Intrauterine growth restriction and absent or reverse end-diastolic blood flow in umbilical artery (Doppler class II or III): A retrospective study of short- and long-term fetal morbidity and mortality.

OBJECTIVE: Absent or reverse end-diastolic flow (Doppler II/III) in umbilical artery is correlated with poor perinatal outcome, particularly in intrauterine growth restricted (IUGR) fetuses. The optimal timing of delivery is still controversial. We studied the short- and long-term morbidity and mortality among these children associated with our defined management. STUDY DESIGN: Sixty-nine IUGR fetuses with umbilical Doppler II/III were divided into three groups; Group 1, severe early IUGR, no therapeutic intervention (n = 7); Group 2, fetuses with pathological biophysical profile, immediate delivery (n = 35); Group 3, fetuses for which expectant management had been decided (n = 27). RESULTS: In Group 1, stillbirth was observed after a mean delay of 6.3 days. Group 2 delivered at an average of 31.6 weeks and two died in the neonatal period (6%). In Group 3 after a mean delay of 8 days, average gestational age at delivery was 31.7 weeks; two intra uterine and four perinatal deaths were observed (22%). Long-term follow-up revealed no sequelae in 25/31 (81%) and 15/18 (83%), and major handicap occurred in 1 (3%) and 2 patients (11%), respectively, for Groups 2 and 3. CONCLUSION: Fetal mortality was observed in 22% of this high risk group. After a mean period of follow-up of 5 years, 82% of infants showed no sequelae. According to our management, IUGR associated with umbilical Doppler II or III does not show any benefit from an expectant management in term of long-term morbidity.

Traffic-Related Air Pollution and Perinatal Mortality: A Case-Control Study

BACKGROUND: Ambient levels of air pollution may affect the health of children, as indicated by studies of infant and perinatal mortality. Scientific evidence has also correlated low birth weight and preterm birth, which are important determinants of perinatal death, with air pollution. However, most of these studies used ambient concentrations measured at monitoring sites, which may not consider differential exposure to pollutants found at elevated concentrations near heavy-traffic roadways. OBJECTIVES: Our goal was to examine the association between traffic-related pollution and perinatal mortality. METHODS: We used the information collected for a case-control study conducted in 14 districts in the City of Sao Paulo, Brazil, regarding risk factors for perinatal deaths. We geocoded the residential addresses of cases (fetal and early neonatal deaths) and controls (children who survived the 28th day of life) and calculated a distance-weighted traffic density (DWTD) measure considering all roads contained in a buffer surrounding these homes. RESULTS: Logistic regression revealed a gradient of increasing risk of early neonatal death with higher exposure to traffic-related air pollution. Mothers exposed to the highest quartile of the DWTD compared with those less exposed exhibited approximately 50% increased risk (adjusted odds ratio = 1.47; 95% confidence interval, 0.67-3.19). Associations for fetal mortality were less consistent. CONCLUSIONS: These results suggest that motor vehicle exhaust exposures may be a risk factor for perinatal mortality.

Risk factors for perinatal mortality in an urban area of Southern Brazil, 1993

INTRODUCTION: Although there was a considerable reduction in infant mortality in Pelotas, Rio Grande do Sul in the last decade, its perinatal causes were reduced only by 28%. The associated factors of these causes were analised. MATERIAL AND METHOD: All hospital births and perinatal deaths were assessed by daily visits to all the maternity hospitals in the city, throughout 1993 and including the first week of 1994. RESULTS: The perinatal mortality rate was 22.1 per thousand births. The multivariate analysis showed the following risk factors: low socioeconomic level, male sex and maternal age above 35 years . Among multigravidae women, the fetal mortality rate was significantly increased for mothers with a previously low birthweight and a previous stillbirth. For early neonatal mortality the risk was significantly increased by a smaller number of antenatal visits than 5 and low birthweight. CONCLUSIONS: Main risk factors for perinatal mortality: low socioeconomic level, maternal age above 35 years and male sex. For early neonatal mortality the risk was significantly increased by a smaller number of antenatal visits than 5 and low birthweight.

Trends in the modes of delivery and their impact on perinatal mortality rates

OBJECTIVE: To determine changes in the incidence of vaginal deliveries, cesarean sections, and forceps deliveries and their potential association with fetal, early neonatal, and perinatal mortality rates over time. METHODS: A retrospective study was carried out and the occurrence of deliveries supervised by university services between January 1991 and December 2000 was determined. Data regarding fetal, early neonatal, and perinatal deaths were assessed using obstetric and pediatric records and autopsy reports. RESULTS: Of a total of 33,360 deliveries, the incidence of vaginal deliveries, cesarean sections, and forceps deliveries was relatively steady (around 60, 30, and 10%, respectively) while, at the same time, there was a marked reduction in fetal mortality (from 33.3 to 13.0‰), early neonatal mortality (from 30.6 to 9.0‰), and perinatal mortality (from 56.4 to 19.3‰). CONCLUSIONS: The marked reduction in perinatal mortality rates seen during the study period without an increase in cesarean sections indicates that the decrease in perinatal mortality was not impacted by cesarean section rates. The plausible hypothesis seems to be that the reduction in perinatal mortality of deliveries performed under the supervision of university services was more likely to be associated with better neonatal care rather than the mode of delivery.

Risk-factors for antepartum fetal deaths in the city of São Paulo, Brazil

OBJECTIVE: To assess risk factors for antepartum fetal deaths. METHODS: A population-based case-control study was carried out in the city of São Paulo from August 2000 to January 2001. Subjects were selected from a birth cohort from a linked birth and death certificate database. Cases were 164 antepartum fetal deaths and controls were drawn from a random sample of 313 births surviving at least 28 days. Information was collected from birth and death certificates, hospital records and home interviews. A hierarchical conceptual framework guided the logistic regression analysis. RESULTS: Statistically significant factors associated with antepartum fetal death were: mother without or recent marital union; mother's education under four years; mothers with previous low birth weight infant; mothers with hypertension, diabetes, bleeding during pregnancy; no or inadequate prenatal care; congenital malformation and intrauterine growth restriction. The highest population attributable fractions were for inadequacy of prenatal care (40%), hypertension (27%), intrauterine growth restriction (30%) and absence of a long-standing union (26%). CONCLUSIONS: Proximal biological risk factors are most important in antepartum fetal deaths. However, distal factors - mother's low education and marital status - are also significant. Improving access to and quality of prenatal care could have a large impact on fetal mortality.

Fetal deaths in Brazil: a systematic review

OBJECTIVE To review the frequency of and factors associated with fetal death in the Brazilian scientific literature.METHODS A systematic review of Brazilian studies on fetal deaths published between 2003 and 2013 was conducted. In total, 27 studies were analyzed; of these, 4 studies addressed the quality of data, 12 were descriptive studies, and 11 studies evaluated the factors associated with fetal death. The databases searched were PubMed and Lilacs, and data extraction and synthesis were independently performed by two or more examiners.RESULTS The level of completeness of fetal death certificates was deficient, both in the completion of variables, particularly sociodemographic variables, and in defining the underlying causes of death. Fetal deaths have decreased in Brazil; however, inequalities persist. Analysis of the causes of death indicated maternal morbidities that could be prevented and treated. The main factors associated with fetal deaths were absent or inadequate prenatal care, low education level, maternal morbidity, and adverse reproductive history.CONCLUSIONS Prenatal care should prioritize women that are most vulnerable (considering their social environment or their reproductive history and morbidities) with the aim of decreasing the fetal mortality rate in Brazil. Adequate completion of death certificates and investment in the committees that investigate fetal and infant deaths are necessary.

Anti-60-kDa heat shock protein antibodies in fetal serum: a biomarker for unexplained small for gestational age fetuses.

Introduction: Small for gestational age (SGA) is an important problem affecting 10% of pregnancies and is associated with significant perinatal morbidity. In about 80% of cases, a probable etiology or a major risk factor can be identified. But almost 20% of SGA cases are considered unexplained. The 60-kDa heat shock protein (HSP60) is a highly immunogenic protein whose synthesis is greatly upregulated under nonphysiological conditions. Bacterial and human HSP60 share a high degree of sequence homology, and immunity to conserved epitopes may result in development of autoimmunity following a bacterial infection. We hypothesized that unexplained SGA could be the consequence of immune sensitization to human HSP60. Methods: Unexplained SGA fetuses were identified by ultrasound biometry with normal Doppler velocimetry and with no detectable maternal or fetal abnormalities. Fetal sera were obtained by cordocentesis performed for a karyotype analysis in cases of unexplained SGA (study group) or for screening of Rhesus incompatibility (control group). Fetal sera were tested for HSP60 antigen and for IgG and IgM anti-HSP60 by ELISA as well as for other immune and hematological parameters. Results: Maternal parameters were similar between the 12 study cases and the 23 control cases. The mean gestational age at cordocentesis was 29 weeks. IgM anti-HSP60 was detected in 12 cases (100%) and in no controls (p < 0.00017), while IgG anti-HSP60 was detected in 7 cases (58%) and only 1 control (p < 0.001). Three of the 4 cases with the highest IgM antibody levels died. There were no differences in fetal serum levels of HSP60 antigen or other immune and hematological markers between the two groups. Conclusion: Fetuses with unexplained SGA are positive for IgM and IgG antibody to human HSP60 and the specific IgM antibody level is predictive of fetal mortality. Detection of these antibodies indicates that a placental perturbation and a fetal autoimmune reaction to HSP60 are associated with this developmental delay.

The vulnerable male, or the sex ratio among fetal deaths in Brazil

Some studies indicate the existence of innate male vulnerabilities, especially during the perinatal period. The current study is a cross-sectional analysis of fetal mortality in Brazil according to sex from 2000 to 2009, stratified by maternal characteristics (age, schooling, and gestational age), using Ministry of Health data (DATASUS). The analysis included all fetal deaths from 2000 to 2009, except when the sex of the fetus was not recorded. The male/female sex ratio (SR) for all fetal deaths was 1.188. Analysis of maternal characteristics showed that the SR was statistically higher (p < 0.01) in mothers that were younger (10-14 years), had no formal schooling, and with gestational age < 22 weeks. The study showed a statistically higher-than-expected SR (p < 0.01) for 13 underlying causes of death and a lower SR for two others. The results suggest a potential innate male vulnerability.

Accounting for Fetal Death: Vital Statistics and the Medicalization of Pregnancy in the United States

Recent reports by the Centers for Disease Control and Prevention have decried the high rate of fetal mortality in the contemporary United States. Much of the data about fetal and infant deaths, as well as other poor pregnancy outcomes, are tabulated and tracked through vital statistics. In this article, I demonstrate how notions of fetal death became increasingly tied to the surveillance of maternal bodies through the tabulating and tracking of vital statistics in the middle part of the twentieth century. Using a historical analysis of the revisions to the United States Standard Certificate of Live Birth, and the United States Standard Report of Fetal Death, I examine how the categories of analysis utilized in these documents becomes integrally linked to contemporary ideas about fetal and perinatal death, gestational age, and prematurity. While it is evident that there are relationships between maternal behavior and birth outcomes, in this article I interrogate the ways in which the surveillance of maternal bodies through vital statistics has naturalized these relationships. Copyright 2013 Elsevier Ltd. All rights reserved.

Epidemiology of perinatal mortality: Birthweight, crown -heel length, gestational age, and weight -for -height

Studies suggest that slim infants (low weight-for-height) experienced higher mortality rates than average or high weight-for-height infants (Miller and Hassanein, 1973; Hoffman, Meirik, and Bakketeig, 1984). In this study, the 1980 National Natality Survey and the National Fetal Mortality Survey were used to examine the association of weight, height and perinatal mortality. All singleton births to white married mothers, between 18 and 34 years of age and of parity less than 4, for whom both mother's and hospital questionnaires were completed in those two surveys (3796 live births and 2043 fetal deaths) were selected for analysis. Overall, low weight and height infants had excess mortality rates. However, after adjustment for low birthweight and preterm birth status, low weight and height infants had only slightly higher mortality rates than their medium or high weight and height counterparts. The current study consists of relatively well-educated white married mothers of optimal reproductive age and low parity. Therefore, lower than expected mortality rates for slim infants may be attributed to these favorable demographic factors in this sample as compared with previous studies, or because of advances in perinatal medicine, slim infants may be prevented from achieving the high mortality seen in earlier studies. ^

Mortalidade fetal e infantil na cidade de Surubim, Pernambuco

Enquadramento: Com a redução global da mortalidade infantil no Brasil, o componente perinatal passou a exercer maior influência neste indicador, sendo necessário, portanto, um maior enfoque nas análises dessa componente. Objectivo: Levantar o perfil da mortalidade infantil e fetal e a evitabilidade destes óbitos, no município de Surubim, Pernambuco, no período de Junho de 2011 a Dezembro de 2014. Métodos: Estudo retrospectivo com enfoque descritivo, cuja a amostra foi de 56 óbitos investigados com base em 53 Fichas de Investigação da Secretaria de Saúde de Surubim. Este número corresponde a 66,66% dos casos entre 2011 e 2014 em fetos e menores de um ano, residentes de Surubim, Pernambuco. Utilizados como fontes de dados, os Bancos do Sistema de Informações sobre Mortalidade (SIM) e o Sistema de Informações sobre Nascidos Vivos (SINASC) do Ministério da Saúde (DATASUS), ambos com boa cobertura e qualidade satisfatória das informações, e Fichas usadas pelo Grupo Técnico de Investigação do Óbito do Município. Resultados: Em 2011, 23 óbitos (11 fetais e 12 infantis), 07 investigados, 1 fetal e 6 infantis; em 2012, 26 óbitos (12 fetais e 14 infantis), 23 investigados, 9 fetais e 14 infantis; em 2013, 17 óbitos (11 fetais e 6 infantis), 14 investigados, 9 fetais e 5 infantis; e em 2014, 19 óbitos (7 fetais e 12 infantis), 12 investigados, 4 fetais e 8 infantis. A Taxa de Mortalidade Infantil e Fetal para o período foi de 13,8/1000nv e 12,6/1000nv(2011), 15/1000nv e 13/1000nv(2012), 7/1000nv e 12,7/1000nv(2013),13/1000nv e 8/1000nv(2014)nv. 60,61% dos óbitos fetais e 91,3% dos óbitos infantis foram por causas evitáveis. Inconclusivos 06, não evitáveis 02 fetais e 07 Infantis. Conclusão:Consideram-se necessárias mudanças no processo de trabalho da equipe de saúde, capacitação da equipe multidisciplinar na perspectiva de trabalho colaborativo de maior equidade e efetividade clínica de forma a dotar a assistência à mulher fértil, à mulher grávida, à puérpera,ao feto e ao recém-nascido,com vistas à redução da mortalidade infantil e neonatal precoce por causas evitáveis. Palavras-chave: mortalidade infantil, mortalidade neonatal precoce, evitabilidade.

Efeitos da administração diária da associação estavudina/nelfinavir sobre os fetos e placentas da rata albina

OBJETIVO: avaliar o efeito da administração da associação estavudina/nelfinavir durante toda a prenhez da rata, avaliando seu peso e dos conceptos, bem como o número de implantações, fetos, placentas, reabsorções e mortalidades materna e fetal. MÉTODOS: quarenta ratas albinas EPM-1 Wistar, prenhes, foram aleatoriamente divididas em quatro grupos: GCtrl (controle do veículo) e três experimentais, ExpI, ExpII e ExpIII, que receberam, respectivamente, 1/40, 3/120 e 9/360 mg/kg por dia de estavudina/nelfinavir por via oral. As drogas e o veículo (água destilada) foram administrados por gavagem em duas tomadas diárias (12/12 horas), desde o dia 0 até o 20º dia da prenhez. No último dia do experimento, todos os animais foram anestesiados e eutanasiados. Foram avaliados a evolução do peso materno no 7º, 14º e 20º dias, número de fetos, placentas, implantações, reabsorções, óbitos intrauterinos, malformações maiores e o peso dos fetos e das placentas. A análise estatística foi realizada por análise de variância (ANOVA), complementada pelo teste de Kruskal-Wallis (p<0,05). RESULTADOS: em relação ao peso corporal das ratas, houve ganho gradual e progressivo durante o decorrer da prenhez em todos os grupos, sendo este ganho mais evidente no período final; porém não foram constatadas diferenças estatisticamente significantes entre eles. O número de fetos, placentas, implantações, assim como os pesos fetais e placentários também não mostraram diferenças estatisticamente significantes entre os grupos analisados. Não foram observadas, também nos grupos experimentais, reabsorções e malformações fetais maiores externas, no entanto, observamos entre o 8º e o 14º dias de gestação um caso de morte materna em cada grupo experimental. CONCLUSÕES: a administração da associação estavudina/nelfinavir não mostrou efeitos deletérios sobre os conceptos.

Declarações de nascidos mortos no município de São Paulo: avaliação descritiva do preenchimento

OBJECTIVES: to study the information contained in Stillbirth Registers (SBRs) in the Municipality of São Paulo. METHODS: the adequacy of the filling out of SBR forms was assessed on the basis of the SBRs (6722) made available by the FSEADE (Foundation for Statistical Data Analysis System), using a Data Completion Index (DCI), making it possible to compare the three years studied (2001-3). Variables relating to the mother and the fetus were included where the DCI was greater than 10%. Education, parity, place of residence, birth type, for the mother and weight, gestational age and underlying cause of death, for the fetus. RESULTS: the absolute stillbirth component changed little in the first two of the three years, falling slightly in the third. The variable most frequently registered was sex (98%), followed by place of residence (82.9%) and parity (70%). The data least often registered were those relating to the mother's age and schooling, 20.0% and 16.7%, respectively. The underlying cause was recorded in 46.7%, fetal weight in 37% and type of birth in 25.3%. CONCLUSIONS: the data demonstrate that the difficulty encountered in incorporating this health indicator into the traditional set of indicators is in part due to the inadequacy of the data provided on the SBR form.

Histopathological Changes in the Placentas and Fetuses of Mice Infected with Trypanosoma cruzi Isolated from the Myotis nigricans nigricans Bat

Histopathological changes and placental transmission were studied in the late stages of pregnancy in mice infected with a strain of Trypanosoma cruzi, isolated from a Myolis nigricans nigricans bat. Large amastigote nests were observed in uterine muscles, as well as in decidual and endothelial placental cells. In addition, persistent coagulative and fibrotic Vascular degeneration was observed. Large amastigote burdens were found in giant cells, spongioblasts and endothelial cells within the labyrinthine layer. Transplacental transmission was confirmed in 30% of the fetuses examined, in which amastrigote nests were seen only in striated muscle. During tire acute phase, intrauterine development was impaired as the result of parasitic invasion of the placenta, and fetal mortality rose to 10%. (C) 2008 Elsevier Ltd. All rights reserved.

Perioperative Temporary Occlusion of the Internal Iliac Arteries as Prophylaxis in Cesarean Section at Risk of Hemorrhage in Placenta Accreta

Purpose The purpose of this study was to describe the preliminary results of prophylactic temporary balloon occlusion of the internal iliac arteries for bleeding control in patients with placenta accreta during cesarean hysterectomy. Methods From May 2006 to March 2010, 21 patients diagnosed with placenta accreta using ultrasound and/or magnetic resonance imaging were submitted to prophylactic balloon occlusion before hysterectomy. Fluoroscopy, balloon occlusion time, surgical duration, intraoperative blood loss, transfusion volume, and procedure complications were analyzed. Results The mean age was 30.5 years with a mean of 3.6 previous gestations. Imaging studies revealed that all patients had placenta accreta and all were submitted to cesarean hysterectomy. One hysterectomy was due to previous diagnosis of fetal death and another due to cesarean with uterine curettage. Mean fluoroscopy time was 7.5 min, balloon occlusion time was 164 min, and surgery duration was 260 min. Estimated blood loss was 1,671.5 ml with mean reposition fluids of 3,538 ml of crystalloids, 309.5 ml of colloids, and 1.24 ml of packed red blood cells. Two patients were submitted to thromboembolectomy due to prolonged surgical time. There was no maternal or fetal mortality related to the procedure. Conclusions The results demonstrated that prophylactic balloon occlusion of internal iliac artery is a safe method and appears to reduce blood loss and transfusion requirements in patients diagnosed with placenta accreta who undergo cesarean hysterectomy. Antenatal imaging diagnosis of placenta accreta enables preoperative planning.