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The Australian & New Zealand Journal of... Oct 2021Stillbirth is a major public health problem that is slow to improve in Australia. Understanding the causes of stillbirth through appropriate investigation is the...
BACKGROUND
Stillbirth is a major public health problem that is slow to improve in Australia. Understanding the causes of stillbirth through appropriate investigation is the cornerstone of prevention and important for parents to understand why their baby died.
AIM
The aim of this study is to assess compliance with the Perinatal Society of Australia and New Zealand (PSANZ) Perinatal Mortality Clinical Practice Guidelines (2009) for stillbirths.
METHODS
This is a prospective multi-centred cohort study of stillbirths at participating hospitals (2013-2018). Data were recorded into a purpose-built database. The frequency of the recommended core investigations was calculated, and χ test was performed for subgroup analyses by gestational age groups and timing of fetal death. A 70% compliance threshold was defined for investigations. The cause of death categories was provided according to PSANZ Perinatal Death Classification.
RESULTS
Among 697 reported total stillbirths, 562 (81%) were antepartum, and 101 (15%) were intrapartum. The most common cause of death categories were 'congenital abnormality' (12.5%), 'specific perinatal conditions' (12.2%) and 'unexplained antepartum death' (29%). According to 2009 guidelines, there were no stillbirths where all recommended investigations were performed (including or excluding autopsy). A compliance of 70% was observed for comprehensive history (82%), full blood count (94%), cytomegalovirus (71%), toxoplasmosis (70%), renal function (75%), liver function (79%), external examination (86%), post-mortem examination (84%) and placental histopathology (92%). The overall autopsy rate was 52%.
CONCLUSIONS
Compliance with recommended investigations for stillbirth was suboptimal, and many stillbirths remain unexplained. Education on the value of investigations for stillbirth is needed. Future studies should focus on understanding the yield and value of investigations and service delivery gaps that impact compliance.
Topics: Australia; Cause of Death; Cohort Studies; Female; Humans; Placenta; Pregnancy; Prospective Studies; Stillbirth
PubMed: 33872393
DOI: 10.1111/ajo.13334 -
PloS One 2023Stillbirths are indicators of the quality of obstetrics care in health systems. Stillbirth rates and their associating factors vary by socio-economic and geographical...
BACKGROUND
Stillbirths are indicators of the quality of obstetrics care in health systems. Stillbirth rates and their associating factors vary by socio-economic and geographical settings. Published data on stillbirths and their associating factors in the Volta Region of Ghana are limited. This limits understanding of local factors that must be considered in designing appropriate interventions to mitigate the occurrence of stillbirths. This study determined the incidence of stillbirths and associated factors among deliveries at Ho Teaching Hospital (HTH) and contributes to understanding the consistent high stillbirths in the country and potentially in other low-resourced settings in sub-Saharan Africa.
METHOD
This was a prospective cohort study involving pregnant women admitted for delivery at HTH between October 2019 and March 2020. Data on socio-demographic characteristics such as age and employment, obstetric factors including gestational age at delivery and delivery outcomes like birthweight were collected using a pretested structured questionnaire. The primary outcome was the incidence of stillbirths at the facility. Summary statistics were reported as frequencies, percentages and means. Logistic regression methods were used to assess for association between stillbirths and independent variables including age and birthweight. Odds ratios were reported with 95% confidence intervals and associations with p-values < 0.05 were considered statistically significant.
RESULTS
A total of 687 women and their 702 newborns contributed data for analysis. The mean age (SD) was 29.3 (6.3) years and close to two-thirds had had at least one delivery previously. Overall stillbirth incidence was 31.3 per 1000 births. Of the 22 stillbirths, 17 were antepartum. Pre-eclampsia was the most common hypertensive disorder of pregnancy observed (49.3%, 33/67). Among others, less than 3 antenatal visits and low birthweight increased the odds of stillbirths in the bivariate analysis. In the final multivariate model, pregnancy and delivery at 28-34 weeks gestation [AOR 9.37(95% CI 1.18-74.53); p = 0.034] and induction of labour [AOR 11.06 (95% CI 3.10-39.42); p < 0.001] remained significantly associated with stillbirths.
CONCLUSION
Stillbirth incidence was 31.3 per 1000 births with more than half being antepartum stillbirths. Pregnancy/delivery at 28-34 weeks' gestation increased the odds of a stillbirth. Improving the quality of antenatal services, ensuring adherence to evidence-based protocols, accurate and prompt diagnosis and timely interventions of medical conditions in pregnancy particularly at 28-34 weeks' gestation could reduce incidence of stillbirths.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Adult; Stillbirth; Birth Weight; Ghana; Incidence; Prospective Studies; Health Facilities
PubMed: 38128029
DOI: 10.1371/journal.pone.0296076 -
Clinical Obstetrics and Gynecology Mar 1995Monitoring fetal movement serves as an indirect measure of central nervous system integrity and function. The coordination of whole-body movement, which requires complex... (Review)
Review
Monitoring fetal movement serves as an indirect measure of central nervous system integrity and function. The coordination of whole-body movement, which requires complex neurologic control, is similar to that of the preterm newborn infant. Short-term observations of the fetus are best performed using real-time ultrasound imaging or Doppler ultrasound. Daily fetal movement charting by the compliant patient is a worthwhile adjunct in determining the frequency of fetal surveillance tests in the office and in predicting abnormal FHR patterns and perhaps impending stillbirth. Monitoring has its greatest value when placental insufficiency is long-standing, and its routine role in low-risk pregnancies requires further clinical investigation. The presence of a vigorous fetus is reassuring. Perceived inactivity requires reassessment of any underlying antepartum complication and more precise evaluation by FHR testing or real-time ultrasonography before delivery is considered.
Topics: Central Nervous System; Diagnostic Errors; Female; Fetal Monitoring; Fetal Movement; Heart Rate, Fetal; Humans; Neurologic Examination; Patient Satisfaction; Pregnancy; Ultrasonography, Doppler; Ultrasonography, Prenatal
PubMed: 7796553
DOI: 10.1097/00003081-199503000-00008 -
Journal de Gynecologie, Obstetrique Et... Dec 2014To give consistent data of the prevalence of intrauterine fetal death (IUFD), to assess risk factors and causes related to IUFD, to evaluate prevention of IUFD, to... (Review)
Review
OBJECTIVES
To give consistent data of the prevalence of intrauterine fetal death (IUFD), to assess risk factors and causes related to IUFD, to evaluate prevention of IUFD, to evaluate fetal autopsy and MRI and to determine the management of inhibition of lactation.
METHODS
French and English publications were searched using PubMed, Cochrane Library.
RESULTS
Intrauterine fetal death occurs in 2% of the pregnancies worldwide, and in around 0,5% of pregnancies in France (NP1). Major risk factors related to IUFD are maternal overweight, maternal age, and smoking, small for gestational age fetuses or placental abruption, and pre-gestational maternal diseases such as hypertension and diabetes (NP1). The most relevant causes of IUFD are placental anomalies, followed by abnormal karyotypes and congenital malformations (NP3). Data are insufficient to recommend a classification for causes of IUFD. Data concerning primary and secondary prevention do not recommend a specific management for the following of pregnancy. Fetal autopsy is still the gold standard of fetal examination, but fetal post-mortem MRI can be offered when fetal autopsy is refused (NP4). Inhibition of lactation should be started within 24hours postpartum with cabergoline, if the patient demands a treatment (NP4).
Topics: Female; Fetal Death; Humans; Pregnancy
PubMed: 25447381
DOI: 10.1016/j.jgyn.2014.09.018 -
Indian Journal of Pediatrics Dec 2023India contributes the highest absolute number of stillbirths in the world. This systematic review and meta-analysis was conducted to synthesize the burden, timing and... (Meta-Analysis)
Meta-Analysis Review
India contributes the highest absolute number of stillbirths in the world. This systematic review and meta-analysis was conducted to synthesize the burden, timing and causes of stillbirths in India. Forty-nine reports from 46 studies conducted in 21 Indian states and Union Territories were included. It was found that there was no uniformity/standardization in the definition of stillbirths and in the classification system used to assign the cause. The share of antepartum stillbirths was estimated to be two-third while remaining were intrapartum stillbirths. Maternal conditions and fetal causes were found to be the leading cause of stillbirth in India. The maternal condition was assigned as the commonest cause (25%) followed by fetal (14%), placental cause (13%), congenital malformation (6%) and intrapartum complications (4%). Approximately 20% of the stillbirths were assigned as unknown or unexplained. This review demonstrates that there is a paucity of quality stillbirth data in India. Other than the state level differences in stillbirth rates, no other data is available on inequities in stillbirths in India. There is an urgent need for strengthening availability and quality of stillbirth data in India on both stillbirth rates as well as the causes. There is a need to conduct additional research to know the timing of the stillbirths, causes of death and actual burden. India needs to strengthen stillbirth audits along with registry to find out the modifiable factors and delays for making country specific preventive strategies. The policy makers, academic community and researchers need to work together to ensure accelerated and equitable reduction in stillbirths in India.
Topics: Humans; Female; Pregnancy; Stillbirth; Placenta; Risk Factors; Prenatal Care; India
PubMed: 37556034
DOI: 10.1007/s12098-023-04749-9 -
Acta Obstetricia Et Gynecologica... Nov 2016Maternal smoking during pregnancy has been associated with an increased risk of stillbirth. Only a few studies have been conducted to determine whether smoking affects...
INTRODUCTION
Maternal smoking during pregnancy has been associated with an increased risk of stillbirth. Only a few studies have been conducted to determine whether smoking affects the risk of antepartum and intrapartum stillbirth differently or whether smoking cessation in early pregnancy reduces the risk. Previous results are inconclusive. We addressed these questions in a large Danish population-based cohort study.
MATERIAL AND METHODS
From the Danish Medical Birth Register, we identified 841 228 singleton births in Denmark between 1997 and 2010 and gathered detailed information on maternal smoking during pregnancy and the vital status of the infant. Associations (odds ratios with 95% confidence intervals) between maternal smoking and risk of stillbirth overall and separately for antepartum and intrapartum stillbirth were analyzed using logistic regression models (generalized estimating equations), adjusting for potential confounders.
RESULTS
Any smoking during pregnancy increased the risk of stillbirth, both overall (odds ratio 1.42, 95% confidence interval 1.30-1.55) and for antepartum (odds ratio 1.38, 95% confidence interval 1.25-1.53) and intrapartum (odds ratio 1.52, 95% confidence interval 1.18-1.96) stillbirths. Women who quit smoking at the beginning of the second trimester at the latest had no increased risk of stillbirth overall (odds ratio 1.03, 95% confidence interval 0.80-1.32).
CONCLUSIONS
Maternal smoking during pregnancy increases the risk of stillbirth, both overall and for antepartum and intrapartum stillbirth separately. Women who quit smoking in the beginning of their pregnancy reduce their risk compared with that of non-smokers.
Topics: Adult; Cohort Studies; Denmark; Female; Humans; Logistic Models; Maternal Behavior; Pregnancy; Registries; Risk Factors; Smoking; Smoking Cessation; Stillbirth
PubMed: 27580369
DOI: 10.1111/aogs.13011 -
Ultrasound in Obstetrics & Gynecology :... Jan 2022To examine the performance of a model combining maternal risk factors, uterine artery pulsatility index (UtA-PI) and estimated fetal weight (EFW) at 19-24 weeks'...
Development and validation of model for prediction of placental dysfunction-related stillbirth from maternal factors, fetal weight and uterine artery Doppler at mid-gestation.
OBJECTIVE
To examine the performance of a model combining maternal risk factors, uterine artery pulsatility index (UtA-PI) and estimated fetal weight (EFW) at 19-24 weeks' gestation, for predicting all antepartum stillbirths and those due to impaired placentation, in a training dataset used for development of the model and in a validation dataset.
METHODS
The data for this study were derived from prospective screening for adverse obstetric outcome in women with singleton pregnancy attending for routine pregnancy care at 19 + 0 to 24 + 6 weeks' gestation. The study population was divided into a training dataset used to develop prediction models for placental dysfunction-related antepartum stillbirth and a validation dataset to which the models were then applied. Multivariable logistic regression analysis was used to develop a model based on a combination of maternal risk factors, EFW Z-score and UtA-PI multiples of the normal median. We examined the predictive performance of the model by, first, the ability of the model to discriminate between the stillbirth and live-birth groups, using the area under the receiver-operating-characteristics curve (AUC) and the detection rate (DR) at a fixed false-positive rate (FPR) of 10%, and, second, calibration by measurements of calibration slope and intercept.
RESULTS
The study population of 131 514 pregnancies included 131 037 live births and 477 (0.36%) stillbirths. There are four main findings of this study. First, 92.5% (441/477) of stillbirths were antepartum and 7.5% (36/477) were intrapartum, and 59.2% (261/441) of antepartum stillbirths were observed in association with placental dysfunction and 40.8% (180/441) were unexplained or due to other causes. Second, placental dysfunction accounted for 80.1% (161/201) of antepartum stillbirths at < 32 weeks' gestation, 54.2% (52/96) at 32 + 0 to 36 + 6 weeks and 33.3% (48/144) at ≥ 37 weeks. Third, the risk of placental dysfunction-related antepartum stillbirth increased with increasing maternal weight and decreasing maternal height, was 3-fold higher in black than in white women, was 5.5-fold higher in parous women with previous stillbirth than in those with previous live birth, and was increased in smokers, in women with chronic hypertension and in parous women with a previous pregnancy complicated by pre-eclampsia and/or birth of a small-for-gestational-age baby. Fourth, in screening for placental dysfunction-related antepartum stillbirth by a combination of maternal risk factors, EFW and UtA-PI in the validation dataset, the DR at a 10% FPR was 62.3% (95% CI, 57.2-67.4%) and the AUC was 0.838 (95% CI, 0.799-0.878); these results were consistent with those in the dataset used for developing the algorithm and demonstrate high discrimination between affected and unaffected pregnancies. Similarly, the calibration slope was 1.029 and the intercept was -0.009, demonstrating good agreement between the predicted risk and observed incidence of placental dysfunction-related antepartum stillbirth. The performance of screening was better for placental dysfunction-related antepartum stillbirth at < 37 weeks' gestation compared to at term (DR at a 10% FPR, 69.8% vs 29.2%).
CONCLUSIONS
Screening at mid-gestation by a combination of maternal risk factors, EFW and UtA-PI can predict a high proportion of placental dysfunction-related stillbirths and, in particular, those that occur preterm. Such screening provides poor prediction of unexplained stillbirth or stillbirth due to other causes. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Adult; Female; Fetal Weight; Gestational Age; Humans; Placenta; Placenta Diseases; Placentation; Predictive Value of Tests; Pregnancy; Pregnancy Trimester, Second; Prenatal Diagnosis; Prospective Studies; Pulsatile Flow; Risk Assessment; Stillbirth; Ultrasonography, Doppler; Ultrasonography, Prenatal; Uterine Artery
PubMed: 34643306
DOI: 10.1002/uog.24795 -
Current Diabetes Reports Sep 2018To elaborate on the risks and benefits associated with antenatal fetal surveillance for stillbirth prevention in women with diabetes. (Review)
Review
PURPOSE OF REVIEW
To elaborate on the risks and benefits associated with antenatal fetal surveillance for stillbirth prevention in women with diabetes.
RECENT FINDINGS
Women with pregestational diabetes have a 3- to 5-fold increased odds of stillbirth compared to women without diabetes. The stillbirth risk in women with gestational diabetes (GDM) is more controversial; while recent data suggest the odds for stillbirth are approximately 50% higher in women with GDM at term (37 weeks and beyond) than in those without GDM, it is unclear if this risk is seen in women with optimal glycemic control. Current professional society guidelines are broad with respect to fetal testing strategies and delivery timing in women with diabetes. The data supporting strategies to reduce the risk of stillbirth in women with diabetes are limited. Antepartum fetal surveillance should be performed to reduce stillbirth rates; however, the optimal test, frequency of testing, and delivery timing are not yet clear. Future studies of obstetric management for women with diabetes should consider not just individual but also system level costs and benefits associated with antenatal surveillance.
Topics: Cost-Benefit Analysis; Diabetes, Gestational; Female; Fetus; Humans; Obstetrics; Pregnancy; Risk Factors; Stillbirth
PubMed: 30194499
DOI: 10.1007/s11892-018-1058-5 -
Lancet (London, England) Nov 2003
Topics: Cesarean Section; Female; Fetal Death; Gestational Age; Humans; Infant, Newborn; Placenta Diseases; Pregnancy; Pregnancy Outcome; Risk Factors
PubMed: 14654309
DOI: 10.1016/S0140-6736(03)14938-0 -
Obstetrics and Gynecology Jul 2004Older women are at an increased risk for unexplained stillbirth late in pregnancy. The purpose of this study was to compare 3 strategies for the prevention of... (Comparative Study)
Comparative Study
OBJECTIVE
Older women are at an increased risk for unexplained stillbirth late in pregnancy. The purpose of this study was to compare 3 strategies for the prevention of unexplained fetal death in women aged 35 years and older. We compared usual care (no antepartum testing or induction before 41 weeks), weekly testing at 37 weeks with induction after a positive test, and no testing with induction at 41 weeks.
METHOD
We used a Markov model to quantify the risks and benefits of each strategy in terms of the number of antepartum tests, inductions, and additional cesarean deliveries per fetal death averted. Probability data used in the model were derived from obstetrical databases and the literature.
RESULTS
Without a strategy of antepartum surveillance between 37 and 41 weeks, women aged 35 years and older would experience 5.2 unexplained fetal deaths per 1,000 pregnancies. For nulliparous women 35 and older, weekly antepartum testing initiated at 37 weeks would avert 3.9 fetal deaths per 1,000 pregnancies but would require 863 antepartum tests, 71 inductions, and 14 additional cesarean deliveries per fetal death averted. A strategy of no testing but induction at 41 weeks would avert 0.9 fetal deaths per 1,000 pregnancies and require 469 inductions and 219 additional cesareans per fetal death averted.
CONCLUSION
A strategy of antepartum testing in older women would reduce the number of unexplained stillbirths at term and would result in fewer inductions and cesareans per fetal death averted than a strategy of no antepartum testing but induction at 41 weeks.
Topics: Cesarean Section; Female; Humans; Labor, Induced; Markov Chains; Maternal Age; Parity; Pregnancy; Pregnancy Outcome; Pregnancy, High-Risk
PubMed: 15229001
DOI: 10.1097/01.AOG.0000129237.93777.1a