Biological indicators of the in-utero environment and their association with birth weight for gestational age.

Birth weight for gestational age (BW/GA) has been associated with a risk of adverse health outcomes. Biological indices of pregnancy complications, maternal mid-pregnancy serum biomarkers and placental pathology may shed light on these associations, but at present, they are most often examined as single entities and offer little insight about overlap. In addition, these indices are typically assessed in relation to the extremes of the BW/GA distribution, leaving open the question of how they relate to the entire BW/GA distribution. Addressing issues such as these may help elucidate why postnatal health outcomes vary across the BW/GA continuum. In this study, we focused on a subset of women who participated in the Pregnancy Outcomes and Community Health Study (n = 1371). We examined BW/GA (i.e. gestational age and sex-referenced z-scores) in relation to obstetric complications, second trimester maternal serum screening results and histologic evidence of placental pathology along with maternal demographics, anthropometrics and substance use. In adjusted models, mean reductions in BW/GA z-scores were associated with preeclampsia (ß = -0.70, 95% CI -1.04, -0.36), high maternal serum alpha fetoprotein (ß = -0.28, 95% CI -0.43, -0.13), unconjugated estriol (ß = -0.31/0.5 multiples of the median decrease, 95% CI -0.41, -0.21) and high levels of maternal obstructive vascular pathology in the placenta (ß = -0.46, 95% CI -0.67, -0.25). The findings were similar when preterm infants, small-for-gestational age or large-for-gestational age infants were excluded. More research is needed to examine how the factors studied here might directly mediate or mark risk when evaluating the associations between BW/GA and postnatal health outcomes.

Evidence of placental haemorrhage and preterm delivery.

OBJECTIVE: To evaluate evidence of placental haemorrhage (PH) obtained through maternal interviews, patient charts and placental pathology examinations as potential indicators of a 'bleeding pathway' to preterm delivery (PTD). DESIGN: Prospective cohort. SETTING: Fifty-two clinics in five communities in Michigan, USA (1998-2004). POPULATION: A subset (n = 996) of cohort participants with complete placental pathology data. METHODS: First-trimester bleeding and placental abruption were ascertained by mid-trimester interviews and chart review, respectively. Disc-impacting blood clot was defined as a gross placental examination finding of a blood clot impacting adjacent tissue. Microscopic haemorrhage was defined as 'high' (top quintile) scores on an aggregate measure of placental pathology findings suggestive of atypical maternal vessel haemorrhage. These four PH indicators were compared with one another and with risk of PTD assessed by logistic regression analyses. MAIN OUTCOME MEASURES: Preterm delivery and PTD subtypes (i.e. <35 weeks, 35-36 weeks; spontaneous, medically indicated) compared with term deliveries. RESULTS: Placental abruption cases had 2.3-fold to 5.5-fold increased odds of the other three PH indicators. Disc-impacting blood clots and microscopic haemorrhage were associated with one another (odds ratio [OR] = 4.6), but not with first-trimester bleeding. In a multivariable model that included all four PH indicators and confounders, risk of PTD < 35 weeks was elevated with first-trimester bleeding (OR = 1.9 [1.0, 3.4]), placental abruption (OR = 5.2 [1.7, 16.2]), disc-impacting blood clots (OR = 2.3 [1.0, 5.0]) and microscopic haemorrhage (OR = 2.4 [1.4, 4.2]). CONCLUSIONS: Multiple clinical and subclinical PH indicators are associated with PTD, particularly early PTD.

Pericardial laceration and fatal cardiac herniation in an improperly restrained six-month-old infant.

We present the youngest reported patient to suffer pleuropericardial laceration with fatal cardiac herniation from blunt chest trauma, apparently related to the improper use of an infant restraint device. Pericardial laceration with cardiac herniation occurs infrequently, but should be suspected in this setting when a patient in electromechanical dissociation is unresponsive to standard resuscitation measures.