IN THE LIT

R. M. Pauli, MD, Ph.D.

Population-based recurrence risk of sudden infant death syndrome compared with other infant and fetal deaths. Øyen N, Skjærven R, Irgens LM. Am J Epidemiol 144:300-305, 1996.

It is refreshing to read an epidemiologic article that not only asks salient and relevant questions but is also well written and clear.

The authors use data from the extensive birth registry in Norway, and ask a series of questions regarding risks for recurrence of various kinds of perinatal and infant death. Some are directly relevant to questions surrounding stillbirth and will be addressed in this summary.

Since we often fail to find a specific cause for stillbirth, some health care workers and families have asked whether these might be analogous to sudden infant death syndrome. One way to help answer that question is to ask if occurrence of intrauterine death increases subsequent risk for SIDS in a next baby, and conversely. This article demonstrates that, while there is some suggestion of such a relationship, in fact, recurrence risk is far greater within every class of death examined than between such classes. That is, a late stillbirth increases most the risk for another late stillbirth, a SIDS death increases most the risk for another baby dying of SIDS and so forth. If there is an etiologic link between SIDS and stillbirth it is likely either a weak association or a rare event (or both).

Extensive data regarding recurrence risk for stillbirths are also presented within this article. These data allow another, independent assessment of recurrence risks following one stillbirth. Best previous estimates were that a couple who experienced one stillbirth would have about a 3% risk that a next pregnancy would also result in such an intrauterine death. In the current study, similar estimates can be generated for early stillbirths (16-27 weeks), late stillbirths (27 weeks and beyond) or for all stillbirths together. Taken as a whole, the data here show a population rate of about 8 per 1,000 (0.8%). In those who have had a prior stillbirth, the risk in the next pregnancy is about 45 per 1,000 (4.5%). That risk is greater following earlier gestation losses (before 27 weeks) than in later losses; in fact, for the later losses the risk for recurrence is almost precisely 3% — just as has been previously estimated. This is a nice confirmation of the empiric recurrence risks that can be used in counseling families — that if no specific diagnosis is found it is likely that, on average, the probability of recurrence of stillbirth, while modestly increased, if probably no greater than about a 3% risk in the next pregnancy.

Non-invasive perinatal necropsy by magnetic resonance imaging. Brookes JAS, Hall-Craggs MA, Sams VR, Lees WR. Lancet 348:1139-1141,1996 .

Many families decline to have an internal post-mortem evaluation completed after the stillbirth of their child. Often their reluctance is based upon religious belief, personal antipathy, incorrect counsel or a sense that little will be gained from such a violation of the baby’s body. So, while there is virtually universal consensus that perinatal autopsy is essential and should be completed in all babies, reality (in all western countries) is that fewer the 50% of all stillborn babies undergo pathologic autopsy. WiSSP has emphasized the utility of ancillary studies (e.g. photographs, clinical examination, xrays etc.) when an internal postmortem examination is not to be completed. This article extends that approach. The authors attempt to determine whether whole body magnetic resonance imaging might prove to be a useful option when internal examination is not allowed.

They assessed twenty infants by MRI (who then had standard pathologic autopsy) and compared the findings of MRI with necropsy findings. They found that most often MRI could detect major abnormalities. In most instances major diagnoses were similar. MRI was better at assessing central nervous system abnormalities; this is not surprising given the delicate nature of the fetal brain and the rapidity with which it undergoes macerative changes that make autopsy assessment challenging, if not impossible.

While this is not a particularly rigorous investigation (highly selected series, suspect diagnoses — e.g. how can hyaline membrane disease result in stillbirth, etc.) nonetheless it does suggest that MRI could be a reasonable alternative to internal post-mortem assessment. Cost and logistics are likely to keep this from becoming at all routine any time in the near future, however. Perhaps more relevantly, MRI could be the method of choice for assessing suspected central nervous system malformations. So, for example, it would be an excellent means of evaluating such lesions identified prenatally, for investigating possible brain anomalies in stillborns with midline facial abnormalities etc.

The psychological sequelae of miscarriage: a critical review of the literature. Frost M, Condon JT. Austral N Z J Psychiat 30:54-62, 1996.

This is a remarkably complete, sensitive and sensible review of the psychological consequence of early pregnancy loss. Appropriately the authors emphasize the features of grieving that are specific to miscarriage and highlight how such early losses may be different from other deaths (even from later intrauterine deaths).

As they note, loss of a pregnancy has become a more central experience in many families, not because it has increased in frequency (it hasn’t) but because as families become smaller, losses acquire greater significance. Nonetheless, miscarriage remains a situation for which many may continue to view the loss as an inconsequential occurrence with little psychological implication. That one article can comprehensively survey all of the literature concerning grief after miscarriage suggests that caring professionals have not attended to this loss particularly intensively either.

The authors (psychiatrists) emphasize a psychological construct through which the unusual features of grieving after miscarriage can be understood. Emotional turbulence surrounding early pregnancy includes the following: pregnancy may be a maturational crisis for the now pregnant woman; pregnancy may focus energies on previous unresolved conflicts (particularly with a woman’s own mother); pregnancy may result in marked enhancement of self esteem; pregnancy creates the role of mother to be as protector; pregnancy often results in feelings of ambivalence towards the developing baby. In early pregnancy loss, the baby is not yet viewed as independent of self, loss is then of part of oneself and that loss can be more troubling than later deaths because of the conflicts and ambivalence that may still predominate and the loss of self that it implies.

They list twelve factors that are unique (or at least more prominent) in the grief following miscarriage. These include, for example the absence of time for anticipatory grieving, the tendency for grieving to be done completely in private, the high levels of self-blame and self-anger that may be present, the greater feelings of ambivalence etc.

The authors do a fine job in synthesizing a coherent view of the literature that is available and in providing a critique of the problems that this literature contains. I appreciate good endings. This paper ends with a heartfelt and substantial summary: "The anguish of infertility, therapeutic abortion, spontaneous abortion and perinatal loss can be immense. Too often we overlook these losses and concentrate on the dynamics of living relationships. However for some women, the sorrow of that which was wanted but never realised is greater than the suffering associated with the living."