Investigating Mechanisms of Stillbirth in the Setting of Prenatal Substance Use

Intrauterine and Neonatal Deaths: The 2013-2023 Experience of the Cuyahoga County Medical Examiner's Office

ABSTRACT

Forensic investigation of intrauterine and perinatal deaths can be challenging, given their relative infrequency and the possible involvement of maternal substance use, trauma, and socioeconomic factors. Intrauterine and perinatal deaths investigated by the Cuyahoga County Medical Examiner's Officer between 2013-2023 were reviewed. One hundred twenty-eight cases were identified (83 stillborn and 45 live births). The predominant indications for referral were concern for maternal substance use (57.8%) or trauma (35.2%). Gestational ages ranged from 11.5 to 42.5 weeks; 36.7% were <22 weeks, and only 10.2% were full term (>37 weeks). The maternal age range was 16-41 years, with most (65.2%) between 20-34 years. Not all case files included obstetric history or home address; of those which did, 53.0% received no prenatal care and 81.7% came from zip codes in the bottom quartile of household incomes. Causes of death included acute and/or chronic maternal substance use (28.9%), chorioamnionitis (21.9%), and abruption (19.5%). Manners of death (when applicable) included natural (53.3%), accident (26.7%), homicide (8.9%), and undetermined/unassigned (11.1%). Potentially confounding socioeconomic factors were identified in most cases. This demonstrates the importance of considering these factors and exercising caution when assigning specific causes and manners to intrauterine and perinatal deaths.

Prenatal Alcohol Exposure and Transient Systemic Hypoxia-Ischemia Result in Subtle Alterations in Dendritic Complexity in Medial Frontal Cortical Neurons in Juvenile and Young Adult Rat Offspring in a Pilot Study

Prenatal alcohol exposure (PAE) is associated with long-term neurodevelopmental deficits resulting in impaired executive functioning and motor control. Intriguingly, PAE has been linked with an increased risk of transient systemic hypoxia-ischemia (TSHI), which alone results in suboptimal fetal growth and neurodevelopmental consequences. Here, using two translationally relevant preclinical models, we investigated the short-term and lasting effects of PAE and TSHI on the morphology of the medial prefrontal cortex (mPFC), a region important in executive function, and tested whether PAE interacts with TSHI to produce a distinct pattern of injury relative to either condition alone. The four experimental groups included sham (saccharin water, no TSHI), PAE (5% alcohol, no TSHI), TSHI (saccharin water, TSHI), and PAE+TSHI (5% alcohol, TSHI). Brains were extracted for Golgi-Cox staining at Postnatal Day 35 (P35) or P100 and processed for 3D Sholl analysis. The analysis of the mPFC at P35 showed no significant differences in the number of branches or dendritic length overall, although the impact of TSHI compared to alcohol was significant for both. There were no significant differences in the number of Sholl intersections overall at P35, although a sex difference was noted in PAE offspring. At P100, analysis of filament dendritic length and branching number was also significantly impacted by TSHI compared to alcohol. Interestingly, sex was also a significant factor when assessing the impact of alcohol. PAE and TSHI both had an insignificantly increased number of Sholl intersections at P100 compared to the control. The observed changes to dendritic complexity at P100 demonstrate altered neuronal morphology in the mPFC that endure into adulthood. Given the importance of the mPFC in executive functioning, these pilot data provide insight into morphological changes that may contribute to the neurobehavioral deficits observed following exposure to PAE and TSHI and highlight the need for additional investigations into this area.

Perinatal arterial ischemic stroke: how informative is the placenta?

Neuroplacentology is an expanding field of interest that addresses the placental influence on fetal and neonatal brain lesions and on further neurodevelopment. The objective of this study was to clarify the link between placental pathology and perinatal arterial ischemic stroke (PAIS). Prior publications have reported different types of perinatal stroke with diverse methodologies precluding firm conclusions. We report here the histological placental findings in a series of 16 neonates with radiologically confirmed PAIS. Findings were grouped into 3 categories of lesions: (1) inflammation, (2) placental and fetal hypoxic lesions, and (3) placentas with a high birthweight/placenta weight ratio. Matched control placentas were compared to the pathological placentas when feasible. The eight term singleton placentas were compared to a series of 20 placentas from a highly controlled amniotic membrane donation program; in three twin pregnancies, the placental portions from the affected twin and unaffected co-twin were compared. Slightly more than half (9/16, 56%) had histopathological features belonging to more than one category, a feature shared by the singleton control placentas (13/20, 65%). More severe and extensive lesions were however observed in the pathological placentas. One case occurring in the context of SARS-CoV-2 placentitis further expands the spectrum of COVID-related perinatal disease. Our study supports the assumption that PAIS can result from various combinations and interplay of maternal and fetal factors and confirms the value of placenta examination. Yet, placental findings must be interpreted with caution given their prevalence in well-designed controls.

Sex-specific alterations in cognitive control following moderate prenatal alcohol exposure and transient systemic hypoxia ischemia in the rat

BACKGROUND

Prenatal alcohol exposure (PAE) continues to be a worldwide problem. Affected offspring display impaired neurodevelopment, including difficulties with executive control. Although PAE has also been associated with decreased blood flow to fetuses, the relationship between PAE and altered blood flow is not well understood.

METHODS

We used preclinical models of PAE, transient systemic hypoxia ischemia (TSHI), and PAE + TSHI combined to assess the effects on neurodevelopmental outcomes using translationally relevant touchscreen operant platform testing. Twenty-eight Long-Evans (Blue Spruce, Strain HsdBlu:LE) dams were randomly assigned to one of four experimental groups: Saccharin Control (Sham), 5% Ethanol (PAE), TSHI, or 5% Ethanol and TSHI (PAE + TSHI). Dams consumed either saccharin or 5% ethanol during gestation. TSHI was induced on Embryonic Day 19 (E19) during an open laparotomy where the uterine arteries were transiently occluded for 1 h. Pups were born normally and, after weaning, were separated by sex. A total of 80 offspring, 40 males and 40 females, were tested on the 5-Choice Continuous Performance paradigm (5C-CPT).

RESULTS

Female offspring were significantly impacted by TSHI, but not PAE, with an increase in false alarms and a decrease in hit rates, omissions, accuracy, and correct choice latencies. In contrast, male offspring were mildly affected by PAE, but not TSHI, showing decreases in premature responses and increases in accuracy. No significant interactions between PAE and TSHI were detected on any measure.

CONCLUSION

Transient systemic hypoxia ischemia impaired performance on the 5C-CPT in females, leading to a bias toward stimulus responsivity regardless of stimulus type. In contrast, TSHI did not affect male offspring, and only slight effects of PAE were seen. Together, these data suggest that TSHI in females may cause alterations in cortical structures that override alterations caused by moderate PAE.

Beyond body mass index: a synthesis of lifestyle factors that may influence in vitro fertilisation outcomes

There are several lifestyle factors that are thought to potentially impact in vitro fertilisation outcomes, including body mass index, smoking, alcohol consumption, caffeine, dietary patterns and physical activity. Eligibility criteria for in vitro fertilisation in England often require individuals to be non-smokers, drug free and have a body mass index <30kg/m2. Some researchers have questioned the scientific and ethical basis for the use of body mass index thresholds in fertility treatment, citing evidence that other factors may have a greater effect on the chance of success of in vitro fertilisation. This article aims to briefly synthesise the current evidence on how other factors such as smoking, alcohol, recreational drugs, smoking, caffeine, dietary patterns and physical activity may impact in vitro fertilisation outcomes.

Effect of Prenatal Opioid Exposure on the Human Placental Methylome

Prenatal exposure to addictive drugs can lead to placental epigenetic modifications, but a methylome-wide evaluation of placental DNA methylation changes after prenatal opioid exposure has not yet been performed. Placental tissue samples were collected at delivery from 19 opioid-exposed and 20 unexposed control full-term pregnancies. Placental DNA methylomes were profiled using the Illumina Infinium HumanMethylationEPIC BeadChip. Differentially methylated CpG sites associated with opioid exposure were identified with a linear model using the ‘limma’ R package. To identify differentially methylated regions (DMRs) spanning multiple CpG sites, the ‘DMRcate’ R package was used. The functions of genes mapped by differentially methylated CpG sites and DMRs were further annotated using Enrichr. Differentially methylated CpGs (n = 684, unadjusted p < 0.005 and |∆β| ≥ 0.05) were mapped to 258 genes (including PLD1, MGAM, and ALCS2). Differentially methylated regions (n = 199) were located in 174 genes (including KCNMA1). Enrichment analysis of the top differentially methylated CpG sites and regions indicated disrupted epigenetic regulation of genes involved in synaptic structure, chemical synaptic transmission, and nervous system development. Our findings imply that placental epigenetic changes due to prenatal opioid exposure could result in placental dysfunction, leading to abnormal fetal brain development and the symptoms of opioid withdrawal in neonates.

Scoping Review of Best Practice Guidelines for Care in the Labor and Birth Setting of Pregnant Women Who Use Methamphetamines

OBJECTIVE

To use a scoping review to explore the existing literature on best practice guidelines for safe, dignified, and compassionate care in the labor and birth setting for pregnant women who use methamphetamines.

DATA SOURCES

We conducted a systematic search for articles and best practice guidelines from health-related databases (MEDLINE; CINAHL; and the Web of Science, including the Core Collection and Social Science Citation Index, PsycInfo, Women's Studies International, and Sociological Abstracts) and gray literature. Search terms included substance use disorder, methamphetamine, childbirth, and labor and delivery.

STUDY SELECTION

We included English-language, peer-reviewed reports of primary research, systematic reviews, and practice guidelines from credible databases and organizations published between 1991 and 2020. We screened 1,297 resources and agreed to review 156 articles and 16 gray literature resources in the full-text analysis. Nine of the 156 articles and 16 gray literature resources met the inclusion criteria.

DATA EXTRACTION

We used the Joanna Briggs Institute review guidelines (2015) criteria for extraction of the following data: author(s); year of publication; type of study; objectives; country of origin; study population and sample size (if applicable); inclusion of best practice guidelines for the labor and birth setting; care approaches specific to safety, dignity, compassion; and the targeted substance(s) discussed (e.g., methamphetamine, opioids, etc.). We further documented the phenomena of interest to determine if articles or best practice guidelines included safe, dignified, and compassionate care approaches specific to pregnant women who use methamphetamine.

DATA SYNTHESIS

We summarized the best practice guidelines, which included universal screening, assessment, and management of analgesia during labor, as well as broad guidance regarding the inclusion of a multidisciplinary health care team. Safe, dignified, and compassionate care approaches were focused on communication, shared decision making, and the provision of nonjudgmental care. Although evidence about substance use during the childbearing years is increasing, stronger evidence for clinical care approaches in the labor and birth setting is needed, inclusive of all stakeholder perspectives.

CONCLUSION

The articles and best practice guidelines reviewed provided broad clinical recommendations that were applicable to pregnant women who use methamphetamine. However, we did not find a complete comprehensive best practice guideline for labor and birth that was specific, was solution focused, and delineated a safe, dignified, and compassionate care approach.

A Survey of Fetal Deaths as Reported to a Medical Examiner's Office

ABSTRACT

This article is a review of the fetal deaths reported to the Pima County Office of the Medical Examiner in Tucson, Arizona, from January 2000 to May 2020. The 115 cases included in this study were analyzed for the decedent's estimated gestational age, sex, maternal drug use, toxicology results, and cause of death. The male/female ratio was 0.95:1.0. The average gestational age of nonterm infants older than 20 weeks was 27.2 weeks. Nearly half of the cases had suspected or known maternal drug use. In these cases, cocaine and methamphetamine were most often detected in postmortem testing of the fetus. The most common causes of death in descending frequency were intrauterine fetal demise of unknown etiology, drugs, infection, and prematurity. Other notable causes of death included trauma and placental abruption. Congenital malformations were detected in only 3.5% of cases.