IN THE LIT

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

The 'retrait préventif': An evaluation. McDonald AD. Canadian j pub health 85:136-139, 1994.

This is a fascinating, if not directly applicable, article. Did you know that in Quebec there is a law which requires either work place transfer or leave at 90% of regular salary for every pregnant woman who obtains a physician's statement that her regular work is physically dangerous to her unborn child? Or that nearly a third of all pregnant women took advantage of this option (most taking leave rather than reassignment)? Or that overall societal cost for the program (involving about 70,000 births per year) is now about $100,000,000.? This article summarizes an analysis of apparent work place risk factors and upon that job-specific risk evaluation superimposes an effort at cost-benefit analysis. The only factors identified as making a job risky in pregnancy were: a. a series of ergonomic measures (lifting heavy weights, marked physical effort, standing or walking 8 or more hours per day); b. some time-dependent measures (working more than 46 hours a week, changing shifts) and c. exposure to organic/volatile solvents. These factors were not associated with risk for birth defects but did seem correlated with risk for miscarriage or stillbirth. Many of you may have already guessed which occupation had the highest relative risk and contributed the most to estimated excess fetal deaths: nursing. In all, this analysis (with all of its questionable methods and assumptions) suggests that there are about 640 excess miscarriages and stillbirths (out of the approximately 85,000 births + miscarriages per year) attributable to occupational requirements. So, is this a justified and good law? First, the authors point out how costly it is -- even making the most forgiving assumptions, the province spends about $150,000 for every miscarriage prevented. Could those monies be more effectively used? Secondly, "the law inevitably invites discrimination against the employment of women of childbearing age which, although illegal, may be difficult to prevent."

Outcome of twin pregnancies complicated by a single intrauterine death: A comparison with viable twin pregnancies. Kilby MD, Govind A, O’Brien PMS. Obstet gynecol 84:107-109, 1994.

This analysis examines 20 twin pregnancies complicated by death of one co-twin (5.5% of all twin pregnancies) and compares them with 342 viable twin pregnancies, based on a five year consecutive experience in a single hospital, to assess what factors make the death of a twin more likely. Not too surprisingly there were two factors which were strongly correlated with fetal death of one twin. First, many more were in pregnancies with monochorionic placentae; such placentae only arise in identical twinning and this correlation then is simply another away of demonstrating that monozygotic twins are at high risk for death. Secondly, a quarter of the twins who died had (discordant) structural anomalies; these deaths, then, were likely not directly related to twinning per se but rather resulted from the birth defects present in one twin. The authors also assessed the living co-twins who were products of pregnancies with death of their twin sibling. Most required intensive care. One had evidence of a twin-twin transfusion. Two had significant neurologic sequelae. In summary, this study demonstrates once again that twins are at much greater risk to die in utero, that monozygotic twins are significantly more likely to suffer intrauterine death and that survivors of the death of one twin have increased likelihood of neonatal complications than do twins resulting from pregnancies in which both survive.

Risk factors for fetal death in white, black, and hispanic women. Copper RL, Goldenberg RL, DuBard MB, Davis RO, and the Collaborative Group on Preterm Birth Prevention. Obstet gynecol 84:490-495, 1994.

This analysis is of 403 stillbirths which occurred during the March of Dimes Preterm Birth Prevention Trial (34,350 births total). Measurable demographic features were then evaluated to see what factors are correlated with risk for stillbirth. Note that association does not mean cause! That is, while the identified factors might be used to identify women at higher risk, and may allow for generation of testable hypotheses regarding intervention, they say nothing about why those higher risks are present. Maternal characteristics associated with increased risk included black race; maternal age greater than 35 years; maternal obesity; single marital status; smoking. Maternal health conditions associated with risk for stillbirth included maternal hemoglobinopathy; Rh sensitization; documented maternal infection. Finally, obstetrical features included presence of abruptio placentae; history of previous preterm delivery; first trimester bleeding. The authors hypothesize that intrauterine infection, preterm labor and stillbirth may be different manifestations of a single underlying process. It is important to realize that one can not conclude from such a study of associations what interventions are going to make a difference.

Social isolation and support in pregnancy loss. Rajan L. Health visitor 67[3]:97-101, 1994.

This article provides a long review of the psychological manifestations and psychological needs of mothers following stillbirth. It also shows data derived from a larger study of post partum women. A couple of items were interesting to me. First, in assessing who was the most helpful at time of the pregnancy loss, 41% identified their partner (no surprise) and the second most frequently mentioned was their own mother (14%). We shouldn’t forget how important grandmothers can be in the grieving of their daughters. Secondly, mothers identified who had been most unhelpful at the time of their loss: all four highest ranks were health care providers… One other finding which, while not surprising, deserves reemphasis: "While it is understandable that others may not want to intrude into private grief, the overwhelming feeling of the mothers in this study was that they would have welcomed any attempt at sympathy or support." Well said.

Fathers, as is frequently the case, were not directly assessed.