Trends and risk factors of stillbirth in Taiwan 2006–2013: a population-based study

A prediction model for stillbirth based on first trimester pre-eclampsia combined screening

OBJECTIVE

To evaluate the accuracy of combined models of maternal biophysical factors, ultrasound, and biochemical markers for predicting stillbirths.

METHODS

A retrospective cohort study of pregnant women undergoing first-trimester pre-eclampsia screening at 11-13 gestational weeks was conducted. Maternal characteristics and history, mean arterial pressure (MAP) measurement, uterine artery pulsatility index (UtA-PI) ultrasound, maternal ophthalmic peak ratio Doppler, and placental growth factor (PlGF) serum were collected during the visit. Stillbirth was classified as placental dysfunction-related when it occurred with pre-eclampsia or birth weight <10th percentile. Combined prediction models were developed from significant variables in stillbirths, placental dysfunction-related, and controls. We used the area under the receiver-operating-characteristics curve (AUC), sensitivity, and specificity based on a specific cutoff to evaluate the model's predictive performance by measuring the capacity to distinguish between stillbirths and live births.

RESULTS

There were 13 (0.79%) cases of stillbirth in 1643 women included in the analysis. The combination of maternal factors, MAP, UtA-PI, and PlGF, significantly contributed to the prediction of stillbirth. This model was a good predictor for all (including controls) types of stillbirth (AUC 0.879, 95% CI: 0.799-0.959, sensitivity of 99.3%, specificity of 38.5%), and an excellent predictor for placental dysfunction-related stillbirth (AUC 0.984, 95% CI: 0.960-1.000, sensitivity of 98.5, specificity of 85.7).

CONCLUSION

Screening at 11-13 weeks' gestation by combining maternal factors, MAP, UtA-PI, and PlGF, can predict a high proportion of stillbirths. Our model has good accuracy for predicting stillbirths, predominantly placental dysfunction-related stillbirths.

Incidence and first trimester risk factors of stillbirth in Indonesia

OBJECTIVES

To determine the incidence and the risk factors of stillbirth from maternal biophysical, ultrasound, and biochemical markers at 11-13 weeks of gestation in the Indonesian population.

METHODS

This was a retrospective cohort study of pregnant women for first-trimester preeclampsia screening at 11-13 weeks of gestation in some clinics and hospital in Jakarta. Maternal characteristics and history, mean arterial pressure (MAP) measurement, uterine artery pulsatility index (UtA-PI) ultrasound, maternal ophthalmic peak ratio (Oph-PR) Doppler, and placental growth factor (PlGF) serum were collected during the visit. Stillbirth was classified into placental dysfunction-related when it occurred with preeclampsia or birth weight <10th percentile and non-placental dysfunction-related. Bivariate and multivariate logistic regression analyses were employed to determine the risk factors associated with stillbirth.

RESULTS

Of 1,643 eligible participants, 13 (0.79 %) stillbirth cases were reported. More than half of the stillbirths (7) were placental dysfunction-related. After adjusted with maternal age, body mass index (BMI), and parity status, chronic hypertension (aOR (adjusted odds ratio)) 24.41, 95 % CI {confidence interval} 5.93-100.43), previous pregnancy with preeclampsia (aOR 15.79, 95 % CI 4.42-56.41), MAP >101.85 (aOR 26.67, 95 % CI 8.26-86.06), UtA-PI >1.90 (aOR 10.68, 95 % CI 2.34-48.58, and PlGF <28.77 pg/mL (aOR 18.60, 95 % CI 5.59-61.92) were associated with stillbirth.

CONCLUSIONS

The incidence of stillbirth in the population is comparable to studies conducted in developed countries. Most routine variables assessed at the 11-13 weeks combined screening for preeclampsia are associated with the risk of stillbirth.

Comparison of the Autopsy and Placental Findings in Second vs Third Trimester Stillbirth

BACKGROUND

The pathology of second trimester fetal loss is not well-characterized due to lack of comprehensive autopsy studies. The purpose of this study is to compare autopsy pathology of second trimester and third trimester stillbirth.

METHODS

In this retrospective cohort study, fetal autopsies performed in-house with complete placental examination were included. From autopsy reports, maternal demographics, gestational age, sex, body and placental weight, congenital anomalies, and cause of death (COD) were obtained. Immediate COD was coded "probable" or "possible" according to Initial Causes of Fetal Death (INCODE).

RESULTS

Among 68 second trimester and 54 third trimester fetal autopsies, at least 1 probable COD was identified in 59/68 (87%) second trimester and 44/54 (81%) third trimester cases. 42/68 (62%) second trimester and 28/54 (52%) third trimester fetuses had probable COD secondary to placental pathology. Among placental causes, 29/42 (69%) second trimester and 14/28 (50%) third trimester stillbirths were related to compromised fetal microcirculation with umbilical cord abnormality.

CONCLUSIONS

Among stillborn first and second trimester fetuses who undergo autopsy, the most prevalent COD is pathologic placental conditions, particularly those associated with umbilical cord obstruction. This study stresses the importance of placenta examination for establishing COD in both second and third trimester fetuses.

Safety monitoring of oral iron supplements in pregnant women with anemia: a multi-center observational clinical study

Aims

To investigate the safety of oral iron therapy in pregnant women with iron-deficiency anemia (IDA) in the real world.

Methods

A retrospective analysis was performed on 1792 pregnant patients with IDA who received oral iron supplements from 12 hospitals in Shandong Province from 1 April to 31 June 2021; follow-up and adverse reactions were recorded. They were divided into six groups according to the treatment drugs.

Results

The overall adverse reaction rate was 15.4%, and the main adverse reaction site was the digestive system. The incidence of all kinds of oral iron adverse reactions from high to low in order: compound ferrous sulfate and folic acid tablets (21.88%); iron proteinsuccinylate oral solution (20.90%); ferrous succinate tablets (19.76%); ferrous succinate sustained-release tablets (18.00%); iron polysaccharide complex capsule (12.06%); and iron dextran oral solution (6.94%). It was found that there was a significant difference in the incidence of adverse reactions among the six drugs (p < 0.05). Pairwise comparison showed that the incidence of adverse reactions was higher in the iron proteinsuccinylate oral solution than that in the iron polysaccharide complex capsule (p < 0.05). There was no significant difference in the incidence of adverse reactions in different ages (p > 0.05), but there was a significant difference in the incidence of adverse reactions in different gestational ages (p < 0.05). In Adverse Drug Reaction (ADR) patients, the adverse reaction result of most patients is recovery or improvement, and there was no serious adverse reaction outcome such as sequela and death.

Conclusion

All the adverse reactions of oral iron were mainly gastrointestinal adverse reactions, and no heavy adverse reactions were found. Iron proteinsuccinylate oral solution has a higher incidence of adverse reactions than iron polysaccharide complex capsule. The results showed that oral iron was safer for anemia patients during pregnancy.

Maternal low and high hemoglobin concentrations and associations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis

BACKGROUND

Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment.

METHODS

We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals.

RESULTS

The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia.

CONCLUSION

Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.

Timing of perinatal death; causes, circumstances, and regional variations among reviewed deaths in Ethiopia

INTRODUCTION

Ethiopia is one of the countries facing a very high burden of perinatal death in the world. Despite taking several measures to reduce the burden of stillbirth, the pace of decline was not that satisfactory. Although limited perinatal mortality studies were conducted at a national level, none of the studies stressed the timing of perinatal death. Thus, this study is aimed at determining the magnitude and risk factors that are associated with the timing of perinatal death in Ethiopia.

METHODS

National perinatal death surveillance data were used in the study. A total of 3814 reviewed perinatal deaths were included in the study. Multilevel multinomial analysis was employed to examine factors associated with the timing of perinatal death in Ethiopia. The final model was reported through the adjusted relative risk ratio with its 95% Confidence Interval, and variables with a p-value less than 0.05 were declared statistically significant predictors of the timing of perinatal death. Finally, a multi-group analysis was carried out to observe inter-regional variation among selected predictors.

RESULT

Among the reviewed perinatal deaths, 62.8% occurred during the neonatal period followed by intrapartum stillbirth, unknown time of stillbirth, and antepartum stillbirth, each contributing 17.5%,14.3%, and 5.4% of perinatal deaths, respectively. Maternal age, place of delivery, maternal health condition, antennal visit, maternal education, cause of death (infection and congenital and chromosomal abnormalities), and delay to decide to seek care were individual-level factors significantly associated with the timing of perinatal death. While delay reaching a health facility, delay to receive optimal care health facility, type of health facility and type region were provincial-level factors correlated with the timing of perinatal death. A statistically significant inter-regional variation was observed due to infection and congenital anomalies in determining the timing of perinatal death.

CONCLUSION

Six out of ten perinatal deaths occurred during the neonatal period, and the timing of perinatal death was determined by neonatal, maternal, and facility factors. As a way forward, a concerted effort is needed to improve the community awareness of institutional delivery and ANC visit. Moreover, strengthening the facility level readiness in availing quality service through all paths of the continuum of care with special attention to the lower-level facilities and selected poor-performing regions is mandatory.

Extreme temperature increases the risk of stillbirth in the third trimester of pregnancy

Epidemiological studies have reported the association between extreme temperatures and adverse reproductive effects. However, the susceptible period of exposure during pregnancy remains unclear. This study aimed to assess the impact of extreme temperature on the stillbirth rate. We performed a time-series analysis to explore the associations between temperature and stillbirth with a distributed lag nonlinear model. A total of 22,769 stillbirths in Taiwan between 2009 and 2018 were enrolled. The mean stillbirth rate was 11.3 ± 1.4 per 1000 births. The relative risk of stillbirth due to exposure to extreme heat temperature (> 29 °C) was 1.18 (95% CI 1.11, 1.25). Pregnant women in the third trimester were most susceptible to the effects of extreme cold and heat temperatures. At lag of 0-3 months, the cumulative relative risk (CRR) of stillbirth for exposure to extreme heat temperature (29.8 °C, 97.5th percentile of temperature) relative to the optimal temperature (21 °C) was 2.49 (95% CI: 1.24, 5.03), and the CRR of stillbirth for exposure to extreme low temperature (16.5 °C, 1st percentile) was 1.29 (95% CI: 0.93, 1.80). The stillbirth rate in Taiwan is on the rise. Our findings inform public health interventions to manage the health impacts of climate change.

Macrosomia and large for gestational age in Asia: One size does not fit all

Macrosomia, usually defined as infant birth weight of ≥4000 g, does not consider gestational age, sex, or country/region-specific differences in mean birth weight and maternal body weight. This issue is particularly relevant for Asia, where 60% of the world's population lives, due to variations in maternal size and birth weights across populations. Large for gestational age (LGA), defined as birth weight > 90th centile, is a more sensitive measure as it considers gestational age and sex, though it is dependent on the choice of growth charts. We aimed to review reporting of macrosomia and LGA in Asia. We reviewed the literature on prevalence and risk of macrosomia and LGA in Asia over the last 29 years. Prevalence of macrosomia ranged from 0.5% (India) to 13.9% (China) while prevalence of LGA ranged from 4.3% (Korea) to 22.1% (China), indicating substantial variation in prevalence within and between Asian countries. High pre-pregnancy body mass index, excessive gestational weight gain, and impaired glucose tolerance conferred risk of macrosomia/LGA. Incidence of macrosomia and LGA varies substantially within and between Asian countries, as do the growth charts and definitions. The latter makes it impossible to make comparisons but suggests differences in intrauterine growth between populations. Reporting LGA, using standardized country/regional growth charts, would better capture the incidence of high birth weight and allow for comparison and identification of contributing factors. Better understanding of local drivers of excessive intrauterine growth could enable development of improved strategies for prevention and management of LGA.

Association between gestational anemia in different trimesters and neonatal outcomes: a retrospective longitudinal cohort study

BACKGROUND

Previous studies investigated the association between gestational anemia and neonatal outcomes. However, few studies explored whether the effects of gestational anemia could be eliminated by subsequent correction of anemia in the later stages of pregnancy. This study aimed to investigate the relationship between anemia in different trimesters and neonatal outcomes.

METHODS

The study was conducted in Shanghai, China, with a sample of 46,578 pregnant women who delivered between January 1, 2016 and July 1, 2019. A multivariable logistic regression model was adopted to analyse the associations between maternal anemia and neonatal outcomes.

RESULTS

The incidence of gestational anemia was 30.2%, including 4.4% in the first trimester, 9.6% in the second trimester, and 16.2% in the third trimester. Only 24.5% (507/2066) of anemia that occurred in the first trimester and 29.6% (1320/4457) that occurred in the second trimester could be corrected in the later stages of pregnancy. Anemia occurring in the first trimester was associated with small for gestational age [odds ratio (OR) 1.46; 95% confidence interval (CI) 1.20-1.78] and with fetal distress (OR 1.23; 95% CI 1.08-1.40). Anemia corrected in the first trimester also was associated with a higher risk of small for gestational age.

CONCLUSIONS

Gestational anemia is a public health problem in China impacting neonatal health. Anemia in pregnancy could be corrected in only about a quarter of the women. Anemia in the first trimester, whether corrected or not, still led to lower birth weight; therefore, the prevention of anemia prior to pregnancy is important.

A population-based study on the prevalence of gestational diabetes mellitus in association with temperature in Taiwan

BACKGROUND

Previous studies showing seasonal clustering of gestational diabetes mellitus (GDM) were conducted in the temperate or frigid zones and mostly included pregnant Caucasian women. This study aims to investigate the association of ambient temperature with prevalence of GDM in Taiwan, a sub-tropic country.

METHODS

This population-based cohort study comprised women (n = 371,131) who gave births between 2013 and 2014; of which, 43,538 (11.7%) were diagnosed with GDM. The mean daily temperature and difference in temperature within a day was calculated over a 35-day period prior to GDM diagnosis or the first day of the 27th gestational week (for non-GDM subjects). Multiple logistic regression models with generalized estimation equation were performed to estimate the adjusted odds ratio (aOR) and 95% confidence interval (CI) of GDM in association with temperature.

RESULTS

After controlling for potential confounders, summer and fall were associated with higher risk of GDM diagnosis, with aOR [95% CI] of 1.05 [1.04-1.07] and 1.04 [1.02-1.06] in reference to winter. Additionally, an increase of 1 °C from 14 °C to 27 °C was associated with an aOR of 1.03 [1.02-1.03]. The aOR greatly increased to 1.54 [1.48-1.60] after 28 °C. An increase of 1 °C difference within a day was associated with a reduced aOR at 0.90 [0.87-0.92].

CONCLUSION

A higher prevalence of GDM was associated with a higher daily temperature, but with a smaller difference in temperature within a day.

Gestational risk factors and childhood cancers: A cohort study in Taiwan

Gestational risk factors such as birth weight, gestational age and parity have been repeatedly found to be related to pediatric cancers, but few reports have emerged from Asian countries. Here we report on demographic and gestational factors in a Taiwanese cohort. Our study included all children born in Taiwan 2004-2014 for whom there was a birth record (n = 2,079,037), of which 1900 children had been diagnosed with cancer prior to age 12. We conducted multivariable hazard regression to examine associations between demographic and gestational factors with cancer. Greater parity (family with 2+ older children) was related to acute myeloid leukemia [Hazard ratio (HR) = 2.15, 95% confidence interval (CI): 1.31, 3.55), central nervous system tumors (HR = 1.67, CI: 1.13, 2.48) and neuroblastoma (HR = 1.67, CI: 1.07, 2.63). Hepatoblastoma cases had a higher risk of low birth weight (<2,500 g; HR = 3.01, CI: 1.85, 4.91), very preterm birth (<33 weeks gestation; HR = 13.71, CI: 7.45, 25.23), plural pregnancies (HR = 2.37, CI: 1.10, 5.14) and both small (HR = 2.13, CI: 1.23, 3.67) and large (HR = 1.83, CI: 1.01, 3.32) for gestational age. Germ cell tumors were more common among children born in rural areas (HR = 1.63, CI: 1.02, 2.60). Despite that Taiwan has lower rates of both high and low birthweight compared to other developed nations, we observed several similar associations to those reported in Western Countries. Further research should examine unique exposures in Taiwan that may be contributing to higher incidence of certain cancer types.