Pregnancy, antiseizure medications and unexplained intrauterine foetal death.

OBJECTIVE: To assess the role of antiseizure medication (ASM) regimens and other factors in relation to the occurrence of intrauterine foetal death (IUFD) in pregnant women with epilepsy (WWE) enrolled in the Raoul Wallenberg Australian Pregnancy Register of Antiepileptic Drugs (APR). RESULTS: IUFDs occurred in 70 (3.01 %) of 2,323 prospective pregnancies from WWE with known outcomes in the APR. Factors associated with IUFD occurrence included older maternal age, enrolment in the APR at an earlier stage of pregnancy, history of pregnancies which did not result in livebirths, parental history of foetal malformations, and maternal use of carbamazepine, lamotrigine or ethosuximide. Individual ASM dosages were not associated with IUFD occurrence. Relative to no exposure, the risk of IUFD increased with the increasing number of ASMs used in combination (2 ASMs: relative risk, RR = 5.45 [95 % CI: 0.73-41.80]; 3 ASMs: RR = 10.70 [95 % CI: 1.27-90.17]), >3 ASMs: RR = 10.70 [95 % CI: 1.27-90.17]), but this finding was attenuated after adjusting for other factors implicated in IUFD occurrence. Several ASM pairs were associated with an increased risk of IUFD relative to no exposure, but these associations were lost after accounting for confounders. CONCLUSIONS: Although it is possible that prenatal ASM exposure may increase the risk of IUFD, other non-pharmacological factors are more relevant to the occurrence to IUFD in pregnant WWE.

Maternal COVID-19 causing intrauterine foetal demise with microthrombotic placental insufficiency: a case report.

BACKGROUND: Pregnant women have an increased risk of getting infected with SARS-CoV-2 and are more prone to severe illness. Data on foetal demise in affected pregnancies and its underlying aetiology is scarce and pathomechanisms remain largely unclear. CASE: Herein we present the case of a pregnant woman with COVID-19 and intrauterine foetal demise. She had no previous obstetric or gynaecological history, and presented with mild symptoms at 34 + 3 weeks and no signs of foetal distress. At 35 + 6 weeks intrauterine foetal death was diagnosed. In the placental histopathology evaluation, we found inter- and perivillous fibrin depositions including viral particles in areas of degraded placental anatomy without presence of viral entry receptors and SARS-CoV-2 infection of the placenta. CONCLUSION: This case demonstrates that maternal SARS-CoV-2 infection in the third trimester may lead to an unfavourable outcome for the foetus due to placental fibrin deposition in maternal COVID-19 disease possibly via a thrombogenic microenvironment, even when the foetus itself is not infected.

Awareness of gestational diabetes mellitus foetal-maternal risks: an Italian cohort study on pregnant women.

BACKGROUND: Gestational diabetes mellitus (GDM) incidence is increasing worldwide. It represents a major risk factor for adverse foetal-maternal outcomes. Awareness among women in regard to GDM-related risks (in particular foetus ones) has been proven to have an impact on compliance with recommendations. Therefore we aimed to evaluate the efficacy of our post-diagnosis counselling, that informs affected women of the GDM related risks for complications, in determining an adequate level of understanding. METHOD: This is a cohort study involving 400 women undergoing the 24-28 weeks 75 g oral glucose tolerance test. Two hundred women diagnosed with GDM received the post-diagnosis counselling (treatment group) and two hundred women diagnosed without did not receive any counselling (control group). Both populations were surveyed with a 5 question questionnaire regarding their awareness about GDM foetal-maternal related risks. Their level of education about GDM foetal-maternal related risks, estimated according to the number of correct answers, was scored as: primary (score 0-1), secondary (score 2-3) or tertiary (score 4-5). RESULTS: Most of the women in the treatment group after receiving the post-diagnosis counselling have demonstrated a secondary level of education 132/200 (66%). Their mean level of awareness was higher in comparison to the control group 2.6 ± 1.8 (SD) versus 2.14 ± 1.8 (SD) p value = 0.012. In particular, they've demonstrated to be more aware of the risks for the foetus to become macrosomic (p = 0.004) or to die in utero (p = 0.0001). A high level of education and to have had previous pregnancies positively affected correct answers. CONCLUSIONS: Our post-diagnosis counselling has played a role in improving women awareness about GDM foetal-maternal related risks. Future study will explore the impact of women's level of awareness on glycaemic control.

Influence of indications on perinatal outcomes after radio frequency ablation in complicated monochorionic pregnancies: a retrospective cohort study.

BACKGROUND: Radiofrequency ablation (RFA) is recommended to prevent potential neurological injury or intrauterine foetal death (IUFD) of the co-twin(s) in complicated monochorionic (MC) pregnancies. However, the impacts of various indications on the pregnancy outcome following RFA remain unclear. This study aimed to determine how the indications influence the perinatal outcomes in complicated MC pregnancies undergoing radiofrequency ablation. METHODS: This was a retrospective cohort study performed in a single centre. All consecutive MC pregnancies treated with RFA between July 2011 and July 2019 were included. The adverse perinatal outcomes and the survival rate were analysed based on various indications. The continuous variables with and without normal distribution were compared between the groups using Student's t-test and Mann-Whitney U test, respectively, and for categorical variables, Chi-square and Fisher's exact tests were used. P < 0.05 indicated a significant difference. RESULTS: We performed 272 RFA procedures in 268 complicated MC pregnancies, including 60 selective intrauterine growth restriction (sIUGR), 64 twin-twin transfusion syndrome (TTTS), 12 twin reversed arterial perfusion sequence (TRAPs), 66 foetal anomaly and 66 elective foetal reduction (EFR) cases. The overall survival rate of the co-twin was 201/272 (73.9%). The overall technical successful rate was determined at 201/263 (76.7%). The IUFD rate in the co-twin was 20/272 (7.4%). The TTTS group had recorded the lowest survival rate (37/64, 57. 8%), and the survival rate was significantly correlated with Quintero stages (P = 0.029). Moreover, the sIUGR III subgroup had a lower survival rate compared with sIUGR II (55.6%, versus 84.3%). The subgroup of foetal anomaly of gastroschisis or exomphalos had the highest IUFD rate (4/10, 40%), followed by sIUGR III (2/9, 22.2%) and dichorionic triamniotic (DCTA) subgroup (8/46, 17.9%). In EFR group, eight IUFD cases were all coming from the DCTA subgroup and received RFA before 17 weeks. CONCLUSIONS: The perinatal outcome of RFA was correlated with the indications, with the lowest survival rate in TTTS IV and the highest IUFD incidence in abdominal wall defect followed by sIUGR III. Elective RFA after 17 weeks may prevent IUFD in DCTA pregnancies.

Serum mannose-binding lectin (MBL) concentrations are reduced in non-pregnant women with previous adverse pregnancy outcomes.

Mannose-binding lectin (MBL) is an important component of the innate immunity, and it is responsible not only for opsonization of micro-organisms, but also for efferocytosis. The aim of this study was to investigate whether MBL concentrations and lectin complement pathway activity are altered in non-pregnant women with previous adverse pregnancy outcomes. Patients were divided into four groups on the basis of their history of pregnancy complications, including control patients who had uncomplicated pregnancies and term deliveries (control, n = 33), and three groups of patients with a history of pregnancy complications, including preterm labour (n = 29), recurrent miscarriage (n = 19) or unexplained intrauterine foetal death (IUFD; n = 17). All women enrolled in the study had an interval of three to six months following their previous pregnancy, and they agreed to have a blood sample taken. We found significantly higher MBL concentrations and functional activity of the lectin complement pathway in healthy controls who had previous uneventful term pregnancies (1341 ng/mL; activity 100% (IQR: 62%-100%)), compared to women with the history of IUFD (684 ng/mL, P = .008; activity 8.5% (IQR: 0%-97.8%), P = .011), recurrent miscarriage (524 ng/mL, P = .022; activity 44% (IQR: 4%-83%), P = .011) or preterm labour (799 ng/mL, P = .022; activity 62.5% (IQR: 0%-83%), P = .003). Our results suggest that inadequate function of the complement lectin pathway is associated with a higher risk of preterm labour, recurrent miscarriage and unexplained intrauterine foetal death.

[The specificities of perinatal bereavement]. / Les spécificités du deuil périnatal.

Parents can be faced with a situation of bereavement during pregnancy or birth. It is often during a later pregnancy, an ultrasound scan or a subsequent birth, that some will talk about the loss of a child. These situations resulting in bereavement during pregnancy or perinatal bereavement are specific and all perinatal caregivers must be aware of them.

The psychosomatic experiences of women who had intrauterine foetal death in rural South Africa.

BACKGROUND:  Intrauterine foetal death (IUFD) is a traumatic event leading to substantial grief reactions with a variety of experiences in an expectant woman. After delivery, these experiences have shown to impact the mother's psychological well-being, where she experiences post-traumatic stress, sadness, anxiety and depression. The psychosomatic experiences before labour commenced are not known. OBJECTIVES:  This study explored the psychosomatic (mind-body connection) experiences of women who had an IUFD before labour commenced in rural areas of Limpopo province, South Africa. METHOD:  A qualitative approach with an explorative descriptive design was carried out among all 10 consented participants who were selected using a purposive sampling technique. The sample consisted of women who delivered an IUFD as reflected by the hospital register from the selected hospitals. Data were collected at the participants' homes through in-depth individual interviews guided by one open-ended central question as follows, 'Please share with me your experiences of IUFD before you went into labour', and analysed using Tesch's open coding method. RESULTS:  Two themes reflecting the psychosomatic (mind-body connection) experiences of women who had an IUFD emerged from the analysis. The themes are danger alerts and emotional responses. CONCLUSION:  This qualitative study revealed that women could relate a lack of or decreased foetal movement as the danger alert or warning sign that the baby was in danger before labour commenced. Upon noticing that something was wrong with the baby, a message was sent to the women's minds, which equally affected and activated their emotional dimensions. An investigation regarding the kind of support needed by women after being informed of an IUFD is recommended.

Effects of Intrahepatic Cholestasis on the Foetus During Pregnancy.

The most typical condition of the liver in pregnancy is intrahepatic cholestasis of pregnancy (ICP). There is the occurrence of itching/pruritus together with a decline in liver function tests (LFTs) and frequently higher blood levels of total bile acids, which are used to make the diagnosis. ICP often shows symptoms during the third term of pregnancy and sometimes in the second term. After delivery, the disease's symptoms disappear on their own. It is still unclear what causes this disorder. It constitutes a hazard for the infant and is exceedingly stressful for the mother. Although relatively harmless for the expectant mother, ICP poses a significant risk to the unborn child. Preterm birth, meconium excreted in the amniotic fluid, respiratory distress syndrome, foetal distress and abrupt intrauterine foetal death are all risks seen in this disorder. It is still challenging to identify foetuses who are at risk for ICP issues. There needs to be a clear consensus on the best obstetrical care for ICPs. This review is done to brief the research on the foetal consequences of ICP and to discuss treatment strategies for its avoidance. Serum alanine transaminase, aspartate transaminase, total bilirubin, alkaline phosphatase, albumin, direct bilirubin, total protein, and total bile acids were among the biochemical predictors. Blood tests that confirm obstetric cholestasis should alter the course of treatment. Ursodeoxycholic acid may be prescribed to affected individuals to cure itching and prevent the build-up of biliary components of maternal origin in the baby, which may increase the danger of foetal discomfort and stillbirth.

Transient gestational hypertension and pre-eclampsia: Two case reports and literature review on the need for stringent monitoring.

Transient gestation hypertension is a contributor to adverse pregnancy outcomes particularly when it progresses to pre-eclampsia (PE). This requires frequent monitoring. We illustrate the need for stringent monitoring of gestational hypertension, transient gestational hypertension (TGH) and PE without severe features and conducted a brief rapid review of the literature. Two cases are presented: Firstly, a 25-year-old primigravida at 30 gestational weeks who had an isolated TGH with high blood pressure (BP) of 141/87 mmHg, which was not investigated. Four weeks later, she presented with a BP of 202/128 mmHg, imminent eclampsia and intrauterine foetal death and had an uncomplicated induction of labour and delivered a 1400 g macerated male stillborn. Secondly, a 30-year-old primigravida at 30 gestational weeks who developed PE but her monitoring was compromised initially by inadequate healthcare capacity including unavailability of hospital bed-space for inpatient care and later by poor clinic attendance as a result of poor finances. At 32 gestational weeks, she presented with decreased foetal movement and was diagnosed as haemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome and intrauterine foetal death. She was stabilised, had induction of labour and delivered a 1400 g male macerated stillborn. Thereafter, the need for her to go home to complete the cultural burial rites of her baby and the pressure from her workplace resulted in an inadequate postpartum follow-up care. In conclusion, transient gestational hypertension is associated with adverse maternal and foetal outcomes, including foetal demise. Unavailability of hospital bed-space and poor personal finances interfere with stringent monitoring of hypertensive disorders and can be associated with adverse pregnancy outcomes. Stringent laboratory monitoring in these cases is defined by the authors as testing at least blood levels of serum Creatinine, Haemoglobin concentration, Alanine transaminase and Platelet count (abbreviated as 'CHAP') weekly.

Current Practices of Cervical Ripening and Induction of Labour in Intrauterine Foetal Demise: An Observational Study.

BACKGROUND: Objectives of the current study were to find the most effective method of induction of labour in case of intrauterine foetal death (IUFD), with efficacy described as least induction-to-delivery time, and the agent with the best safety profile, i.e. least maternal complications. METHODS: This was a prospective observational descriptive study carried out between January and November 2015 in a tertiary care centre. Hundred consecutive cases of IUFD after 20 weeks of gestation requiring induction of labour and fulfilling inclusion criteria were selected. The method of induction decided by each consultant was noted, and results were analysed. As this was a purely observational study, all agents used for induction of labour (misoprostol, dinoprostone gel, intracervical Foley catheter) and all dose variations were included. RESULTS: The induction-to-delivery interval was shortest with dinoprostone (12.52 h) followed by Foley catheter (13.28 h) and misoprostol (15.82 h). However, the p value (0.301) was not statistically significant. Misoprostol was used more often in second trimester, while dinoprostone gel was most commonly used in third trimester. Failure occurred in 3 cases; all required lower segment caesarean section (LSCS). No significant complications were associated with any of the methods. CONCLUSIONS: Dinoprostone gel, misoprostol and Foley catheter are safe for induction of labour in all cases of IUFD, even for those with previous LSCS with IUFD.

Comparison of risk factors and perinatal outcomes in early onset and late onset preeclampsia: A cohort based study in Reunion Island.

Clinical differences, maternal risk factors and pregnancy outcomes of deliveries complicated by early- (delivery<34 weeks) and late-onset (delivery≥34 weeks) preeclampsia were studied in a cohort of women in Reunion Island during 15 years (period 2001-2015; N=62,230 pregnancies). The overall preeclampsia rate in singleton pregnancies was 2.37%. Early- and late-onset preeclampsia rates were 0.75% and 1.5% respectively, and the trend for each type of disease was stable over time. In both form of preeclampsia, smoking during pregnancy was a protective factor and associated risk factors were: older age, primiparity, pre-existing diabetes, chronic hypertension, higher pre-pregnancy body mass index and obesity, infertility treatment, history of renal disease and hypercholesterolemia (all p<0.05). The rate of caesarean section, medically-induced delivery and impaired foetal and neonatal outcomes were significantly higher in preeclamptic women (all p<0.0001). When comparing early- versus late-onset preeclampsia, the only difference was the older maternal age in primiparae with early-onset preeclampsia (p=0.02), and the two groups of preeclamptic women were similar in terms of maternal risk factors, with the exception of higher rates of chronic hypertension in early-onset preeclampsia (p=0.02). Foetal and neonatal outcomes were evaluated after adjustment for gestational age at delivery and no difference was detected between early- and late-onset preeclamptic women. These analyses failed to identify a specific phenotype of preeclampsia in terms of predisposition or pre-existing risk factors for one form or another. Gestational age at delivery was the most important predictor for offspring outcome.

Umbilical Cord Haematoma Causing Still Birth- A Case Report.

Still birth continues to be one of the many challenges that an obstetrician has to face. Still births that occur in the antenatal period are more difficult to explain than that which occurs intrapartum. The latter is most often due to intrapartum asphyxia, medical complications or infections; however a cause for antenatal still birth is difficult to ascertain. A thorough examination of the case along with necessary investigations might not necessarily reveal any cause and this leads to considerable anxiety for both the mother and the treating obstetrician. In the investigation of a case of still birth a detailed examination of the placenta and cord has to be emphasised as a considerable number of still births that are thought to be unexplained may be attributable to placental or cord pathologies. Here we present one such case where an umbilical cord haematoma resulted in intrauterine foetal death.

Incidence of anticardiolipin antibodies and lupus anticoagulant factor among women experiencing unexplained recurrent abortion and intrauterine fetal death.

The aim of this research study was to estimate anticardiolipin (IgG & IgM) antibodies (aCL) and lupus anticoagulant (LA) factor in patients of recurrent unexplained pregnancy loss and intrauterine fetal deaths (IUFD). 82 women were selected for this study by virtue of having more than two consecutive unexplained pregnancy losses in their first trimester and were referred by the department of Obstetrics and Gynecology, King Saud Medical City Hospital, Riyadh, KSA. All patients had gone through a standardized investigation sequence. Lupus anticoagulants and Anticardiolipin antibodies (IgM and IgG) were detected in the serum by the enzyme linked immunosorbent assay method. To check the significance of aCL and LA, two-tailed t-test was done. Non parametric data was calculated either by Chi-Square test or Fischer exact test when relevant. Total 82 females grouped as 52 cases of recurrent (≥2) mainly first and second trimester miscarriage and 30 cases of recurrent (≥2) late intrauterine fetal death. Lupus anticoagulants was observed in twenty one (21) cases (25.6%) while anticardiolipin antibodies IgM and or IgG positive cases were estimated in forty four (44) cases (53.65%). The prevalence of APS in both studied group was thirty five (35) cases (42.68%). Antiphospholipid antibodies are calculated as the most important reason for recurrent abortion. The patients with unexplained recurrent pregnancy loss must be advised to go for a screening test for all this aPL antibodies.