Jane Zuccollo

Evaluation of sonographic diagnostic criteria for placenta accreta

To compare the diagnostic value of reported sonographic criteria for placenta accreta and to develop a composite score system for antenatal evaluation.

Association between maternal sleep practices and risk of late stillbirth: a case-control study

Objectives To determine whether snoring, sleep position, and other sleep practices in pregnant women are associated with risk of late stillbirth. Design Prospective population based case-control study. Setting Auckland, New Zealand Participants Cases: 155 women with a singleton late stillbirth (≥28 weeks’ gestation) without congenital abnormality born between July 2006 and June 2009 and booked to deliver in Auckland. Controls: 310 women with single ongoing pregnancies and gestation matched to that at which the stillbirth occurred. Multivariable logistic regression adjusted for known confounding factors. Main outcome measure Maternal snoring, daytime sleepiness (measured with the Epworth sleepiness scale), and sleep position at the time of going to sleep and on waking (left side, right side, back, and other). Results The prevalence of late stillbirth in this study was 3.09/1000 births. No relation was found between snoring or daytime sleepiness and risk of late stillbirth. However, women who slept on their back or on their right side on the previous night (before stillbirth or interview) were more likely to experience a late stillbirth compared with women who slept on their left side (adjusted odds ratio for back sleeping 2.54 (95% CI 1.04 to 6.18), and for right side sleeping 1.74 (0.98 to 3.01)). The absolute risk of late stillbirth for women who went to sleep on their left was 1.96/1000 and was 3.93/1000 for women who did not go to sleep on their left. Women who got up to go to the toilet once or less on the last night were more likely to experience a late stillbirth compared with women who got up more frequently (adjusted odds ratio 2.28 (1.40 to 3.71)). Women who regularly slept during the day in the previous month were also more likely to experience a late stillbirth than those who did not (2.04 (1.26 to 3.27)). Conclusions This is the first study to report maternal sleep related practices as risk factors for stillbirth, and these findings require urgent confirmation in further studies.

Maternal Perception of Fetal Activity and Late Stillbirth Risk: Findings from the Auckland Stillbirth Study

BACKGROUND   Maternal perception of decreased fetal movements has been associated with adverse pregnancy outcomes, including stillbirth. Little is known about other aspects of perceived fetal activity. The objective of this study was to explore the relationship between maternal perception of fetal activity and late stillbirth (≥28 wk gestation) risk. METHODS   Participants were women with a singleton, late stillbirth without congenital abnormality, born between July 2006 and June 2009 in Auckland, New Zealand. Two control women with ongoing pregnancies were randomly selected at the same gestation at which the stillbirth occurred. Detailed demographic and fetal movement data were collected by way of interview in the first few weeks after the stillbirth, or at the equivalent gestation for control women. RESULTS   A total of 155/215 (72%) women who experienced a stillbirth and 310/429 (72%) control group women consented to participate in the study. Maternal perception of increased strength and frequency of fetal movements, fetal hiccups, and frequent vigorous fetal activity were all associated with a reduced risk of late stillbirth. In contrast, perception of decreased strength of fetal movement was associated with a more than twofold increased risk of late stillbirth (aOR: 2.37; 95% CI: 1.29-4.35). A single episode of vigorous fetal activity was associated with an almost sevenfold increase in late stillbirth risk (aOR: 6.81; 95% CI: 3.01-15.41) compared with no unusually vigorous activity. CONCLUSIONS   Our study suggests that maternal perception of increasing fetal activity throughout the last 3 months of pregnancy is a sign of fetal well-being, whereas perception of reduced fetal movements is associated with increased risk of late stillbirth.

The Histopathology of Endocardial Sclerosis

This histological study of endocardial thickening in human hearts revealed that as in adult hearts, the proliferation in fetal, neonatal, and infant hearts consisted of collagen, elastin, and smooth muscle cells. Variation in severity from chamber to chamber and site to site indicated that severity is not an aging phenomenon and that predominantly local blood flow conditions determine localization and progression of proliferation. The similarity to endocardial thickening of cardiac valves and to intimal proliferation in blood vessels was remarkable. In old age and in chronic rheumatic heart disease the proliferation exhibited hyalinization, cell depletion, loss and fragmentation of elastin, lipid accumulation, and thrombosis, indicative of a similar pathogenesis to atherosclerotic changes in valvular endocardium and blood vessels. It was concluded that these chronic hemodynamically induced degenerative changes in the endocardium, including cardiac valves, should be classified as endocardial atherosclerosis analogous to that in arteries and veins and that severity is aggravated by high blood pressure, cardiac malformations, and dysfunction or damage caused by other disease processes.

The Auckland Stillbirth study, a case-control study exploring modifiable risk factors for third trimester stillbirth: methods and rationale.

Background:  In high‐income countries, stillbirth rates have been static in recent decades. Unexplained stillbirths account for up to 50% of these deaths.

Antenatal diagnosis of non‐previa placenta increta with histological confirmation

A 36-year-old woman, gravida 4 para 3, was referred to our unit at 20 weeks’ gestation because of a complicated obstetric history. She had had three previous vaginal deliveries, all of which had been associated with primary postpartum hemorrhage. In the second and third deliveries, the placenta was noted to be adherent at the third stage of labor. Manual removal of the placenta resulted in profuse hemorrhage, requiring massive blood transfusion and intensive care admission. In the third pregnancy, partial/focal placenta accreta was confirmed on histopathological examination of the placenta. On ultrasound examination in the current pregnancy (ATL HDI 5000, Philips, Bothell, WA, USA), the placenta was noted to be bilobed, with one lobe located posteriorly and the other anteriorly, and with the cord insertion between the lobes. Placental lacunae were not seen in the anterior lobe. However, tongues of placental tissue could be seen interrupting the placental–uterine wall interface in the anterior, lateral and posterior walls of the uterus (Figures 1 and 2a). Communicating vessels were seen running directly between the placental substance and the uterine musculature at these interface-interruption sites on Doppler examination of both posterior (Figure 2a) and anterior (Figure 2b) walls. Placenta increta was diagnosed. Since the couple had completed their family, an elective Cesarean hysterectomy was planned and this was performed uneventfully at 37 weeks’ gestation. The placenta was bilobed and adherent to the uterine wall both anteriorly and posteriorly, with histological evidence of increta. Abnormal placentation varies in the degree of myometrial invasion from placenta accreta, to increta and percreta. Detection rates recorded in the literature of antenatal sonographic detection of placenta accreta vary, ranging from 33% (4/12)1 to 100% (5/5)2. The diagnostic criteria suggested in the literature for the sonographic diagnosis of placenta accreta, increta or percreta include loss of hypoechoic retroplacental myometrial zone, presence Figure 1 On gray-scale ultrasound, the placental–uterine wall interface is interrupted by tongues (arrows) of placental (PL) tissue in the anterior (a) and lateral (b) uterine (UT) walls. L, left; LAT, lateral.

Antenatal care, identification of suboptimal fetal growth and risk of late stillbirth: findings from the Auckland stillbirth study

Stillbirth remains an important public health problem in Australia and New Zealand. The role that antenatal care plays in the prevention of stillbirth in high‐income countries is unclear.

A Case of Thanatophoric Dysplasia : The Early Prenatal 2D and 3D Sonographic Findings and Molecular Confirmation of Diagnosis

Objective: To present the early 2D and 3D ultrasound findings and the molecular confirmation in a case of thanatophoric dysplasia. Methods: On ultrasound examination, there was frontal bossing, increased nuchal translucency and short limbs at 12 weeks’ gestation and a small thorax and short and bowed long bones on 3D at 16 weeks. Amniocentesis and DNA analysis confirmed the mutation of FGFR3 gene indicating thanatophoric dysplasia. Results: After medical termination of pregnancy, the postmortem X-ray and pathology examination findings were consistent with the diagnosis. Conclusion: 3D anatomy scan and molecular confirmation may be helpful in early diagnosis and genetic counseling of thanatophoric dysplasia.

Forensic issues in cases of water birth fatalities.

Birth under water has become a widely disseminated technique that is promoted to improve the quality of labor. The case of a 42-week gestation male infant is reported who died of respiratory and multiorgan failure secondary to florid pneumonia and sepsis due Pseudomonas aeruginosa following a water birth. Other infants who have been delivered underwater have drowned or have had near-drowning episodes with significant hyponatremia and water intoxication. Local and disseminated sepsis has been reported, with respiratory distress, fevers, hypoxic brain damage, and seizures. There have also been episodes of cord rupture with hemorrhage. The postmortem investigation of such cases requires a complete autopsy of the infant, with examination of the placenta. Full details of the pregnancy and delivery and inspection of the birthing unit are also needed. A septic workup of the infant and placenta should be undertaken along with sampling of water from the birthing unit and microbiological swabbing of the equipment. Vitreous sodium levels may reveal electrolyte disturbances. While fatal cases appear rare, this may change if water births gain in popularity.

Can a pressure-limited vesico-amniotic shunt tube preserve normal bladder function?

INTRODUCTION We have previously shown that a vesico-amniotic shunt (V-A shunt) produces fibrotic bladders with poor compliance in normal fetal lambs. We hypothesized that using a ventriculo-peritoneal shunt (V-P shunt) as a V-A shunt in normal bladders may preserve the filling/emptying cycle and normal bladder development. MATERIALS AND METHODS The V-A shunting in normal fetal lambs was performed at 74 days of gestation using a V-P shunt (group A) and a free-draining shunt tube (group B). Sham-operated lambs were used as controls (group C). They were all delivered at term (145 days), and the pressure-volume curve, bladder volume, and histologic features of the bladder wall were compared. RESULT The mean bladder volume in group B (n = 5), 5 +/- 2.4 mL, was significantly smaller (P < .01) than that in group A (n = 6), 53 +/- 14 mL, and group C (n = 10), 57.3 +/- 12 mL. The bladder wall thickness in group A was 338 + 94.2 microm; group B, 741 +/- 128 microm; and group C, 374 +/- 120 microm. Group B bladders had very poor compliance with thick bladder wall (P < .01). Histologically, group B bladders showed prominent submucosal fibrotic change, but group A bladders were similar to controls. CONCLUSION This study shows that a pressure-limited shunt tube for V-A shunting preserves the normal fetal bladder development.