Types of Pregnancy Loss

Chemical Pregnancy

Posted on July 27, 2011 by Heidi Faith

 

If you have begun to miscarry, and hadn’t yet been able to hear your baby’s heartbeat with a doppler, your doctor might have said that you are having a chemical pregnancy.

This means that it’s a very early miscarriage.

This very early miscarriage–or the name of it–doesn’t make your baby any less real.  At 5 weeks gestation, just about the time you may have found out that you were pregnant, your baby was about the size of a sesame seed.  And, at 5 weeks gestation, your tiny baby’s heart has already begun to beat.  It’s just too small to be heard on a Doppler.

While identifying your baby at this stage is probably just not going to happen, because of everything that is delivered during the miscarriage, including uterine lining and lots of blood, your baby is real.  Your feelings about your baby are real.

Ectopic Pregnancy

Posted on July 25, 2011 by Heidi Faith

 

An ectopic pregnancy means that your baby has attached itself to an area outside of the uterus rather than inside your actual uterus.  This situation can be fatal to the mother unless the pregnancy ends as quickly as possible.

This can be a very heartwrenching situation for a mother, who may mistakenly believe that she needs to have an “elective abortion”.  In an elective abortion, a mother electively chooses to terminate her pregnancy-despite the knowledge that the baby most probably would go on to develop through a full term pregnancy, and have a live birth.  In an ectopic pregnancy, the very high probability of the both the baby dying and the mother dying, make delivering the baby as quickly as possible a necessity.

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Heartfelt : giving the gift of photographic memories from Gavin Blue on Vimeo.

Stillbirths: missing from the family and from family health/.

Original Text

Gary L Darmstadt a

Stillbirth is a devastating occurrence for families, and women bear the brunt of the consequences.1, 2 Hopes and dreams are dashed, and expectant women might suddenly face scorn, isolation, and rejection. They can be pressured to become pregnant again soon, and hence face a shortened birth interval and an increased risk for themselves and for subsequent pregnancies. This cycle continues—unbroken and unvoiced—every day in homes and communities around the world, especially in poor families.

The Lancet's Stillbirths Series is a landmark summation of the causes and global burden of stillbirths, along with a framework to deliver solutions within the context of reproductive, maternal and child health, and nutrition programmes, and a rallying cry for collective action. The Series builds on several recent reviews3—6 that have shaped the evidence base needed to address the problem.

This Series now authoritatively identifies stillbirth as one of the most shamefully neglected areas of public health. Although stillbirth is a universal problem, and exists along a spectrum of intrapartum stillbirths and intrapartum-related neonatal deaths (ie, birth asphyxia), the burden is woefully inequitable. Series authors J Frederik Frøen and colleagues1 point out that stillbirth rates in low-income countries are now where they were in high-income countries 50—100 years ago. They conclude that by simply addressing this inequity, bringing global stillbirth rates down to the average of low-burden settings, four in five stillbirths would be eliminated. The stillbirth burden, as enormous as it is with 2·6 million born dead after 28 weeks' gestation (an estimate from Simon Cousens and colleagues7 in another Series paper) is grossly underestimated. Such underestimation is due to under-reporting, inconsistent definitions, and the fact that stillbirths do not feature in major global or national health targets and commitments, in part because no global health constituency has taken full ownership of the problem.

This Series makes major strategic advances to show that the way to address the problem of stillbirth is to strengthen existing maternal, newborn, and child health programmes by focusing on a few key interventions, which also have benefits for mothers and neonates. If implemented, according to Zulfiqar Bhutta and co-workers8 in the Series, 15 proven antenatal and intrapartum interventions—ten of them also effective for averting stillbirths—could avert more than 2·7 million deaths of mothers and neonates, and stillbirths, each year by 2015. Tools are already available and a strong case has been made for their benefits for mothers and neonates;9—11 no new stillbirth-specific interventions, delivery platforms, or health-system elements are needed, a point made by Series authors Robert Pattinson and colleagues.12 What is needed, however, is a change in our framing of the continuum of care to include stillbirths.

The Stillbirths Series further emphasises the critical nature of the intrapartum period as a narrow window for intervention, when nearly half of stillbirths, three-quarters of maternal deaths, and one-quarter of newborn deaths occur (totalling 2·3 million deaths). If all we did was to provide good-quality care during childbirth, at a cost of less than US$1 per head, we could avert 1·4 million deaths of mothers and neonates, and stillbirths, each year. The stillbirths and newborn deaths that could be averted in addition to maternal deaths substantially strengthen the argument for childbirth care, which safe-motherhood advocates have been making for decades. In one of the more illuminating analyses in the Series, Pattinson and colleagues12 show that, if maternal deaths are only considered in deriving cost-effectiveness estimates of obstetric care, the figure of US$54 347 per death averted is not cost effective. When the stillbirths and neonatal deaths averted by these same interventions are also considered, the cost-effectiveness estimate improves dramatically to $3920 per death averted. Figures such as these show why advocates across all of women's and children's health should rally together to count and address stillbirth, and ensure integration of this issue into the continuum of care.

Antenatal care might play an important part in reducing the number of stillbirths in ways that current modelling does not take into account, for example, as a gateway behaviour associated with the uptake of other health-promoting behaviours. Family planning probably also has an important role, but its effect on stillbirth reduction was not modelled in this Series either. Selected nutritional interventions reduce stillbirths, but links between nutrition, infection, and susceptibility to hypoxic insults need further elucidation,13 as does the role of improved adolescent and maternal nutrition.

To improve women's and children's health, we need to optimise every interaction families have with the health system, particularly with frontline workers. Families should be empowered as producers of good health themselves, through the adoption of improved preventive and promotive practices, and care-seeking for complications. Simultaneously, frontline workers' capabilities, performance, and connections to the health system must be enhanced so they can provide more timely and effective counsel and care.14

Stillbirth is a major global public health problem and its day has come. New research is needed to improve our ability to prevent 60% of the stillbirth burden that cannot be averted with current interventions.8, 12 Meanwhile, inclusion of stillbirth when designing integrated family health programmes, and improving collection of stillbirth data, are important first steps to address this issue while also advancing the continuum of care.

Full-size image (20K) David Scott Smith/Stock Connection/Rex Features

I declare that I have no conflicts of interest.

References

1 Frøen JF, Cacciatore J, McClure EM, et alfor The Lancet's Stillbirths Series steering committee. Stillbirths: why they matter. Lancet 201110.1016/S0140-6736(10)62232-5. published online April 14. PubMed

2 Haws RA, Mashasi I, Mrisho M, Schellenberg JA, Darmstadt GL, Winch PJ. “These are not good things for other people to know”: how women's understandings of pregnancy loss and early neonatal death in southern Tanzania may impact survey data quality. Soc Sci Med 2010; 71: 1764-1772. CrossRef | PubMed

3 Lawn JE, Kinney M, Lee ACC, et al. Reducing intrapartum-related deaths and disability: can the health system deliver?. Int J Obstet Gynecol 2009; 107: S123-S142. PubMed

4 Bhutta ZA, Darmstadt GL, Haws RA, Yakoob MY, Lawn JE. Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand. BMC Pregnancy Childbirth 2009; 9 (suppl 1): S7. CrossRef | PubMed

5 Rubens CE, Gravett MG, Victora CG, Nunes TMthe GAPPS Review Group. Global report on preterm birth and stillbirth (7 of 7): mobilizing resources to accelerate innovative solutions (Global Action Agenda). BMC Pregnancy Childbirth 2010; 10 (suppl 1): S7. PubMed

6 Yakoob MY, Lawn JE, Darmstadt GL, Bhutta ZA. Stillbirths: epidemiology, evidence and priorities for action. Semin Perinatol 2010; 34: 387-394. CrossRef | PubMed

7 Cousens S, Stanton C, Blencowe H, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet 201110.1016/S0140-6736(10)62310-0. published online April 14. PubMed

8 Bhutta ZA, Yakoob MY, Lawn JE, et alfor The Lancet's Stillbirths Series steering committee. Stillbirths: what difference can we make and at what cost?. Lancet 201110.1016/S0140-6736(10)62050-8. published online April 14. PubMed

9 Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis Lfor the Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn babies can we save?. Lancet 2005; 365: 977-988. Summary | Full Text | PDF(147KB) | CrossRef | PubMed

10 Bhutta ZA, Ali S, Cousens S, et al. Interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make?. Lancet 2008; 372: 972-989. Summary | Full Text | PDF(340KB) | CrossRef | PubMed

11 Campbell OMR, Graham WJon behalf of The Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006; 368: 1284-1299. Summary | Full Text | PDF(296KB) | CrossRef | PubMed

12 Pattinson R, Kerber K, Buchmann E, et alfor The Lancet's Stillbirths Series steering committee. Stillbirths: how can health systems deliver for mothers and babies?. Lancet 201110.1016/S0140-6736(10)62306-9. published online April 14. PubMed

13 Lee AC, Mullany LC, Tielsch JM, et al. Risk factors for birth asphyxia mortality in a community-based setting in Southern Nepal. Pediatrics 2008; 121: e1381-e1390. CrossRef | PubMed

14 Kumar V, Kumar A, Darmstadt GL. Behavior change for newborn survival in resource-poor community settings: bridging the gap between evidence and impact. Semin Perinatol 2010; 34: 446-461. CrossRef | PubMed

 

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Stillbirths: what difference can we make and at what cost?

Worldwide, 2·65 million (uncertainty range 2·08 million to 3·79 million) stillbirths occur yearly, of which 98% occur in countries of low and middle income. Despite the fact that more than 45% of the global burden of stillbirths occur intrapartum, the perception is that little is known about effective interventions, especially those that can be implemented in low-resource settings. We undertook a systematic review of randomised trials and observational studies of interventions which could reduce the burden of stillbirths, particularly in low-income and middle-income countries. We identified several interventions with sufficient evidence to recommend implementation in health systems, including periconceptional folic acid supplementation or fortification, prevention of malaria, and improved detection and management of syphilis during pregnancy in endemic areas. Basic and comprehensive emergency obstetric care were identified as key effective interventions to reduce intrapartum stillbirths. Broad-scale implementation of intervention packages across 68 countries listed as priorities in the Countdown to 2015 report could avert up to 45% of stillbirths according to a model generated from the Lives Saved Tool. The overall costs for these interventions are within the general estimates of cost-effective interventions for maternal care, especially in view of the effects on outcomes across maternal, fetal, and neonatal health.

pdf

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Stillbirths: Where? When? Why? How to make the data count?

Despite increasing attention and investment for maternal, neonatal, and child health, stillbirths remain invisible—not counted in the Millennium Development Goals, nor tracked by the UN, nor in the Global Burden of Disease metrics. At least 2·65 million stillbirths (uncertainty range 2·08 million to 3·79 million) were estimated worldwide in 2008 (≥1000 g birthweight or ≥28 weeks of gestation). 98% of stillbirths occur in low-income and middle-income countries, and numbers vary from 2·0 per 1000 total births in Finland to more than 40 per 1000 total births in Nigeria and Pakistan. Worldwide, 67% of stillbirths occur in rural families, 55% in rural sub-Saharan Africa and south Asia, where skilled birth attendance and caesarean sections are much lower than that for urban births. In total, an estimated 1·19 million (range 0·82 million to 1·97 million) intrapartum stillbirths occur yearly. Most intrapartum stillbirths are associated with obstetric emergencies, whereas antepartum stillbirths are associated with maternal infections and fetal growth restriction. National estimates of causes of stillbirths are scarce, and multiple (>35) classification systems impede international comparison. Immediate data improvements are feasible through household surveys and facility audit, and improvements in vital registration, including specific perinatal certificates and revised International Classification of Disease codes, are needed. A simple, programme-relevant stillbirth classification that can be used with verbal autopsy would provide a basis for comparable national estimates. A new focus on all deaths around the time of birth is crucial to inform programmatic investment.

Stillbirths: the professional organisations' perspective

Original Text

Gamal I Serour a, Sergio A Cabral b, Bridget Lynch c

The International Federation of Gynecology and Obstetrics (FIGO), the International Paediatric Association (IPA), and the International Confederation of Midwives (ICM) are well aware of the often forgotten issue of stillbirth, and recognise it as one of the most common adverse pregnancy outcomes worldwide—with about 2·6 million or more stillbirths happening every year.1 The explanation for many of these deaths is straightforward and terrible: all too often a trained health worker is not available when an expectant mother or woman in labour faces a situation endangering her baby's life. When confronted with a stillbirth, obstetricians, midwives, and paediatricians have to contend not only with the loss of life, but also the distress of parents and disappointment of family at a time that should be joyous and about bringing a new life into the world. Furthermore, the outcome of the next pregnancy is often a major concern for parents, because a previous stillbirth is, depending on the population, associated with a two-fold to four-fold increased risk2—4 of recurrence compared with women who have had a previous livebirth. Additionally, risk of pregnancy and birth complications in the subsequent pregnancy is heightened.5

Maternal and fetal outcomes at birth are a sensitive indicator of the status of health systems. They show the quality of care that is available to manage maternal and fetal life-threatening complications, which are often unpredictable and need a rapid, skilled response and access to tertiary emergency obstetric services, including well coordinated teamwork between obstetricians, midwives, and paediatricians. Access to such services in 33 of 51 Countdown countries is poor, resulting in rural coverage rates for caesarean section below 5%, which are indicative of challenges to human resources and other health systems. Four countries, Burkina Faso, Chad, Ethiopia, and Niger, have rural rates below 1%.6 Only 15 Countdown countries meet the crucial threshold of 23 doctors, nurses, and midwives per 10 000 people. These numbers are estimated to be necessary to ensure that 80% of all births have assistance from a skilled attendant to deliver essential health services.7 This shortage is compounded by uneven geographical distribution of these health-care workers within countries.8

FIGO's mission to improve women's health, rights, and access to reproductive and sexual health services, and reduce disparities in health care for women and newborn babies places prevention and management of stillbirth in the centre of its interest and activities.9 The ultimate goal of obstetricians, midwives, and paediatricians is that every pregnancy is wanted, every birth safe, every newborn baby healthy, and every woman, including adolescents, treated with dignity and respect. In cases of stillbirth, obstetricians, midwives, and paediatricians face the psychological and emotional issues arising for women, their partners, and families. Unfortunately, many of these women and couples do not receive comprehensive counselling about the reasons behind the stillbirth, the potential for it to recur, and how to prevent it in a subsequent pregnancy. Because a definitive cause cannot be identified in about half of cases,2 stillbirth baffles obstetricians, midwives, neonatologists, and paediatricians, making counselling very difficult, even in developed countries where advances in socioeconomic standards and high-quality antenatal and intrapartum care have contributed to reduced rates.

Obstetricians, midwives, and paediatricians should be pleased that The Lancet has published a Series on this important health issue. We believe that FIGO, IPA, and ICM have a major part to play in saving the lives of millions of stillborn babies worldwide, especially in developing countries. We must also address the distress of millions of couples who are affected. At the microlevel, obstetricians, midwives, and paediatricians can contribute to important measures such as advocacy, health education, high-quality health-care services during pregnancy and childbirth, including addressing the leading causes of stillbirths, and access to emergency obstetric care when needed. We must also work together to provide proper informative and supportive counselling of parents of a stillborn baby. At the macrolevel, these three organisations can make a difference through advocacy, partnership with UN and other organisations, training and education, capacity building of member associations to provide high-quality maternal and neonatology care, and task shifting when specialists are in short supply.10

Full-size image (77K) Science Photo Library

GIS is the President of FIGO, SAC is the President of IPA, and BL is the President of ICM.

References

1 Cousens S, Stanton C, Blencowe H, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet 201110.1016/S0140-6736(10)62310-0. published online April 14. PubMed

2 Herring A, Reddy U. Recurrence risk of stillbirth in the second pregnancy. BJOG 2010; 117: 1173-1174. CrossRef | PubMed

3 Sharma PP, Salihu HM, Kirby RS. Stillbirth recurrence in a population of relatively low risk mothers. Paediatric Perinat Epidemiol 2007; 21 (supp 1): 24-30. PubMed

4 Bhattacharya S, Prescott G, Black M, Shelty A. Recurrence risk of stillbirth in a second pregnancy. BJOG 2010; 117: 1234-1247. PubMed

5 Black M, Sheltie A, Bhattacharya S. Obstetric outcomes subsequent to intrauterine death in the first pregnancy. BJOG 2008; 115: 269-274. CrossRef | PubMed

6 WHO, UNICEF. Countdown to 2015: decade report (2000—2010). Taking stock of maternal, newborn and child survival. http://www.countdown2015mnch.org/documents/2010report/CountdownReportOnly.pdf. (accessed Jan 16, 2011).

7 WHO. Working together for health: the world health report 2006. http://www.who.int/whr/2006/whr06_en.pdf. (accessed Jan 16, 2011).

8 WHO. Global health atlas. http://apps.who.int/globalatlas/default.asp. (accessed Jan 16, 2011).

9 Serour GI. A vision for FIGO 2009—2012. Int J Gynaecol Obstet 2010; 108: 93-96. CrossRef | PubMed

10 Serour GI. Brain drain. Int J Gynaecol Obstet 2009; 106: 175-178. CrossRef | PubMed

a International Islamic Centre For Population Studies and Research, Al Azhar University, Cairo, Egypt

b International Pediatric Association, Estacio de Sa University, Rio de Janeiro, Brazil

c Canadian Association of Midwives, Montréal, Québec, Canada

 

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2.6 Million Babies Stillborn In 2009

Some 2.6 million stillbirths occurred worldwide in 2009, according to the first comprehensive set of estimates published today in a special series of The Lancet medical journal.

Every day more than 7200 babies are stillborn - a death just when parents expect to welcome a new life - and 98% of them occur in low- and middle-income countries. High-income countries are not immune, with one in 320 babies stillborn - a rate that has changed little in the past decade.

The new estimates show that the number of stillbirths worldwide has declined by only 1.1% per year, from 3 million in 1995 to 2.6 million in 2009. This is even slower than reductions for both maternal and child mortality in the same period.

The five main causes of stillbirth are childbirth complications, maternal infections in pregnancy, maternal disorders (especially hypertension and diabetes), fetal growth restriction and congenital abnormalities.

When and where do stillbirths occur?

Almost half of all stillbirths, 1.2 million, happen when the woman is in labour. These deaths are directly related to the lack of skilled care at this critical time for mothers and babies.

Two-thirds happen in rural areas, where skilled birth attendants - in particular midwives and physicians - are not always available for essential care during childbirth and for obstetric emergencies, including caesarean sections.

The stillbirth rate varies sharply by country, from the lowest rates of 2 per 1000 births in Finland and Singapore and 2.2 per 1000 births in Denmark and Norway, to highs of 47 in Pakistan and 42 in Nigeria, 36 in Bangladesh, and 34 in Djibouti and Senegal. Rates also vary widely within countries. In India, for example, rates range from 20 to 66 per 1000 births in different states.

It is estimated that 66% - some 1.8 million stillbirths - occur in just 10 countries: Afghanistan, Bangladesh, China, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria, Pakistan, and the United Republic of Tanzania.

Comparing stillbirth rates in 1995 to 2009, the least progress has been seen in sub-Saharan Africa and Oceania. However, some large countries have made progress, such as Bangladesh, China, and India, with a combined estimate of 400 000 fewer stillbirths in 2009 than in 1995. Mexico has halved its rate of stillbirths in that time.

"Many stillbirths are invisible because they go unrecorded, and are not seen as a major public health problem. Yet, it is a heartbreaking loss for women and families. We need to acknowledge these losses and do everything we can to prevent them. Stillbirths need to be part of the maternal, newborn and child health agenda," says Dr Flavia Bustreo, WHO's Assistant Director-General for Family and Community Health.

Well-known interventions for women and babies would save stillbirths too

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