Stillbirth

Disparities in perinatal medicine: preterm birth, stillbirth, and infant mortality

Infant mortality, stillbirths, and preterm births are major public health priorities with significant disparities based on race and ethnicity. Interestingly, when evaluating the rates over the past 30 to 50 years, the disparity persists in all three and is remarkably consistent. In the United States, the infant mortality rate is 6.7 deaths per 1,000 live births, the stillbirth rate is 6.2 per 1,000 deliveries, and the preterm birth rate is 12.8% of live births. The rates among non-Hispanic African Americans are dramatically higher, nearly double the infant mortality at 13.4 infant deaths per 1,000 live births, nearly double the stillbirth rate at 11.1 stillbirths per 1,000 deliveries, and one third higher with preterm births at 18.4% of live births. Despite numerous conferences, workshops, articles, and investigators focusing on this line of work, the disparities persist and, in some cases, are growing. In this article, we summarize a Eunice Kennedy Shriver National Institute of Child Health and Human Development workshop that focused on these disparities to identify the associated factors to determine their relative contributions, identify gaps in knowledge, and develop specific strategies to address the disparities in the short-term and long-term.

[Risk factors for perinatal mortality in the city of Lubumbashi, Democratic Republic of Congo]

BACKGROUND

The aim of this study is to establish factors explaining perinatal death rates in the city of Lubumbashi.

METHODS

We have carried out a case controlled study in the maternity ward of Jason Sendwe hospital. Perinatal death cases have been compared to those of surviving newborn children among parturient women in the course of 2008. Sociodemographic characteristics, maternal morbidity, children's typical features, have been studied as independent variables. Their effect on perinatal mortality has been assessed using an adjusted odds ratio value at a 5% confidence interval and a logistic regression model.

RESULTS

In total, we considered 2279 births (mother and child pairs) for our study. Among these were 415 perinatal mortality cases and 1864 control cases. After adjustment for several parameters, household chores (AOR=1.8; 95% IC=1.2-2.9), multiple pregnancies (AOR=1.9; 95% IC=1.2-2.9), malaria (AOR=1.4; 95% IC=1.1-1.8), primiparity (AOR=1.7; 95% IC=1.3-2.4), stillbirth (AOR=5.2; 95% IC=2.5-11.0) and prematurity (AOR=2.9; 95% IC=1.5-5.5) in previous pregnancies, onset of antepartum ferver (AOR=3.0; 95% IC=1.2-7.3) and antepartum hemorrhage (AOR=6.8; 95% IC=3.1-15.0), lack of fetal motions near delivering time, dystocias (AOR=2.0; 95% IC=1.3-3.0), low birthweight (AOR=15.7; 95% IC=11.2-22.0), very low birthweight (AOR=49.0; 95% IC=28.6-85.1) and foetal macrosomia (AOR=3.5; 95% IC=1.8-7.0) were the main factors explaining perinatal mortality.

CONCLUSION

Perinatal mortality in Lubumbashi remains associated with several avoidable factors. Basic and emergency obstetrical-neonatal care (B-EMONC) should be improved. Significant efforts should be made in this direction. Perinatal audits should be established for a good heath care quality follow-up. Obstetrical care should be offered as a continuum in order to facilitate communication between the different caregivers.

Relation between maternal thrombophilia and stillbirth according to causes/associated conditions of death

OBJECTIVE

To investigate maternal thrombophilia in cases of Stillbirth (SB), also an uncertain topic because most case series were not characterised for cause/associated conditions of death.

STUDY DESIGN

In a consecutive, prospective, multicentre design, maternal DNA was obtained in 171 cases of antenatal SB and 326 controls (uneventful pregnancy at term, 1:2 ratio). Diagnostic work-up of SB included obstetric history, neonatologist inspection, placenta histology, autopsy, microbiology/chromosome evaluations. Results audited in each centre were classified by two of us by using CoDAC. Cases were subdivided into explained SB where a cause of death was identified and although no defined cause was detected in the remnants, 64 cases found conditions associated with placenta-vascular disorders (including preeclampsia, growth restriction and placenta abruption - PVD). In the remnant 79 cases, no cause of death or associated condition was found. Antithrombin activity, Factor V Leiden, G20210A Prothrombin mutation (FII mutation) and acquired thrombophilia were analysed.

RESULTS

Overall, the presence of a thrombophilic defect was significantly more prevalent in mothers with SBs compared to controls. In particular, SB mothers showed an increased risk of carrying Factor II mutation (OR=3.2, 95% CI: 1.3-8.3, p=0.01), namely in unexplained cases. Such mutation was significantly associated also with previous SB (OR=8.9, 95%CI 1.2-70.5). At multiple logistic regression, Factor II mutation was the only significantly associated variable with SB (adj OR=3.8, 95% CI: 1.3-13.5).

CONCLUSION

These data suggest that Factor II mutation is the only condition specifically associated with unexplained SB and could represents a risk of recurrence. PVD-associated condition is unrelated to thrombophilia.

Trends in socioeconomic inequalities in risk of sudden infant death syndrome, other causes of infant mortality, and stillbirth in Scotland: population based study

OBJECTIVES

To compare changes in inequalities in sudden infant death syndrome with other causes of infant mortality and stillbirth in Scotland, 1985-2008.

DESIGN

Retrospective cohort study.

SETTING

Scotland 1985-2008, analysed by four epochs of six years.

PARTICIPANTS

Singleton births of infants with birth weight >500 g born at 28-43 weeks' gestation.

MAIN OUTCOME MEASURES

Sudden infant death syndrome, other causes of postneonatal infant death, neonatal death, and stillbirth. Odds ratios expressed as the association across the range of seven categories of Carstairs deprivation score.

RESULTS

The association between deprivation and the risk of all cause stillbirth and infant death varied between the four epochs (P=0.04). This was wholly explained by variation in the risk of sudden infant death syndrome (P<0.001 for interaction). Among women living in areas of low deprivation, there was a sharp decline in the rate of sudden infant death syndrome from 1990 to 1993. Among women living in areas of high deprivation, there was a slower decline in sudden infant death syndrome rates between 1992 and 2004. Consequently, the odds ratio for the association between socioeconomic deprivation and sudden infant death syndrome increased from 2.04 (95% confidence interval 1.53 to 2.72) in 1985-90, to 7.52 (4.62 to 12.25) in 1991-6, and 9.50 (5.46 to 16.53) in 1997-2002 but fell to 1.78 (0.87 to 3.65) in 2002-8. The interaction remained significant after adjustment for maternal characteristics.

CONCLUSION

The rate of sudden infant death syndrome declined throughout Scotland in the early 1990s. The decline had a later onset and was slower among women living in areas of high deprivation, probably because of slower uptake of recommended changes in infant sleeping position. The effect was to create a strong independent association between deprivation and sudden infant death syndrome where one did not exist before.

Maternal marital status and the risk of stillbirth and infant death: a population-based cohort study on 40 million births in the United States

OBJECTIVE

The objective of our study was to evaluate the association between maternal marital status and the risk of fetal and infant death, including sudden infant death syndrome (SIDS).

METHODS

We conducted a population-based cohort study using the Centers for Disease Control and Prevention's Linked Birth-Infant Death and Fetal Death data on all births in the United States between 1995 and 2004. Marital status was obtained from the birth certificate. The adjusted effect of marital status on the risk of fetal and infant mortalities was estimated using unconditional logistic regression analysis.

RESULTS

The cohort consisted of 40,529,306 births, of which 37,461,715 met study criteria. There were 130,353 stillbirths (3.5/1,000 births) and 140,175 infant deaths (3.8/1,000 births), of which 24,066 were due to SIDS (0.6/1,000 births). Rates of nonmarital births increased from 31.3% to 35.4% over the study period. As compared with births from married women, births from unmarried women were at an increased risk of stillbirths (relative rise [RR], 1.24; 95% confidence interval [CI], 1.21-1.26), total infant deaths (RR, 1.45; 95% CI, 1.42-1.47), and SIDS (RR, 1.70; 95% CI, 1.63-1.78). Among unmarried women, those at a higher risk of fetal and infant death were women under 15 or over 40 years of age, African-American women, and those who received no prenatal care.

CONCLUSION

Nonmarital childbearing seems to be associated with an increased risk of fetal and infant death, including SIDS. Promoting access to care and targeting unmarried mothers-to-be with the goal of educating, increasing awareness, and providing resources for proper obstetrical and maternal care may be of great benefit to their pregnancies.

Evaluation of 1025 fetal deaths: proposed diagnostic workup

OBJECTIVE

We sought to evaluate the contribution of different diagnostic tests for determining cause of fetal death. Our goal was to propose a workup guideline.

STUDY DESIGN

In a multicenter prospective cohort study from 2002 through 2008, for 1025 couples with fetal death ≥20 weeks' gestation, an extensive nonselective diagnostic workup was performed. A panel classified cause and determined contribution of diagnostics for allocating cause.

RESULTS

A Kleihauer-Betke, autopsy, placental examination, and cytogenetic analysis were abnormal in 11.9% (95% confidence interval [CI], 9.8-14.2), 51.5% (95% CI, 47.4-55.2), 89.2% (95% CI, 87.2-91.1), and 11.9% (95% CI, 8.7-15.7), respectively. The most valuable tests for determination of cause were placental examination (95.7%; 95% CI, 94.2-96.8), autopsy (72.6%; 95% CI, 69.2-75.9), and cytogenetic analysis (29.0%; 95% CI, 24.4-34.0).

CONCLUSION

Autopsy, placental examination, cytogenetic analysis, and testing for fetal maternal hemorrhage are basic tests for workup after fetal death. Based on the results of these tests or on specific clinical characteristics, further sequential testing is indicated.

Maternal obesity and stillbirth

The current obesity epidemic appears to contribute significantly to adverse fetal outcomes, and in this work we compile up-to-date evidence for the link between maternal obesity and risk of stillbirth. The review revealed a preponderance of evidence showing that the risk of stillbirth is increased among obese mothers with amplified risk estimates as the severity of obesity increases. Changes in interpregnancy body mass index (BMI) influence subsequent fetal survival and obese women that normalize their BMI values experience enhanced fetal survival in future pregnancies. The elevated risk of stillbirth among obese mothers affect all gestations regardless of fetal number, with the most profound risk (4-fold increase) noted among triplet gestations. The literature has predominantly reported a strong association between maternal prepregnancy obesity and stillbirth. The considerable magnitude of association, consistency of positive results for the association between maternal obesity and stillbirth, the establishment of temporality between maternal obesity and stillbirth, the incremental elevation in risk with ascending BMI values, as well as the improvement in fetal survival with decrease in interpregnancy BMI among obese mothers strongly provide sufficient evidence that the relationship between maternal obesity and stillbirth may be causal.

Gestational age patterns of fetal and neonatal mortality in Europe: results from the Euro-Peristat project

Background

The first European Perinatal Health Report showed wide variability between European countries in fetal (2.6–9.1‰) and neonatal (1.6–5.7‰) mortality rates in 2004. We investigated gestational age patterns of fetal and neonatal mortality to improve our understanding of the differences between countries with low and high mortality.

Methodology/Principal Findings

Data on 29 countries/regions participating in the Euro-Peristat project were analyzed. Most European countries had no limits for the registration of live births, but substantial variations in limits for registration of stillbirths before 28 weeks of gestation existed. Country rankings changed markedly after excluding deaths most likely to be affected by registration differences (22–23 weeks for neonatal mortality and 22–27 weeks for fetal mortality). Countries with high fetal mortality ≥28 weeks had on average higher proportions of fetal deaths at and near term (≥37 weeks), while proportions of fetal deaths at earlier gestational ages (28–31 and 32–36 weeks) were higher in low fetal mortality countries. Countries with high neonatal mortality rates ≥24 weeks, all new member states of the European Union, had high gestational age-specific neonatal mortality rates for all gestational-age subgroups; they also had high fetal mortality, as well as high early and late neonatal mortality. In contrast, other countries with similar levels of neonatal mortality had varying levels of fetal mortality, and among these countries early and late neonatal mortality were negatively correlated.

Conclusions

For valid European comparisons, all countries should register births and deaths from at least 22 weeks of gestation and should be able to distinguish late terminations of pregnancy from stillbirths. After excluding deaths most likely to be influenced by existing registration differences, important variations in both levels and patterns of fetal and neonatal mortality rates were found. These disparities raise questions for future research about the effectiveness of medical policies and care in European countries.

Recurrence of placental dysfunction disorders across generations

OBJECTIVE

Knowledge about the causes of placental dysfunction disorders is limited. We performed an intergenerational study, focusing on the risks of placental dysfunction disorders in mothers and fathers who had been born small for gestational age (SGA).

STUDY DESIGN

Using linked generational data from the Swedish Medical Birth Register from 1973-2006, we identified 321,383 mother-offspring units and 135,637 mother-father-offspring units.

RESULTS

Compared with mothers who had not been born SGA, mothers who had been born SGA had the following adjusted odds ratios: late preeclampsia, 1.41 (95% confidence interval [CI], 1.26-1.57); early preeclampsia, 1.87 (95% CI, 1.38-2.35); placental abruption, 1.60 (95% CI, 1.23-2.09); spontaneous preterm birth, 1.11 (95% CI, 1.00-1.23); and stillbirth, 1.24 (95% CI, 0.84-1.82). Compared with parents who had not been born SGA, the risk of preeclampsia was more than 3-fold increased if both parents had been born SGA, whereas if only the mother had been born SGA, the corresponding risk was increased by only 50%.

CONCLUSION

There is an intergenerational recurrence of placental dysfunction disorders on the maternal side and most likely also on the paternal side.

Perinatal morbidity associated with late preterm deliveries compared with deliveries between 37 and 40 weeks of gestation

OBJECTIVE

To estimate the risk of short-term complications in neonates born between 34 and 36 weeks of gestation.

DESIGN

This is a retrospective cohort study.

SETTING

Deliveries in 2005 in the USA.

POPULATION

Singleton live births between 34 and 40 weeks of gestation.

METHODS

Gestational age was subgrouped into 34, 35, 36 and 37-40 completed weeks of gestation. Statistical comparisons were performed using chi-square test and multivariable logistic regression models, with 37-40 weeks of gestation designated as referent.

MAIN OUTCOME MEASURES

Perinatal morbidities, including 5-minute Apgar scores, hyaline membrane disease, neonatal sepsis/antibiotics use, and admission to the intensive care unit.

RESULTS

In all, 175,112 neonates were born between 34 and 36 weeks in 2005. Compared with neonates born between 37 and 40 weeks, neonates born at 34 weeks had higher odds of 5-minute Apgar <7 (adjusted odds ratio [aOR] 5.51, 95% CI 5.16-5.88), hyaline membrane disease (aOR 10.2, 95% CI 9.44-10.9), mechanical ventilation use >6 hours (aOR 9.78, 95% CI 8.99-10.6) and antibiotic use (aOR 9.00, 95% CI 8.43-9.60). Neonates born at 35 weeks were similarly at risk of morbidity, with higher odds of 5-minute Apgar <7 (aOR 3.42, 95% CI 3.23-3.63), surfactant use (aOR 3.74, 95% CI 3.21-4.22), ventilation use >6 hours (aOR 5.53, 95% CI 5.11-5.99) and neonatal intensive-care unit admission (aOR 11.3, 95% CI 11.0-11.7). Neonates born at 36 weeks remain at higher risk of morbidity compared with deliveries at 37-40 weeks of gestation.

CONCLUSIONS

Although the risk of undesirable neonatal outcomes decreases with increasing gestational age, the risk of neonatal complications in late preterm births remains higher compared with infants delivered at 37-40 weeks of gestation.

Race and ethnic disparities in fetal mortality, preterm birth, and infant mortality in the United States: an overview

Infant mortality, fetal mortality, and preterm birth all represent important health challenges that have shown little recent improvement. The rate of decrease in both fetal and infant mortality has slowed in recent years, with little decrease since 2000 for infant mortality, and no significant decrease from 2003 to 2005 for fetal mortality. The percentage of preterm births increased by 36% from 1984 to 2006, and then decreased by 4% from 2006 to 2008. There are substantial race and ethnic disparities in fetal and infant mortality and preterm birth, with non-Hispanic black women at greatest risk of unfavorable birth outcomes, followed by American Indian and Puerto Rican women. Infant mortality, fetal mortality, and preterm birth are multifactorial and interrelated problems with similarities in etiology, risk factors and disease pathways. Preterm birth prevention is critical to lowering the infant mortality rate, and to reducing race and ethnic disparities in infant mortality.

Histological chorioamnionitis is increased at extremes of gestation in stillbirth: a population-based study

Objective. To determine the incidence of histological chorioamnionitis and a fetal response in stillbirths in New South Wales (NSW), and to examine any relationship of fetal response to spontaneous onset of labour and to unexplained antepartum death. Study Design. Population-based cohort study. Setting. New South Wales Australia. Population. All births between 2002 and 2004 with stillbirths reviewed and classified by the state perinatal mortality review committee. Methods. Record linkage of the Midwives Data Collection and the Perinatal Death Database including placental histopathology and standardised cause of death classification. Results. 952 stillbirths were included. The incidence of histopathological chorioamnionitis was 22.6%, with a bimodal distribution. A fetal inflammatory response was present in 10.1% and significantly correlated with spontaneous onset of labour. The absence of a fetal inflammatory response was strongly associated with unexplained antepartum death. Conclusions. The increased incidence of histological chorioamnionitis at extremes of gestation is confirmed in the largest dataset to date using population data. This has important implications for late gestation stillbirth as the percentage of unexplained stillbirths increases near term.

Genome-wide array-based copy number profiling in human placentas from unexplained stillbirths

OBJECTIVE

Accumulating evidence suggests that genomic structural variations, particularly copy number variations (CNV), are a common occurrence in humans that may bear phenotypic consequences for living individuals possessing the variant. While precise estimates vary, large-scale karyotypic abnormalities are present in 6-12% of stillbirths (SB). However, due to inherent limitations of conventional cytogenetics, the contribution of genomic aberrations to stillbirth is likely underrepresented. High-resolution copy number variant analysis by genomic array-based profiling may overcome such limitations.

METHODS

Prospectively acquired SB cases > 22 weeks underwent classification of 'unexplained' stillbirth by Wigglesworth and Aberdeen criteria after extensive testing and rigorous multidisciplinary audit. Genome-wide analysis was conducted using high-resolution Illumina single nucleotide polymorphism (SNP) arrays (Human CNV370-Duo) on placental and fetal samples. Potential alternate detection methods were completed by one or more of three independent means (quantitative PCR, Illumina1M, or Agilent105K comparative genomic hybridization arrays).

RESULTS

In our cohort of 54 stillbirths, 29 met strict unexplained criteria. Among these, we identified 24 putative novel CNVs. Subsequent interrogation detected 18 of 24 CNVs (75%) in placental samples, 8 of which were also confirmed in available fetal samples; none were present in maternal blood.

CONCLUSION

We describe the potential of whole-genome placental profiling to identify small genomic imbalances, which might contribute to a small proportion of well-characterized, unexplained stillbirths.

Stillbirths: the vision for 2020

Stillbirth is a common adverse pregnancy outcome, with nearly 3 million third-trimester stillbirths occurring worldwide each year. 98% occur in low-income and middle-income countries, and more than 1 million stillbirths occur in the intrapartum period, despite many being preventable. Nevertheless, stillbirth is practically unrecognised as a public health issue and few data are reported. In this final paper in the Stillbirths Series, we call for inclusion of stillbirth as a recognised outcome in all relevant international health reports and initiatives. We ask every country to develop and implement a plan to improve maternal and neonatal health that includes a reduction in stillbirths, and to count stillbirths in their vital statistics and other health outcome surveillance systems. We also ask for increased investment in stillbirth-related research, and especially research aimed at identifying and addressing barriers to the aversion of stillbirths within the maternal and neonatal health systems of low-income and middle-income countries. Finally, we ask all those interested in reducing stillbirths to join with advocates for the improvement of other pregnancy-related outcomes, for mothers and their offspring, so that a united front for improved pregnancy and neonatal care for all will become a reality.

Stillbirths: the way forward in high-income countries

Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has slowed or stalled over recent times. The present variation in stillbirth rates across and within high-income countries indicates that further reduction in stillbirth is possible. Large disparities (linked to disadvantage such as poverty) in stillbirth rates need to be addressed by providing more educational opportunities and improving living conditions for women. Placental pathologies and infection associated with preterm birth are linked to a substantial proportion of stillbirths. The proportion of unexplained stillbirths associated with under investigation continues to impede efforts in stillbirth prevention. Overweight, obesity, and smoking are important modifiable risk factors for stillbirth, and advanced maternal age is also an increasingly prevalent risk factor. Intensified efforts are needed to ameliorate the effects of these factors on stillbirth rates. Culturally appropriate preconception care and quality antenatal care that is accessible to all women has the potential to reduce stillbirth rates in high-income countries. Implementation of national perinatal mortality audit programmes aimed at improving the quality of care could substantially reduce stillbirths. Better data on numbers and causes of stillbirth are needed, and international consensus on definition and classification related to stillbirth is a priority. All parents should be offered a thorough investigation including a high-quality autopsy and placental histopathology. Parent organisations are powerful change agents and could have an important role in raising awareness to prevent stillbirth. Future research must focus on screening and interventions to reduce antepartum stillbirth as a result of placental dysfunction. Identification of ways to reduce maternal overweight and obesity is a high priority for high-income countries.

Stillbirths: Where? When? Why? How to make the data count?

Despite increasing attention and investment for maternal, neonatal, and child health, stillbirths remain invisible-not counted in the Millennium Development Goals, nor tracked by the UN, nor in the Global Burden of Disease metrics. At least 2·65 million stillbirths (uncertainty range 2·08 million to 3·79 million) were estimated worldwide in 2008 (≥1000 g birthweight or ≥28 weeks of gestation). 98% of stillbirths occur in low-income and middle-income countries, and numbers vary from 2·0 per 1000 total births in Finland to more than 40 per 1000 total births in Nigeria and Pakistan. Worldwide, 67% of stillbirths occur in rural families, 55% in rural sub-Saharan Africa and south Asia, where skilled birth attendance and caesarean sections are much lower than that for urban births. In total, an estimated 1·19 million (range 0·82 million to 1·97 million) intrapartum stillbirths occur yearly. Most intrapartum stillbirths are associated with obstetric emergencies, whereas antepartum stillbirths are associated with maternal infections and fetal growth restriction. National estimates of causes of stillbirths are scarce, and multiple (>35) classification systems impede international comparison. Immediate data improvements are feasible through household surveys and facility audit, and improvements in vital registration, including specific perinatal certificates and revised International Classification of Disease codes, are needed. A simple, programme-relevant stillbirth classification that can be used with verbal autopsy would provide a basis for comparable national estimates. A new focus on all deaths around the time of birth is crucial to inform programmatic investment.

Screening and triage of intrauterine growth restriction (IUGR) in general population and high risk pregnancies: a systematic review with a focus on reduction of IUGR related stillbirths

BACKGROUND

There is a strong association between stillbirth and fetal growth restriction. Early detection and management of IUGR can lead to reduce related morbidity and mortality. In this paper we have reviewed effectiveness of fetal movement monitoring and Doppler velocimetry for the detection and surveillance of high risk pregnancies and the effect of this on prevention of stillbirths. We have also reviewed effect of maternal body mass index (BMI) screening, symphysial-fundal height measurement and targeted ultrasound in detection and triage of IUGR in the community.

METHODS

We systematically reviewed all published literature to identify studies related to our interventions. We searched PubMed, Cochrane Library, and all World Health Organization Regional Databases and included publications in any language. Quality of available evidence was assessed using GRADE criteria. Recommendations were made for the Lives Saved Tool (LiST) based on rules developed by the Child Health Epidemiology Group. Given the paucity of evidence related to the effect of detection and management of IUGR on stillbirths, we undertook Delphi based evaluation from experts in the field.

RESULTS

There was insufficient evidence to recommend against or in favor of routine use of fetal movement monitoring for fetal well being. (1) Detection and triage of IUGR with the help of (1a) maternal BMI screening, (1b) symphysial-fundal height measurement and (1c) targeted ultrasound can be an effective method of reducing IUGR related perinatal morbidity and mortality. Pooled results from sixteen studies shows that Doppler velocimetry of umbilical and fetal arteries in 'high risk' pregnancies, coupled with the appropriate intervention, can reduce perinatal mortality by 29 % [RR 0.71, 95 % CI 0.52-0.98]. Pooled results for impact on stillbirth showed a reduction of 35 % [RR 0.65, 95 % CI 0.41-1.04]; however, the results did not reach the conventional limits of statistical significance. This intervention could be potentially recommended for high income settings or middle income countries with improving rates and standards of facility based care. Based on the Delphi, a combination of screening with maternal BMI, Symphysis fundal height and targeted ultrasound followed by the appropriate management could potentially reduce antepartum and intrapartum stillbirth by 20% respectively. This estimate is presently being recommended for inclusion in the LiST.

CONCLUSION

There is insufficient evidence to recommend in favor or against fetal movement counting for routine use for testing fetal well being. Doppler velocimetry of umbilical and fetal arteries and appropriate intervention is associated with 29 % (95 % CI 2% to 48 %) reduction in perinatal mortality. Expert opinion suggests that detection and management of IUGR with the help of maternal BMI, symphysial-fundal height measurement and targeted ultrasound could be effective in reducing IUGR related stillbirths by 20%.

Wisconsin stillbirth services program: a multifocal approach to stillbirth analysis

Stillbirth accounts for about 26,000 deaths annually in the US. In most previous studies, discrete causes are identified in less than half of all stillbirths. In order to identify causes and non-causal but potentially contributing abnormalities, we analyzed 416 of the most recent (2004-2010) Wisconsin Stillbirth Service Program (WiSSP) cases from a multifocal approach. In 70% of cases a cause sufficient to independently explain the demise was identified including 40% placental, 21.5% fetal, and 12.7% maternal. Results for stillbirths and second trimester miscarriages did not differ significantly. In 95% of cases at least one cause or non-causal abnormality was recognizable, and in two-thirds of cases, more than one cause or non-causal abnormality was identified. In cases with maternal cause, the placenta was virtually always abnormal. Both placentas (59%) and fetuses (38%) were frequently smaller than expected for gestational age. Previous miscarriage and/or stillbirth were risk factors for second and third trimester losses, with 35% of previous pregnancies ending in fetal demise. Recommendations include complete evaluation of all second and third trimester losses with special attention to placental pathology and thorough investigation for multiple causes or abnormalities whether or not a primary cause is initially recognized. Improved understanding of the causes of late miscarriage and stillbirth may contribute to recognition and management of pregnancies at risk and eventually to prevention of stillbirth.

Levels, timing, and etiology of stillbirths in Sylhet district of Bangladesh

BACKGROUND

Lack of data is a critical barrier to addressing the problem of stillbirth in countries with the highest stillbirth burden. Our study objective was to estimate the levels, types, and causes of stillbirth in rural Sylhet district of Bangladesh.

METHODS

A complete pregnancy history was taken from all women (n=39 998) who had pregnancy outcomes during 2003-2005 in the study area. Verbal autopsy data were obtained for all identified stillbirths during the period. We used pre-defined case definitions and computer programs to assign causes of stillbirth for selected causes containing specific signs and symptoms. Both non-hierarchical and hierarchical approaches were used to assign causes of stillbirths.

RESULTS

A total of 1748 stillbirths were recorded during 2003-2005 from 48,192 births (stillbirth rate: 36.3 per 1000 total births). About 60% and 40% of stillbirths were categorized as antepartum and intrapartum, respectively. Maternal conditions, including infections, hypertensive disorders, and anemia, contributed to about 29% of total antepartum stillbirths. About 50% of intrapartum stillbirths were attributed to obstetric complications. Maternal infections and hypertensive disorders contributed to another 11% of stillbirths. A cause could not be assigned in nearly half (49%) of stillbirths.

CONCLUSION

The stillbirth rate is high in rural Bangladesh. Based on algorithmic approaches using verbal autopsy data, a substantial portion of stillbirths is attributable to maternal conditions and obstetric complications. Programs need to deliver community-level interventions to prevent and manage maternal complications, and to develop strategies to improve access to emergency obstetric care. Improvements in care to avert stillbirth can be accomplished in the context of existing maternal and child health programs. Methodological improvements in the measurement of stillbirths, especially causes of stillbirths, are also needed to better define the burden of stillbirths in low-resource settings.

The association between stillbirth and fetal gender

OBJECTIVE

Stillbirth accounts for approximately 50% of all perinatal deaths. We aimed to characterize the relationship between fetal gender and stillbirths.

METHODS

A retrospective cohort study of all stillbirths cases in a tertiary medical center, between 1995 and 2007. Patient's medical charts were reviewed for demographic information, medical data, and assumed etiology for stillbirth. Stillbirth was defined as fetal death after 20 completed weeks of gestation or birth weight above 500 g, excluding cases of fetal death due to elective termination of pregnancy.

RESULTS

Overall, during the study period there were 77,120 deliveries, of them the stillbirth rate was 0.14% (n = 105). There were 59 females, 39 males (60.2% vs. 48.5%, p = 0.04) and 7 cases of stillbirth with undetermined gender. There were no differences in the demographic and obstetrical characteristics at diagnosis between women carrying a male versus female stillbirth fetuses. The rate of intra uterine fetal death due to placental abruption was significantly higher for male fetuses (OR = 2.1, 95% CI 1.3-4.5) and the rate of stillbirth due to placental insufficiency was significantly higher for female fetuses (OR = 3.7, 95% CI 1.6-5.1).

CONCLUSIONS

Female fetuses are overrepresented in cases of stillbirths compared with male fetuses.

The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality

OBJECTIVE

The overall annual incidence rate of caesarean delivery in the United States has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study's goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

METHODS

A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

RESULTS

If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

CONCLUSIONS

If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

How important is placental examination in cases of perinatal deaths?

Research on stillbirths and placental pathology has traditionally been given low priority, causing a lack of understanding of the mechanisms leading to death. The purpose of this study was to gain knowledge on how many perinatal deaths relate to morphologic changes in the placenta, and what role the placenta plays in the pathogenesis of intrauterine, intrapartum, and neonatal deaths. The autopsy reports from 104 consecutive perinatal deaths in a 5-year period (2004-2008) were reviewed. Intrauterine, intrapartum, and neonatal deaths ranging from gestational age of 22 weeks up to 7 days postpartum were included. The following three questions were considered: Could placental examination (with autopsy) explain fetal/infant death; could the cause of death be explained by placental examination alone; and could the cause of death be explained with autopsy alone? The distribution of pathologic findings in the placenta was registered. The placenta had changes that could explain fetal/infant death in 69.2% of the cases. The cause of death could be explained by placental examination alone, without autopsy, in 48.1% of the cases. Only 16.3% of the deaths could be explained by autopsy alone. The most frequently observed diagnoses were infection (22.1%), degenerative changes (13.5%), and abruptio placentae (12.5%). To conclude, our study shows that placental examination in addition to autopsy is necessary in investigating the causes of perinatal deaths. Further research, including maternal and environmental factors, is needed to clarify the underlying causes of placental malfunction.

Previous preeclampsia and risks of adverse outcomes in subsequent nonpreeclamptic pregnancies

OBJECTIVE

We hypothesized that preeclampsia partly shares pathophysiology with stillbirth, placental abruption, spontaneous preterm birth, and giving birth to a small-for-gestational-age infant, and that women who develop preeclampsia in the first pregnancy may have increased risks of the other outcomes in the second pregnancy, even in the absence of preeclampsia.

STUDY DESIGN

In a nationwide Swedish cohort (n = 354,676) we estimated risks of adverse outcomes in the second pregnancy related to preterm (< 37 weeks) and term (≥ 37 weeks) preeclampsia in the first pregnancy, using women without preeclampsia in the first pregnancy as reference.

RESULTS

Women with prior preterm preeclampsia had, in second pregnancy, more than doubled risks of stillbirth, placental abruption, and preterm births, and an even greater risk of giving birth to a small-for-gestational-age infant.

CONCLUSION

Women with previous preterm preeclampsia have increased risks of adverse pregnancy outcomes in a second pregnancy despite the absence of preeclampsia.

Management of subsequent pregnancy after antepartum stillbirth. A review

In literature, there is a paucity of information about the management of the subsequent pregnancy after stillbirth (SB). we undertook a systematic review of the literature focusing on the evidence for antenatal interventions with the potential to prevent SB and we try to summarise the management of the pregnancy subsequent to a SB. The diverse interventions and their efficacy will be reported according to the possible causes and/or conditions associated to the previous SB. Few of the studies reported SB as an outcome and the evidence was frequently conflicting. Several interventions showed clear evidence of impact on SB, including the scrupulous control of blood sugar by using multiple doses of insulin, frequent antenatal foetal monitoring and timing of delivery in diabetic women; the prophylaxis with low dose of aspirin in high-risk women; or serial sonograms for foetal growth, Doppler studies and antepartum foetal testing in women with previous growth restricted foetus. Other interventions instead reduced know risk factors for SB but failed to show statistically significant impact on SB rate. Overall, early access to care, at least three ultrasounds examinations, screening for the main pregnancy-related disorders and timely delivery are the milestone of appropriate antenatal care in women with previous SB.

Stillbirths: epidemiology, evidence, and priorities for action

The annual global burden of stillbirths amounts to an estimated 3.2 million%, 98% of which occur in low- and middle-income countries (LMICs). Of these, 1.02 million (32%) are intrapartum, ie, taking place during labor. The most important causes of stillbirths in LMICs include obstructed or prolonged labor, hypertensive diseases of pregnancy, syphilis and gram-negative infections, malaria in endemic areas, and undernutrition. Interventions that target these causes can play an important role in reducing stillbirths. There is a clear benefit of emergency obstetrical care, particularly Cesarean delivery, on intrapartum rates in LMICs when Cesarean rates are less than 8% to 10%. Provision of a skilled birth attendant is another important intervention whereby labor complications can be prevented, identified, managed, and/or referred. Among interventions for infections, syphilis screening and treatment can prevent as many as 50% of all stillbirths in areas with high syphilis prevalence, reducing the risk of stillbirths among treated women to that of untreated women. Intermittent preventive treatment of malaria and insecticide-treated mosquito nets are also interventions with strong recommendation, especially in the first 2 pregnancies. Balanced energy protein supplementation is an important nutritional intervention to prevent stillbirths in undernourished women, especially in LMICs. Creation of increased demand for health services within communities and increasing their uptake also can play a role in averting stillbirths. Other potential social and behavioral interventions include birth spacing, smoking cessation and indoor air pollution control, although the evidence for these is weak.

Stillbirth and fetal growth restriction

The association between stillbirth and fetal growth restriction is strong and supported by a large body of evidence and clinically employed for the stillbirth prediction. However, although assessment of fetal growth is a basis of clinical practice, it is not trivial. Essentially, fetal growth is a result of the genetic growth potential of the fetus and placental function. The growth potential is the driving force of fetal growth, whereas the placenta as the sole source of nutrients and oxygen might become the rate limiting element of fetal growth if its function is impaired. Thus, placental dysfunction may prevent the fetus from reaching its full genetically determined growth potential. In this sense fetal growth and its aberration provides an insight into placental function. Fetal growth is a proxy for the test of the effectiveness of placenta, whose function is otherwise obscured during pregnancy.

Recurrence of stillbirth in sibships: Population-based cohort study

Knowledge of stillbirth recurrence risk is of clinical interest and may give etiological insight. The authors studied "gestational age-" and "weight-by-gestation-specific" stillbirth recurrence, and evaluated time trends in a population-based cohort study from the Medical Birth Registry of Norway, from 1967 to 2004. Singleton births, including stillbirths from 20 weeks' gestation, were linked to their mothers by national identification numbers. Stillbirth rates in second pregnancies among mothers with (N = 5,091) and without (N = 562,057; the reference group) a stillbirth in first pregnancies were compared across 4 gestational age and 3 weight-by-gestation groups. A remarkable symmetric pattern of gestational age-specific recurrence of stillbirth was found, with highest odds of stillbirth in the same age group. The adjusted odds ratio values associated with preterm stillbirth recurrence were high, for example, 25.7 (95% confidence interval: 19.8, 33.3) for stillbirth at 20-27 weeks' gestation (73/1,511 vs. 1,021/562,057), while lower for term stillbirth: adjusted odds ratio = 2.3 (95% confidence interval: 1.2, 4.7) (9/1,844 vs. 1,021/538,499). The proportion of second early stillbirths in the population attributable to previous early stillbirth was 6.4%, compared with 0.5% for second term stillbirth. Over time, recurrence of early stillbirth decreased, whereas that of mid/late stillbirth did not change significantly. A symmetric pattern of recurring stillbirth in similar weight-by-gestation groups was not found.

Unexplained fetal death is associated with increased concentrations of anti-angiogenic factors in amniotic fluid

OBJECTIVE

Angiogenesis is critical for successful pregnancy. An anti-angiogenic state has been implicated in preeclampsia, fetal growth restriction and fetal death. Increased maternal plasma concentrations of the anti-angiogenic factor, soluble vascular endothelial growth factor receptor (sVEGFR)-1, have been reported in women with preeclampsia and in those with fetal death. Recent observations indicate that an excess of sVEGFR-1 and soluble endoglin (sEng) is also present in the amniotic fluid of patients with preeclampsia. The aim of this study was to determine whether fetal death is associated with changes in amniotic fluid concentrations of sVEGFR-1 and sEng, two powerful anti-angiogenic factors. Study design. This cross-sectional study included patients with fetal death (n = 35) and controls (n = 129). Fetal death was subdivided according to clinical circumstances into: (1) unexplained (n = 25); (2) preeclampsia and/or placental abruption (n = 5); and (3) chromosomal/congenital anomalies (n = 5). The control group consisted of patients with preterm labor (PTL) who delivered at term (n = 92) and women at term not in labor (n = 37). AF concentrations of sVEGFR-1 and sEng were determined by ELISA. Non-parametric statistics and logistic regression analysis were applied. Results. (1) Patients with a fetal death had higher median amniotic fluid concentrations of sVEGFR-1 and sEng than women in the control group (p < 0.001 for each); (2) these results remained significant among different subgroups of stillbirth (p < 0.05 for each); and (3) amniotic fluid concentrations of sVEGFR-1 and those of sEng above the third quartile were associated with a significant risk of unexplained preterm fetal death (adjusted OR = 10.8; 95%CI 1.3-89.2 and adjusted OR 87; 95% CI 2.3-3323, respectively). Conclusion. Patients with an unexplained fetal death at diagnosis are characterized by an increase in the amniotic fluid concentrations of sVEGFR-1 and sEng. These observations indicate that an excess of anti-angiogenic factors in the amniotic cavity is associated with unexplained fetal death especially in preterm gestations.

Epidemiology of stillbirth and strategies for its prevention in Vietnam

OBJECTIVE

To describe major epidemiologic and placental findings regarding stillbirth in Vietnam.

METHODS

A cross-sectional study of all stillbirths in a tertiary referral facility in Ho Chi Minh City, Vietnam, was performed. Detailed examination of each infant, placental pathology, and semi-structured maternal interviews were conducted according to the Perinatal Society of Australia and New Zealand Perinatal Death Classification guidelines. Maternal, fetal, and placental characteristics were examined.

RESULTS

Between December 8, 2008, and January 9, 2009, there were 4694 live births and 122 stillbirths at the facility. In total, 107 (87.7%) cases were included in the study. Low education level was associated with a lack of prenatal care; induced abortion accounted for 34.6% of fetal deaths (gender selection was not the reason); 35.5% of infants were born at 22-28 weeks of gestation; 31.8% of stillbirths were small for gestational age; histologic evidence of chorioamnionitis was present in 40.2% of cases. Calcium supplements were less likely to have been taken in cases in which death from hypertension occurred. alpha-Thalassemia was the main cause of fetal hydrops (6.2%).

CONCLUSION

Improving access to prenatal care and prenatal calcium and iron supplementation, and screening for congenital abnormalities and alpha-thalassemia may help to reduce rates of perinatal death in Vietnam.

Rheumatoid arthritis and birth outcomes: a Danish and Swedish nationwide prevalence study

OBJECTIVES

To examine the prevalence of preterm birth, infants with low Apgar score, small for gestational age (SGA) birth, stillbirth and congenital abnormalities in women with rheumatoid arthritis (RA) compared with women without RA.

DESIGN

Prevalence study.

SETTING

Combined Sweden and Denmark nationwide from 1994 to 2006.

SUBJECTS

We included 871,579 women with a first-time singleton birth identified through population-based healthcare databases.

MAIN OUTCOME MEASURES

We compared the prevalence of preterm birth, low Apgar score (<7 at 5 min), SGA birth, stillbirth and congenital abnormalities amongst women with RA compared with women without RA using prevalence odds ratio (OR) with 95% confidence interval (95% CI), whilst controlling for maternal age, smoking, parental cohabitation and year. We stratified analyses by period of birth (1994-1997, 1998-2001 and 2002-2006).

RESULTS

Amongst 1199 women with RA, 7.8% gave birth between 32 and 36 gestational weeks (adjusted OR, 1.44; 95% CI, 1.14-1.82), 1.4% gave birth before gestational week 32 (adjusted OR, 1.55; 95% CI, 0.97-2.47), 1.6% had an infant with a low Apgar score (OR, 0.99; 95% CI, 0.95-1.65), 5.9% had an SGA birth (adjusted OR, 1.56; 95% CI, 1.2-2.01), 0.9% experienced stillbirth (adjusted OR, 2.07; 95% CI, 0.98-4.35) and 4.3% gave birth to an infant with congenital abnormalities (adjusted OR,1.32; 95% CI, 0.98-1.79). The OR for congenital abnormalities decreased from 2.57 (95% CI, 1.59-4.16) in 1994-1997 to 1.00 (95% CI, 0.64-1.56) in 2002-2006.

CONCLUSIONS

Women with RA had a high prevalence of most adverse birth outcomes. This could be due to inflammatory activity, medical treatment or other factors not controlled for.

[Risk factors for fetal mortality in a public maternity hospital in Rio de Janeiro, Brazil: a case-control study]

Stillbirth rate is high in Brazil, and it is important to identify its determinants. A nested case-control was conducted to explore the determinants of fetal death in a population treated at public services in Rio de Janeiro from 2002 to 2004. Data were collected from mothers' interviews and medical records. A structured model was proposed to perform statistical analysis, attributing hierarchical levels: socioeconomic factors (distal level), reproductive, behavioral, and healthcare determinants (intermediate level), and fetal biological characteristics (proximal level). According to the findings, work stability, stable marital status, presence of a companion during admission, and adequate prenatal care had a protective effect against fetal death, while domestic violence, maternal morbidity, and intrauterine growth restriction increased the risk. Quality of prenatal care showed a large protective effect, thus becoming a key strategy for reducing fetal mortality in populations with low socioeconomic status.

Identifying placental dysfunction in women with reduced fetal movements can be used to predict patients at increased risk of pregnancy complications

Maternal perception of fetal movements has historically been used to indicate fetal wellbeing, and has been used with varying success in recent years to identify those pregnancies at increased risk of stillbirth, and other placental pathologies. We present a hypothesis that links reduced fetal movements (RFM) to fetal growth restriction (FGR) and stillbirth through placental dysfunction, and suggests the possibility that this can allow development of a reliable method to identify those women experiencing RFM who are at increased risk of adverse outcome. Reduced fetal movement is thought to represent fetal compensation in a chronic hypoxic environment due to inadequacies in the placental supply of oxygen and nutrients. Placental analysis in FGR and in stillbirth has revealed a number of structural abnormalities and an imbalance in cell turnover, and in terms of function, FGR is also associated with reduced nutrient transport. Both FGR and stillbirth are linked to changes in maternal levels of placental hormones. However, no such studies have been performed in samples from pregnancies affected by RFM. Currently, there are no formal guidelines to direct the management of such women, although it is recommended they undergo measurement of symphysis-fundal height and cardiotocography, and possibly Doppler ultrasound and biophysical profiling. Novel tests could involve the measurement of placental-derived hormones in maternal serum. To address this hypothesis, macroscopic and microscopic analysis of placental samples from both normal pregnancies and those affected by RFM is needed to detect any changes in structure. Placental function could be evaluated by levels of placental hormones in maternal blood. If placental dysfunction can be linked to RFM, and a robust method of identifying those women with placental insufficiency can be developed; screening patients with RFM could lead to a reduction in perinatal morbidity and mortality.

Fetal death: a condition with a dissociation in the concentrations of soluble vascular endothelial growth factor receptor-2 between the maternal and fetal compartments

OBJECTIVE

An anti-angiogenic state has been implicated in the pathophysiology of preeclampsia, fetal growth restriction and fetal death. Vascular endothelial growth factor (VEGF), an indispensible angiogenic factor for embryonic and placental development exerts its angiogenic properties through the VEGF receptor (VEGFR)-2. A soluble form of this protein (sVEGFR-2) has been recently detected in maternal blood. The aim of this study was to determine if fetal death was associated with changes in the concentrations of sVEGFR-2 in maternal plasma and amniotic fluid.

STUDY DESIGN

Maternal plasma was obtained from patients with fetal death (n = 59) and normal pregnant women (n = 134). Amniotic fluid was collected from 36 patients with fetal death and the control group consisting of patients who had an amniocentesis and delivered at term (n = 160). Patients with fetal death were classified according to the clinical circumstances into the following groups: (1) unexplained; (2) preeclampsia and/or placental abruption; (3) chromosomal and/or congenital anomalies. Plasma and amniotic fluid concentrations of sVEGFR-2 were determined by ELISA. Non-parametric statistics and logistic regression analysis were applied.

RESULTS

(1) Patients with a fetal death had a significantly lower median plasma concentration of sVEGFR-2 than normal pregnant women (p < 0.001). The median plasma concentration of sVEGFR-2 in patients with unexplained fetal death and in those with preeclampsia/abruption, but not that of those with congenital anomalies, was lower than that of normal pregnant women (p = 0.006, p < 0.001 and p = 0.2, respectively); (2) the association between plasma sVEGFR-2 concentrations and preterm unexplained fetal death remained significant after adjusting for potential confounders (OR: 3.2; 95% CI: 1.4-7.3 per each quartile decrease in plasma sVEGFR-2 concentrations); (3) each subgroup of fetal death had a higher median amniotic fluid concentration of sVEGFR-2 than the control group (p < 0.001 for each); (4) the association between amniotic fluid sVEGFR-2 concentrations and preterm unexplained fetal death remained significant after adjusting for potential confounders (OR: 15.6; 95% CI: 1.5-164.2 per each quartile increase in amniotic fluid sVEGFR-2 concentrations); (5) among women with fetal death, there was no relationship between maternal plasma and amniotic fluid concentrations of sVEGFR-2 (Spearman Rho: 0.02; p = 0.9).

CONCLUSION

Pregnancies with a fetal death, at the time of diagnosis, are characterized by a decrease in the maternal plasma concentration of sVEGFR-2, but an increase in the amniotic fluid concentration of this protein. Although a decrease in sVEGFR-2 concentration in maternal circulation depends upon the clinical circumstances of fetal death, an increase in sVEGFR-2 concentration in amniotic fluid seems to be a common feature of fetal death. It remains to be determined if the perturbation in sVEGFR-2 concentrations in maternal and fetal compartments observed herein preceded the death of a fetus.

Time of birth and risk of neonatal death at term: retrospective cohort study

OBJECTIVE

To determine the effect of time and day of birth on the risk of neonatal death at term.

DESIGN

Population based retrospective cohort study.

SETTING

Data from the linked Scottish morbidity records, Stillbirth and Infant Death Survey, and birth certificate database of live births in Scotland, 1985-2004.

SUBJECTS

Liveborn term singletons with cephalic presentation. Perinatal deaths from congenital anomalies excluded. Final sample comprised 1,039,560 live births.

MAIN OUTCOME MEASURE

All neonatal deaths (in the first four weeks of life) unrelated to congenital abnormality, plus a subgroup of deaths ascribed to intrapartum anoxia.

RESULTS

The risk of neonatal death was 4.2 per 10,000 during the normal working week (Monday to Friday, 0900-1700) and 5.6 per 10 000 at all other times (out of hours) (unadjusted odds ratio 1.3, 95% confidence interval 1.1 to 1.6). Adjustment for maternal characteristics had no material effect. The higher rate of death out of hours was because of an increased risk of death ascribed to intrapartum anoxia (adjusted odds ratio 1.7, 1.2 to 2.3). Though exclusion of elective caesarean deliveries attenuated the association between death ascribed to anoxia and delivery out of hours, a significant association persisted (adjusted odds ratio 1.5, 1.1 to 2.0). The attributable fraction of neonatal deaths ascribed to intrapartum anoxia associated with delivery out of hours was 26% (95% confidence interval 5% to 42%).

CONCLUSIONS

Delivering an infant outside the normal working week was associated with an increased risk of neonatal death at term ascribed to intrapartum anoxia.

A multicenter, case-control study on risk factors for antepartum stillbirth

OBJECTIVE

As the influence of socio-demographic variables, lifestyle and medical conditions on the epidemiology of stillbirth (SB) is modified by population features, we aimed at investigating the role played by these factors on the incidence of SB in a developed country.

STUDY DESIGN

Multivariate logistic regression analysis (OR with 95% CI) was utilized in a prospective multicentre nested case-control study to compare in a 1:2 ratio stillborn of >22 weeks gestation with matched for gestational age live-born (LB) infants. Intrapartum SB were excluded.

RESULTS

Two hundred fifty-four consecutive SBs and 497 LBs were enrolled. Socio-demographic variables were equally distributed. Fetal malformations (7.96, 2.69-23.55), severe intrauterine growth restriction (IUGR) (birthweight ≤ 5(th) %ile) (4.32, 2.27?8.24), BMI > 25 (2.87, 1.90-4.33), and preeclampsia (PE, 0.40, 0.21-0.77) were recognized as independent predictors for SB. At term, only BMI > 25 was associated with SB (7.70, 2.9-20.5).

CONCLUSION

Fetal malformations, severe IUGR and maternal BMI > 25 were associated with a significant increase in the risk of SB; PE presented instead a protective role. Maternal BMI > 25 was the only risk factor for SB identified in term pregnancies.