B) The Electoral College was designed at a time when the framers of Essay

B) The Electoral College was designed at a time when the framers of the Constitution decided not to trust the common man in sele - Essay Example It is only used in presidential elections and appears to be used simply to increase the perceived margin of victory from the actual popular vote. Election reform supporters want to either eradicate the Electoral College system entirely and replace it with the direct popular vote or repair perceived defects in the present system. However, the Electoral College was put in place for a reason by the same minds who founded the nation. Maybe we should try to better understand their motives before scrapping the system. States with smaller populations argue that if the electoral system were eliminated candidates for president would have no motivation to advertise or campaign there. â€Å"Why visit a small state with a media market that reaches, say, 100,000 people, when a visit to a large state can put the candidate in touch with millions?† (Gregg, 2001). Those opposed to the Electoral College want a direct national election, contending that it would better represent the diversity of the country. A direct election system would create incentives for campaigns to spend time and money in small states. Candidates would collect votes for their effort even if they lost the state as a whole. Even more importantly, â€Å"the financial calculus of election campaigns in a direct-election system might help level the playing field between large and small states.

Industrial Revolution Essay Example for Free

Industrial Revolution Essay While the Industrial Revolution had both positive and negative effects on society and the economy, the positive effects outweighed the negative. The Industrial Revolution was absolutely beneficial to the progress of the world from the 1800s all the way to present day. Sacrifices were made which allowed technological advancements during the Industrial Revolution, which in turn, created happiness, life opportunities, and an over-all, definite improvement of life. Even though at the beginning of the Industrial Revolution, many hardships had to be overcome, causing great grief to most of the population. Faith was lost, patience was tried, and a blanket of oppression covered the people of Europe. When new inventions rose to aid the producing and mass-producing of goods that supplied the people of Europe, nearly everyone was forced to begin a new career within a factory. These are just some of the hardships that many loyal, hardworking citizens were faced with. The Industrial Revolution had a more positive effect on Western society in the 19th century. Although child labor during the 1820s was quite hard on most of the children working and also proved to be quite dangerous, it still brought about the creation of child labor laws and also the funding of schools. As factories began to develop, the organization within them also stepped up. There was an increase in production and assembly lines took place creating a more orderly environment to be working in. Also, many inventions started to develop and be discovered, creating an easier and more accurate way of doing things, not just in factories, but also in the home. Lastly, railroads were a big part of the Industrial Revolution in that they created a faster and cheaper way to transport goods and materials from one place to another. The Industrial Revolution had many hardships, but also it had point were it created happiness for many people. Now you know why I believe that the positive effects outweighed the negative effects.

Causes of Stillbirth

Causes of Stillbirth Abstract: Feto-infant mortality is increasing worldwide. Stillbirth is defined as uterofetal death at 20 weeks of gestation or greater. Stillbirths contribute as a primary factor to the growing magnitude of feto-infant mortality. The reasons for stillbirth are usually not reported. In many cases, the specific cause of fetal death remains unknown. The key risk factors include smoking, increased maternal age, being overweight, fetal-maternal hemorrhage. Even though there has been remarkable development in prenatal and intranatal care, stillbirths have been consistently increasing and remain an important problem in obstetrics and gynecology. Current research studies focus mainly on the epidemiology of stillbirths. I review the known and suspected causes of stillbirth. It also describes the recommended diagnostic tests to evaluate definite cause of stillbirth. In this paper, I also review analysis of stillbirths in the United States (US). The National Center of Health Statistics recorded 26,359 stillbirths in 2001. The number of stillbirths can be greatly reduced if the specific reasons for stillbirth are understood. Introduction: A pregnancy ending in stillbirth can be mentally devastating to a patient and her family. The most widely accepted definition of stillbirth is death of the fetus inside the uterus at 20 weeks of gestation or greater (Cartlidge et al., 1995). Much information is available on protocols for evaluating other types of postmortem examination but little work has been done on the evaluation of the causes of stillbirths (Mirlene et al., 2004). No universally followed protocol is available to guide the evaluation of stillbirths. In part because a wide variety of causes can be involved in stillbirths and it can be difficult to designate a specific cause of death. A stillbirth might result from various diseases, infections, trauma or genetic defects in the mother or fetus (Gardosi et al., 2005). In many cases, a specific reason is not known. Even though stillbirths are a serious problem, few resources have been focused on them and most obstetricians lack a sound method of evaluating of stillbirths (Petersson, 2002). In this document, I will review the accepted causes of still birth and the suggested diagnostic tests for evaluating the reason behind stillborn infants. In the year 2001 in the US, the National Center of Health Statistics recorded 26,359 stillbirths (Ananth et al., 2005). When compared to 27,568 infant deaths were reported in the same year. More than half of the stillbirths are before 28 weeks of gestation and almost 20% are close to the term. If a history of stillbirth exists then there is a 5-fold increase for subsequent stillbirth to occur. Prominent racial discrimination occurs in the rates of stillbirths. Stillbirths are almost three times more prevalent in African Americans when compared to whites (Puza et al., 2006). In 2001, the rate of stillbirths among white mothers was 5.5 per 1000 live births and 12.1 per 1000 among the black mothers. According to an analysis of U.S. vital statistics between 1995 and 1998, the increased risk of black, compared with white, stillbirths is greatest among singleton stillbirths (Puza et al., 2006). Reduction of proportion of fetal deaths at gestation of 20weeks or longer to 4.1 per 1000 live births and also reduction of fetal deaths for all racial and ethnic groups are the objectives of U.S. National Health for 2010. Categorization of Stillbirths: Different attempts were made in order to classify causes of stillbirth. Baird and his colleagues were among the first to classify the causes of perinatal death from the available clinical information. Depending on the British perinatal mortality survey, in 1958 Butler and Bonham designed a classification scheme that included the results of postmortem examinations. The most widely used is the 9 category classification system formulated by Wigglesworth and his coworkers (Wigglesworth, 1980). A new classification scheme which does not include neonatal deaths was proposed by Gardosi and his colleagues known as the ReCoDe Classification which focuses on the relevant conditions at the time of death in the uterus. It includes factors which affect the fetus followed by the factors which affect the mother (Gardosi et al., 2005). When compared with the Wigglesworth classification, a remarkable decrease in the number of unclassified stillbirth was achieved using this classification. One of the most vital aspects is to develop a proper definition of the factors that lead to death of the fetus. The basic definition for the â€Å"cause of death† is injury or disease responsible for a death. Froendefined cause of death in stillbirth as â€Å"an event or condition of sufficient severity, magnitude, and duration for death to be expected in a majority of such cases in a continued pregnancy in the clinical setting where it was observed† (Froen, 2002). When the definition of â€Å"cause of death† is reviewed, it is observed that only a few disorders are directly responsible for fetal death while many others are not. Causes of Stillbirth: Infection: Infections such as viral, protozoal and bacterial are linked with stillbirth. Almost 10-25% of stillbirths result from feto-maternal infections in the developed countries where as bacterial infections are common in developing countries (Goldenberg et al., 2003). Stillbirths that result from infection might be due to various factors which include direct infection, placental damage, and severe maternal illness. Usually the stillbirths in the initial weeks of gestation are linked with infection. Bacterial infections caused by Escherichia coli, group B streptococci, and Ureaplasma urealyticum are a cause of stillbirth in developed countries (Goldenberg et al., 2003). If syphilis epidemic occurs in an area then it might be the cause of a considerable proportion of stillbirths. If women come in contact with a parasite like malaria for the first time then stillbirth might be attributed to it. Toxoplasma gondii, leptospirosis, Listeria monocytogenes, Q fever, and Lyme disease are associated with the occurrence of stillbirth (Goldenberg et al., 2003). The magnitude of stillbirths due to viral infections is not known mainly due to the absence of a well defined systematic evaluation of infections in stillborn infants. The problem lies behind the fact that these viruses are difficult to culture and moreover, a positive viral serological diagnostic test identifying the DNA or RNA of the virus in the fetal tissue or placental tissue does not definitely determine that infection was the reason behind death. In most of the cases, infection is linked with stillbirth in early gestational weeks around twenty weeks. If molecular diagnostic technology (DNA and RNA polymerase chain reaction [PCR]) is utilized, it will help in diagnosis of viral infections without any error. Parvovirus B-19 appears to have the strongest association with stillbirth. According to a Swedish survey, in 8%of stillbirths B-19 PCR positive tissues were observed (Enders et al., 2004). In the United States, less than 1% of all stillbirths are reported to be due to parvovirus infection Parvovirus B19 moves across the placenta spreading the infection to fetal erythropoetic tissue resulting in fetal anemia leading to fetal death (Wapner et al., 2002). Myocardial damage may also occur due to Parvovirus B19. Here the virus directly attacks the fetal cardiac tissue. Parvovirus infection that leads to stillbirth usually occurs before 20 weeks of gestation (Wapner et al., 2002). Enteroviruses which include Coxsackie A and B, echoviruses and other enteroviruses are associated with stillbirth. Coxsackie viruses can cross the placenta and lead to villous necrosis, inflammatory cell infiltration, calcific pancarditis, and hydrops. Echovirus infection begins with severe maternal illness and finally ends with stillbirth. Cytomegalovirus (CMV) belongs to herpesvirus family and it is a congenital viral infection. Initially, the mother is infected and then it is transmitted to the fetus. CMV causes placental damage leading to intrauterine fetal growth restriction, but an association with stillbirth remains controversial (Goldenberg et al., 2003). Viral infections in the mother like rubella, mumps and measles are linked with stillbirth. If the vaccinations are administered on time then the proportion of stillbirths occurring due to infections can be reduced greatly. Genetics: Genetic causes are responsible for a considerable magnitude of stillbirths. 6- 12% of stillbirths attributed to genetic etiologies are due to karyotyping abnormalities. Due to the fact that in some of the cases cells cannot be cultured, karyotyping is not possible. Such factors alter the exact estimate of stillbirths resulting from chromosomal abnormalities. In stillborn fetuses which show apparent structural defects the probability of chromosomal abnormality is much higher when compared to normal stillborn fetuses. The usually focused abnormalities include monosomy X (23%), trisomy 21 (23%), trisomy 18 (21%), and trisomy 13 (8%). There are many instances where the karyotype of the stillborn is normal yet the cause of death is a genetic abnormality. Indeed, 25-35% of stillborn infants undergoing autopsy have intrinsic abnormalities (Wapner et al., 2002) .These include single malformations (40%), multiple malformations (40%), and deformations or dysplasia (20%) (Wapner et al., 2002). Almost 25% ofstillborns due to intrinsic defects show an abnormal karyotype whereas the rest of the 75% may have genetic defects which are not identifiable by the regular cytogenetic tests. This holds good for fetuses with multiple abnormalities. Single gene mutations may be responsible for death of the fetus in early weeks of development. Stillbirths in the midgestational weeks might be due to abnormal placental growth, development, or angiogenesis. Some autosomal recessive disorders including glycogen storage diseases and hemoglobinopathies have been reported as the cause of stillbirth (Wapner et al., 2002). In male fetuses, X-linked disorders may prove to be fatal. Many other genetic defects that are not recognized by the conventional cytogenetic diagnostics may lead to stillbirth. For example, conventional karyotype cannot identify chromosomal microdeletions that are linked with unexplained mental retardation. Confined placental mosaicism has also been associated with fetal growth impairment and stillbirth (Kalousek et al., 1994). Heritable Thrombophilia is another probable etiology of stillbirth.It is thought that placental infarction occurs due to thrombosis in the uteroplacental circulation leading to death. This poses concern over other thrombophilic defects and their effects on stillbirth. It is noteworthy that many heritable thrombophilias are common in normal individuals without a history of thrombosis or pregnancy loss (Rey et al., 2003). Even though many studies relate thrombophilias to fetal loss, most of the women with thrombophilias have healthy pregnancies with no lethal complications. It can be said that in the absence of any previous obstetric problems, thrombophilia will not result in stillbirth. Feto-maternal Hemorrhage: Feto-maternal hemorrhage has been linked to almost 3- 14% of all stillbirths which implies that it is responsible for a considerable number of stillbirths. Obstetric procedures such as external cephalic version and cesarean section lead to fetal maternal hemorrhage. Hemorrhage can also result due to placental abruption and/or abdominal trauma during pregnancy. Fetal maternal hemorrhage must be identified and quantitated using a proper dependable diagnostic test to attribute this reason behind the death of fetus. Hypoxia and anemia are indicators of death due to fetal hemorrhage. So, they should be confirmed by autopsy as in some normal cases too, few fetal cells can be seen in maternal blood. Maternal Features: Delayed child bearing or increased maternal age, prepregnancy obesity and stress are found to have their effects on the occurrence of stillbirth. The underlying mechanisms of action are unknown; however, with both obesity and delayed child-bearing on the rise, their importance as potential causes of stillbirth deserves greater attention (Cnattingius et al., 2002). Women whose only risk factor is being overweight have about a 2-fold increased risk of stillbirth (Nohr et al., 2005). Likewise, compared with women younger than 35 years of age, the stillbirth rate is increased 2- fold for women 35-39 years of age, and 3- to 4-fold for women aged 40 years old or olderwhereas some age-associated risk is due to higher rates of maternal complications, in uncomplicated pregnancies there may be a 50% increased risk associated only with maternal age 35 years or older (Nohr et al., 2005). Stress is a suspected cause of stillbirth which might occur as a result of a major life event (such as loss or poverty) (Huang et al., 2000) or through unexplained health changes related to adverse childhood experiences (Hillis et al., 2004). Different exposures are attributed to stillbirth. One of the most prevalent and preventable cause of stillbirth is cigarette smoking (Hillis et al., 2004). Smoking negatively affects fetal growth and oxygen supply to the tissues as it produces high levels of carboxyhemoglobin and decreases blood supply to the placenta. Smoking is also associated with increased risks of placenta previa and placental abruption and women who stop smoking in the first trimester have stillbirth rates equivalent to women who never smoked which indicates that quitting smoking in early pregnancy may significantly reduce the chances of occurrence of stillbirth (Hillis et al., 2004). A variety of complications result due to continuous exposure of different recreational drugs. Consumption of cocaine during pregnancy is also linked with stillbirth because it causes fetal growth restriction and/or abruption. The use of meth amphetamines leads to premature deliveries and stunted growth but its association with stillbirth remains unknown. In some cases, alcohol consumption during pregnancy has been associated with an increased risk of stillbirth (Mary et al., 2006). According to a study in Scandinavia, for women who consume less than 1 drink per week, the rate of stillbirth is 1.37 per 1000 births while the rate increases to 8.83 per 1000 births in women who consume 5 drinks or more per week. If smoking habits, caffeine intake, prepregnancy body mass index, marital status, occupational status, education, parity, and fetal gender are considered, the risk of stillbirth for women consuming 5 drinks or more per week was 2.96 (95% confidence interval 1.37 to 6.41) (Mary et al., 2006). Some studies show a protective effect on both stillbirth and fetal growth restriction rates if small amounts of alcohol are consumed during pregnancy (Mary et al., 2006). A link between pesticide exposure and stillbirth was observed by Pastore and his colleagues in 1997. Occupational exposures prove to be deleterious compared to residential exposure because the occupational exposures cause congenital abnormalities in addition to risk of stillbirth. A noteworthy fact is that the use of fertility drugs is also associated with stillbirths. This finding is problematic due to the fact that many women make use of fertility treatments to conceive. However, data on stillbirths due to exposures is obtained from retrospective studies which are prone to bias. The link between exposures and stillbirth should therefore be dealt with great attention and care. Maternal Diseases: Diabetes: There is always an increased danger of stillbirths in second and third trimester for mothers who are affected with type I or type II diabetes mellitus (DM) pregestationally. Even with modern obstetric care and diabetes management, stillbirth rates in women with type 2 DM have been reported to be 2.5-fold higher than nondiabetic women (Mary et al., 2006). The rate of stillbirth is the same between women with gestational diabetes (GDM) as well as normal women when the whole population is taken into account. The magnitude of danger involved with fetal death in women with type II DM is identical to women with GDM who in fact entered the pregnancy with undiagnosed type II DM. Therefore, women with GDM who have an undiagnosed type II DM are usually at a greater danger of encountering stillbirth. Examples of women with undiagnosed type II DM include history of GDM in previous pregnancies, high fasting glucose values;random glucose values greater than 200mg/dL or diagnosis of GDM early in pregnancy. The reason behind fetal death in late gestation in diabetic women is not known precisely. In addition to an increased risk of fetal death in diabetic women, there also exists a higher magnitude of danger associated with fetal abnormalities in these women compared to healthy women. Stress, hypertension and obesity complement each other in DM patients. In women with DM, there is a higher risk of stillbirth as it may lead to fetal abnormalities which may be either abnormally increased growth rate or retarded growth. To maintain the physiological range of the plasma glucose level, tremendous amounts of insulin is produced by the fetus resulting in fetal hyperglycemia. This fetal hyperglycemia is acquired from maternal hyperglycemia which finally results in fetal death due to excessive growth. The precise limit of plasma glucose level which poses a threat to the fetal life is not well defined. The most that could be done is to detect and deal with it using needed medications to lower the incidents of stillbirths.Many other maternal diseases have been linked to stillbirth, including thyroid disease, cardiovascular disease, asthma, kidney disease, and systemic lupus erythematosus (Simpson, 2002). These are subclinical diseases which in many cases has not been proven to be direct causes of stillbirth and women had normal pregnancies giving birth to healthy babies. Multiple Gestation and Stillbirth: Nearly 3% of all births and 10% of all stillbirths result from multiple pregnancies. According to national vital statistics, 1.8% of twin, 2.4% of triplet, 3.7% of quadruplet, and 5.6% of quintuplet fetuses suffered intrauterine fetal deaths (Salihu et al., 2003). The stillbirth rate among singleton pregnancies is approximately 0.5%. The reason behind fetal death in multiple pregnancies is difficult to be resolved when compared to singleton pregnancies. The broad causes of fetal death in multiple pregnancies include fetal growth retardation, preclamsia, abruption and cord accidents. It is vital to determine the chorionicity of multiple gestations as the rate of stillbirth is higher in monochorionic multiple gestations (Salihu et al., 2003) (Lynch et al., 2007). Assisted Reproductive Technology (ART) is an essential aspect in the occurrence of multiple pregnancies and stillbirth (Helmerhorst et al., 2004). Complications in Fetus: Fetal Growth Restriction: Some stillbirths result from fetuses which are smaller for a particular gestational age (SGA) compared to normal fetuses. Birth weight and risk of stillbirth are inversely proportional. If one increases, the other decreases. The main fact behind stillbirths in this condition is retardation of fetal growth and not the small size of fetus. An obstacle that occurs in determining the precise time of death of fetus due to SGA is the fact that the death might have occurred a long time before but the gestational age at the time of delivery is considered to be the time of death. This gives a false implication of the magnitude of stillbirths resulting from SGA. This problem can be solved by analysis of early and mid pregnancy placental hormones which are very specific for gestational periods (Smith et al., 2004). An evaluation of the amounts of these hormones relates directly to the time of death. Umbilical Cord Accidents: An increased number of stillbirths are due to â€Å"accidents† of umbilical cord like cord occlusion or blockage due to true knots, nuchal cords and compression of the cord. In almost 30% of normal healthy infant deliveries, nuchal cord and true knots in umbilical cords are observed. According to a study in Sweden, 9% of stillbirths were due to cord accidents (Petersson, 2002). Determination of cord accidents leading to fetal death by autopsy is smaller in proportion (up to 2.5%) (Horn et al., 2004). This difference indicates that in the absence of a proper cause, many times fetal death is attributed to cord entanglement. Due to the increased load of complications with live infants, little concern is expressed towards dead fetuses. In order to precisely relate a fetal death to cord accident, a clear indication of either hypoxic tissue injury or cord occlusion must be observed in autopsy. As nuchal cords are observed in normal deliveries also, the exact proportion of stillbirths due to cord accidents is biased. Obstetric Complications: Some of the obstetric complications are preclampsia, preterm premature rupture of membranes, preterm labor, cervical insufficiency, abruption, placenta previa, and vasa previa. These may either be direct or primary causes or may be indirect or secondary causes of stillbirth. Almost 10-19% of stillbirths occur due to abruption. Since cervical insufficiency or preterm labor lead to neonatal death, their role in causing stillbirth is not well defined. Evaluation of Stillbirth Stillbirth in itself may be emotionally devastating to many patients and their families. There the likelihood of carrying out genetic testing or autopsy on the fetus may not be readily agreeable from the family and culture. Lastly the procedures for evaluation must be cost effective and within reach. The two important facts that should be kept in mind while deciding which tests would prove as the most useful ones are primarily the consideration of cost of that test. It should not be beyond limits. Secondarily, if this test would be helpful in prevention of recurrent or sporadic stillbirths. In recurrent stillbirths, medical interference may prove helpful by preventing them in future. Analyzing the etiology of sporadic stillbirths might lead to reassurance and avoid irrelevant diagnostic tests in future pregnancies. The single most useful diagnostic test is a fetal autopsy (Peterson et al., 1999). Not only does the visible genetic and structural abnormalities but also an autopsy would be of great help in relating specific etiologies to stillbirth. The frequency of fetal autopsy is very less due to the fact that it is costly, not many trained pathologists are available and also it may be of great discomfort to the family and clinicians to deal with such a case. If autopsy is refused, partial autopsy or postmortem magnetic resonance imaging (MRI) scans may provide the necessary data. Embryonic membranes, placenta and umbilical cord must be physically and histologically examined while evaluating stillbirth etiology. This would give a precise cause of fetal death and might also provide clues for death due to secondary causes like infections, thrombophilia, and anemia. In most cases, families do not object on placental evaluation. In the cases where autopsy is not performed karyotyping the fetus would prove helpful. Cells and tissues from placenta (especially chorionic plate), fascia lata, skin from the nape of the neck, and tendons can be isolated and cultured and used for diagnostic tests like karyotyping. Comparative genomic hybridization shows tremendous promise for the identification of chromosomal abnormalities in stillbirths wherein fetal cells cannot be successfully cultured (Silver et al., 2006). An autopsy followed by a careful histological examination might help in relating stillbirths that result due to infections from the bacteria or virus. Parvovirus serology may be useful because this virus has been implicated in a meaningful proportion of cases (Erik et al., 2002). Diagnostic tests are performed for the detection of syphilis also since it contributes to the list of accepted causes of stillbirth. For various viral and protozoal agents like toxoplasmosis, rubella, cytomegalovirus (CMV) and herpes simplex virus (HSV) {TORCH}, serological screening is carried out. For bacterial and viral infections in the fetus, nucleic acid based tests are more helpful when compared to tissue cultures. Feto-maternal hemorrhage can be detected using Kleihauer – Betke test (KBT). Most laboratories use manual KBT which is prone to error. It has been found that flow cytometry is a better tool in detecting fetal erythrocytes in maternal blood. In order to eliminate red cell alloimmunization as an etiology of stillbirth, an indirect Coomb’s test is performed. Autopsy and examination of placenta are helpful in this situation. During the initial prenatal visits, if the antibody screen comes out to be negative then there is a need for recurrent testing. Diagnostic tests for conditions like diabetes and heritable thrombophilias must be carried out on a regular basis to prevent any complications which may lead to stillbirth. The treatment of such conditions at the appropriate time may prevent similar complications in subsequent pregnancies. Heritable thrombophilia might be of concern in the cases where there is recurrent fetal loss or there is a history of thrombosis or with complications involving placental insufficiency like placental infarction and intrauterine growth restriction. Administration of illicit drugs through various modes may be a cause of stillbirth in many cases. Toxicological examination may reveal the results for women who are subjected to such exposures. A simple urinary examination may prove helpful. The advanced and cost effective technology like ELISA (Enzyme Linked Immuno Sorbent Assay) can be used to detect a variety of metabolites like steroids in various tissues like blood, hair, and homogenized umbilical cord. Conclusion: Many medical and nonmedical agents govern the best approach to evaluate a stillbirth. The obstacles faced by obstetricians in solving these issues include the fact that in most of the cases the reason behind fetal death is unknown. Also the magnitude of stillbirths resulting from a single cause is not known precisely. Here there arises a need for population based studies to attribute stillbirths to their specific etiologies. There is a clear cut need of experts in the field of perinatal pathology and the required funding should be provided at the national level to promote it. Moreover, the clinician should be aware of the history of pregnant women in better evaluation. In cases where the local clinicians cannot reach a conclusion, the tissue samples must be sent to senior pathologists who have a thorough command on the subject and can help in reaching decisive conclusions. A universally accepted protocol is required for a systematic evaluation of stillbirths. Due to its absence a difference of opinion occurs among the obstetricians and gynecologists. The institutions like Stillbirth Collaborative Research Network should formulate guidelines for the proper judgement of stillbirth etiologies. The responsibility lies in the hands of the clinicians to do the best they can to reach a definite conclusion from the available data. It is noteworthy that the proportion of stillbirths that are â€Å"explained† is much higher in centers using systematic evaluations for recognized causes and potential causes of stillbirth (Petersson, 2002) (Horn et al., 2004). In conclusion, autopsy, placental evaluation, karyotype, Kleihauer-Betke, antibody screen, and serologic test for syphilis are useful in evaluating the etiologies of stillbirth. Depending on the case, other relative tests should be performed. The approach towards the testing of potential causes of stillbirth is not clear if it should be very specific and sequential or should it be comprehensive which means that it is targeted towards a broad spectrum of causes. Each of these has its own advantage. Sequential testing avoids false positive results and is directed to a specific cause and more over, it is cost effective. Comprehensive testing may prove helpful in cases where more than one factor is responsible for stillbirth. The problem with autopsy, placental evaluation, karyotype, screen for fetal-maternal hemorrhage, and toxicology screen is that they are dependant on time, that is, these tests should be performed immediately after the delivery. Autopsy cannot be delayed because death of the fetus already occurred and this would lead to physiological changes in the whole body and decay begins. The necessary evidence for stillbirth is easily available from fresh samples of placenta and also for toxicology screen. As the time since death increases, the physiology of fetus also changes leading to false positive or false negative results. If the time of fetal examination is delayed, fetal hemorrhage may be mistaken for postmortem lividity. Therefore a serious call for action is expected from institutions like Stillbirth Collaborative Research Network (SCRN) which would help in creating the most applicable diagnostic setting for evaluation of stillbirth (Silver et al., 2006). SCRN was developed by the National Institute of Child Health and Human Development to target the range of etiologies of stillbirth in the U.S. The aim of SCRN is to focus on the following objectives. The use of standardized surveillance in a geographic catchment area will show that the stillbirth rates are greater than those reported in the vital statistics catchment. The use of a prospectively implemented, standardized, postmortem, and placental examination protocols will improve diagnosis of fetal or placental conditions that cause or contribute to stillbirth. Maternal biologic and environmental risk factors in combination with genetic predisposition increase the risk for stillbirth. This is a population based study which is carried out in different counties of different states in the U.S. This study would take into account all the stillbirths and live births occurring in rural as well as urban areas in different racial groups. Even though occurrence of stillbirths cannot be stopped completely, yet attempts of such sort can be made atleast to prevent them to a maximum extent. Glossary Abruptio placenta totalis A placental abruption is a serious condition in which the placenta partially or completely separates from the uterus before the baby is born. Achondrogenesis Dwarfism characterized by various bone aplasias and hypoplasias of the extremities and a short trunk with delayed ossification of the lower spine. Alloimmunization Development of antibodies in response to alloantigens; antigens derived from a genetically dissimilar animal of the same species. Angiogenesis The formation of new blood vessels. Anomaly abnormality Autosome a chromosome other than the X and Y sex-determining chromosomes. Camptomelia bending of the limbs that produce a permanent curving or bowing. Cholestasis a condition caused by rapidly developing or long-term interruption in the excretion of bile (a digestive fluid that helps the body process fat). Chondrodysplasia Congenital dwarfism similar to but milder than achondroplasia, not familial and not evident until mid-childhood, in which the skull and facial features remain normal. Chorioamnionitis Inflammation of the fetal membranes. Dystocia Difficult delivery or parturition. Erythema infectiosum mild infectious disease occurring mainly in early childhood, marked by a rosy-red maculopapular rash on the cheeks, often spreading to the tr Causes of Stillbirth Causes of Stillbirth Abstract: Feto-infant mortality is increasing worldwide. Stillbirth is defined as uterofetal death at 20 weeks of gestation or greater. Stillbirths contribute as a primary factor to the growing magnitude of feto-infant mortality. The reasons for stillbirth are usually not reported. In many cases, the specific cause of fetal death remains unknown. The key risk factors include smoking, increased maternal age, being overweight, fetal-maternal hemorrhage. Even though there has been remarkable development in prenatal and intranatal care, stillbirths have been consistently increasing and remain an important problem in obstetrics and gynecology. Current research studies focus mainly on the epidemiology of stillbirths. I review the known and suspected causes of stillbirth. It also describes the recommended diagnostic tests to evaluate definite cause of stillbirth. In this paper, I also review analysis of stillbirths in the United States (US). The National Center of Health Statistics recorded 26,359 stillbirths in 2001. The number of stillbirths can be greatly reduced if the specific reasons for stillbirth are understood. Introduction: A pregnancy ending in stillbirth can be mentally devastating to a patient and her family. The most widely accepted definition of stillbirth is death of the fetus inside the uterus at 20 weeks of gestation or greater (Cartlidge et al., 1995). Much information is available on protocols for evaluating other types of postmortem examination but little work has been done on the evaluation of the causes of stillbirths (Mirlene et al., 2004). No universally followed protocol is available to guide the evaluation of stillbirths. In part because a wide variety of causes can be involved in stillbirths and it can be difficult to designate a specific cause of death. A stillbirth might result from various diseases, infections, trauma or genetic defects in the mother or fetus (Gardosi et al., 2005). In many cases, a specific reason is not known. Even though stillbirths are a serious problem, few resources have been focused on them and most obstetricians lack a sound method of evaluating of stillbirths (Petersson, 2002). In this document, I will review the accepted causes of still birth and the suggested diagnostic tests for evaluating the reason behind stillborn infants. In the year 2001 in the US, the National Center of Health Statistics recorded 26,359 stillbirths (Ananth et al., 2005). When compared to 27,568 infant deaths were reported in the same year. More than half of the stillbirths are before 28 weeks of gestation and almost 20% are close to the term. If a history of stillbirth exists then there is a 5-fold increase for subsequent stillbirth to occur. Prominent racial discrimination occurs in the rates of stillbirths. Stillbirths are almost three times more prevalent in African Americans when compared to whites (Puza et al., 2006). In 2001, the rate of stillbirths among white mothers was 5.5 per 1000 live births and 12.1 per 1000 among the black mothers. According to an analysis of U.S. vital statistics between 1995 and 1998, the increased risk of black, compared with white, stillbirths is greatest among singleton stillbirths (Puza et al., 2006). Reduction of proportion of fetal deaths at gestation of 20weeks or longer to 4.1 per 1000 live births and also reduction of fetal deaths for all racial and ethnic groups are the objectives of U.S. National Health for 2010. Categorization of Stillbirths: Different attempts were made in order to classify causes of stillbirth. Baird and his colleagues were among the first to classify the causes of perinatal death from the available clinical information. Depending on the British perinatal mortality survey, in 1958 Butler and Bonham designed a classification scheme that included the results of postmortem examinations. The most widely used is the 9 category classification system formulated by Wigglesworth and his coworkers (Wigglesworth, 1980). A new classification scheme which does not include neonatal deaths was proposed by Gardosi and his colleagues known as the ReCoDe Classification which focuses on the relevant conditions at the time of death in the uterus. It includes factors which affect the fetus followed by the factors which affect the mother (Gardosi et al., 2005). When compared with the Wigglesworth classification, a remarkable decrease in the number of unclassified stillbirth was achieved using this classification. One of the most vital aspects is to develop a proper definition of the factors that lead to death of the fetus. The basic definition for the â€Å"cause of death† is injury or disease responsible for a death. Froendefined cause of death in stillbirth as â€Å"an event or condition of sufficient severity, magnitude, and duration for death to be expected in a majority of such cases in a continued pregnancy in the clinical setting where it was observed† (Froen, 2002). When the definition of â€Å"cause of death† is reviewed, it is observed that only a few disorders are directly responsible for fetal death while many others are not. Causes of Stillbirth: Infection: Infections such as viral, protozoal and bacterial are linked with stillbirth. Almost 10-25% of stillbirths result from feto-maternal infections in the developed countries where as bacterial infections are common in developing countries (Goldenberg et al., 2003). Stillbirths that result from infection might be due to various factors which include direct infection, placental damage, and severe maternal illness. Usually the stillbirths in the initial weeks of gestation are linked with infection. Bacterial infections caused by Escherichia coli, group B streptococci, and Ureaplasma urealyticum are a cause of stillbirth in developed countries (Goldenberg et al., 2003). If syphilis epidemic occurs in an area then it might be the cause of a considerable proportion of stillbirths. If women come in contact with a parasite like malaria for the first time then stillbirth might be attributed to it. Toxoplasma gondii, leptospirosis, Listeria monocytogenes, Q fever, and Lyme disease are associated with the occurrence of stillbirth (Goldenberg et al., 2003). The magnitude of stillbirths due to viral infections is not known mainly due to the absence of a well defined systematic evaluation of infections in stillborn infants. The problem lies behind the fact that these viruses are difficult to culture and moreover, a positive viral serological diagnostic test identifying the DNA or RNA of the virus in the fetal tissue or placental tissue does not definitely determine that infection was the reason behind death. In most of the cases, infection is linked with stillbirth in early gestational weeks around twenty weeks. If molecular diagnostic technology (DNA and RNA polymerase chain reaction [PCR]) is utilized, it will help in diagnosis of viral infections without any error. Parvovirus B-19 appears to have the strongest association with stillbirth. According to a Swedish survey, in 8%of stillbirths B-19 PCR positive tissues were observed (Enders et al., 2004). In the United States, less than 1% of all stillbirths are reported to be due to parvovirus infection Parvovirus B19 moves across the placenta spreading the infection to fetal erythropoetic tissue resulting in fetal anemia leading to fetal death (Wapner et al., 2002). Myocardial damage may also occur due to Parvovirus B19. Here the virus directly attacks the fetal cardiac tissue. Parvovirus infection that leads to stillbirth usually occurs before 20 weeks of gestation (Wapner et al., 2002). Enteroviruses which include Coxsackie A and B, echoviruses and other enteroviruses are associated with stillbirth. Coxsackie viruses can cross the placenta and lead to villous necrosis, inflammatory cell infiltration, calcific pancarditis, and hydrops. Echovirus infection begins with severe maternal illness and finally ends with stillbirth. Cytomegalovirus (CMV) belongs to herpesvirus family and it is a congenital viral infection. Initially, the mother is infected and then it is transmitted to the fetus. CMV causes placental damage leading to intrauterine fetal growth restriction, but an association with stillbirth remains controversial (Goldenberg et al., 2003). Viral infections in the mother like rubella, mumps and measles are linked with stillbirth. If the vaccinations are administered on time then the proportion of stillbirths occurring due to infections can be reduced greatly. Genetics: Genetic causes are responsible for a considerable magnitude of stillbirths. 6- 12% of stillbirths attributed to genetic etiologies are due to karyotyping abnormalities. Due to the fact that in some of the cases cells cannot be cultured, karyotyping is not possible. Such factors alter the exact estimate of stillbirths resulting from chromosomal abnormalities. In stillborn fetuses which show apparent structural defects the probability of chromosomal abnormality is much higher when compared to normal stillborn fetuses. The usually focused abnormalities include monosomy X (23%), trisomy 21 (23%), trisomy 18 (21%), and trisomy 13 (8%). There are many instances where the karyotype of the stillborn is normal yet the cause of death is a genetic abnormality. Indeed, 25-35% of stillborn infants undergoing autopsy have intrinsic abnormalities (Wapner et al., 2002) .These include single malformations (40%), multiple malformations (40%), and deformations or dysplasia (20%) (Wapner et al., 2002). Almost 25% ofstillborns due to intrinsic defects show an abnormal karyotype whereas the rest of the 75% may have genetic defects which are not identifiable by the regular cytogenetic tests. This holds good for fetuses with multiple abnormalities. Single gene mutations may be responsible for death of the fetus in early weeks of development. Stillbirths in the midgestational weeks might be due to abnormal placental growth, development, or angiogenesis. Some autosomal recessive disorders including glycogen storage diseases and hemoglobinopathies have been reported as the cause of stillbirth (Wapner et al., 2002). In male fetuses, X-linked disorders may prove to be fatal. Many other genetic defects that are not recognized by the conventional cytogenetic diagnostics may lead to stillbirth. For example, conventional karyotype cannot identify chromosomal microdeletions that are linked with unexplained mental retardation. Confined placental mosaicism has also been associated with fetal growth impairment and stillbirth (Kalousek et al., 1994). Heritable Thrombophilia is another probable etiology of stillbirth.It is thought that placental infarction occurs due to thrombosis in the uteroplacental circulation leading to death. This poses concern over other thrombophilic defects and their effects on stillbirth. It is noteworthy that many heritable thrombophilias are common in normal individuals without a history of thrombosis or pregnancy loss (Rey et al., 2003). Even though many studies relate thrombophilias to fetal loss, most of the women with thrombophilias have healthy pregnancies with no lethal complications. It can be said that in the absence of any previous obstetric problems, thrombophilia will not result in stillbirth. Feto-maternal Hemorrhage: Feto-maternal hemorrhage has been linked to almost 3- 14% of all stillbirths which implies that it is responsible for a considerable number of stillbirths. Obstetric procedures such as external cephalic version and cesarean section lead to fetal maternal hemorrhage. Hemorrhage can also result due to placental abruption and/or abdominal trauma during pregnancy. Fetal maternal hemorrhage must be identified and quantitated using a proper dependable diagnostic test to attribute this reason behind the death of fetus. Hypoxia and anemia are indicators of death due to fetal hemorrhage. So, they should be confirmed by autopsy as in some normal cases too, few fetal cells can be seen in maternal blood. Maternal Features: Delayed child bearing or increased maternal age, prepregnancy obesity and stress are found to have their effects on the occurrence of stillbirth. The underlying mechanisms of action are unknown; however, with both obesity and delayed child-bearing on the rise, their importance as potential causes of stillbirth deserves greater attention (Cnattingius et al., 2002). Women whose only risk factor is being overweight have about a 2-fold increased risk of stillbirth (Nohr et al., 2005). Likewise, compared with women younger than 35 years of age, the stillbirth rate is increased 2- fold for women 35-39 years of age, and 3- to 4-fold for women aged 40 years old or olderwhereas some age-associated risk is due to higher rates of maternal complications, in uncomplicated pregnancies there may be a 50% increased risk associated only with maternal age 35 years or older (Nohr et al., 2005). Stress is a suspected cause of stillbirth which might occur as a result of a major life event (such as loss or poverty) (Huang et al., 2000) or through unexplained health changes related to adverse childhood experiences (Hillis et al., 2004). Different exposures are attributed to stillbirth. One of the most prevalent and preventable cause of stillbirth is cigarette smoking (Hillis et al., 2004). Smoking negatively affects fetal growth and oxygen supply to the tissues as it produces high levels of carboxyhemoglobin and decreases blood supply to the placenta. Smoking is also associated with increased risks of placenta previa and placental abruption and women who stop smoking in the first trimester have stillbirth rates equivalent to women who never smoked which indicates that quitting smoking in early pregnancy may significantly reduce the chances of occurrence of stillbirth (Hillis et al., 2004). A variety of complications result due to continuous exposure of different recreational drugs. Consumption of cocaine during pregnancy is also linked with stillbirth because it causes fetal growth restriction and/or abruption. The use of meth amphetamines leads to premature deliveries and stunted growth but its association with stillbirth remains unknown. In some cases, alcohol consumption during pregnancy has been associated with an increased risk of stillbirth (Mary et al., 2006). According to a study in Scandinavia, for women who consume less than 1 drink per week, the rate of stillbirth is 1.37 per 1000 births while the rate increases to 8.83 per 1000 births in women who consume 5 drinks or more per week. If smoking habits, caffeine intake, prepregnancy body mass index, marital status, occupational status, education, parity, and fetal gender are considered, the risk of stillbirth for women consuming 5 drinks or more per week was 2.96 (95% confidence interval 1.37 to 6.41) (Mary et al., 2006). Some studies show a protective effect on both stillbirth and fetal growth restriction rates if small amounts of alcohol are consumed during pregnancy (Mary et al., 2006). A link between pesticide exposure and stillbirth was observed by Pastore and his colleagues in 1997. Occupational exposures prove to be deleterious compared to residential exposure because the occupational exposures cause congenital abnormalities in addition to risk of stillbirth. A noteworthy fact is that the use of fertility drugs is also associated with stillbirths. This finding is problematic due to the fact that many women make use of fertility treatments to conceive. However, data on stillbirths due to exposures is obtained from retrospective studies which are prone to bias. The link between exposures and stillbirth should therefore be dealt with great attention and care. Maternal Diseases: Diabetes: There is always an increased danger of stillbirths in second and third trimester for mothers who are affected with type I or type II diabetes mellitus (DM) pregestationally. Even with modern obstetric care and diabetes management, stillbirth rates in women with type 2 DM have been reported to be 2.5-fold higher than nondiabetic women (Mary et al., 2006). The rate of stillbirth is the same between women with gestational diabetes (GDM) as well as normal women when the whole population is taken into account. The magnitude of danger involved with fetal death in women with type II DM is identical to women with GDM who in fact entered the pregnancy with undiagnosed type II DM. Therefore, women with GDM who have an undiagnosed type II DM are usually at a greater danger of encountering stillbirth. Examples of women with undiagnosed type II DM include history of GDM in previous pregnancies, high fasting glucose values;random glucose values greater than 200mg/dL or diagnosis of GDM early in pregnancy. The reason behind fetal death in late gestation in diabetic women is not known precisely. In addition to an increased risk of fetal death in diabetic women, there also exists a higher magnitude of danger associated with fetal abnormalities in these women compared to healthy women. Stress, hypertension and obesity complement each other in DM patients. In women with DM, there is a higher risk of stillbirth as it may lead to fetal abnormalities which may be either abnormally increased growth rate or retarded growth. To maintain the physiological range of the plasma glucose level, tremendous amounts of insulin is produced by the fetus resulting in fetal hyperglycemia. This fetal hyperglycemia is acquired from maternal hyperglycemia which finally results in fetal death due to excessive growth. The precise limit of plasma glucose level which poses a threat to the fetal life is not well defined. The most that could be done is to detect and deal with it using needed medications to lower the incidents of stillbirths.Many other maternal diseases have been linked to stillbirth, including thyroid disease, cardiovascular disease, asthma, kidney disease, and systemic lupus erythematosus (Simpson, 2002). These are subclinical diseases which in many cases has not been proven to be direct causes of stillbirth and women had normal pregnancies giving birth to healthy babies. Multiple Gestation and Stillbirth: Nearly 3% of all births and 10% of all stillbirths result from multiple pregnancies. According to national vital statistics, 1.8% of twin, 2.4% of triplet, 3.7% of quadruplet, and 5.6% of quintuplet fetuses suffered intrauterine fetal deaths (Salihu et al., 2003). The stillbirth rate among singleton pregnancies is approximately 0.5%. The reason behind fetal death in multiple pregnancies is difficult to be resolved when compared to singleton pregnancies. The broad causes of fetal death in multiple pregnancies include fetal growth retardation, preclamsia, abruption and cord accidents. It is vital to determine the chorionicity of multiple gestations as the rate of stillbirth is higher in monochorionic multiple gestations (Salihu et al., 2003) (Lynch et al., 2007). Assisted Reproductive Technology (ART) is an essential aspect in the occurrence of multiple pregnancies and stillbirth (Helmerhorst et al., 2004). Complications in Fetus: Fetal Growth Restriction: Some stillbirths result from fetuses which are smaller for a particular gestational age (SGA) compared to normal fetuses. Birth weight and risk of stillbirth are inversely proportional. If one increases, the other decreases. The main fact behind stillbirths in this condition is retardation of fetal growth and not the small size of fetus. An obstacle that occurs in determining the precise time of death of fetus due to SGA is the fact that the death might have occurred a long time before but the gestational age at the time of delivery is considered to be the time of death. This gives a false implication of the magnitude of stillbirths resulting from SGA. This problem can be solved by analysis of early and mid pregnancy placental hormones which are very specific for gestational periods (Smith et al., 2004). An evaluation of the amounts of these hormones relates directly to the time of death. Umbilical Cord Accidents: An increased number of stillbirths are due to â€Å"accidents† of umbilical cord like cord occlusion or blockage due to true knots, nuchal cords and compression of the cord. In almost 30% of normal healthy infant deliveries, nuchal cord and true knots in umbilical cords are observed. According to a study in Sweden, 9% of stillbirths were due to cord accidents (Petersson, 2002). Determination of cord accidents leading to fetal death by autopsy is smaller in proportion (up to 2.5%) (Horn et al., 2004). This difference indicates that in the absence of a proper cause, many times fetal death is attributed to cord entanglement. Due to the increased load of complications with live infants, little concern is expressed towards dead fetuses. In order to precisely relate a fetal death to cord accident, a clear indication of either hypoxic tissue injury or cord occlusion must be observed in autopsy. As nuchal cords are observed in normal deliveries also, the exact proportion of stillbirths due to cord accidents is biased. Obstetric Complications: Some of the obstetric complications are preclampsia, preterm premature rupture of membranes, preterm labor, cervical insufficiency, abruption, placenta previa, and vasa previa. These may either be direct or primary causes or may be indirect or secondary causes of stillbirth. Almost 10-19% of stillbirths occur due to abruption. Since cervical insufficiency or preterm labor lead to neonatal death, their role in causing stillbirth is not well defined. Evaluation of Stillbirth Stillbirth in itself may be emotionally devastating to many patients and their families. There the likelihood of carrying out genetic testing or autopsy on the fetus may not be readily agreeable from the family and culture. Lastly the procedures for evaluation must be cost effective and within reach. The two important facts that should be kept in mind while deciding which tests would prove as the most useful ones are primarily the consideration of cost of that test. It should not be beyond limits. Secondarily, if this test would be helpful in prevention of recurrent or sporadic stillbirths. In recurrent stillbirths, medical interference may prove helpful by preventing them in future. Analyzing the etiology of sporadic stillbirths might lead to reassurance and avoid irrelevant diagnostic tests in future pregnancies. The single most useful diagnostic test is a fetal autopsy (Peterson et al., 1999). Not only does the visible genetic and structural abnormalities but also an autopsy would be of great help in relating specific etiologies to stillbirth. The frequency of fetal autopsy is very less due to the fact that it is costly, not many trained pathologists are available and also it may be of great discomfort to the family and clinicians to deal with such a case. If autopsy is refused, partial autopsy or postmortem magnetic resonance imaging (MRI) scans may provide the necessary data. Embryonic membranes, placenta and umbilical cord must be physically and histologically examined while evaluating stillbirth etiology. This would give a precise cause of fetal death and might also provide clues for death due to secondary causes like infections, thrombophilia, and anemia. In most cases, families do not object on placental evaluation. In the cases where autopsy is not performed karyotyping the fetus would prove helpful. Cells and tissues from placenta (especially chorionic plate), fascia lata, skin from the nape of the neck, and tendons can be isolated and cultured and used for diagnostic tests like karyotyping. Comparative genomic hybridization shows tremendous promise for the identification of chromosomal abnormalities in stillbirths wherein fetal cells cannot be successfully cultured (Silver et al., 2006). An autopsy followed by a careful histological examination might help in relating stillbirths that result due to infections from the bacteria or virus. Parvovirus serology may be useful because this virus has been implicated in a meaningful proportion of cases (Erik et al., 2002). Diagnostic tests are performed for the detection of syphilis also since it contributes to the list of accepted causes of stillbirth. For various viral and protozoal agents like toxoplasmosis, rubella, cytomegalovirus (CMV) and herpes simplex virus (HSV) {TORCH}, serological screening is carried out. For bacterial and viral infections in the fetus, nucleic acid based tests are more helpful when compared to tissue cultures. Feto-maternal hemorrhage can be detected using Kleihauer – Betke test (KBT). Most laboratories use manual KBT which is prone to error. It has been found that flow cytometry is a better tool in detecting fetal erythrocytes in maternal blood. In order to eliminate red cell alloimmunization as an etiology of stillbirth, an indirect Coomb’s test is performed. Autopsy and examination of placenta are helpful in this situation. During the initial prenatal visits, if the antibody screen comes out to be negative then there is a need for recurrent testing. Diagnostic tests for conditions like diabetes and heritable thrombophilias must be carried out on a regular basis to prevent any complications which may lead to stillbirth. The treatment of such conditions at the appropriate time may prevent similar complications in subsequent pregnancies. Heritable thrombophilia might be of concern in the cases where there is recurrent fetal loss or there is a history of thrombosis or with complications involving placental insufficiency like placental infarction and intrauterine growth restriction. Administration of illicit drugs through various modes may be a cause of stillbirth in many cases. Toxicological examination may reveal the results for women who are subjected to such exposures. A simple urinary examination may prove helpful. The advanced and cost effective technology like ELISA (Enzyme Linked Immuno Sorbent Assay) can be used to detect a variety of metabolites like steroids in various tissues like blood, hair, and homogenized umbilical cord. Conclusion: Many medical and nonmedical agents govern the best approach to evaluate a stillbirth. The obstacles faced by obstetricians in solving these issues include the fact that in most of the cases the reason behind fetal death is unknown. Also the magnitude of stillbirths resulting from a single cause is not known precisely. Here there arises a need for population based studies to attribute stillbirths to their specific etiologies. There is a clear cut need of experts in the field of perinatal pathology and the required funding should be provided at the national level to promote it. Moreover, the clinician should be aware of the history of pregnant women in better evaluation. In cases where the local clinicians cannot reach a conclusion, the tissue samples must be sent to senior pathologists who have a thorough command on the subject and can help in reaching decisive conclusions. A universally accepted protocol is required for a systematic evaluation of stillbirths. Due to its absence a difference of opinion occurs among the obstetricians and gynecologists. The institutions like Stillbirth Collaborative Research Network should formulate guidelines for the proper judgement of stillbirth etiologies. The responsibility lies in the hands of the clinicians to do the best they can to reach a definite conclusion from the available data. It is noteworthy that the proportion of stillbirths that are â€Å"explained† is much higher in centers using systematic evaluations for recognized causes and potential causes of stillbirth (Petersson, 2002) (Horn et al., 2004). In conclusion, autopsy, placental evaluation, karyotype, Kleihauer-Betke, antibody screen, and serologic test for syphilis are useful in evaluating the etiologies of stillbirth. Depending on the case, other relative tests should be performed. The approach towards the testing of potential causes of stillbirth is not clear if it should be very specific and sequential or should it be comprehensive which means that it is targeted towards a broad spectrum of causes. Each of these has its own advantage. Sequential testing avoids false positive results and is directed to a specific cause and more over, it is cost effective. Comprehensive testing may prove helpful in cases where more than one factor is responsible for stillbirth. The problem with autopsy, placental evaluation, karyotype, screen for fetal-maternal hemorrhage, and toxicology screen is that they are dependant on time, that is, these tests should be performed immediately after the delivery. Autopsy cannot be delayed because death of the fetus already occurred and this would lead to physiological changes in the whole body and decay begins. The necessary evidence for stillbirth is easily available from fresh samples of placenta and also for toxicology screen. As the time since death increases, the physiology of fetus also changes leading to false positive or false negative results. If the time of fetal examination is delayed, fetal hemorrhage may be mistaken for postmortem lividity. Therefore a serious call for action is expected from institutions like Stillbirth Collaborative Research Network (SCRN) which would help in creating the most applicable diagnostic setting for evaluation of stillbirth (Silver et al., 2006). SCRN was developed by the National Institute of Child Health and Human Development to target the range of etiologies of stillbirth in the U.S. The aim of SCRN is to focus on the following objectives. The use of standardized surveillance in a geographic catchment area will show that the stillbirth rates are greater than those reported in the vital statistics catchment. The use of a prospectively implemented, standardized, postmortem, and placental examination protocols will improve diagnosis of fetal or placental conditions that cause or contribute to stillbirth. Maternal biologic and environmental risk factors in combination with genetic predisposition increase the risk for stillbirth. This is a population based study which is carried out in different counties of different states in the U.S. This study would take into account all the stillbirths and live births occurring in rural as well as urban areas in different racial groups. Even though occurrence of stillbirths cannot be stopped completely, yet attempts of such sort can be made atleast to prevent them to a maximum extent. Glossary Abruptio placenta totalis A placental abruption is a serious condition in which the placenta partially or completely separates from the uterus before the baby is born. Achondrogenesis Dwarfism characterized by various bone aplasias and hypoplasias of the extremities and a short trunk with delayed ossification of the lower spine. Alloimmunization Development of antibodies in response to alloantigens; antigens derived from a genetically dissimilar animal of the same species. Angiogenesis The formation of new blood vessels. Anomaly abnormality Autosome a chromosome other than the X and Y sex-determining chromosomes. Camptomelia bending of the limbs that produce a permanent curving or bowing. Cholestasis a condition caused by rapidly developing or long-term interruption in the excretion of bile (a digestive fluid that helps the body process fat). Chondrodysplasia Congenital dwarfism similar to but milder than achondroplasia, not familial and not evident until mid-childhood, in which the skull and facial features remain normal. Chorioamnionitis Inflammation of the fetal membranes. Dystocia Difficult delivery or parturition. Erythema infectiosum mild infectious disease occurring mainly in early childhood, marked by a rosy-red maculopapular rash on the cheeks, often spreading to the tr

Wuthering Heights, Chapters 11-23 :: Free Essay Writer

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Organizations Become More Global

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Financial Statements Paper Financial Statements Paper December 11, 2012 Acc/280 Professor Kenneth Popp Accounting is a technique where a person/people create(s) reports of business dealings and records the fiscal infrastructure of the company. Three key activities of accounting are determining, communication and documenting. The main goal of these activities are to determine and properly document the activity which has had a fiscal effect (if any) on the organization and to assist in control, recognize danger, and make decisions. All activities are put into categories in fiscal words, as per their financial assumption, and placed in specific accounts in journals, and ledgers. This is the procedure of bookkeeping, which then allows the data created from bookkeeping to be utilized to produce correct and timely financial statements for the organization. Two key divisions of accounting incorporate managerial accounting as well as financial accounting. Managerial accounting assists people in dealing with their finances. It allows inner records to assist people in making decisions and then helping to predict the wants regarding their organization. Financial accounting helps outside people because it gives economic/financial details to them on whether or not their organization complies with laws, rules, and regulations. To know an organization, a person must first be able to understand figures. There are four fiscal reports that an organization produces: Income Statements, Retained Earnings Statements, Balance Sheets, and Statements of Cash Flow. Each one of the reports plays their individual part in being able to display what is going on inside the fiscal infrastructure of the company. An income statement- displays company revenues, expenditures, and net income or net loss of the company through a specific time period. Retained earnings statements- summarize any alterations in built up net income that has been reused for reinvestment in an organization. A balance sheet- states any possessions, debts, and stockholders’ equity of a firm by a specific date. A report of cash flows- summarizes the information regarding money arriving in (bills) and going out their door in (payments) throughout a particular period of time (Weygandt, 2008). Fiscal reports are a comprehensive approach to convey fiscal information to both internal and external people. Inner consumers, for example: a marketing manager, administrator, CEO, or CFOs, utilize information to reply to significant queries, for example â€Å"can we afford to give raises, or should we revisit selling a product or another (Weygandt, 2008, p. 6)?† Outer people, for example: a shareholders or lenders, utilize details to make decisions and assess any dangers of approving credit or financing funds (Weygandt, 2008, p. 6). They reply to such queries like- will the organization be capable to pay back any debt loaned to them? Financial reports have been created to satisfy requirements, and the details given in fiscal reports are stated in units of money as per the fiscal assumption, one of 2 key assumptions. The details that are given on the reports are usually

The Dance Class essays

The Dance Class essays Edgar Degas, a French painter and sculptor whose innovative composition, skillful drawing, and perceptive analysis of movement, makes himself one of the masters of modern art in the late nineteenth century. He was acknowledged as the master of drawing the human figure in motion. Degas worked in many mediums, preferring pastel to all others. He is perhaps best known for his paintings, drawings, and bronzes of ballerinas and of race horses. One of his known particular paintings done in oil, The Dance Class, was exhibited in 1876 at the second Impressionist exhibition. Reflecting the concern for the psychology of movement and expression and the harmony of line and continuity of contour set Edgar Degas apart from the other impressionist painters. The Dance Class, one of Degass greatest pieces of artwork, portrays a dance class conducted by the famous ballet master Jules Perrot. The work is generally thought to be a tribute to the teacher rather than a depiction of an actual dance class conducted by him. The scene is a careful arrangement of what seems to be a random collection of postures and poses. He depicts a rehearsal in which the dancers are on stage, resting or waiting to perform from an oblique angle of vision. One ballerina, who is the central focus of the composition, dances while the others are practicing around her, presumably waiting for their turns. Some adjust their costumes while others just sit or stand in various postures. The women in the background that are on the right are the dancers mothers who are chaperoning their young girls during the rehearsals. Like most of the dancers in Degass works, these ballerinas are not performing but rather doing their own thing. Each ballerina is doing somethin g different. These ballerinas in different poses and postures on different grounds also bring forth movement into the composition. Interesting as it is, the dancer performs a graceful arabes...

Essay on Food Chain and Trophic Level

Essay on Food Chain and Trophic Level Essay on Food Chain and Trophic Level Bio I Name KEY Unit 7: Ecology 3.1 What Is Ecology? Studying Our Living Planet 1. What is ecology? It is the scientific study of interactions among organisms and between organism and their environment. 2. What does the biosphere contain? It contains all the organisms and physical environments of the Earth. 3. How are human economics and ecology linked? Economics has to do with human â€Å"houses† and interactions based on money and trade. Ecological interactions have to do with nature’s â€Å"houses† and are based on energy and nutrients. Humans depend on ecological processes to provide nutrients that can be bought or traded. 4. Label each level of organization on the diagram. biosphere biome ecosystem population individual/species community 5. Explain the relationship between ecosystems and biomes. An ecosystem describes all of the organisms that live in a place , together with their physical environment. A group of ecosystems that share similar climates and organisms is considered a biome. Bio I Unit 7: Ecology 6. Use the terms in the box to fill in the Venn diagram. List parts of the environment that consist of biotic factors, abiotic factors, and some components that are a mixture of both. air animals bacteria heat mushrooms plants Both Biotic Factors Abiotic Factors precipitation soil sunlight animals, plants, mushrooms, bacteria soil sunlight, heat, precipitation, air 3.2 Energy, Producers, and Consumers Primary Producers 7. What do autotrophs do during photosynthesis? They use light energy to power chemical reactions that convert carbon dioxide and water into oxygen and energy rich carbohydrates such as sugars and starch. 8. What do autotrophs do during chemosynthesis? They use chemical energy to produce energy rich carbohydrates. Consumers 9. Complete the table about types of heterotrophs. Types of Heterotrophs Type Herbivore Carnivore Omnivore Detritivore Decomposer Scavenger Definition Heterotroph that obtains energy by eating only plants Heterotroph that eats animals Heterotroph that obtains eats both plants & animals Heterotroph that feeds on detritus Heterotroph that breaks down organic matter Heterotroph that consumes the carcasses of dead animals but does not typically kill them itself Examples cows, rabbits snakes, dogs, owls humans, bears, pigs mites, earthworms, snails, crabs bacteria, fungi vulture, hyena Bio I Unit 7: Ecology 10. What is a consumer? A consumer is any organism that relies on other organisms for energy and nutrients 3.3 Energy Flow in Ecosystems Food Chains and Food Webs 11. Complete the table about feeding relationships. Feeding Relationships Relationship Food Chain Food Web Description A series of steps in which organisms transfer energy by eating and being eaten A network of complex interactions formed by the feeding relationships among the various organisms in an ecosystem Use the food chain to answer Questions 2–4. 12. Explain how energy flows through a food chain. Phytoplankton are photosynthetic organisms. They use energy from the sun to create carbohydrates. The zooplankton eats the phytoplankton to obtain energy. The small fish eat the zooplankton. The squid eats the small fish. The shark eats the squid. 13. What would happen to a food chain if a disturbance caused a serious decline in the population of a high level consumer? If the shark numbers declined, there would be no natural predators to control the number of squids. Therefore

Dental Hygiene and the safety of Fluoride Essay

Dental Hygiene and the safety of Fluoride - Essay Example The most interesting finding was that, with all variables taken into account, nurses with a bachelor’s degree corresponded to a 5% decrease in the likelihood of patient death and failure to rescue on the part of these nurses. Using this as a basis, it is evident that having bachelor prepared nurses is important in maintaining the health of patients. Sasichay-Akkadechanunt, Scalzi, & Jawad (2003) found similar results. This study examined data from 2531 patients in various surgical and ward units in one large hospital in Thailand. The patients were split into four major categories (disease of the heart, disease of the lung, all types of cancer and cerebrovascular diseases) and data was observationally taken from their charts, as well as information from the nursing staff. The results showed again that there was a decrease in in-hospital mortality with bachelor prepared nurses. It should be noted that using this technique means that many diseases are ignored by the study which m ay not benefit from nurse education at this level, but it seems suggestible from the research that it is. Primm (1987) compared the competency of AND prepared nurses to BSN prepared nurses. BSN qualifications take roughly twice the amount of time as an AND qualification. Although both lead to RN status, Primm found evidence to suggest that BSN prepared nurses had a higher competence rating in the majority of the five areas surveyed in the study. This gives further evidence that bachelor preparation may lead to better prepared nurses, although the evidence from one study should be carefully used when generalising as many programs can be different between areas. White, Coyne & Patel (2001) investigated all members of the Oncology Nursing Society to ascertain whether nurses felt adequately prepared for end-of-life care. All the respondents said that end-of-life care was an important aspect of their work life, and each of them had covered this area in their bachelor preparation. One asp ect that came up is that nurses felt that continuing education was very important, although only two respondents had covered end-of-life care in the previous two years. This suggests that, whilst bachelor prepared nurses are important and feel qualified, there could be more education provided for nurses during their career. It must be noted that the nurses here were only questioned on their participation in end-of-life care so we must be careful not to generalize these views without careful consideration. Further evidence that bachelor prepared nurses are useful in specialized situations is provided by Kardong-Edgren & Campinha-Bacote (2008). This paper examined four groups of nurses, each from different geographical areas, and surveyed the cultural sensitivity of those with an American BSN qualification. The study found that, because cultural sensitivity and awareness of beliefs is an important aspect of gaining the BSN qualification, nurses with the qualification were more highly prepared to deal with various groups of patients. This is important as it shows that nurses with bachelor preparation may be more able to create a comfortable environment for the patient which will lead to lower in-hospital death rates and a more pleasant experience for the patient. It is important to note that this is an important aspect of nursing that can be overlooked by the literature. Thornton (1997)

Leadership in Global Health Care Essay Example | Topics and Well Written Essays - 750 words

Leadership in Global Health Care - Essay Example ctiveness, and agility whereas her negative attributes include being judgmental, occasional lack of understanding, and too much kindness, so I would like her to change her negative attributes while strengthening the positive ones. As a nurse, my mother has to deal with patients on daily basis. Patients come from different backgrounds, have different cultures and ethnicities. Some speak English well while others do not. Some act restless because of the pain of their injury, illness, or disease, while others are frustrated by the environment of the hospital. It is not uncommon for a patient to lose his temper for no good reason. In such times, my mother remains patient and maintains her cool. She immediately attends them, and tries to address their concern. Likewise, my mother is often suddenly called on duty which is not scheduled. She might have to serve in place of a nurse on-leave. She tends to understand it and does not mind. â€Å"Good leaders are patient† (Adventure Scouts USA, 2007). My mother is quite pro-active in her approach. She remains completely aware of the present circumstances, and tends to forecast the future depending upon them. For example, she always maintains two sets of documents, one in hard copy and one in soft copy to make sure she has another version available if one is somehow lost. Before going on duty, she has the list of tasks to do ready with her so that nothing is delayed or missed out. My mother is very active. She follows a weight-loss as well as energy-boosting plan. She takes several short meals in a day that help her maintain a high metabolism. Most of these meals are based on fresh fruits and vegetables. In addition, she jogs for at least 20 minutes in the morning. She is not weight-conscious as she is already very smart. She does all this to maintain a high energy level. She says that controlling diet and doing exercise helps her remain active throughout the day both physically and mentally. At times, my mother gets a

Community Nursing Essay Example | Topics and Well Written Essays - 4000 words

Community Nursing - Essay Example The plan proposes various measures that would promote good health in a wider sense. There are various strengths that are highlighted and areas where improvements need to be made and all these seeks to have a health promotion program that will become a success. The teaching program is to be initiated in a community where there are elderly people and individuals who are unable to take care of their health or those who have no health insurance. This teaching program would ensure that the members of the community are well endowed with the information they need in order to make them responsible for their own health. The project also addresses the kind of engagements that would lead to the actual learning process taking place and the very important tools that would be needed for this project to be a success. Key among the things outlined in the plan is the resources that would be needed for this kind of a venture just for the purpose of having a process that is above board. In conclusion, the plan addresses the objectives and aims of this teaching program and what would be achieved after such a noble course. Epidemiology Rationale for the Topic The problem of lifestyle diseases has been a major concern for the community in Georgia. Diabetes has been the leading illness in the lifestyle diseases with obesity being a key concern. ... As for the lifestyle diseases, the elderly had cancer as a big challenge to those aged 65 and above. Diabetes was found to be a serious challenge affecting everyone across the board; the old people to younger people. Obesity among the young people and smoking habits was a major cause of diabetes among the young people. For these urgent care had to be initiated to help those already affected and those who are likely to be affected. Statistics from the health superintendent of the Georgia center for disease control and prevention in the state of Georgia has provided very shocking results about people who are affected by the lifestyle diseases like diabetes (Stroup & Teutsch, 1998). The results showed that: 35% of the adults in old age had diabetes. 40% of the young adults had diabetes 33% of the teens were diabetic and had obesity with heart complications 40% of those above the age of 65 years had cancer disease 50% of those in old age around 75 years had heart disease Evaluation of Te aching Experience The experience of teaching in the community was an interesting affair that really opened my eyes to various possibilities. At first, I thought that the experience was going to be a tough one and I was very nervous at some point, as I did not know what was going to be about my teaching experience. My experience in the community and having to interact with different groups of people was one that remained painted in my mind for the longest time ever. The fear of the unknown once again caught up with me in an unprecedented manner as I prepared myself for the teaching exercise. The responsibilities which I was to teach the people on the benefits of primary prevention or health promotion, and I knew it was not going to be an easy task even though I

Does social media promote freedom Assignment Example | Topics and Well Written Essays - 3000 words

Does social media promote freedom - Assignment Example On YouTube, he watches videos with content unsuitable for young people. On all his accounts, he posts comments, shares and likes on photos, videos, music, etc. he finds worth his attention. Lucy is 10 years old. She can only use her mother’s iPad after she is done with her homework. Using her information, Lucy’s mother created a Facebook account for her daughter. On Facebook, Lucy plays with free applications such as Farmville, Chefville and Pet Society. Some things she wants to get for her pet in Pet Society need to be bought with gold. Lucy’s mom doesn’t want to buy gold so Lucy is starting to be bored with this app. One time, Lucy posted a picture on Facebook. The picture did not appear on her Facebook page. Also, she got a message that the picture was offensive. Her mother had to help her reply to the message and adjust the settings of her profile. Vien is 18 years old and a student majoring in film-making. She has a YouTube account and primarily uses it to upload her home videos and do research for her distance learning classes. Since opening an account on YouTube was free, Vien didn’t need to figure it into her tight budget. Right now, she is very upset. The film her teacher assigned for a research paper was indeed available on YouTube. However, only a few minutes of it was uploaded by the user. There was a link to the full video but, when Vien went on the site, it asked her to pay $10 to access the full video. a. 21-year old Mark works as a freelance consultant. When meeting clients, Mark is available any time of the day. He lives alone in his comfortable & spacious apartment and pays all the bills from money he has earned. His consultancy fees vary, depending on the case. There is no curfew in this building so he can come and go as he pleases. This is perfect for his job which is the reason he decided to stay here. When he does not feel like meeting a client, he calls and tells them he is sick or has a sudden

PSY-499 Essay Example | Topics and Well Written Essays - 500 words

PSY-499 - Essay Example Pougnet, et al, (2011) there is significant difference in the cognitive command and social wellbeing of the children who have a longer and close attachment with the male parent In the development of a child from infancy, the immediate environment plays a vital role in defining the cognitive development of the child. This explains the varied behavior of children in various interactive social environments. In respect of the cardinal social input of the male parent to the child’s future behavior, children from parents who are incarcerated tend to differ marginally from the ones with their male parents around their daily life (Dick, 2011). Both the mother and the father have an influence in shaping the psychological development and maturity of the children. Finley & Schwartz,(2007) from their analytical experiments using Statistical tests of significance indicates that the mother plays primary role as far as the infant’s perception of the world is concerned. However as the child grows, the male parent also contribute immensely in his/her interaction with the new world and absorption of various concepts in life. Various scholars have explored the social inadequacies that are likely to erupt in the life of the child in the absence of the male parent. Some of the cases that may lead to this absence are also highlighted with more focus on male incarceration (Menning & Stewart, 2008). The effect of male parent’s absence is two sided in the social life of the child since there is a certain perception such children will develop about the absent fathers and this gradually alters the cognitive and moral interaction of the child in the society. The child’s language skills cannot be learnt from watching infant directed DVD’s or any audio-visual program from the media and it is this point where physical interaction of the male parent through playing with the child come in handy .Coakley,(2013) asserts that children are not able to relate visual objects with real

Assay of protein turnover using a bioluminescent reporter Essay

Assay of protein turnover using a bioluminescent reporter - Essay Example It is important for some proteins to have a short half-life but no others like clusterin because they have to control excessive growth of cells. Clusterin in this case controls prostate cancer cells (Rizzi, Caccamo, Belloni, & Bettuzzi, 2009). In designing an experiment using MetLUC to assay the efficacy of three compounds with respect to BF A, the first thing to consider is that the activity of BF A is known. The BF A would thus be used as the control variable (Schultz, Cegielski, & Hastings, 2005). Analysis of each of the three novel compounds would be done. This would be based on their respective signal sequence, in which each of them would be expressed in tissue culture cess. Comparison of how the MetLUC protein for each compound would be translocated to the ER and the resulting secretion into the medium in which the cells are growing would be done. The results of each would be compared to the known facts about the same experiment in BF A. Rizzi, F., Caccamo, A., Belloni, L., & Bettuzzi, S. (2009). Clusterin is a short half-life, poly-ubiquitinated protein, which controls the fate of prostate cancer cells. Journal of Cell Physioly, 19(2), 14-23. Schultz, L. L., Cegielski, M., & Hastings, J. (2005). Crystal structure of a pH-regulated luciferase catalyzing the bioluminescent oxidation of an open tetrapyrrole . Proc. Natl. Acad. Sci. U.S.A., 102 (5),

Does social media promote freedom Assignment Example | Topics and Well Written Essays - 3000 words

Does social media promote freedom - Assignment Example On YouTube, he watches videos with content unsuitable for young people. On all his accounts, he posts comments, shares and likes on photos, videos, music, etc. he finds worth his attention. Lucy is 10 years old. She can only use her mother’s iPad after she is done with her homework. Using her information, Lucy’s mother created a Facebook account for her daughter. On Facebook, Lucy plays with free applications such as Farmville, Chefville and Pet Society. Some things she wants to get for her pet in Pet Society need to be bought with gold. Lucy’s mom doesn’t want to buy gold so Lucy is starting to be bored with this app. One time, Lucy posted a picture on Facebook. The picture did not appear on her Facebook page. Also, she got a message that the picture was offensive. Her mother had to help her reply to the message and adjust the settings of her profile. Vien is 18 years old and a student majoring in film-making. She has a YouTube account and primarily uses it to upload her home videos and do research for her distance learning classes. Since opening an account on YouTube was free, Vien didn’t need to figure it into her tight budget. Right now, she is very upset. The film her teacher assigned for a research paper was indeed available on YouTube. However, only a few minutes of it was uploaded by the user. There was a link to the full video but, when Vien went on the site, it asked her to pay $10 to access the full video. a. 21-year old Mark works as a freelance consultant. When meeting clients, Mark is available any time of the day. He lives alone in his comfortable & spacious apartment and pays all the bills from money he has earned. His consultancy fees vary, depending on the case. There is no curfew in this building so he can come and go as he pleases. This is perfect for his job which is the reason he decided to stay here. When he does not feel like meeting a client, he calls and tells them he is sick or has a sudden

Assay of protein turnover using a bioluminescent reporter Essay

Assay of protein turnover using a bioluminescent reporter - Essay Example It is important for some proteins to have a short half-life but no others like clusterin because they have to control excessive growth of cells. Clusterin in this case controls prostate cancer cells (Rizzi, Caccamo, Belloni, & Bettuzzi, 2009). In designing an experiment using MetLUC to assay the efficacy of three compounds with respect to BF A, the first thing to consider is that the activity of BF A is known. The BF A would thus be used as the control variable (Schultz, Cegielski, & Hastings, 2005). Analysis of each of the three novel compounds would be done. This would be based on their respective signal sequence, in which each of them would be expressed in tissue culture cess. Comparison of how the MetLUC protein for each compound would be translocated to the ER and the resulting secretion into the medium in which the cells are growing would be done. The results of each would be compared to the known facts about the same experiment in BF A. Rizzi, F., Caccamo, A., Belloni, L., & Bettuzzi, S. (2009). Clusterin is a short half-life, poly-ubiquitinated protein, which controls the fate of prostate cancer cells. Journal of Cell Physioly, 19(2), 14-23. Schultz, L. L., Cegielski, M., & Hastings, J. (2005). Crystal structure of a pH-regulated luciferase catalyzing the bioluminescent oxidation of an open tetrapyrrole . Proc. Natl. Acad. Sci. U.S.A., 102 (5),