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Data based on forensic autopsy in neonates and infants in China are rare in the literature. The purpose of this study is to evaluate the characteristics of fetal, neonatal, and infant death and to determine the main cause of death among them.A retrospective analysis of fetal and infant forensic autopsies referred to the Tongji Forensic Medical Center (TFMC) in Hubei, central China, during a 16-year period between January 1999 and December 2014, was performed.In this period, there were 1111 males and 543 females; the total male-to-female ratio (MFR) was 2.05:1. There were 173 fetal and infant autopsies conducted, comprised of 43 fetal, 84 neonatal (<28 days) and 46 infant (4 weeks to 1 year) cases. The annual case number ranged from 5 in 2004 to 18 in 2014 (annual mean of 10.8). MFR was 1.75:1. About 94% of these deaths (163/173) resulted from natural causes, 6 cases (3.5%) were accidental deaths, and 4 (2.3%) resulted from homicide (4 abandoned babies). Among fetuses, the most common causes of death were placental and umbilical cord pathologies (28%, 12/43), followed by intrapartum asphyxia resulting from amniotic fluid aspiration (AFA) or meconium aspiration syndrome (MAS) (18.6%, 8/43), congenital malformation (14%, 6/43), and intrapartum infection (9.3%, 4/43). A majority of neonatal deaths (66.7%, 56/84) died within 24 hours of birth. The main causes of neonatal death were asphyxia resulting from AFA, MAS, or hyaline membrane disease, and congenital malformation. The main causes of infant (1-12 months) death were infectious diseases, including pneumonia, meningitis, and viral brainstem encephalitis.This study was the 1st retrospective analysis of autopsies of fetal, neonatal, and infant death in TFMC and central China. We delineate the common causes of early demise among cases referred for autopsy, and report a male preponderance in this population. Our data observed that placental and/or umbilical cord pathology, asphyxia due to AFA, and/or MAS, and pneumonia were the leading causes of fetal, neonatal, and infant death, respectively. And it can inform clinical practitioners about the underlying causes of some of the most distressing cases in their practices.

Background: Fetal specialists support standardizing the practice of offering women palliative care for life limiting fetal diagnoses. However, there is little data available regarding what fetal specialists do in practice. Since 2003, our center has kept a database of all women referred for fetal complications., Methods: Retrospective electronic chart review of pregnant women between 2006 and 2012 using UCSD's Fetal Care and Genetics Center referral database. Objectives were to determine: (I) how many high risk pregnancies referred to the University of California San Diego Medical Center (UCSD) over a 6-year period have potentially life limiting fetal diagnoses; (II) pregnancy outcome; and (III) referral rate to perinatal palliative care., Results: Between July 2006 and July 2012, 1,144 women were referred to UCSD's Fetal Care and Genetics Center, a tertiary care center. Of that cohort, 332 women (29%) were diagnosed prenatally with a potentially life limiting fetal diagnosis. Most women were Hispanic or Latino, married, and had previous children. The median gestation at confirmed diagnosis was 19 weeks. Trisomy 13, Trisomy 18, and anencephaly comprised 21% of cases. The pregnancy outcome was determined in 95% cases: 56% therapeutic abortion, 16% intrauterine fetal demise, and 23% live birth. Only 11% of cases were referred to perinatal palliative care., Conclusions: The vast majority of women with potentially life limiting fetal diagnoses are not referred to perinatal palliative care. Evaluation of how to integrate palliative care into high-risk obstetrics is needed.

Aim: Autopsy is a beneficial procedure to determine the cause of death and the frequency of anomalies in perinatal losses. Even in the event of an autopsy not providing any additional information, completion of the procedure confirming the clinical diagnoses gives reassurance to both clinicians and parents. Here we present a 15-year archival study based on findings of perinatal autopsies., Design and Methods: Four hundred and eighty-six cases from our archive were reviewed and according to the findings they were divided into three subcategories; (1) miscarriages (MCF); (2) fetuses terminated (FTA) for vital anomalies detected by prenatal ultrasonography; (3) premature or term newborns died within first month of life (neonates: NN). Autopsies were documented and classified according to week/age of cases, anomalies and causes of abortion or death., Results: Two hundred and twenty-six of 486 cases (46.5%) were in MCF group while 227 (46.7%) and 33 (6.8%) were of them in FTA and NN groups, respectively. In FTA group, the most frequent anomaly detected was neural tube defects. In NN group, prematurity related complications were the most common cause of death. The autopsy process was found valuable in 39.7% of all cases., Conclusions: We suggest that autopsy procedure is diagnostically valuable even in situations when there is USG findings that are confirming FTAs or there is no important major fetal or placental anomaly detected in MCFs.

Background: San Diego Hospice and the Institute for Palliative Medicine created one of the earliest perinatal palliative care programs in the country. Only four studies have reported outcomes for pregnant women referred to perinatal palliative care services for potentially lethal prenatal diagnoses., Objectives: To learn: (1) who is referred for perinatal palliative care at San Diego Hospice; (2) what happens after referral to perinatal palliative care; and (3) what happens after delivery for this population., Design: This was an exploratory retrospective electronic chart review of all patients referred to a home perinatal palliative program., Results: Sixty-six women were referred to the San Diego Hospice and the Institute for Palliative Care home perinatal palliative care program between October 2006 and August 2012. Mean age was 31 years. The majority of women were Hispanic, Christian/Catholic, married, with full prenatal care, and previous children. Average gestational age at referral was 27 (18-39] weeks. Thirty-two cases were referred for Trisomy 13, Trisomy 18, or anencephaly. Palliative care services were given over a mean 45 (0-132) days and 3 (0-12) visits prior to delivery. Most women completed a birth plan prior to delivery, chose palliative treatment only, and made final arrangements with the palliative team. Forty-one deliveries resulted in a liveborn infant. Twelve liveborn infants survived past 72 hours and were admitted to pediatric hospice care., Conclusions: One-third of women met with the palliative care team only once or twice prior to delivery, indicating a need for earlier referral to provide more comprehensive palliative care.

Study Question: Does neonatal outcome including congenital malformations in children born after ICSI with epididymal and testicular sperm [testicular sperm extraction (TESE)/percutaneous epididymal sperm aspiration (PESA)/testicular sperm aspiration (TESA) (TPT)] differ from neonatal outcome in children born after ICSI with ejaculated sperm, IVF and natural conception (NC)?, Summary Answer: Children born after TPT have similar neonatal outcome, including total malformation rates, as have children born after ICSI and IVF with ejaculated sperm. Testing for variance over the four groups may indicate smaller differences in specific malformation rates with TPT as the highest risk group., What Is Known Already: Regarding neonatal outcome as well as congenital malformations in children born after TPT, studies are few, with limited sample size, heterogeneous and often performed without relevant control groups., Study Design, Size, Duration: Population-based cohort study including all Danish children born after TPT and fresh embryo transfer in Denmark from 1995 to 2009. Children born after transfer of frozen-thawed embryos were excluded. Control groups of children conceived by ICSI with ejaculated sperm, IVF and NC were identified by cross-linkage of the Danish IVF Register, Medical Birth Register (MBR) and National Hospital Discharge Register (HDR)., Participants/materials, Setting: The study group consisted of 466 children born after TPT, while the control groups consisted of 8967 (ICSI with ejaculated sperm), 17 592 (IVF) and 63 854 (NC) children. Neonatal outcomes and congenital malformations were analysed for singletons and twins separately. Risk estimates for low birthweight (LBW, <2500 g) and preterm birth (PTB, <37 gestational weeks) were adjusted for maternal age, parity, child gender and year of childbirth. The study group was identified from the Danish national database on children born after TPT. Control groups were obtained from the IVF register and the MBR. All information included in the study was retrieved from the national registers., Main Results and the Role of Chance: Considering singletons and twins as one group, the sex ratio (♂/♀) was significantly lower for children born after TPT (0.89) compared with conventional IVF (1.11; P = 0.017) but did not differ significantly when compared with ICSI with ejaculated sperm (0.94) and NC (1.05). The mean birthweight (BW) for singletons did not differ significantly between groups when including only first-born children. The mean gestational age (GA) in the TPT singletons (279 ± 12 days) was significantly higher compared with IVF (276 ± 18 days; P = 0.02), but similar to ICSI with ejaculated sperm and NC singletons when including only first-born children (277 ± 16 days and 279 ± 14 days, respectively). Rate of stillbirths, perinatal and neonatal mortality in the group of TPT singletons did not differ significantly from any of the control groups. Comparable results were found for the TPT twin group, except for perinatal mortality, which was significantly lower in the TPT group compared with naturally conceived twins. The adjusted risk of LBW was significantly higher for TPT versus NC singletons [adjusted odds ratio (AOR) = 0.67 (0.48-0.93)]; however AOR for PTB was similar in the two groups. Regarding twins, similar adjusted risks were observed for PTB and LBW between the TPT and all three control groups. Significantly more Caesarean sections were performed after IVF (27.3% for singletons) and ICSI (25.1% for singletons) with ejaculated sperm compared with the TPT group (16.4% for singletons). The total rate of congenital malformations in the TPT group was 7.7% and did not differ significantly from any of the control groups. However, singleton TPT boys showed an increased rate of cardiac malformations (3.6%) compared with singleton boys after IVF (1.4%; P = 0.04) and NC (1.1%; P = 0.02). Considering the level of male infertility as a continuum over the four groups, tests for variance in the rate of cardiac malformations in singleton boys, and undescended testicles for singleton as well as twin boys were each significantly increased from NC to IVF to ICSI to TPT (P < 0.001). The rate of hypospadias showed the same pattern, but the TPT group did not differ significantly compared with the control groups., Limitations, Reasons for Caution: One of the limitations is that the TPT group could not be classified according to testicular or epididymal sperm, as these data were not available in the IVF register. Another limitation is that registry-based studies are encumbered with the risk of reporting or coding errors or missing data due to insufficient coding. However, the quality of data on congenital malformations in HDR has, in other studies, been validated and found acceptable for epidemiological research, and furthermore, recordings on study and control groups are performed similarly., Wider Implications of the Findings: Accumulating data show that TPT treatment is equally safe as conventional ICSI and IVF treatment and as NC with regard to neonatal outcome including congenital malformation., Study Funding/potential Competing Interests: This study is supported by Laboratory of Reproductive Biology, Scientific Unit, Horsens Hospital. No competing interests declared.

Objectives: High perinatal autopsy rates are necessary for institutional management protocols and national policy-making. This study reviews perinatal autopsy rates and factors affecting these rates at the University Hospital of the West Indies., Method: All perinatal deaths (stillborn infants > or = 24 weeks gestation or 500 g; early neonatal deaths ie 0-7 days old) at the University Hospital of the West Indies, between January 2002 and December 2008, were reviewed retrospectively, using the annual perinatal audit records. The annual autopsy rates were calculated and the reasons why autopsies were not done examined., Results: The average stillbirth (SB) autopsy rate was 59.6% (range 51.9 - 76.7%), while that for early neonatal deaths (ENDs) was 47.9% (range 34.4 - 63.2), with an overall average perinatal autopsy rate of 54.0% (range 42.2 - 62.2). Autopsies were requested in 79.3% and 51.7% of SBs and ENDs, respectively. Of those requested, 81.7% were done (75.2% stillbirths; 92.5% ENDs). In the ENDs, failure to request an autopsy was predominantly noted in premature infants weighing < 1000 g (75.2% of those not requested). In stillbirths, the reasons for failure to request were largely unknown with failure to gain permission accounting for only 20.3% of these cases., Conclusions: The average annual perinatal autopsy rate at the University Hospital of the West Indies between 2002 and 2008 was 54.0%. This is below the internationally recommended rate of 75%. Failure to request an autopsy was the most significant factor contributing to this. The reasons for this are not entirely clear and require further study.

Objective: To identify the disease processes underlying the increasing rate of gestational age-specific perinatal mortality observed under the fetuses-at-risk model., Design: Retrospective cohort study., Setting: USA and Nova Scotia, Canada., Population: Births in the USA (1995 and 2005) and Nova Scotia, Canada (1988-2007)., Methods: Incidence rates of perinatal death and serious neonatal morbidity were calculated using the fetuses-at-risk approach (e.g. cumulative incidence of stillbirth during any gestational week per 1000 fetuses at risk of stillbirth)., Main Outcome Measures: Perinatal mortality and serious neonatal morbidity., Results: Perinatal mortality rates increased with advancing gestation. Rates of bronchopulmonary dysplasia, intraventricular haemorrhage, periventricular leucomalacia and retinopathy of prematurity were highest in early gestation, whereas rates of meconium aspiration syndrome and aspiration pneumonitis were highest at late term and post-term gestation. Respiratory depression (i.e. delay in initiating and maintaining respiration after birth, low 5-minute Apgar score or seizures caused by neonatal encephalopathy) showed an increase from 34 weeks onwards. The increase in perinatal mortality rates at late gestation was congruent with increases in respiratory depression. Other findings included a high incidence of respiratory distress syndrome at late gestation, a nonspecific pattern in the gestational age-specific rates of necrotising enterocolitis and high rates of sudden infant death syndrome at late gestation., Conclusions: The natural history of pregnancy is characterised by diseases of early and late gestation, with the latter largely determining patterns of gestational age-specific perinatal mortality. These findings have implications for obstetric theory and provide insight into various contemporary phenomena, including the rise in iatrogenic late preterm birth., (© 2011 The Author BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.)

Objective: To evaluate fetal and neonatal outcomes related to prolonged pregnancy., Methods: This study is based on Pubmed search, Cochrane library and HAS recommendations., Results: The risk of fetal complications including macrosomia (6 %), oligohydramnios (10 %-15 %), abnormal fetal heart rate pattern and meconium-stained fluid is increased in prolonged pregnancy (≥ 41(+0) weeks). The rate of stillbirth was estimated between 1.6 ‰ and 3.0 ‰ live births according to countries in post-term pregnancies (≥ 42(+0) weeks). The risk of umbilical cord pH less than 7.10, Apgar score at five minutes inferior to 7, ICU admissions and perinatal asphyxia is increased in post-term infants (≥ 42(+0) weeks) compared with term infants. The risk of neurologic complications including neonatal convulsion, hypoxic ischemic encephalopathy, cerebral palsy, developmental deviations and epilepsy in childhood is increased in post-term infants. The risk of meconium aspiration syndrome, neonatal sepsis, and birth trauma including shoulder dystocia and bone fracture is increased in post-term infants. The rate of perinatal mortality increases in post-term infants. The perinatal mortality in post-term infants could be explained by perinatal asphyxia and meconium aspiration syndrome., Conclusions: The risk of perinatal complications and mortality are increased in prolonged pregnancy., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Preterm delivery is the chief problem in obstetrics today and the main determinant of infant mortality and morbidity. Despite the dramatic decrease in infant mortality rate during the past several years, the percentage of preterm (<37 weeks gestation) and low birth weight (LBW) (<2500) rates remain elevated. Approximately 10% of all births are preterm, with a rate of 1-2% of infant born before the end of the 32 weeks of gestation and with a weight <1500 g. Despite the importance of the problem, the majority of preterm live births remain unexplained, and programmatic attempts at reversing the high level of preterm births have not been successful. Numerous studies have linked bacterial vaginosis, chorioamniotitis and endometritis with preterm birth and LBW, especially among African women. The number of preterm live births among African women is twice the one among Caucasians. Bacterial vaginosis is an independent risk factor for preterm and LBW births and the mechanism by which bacterial vaginosis causes the preterm birth of an infant with LBW is unknown. The aim of this article was to underline the importance of the treatment and early identification of vaginal infection, in particular if due to bacterial vaginosis, as it can have a substantial affect on the incidence of preterm delivery with LBW.

Objective: To evaluate perinatal outcomes in case of gestational diabetes (GD) treated or not., Methods: This study is based on Pubmed search and on NICE and HAS recommendations., Results: Moderate or severe GD increases the risk of foetal and neonatal complications [EL1]. The risk of malformation is slightly increased in case of GD compared with non diabetic population [EL2]. The increased risk of malformation is probably linked to undiagnosed cases of type 2 diabetes among cases of GD [EL2]. There is a continuous association of maternal glucose levels with increased birth weight [EL2]. The incidence of macrosomia decreases when diabetes is treated [EL1]. Data from the literature don't allow estimating precise risk of hypertrophic cardiomyopathy in case of GD, but severe clinical form is exceptional. Risk of neonatal asphyxia and perinatal death is not increased in case of GD [EL2]. Birth injuries and nerve palsy are rare in case of GD, and there is no evidence for increased incidence of such events when GD is not treated. The risk of neonatal respiratory distress whatever is the cause, is difficult to estimate. There is no evidence to establish a link between GD and neonatal respiratory distress. It is difficult to estimate the risk of neonatal hypoglycaemia because of various definitions used in the different studies, but the frequency of hypoglycaemia treated with IV glucose is low [EL1]. The risk of hypocalcemia [EL4] and hyperbilirubinemia [EL1] is similar to that of the general population., Conclusion: Severe perinatal complications specifically linked to GD are rare. Macrosomia is the principal neonatal adverse outcomes demonstrated in case of GD. It is the main factor related to the complications reported in case of GD. Maternal obesity is an additional risk factor of neonatal adverse outcomes and is independent from the diabetes., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Purpose: To evaluate the antenatal and postnatal risk factors of neonatal death in pregnancies with absent (DZ) or reverse (DR) end-diastolic flow in the umbilical artery., Methods: A cross-sectional retrospective study based on data from 48 medical records of singleton pregnancies with DZ or DR, and gestational age of 24 to 34 weeks, at a maternity in the Brazilian Northeast. Mean age was 27.3 (SD: 7.9) years. Twenty (41.7%) patients were primiparas. Hypertensive disorders were found in 44 (91.7%) cases. Thirty-five women (72.9%) had DZ and 13 (27.1%) had DR. Univariate analysis was firstly done (Student's t-test and Fisher's exact test) correlating the parameters with the assessed outcome (neonatal death). Variables that showed significant association were included in the logistic regression model (Wald statistics). The level of significance was set at 5%., Results: The perinatal mortality rate was 64.6% (31/48). There were five stillbirths and 26 neonatal deaths. The mean gestational age at diagnosis was 27.9 (SD: 2.8) weeks. Deliveries before 24 hours after diagnosis occurred in 52.1% of the cases. Cesarean section was performed in 85.4% of the sample. The newborns weighed 975.9 g on average (SD: 457.5). Twenty-four (57.1%) presented Apgar scores below 7 in the first minute and 21.4% in the fifth minute. Gestational age at diagnosis, birth weight and Apgar of the first minute proved to be variables significantly related to neonatal death (p values were: 0.008, 0.004, and 0.020, respectively). The Odds Ratio was 6.6, 25.3 and 13.8 for neonatal death, when the diagnosis was established at the 28th week, weight was <1000 g and first minute Apgar score was <7, respectively., Conclusions: Gestational age at diagnosis, birth weight and Apgar score at the first minute were factors that could predict neonatal death in pregnancies with DV or DR determined by umbilical artery Doppler velocimetry.

Objective: The purpose of this study was to determine whether prenatal intraabdominal bowel dilation (IBD) is associated with increased postnatal complications in fetuses with gastroschisis., Study Design: A retrospective review was performed on all maternal-fetus pairs with prenatally diagnosed gastroschisis that was treated at the University of California San Francisco from 2002-2008. Postnatal outcomes were compared between fetuses with and without IBD., Results: Forty-three of 61 maternal-fetal pairs met the criteria for inclusion. Sixteen fetuses (37%) had evidence of IBD. Fetuses with IBD were significantly more likely to have postnatal bowel complications (38% vs 7%; P = .037). The presence of multiple loops of IBD (n = 6) as opposed to a single loop (n = 10) was associated highly with bowel complications and increased time to full enteral feeding and length of hospital stay (100% vs 0% [P = .001]; 44 vs 23 days [P = .034]; 69 vs 27 days [P = .001], respectively)., Conclusion: IBD is associated with increased postnatal complications in infants with prenatally diagnosed gastroschisis; however, this association seems to be limited to those with multiple loops of dilated intraabdominal bowel., (Copyright 2010 Mosby, Inc. All rights reserved.)

Background: Procreation and perinatal health which includes maternal health, fetal growth and well being of newborns are a challenge for modern medicine. One of the indices of evaluation of perinatal health is perinatal mortality of fetuses and newborns. This has been emphasised in the National Health Programme in Poland for 2007-2015., Aim: Analysis of perinatal mortality in the period 1999-2008 of fetuses, newborn and stillborn, with, Material and Methods: The analysis was based on data from the Central Statistical Office, from the Ministry of Health dokument MZ-29 and on data obtained from own studies., Results: In the second part of the analysed period there was a reduction in the rate of fall of the number of newborn deaths. This was particulary marked in newborn with low and extremely low birthweight. Throughout the whole period of analysis there was a significant difference in the perinatal mortality between the newborn group with birthweight above 2500 g and the newborn group below 2500 g. Higher newborn mortality and particularly higher stillbirth rate was found in the group of mothers above 40 years of age. In the maternal group aged 15-19 years, these indices were slightly less increased. Throughout the analysis period it was noted that there were significant differences between individual voivodeships in perinatal mortality of newborn, as well as of still births., Conclusions: 1. In order to improve perinatal health and to further reduce the perinatal mortality and in particular to reduce the number of stillbirths and newborn with low and very low birthweight, it is essential to create a well functioning system of triple level perinatal care. There is on urgent need for elaboration of such a programme and finding financial resources for its implementation. 2. Part of this task is to modernise and improve the medical documentation concerning perinatal health.

Monochorionic monoamniotic (MCMA) multiple pregnancies are rare events with an incidence of around 0.004% of all life births. They are the result of a delayed splitting of a single blastocyst whereby the stimuli and mechanisms are still unknown. The Incidence of MCMA multiple pregnancies is increased after artificial reproductive techniques. With the advent of modern ultrasonography the diagnosis of MCMA multiple pregnancies and the combined complications such as cord entanglement, malformations including the incidence if conjoined twins and even threatening preterm delivery or twin-twin transfusion syndrome has improved. The chances of intact survival of up to 80-90% have improved through intensified surveillance. It is recommended to perform a Cesarean section at around 32 gestational weeks. Postnatal investigations of the placenta and its anastomoses have increased our understanding of the pathophysiology of MCMA multiple pregnancies.

Background: Twin pregnancies and deliveries are at higher risk of complications such as prematurity, preeclampsia and fetal distress. The level of regionalization in relation to the risk profile was evaluated., Methods: The Data of the Perinatal survey of the state of Hesse - Germany of the years 1990-2008 were evaluated according to the type of hospital. Distinctively Perinatal Centres were compare with small (<500 births per anno) and larger (>500 births per anno) community hospitals. The analysers focuses on the degree of adaptation according to a given additional risk in twin pregnancies - prematurity, preeclampsia and diabetes and growth restriction., Results: Twin pregnancies and deliveries are regionalized in prenatal centres of the State of Hesse in the large majority. Risk adjusted admission is organized in cases of prematurity (<33+0 gestation) and diabetes. In cases of preeclampsia and growth retardation regionalization seem insufficient., Conclusion: Further improvement in the case of complicated twin pregnancy is essential to improve fetal and maternal health.

Background: In industrialised countries, 1-4% of all children are born as a result of assisted reproductive therapies (ART), such as IVF and ICSI. Possible associations of these ARTs with obstetric and neonatal risk constellations are analysed critically in the context of this review., Methods: A selective literature search was conducted to examine the influence of ART on obstetric and neonatal aspects., Results: Multiple gestations, occurring more frequently after ART, are of special significance with regard to their associated risks. In comparison to spontaneous pregnancies, singleton gestations after ART are associated with higher rates of complications, such as preeclampsia, prematurity, low birth weight, foetal malformations and a higher rate of Caesarean sections. Although causal associations between extracorporeal fertilisation methods and health risks for mothers and infants in singleton pregnancies cannot be ruled out, these complications are rather attributed to the underlying causes of infertility than to the methods of assisted reproduction themselves., Conclusions: Pregnancies after ART are to be regarded as risk constellations with a need for closer surveillance during gestation - irrespective of the number of developing foetuses. Couples seeking advice about infertility should be informed in detail before the onset of ART.

Background: Neonatal deaths still represent the largest percentage of overall childhood mortality. Many deaths of neonates are preceded by end-of-life decisions; however, decision-making practices have been reported to vary widely from country to country., Objectives: To analyze principal causes and circumstances of all consecutive neonatal deaths at our institution over a 10-year period., Methods: All neonates who had died either in the delivery room (DR) or the neonatal intensive care unit (NICU) between January 1, 1997 and December 31, 2006 were identified. Demographic information, principal causes and circumstances of death were abstracted from the individual medical records., Results: There were approximately 72,000 live births in the catchment area of our center with 15,150 deliveries occurring at the Women's Hospital of Lucerne. Of the 108 deaths identified, 29 occurred in the DR (DR mortality rate 0.2%) and 79 in the NICU (NICU mortality rate 2.3%). The majority of DR deaths occurred in the setting of primary nonintervention and were related to extreme prematurity (n = 20), lethal congenital malformations (n = 6) and trisomy 13 (n = 2). One patient with severe perinatal asphyxia died despite full resuscitative efforts. In the NICU, overall mortality rate was inversely related to gestational age (GA). Cardiovascular and respiratory system failures were the predominant causes of death in premature infants with a GA <32 weeks, whereas CNS catastrophes accounted for the majority of deaths in the more mature NICU population. End-of-life decisions were common with less than 10% of deaths occurring despite maximal intensive care., Conclusions: In our perinatal center, primary nonintervention and redirection of care are the most common circumstances of death in neonates. This reflects our belief that, apart from futility, quality-of-life considerations are an important part of decision making in neonatology.

Neuroblastoma is the foremost malignant neoplasm of the fetus and neonate. The tumor is unique because of its distinctive biologic behavior and many different clinical manifestations. The purpose of this review is to focus on the fetus and neonate to determine the various ways perinatal neuroblastomas differ clinically and morphologically and in their treatment from those found in the older child to show that some forms of the tumor have a better outcome than others. The report attempts to evaluate the influence of site, histology, stage, biologic markers, and treatment on survival.

The Wigglesworth pathophysiological classification was used to analyse perinatal deaths occurring in 5 health centres in Bangladesh. The aims were to assess the feasibility of this classification, to determine the causes of perinatal deaths and thereby to identify the areas in need of intervention. A total of 8058 births were recorded at 5 centres during the period of 11 months from mid-January to mid-December 2001. There were 1069 deaths in the perinatal period. Stillbirths were slightly more frequent (53.5%) than early neonatal deaths (46.5%). Among the stillbirths, fresh stillbirths predominated over normally formed macerated ones at all centers except BIRDEM, where the majority (52.5%) was macerated. The majority (71.6%) of perinatal deaths were in the groups comprising asphyxial conditions (46.8%), conditions associated with immaturity (13.3%), and normally formed macerated stillbirths (NFMSB, 11.5%). In the group, 'other specific conditions' which was responsible for 9.3% of perinatal deaths, all but one case was attributed to sepsis. When the cases were subdivided by birth groups, asphyxia predominated in all but the <1000g group, in whom immaturity was responsible. Conditions associated with immaturity were second highest in number. The majority of the perinatal deaths (83.4%) was in babies less than 2500g. The study has shown that the Wigglesworth classification can be used in different types of health facilities in Bangladesh by doctors, nurses and midwives. The areas which need intervention are antepartum care, obstetric and newborn care practices, and environmental factors responsible for the high prevalence of prematurity and low birth weight.

Background: Using a critical systematic analysis of perinatal mortality, this study aims to examine, on the basis of current medical and scientific knowledge, whether there are still situations in which feto-neonatal death could be prevented and to define and evaluate the feasibility of realising this goal., Methods: The concept of preventable feto-neonatal death refers to the number of individuals who could have survived with better pre-, intra and postnatal care. In other words, it indicates the number of deaths that could have been avoided in an almost perfect health organisation and therefore, by reference, the number of inevitable deaths (not preventable). In this field it is important to distinguish between clinically preventable, where there are preventable factors at the time of hospitalisation and during the clinical phase of the disease, and extra-clinically preventable when these factors, if potentially present during the preclinical phase of disease, disappear owing to the gravity of conditions at the time of hospitalisation. Using data from maternal and neonatal clinical records, death certificates and autopsy findings, the authors examined the perinatal mortality rate in Department B of the Gynecological and Obstetrics Clinic of Turin University during the period 1979-1998. The results of these two decades were compared in terms of clinical practice., Results: The perinatal mortality rate fell significantly (p<0.01) during the period 1989-1998: 1.02 vs 1.77%. It is worth underlining that this was mainly the result of a marked reduction (over 50%) in late fetal mortality: 0.43 vs 0.98% (p<0.01). Early neonatal mortality also diminished, although not significantly (0.59 vs 0.79%). In order to evaluate preventable deaths, perinatal mortality was subject to a detailed critical analysis to analyse its chronological evolution: prenatal, intranatal, early neonatal. During the second period examined, the preventable nature of perinatal mortality, although slightly lower, applied to 36.35% of cases. It is important to underline that although clinically preventable deaths were unfortunately still present (approx. 10%), most cases (approx. 90%) referred to extra-clinically preventable deaths., Conclusions: On the basis of current medical and scientific knowledge, the authors outline the directives for medical and specialist obstetric and social care required in the specific fight against preventable perinatal deaths. Recent progress in basic scientific research, especially in the genetic field, may make a vital contribution to limit and reduce the coefficient of feto-neonatal pathology that is still beyond control.

Objective: To estimate whether higher magnesium levels in umbilical cord blood at delivery are associated with increased total pediatric (fetal + neonatal + postneonatal) mortality., Methods: During the Magnesium and Neurologic Endpoints Trial, in addition to randomizing mothers having preterm labor into arms containing magnesium sulfate, other tocolytic agents, or saline controls, we obtained biologic specimens at delivery, including umbilical cord venous blood on which was determined the serum ionized magnesium level using the AVL 988-4 analyzer (Graz, Austria). Laboratory results were then matched with the pediatric mortalities. The study power was based on the anticipated reductions in neonatal intraventricular hemorrhage related to magnesium usage from 18.9% to 4.4%. For alpha =.05, 1-beta (power)=80%, two tailed, the total number of infants needed would be 140., Results: Of 149 mothers who gave permission for randomization, ionized magnesium levels were available for 82 children. Seven deaths occurred (one immediately before delivery, three as neonates, and three in the postneonatal period). The median level of ionized magnesium among the seven dead children was 0.76 mmol/L; among the 75 survivors, the median level of ionized magnesium was 0.55 mmol/L (Mann-Whitney U test, P =.03). Using multivariable logistic regression analysis, the association remained statistically significant when controlling for possible confounding factors (adjusted odds ratio 7.7, 95% confidence interval 1.2, 47.6, P =.03)., Conclusion: These findings of a dose response between serum ionized magnesium and deaths in children increase our concern about the improper use of tocolytic magnesium.

Objective: To investigate the risk of postnatal death in pregnancies with preterm prelabor amniorrhexis in relation to gestational age at both amniorrhexis and delivery., Methods: In 172 singleton pregnancies with preterm prelabor amniorrhexis resulting in live births, postnatal survival and cause of death were examined in relation to gestational age at both amniorrhexis and delivery. In 108 of the patients, the amniotic fluid index (AFI) and fetal breathing movements were determined, and in 98, the internal thoracic circumference and cardiothoracic ratio were also measured. The value of these indices in the prediction of pulmonary hypoplasia was examined., Results: There were 30 (17%) deaths, 18 of which were due to pulmonary hypoplasia and 12 to prematurity-related complications. Survival was related to both gestational age at amniorrhexis (50% for amniorrhexis before 20 weeks' gestation and 98% when amniorrhexis occurred after 25 weeks) and gestational age at delivery (57% for those born at 24-28 weeks' gestation and 96% for those born after 32 weeks). Pulmonary hypoplasia was also related to both gestational age at amniorrhexis (causing 92% of deaths in the group with amniorrhexis at less than 20 weeks' gestation but none of those with amniorrhexis after 23 weeks) and gestational age at delivery (causing 50% of deaths in the group delivered at 24-28 weeks' gestation and 87% of deaths in infants delivered after 28 weeks). Fetal breathing movements were present in 33 and 63% of cases with and without pulmonary hypoplasia, respectively. The corresponding values for internal thoracic circumference below the 2.5 percentile were 33 and 9%, respectively. There were no significant differences in the AFI or cardiothoracic ratio between the cases with and without pulmonary hypoplasia. Multivariate analysis demonstrated that the only characteristic that contributed significantly in distinguishing between cases with and without pulmonary hypoplasia was gestational age at amniorrhexis., Conclusion: In pregnancies with preterm prelabor amniorrhexis, postnatal survival is related to both gestational age at amniorrhexis and gestational age at delivery. Prediction of pulmonary hypoplasia is primarily dependent on gestational age at amniorrhexis.

New forms of the pathology analysis are suggested to develop and introduce into the practice of pediatric pathologists in order to decrease the level of perinatal mortality in USSR: 1) the study of causes of death in children weighing from 500 to 999 g; 2) anatomopathological determination of the gestational period; 3) pathomorphology of transitional conditions in newborns; 4) early autopsies of foetuses and newborns, improving the reanimation pathology diagnosis; 5) the increase of the thoroughness in the study of placenta and reconsideration of the nosological approaches in the evaluation of the placenta pathology; 6) current etiological diagnosis of infectious diseases including HIV-infections.

The prognosis for pregnancy in chronically ill women (mainly heart or kidney diseases) has improved dramatically. However, despite a decrease in the parent's mortality, foetal mortality and morbidity remains unchanged because of the consequences of the mother's disease and treatment on foetal physiology. The mother must be informed of the risks and the medical supervision during the pregnancy. The follow-up and the medical and/or surgical management during pregnancy and at birth are discussed. Pregnancies in women with heart diseases often have a favourable outcome. In women with renal failure, transplantation can result in a successful pregnancy and the birth of a healthy child. The pediatrician is involved in all decisions during pregnancy and must undertake long-term surveillance of the child in order to detect for any somatic or psychological abnormality which might appear later on in life.