Challenges in classification and assignment of causes of stillbirths in low- and lower middle-income countries.

Stillbirths account for 2.6 million deaths annually. 98% occur in low- and lower middle-income countries. Accurate classification of stillbirths in low-resource settings is challenged by poor pregnancy dating and infrequent access to electronic heart rate monitoring for both the newborn and fetus. In these settings, liveborn infants may be misclassified as stillbirths, and stillbirths may be misclassified as miscarriages. Causation is available for only 3% of stillbirths globally due to the absence of registration systems. In low-resource settings where culture and autopsy are infrequently available, clinical course is used to assign cause of stillbirth. This method may miss rare or subtle causes, as well as those with non-specific clinical presentations. Verbal autopsy is another technique for assigning cause of stillbirth when objective medical data are limited. This method requires family engagement and physician attribution of cause. As interventions to reduce stillbirths in LMICs are increasingly implemented, attention to accurate classification and assignment of causes of stillbirth are critical to charting progress.

Early Pregnancy Losses: Review of Nomenclature, Histopathology, and Possible Etiologies.

Miscarriage is a frequent complication of human pregnancy: ∼50% to 70% of spontaneous conceptions are lost prior to the second trimester. Etiology of miscarriage includes genetic abnormalities, infections, immunological and implantation disorders, uterine and endocrine abnormalities, and lifestyle factors. Given such variability, knowledge regarding causes, pathophysiological mechanisms, and morphologies of primary early pregnancy loss has significant gaps; often, pregnancy losses remain unexplained. Pathologic evaluation of miscarriage tissue is an untapped source of knowledge. Although miscarriage specimens comprise a significant part of pathologists' workload, information reported from these specimens is typically of minimal clinical utility for delineating etiology or predicting recurrence risk. Standardized terminology is available, though not universally used. We reintroduce the terminology and review new information about early pregnancy losses and their morphologies. Current clinical terminology is inconsistent, hampering research progress. This review is a resource for diagnostic pathologists studying this complex problem.

Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE early pregnancy special interest group.

Pregnancy loss prior to viability is common and research in the field is extensive. Unfortunately, terminology in the literature is inconsistent. The lack of consensus regarding nomenclature and classification of pregnancy loss prior to viability makes it difficult to compare study results from different centres. In our opinion, terminology and definitions should be based on clinical findings, and when possible, transvaginal ultrasound. With this Early Pregnancy Consensus Statement, it is our goal to provide clear and consistent terminology for pregnancy loss prior to viability.

Anti-Müllerian hormone concentration as a biomarker of pregnancy success or failure.

OBJECTIVE: This study was conducted to determine serum anti-Müllerian hormone (AMH) concentration influence on pregnancy outcome. STUDY DESIGN: In this study we investigated sixty one infertile women (aged 27 to 44 years) who were diagnosed and treated between 2011 and 2013. We determine ovarian reserve measured by AMH concentration. Patients were divided in three groups according to their serum AMH concentration (<1 ng/ml; 1-2.5 ng/ml; >2.5 ng/ml respectively). We investigated the relationship between clinical pregnancy rate and AMH concentration. In addition, anti-thyroid antibodies (anti-TG and/or anti-TPO) positivity and insulin concentration were correlated with AMH level and pregnancy outcome in the study groups. RESULTS: We found no statistical differences between AMH concentration regarding number of pregnancies (42.3%; 41.1 %; 38.9% respectively in study groups; p>0.05). The miscarriage rate was highest in women with AMH>2.5 ng/mL (27.3%, 0%, 86% respectively in study groups; p>0.05). We found that anti-thyroid positivity is more frequent in women with lower AMH concentration (23.1%; 11.7%; 5.5% respectively; p>0.05) and patients with lower serum AMH had higher serum insulin concentration (p<0.05). CONCLUSIONS: It seems that AMH concentration might not reflect oocyte quality and the chance of pregnancy, but increased AMH concentration may be associated with negative pregnancy outcome. Moreover, it cannot be excluded that presence of anti-thyroid antibodies and increased insulin serum concentration may be connected to diminished ovarian reserve measured by AMH concentration.

Is there a relationship between maternal periodontitis and pre-term birth? A prospective hospital-based case-control study.

OBJECTIVE: The aim of this study is to verify the existence of an association between maternal periodontal disease and pre-term delivery in an unselected population of post-partum Turkish women. MATERIALS AND METHODS: This case-control study was conducted on 100 women who gave birth in either a special or a government maternity hospital. The case group consisted of 50 mothers who had delivered an infant before 37 weeks' gestation and weighed under 2500 g. The control group included 50 mothers who had given birth to an infant with a birth weight of more than 2500 g and a gestational age of ≥37 weeks. Data of mothers and infants were collected using medical registers and questionnaires. Clinical periodontal examinations were carried out in six sites on every tooth in the mother's mouth. A participant who presented at least four teeth with one or more sites with a PPD ≥4 mm and CAL ≥3 mm at the same site was considered to have periodontal disease. Statistical methods included parametric and non-parametric tests and multiple logistic regression analysis. RESULTS: There were no statistically significant differences between the cases and controls with regard to periodontal disease and pre-term delivery (OR = 1.48; 95% CI = 0.54-4.06). CONCLUSION: The findings indicated that maternal periodontitis was not a possible risk factor for pre-term delivery. Further studies with additional clinical trials are needed to explore the possible relationship between periodontal disease and pre-term birth.

Anomalías congénitas del útero / Congenital uterine anomalies (updated February 2013)

No disponible

Interleukin-6 level and gene polymorphism in spontaneous miscarriage.

The aetiology of spontaneous miscarriage, the most common pregnancy complication, remains undefined. One of postulated factors involved in miscarriage pathology is interleukin 6 (IL-6). Therefore, the aim of the study was to evaluate IL-6 and interleukin 6 receptor (IL-6R) gene polymorphisms in patients with spontaneous miscarriage. One hundred fifty-seven patients diagnosed with spontaneous miscarriage and age and gestational time matched controls were included in the case-control study. In all study participants circulating IL-6 levels (chemiluminescent immunoassay) and IL6-174G>C as well as IL6R rs2228145:A>C polymorphisms were evaluated. The distribution of IL6 as well as IL6R alleles and genotypes were similar in the controls and patients with miscarriage. Only a trend of more frequent appearance of -174GC+CC and C allele in the patients with miscarriage was noted. Blood serum concentrations of IL-6 were significantly elevated in patients with miscarriage vs those with physiological pregnancy. Likewise, IL-6 concentrations differ significantly with the types of miscarriage. The highest concentrations of the cytokine was seen in subjects with incomplete miscarriage (4.28 ± 4.88 pg/ml) followed by imminent miscarriage (2.97 ± 2.42 pg/ml), and then missed miscarriage (2.07 ± 1.90 pg/ml), being significantly the lowest in missed miscarriage group. No association between the IL6 genotype and IL-6 serum concentration were noted, both in the miscarriage group and in the control group. The findings of the study support the role of IL-6 in spontaneous miscarriage irrespectively of its type. However, no correlation between circulating IL-6 and IL6 gene polymorphism, as well as IL-6 and IL-6R polymorphisms associations with spontaneous miscarriage were revealed.

Nomenclature for pregnancy outcomes: time for a change.

Traditionally, obstetricians have grouped together all pregnancy losses before the mid-second trimester as spontaneous abortions. However, this nomenclature is arbitrary, outdated, and not clinically useful. Using this system, miscarriages due to genetic abnormalities, fetal deaths associated with abnormal placental growth and development, and spontaneous preterm births of liveborn fetuses at previable gestations are lumped together in a single category. In addition, the term abortion is fraught with emotional connotations for families suffering the loss of a pregnancy. Thus, whereas the existing classification for pregnancy loss has served a somewhat pragmatic role, it ignores precepts of developmental biology and the clinical realities of these adverse pregnancy outcomes. In this article, we propose a more useful nomenclature for pregnancy loss and preterm births that is informative and is based on developmental periods in gestation and shared pathophysiology.

Limitations of current definitions of miscarriage using mean gestational sac diameter and crown-rump length measurements: a multicenter observational study.

OBJECTIVES: There is significant variation in cut-off values for mean gestational sac diameter (MSD) and embryo crown-rump length (CRL) used to define miscarriage, values suggested in the literature ranging from 13 to 25 mm for MSD and from 3 to 8 mm for CRL. We aimed to define the false-positive rate (FPR) for the diagnosis of miscarriage associated with different CRL and MSD measurements with or without a yolk sac in a large study population of patients attending early pregnancy clinics. We also aimed to define cut-off values for CRL and MSD that, on the basis of a single measurement, can definitively diagnose a miscarriage and so exclude possible inadvertent termination of pregnancy. METHODS: This was an observational cross-sectional study. Data were collected prospectively according to a predefined protocol. Intrauterine pregnancy of uncertain viability (IPUV) was defined as an empty gestational sac or sac with a yolk sac but no embryo seen with MSD < 20 or < 30 mm or an embryo with an absent heartbeat and CRL < 6 mm or < 8 mm. We recruited to the study 1060 consecutive women with IPUV. The endpoint was presence or absence of a viable pregnancy at the time of first-trimester screening ultrasonography between 11 and 14 weeks. The sensitivity, specificity, positive and negative predictive values were calculated for potential cut-off values to define miscarriage from MSD 8 to 30 mm with or without a yolk sac and from CRL 3 to 8 mm. RESULTS: Of the 1060 women with a diagnosis of IPUV, 473 remained viable and 587 were non-viable by the time of the 11-14-week scan. In the absence of both embryo and yolk sac, the FPR for miscarriage was 4.4% when an MSD cut-off of 16 mm was used and 0.5% for a cut-off of 20 mm. There were no false-positive test results for miscarriage when a cut-off of MSD ≥ 21 mm was used. If a yolk sac was present but an embryo was not, the FPR for miscarriage was 2.6% for an MSD cut-off of 16 mm and 0.4% for a cut-off of 20 mm, with no false-positive results when a cut-off of MSD ≥ 21 mm was used. When an embryo was visible with an absent heartbeat, using a CRL cut-off of 4 mm the FPR for miscarriage was 8.3%, and for a CRL cut-off of 5 mm it was also 8.3%. There were no false-positive results using a CRL cut-off of ≥ 5.3 mm. CONCLUSIONS: These data show that some current definitions used to diagnose miscarriage are potentially unsafe. Current national guidelines should be reviewed to avoid inadvertent termination of wanted pregnancies. An MSD cut-off of > 25 mm and a CRL cut-off of > 7 mm could be introduced to minimize the risk of a false-positive diagnosis of miscarriage.

Can we communicate gravidity and parity better?

Communication of gravidity and parity is a typical part of any written or oral presentation related to an obstetric or gynecologic patient. The ostensible purpose of including this information at the beginning of a discussion of a woman's care is to provide a quick context of the patient from a reproductive standpoint. Unfortunately, the systems in use for describing gravidity, parity, and reproductive outcomes are without clear epidemiologic, biologic, or clinical basis. In description of parous events, births and abortions easily can be confused in the gray zone of 20 to 24 weeks, and terminology used often fails to take into account the clinical context. In this article, we discuss the pitfalls of current systems used for describing a woman's reproductive history and recommend new and simple nomenclature to enhance our ability to communicate properly.

[Quality monitoring based on data from the Danish National Patient Registry]. / Kvalitetsmonitorering ud fra data i Landspatientregisteret.

The Danish National Patient Registry (DNRP) was established in Denmark in 1976, and since then in accordance with current law, it has been collecting discharge diagnoses, surgical codes and recently also different diagnostic and treatment codes from all Danish hospitals. Besides being an administrative tool and a tool for epidemiological research through recent years, the DNPR has also supported national clinical quality databases. We report the experiences from a national quality control in Danish reproductive gynaecology based on data from the DNPR. We conclude that the NRP is a suitable tool for continuous clinical quality control, and discuss ways of improving the validity of DNPR data.

[Embryo and fetal pathology in routine diagnostics: what has changed and what needs to be changed]. / L'embrio-patologia e la patologia feto-perinatale nella diagnostica anatomo-patologica: cosa e cambiato e cosa e necessario cambiare.

The Authors have focused on the most important feto-neonatal and placental diseases in order to develop modern diagnostic tools which can meet the needs of clinicians (obstetricians, gynecologists, and neonatologists) for the best possible management of both the mother and the newborn. Although far from being operational instructions, it should be intended as a programmatic document providing a guideline on the issues that have cropped up in eight years of work of the APEFA group, as well as during several residential and practical classes. First of all, a synopsis is provided of the main issues concerning placental diagnosis in the newborn, as well as in case of fetal loss. A reasoned review is then provided of the main diagnostic criteria in placental pathology, in the light of therapeutical measures toward the mother (monitoring of future pregnancies) and the newborn (management of newborns at risk or with infectious disease). Legal issues in case of fetal distress at the end of pregnancy, neonatal damage and peripartum death have also been discussed with particular attention. Early and late miscarriages have also been separately examined, as well as fetal deaths. For each of these categories, a critical analysis is presented of current issues, followed by some considerations on the development of diagnostic methods and technology, and a modern diagnostic process is then outlined. Reference tables are also provided for diagnostic, auxological parameters, as well as on essential procedures. Issues concerning legal abortions and terminations of pregnancies have also been considered, with particular reference to tests and supplemental genetic and ultrasound examinations, diagnostic questions about malformations and forensic medicine assessments that are often involved with these specific categories. Malformations, fetal distress and growth retardation, sudden fetal and neonatal death, as well as embryo-pathology are all briefly dealt with also with synoptic tables. Diagnostic criteria are thus optimized and specially aimed at solving "human reproduction pathology" issues.

Terminology in early pregnancy loss: what women hear and what clinicians write.

OBJECTIVE: The Royal College of Obstetricians and Gynaecologists recommends that patient-focused terminology be used in early pregnancy care. The objective of the study was to evaluate whether inappropriate terminology is continuing to be used in Scottish gynaecology services. METHODS: A case note review (1259 records) and a patient survey (648 replies) assessed usage of four inappropriate terms ('abortion', 'blighted ovum', 'incompetent cervix' and 'pregnancy failure') in 18 Scottish hospitals providing secondary care to women with early pregnancy loss. RESULTS: Women reported hearing 'abortion' in 4.2% of hospital episodes (95% CI 2.9-6.0), but the term was used in 9.9% (95% CI 8.4-11.7) of hospital records. CONCLUSION: In order to meet national recommendations on terminology for early pregnancy loss, clinicians should not only say 'miscarriage' but also write it.

Incidencia de abortos en el Hospital Samuel Darío Maldonado (HSDM) de San Antonio estado Táchira: año 2003-2004 / Incidence of abortions in the Hospital Samuel Darío Maldonado (HSDM) of San Antonio of the state Táchira: years 2003-2004

En este trabajo se presenta una revisión de 2 años (2003-2004) de pacientes con diagnóstico de Aborto, ingresados al servicio de gineco-obstetricia del Hospital "Samuel Darío Maldonado" de San Antonio del Táchira, para determinar datos epidemiológicos e incidencia anual de los casos estudiados. Para tal fin, se diseño un estudio retrospectivo y comparativo, el cual reportó un total de 488 pacientes, de los cuales 236 pacientes corresponden al año 2003 siendo el grupo etáreo más afectado 30-38 años con un 37,29 por ciento y 252 pacientes corresponden al año 2004 cuyo grupo etáreo más afectado 21-29 años con un 34,8 por ciento. El aborto de tipo incompleto represénta la mayor prevalencia en ambos años con más del 60 por ciento de los casos

Vaginal bleeding in the first 20 weeks of pregnancy.

The first and foremost diagnosis to exclude in the pregnant patient presenting with vaginal bleeding is ectopic pregnancy. Once ectopic pregnancy is ruled out, miscarriage should be considered as a clinical spectrum. Its management is directed according to the integrity of the internal cervical os and patient hemodynamic status. Treatment with anti-D immune globulin is warranted for all Rh-negative patients. Urgent obstetric consultation is necessary for most miscarriage presentations.

A classification of pregnancy losses after invasive prenatal diagnostic procedures: an approach to allow comparison of units with a different case mix.

OBJECTIVE: Pregnancy loss rates after prenatal invasive procedures such as amniocentesis (Amnio), chorionic villous sampling (CVS) and fetal blood sampling (FBS) vary with an underlying indication for the procedure and due to different background risk of miscarriage. Loss rates need to be quantified and available for counselling. We developed a classification of pregnancy losses that will help in calculating procedure-related pregnancy loss rates and allow comparison between units with a different case mix. METHODS: The procedure-related pregnancy loss rate was obtained by subtracting the losses in pregnancies with known lethal conditions and those occurring more than two weeks after the procedure from total pregnancy losses. RESULTS: Out of 436 CVSs, there were 18 losses. Of these, 14 had a known lethal condition and 3 occurred after 2 weeks of CVS. In only one case, there was no known lethal abnormality and the loss occurred within 2 weeks. Thus, the total pregnancy loss rate was 4.1% and the procedure-related loss rate was 0.23% (95% CI; 0.0061-1.28). The procedure-related loss rates for Amnio 0.7% (95% CI; 0.2-1.8) and FBS 1.19 (95% CI; 0.14-4.23) were calculated in a similar way. CONCLUSIONS: We present a method of recording pregnancy loss after prenatal invasive procedures, which would be useful for benchmarking comparison between units and pre-procedural counselling.

Informe Trimestral del Departamento de Atención Integral de la Mujer Nicaragua 2001:: Evaluación trimestral de salud materna / Quarterly report of the department of comprehensive care to women, Nicaragua 2001: Assessment of maternal health quarterly

El Ministerio de Salud de Nicaragua a través del Departamento de Atención a la mujer presenta el porcentaje de captación temprana durante el primer trimestre del año 2001 en el país que es del 47%, registrandose un aumento del 2% en comparación al año2000 siendo lo normado un 60%. Los Silais de Chinandega, Masaya, Managua y Madriz donde se registra un mayor porcentaje en este período. Los Silais con mas bajas captaciones tempranas fueron: RAAN, Chontales y Jinotega, los que demandan mas esfuerzos en la atención temprana a la mujer embarazada para disminuir el riesgo ya que es una zona de limitado acceso geográfico. Se incluyen las estadisticas de la morbilidad relacionada con el embarazo por diferentes patologías; se menciona el porcentaje de la cobertura del parto intitucional y domiciliar ; las cesareas por Silais, cobertura de control puerperal ; los abortos segun grupos etareos , asi como las vigilancia de la mortalidad materna; causas obstetricas, procedencia de las muertes entre enero a marzo dle 2001.Al final se presenta la evaluación de los servicios de planificacion familiar; los servicios de detección precoz del Cancer cervico uterino y de mamas, se concluye con el número de defunciones por cancer del aparato reproductor femenino