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The loss of a child is unlike any other, and the impact that it has on the mother, the father, their family, and their friends is devastating--a shockwave of pain and guilt that spreads through their entire community. But the majority of those affected, especially mothers, often suffer their pain in silence, convinced that their grief and trauma is theirs to bear alone. This anthology of raw memoirs, heartbreaking stories, truthful poems, beautiful painting, and stunning photography from the parents who have suffered child loss offers insight into this unique, devastating and life-changing experience--breaking the silence and offering a ray of hope to the many parents out there in search of answers, understanding, and healing.

Congenital cytomegalovirus infection is a cause of serious perinatal complications. In this randomized trial involving 399 pregnant women, CMV hyperimmune globulin was found to provide no benefit with respect to congenital CMV infection or perinatal death.

2·6 million pregnancies were estimated to have ended in stillbirth in 2015. The aim of the AFFIRM study was to test the hypothesis that introduction of a reduced fetal movement (RFM), care package for pregnant women and clinicians that increased women's awareness of the need for prompt reporting of RFM and that standardised management, including timely delivery, would alter the incidence of stillbirth. This stepped wedge, cluster-randomised trial was done in the UK and Ireland. Participating maternity hospitals were grouped and randomised, using a computer-generated allocation scheme, to one of nine intervention implementation dates (at 3 month intervals). This date was concealed from clusters and the trial team until 3 months before the implementation date. Each participating hospital had three observation periods: a control period from Jan 1, 2014, until randomised date of intervention initiation; a washout period from the implementation date and for 2 months; and the intervention period from the end of the washout period until Dec 31, 2016. Treatment allocation was not concealed from participating women and caregivers. Data were derived from observational maternity data. The primary outcome was incidence of stillbirth. The primary analysis was done according to the intention-to-treat principle, with births analysed according to whether they took place during the control or intervention periods, irrespective of whether the intervention had been implemented as planned. This study is registered with www.ClinicalTrials.gov, number NCT01777022. 37 hospitals were enrolled in the study. Four hospitals declined participation, and 33 hospitals were randomly assigned to an intervention implementation date. Between Jan 1, 2014, and Dec, 31, 2016, data were collected from 409 175 pregnancies (157 692 deliveries during the control period, 23 623 deliveries in the washout period, and 227 860 deliveries in the intervention period). The incidence of stillbirth was 4·40 per 1000 births during the control period and 4·06 per 1000 births in the intervention period (adjusted odds ratio [aOR] 0·90, 95% CI 0·75–1·07; p=0·23). The RFM care package did not reduce the risk of stillbirths. The benefits of a policy that promotes awareness of RFM remains unproven. Chief Scientist Office, Scottish Government (CZH/4/882), Tommy's Centre for Maternal and Fetal Health, Sands.

In this randomized trial comparing delivery strategies in women with twin gestation, planned cesarean section did not significantly increase or decrease the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery. Because of assisted reproductive technologies, twin pregnancy occurs more frequently now than in the past, and it complicates 2 to 3% of all births. 1 , 2 Twins are at higher risk for an adverse perinatal outcome than singletons. 3 , 4 Planned cesarean section, as compared with planned vaginal delivery, may reduce this risk. 5 Although a small, randomized, controlled trial did not show better perinatal outcomes with planned cesarean section than with planned vaginal delivery, 6 several cohort studies have shown a reduced risk of adverse perinatal outcomes for both twins, or for the second twin, when twins at or near term were delivered . . .

In this multicenter randomized trial, the use of fetal electrocardiographic ST-segment analysis as an adjunct to conventional intrapartum electronic fetal heart-rate monitoring did not improve perinatal outcomes or decrease operative-delivery rates. Continuous intrapartum fetal heart-rate monitoring has caused considerable controversy in obstetrics. Despite decades of use and an associated rise in cesarean-delivery rates based at least in part on nonreassuring fetal heart-rate patterns, evidence that such monitoring has reduced the rate of hypoxia-induced neonatal encephalopathy is lacking. In 2005, the Food and Drug Administration (FDA) granted conditional approval of the STAN S31 device (Neoventa Medical) for use as an adjunct to conventional electronic fetal heart-rate monitoring. 1 This technology was designed to provide fetal electrocardiographic (ECG) information reflective of myocardial metabolism and acid–base balance. The rationale is that fetal acidemia is associated . . .

Elevated levels of type I interferon (IFN) during pregnancy are associated with intrauterine growth retardation, preterm birth, and fetal demise through mechanisms that are not well understood. A critical step of placental development is the fusion of trophoblast cells into a multinucleated syncytiotrophoblast (ST) layer. Fusion is mediated by syncytins, proteins deriving from ancestral endogenous retroviral envelopes. Using cultures of human trophoblasts or mouse cells, we show that IFN-induced transmembrane proteins (IFITMs), a family of restriction factors blocking the entry step of many viruses, impair ST formation and inhibit syncytin-mediated fusion. Moreover, the IFN inducer polyinosinic:polycytidylic acid promotes fetal resorption and placental abnormalities in wild-type but not in Ifitm-deleted mice. Thus, excessive levels of IFITMs may mediate the pregnancy complications observed during congenital infections and other IFN-induced pathologies.

Aims/hypothesis Pre-existing diabetes is associated with an increased risk of stillbirth, but few studies have excluded the effect of congenital anomalies. This study used data from a long-standing population-based survey of women with pre-existing diabetes to investigate the risks of fetal and infant death and quantify the contribution of glycaemic control. Methods All normally formed singleton offspring of women with pre-existing diabetes (1,206 with type 1 diabetes and 342 with type 2 diabetes) in the North of England during 1996–2008 were identified from the Northern Diabetes in Pregnancy Survey. RRs of fetal death (≥20 weeks of gestation) and infant death were estimated by comparison with population data from the Northern Perinatal Morbidity and Mortality Survey. Predictors of fetal and infant death in women with pre-existing diabetes were examined by logistic regression. Results The prevalence of fetal death in women with diabetes was over four times greater than in those without (RR 4.56 [95% CI 3.42, 6.07], p  < 0.0001), and for infant death it was nearly doubled (RR 1.86 [95% CI 1.00, 3.46], p  = 0.046). There was no difference in the prevalence of fetal death ( p  = 0.51) or infant death ( p  = 0.70) between women with type 1 diabetes and women with type 2 diabetes. There was no evidence that the RR of fetal and infant death had changed over time ( p  = 0.95). Increasing periconception HbA 1c concentration above 49 mmol/mol (6.6%) (adjusted odds ratio [aOR] 1.02 [95% CI 1.00, 1.04], p  = 0.01), prepregnancy retinopathy (aOR 2.05 [95% CI 1.04, 4.05], p  = 0.04) and lack of prepregnancy folic acid consumption (aOR 2.52 [95% CI 1.12, 5.65], p  = 0.03) were all independently associated with increased odds of fetal and infant death. Conclusions/interpretation Pre-existing diabetes is associated with a substantially increased risk of fetal and infant death in normally formed offspring, the effect of which is largely moderated by glycaemic control.

In  Grieving Pregnancy: Memorializing Loss in Japanese Buddhism and American Catholicism , Maureen L. Walsh compares how the two religious traditions respond ritually and discursively to miscarriage, stillbirth, and abortion experiences marked by grief for the women involved. The experience of pregnancy loss has always been a part of women’s lives, yet only recently has it garnered attention from religious leaders and scholars commensurate with its prevalence. This book examines pregnancy loss as a theological problem for both Buddhism and Catholicism and analyzes the rites and memorials that have developed to address it, such as Japanese Buddhist mizuko kuyō (water children rites) and emergent American Catholic memorial practices focused on pregnancy loss. These parallel practices have emerged within distinct religious landscapes—a fact reflected in their forms and purposes—and when considered together, they raise questions of keen interest to theological and religious studies about the goals of religious practice and the imagination of human life at its earliest stages.  

To compare induction of labour at 41 weeks with expectant management until 42 weeks in low risk women. Open label, randomised controlled non-inferiority trial. 123 primary care midwifery practices and 45 hospitals (secondary care) in the Netherlands, 2012-16. 1801 low risk women with an uncomplicated singleton pregnancy: randomised to induction (n=900) or to expectant management until 42 weeks (n=901). Induction at 41 weeks or expectant management until 42 weeks with induction if necessary. Primary outcome was a composite of perinatal mortality and neonatal morbidity (Apgar score <7 at five minutes, arterial pH <7.05, meconium aspiration syndrome, plexus brachialis injury, intracranial haemorrhage, and admission to a neonatal intensive care unit (NICU). Secondary outcomes included maternal outcomes and mode of delivery. The null hypothesis that expectant management is inferior to induction was tested with a non-inferiority margin of 2%. Median gestational age at delivery was 41 weeks+0 days (interquartile range 41 weeks+0 days-41 weeks+1 day) for the induction group and 41 weeks+2 days (41 weeks+0 days-41 weeks+5 days) for the expectant management group. The primary outcome was analysed for both the intention-to-treat population and the per protocol population. In the induction group, 15/900 (1.7%) women had an adverse perinatal outcome versus 28/901 (3.1%) in the expectant management group (absolute risk difference -1.4%, 95% confidence interval -2.9% to 0.0%, P=0.22 for non-inferiority). 11 (1.2%) infants in the induction group and 23 (2.6%) in the expectant management group had an Apgar score <7 at five minutes (relative risk (RR) 0.48, 95% CI 0.23 to 0.98). No infants in the induction group and three (0.3%) in the expectant management group had an Apgar score <4 at five minutes. One fetal death (0.1%) occurred in the induction group and two (0.2%) in the expectant management group. No neonatal deaths occurred. 3 (0.3%) neonates in the induction group versus 8 (0.9%) in the expectant management group were admitted to an NICU (RR 0.38, 95% CI 0.10 to 1.41). No significant difference was found in composite adverse maternal outcomes (induction n=122 (13.6%) expectant management n=102 (11.3%)) or in caesarean section rate (both groups n=97 (10.8%)). This study could not show non-inferiority of expectant management compared with induction of labour in women with uncomplicated pregnancies at 41 weeks; instead a significant difference of 1.4% was found for risk of adverse perinatal outcomes in favour of induction, although the chances of a good perinatal outcome were high with both strategies and the incidence of perinatal mortality, Apgar score <4 at five minutes, and NICU admission low. Netherlands Trial Register NTR3431.

Women with antiphospholipid syndrome (APS), a condition characterized by the presence of antiphospholipid antibodies (aPL), often suffer pregnancy-related complications, including miscarriage. We have previously shown that C5a induction of tissue factor (TF) expression in neutrophils contributes to respiratory burst, trophoblast injury, and pregnancy loss in mice treated with aPL. Here we analyzed how TF contributes to neutrophil activation and trophoblast injury in this model. Neutrophils from aPL-treated mice expressed protease-activated receptor 2 (PAR2), and stimulation of this receptor led to neutrophil activation, trophoblast injury, and fetal death. An antibody specific for human TF that has little impact on coagulation, but potently inhibits TF/Factor VIIa (FVIIa) signaling through PAR2, inhibited aPL-induced neutrophil activation in mice that expressed human TF. Genetic deletion of the TF cytoplasmic domain, which allows interaction between TF and PAR2, reduced aPL-induced neutrophil activation in aPL-treated mice. Par2-/- mice treated with aPL exhibited reduced neutrophil activation and normal pregnancies, which indicates that PAR2 plays an important role in the pathogenesis of aPL-induced fetal injury. We also demonstrated that simvastatin and pravastatin decreased TF and PAR2 expression on neutrophils and prevented pregnancy loss. Our results suggest that TF/FVIIa/PAR2 signaling mediates neutrophil activation and fetal death in APS and that statins may be a good treatment for women with aPL-induced pregnancy complications.