Is it an abortion: Classification of pregnancy-ending interventions after 24 weeks in the presence of lethal fetal anomalies.

OBJECTIVE: To determine how obstetrician-gynecologists categorize pregnancy-ending interventions in the setting of lethal fetal anomalies. STUDY DESIGN: We conducted a sequential explanatory mixed methods study of U.S. obstetrician-gynecologists from May to July 2021. We distributed a cross-sectional online survey via email and social media and completed qualitative telephone interviews with a nested group of participants. We assessed institutional classification as induced abortion versus indicated delivery for six scenarios of ending a pregnancy with lethal anomalies after 24 weeks, comparing classification using McNemar chi-square tests with Benjamini-Hochburg correction for multiple comparisons with false discovery rate of 0.05. We performed thematic analysis of qualitative data and then performed a mixed methods analysis. RESULTS: We included 205 respondents; most were female (84.4%), had provided abortion care (80.2%), and were general OB/GYNs (59.3%), with broad representation across pre-Dobbs state and institutional abortion policies. Twenty-one qualitative participants had similar characteristics to the whole sample. Scenarios were classified as induced abortion by the majority of respondents, ranging from 53.2% for 32-week induction for anencephaly, to 82.9% for feticidal injection and 24-week induction for anencephaly. Mixed methods analysis revealed the relevance of gestational age (later interventions less likely to be considered induced abortion) and procedure method and setting (dilation and evacuation, feticidal injection, and freestanding facility all increasing classification as induced abortion). CONCLUSION: There is wide variation in classification of pregnancy-ending interventions for lethal fetal anomalies, even among trained OB/GYNs. Method, timing, and location of ending a nonviable pregnancy influence classification, though perinatal outcome is unchanged. IMPLICATIONS: The classification of pregnancy-ending interventions for lethal fetal anomalies after 24 weeks as indicated delivery versus induced abortion is reflective of sociopolitical regulatory factors as opposed to medical science. The regulatory requirement for classification negatively impacts access to care, especially in environments where induced abortion is legally restricted.

Strategies for obstetricians and gynecologists to advance reproductive autonomy in a post-Roe landscape.

The monumental reversal of Roe vs Wade dramatically impacted the landscape of reproductive healthcare access in the United States. The decision most significantly affects communities that historically have been and continue to be marginalized by systemic racism, classism, and ableism within the medical system. To minimize the harm of restrictive policies that have proliferated since the Supreme Court overturned Roe, it is incumbent on obstetrician-gynecologists to modify practice patterns to meet the pressing reproductive health needs of their patients and communities. Change will require cross-discipline advocacy focused on advancing equity and supporting the framework of reproductive justice. Now, more than ever, obstetrician-gynecologists have a critical responsibility to implement new approaches to service delivery and education that will expand access to evidence-based, respectful, and person-centered family planning and early pregnancy care regardless of their practice location or subspecialty.

Classification of periviable pregnancy-ending interventions for maternal life endangerment as induced abortion.

OBJECTIVES: To explore how US obstetrician-gynecologists (OB/GYNs) classify periviable pregnancy-ending interventions for maternal life endangerment. STUDY DESIGN: From May to July 2021, we performed an explanatory sequential mixed methods study of US OB/GYNs, recruited through social media and professional listservs. We administered a cross-sectional survey requesting institutional classification of labor induction or surgical evacuation of a 22-week pregnancy affected by intrauterine infection, using chi-square tests and logistic regression to compare determinations by physician and institutional factors. We then conducted semistructured interviews in a diverse nested sample to explore decision-making, merging quantitative and qualitative data in a mixed methods analysis. RESULTS: We received 209 completed survey responses, with 101 (48.3%) current abortion providers and 48 (20.1%) never-providers, and completed 21 qualitative interviews. Fewer than half of respondents reported that pregnancy-ending intervention for 22-week intrauterine infection would be classified as induced abortion at their institution (induction: 21.1%, dilation & evacuation: 42.6%, p < 0.001). In addition to procedure method, decision-making factors for classification as abortion included personal experience with abortion (with more experienced participants more likely to identify care as abortion) and state and institutional abortion regulations ("I have to call it a medical [induction]… I'm not allowed to use the word abortion"). CONCLUSIONS: Most OB/GYNs do not classify periviable pregnancy-ending interventions for life-threatening maternal complications as induced abortion, especially when physicians and institutions have less abortion expertise. Differential classification of pregnancy-ending care may lead to undercounting of later abortion procedures, masking the impact of abortion restrictions. IMPLICATIONS: Under unclear legal definitions, legislative interference, and administrative overreach, subjectivity in classification creates inconsistency in care for pregnancy complications. Failure to classify life-saving care as abortion contributes to stigma and facilitates restrictions, with increased danger and less autonomy for pregnant people.

Parental Perceptions of Counseling Regarding Interpregnancy Interval after Stillbirth or Neonatal Death.

OBJECTIVE: Although guidelines exist regarding optimal interpregnancy interval (IPI) after live birth, both optimal IPI and counseling regarding recommended IPI (rIPI) after stillbirth or neonatal death is not well established. Our goal was to describe the counseling bereaved parents receive regarding IPI, parents' reactions to that counseling, and actual IPI after loss. STUDY DESIGN: Bereaved parents who had a previous pregnancy result in stillbirth or neonatal death participated in a web-based survey. Questions included demographics, details of stillbirth or neonatal death, IPI counseling, and pregnancy after loss. Demographic information, rIPI, and ac'tual IPI were reported using descriptive statistics. The Wilcoxon's rank sum test was used to test the association between rIPI and mode of delivery. The Spearman's correlation was used to test the association between rIPI and maternal age. RESULTS: A total of 275 surveys were analyzed. Mean gestational age of stillbirth delivery was 33.1 (standard deviation: 6.6) weeks. A total of 29% delivered via cesarean. Median rIPI was 6 (interquartile ratio [IQR]: 2-9) months, with the primary reason for IPI reported as the need to heal (74%). Delivery via cesarean was associated with longer rIPI, 9 versus 4.2 months (p < 0.0001). Maternal age was not associated with rIPI. Of 144 people who pursued pregnancy again, median time until attempting conception was 3.5 (IQR: 2-6) months. Median actual IPI was 6 (IQR: 4-10) months. CONCLUSION: Bereaved parents receive a wide range of counseling regarding rIPI. The majority receive rIPI and pursue actual IPI shorter than current national and international recommendations for optimal IPI. KEY POINTS: · There is variation in IPI recommendation after stillbirth/neonatal death.. · Cesarean birth is associated with longer IPI recommendation, but maternal age is not.. · Median IPI after stillbirth or neonatal death was short: 6 (IQR: 4-10) months..

Society for Maternal-Fetal Medicine Special Statement: A critical examination of abortion terminology as it relates to access and quality of care.

Legal, institutional, and payer policies regulating reproductive health care lack a shared language with medicine, resulting in great confusion and consternation. This paper critically examines the implications and ramifications of unclear language related to abortion care. Using a case-based approach, we highlight the ways in which language and terminology may affect the quality and accessibility of care. We also address repercussions for providers and patients within their team, institutional, state, and payer landscapes. In particular, we explore the stigmatization of abortion as both a word and a process, the role of caregivers as gatekeepers, the implications of viability as a limit for access, and the hierarchy of deservedness and value. Recognizing the role of language in these discussions is critical to building systems that honor the complexities of patient-centered reproductive decision-making, ensure access to comprehensive reproductive health care including abortion, and center patient autonomy. Healthcare providers are uniquely positioned to facilitate institutional, state, and national landscapes in which pregnant patients are supported in their autonomy and provided with just and equitable reproductive health care.

Directly Measured Costs of Severe Maternal Morbidity Events during Delivery Admission Compared with Uncomplicated Deliveries.

OBJECTIVE: To estimate the actual excess costs of care for delivery admissions complicated by severe maternal morbidity (SMM) compared with uncomplicated deliveries. STUDY DESIGN: This is a retrospective cohort study of all deliveries between October 2015 and September 2018 at a single tertiary academic center. Pregnant individuals ≥ 20 weeks' gestation who delivered during a hospital admission (i.e., a "delivery admission") were included. The primary exposure was SMM, as defined by Centers for Disease Control and Prevention (CDC) criteria, CDC criteria excluding blood transfusion, or by validated hospital-defined criteria (intensive care unit admission or ≥ 4 units of blood products). Potential SMM events identified via administrative and blood bank data were reviewed to confirm SMM events had occurred. Primary outcome was total actual costs of delivery admission derived from time-based accounting and acquisition costs in the institutional Value Driven Outcomes database. Cost of delivery admissions with SMM events was compared with the cost of uncomplicated delivery using adjusted generalized linear models, with separate models for each of the SMM definitions. Relative cost differences are reported due to data restrictions. RESULTS: Of 12,367 eligible individuals, 12,361 had complete cost data. Two hundred and eighty individuals (2.3%) had confirmed SMM events meeting CDC criteria. CDC criteria excluding transfusion alone occurred in 1.0% (n = 121) and hospital-defined SMM in 0.6% (n = 76). In adjusted models, SMM events by CDC criteria were associated with a relative cost increase of 2.45 times (95% confidence interval [CI]: 2.29-2.61) the cost of an uncomplicated delivery. SMM by CDC criteria excluding transfusion alone was associated with a relative increase of 3.26 (95% CI: 2.95-3.60) and hospital-defined SMM with a 4.19-fold (95% CI: 3.64-4.83) increase. Each additional CDC subcategory of SMM diagnoses conferred a relative cost increase of 1.60 (95% CI: 1.43-1.79). CONCLUSION: SMM is associated with between 2.5- and 4-fold higher cost than uncomplicated deliveries. KEY POINTS: · Severe maternal morbidity as defined by CDC criteria confers a 2.5-fold increase in delivery hospitalization costs.. · Intensive care unit admission or ≥ 4 units of blood products confer a fourfold increase in cost.. · Costs of maternal morbidity may motivate SMM review..

Society for Maternal-Fetal Medicine Special Statement: Maternal-fetal medicine subspecialist survey on abortion training and service provision.

Following a collaborative workshop at the 39th Annual Pregnancy Meeting, the Society for Maternal-Fetal Medicine Reproductive Health Advisory Group identified a need to assess the attitudes of maternal-fetal medicine subspecialists about abortion services and the available resources at the local and regional levels. The purpose of this study was to identify trends in attitudes, beliefs, and behaviors of practicing maternal-fetal medicine subspecialists in the United States regarding abortion. An online survey was distributed to associate and regular members of the Society for Maternal-Fetal Medicine to assess their personal training experience, abortion practice patterns, factors that influence their decision to provide abortion care, and their responses to a series of scenarios about high-risk maternal or fetal medical conditions. Frequencies were analyzed and univariable and multivariable analyses were conducted on the survey responses. Of the 2751 members contacted, 546 Society for Maternal-Fetal Medicine members completed all (448 of 546, 82.1%) or some (98 of 546, 17.9%) of the survey. More than 80% of the respondents reported availability of abortion services in their state, 70% reported availability at their primary institution, and 44% reported provision as part of their personal medical practice. Ease of referral to family planning subspecialists or other abortion providers, institutional restrictions, and the lack of training or continuing education were identified as the most significant factors contributing to the respondents' limited scope of abortion services or lack of any abortion services offered. In the univariable analysis, exposure to formal family planning training programs, fewer years since the completion of residency, current practice setting not being religiously affiliated, and current state categorized as supportive by the Guttmacher Institute's abortion policy landscape were factors associated with abortion provision (all P values <.01). After controlling for these factors in a multivariable regression, exposure to formal family planning training programs was no longer associated with current abortion provision (P=.20; adjusted odds ratio, 1.34; 95% confidence interval, 0.85-2.10), whereas a favorable state policy environment and fewer years since the completion of residency remained associated with abortion provision. The results of this survey suggest that factors at the individual, institutional, and state levels affect the provision of abortion care by maternal-fetal medicine subspecialists. The subspecialty of maternal-fetal medicine should be active in ensuring adequate training and education to create a community of maternal-fetal medicine physicians able to provide comprehensive reproductive healthcare services.

Physiology of Fetal Heart Rate Monitoring.

Fetal heart tracings (FHTs) are useful as a window into the oxygenation status of the fetal brain. Patterns in the FHT reflect the oxygen status of the fetal brain. Fetal adaptive response to progressive hypoxemia and acidosis are detectable and produce recognizable patterns in the fetal heart rate. The basic physiology and adaptive responses that regulate the fetal heart rate and physiological fetal adaptations to stress as reflected in the FHTs are described. Mechanisms of oxygen delivery to the fetus including ways in which those mechanisms can be disrupted are reviewed.

Maternal Predictors of Disparate Outcomes in Children With Single Ventricle Congenital Heart Disease.

Background Significant variability in morbidity and mortality persists for children with functionally single ventricle congenital heart disease (SV-CHD) despite standardization in medical and surgical care. We hypothesized that maternal health factors may be associated with an increased risk of poor outcomes in children with SV-CHD. Methods and Results This retrospective, observational, cohort study included term maternal-infant pairs with a diagnosis of SV-CHD who underwent surgical palliation from 2006 to 2015 at Primary Children's Hospital. Pairs lacking maternal variables of interest or infant follow-up data were excluded. The association of maternal risk factors of abnormal pre-pregnancy body mass index, abnormal gestational weight gain (<7 or >20 kg), hypertensive disorders, and gestational diabetes mellitus with death/transplant and hemodynamics were analyzed using regression models. Of 190 infants, 135 (71%) maternal-infant dyads had complete data for inclusion. Death or transplant occurred in 48 infants (36%) during an average follow-up of 2.2 years (0.1-11.7 years). Abnormal gestational weight gain was associated with an increased risk of death and/or transplant in logistic regression (odds ratio, 3.22; 95% CI, 1.32-7.86; P=0.01), but not Cox regression (hazard ratio, 1.9; 95% CI, 1.0-3.7; P=0.055). Mean pulmonary artery pressures were higher in the setting of abnormal gestational weight gain (16.5±2.9 versus 14.7±3.0 mm Hg; P<0.001), and abnormal pre-pregnancy body mass index (15.7±3.5 versus 14.2±2.1 mm Hg; P<0.001) in the systemic right ventricle group. Conclusions Abnormal gestational weight gain (excessive or inadequate) is a novel risk factor for worse outcomes in SV-CHD. The fetoplacental environment may alter the trajectory of vascular development to impact outcomes in infants with SV-CHD.

Moms in medicine: Job satisfaction among physician-mothers in obstetrics and gynecology.

BACKGROUND: Physician satisfaction is linked to positive patient outcomes. Mothers form an increasing fraction of the obstetrics and gynecology (ob/gyn) workforce. OBJECTIVE: Define factors that affect physician satisfaction among ob/gyn physicians who are also mothers. METHODS: We constructed and validated a Redcap survey and invited members of online ob/gyn-mom groups to participate. Characteristics of participants' professional and personal lives were evaluated for possible association with the satisfaction outcomes. Comparison testing was performed using Chi-squared test or Fisher's exact test for categorical variables, Student's t-test for parametric variables, and Wilcoxon Rank-Sum test for non-parametric variables. RESULTS: Responses were received from 232 participants. A majority reported being unsatisfied with their time to spend with children (66%), partner (70%), and on personal hobbies/activites (75%). Eighty-percent rate professional morale as very/somewhat positive. Women who rated their morale as very/somewhat positive worked fewer hours per week than women with neutral/negative responses (43.6 vs 49.7, p = 0.01). Women with positive morale were also less likely to work over 50 h/week (39.5% vs 56.8%, p = 0.04). CONCLUSIONS: Ob/gyn physician-mothers have high professional morale but are dissatisfied with time for extra-professional activities. Longer clinical hours correlate with dissatisfaction based on several measurements.

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.

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.

Stillbirth gestational age as a predictor of recurrence risk.

OBJECTIVE: We evaluated risk of subsequent stillbirth (SB) according to gestational age at initial SB. STUDY DESIGN: We retrospectively reviewed a cohort of women delivering a singleton SB with at least one subsequent pregnancy. Relative risks (RRs) were calculated using an initial SB gestational age of 36 to < 40 weeks as the referent. Multivariable logistic regression accounted for potential confounders. RESULTS: In all, 2,887 mothers and 5,090 subsequent births met inclusion criteria. For the immediately next pregnancy, the linear trend for gestational age was not significant (RR 0.41; 95% confidence interval [CI] 0.03 to 5.53). However, women with index SBs occurring between 20 and 23(6/7) weeks' gestation had a RR for subsequent stillbirth of 2.9 (95% CI 1.2 to 7.1). When including subsequent pregnancies, the test for trend for gestational age was nonsignificant (RR 1.5; 95% CI 0.3 to 8.7). However, women suffering a stillbirth between 20(0/7) and 23(6/7) weeks' gestation in the index pregnancy had an almost threefold increase in the risk of subsequent stillbirth. Women suffering an index stillbirth between 28(0/7) and 31(6/7) weeks' and after 40 weeks' gestation had a 2.5- to 3.5-fold increased risk of subsequent SB. CONCLUSIONS: Gestational age at initial SB predicts risk of recurrent SB. This effect is most pronounced in women with very preterm or with postterm pregnancies.

Tachysystole in term labor: incidence, risk factors, outcomes, and effect on fetal heart tracings.

OBJECTIVE: Recent recommendations called for obstetricians to abandon the terms of "hyperstimulation" and "hypercontractility" in favor of the more rigidly defined term, "tachysystole" (TS). The aim of the current study is to describe incidence of and risk factors for TS, describe fetal heart rate (FHR) changes associated with TS, and investigate maternal and neonatal outcomes associated with TS. STUDY DESIGN: For this retrospective cohort study, we reviewed and analyzed the intrapartum FHR and tocometric characteristics of all patients with a singleton, nonanomalous fetus in term labor in a single hospital system over a 28-month period. Univariate association testing was done using χ(2) and t tests, comparing demographics, pregnancy characteristics, outcomes, and TS events. Multivariable association testing between risk factors and TS events were tested using generalized estimating equations, adjusting for multiple pregnancies during the study period for the same woman. RESULTS: There were a total of 50,335 deliveries from 48,529 women during the 28-month period. Of these, there were a total of 7567 TS events in 5363 deliveries among 5332 women. Use of oxytocin or misoprostol, an epidural, hypertension, and induction of labor were associated with an increased risk of TS. We found a doubling of TS events with any oxytocin, a dose-response correlation between oxytocin and TS, FHR changes occurring in a quarter of TS events and, finally, that presence of TS increases the chance of composite neonatal morbidity. CONCLUSION: TS is associated with specific risk factors and impacts FHR and neonatal morbidity.

Survey of physicians' approach to severe fetal anomalies.

OBJECTIVE: Standards of care regarding obstetric management of life-threatening anomalies are not defined. It is hypothesised that physicians' management of these pregnancies is variable and influenced by demographic factors. DESIGN: A questionnaire was mailed to members of the Society of Maternal-Fetal Medicine with valid US addresses assessing obstetric management of both 'uniformly lethal' (eg, anencephaly, renal agenesis) and 'uniformly severe, commonly lethal' (eg, trisomy 13 and 18) anomalies. Respondents were asked to answer as if not limited by state/institutional restrictions. Fisher's exact or χ(2) tests were used as appropriate and correction made for multiple comparisons in analyses that were not prespecified. RESULTS: The response rate was 36% (732/2038). Nearly 100% of respondents discuss termination for both uniformly and commonly lethal anomalies. In continuing pregnancies, with patient request for obstetric non-intervention 99% of providers would comply for either uniformly or commonly lethal anomalies. The majority 'encourage' such management, but some were non-directive or discouraged this management. In continuing pregnancies, with patient request for full obstetric intervention the majority of respondents was willing to comply for both uniformly (71%) and commonly (82%) lethal anomalies. While most practitioners 'discouraged' full intervention, some were non-directive or encouraged this management. Demographics and severity of anomaly influenced counselling. CONCLUSION: Discrepancies exist regarding the management of life-threatening fetal anomalies. Patients may be offered different options based on practitioner demographics. The majority of physicians comply with patient wishes. Differences were noted when comparing the management of lethal with that of severe commonly lethal anomalies, suggesting that practitioners make a distinction when counselling patients.

A case-control study of membrane cofactor protein mutations in two populations of patients with early pregnancy loss.

Mouse models have demonstrated a strong link between complement activation and pregnancy loss. The purpose of this study was to assess if mutations or polymorphisms in the complement regulatory gene membrane cofactor protein (MCP) are associated with recurrent miscarriage (RM) or sporadic fetal loss (FL). This was a case-control study comprising two different populations of cases and controls: subjects with recurrent miscarriage (RM) and controls and maternal-fetal pairs with early fetal loss (at 10-20 weeks' gestation) and controls. In the RM cases and controls, we studied maternal DNA extracted from either whole blood or saliva samples. In the FL cases and controls, fetal DNA was obtained from evacuated products of conception (cases) or cord blood (controls). Exons from the MCP gene, previously identified as having functional mutations, were amplified with flanking primers, purified, and sequenced. Sequences were analyzed against the published reference sequence, the presence of known mutations and polymorphisms and novel polymorphisms. We enrolled and obtained maternal DNA from 75 women with RM and 115 controls. In the FL group, we identified 33 cases and 37 controls. We detected the previously described A304V variant, but neither genotype nor allele frequencies differed significantly between cases and controls in any of the populations (RM, FL (maternal) or FL (fetal)). Although other variants and mutations in MCP were identified, no significant differences were found between the groups. Thus, we conclude that the A304V mutation in the MCP gene is not strongly associated with RM or FL.

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 κ coefficient for categorical variables or Kendall's τ-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 χ 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.

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.

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 patient's 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.