IN THE LIT

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

Psychic and social consequences of women in relation to memories of a stillborn child: a pilot study. Rådestad I, Steineck G, Nordin C, Sjögren B. Gynecol Obstet Inv 41:194-198, 1996; Psychological complications after stillbirth - influence of memories and immediate management: population based study. Rådestad I, Steineck G, Nordin C, Sjögren B. BMJ 312:1505-1508,1996.

These two manuscripts report portions of the same Swedish study. The first reports a pilot, involving 17 women who had delivered a stillborn, the purpose of which was primarily to see whether questionnaire inquiry will yield relevant information about the psychological processes surrounding stillbirth. Its most important finding, probably, is that women were not, at least in general, adversely affected by detailed questioning about events surrounding the death of their babies.

The second article is far more substantial and important. It relates results of a Swedish national population based questionnaire study which involved 380 mothers of stillborns and a similar number of controls (one of the few studies in which carefully matched controls were used). They assessed anxiety and other ‘adverse’ psychological features in women 2-3 years after the birth of a stillborn child. Furthermore, they then evaluated what, if any, intervention variables seem to correlate with (and so perhaps cause) persisting anxiety. Three of the assessed factors seemed to be significantly and independently correlated with lessening of persistent anxiety: •seeing the child for as long as she wished; •possessing tokens of remembrance (i.e. photos, ultrasound images etc.); •delivering within 24 hours of the time of the diagnosis of intrauterine death. The first two are expected and non-controversial. The third led the authors to recommend that early induction of labor be offered to all women in whom intrauterine death is recognized. That is quite discrepant from the routine in many birthing centers in this country, where, in general, physicians recommend that we "allow nature to take its course." I have been told that such a course is the safest and most prudent for the mother. Now, it seems, that prudence needs to be balanced with rather striking evidence of the psychological benefits of early delivery. We may review this controversy in depth in a future issue of WiSSPers.

Controlled prospective study on the mental health of women following pregnancy loss. Jannssen HJEM, Cuisinier MCJ, Hoogduin KAL, deGraauw KPHM. Amer J Psychiat 153:226-230, 1996.

This is another rather well designed European study of the psychological effects of stillbirth (this one from the Netherlands). It asks a simple question. We all "know" the answer. But this article contains some of the most rigorous supporting data to yet appear. The question is: will women who have had a pregnancy loss have more mental health complaints than will women who gave birth to a living child? Of course they will, we all "know". However, little in the way of controlled, reasonably designed study has been carried out and anecdotes can be wrong. Much to all of our relief, I suppose, this study shows that women suffering loss did show significantly greater intensity of depression, anxiety and somatization through 6 months following a loss. After 6 months, however, no such differences were found. So, grieving after intrauterine death is real, intense and appears to resolve, on average, between 6 months and a year after the loss. Quality data to support what all of us already "knew".

Revising psychoanalytic understanding of perinatal loss. Leon IG. Psychoanal Psychol 13:161-176, 1996.

Want a bitter laugh? Read the four basic tenets of psychoanalytic theory that have been used to formulate an understanding of perinatal loss: 1. Perinatal loss needn’t be mourned since the unborn baby is solely experienced as a fantasy of the mother; 2. Initially the pregnant woman equates the wished for baby with a penis (in keeping with Freud’s phallocentric orientation); 3. Perinatal loss results from (i.e. is caused by) unconscious conflicts and wishes of the mother; 4. Feelings of responsibility for the death arise mainly from unconscious ambivalence about the baby. Enough said? This seems to be a perfect formula for providing nothing that families need following the death of a baby. To his credit, Leon attempts to revise and modify these classic Freudian approaches in ways that at least might mean that psychoanalysts will have less probability to cause irrevocable harm. I wonder: Why bother? Why try to resuscitate a view which is so patently wrongheaded and for which there is not one iota of defensible data?

The Umbilical Cord: Obstetrically Important Lesions. Heifetz SA. Clin Obstet Gynecol 39:571-587, 1996.

Heifetz, a pediatric pathologist, reviews his own and others’ experience related to the pathology of the umbilical cord. This is a review, incorporating Heifetz’ generally conservative approach to attributing cause to obvious (but potentially trivial) cord features when an adverse outcome has arisen. I particularly appreciated his discussion of strictures of the umbilical cord, his recognition that most represent postmortem artifacts and his emphasis on strict criteria before they be pointed to as a cause of intrauterine death (see WiSSPers, volume 1, number 2 for a similar discussion); similar caution is applied when discussing, e.g. true knots and cord vessel thrombosis. Overall this is a reasonable summary for those wishing a single source for a pathologic orientation to assessing the cord, including following intrauterine death. It is not a good entré into the literature, however, being sparse in its citations and rather idiosyncratic even for those (23) citations that are provided.

Antiphospholipid Antibodies and Fetal Death. Oshiro BT, Silver RM, Scott JR, Yu H, Branch DW. Obstet Gynecol 87:489-493, 1996.

This is one example of a rather voluminous literature which has accumulated concerning maternal antiphospholipid antibodies (lupus anticoagulant activity and anticardiolipin antibodies) and intrauterine death. The authors rightly point out, however, that the literature has not adequately addressed specifically what kinds of intrauterine loss seem to be caused by these factors. This can lead to uncertainty about which patients should have such testing completed. Most would agree that a rather liberal approach to that testing is warranted given the potential for specific therapy in subsequent pregnancies, but does the character of the losses provide clues to the likelihood that such immune phenomena are causal? This group, from the University of Utah, asked what specific type of pregnancy losses were present in women with and without such antibody activity. They demonstrated that there is a marked excess of fetal (ž 10 weeks gestation) rather than embryonic losses in the antibody positive group. Women who had multiple early losses were only very rarely antibody positive. In fact the highest relative risks were with losses at 20 weeks gestation and beyond. Therefore, recurrent losses in the second or third trimester without other evident cause commend antiphospholipid antibody testing. Certainly other findings would lead to a higher level of suspicion of such antibodies, too, such as the presence of ischemia, infarction and/or thrombosis of the placenta.