial calcification. This diagnosis has important maternal and fetal implications. The detailed evaluation in this case is useful to clinicians in making a definitive diagnosis of idiopathic infantile arterial calcification. Clinicians should be aware that serious maternal complications can occur in these types of cases.

Non-anomalous stillbirth by gestational age: Trends differ based on method of epidemiologic calculation

Objective. The objective of the study is to compare gestational age specific rates, risks and prospective risks of stillbirth. Methods. A retrospective cohort study of women with a singleton non-anomalous pregnancy was conducted. Definitions were chosen to maintain consistency with previous literature. Results. Rate was highest at 20 weeks, nadired at 41 weeks and rose thereafter. Risk was low earlier in gestation, nadired at 29 weeks and rose with increasing gestational age. Prospective risk was highest at 20 weeks, nadired at 40 weeks and rose at 42 weeks. Conclusions. Differences in trends of stillbirth are noted depending on the calculation. All of these calculations are useful in clinical practice.

Stillbirth: the impact of antiphospholipid syndrome?

Fetal death resulting in stillbirth is generally acknowledged as a feature of antiphospholipid syndrome. Recently published studies appear to confirm the association between antiphospholipid antibodies (aPL) and stillbirth, though additional studies of better design would be welcome. Emerging evidence suggests that treatment with heparin agents and low dose aspirin to prevent fetal death is imperfect. New therapeutic approaches for patients with lupus anticoagulant or triple aPL positivity are needed.

Reproductive rights advocacy: not just for the family-planning community

Women and families benefit from access to the full spectrum of reproductive care, including family-planning services. We commend our family-planning colleagues on their tireless dedication to preserve the rights of women through advocacy. While several of our perinatology peers have also set an example by dedication to these issues, advocacy for patient access to reproductive care options has not been a focus of the larger perinatology community. The time has come for individual perinatologists, as well as the overall perinatology community, to join them and do the work needed to preserve access to safe care, including contraception and abortion services. In this call to action, we detail several ways that individuals and the community can become more involved in working for reproductive rights.