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Journal of Clinical Medicine Jan 2024Antepartum fetal surveillance (AFS) is essential for pregnant women with diabetes to mitigate the risk of stillbirth. However, there is still no universal consensus on... (Review)
Review
Antepartum fetal surveillance (AFS) is essential for pregnant women with diabetes to mitigate the risk of stillbirth. However, there is still no universal consensus on the optimal testing method, testing frequency, and delivery timing. This review aims to comprehensively analyze the evidence concerning AFS and the most advantageous timing for delivery in both gestational and pregestational diabetes mellitus cases. This review's methodology involved an extensive literature search encompassing international diabetes guidelines and scientific databases, including PubMed, MEDLINE, Google Scholar, and Scopus. The review process meticulously identified and utilized pertinent articles for analysis. Within the scope of this review, a thorough examination revealed five prominent international guidelines predominantly addressing gestational diabetes. These guidelines discuss the utility and timing of fetal well-being assessments and recommendations for optimal pregnancy resolution timing. However, the scarcity of clinical trials directly focused on this subject led to a reliance on observational studies as the basis for most recommendations. Glucose control, maternal comorbidities, and the medical management received are crucial in making decisions regarding AFS and determining the appropriate delivery timing.
PubMed: 38256447
DOI: 10.3390/jcm13020313 -
PloS One 2023To determine stillbirth ratio and its association with maternal, perinatal, and delivery characteristics, as well as geographic differences in Latin American countries...
OBJECTIVE
To determine stillbirth ratio and its association with maternal, perinatal, and delivery characteristics, as well as geographic differences in Latin American countries (LAC).
METHODS
We analysed data from the Perinatal Information System of the Latin American Center for Perinatology and Human Development (CLAP) between January 2018 and June 2021 in 8 health facilities from five LAC countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic). Maternal, pregnancy, and delivery characteristics, in addition to pregnancy outcomes were reported. Estimates of association were tested using chi-square tests, and P < 0.05 was regarded as significant. Bivariate analysis was conducted to estimate stillbirth risk. Prevalence ratios (PR) with their 95% confidence intervals (CI) for each predictor were reported.
RESULTS
In total, 101,852 childbirths comprised the SIP database. For this analysis, we included 99,712 childbirths. There were 762 stillbirths during the study period; the Stillbirth ratio of 7.7/1,000 live births (ranged from 3.8 to 18.2/1,000 live births across the different maternities); 586 (76.9%) were antepartum stillbirths, 150 (19.7%) were intrapartum stillbirths and 26 (3.4%) with an ignored time of death. Stillbirth was significantly associated with women with diabetes (PRadj 2.36; 95%CI [1.25-4.46]), preeclampsia (PRadj 2.01; 95%CI [1.26-3.19]), maternal age (PRadj 1.04; 95%CI [1.02-1.05]), any medical condition (PRadj 1.48; 95%CI [1.24-1.76, and severe maternal outcome (PRadj 3.27; 95%CI [3.27-11.66]).
CONCLUSIONS
Pregnancy complications and maternal morbidity were significantly associated with stillbirths. The stillbirth ratios varied across the maternity hospitals, which highlights the importance for individual surveillance. Specialized antenatal and intrapartum care remains a priority, particularly for women who are at a higher risk of stillbirth.
Topics: Pregnancy; Female; Humans; Stillbirth; Latin America; Resource-Limited Settings; Risk Factors; Electronics
PubMed: 38134193
DOI: 10.1371/journal.pone.0296002 -
Frontiers in Reproductive Health 2024International studies have reported conflicting data about the effects of COVID-19 pandemic policy measures on maternal and neonatal health. A major impact was reported...
BACKGROUND
International studies have reported conflicting data about the effects of COVID-19 pandemic policy measures on maternal and neonatal health. A major impact was reported on stillbirth and prematurity. The published literature suggests that the economic setting influenced the effects of imposed mitigation measures with a more severe effect in low-income countries.
OBJECTIVES
Our objective is to compare pregnancy outcomes at the only tertiary Maternity Hospital in Bihor County-Romania before and during the COVID-19 pandemic. This study aims to observe and document differences in perinatal outcomes across these periods, without inferring direct causation related to the pandemic or its associated restrictions.
MATERIALS AND METHODS
We used data from the registries of Public Health Services Bihor to conduct a retrospective cohort analysis of preterm births and stillbirths during the COVID-19 pandemic in Bihor County, Romania. Pregnancy outcomes were compared between the pandemic period (March 2020-February 2022) to the corresponding historical pre-COVID-19 period (March 2018-February 2020). Maternal socio-demographic variables and neonatal characteristics of these periods were also examined.
RESULTS
The COVID-19 pandemic period was associated with an increase in the stillbirth rate (RR: 1.53, 95% CI, 1.05-2.23). Preterm birth was significantly impacted during this period and showed changes when analyzing gestational age (RR: 0.88, 95% CI, 0.79-0.96) or birth weight (RR: 0.91, 95% CI, 0.82-1.00). The main cause of stillbirth was intrauterine asphyxia due to placental causes (67.6%) or cord pathology (12.6%), the most frequently encountered maternal pathology was cardiovascular (28.3%) or infectious (21.7%). Our study revealed no significant changes in terms of maternal and neonatal characteristics during the two-year pandemic period.
CONCLUSIONS
Lockdown restrictions in Bihor County, Romania were associated with an increase in stillbirths, whilst preterm birth rate decreased. This raises concerns about whether pandemic policy measures may have led to a failure in identifying and offering proper care for pregnant women who were more likely to experience an antepartum loss. Further studies across the globe are needed in order to integrate comparable data that will help develop adequate protocols and policies for protecting maternal and child health during the next pandemic that will follow.
PubMed: 38486846
DOI: 10.3389/frph.2024.1286496 -
Women and Birth : Journal of the... Feb 2024Reducing preventable perinatal deaths is the focus of perinatal death surveillance and response programmes. Standardised review tools can help identify modifiable... (Review)
Review
INTRODUCTION
Reducing preventable perinatal deaths is the focus of perinatal death surveillance and response programmes. Standardised review tools can help identify modifiable factors in perinatal deaths.
AIM
This systematic review aimed to identify, compare, and appraise perinatal mortality review tools (PMRTs) in upper-middle to high-income countries.
METHODS
Four major scientific databases were searched for publications relating to perinatal death reviews. There were no restrictions on date, study, or publication type. Professional websites for each country were searched for relevant material. The Appraisal of Guidelines Research and Evaluation Health Systems (AGREE-HS) checklist was used for quality appraisal of each tool. A narrative synthesis was used to describe and compare tools.
FINDINGS
Ten PMRTs were included. Five PMRTs were from high-income countries, four from upper-middle income countries and one was designed for use in a global context. The structure, content, and quality of each PMRT varied. Each tool collected information about the antepartum, intrapartum, and neonatal periods and a section to classify perinatal deaths using a standardised classification system. All tools reviewed the care provided. Five tools included recommendation development for changes to clinical care. Four tools mentioned parent involvement in the review process. For quality appraisal, one review tool scored "high quality", six scored "moderate quality" and two scored "poor quality".
CONCLUSION
There is little standardisation when it comes to PMRTs. Guidance on structuring PMRTs in a standardised way is needed. Recommendation development from a review is important to highlight changes to care required to reduce preventable perinatal deaths.
Topics: Female; Humans; Infant, Newborn; Pregnancy; Parturition; Perinatal Death; Perinatal Mortality; Stillbirth; Software
PubMed: 37793961
DOI: 10.1016/j.wombi.2023.09.006 -
Reproductive Sciences (Thousand Oaks,... Feb 2024There are approximately 5 million pregnancies per year in the USA, with 1 million ending in miscarriage (a loss occurring prior to 20 weeks of gestation) and over...
There are approximately 5 million pregnancies per year in the USA, with 1 million ending in miscarriage (a loss occurring prior to 20 weeks of gestation) and over 20,000 ending in stillbirth at or beyond 20 weeks of gestation. As many as 50% of these losses are unexplained. Our objective was to evaluate the effect of expanding the placental pathology diagnostic categories to include the explicit categories of (1) dysmorphic chorionic villi and (2) small placenta in examining previously unexplained losses. Using a clinical database of 1256 previously unexplained losses at 6-43 weeks of gestation, the most prevalent abnormality associated with each loss was determined through examination of its placental pathology slides. Of 1256 cases analyzed from 922 patients, there were 878 (69.9%) miscarriages and 378 (30.1%) antepartum stillbirths. We determined the pathologic diagnoses for 1150/1256 (91.6%) of the entire series, 777/878 (88.5%) of the miscarriages (< 20 weeks' gestation), and 373/378 (98.7%) of the stillbirths (≥ 20 weeks' gestation). The most common pathologic feature observed in unexplained miscarriages was dysmorphic chorionic villi (757 cases; 86.2%), a marker associated with genetic abnormalities. The most common pathologic feature observed in unexplained stillbirths was a small placenta (128 cases; 33.9%). Our classification system reinforced the utility of placental examination for elucidating potential mechanisms behind pregnancy loss. The improved rate of diagnosis appeared to be the result of filling a gap in previous pregnancy loss classification systems via inclusion of the categories of dysmorphic chorionic villi and small placenta.
Topics: Pregnancy; Humans; Female; Abortion, Spontaneous; Stillbirth; Placenta; Placenta Diseases; Gestational Age
PubMed: 37725247
DOI: 10.1007/s43032-023-01344-3 -
PLoS Medicine Jul 2023Ethnic and socioeconomic inequalities in obstetric outcomes are well established. However, the role of induction of labour (IOL) to reduce these inequalities is...
Induction of labour at 39 weeks and adverse outcomes in low-risk pregnancies according to ethnicity, socioeconomic deprivation, and parity: A national cohort study in England.
BACKGROUND
Ethnic and socioeconomic inequalities in obstetric outcomes are well established. However, the role of induction of labour (IOL) to reduce these inequalities is controversial, in part due to insufficient evidence. This national cohort study aimed to identify adverse perinatal outcomes associated with IOL with birth at 39 weeks of gestation ("IOL group") compared to expectant management ("expectant management group") according to maternal characteristics in women with low-risk pregnancies.
METHODS AND FINDINGS
All English National Health Service (NHS) hospital births between January 2018 and March 2021 were examined. Using the Hospital Episode Statistics (HES) dataset, maternal and neonatal data (demographic, diagnoses, procedures, labour, and birth details) were linked, with neonatal mortality data from the Office for National Statistics (ONS). Women with a low-risk pregnancy were identified by excluding pregnancies with preexisting comorbidities, previous cesarean section, breech presentation, placenta previa, gestational diabetes, or a baby with congenital abnormalities. Women with premature rupture of membranes, placental abruption, hypertensive disorders of pregnancy, amniotic fluid abnormalities, or antepartum stillbirth were excluded only from the IOL group. Adverse perinatal outcome was defined as stillbirth, neonatal death, or neonatal morbidity, the latter identified using the English composite neonatal outcome indicator (E-NAOI). Binomial regression models estimated risk differences (with 95% confidence intervals (CIs)) between the IOL group and the expectant management group, adjusting for ethnicity, socioeconomic background, maternal age, parity, year of birth, and birthweight centile. Interaction tests examined risk differences according to ethnicity, socioeconomic background, and parity. Of the 1 567 004 women with singleton pregnancies, 501 072 women with low-risk pregnancies and with sufficient data quality were included in the analysis. Approximately 3.3% of births in the IOL group (1 555/47 352) and 3.6% in the expectant management group (16 525/453 720) had an adverse perinatal outcome. After adjustment, a lower risk of adverse perinatal outcomes was found in the IOL group (risk difference -0.28%; 95% CI -0.43%, -0.12%; p = 0.001). This risk difference varied according to socioeconomic background from 0.38% (-0.08%, 0.83%) in the least deprived to -0.48% (-0.76%, -0.20%) in the most deprived national quintile (p-value for interaction = 0.01) and by parity with risk difference of -0.54% (-0.80%, -0.27%) in nulliparous women and -0.15% (-0.35%, 0.04%) in multiparous women (p-value for interaction = 0.02). There was no statistically significant evidence that risk differences varied according to ethnicity (p = 0.19). Key limitations included absence of additional confounding factors such as smoking, BMI, and the indication for induction in the HES datasets, which may mean some higher risk pregnancies were included.
CONCLUSIONS
IOL with birth at 39 weeks was associated with a small reduction in the risk of adverse perinatal outcomes, with 360 inductions in low-risk pregnancies needed to avoid 1 adverse outcome. The risk reduction was mainly present in women from more socioeconomically deprived areas and in nulliparous women. There was no significant risk difference found by ethnicity. Increased uptake of IOL at 39 weeks, especially in women from more socioeconomically deprived areas, may help reduce inequalities in adverse perinatal outcomes.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Parity; Stillbirth; Cesarean Section; Cohort Studies; Ethnicity; State Medicine; Placenta; Labor, Induced; England; Socioeconomic Factors
PubMed: 37471395
DOI: 10.1371/journal.pmed.1004259 -
Reproductive Health Oct 2023In Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between...
Stillbirth rates and their determinants in a national maternity hospital in Phnom Penh, Cambodia in 2017-2020: a cross-sectional assessment with a nested case-control study.
BACKGROUND
In Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between 2017 and 2020 in a large maternity referral hospital in the country and identify their key determinants to inform future prevention efforts.
METHODS
This was a retrospective cross-sectional analysis with a nested case-control study of women giving birth at the National Maternal and Child Health Centre (NMCHC) in Phnom Penh, 2017-2020. We calculated percentages of singleton births at ≥ 22 weeks' gestation resulting in stillbirth and annual stillbirth rates by timing: intrapartum (fresh) or antepartum (macerated). Multivariable logistic regression was used to explore factors associated with stillbirth, where cases were all women who gave birth to a singleton stillborn baby in the 4-year period. One singleton live birth immediately following each case served as an unmatched control. Multiple imputation was used to handle missing data for gestational age.
RESULTS
Between 2017 and 2020, 3.2% of singleton births ended in stillbirth (938/29,742). The stillbirth rate increased from 24.8 per 1000 births in 2017 to 38.1 per 1000 births in 2020, largely due to an increase in intrapartum stillbirth rates which rose from 18.8 to 27.4 per 1000 births in the same period. The case-control study included 938 cases (stillbirth) and 938 controls (livebirths). Factors independently associated with stillbirth were maternal age ≥ 35 years compared to < 20 years (aOR: 1.82, 95%CI: 1.39, 2.38), extreme (aOR: 3.29, 95%CI: 2.37, 4.55) or moderate (aOR: 2.45, 95%CI: 1.74, 3.46) prematurity compared with full term, and small-for-gestational age (SGA) (aOR: 2.32, 1.71, 3.14) compared to average size-for-age. Breech/transverse births had nearly four times greater odds of stillbirth (aOR: 3.84, 95%CI: 2.78, 5.29), while caesarean section reduced the odds by half compared with vaginal birth (aOR: 0.50, 95%CI: 0.39, 0.64). A history of abnormal vaginal discharge increased odds of stillbirth (aOR: 1.42, 95%CI: 1.11, 1.81) as did a history of stillbirth (aOR: 3.08, 95%CI: 1.5, 6.5).
CONCLUSIONS
Stillbirth prevention in this maternity referral hospital in Cambodia requires strengthening preterm birth detection and management of SGA, intrapartum care, monitoring women with stillbirth history, management of breech births, and further investigation of high-risk referral cases.
Topics: Child; Pregnancy; Female; Infant, Newborn; Humans; Adult; Stillbirth; Case-Control Studies; Cross-Sectional Studies; Retrospective Studies; Cesarean Section; Cambodia; Hospitals, Maternity; Premature Birth; Fetal Growth Retardation
PubMed: 37865789
DOI: 10.1186/s12978-023-01703-y -
Acta Obstetricia Et Gynecologica... Mar 2024Women with a prior stillbirth or a history of recurrent first trimester miscarriages are at increased risk of adverse pregnancy outcomes. However, little is known about... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Women with a prior stillbirth or a history of recurrent first trimester miscarriages are at increased risk of adverse pregnancy outcomes. However, little is known about the impact of a second trimester pregnancy loss on subsequent pregnancy outcome. This review investigated if second trimester miscarriage or termination for medical reason or fetal anomaly (TFMR/TOPFA) is associated with future adverse pregnancy outcomes.
MATERIAL AND METHODS
A systematic review of observational studies was conducted. Eligible studies included women with a history of a second trimester miscarriage or termination for medical reasons and their pregnancy outcomes in the subsequent pregnancy. Where comparative studies were identified, studies which compared subsequent pregnancy outcomes for women with and without a history of second trimester loss or TFMR/TOPFA were included. The primary outcome was livebirth, and secondary outcomes included: miscarriage (first and second trimester), termination of pregnancy, fetal growth restriction, cesarean section, preterm birth, pre-eclampsia, antepartum hemorrhage, stillbirth and neonatal death. Studies were excluded if exposure was nonmedical termination or if related to twins or higher multiple pregnancies. Electronic searches were conducted using the online databases (MEDLINE, Embase, PubMed and The Cochrane Library) and searches were last updated on June 16, 2023. Risk of bias was assessed using the Newcastle-Ottawa scale. Where possible, meta-analysis was undertaken. PROSPERO registration: CRD42023375033.
RESULTS
Ten studies were included, reporting on 12 004 subsequent pregnancies after a second trimester pregnancy miscarriage. No studies were found on outcomes after second trimester TFMR/TOPFA. Overall, available data were of "very low quality" using GRADE assessment. Meta-analysis of cohort studies generated estimated outcome frequencies for women with a previous second trimester loss as follows: live birth 81% (95% CI: 64-94), miscarriage 15% (95% CI: 4-30, preterm birth 13% [95% CI: 6-23]).The pooled odds ratio for preterm birth in subsequent pregnancy after second trimester loss in case-control studies was OR 4.52 (95% CI: 3.03-6.74).
CONCLUSIONS
Very low certainty evidence suggests there may be an increased risk of preterm birth in a subsequent pregnancy after a late miscarriage. However, evidence is limited. Larger, higher quality cohort studies are needed to investigate this potential association.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Pregnancy Outcome; Abortion, Spontaneous; Pregnancy Trimester, Second; Stillbirth; Premature Birth; Cesarean Section; Abortion, Habitual
PubMed: 38037500
DOI: 10.1111/aogs.14731 -
BMC Women's Health Feb 2024The annual global burden of stillbirths is estimated to be 3.2 million, of which 98% occur in low and middle-income countries (LMICs). In the Amhara region of Ethiopia,...
INTRODUCTION
The annual global burden of stillbirths is estimated to be 3.2 million, of which 98% occur in low and middle-income countries (LMICs). In the Amhara region of Ethiopia, the prevalence of stillbirth outcomes was 85 per 1000. Ethiopia is experiencing an increase in the number of health professionals attending deliveries, however, stillbirth rates are not decreasing as anticipated. However, there are limited numbers of studies done related to the proportion of stillbirths and associated factors in the study area. This study aimed to assess the proportion of stillbirths and associated factors among women who attended deliveries at Tibebe Ghion Specialized Hospital and Felege Hiwot Comprehensive Specialized Hospital.
METHODS
An institutional-based cross-sectional study was conducted on 366 women who delivered at two referral hospitals in Bahir Dar from April 1, 2020, to August 30, 2020. Study participants were selected using systematic random sampling techniques. A checklist and structured questionnaire were used to retrieve information from the clients and their attendants. The collected data were cleaned, coded, and entered into Epi-data version 3.1 and then exported into SPSS 23 for analysis. Bivariate and multivariable logistic regression analysis was computed to identify statistically significant associated factors with a P value < 0.05. The results were presented in tables and charts.
RESULT
The proportion of stillbirths was 3.8% in this study area. This study showed that level of education, who completed primary school (AOR = 0.12; 95% CI (0.01, 0.98)), not using partograph (AOR = 3.77, 95%; CI (1.02; 13.93)), and obstetric complication (AOR = 6.7; 95% CI (1.54, 29.79) were the major factors affecting the stillbirth.
CONCLUSION
Our study found that stillbirth rate remains a major public health problem. Illiteracy, not using a partograph, and having obstetric complications were major associated factors for stillbirth. The risk factors identified in this study can be prevented and managed by providing appropriate care during preconception, antepartum, and intrapartum periods.
Topics: Pregnancy; Humans; Female; Stillbirth; Ethiopia; Cross-Sectional Studies; Parturition; Hospitals, Public
PubMed: 38365779
DOI: 10.1186/s12905-024-02920-8 -
BMC Pregnancy and Childbirth Dec 2023Reduction of Tanzania's neonatal mortality rate has lagged behind that for all under-fives, and perinatal mortality has remained stagnant over the past two decades. We...
BACKGROUND
Reduction of Tanzania's neonatal mortality rate has lagged behind that for all under-fives, and perinatal mortality has remained stagnant over the past two decades. We conducted a national verbal and social autopsy (VASA) study to estimate the causes and social determinants of stillbirths and neonatal deaths with the aim of identifying relevant health care and social interventions.
METHODS
A VASA interview was conducted of all stillbirths and neonatal deaths in the prior 5 years identified by the 2015-16 Tanzania Demographic and Health Survey. We evaluated associations of maternal complications with antepartum and intrapartum stillbirth and leading causes of neonatal death; conducted descriptive analyses of antenatal (ANC) and delivery care and mothers' careseeking for complications; and developed logistic regression models to examine factors associated with delivery place and mode.
RESULTS
There were 204 stillbirths, with 185 able to be classified as antepartum (88 [47.5%]) or intrapartum (97 [52.5%]), and 228 neonatal deaths. Women with an intrapartum stillbirth were 6.5% (adjusted odds ratio (aOR) = 1.065, 95% confidence interval (CI) 1.002, 1.132) more likely to have a C-section for every additional hour before delivery after reaching the birth attendant. Antepartum hemorrhage (APH), maternal anemia, and premature rupture of membranes (PROM) were significantly positively associated with early neonatal mortality due to preterm delivery, intrapartum-related events and serious infection, respectively. While half to two-thirds of mothers made four or more ANC visits (ANC4+), a third or fewer received quality ANC (Q-ANC). Women with a complication were more likely to deliver at hospital only if they received Q-ANC (neonates: aOR = 4.5, 95% CI 1.6, 12.3) or ANC4+ (stillbirths: aOR = 11.8, 95% CI 3.6, 38.0). Nevertheless, urban residence was the strongest predictor of hospital delivery.
CONCLUSIONS
While Q-ANC and ANC4 + boosted hospital delivery among women with a complication, attendance was low and the quality of care is critical. Quality improvement efforts in urban and rural areas should focus on early detection and management of APH, maternal anemia, PROM, and prolonged labor, and on newborn resuscitation.
Topics: Infant, Newborn; Female; Pregnancy; Humans; Stillbirth; Perinatal Death; Tanzania; Cross-Sectional Studies; Infant Mortality; Obstetric Labor Complications; Uterine Hemorrhage; Autopsy; Anemia
PubMed: 38082404
DOI: 10.1186/s12884-023-06099-y