An Evaluation of Risk Factors for Intra-Uterine Fetal Demise (IUFD) in the Bronx, NY from 1995-2006
Somnath Pal, Department of Pharmacy and Administrative Sciences, College of Pharmacy and Health Sciences
Sandra E. Reznik, Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences
Michael McLemore, Nitesh Jasani, Jacob J. Steinberg
Abstract
Diabetes mellitus and ascending bacterial infection are complications that affect the structure and function of placental and fetal tissues and can even lead to intrauterine fetal demise, particularly among minority mothers of lower socioeconomic status. Diabetes in particular, is becoming an important risk factor, as the generation with the highest prevalence of obesity and Type II diabetes ever is now reaching reproductive age. At present, no study has evaluated these factors in the medically underserved, low-income, minority community of the Bronx, NY. We hypothesize that in this region, cases associated with these risks have increased in incidence over the last 12 years.
Design: 170 autopsy cases for IUFD, performed at Montefiore Medical Center (MMC) in the Bronx, NY, from 1995-2006, were stratified into 2 groups by date and compared.
Results: Group 1 (1995-2000, n=70): Hispanic (27/66), Black (19/66), male (41/70), and female (29/70). Group 2 (2001-2006, n=100): Hispanic (51/96), Black (37/96), male (47/100), and female (53/100).
Between groups, the incidence of cases with maternal diabetes (I, II, or gestational) increased significantly from 4.3% (3/70) to 13.3% (13/98) (Fisher's exact, p<0.05).
The incidence of cases with chorioamnionitis increased significantly from 10.8% (7/65) to 22.7% (22/97) (p<0.05). None of the group 1 cases and 6 of the group 2 cases (27.3%) were associated with known maternal infection; 5 of these latter 6 cases (83.3%) were linked to Group B Streptococcal infection (GBS).
IUFD cases involving funisitis increased in incidence from 3.1% (2/65) to 11.3% (11/97), which was significant (p<0.05). None of these cases in either group was associated with maternal infection.
The incidence of cases with large placentas for gestational age (weight > 90% expected) increased significantly from 17.7% (11/62) to 29.5% (28/95) (p<0.05). The odds (OR) that these cases were also associated with maternal DM increased significantly between groups from OR=0 to OR=6.2 (95% CI=1.69-22.79).
Cases with placental structural anomalies (circumvellate, circumarginate, or bilobed) significantly decreased in incidence from 13.8% (9/65) to 4.1% (4/97) (p<0.05).
The incidence of large stillborns for gestational age (fetal weight > 1 standard deviation of expected) declined significantly from 31.4% (22/70) to 12.1% (12/99) (p=0.002). The odds that these cases involved maternal DM increased significantly between groups from OR=1.10 (CI=0.09-12.76) to OR=22.4 (CI=5.20-96.51).
Cases involving a maternal history of previous therapeutic abortion significantly decreased in incidence from 34.9% (22/63) to 19.0% (16/84) (p<0.05).
Conclusions
The incidences of cases related to DM, chorioamnionitis, funisitis, and enlarged placentas have all increased at MMC over the last 12 years. Although rates of placental anomalies and fetal macrosomia dropped, the association between diabetes and the size of the placenta or fetus has now become apparent in recent years. These findings are alarming because they reflect a rising trend in the rates of diabetes among mothers of minority, lower socioeconomic backgrounds. Diabetes exerts profound vasculopathic and dystrophic effects on placental and fetal tissue and contributes thereby to structural anomalies, organomegaly, and even adverse obstetrical outcomes. The results here underscore the growing impact of prenatal disease on fetal life, and the need for sustained medical care in regions like the Bronx. Our results can be used to guide prenatal care programs in other low-income neighborhoods, so that initiatives which provide minority mothers with systematic screening and treatment for DM, and for infections due to GBS, can be implemented to reduce their risk for IUFD.