Ugggh!!!

[angieb]

Mom29, thank you so much for that study (and thank you for your poise in not debating a blog here.). Does anyone have full-text access for the study? I'm wondering if women with hypertensive issues were included in that study - I've always been told that hypertensive issues were medical reasons for inductions and would therefore be left out of the studies that count "elective" deliveries - making the number of stillbirths that much more alarming, especially because those should have been "normal" pregnancies.

I didn't have access to the full-text but I believe that the blog (from an OB) did quote some parts from the full-text article. In it, it specifically mentioned that the researchers were surprised with the tripled stillbirth rate and therefore went back through all of the cases to make sure that none of the cases should have been early deliveries for indicated reasons like hypertension, etc., at least from what I understood. I will PM you the blog link, but here is the quote I am referring to:

[this part is the blog author's commentary: Because this increase in stillbirths is so large, the authors reviewed each stillbirth to be sure that they were not the result of risk factors that would have triggered a medically indicated induction.

This part was in a quote which leads me to believe it was from the full-text article:

The authors carefully reviewed the medical records of each stillbirth to identify cause of death and the presence of a maternal risk factor ... No definitive cause-of-death pattern emerged.

[lemons]

I have read the full text of the research article in question (Ehrenthal, et al. Neonatal Outcomes After Implementation of Guidelines Limiting Elective Delivery Before 39 Weeks of Gestation. Obstet Gynecol 118(5):1047–1055)

To provide some answers:

1. The "intervention" for the study was to educate OBs and MFMs about the American College of Obstetricians and Gynecologists recommendations to limit early term (37-38 completed weeks gestation) elective deliveries. These recommendations allow for delivery in cases of either maternal or fetal indications, including: PIH, preeclampsia, HELLP, gestational diabetes, and many others.

2. The data did NOT exclude pregnancies that were complicated by these maternal or fetal indications. Instead, the data include ALL births that completed 37 weeks gestation.

3. Of the 7 stillbirths at tern (37+ weeks) that were recorded PRIOR to the intervention- 4 were due to cord accidents (one was a two vessel cord), 1 was due to placental insufficiency, and 2 were unexplained. Of the stillbirths due to cord accident, there were no maternal risk factors identified. The stillbirth due to placental insufficiency was in a postdated pregnancy (41 completed weeks gestation). One of the unexplained stillbirths was in a mother with the risk factor of "advanced maternal age" (greater than 35). Point being that none of the stillbirths were to mothers with indications of PIH, preeclampsia, or other hypertensive related conditions.

4. Of the 15 stillbirths (which excludes 2 stillbirths related to chromosomal or congenital abnormality) at term (37+ weeks) recorded AFTER the intervention- one was unexplained with a maternal risk factor of gestational diabetes, one was unexplained with a maternal risk factor of chronic hypertension, one was unexplained with a risk factor of prepregnancy diabetes, one was due to IUGR presumably from cocaine exposure, one was due to fetal infection after the in utero repair of a congenital heart defect. All of these 5 pregnancies should have been considered high risk and should have been candidates for early delivery according to the ACOG recommendations. I am not going to provide the rest of the results unless one of you really wants....

And now for my own take on the results-
The take home that I concluded and was subsequently pointed out in comments on the original article, is that apparently, the recommendations from the ACOG were not being effectively implemented. I think that maybe before the intervention (push to limit early term deliveries), physicians were delivering ANYONE who might have a slight indication for delivery, as evidenced by the lack of maternal risk factors for most pre-intervention stillbirths. And then after the intervention, patients with indications warranting elective delivery were being missed.

Overall, I think this study is a great indication of why the Preeclampsia Foundation has such an important role to play in safe guarding the health of both pregnant women and their babies- education, education, education, of care providers, pregnant women, and their partners/families. Hopefully, this has helped. I am happy to answer more questions regarding the actual study. But due to copyright restrictions, I can not distribute the actual article.

[lemons]

mom29 wrote:
I think we make a choice between dwelling on the difficult things in our lives or being thankful for the good things.

I agree with you. And I am glad that your daughter is thriving these days and that your boys are able to enjoy being big brothers! I know how hard an early delivery and NICU stay (58 days) are, and I definitely questioned the decision to deliver, and still do to some extent. But I know that my husband and I are incredibly lucky to have our daughter here with us. That is our focus these days

And thank you for your comment about my signature- I was devastated when I lost my first baby, but I like to think that that baby helped prime my uterus to be able to support his/her little sister (my 30 weeker). Especially, once I found out about the two year theory and uterine artery remodeling.

[blythe]

I think that maybe before the intervention (push to limit early term deliveries), physicians were delivering ANYONE who might have a slight indication for delivery, as evidenced by the lack of maternal risk factors for most pre-intervention stillbirths. And then after the intervention, patients with indications warranting elective delivery were being missed.

Lemons, thank you *so much* for the summary of the full text and the analysis!