Trends in intrapartum fetal death, 1979-2003

Randomized controlled trials: not always the "gold standard" for evidence in obstetrics and gynecology

Randomized controlled trials are considered the "gold standard" for therapeutic interventions, and it is not uncommon for sweeping changes in medical practice to follow positive results from such trials. However, randomized controlled trials are not without their limitations. Physicians frequently view randomized controlled trials as infallible, whereas they tend to dismiss evidence derived from sources other than randomized controlled trials as less credible or reliable. In several situations in obstetrics and gynecology, there are no randomized controlled trials to help guide the clinician. In these circumstances, it is important to evaluate the entire body of evidence including observational studies, rather than dismiss interventions altogether simply because no randomized controlled trials exist. Randomized controlled trials and observational studies should be viewed as complementary rather than at odds with each other. Some reversals in widely adopted clinical practice have recently been implemented following subsequent studies that contradicted the outcomes of major randomized controlled trials. The most notable of these was the withdrawal from the market of 17-hydroxyprogesterone caproate for preterm birth prevention. Such reversals could potentially have been averted if the inherent limitations of randomized controlled trials were carefully considered before implementing these universal practice changes. This Clinical Opinion underscores the limitations of an exclusive reliance on randomized controlled trials while disregarding other evidence in determining how best to care for patients. Solutions are proposed that advocate that clinicians adopt a more balanced perspective that considers the entirety of the available medical evidence and the individual patient characteristics, needs, and wishes.

Trends in Term Intrapartum Stillbirth in Norway

Importance

Fetal death during labor at term is a complication that is rarely studied in high-income countries. There is a need for large population-based studies to examine the rate of term intrapartum stillbirth in high-income countries and the factors associated with its occurrence.

Objective

To evaluate trends in term intrapartum stillbirth over time and to investigate the association between the trends and term intrapartum stillbirth risk factors from 1999 to 2018 in Norway.

Design, Setting, and Participants

This cohort study used data from the Medical Birth Registry of Norway from 1999 to 2018 to examine rates of term intrapartum stillbirth and risk factors associated with this event. A population of 1 021 268 term singleton pregnancies without congenital anomalies or antepartum stillbirths was included in analyses, which were performed from September 2022 to February 2023.

Exposure

The main exposure variable was time, which was divided into four 5-year periods: 1999 to 2003, 2004 to 2008, 2009 to 2013, and 2014 to 2018.

Main Outcomes and Measures

The primary study outcome was term intrapartum stillbirth. Risk ratios were calculated, and multivariable logistic regression analyses were conducted to identify factors associated with secular trends of term intrapartum stillbirth.

Results

The study population consisted of 1 021 268 term singleton births (maternal mean [SD] age, 29.72 [5.01] years; mean [SD] gestational age, 39.69 [1.27] weeks). During the study period, there were 95 term intrapartum stillbirths (0.09 per 1000 births). Maternal age, the proportion of individuals born in a country other than Norway, and the prevalence of gestational diabetes, labor induction, operative vaginal delivery, and previous cesarean delivery increased over the course of the study period. Conversely, the prevalence of infants large for gestational age, hypertensive disorder in pregnancy, and spontaneous vaginal delivery and the proportion of individuals who smoked decreased. The term intrapartum stillbirth rate decreased by 87% (95% CI, 68%-95%) from 0.15 per 1000 births in 1999 to 2008 to 0.02 per 1000 births in 2014 to 2018. Three in 4 term intrapartum stillbirths (70 of 95) occurred during intrapartum operative deliveries. The increased prevalence of older maternal age and obstetric risk factors were not associated with the variation in intrapartum stillbirth rates among the time periods. The prevalence of term intrapartum stillbirth was higher for individuals who gave birth in maternity units with fewer than 3000 annual births (adjusted odds ratio, 1.67; 95% CI, 1.07-2.61) than for those who gave birth in units with 3000 or more annual births.

Conclusions and Relevance

Findings of this study suggest that, despite increases in maternal and obstetric risk factors, term intrapartum stillbirth rates substantially decreased during the study period. Reasons for this decrease may be due to improvements in intrapartum care.

Factors associated with intrapartum stillbirth in a tertiary teaching hospital in Burkina Faso

Introduction

Intrapartum stillbirth is an indicator of health and community development.

Objective

To identify the risk factors associated with intrapartum stillbirth in a tertiary teaching hospital in Burkina Faso.

Patients and methods

A case-control study conducted from January 1 to August 30, 2019. Cases were defined as patients admitted to Yalgado Ouedraogo teaching hospital (YOTH) with a live fetus of at least 28 weeks’ gestation and who gave birth to an intrapartum stillborn, a fetus delivered without any signs of life in the first minute postpartum. Controls were defined as patients who delivered a live newborn. Study controls were gradually recruited and matched to cases. For each case, two controls were recruited and matched according to criteria such as delivery route and day of delivery. Data were cleaned in Epidata and exported to Stata for analysis. Variables with a p < 0.05 significance level in the multivariable regression were retained. Odds ratio (OR) and 95% confidence intervals are reported.

Results

Eighty-three intrapartum stillbirths were documented among a total of 4,122 deliveries, a stillbirth rate of 20.1 per 1,000 births. There was a statistically significant association between intrapartum stillbirth and prior caesarean section (p = 0.045), multiparity (p = 0.03), the receipt of antenatal care (ANC) by a nurse (p = 0.005) and the disuse of the partogram (p = 0.004). We did not find a significant association between the number of ANC consultations performed (p = 0.3), whether membranes were ruptured at admission (p = 0.6), the duration of labor (p = 0.6) and intrapartum fetal death. Multivariate analysis showed that patient referral to another heath facility (OR: 3.33; 95% IC: 1.56, 7.10), no obstetric ultrasound performed (OR: 3.16; 95% IC: 2.11, 4.73), birth weight less than 2,500 g (OR: 7.49; 95% IC: 6.40, 8.76) were significantly associated with intrapartum stillbirth.

Conclusion

Specific interventions must be taken to identify these risk factors of intrapartum stillbirth in order to ensure better and appropriate management.

Timing intrapartum management based on the evolution and duration of fetal heart rate patterns

One of the most important challenges in obstetrics is to determine the appropriate time to deliver the fetus without exposing the mother to unnecessary operative interventions. The use of continuous cardiotocography (cCTG) during labor has resulted in dramatic reductions in intrapartum fetal deaths, but fetal central nervous system (CNS) injury and cerebral palsy (CP) rates have remain relatively unchanged as related to the use of cCTG . In our view, this is due to continuing inability to recognize progressive fetal deterioration and intervene promptly prior to the development of fetal CNS injury. Although the 2008 NICHD workshop proposed a 3-tier classification system, most fetuses born with severe (pathologic) acidemia (cord artery pH < 7.00), as well as those who eventually develop CP, will never reach the stage of NICHD Category III fetal heart rate (FHR) pattern. In the present "Clinical Opinion," we promote a concept derived from observations, that the evolution of the FHR changes of the deteriorating fetus can be visually defined by three color "zones" that are clinically recognizable and, therefore, are actionable. In addition, we will review information regarding how long the fetus may be able to tolerate an abnormal FHR pattern before it suffers an adverse perinatal outcome, an area of investigation that has been rarely addressed before. Based on the available evidence, Category III FHR patterns should not be used as screening criteria because of low sensitivity for either fetal CNS injury (45%) or severe (pathologic) fetal acidemia (36-44%). In addition, the duration of the Category III pattern required for the development of severe fetal acidemia is extremely short to allow for a timely preventative operative intervention. On the contrary, the use of our proposed "red" zone, which includes the most advanced stages in the progressive deterioration of Category II patterns and Category III, will identify the overwhelming majority of fetuses who develop severe (pathologic) acidemia (96%) and/or CNS injury during labor (100%); moreover, the detection of fetal jeopardy by the use of the "red" zone occurs much earlier, as compared to using Category III, thus allowing reasonable amount of time for a timely obstetrical intervention. Further research is needed to determine the false positive rate and positive predictive value for a pre-determined period of time in the red zone.

Impaired validity of the new FIGO and Swedish CTG classification templates to identify fetal acidosis in the first stage of labor

INTRODUCTION

Cardiotocography (CTG) is the main method of intrapartum fetal surveillance. In 2015 a new guideline was introduced by the International Federation of Gynecology and Obstetrics (FIGO), FIGO-15. In Sweden it was adjusted to SWE-17, replacing the previous national template, SWE-09. This study, conducted at one university hospital and one regional hospital in southern Sweden, evaluated the diagnostic validity of these three templates to detect fetal acidosis during the first stage of labor.

MATERIAL AND METHODS

A total of 73 neonates with pH <7.1 in umbilical cord artery or vein at cesarean delivery during the first stage of labor were identified retrospectively. For each acidotic neonate, three non-acidemic neonates, with a pH ≥7.2 in cord artery and vein, and Apgar scores ≥9 at five and ten minutes, in all 219 neonates, were selected. The CTG tracings before birth in acidemic neonates, and tracings at the same cervical dilatation in the non-acidemic neonates, were independently assessed by three professionals from the obstetric staff, blinded to group and clinical data. Based on their categorizations of the included variables (baseline, variability, accelerations, decelerations and contraction rate), each CTG tracing was systematically classified according to the three templates. The sensitivity and specificity to identify acidemia by the classification pathological were determined for each template. Interobserver agreement in the assessments of tracings as pathological or not was analyzed, using free-marginal Kappa index.

RESULTS

The sensitivity for patterns classified as pathological to identify acidemia was similar for FIGO-15 (71%) and SWE-17 (77%, p = .13), and the specificity was 97% for both. SWE-09 had a significantly higher sensitivity (95%, p < .001) albeit with a lower specificity (90%, p < .001) than the other two templates. Among acidemic neonates, the fraction of tracings classified as normal was higher with SWE-17 (9.6%) than with SWE-09 (0%; p = .01) and FIGO-15 (1.4%; p = .06). For tracings from neonates with acidemia, agreement for three independent assessors was strong (κ 0.85) with SWE-09, and weak for FIGO-15 (κ 0.47), and SWE-17 (κ 0.51). For tracings from neonates without acidemia, the agreement was almost perfect for FIGO-15 (κ 0.91), strong withSWE-17 (κ 0.90) and moderate with SWE-09 (κ 0.78).

CONCLUSIONS

The ability of FIGO-15 and SWE-17 to identify fetal acidosis is considered insufficient. The combination of a high sensitivity and a high specificity makes SWE-09 the most discriminatory template during the first stage of labor.

The etiology of stillbirth over 30 years: A cross-sectional study in a tertiary referral unit

INTRODUCTION

Stillbirth remains an often unpredictable and devastating pregnancy outcome, and despite thorough investigation, the number of stillbirths attributable to unexplained causes remains high. Placental examination has become increasingly important where access to perinatal autopsy is limited. We aimed to examine the causes of stillbirth in normally formed infants over 30 years and whether a declining autopsy rate has affected our ability to determine a cause for stillbirths.

MATERIAL AND METHODS

All cases of normally formed singleton infants weighing ≥500 g that died prior to the onset of labor from 1989 to 2018 were examined. Trends for specific causes and uptake of perinatal autopsy were analyzed individually.

RESULTS

In all, 229 641 infants were delivered, with 840 stillbirths giving a rate of 3.66/1000. The rate of stillbirth declined from 4.84/1000 in 1989 to 2.51 in 2018 (P < .001). There was no difference in the rate of stillbirth between nulliparous and multiparous women (4.25 vs 3.66 per 1000, P = .026). Deaths from placental abruption fell (1.13/1000 in 1989 to 0 in 2018, P < .001) and the relative contribution of placental abruption to the incidence of stillbirth also fell, from 23.3% (7/30) in 1989 to 0.0% (0/19) in 2018 (P < .001). Stillbirth attributed to infection remained static (0.31/1000 in 1989 to 0.13 in 2018, P = .131), while a specific causal organism was found in 79.2% (42/53) of cases. Unexplained stillbirths decreased from 2.58/1000 (16/6200) in 1989 to 0.13 (1/7581) in 2018 (P < .001) despite a fall in the uptake of perinatal autopsy (96.7% [29/30] in 1989 to 36.8% (7/19) in 2018; P < .001). Placental disease emerged as a significant cause of stillbirth from 2004 onwards (89.5% [17/19] in 2018).

CONCLUSIONS

The present analysis is one of the largest single-center studies on stillbirth published to date. Stillbirth rates have fallen across the study period across parity. A decrease in deaths secondary to placental abruption contributed largely to this. Infection-related deaths are static; however, in one-fifth of cases a causative organism was not found. Despite a decreasing autopsy rate, the number of unexplained stillbirths continues to fall as the importance of placental pathology is increasingly recognized.

Use of the Robson Ten Group Classification System to categorise operative vaginal delivery

BACKGROUND

Operative vaginal delivery (OVD), either vacuum or forceps, can be used to expedite vaginal delivery. While rates of OVD have been reducing worldwide, rates in Ireland remain high. The Robson Ten Group Classification System (TGCS) was originally created to compare rates of caesarean delivery between healthcare units, although no similar system exists for the analysis of OVD.

AIMS

We sought to examine rates of OVD using the TGCS in an effort to understand which patient groups make significant contributions to the overall rate of OVD.

MATERIALS AND METHODS

This is a retrospective cohort study of all women delivering in a tertiary-level university institution in Dublin, Ireland, from 2007 to 2016. Mode of delivery for all patients was extracted from contemporaneously recorded hospital records. Rates of OVD were analysed according to the TGCS, and the contribution of each group to the overall hospital population was calculated.

RESULTS

There were 86 191 deliveries of women in our institution, of which 19.3% (16 673/86 191) had an OVD. Women in Group 1 (singleton, cephalic, nulliparous women at term in spontaneous labour) contributed the most to the overall rate of OVD, accounting for almost half of all OVDs (46.1% (7679/16 673)). Nulliparous women with a singleton, cephalic fetus at term who were induced (Group 2) were more likely to have an OVD than similar patients who laboured spontaneously (Group 1).

CONCLUSION

OVD accounts for almost one in five deliveries in our population and is predominately performed in nulliparous women. These groups may be the subject of interventions to lower rates of OVD. The Robson TGCS is a freely available tool to hospitals and birthing centres to facilitate comparison of rates of OVD on local and national levels.

Trends and risk factors associated with stillbirths: A case study of the Navrongo War Memorial Hospital in Northern Ghana

BACKGROUND

Maternal and Child health remains at the core of global health priorities transcending the Millennium Development Goals into the current era of Sustainable Development Goals. Most low and middle-income countries including Ghana are yet to achieve the required levels of reduction in child and maternal mortality. This paper analysed the trends and the associated risk factors of stillbirths in a district hospital located in an impoverished and remote region of Ghana.

METHODS

Retrospective hospital maternal records on all deliveries conducted in the Navrongo War Memorial hospital from 2003-2013 were retrieved and analysed. Descriptive and inferential statistics were used to summarise trends in stillbirths while the generalized linear estimation logistic regression is used to determine socio-demographic, maternal and neonatal factors associated with stillbirths.

RESULTS

A total of 16,670 deliveries were analysed over the study period. Stillbirth rate was 3.4% of all births. There was an overall decline in stillbirth rate over the study period as stillbirths declined from 4.2% in 2003 to 2.1% in 2013. Female neonates were less likely to be stillborn (Adjusted Odds ratio = 0.62 and 95%CI [0.46, 0.84]; p = 0.002) compared to male neonates; neonates with low birth weight (4.02 [2.92, 5.53]) and extreme low birth weight (18.9 [10.9, 32.4]) were at a higher risk of still birth (p<0.001). Mothers who had undergone Female Genital Mutilation had 47% (1.47 [1.04, 2.09]) increase odds of having a stillbirth compared to non FGM mothers (p = 0.031). Mothers giving birth for the first time also had a 40% increase odds of having a stillbirth compared to those who had more than one previous births (p = 0.037).

CONCLUSION

Despite the modest reduction in stillbirth rates over the study period, it is evident from the results that stillbirth rate is still relatively high. Primiparous women and preterm deliveries leading to low birth weight are identified factors that result in increased stillbirths. Efforts aimed at impacting on stillbirths should include the elimination of outmoded cultural practices such as FGM.

Fetal electrocardiography ST-segment analysis for intrapartum monitoring: a critical appraisal of conflicting evidence and a way forward

BACKGROUND

In the past century, some areas of obstetric including intrapartum care have been slow to benefit from the dramatic advances in technology and medical care. Although fetal heart rate monitoring (cardiotocography) became available a half century ago, its interpretation often differs between institutions and countries, its diagnostic accuracy needs improvement, and a technology to help reduce the unnecessary obstetric interventions that have accompanied the cardiotocography is urgently needed.

STUDY DESIGN

During the second half of the 20th century, key findings in animal experiments captured the close relationship between myocardial glycogenolysis, myocardial workload, and ST changes, thus demonstrating that ST waveform analysis of the fetal electrocardiogram can provide information on oxygenation of the fetal myocardium and establishing the physiological basis for the use of electrocardiogram in intrapartum fetal surveillance.

RESULTS

Six randomized controlled trials, 10 meta-analyses, and more than 20 observational studies have evaluated the technology developed based on this principle. Nonetheless, despite this intensive assessment, differences in study protocols, inclusion criteria, enrollment rates, clinical guidelines, use of fetal blood sampling, and definitions of key outcome parameters, as well as inconsistencies in randomized controlled trial data handling and statistical methodology, have made this voluminous evidence difficult to interpret. Enormous resources spent on randomized controlled trials have failed to guarantee the generalizability of their results to other settings or their ability to reflect everyday clinical practice.

CONCLUSION

The latest meta-analysis used revised data from primary randomized controlled trials and data from the largest randomized controlled trials from the United States to demonstrate a significant reduction of metabolic acidosis rates by 36% (odds ratio, 0.64; 95% confidence interval, 0.46-0.88) and operative vaginal delivery rates by 8% (relative risk, 0.92; 95% confidence interval, 0.86-0.99), compared with cardiotocography alone.

Cellular kinetics of MED12-mutant uterine leiomyoma growth and regression in vivo

Cellular mechanisms of uterine leiomyoma (LM) formation have been studied primarily utilizing in vitro models. However, recent studies established that the cells growing in the primary cultures of MED12-mutant LM (MED12-LM) do not carry causal mutations. To improve the accuracy of LM research, we addressed the cellular mechanisms of LM growth and regression utilizing a patient-derived xenograft (PDX) model, which faithfully replicates the patient tumors in situ The growth and maintenance of MED12-LMs depend on 17β-estradiol (E2) and progesterone (P4). We determined E2 and P4-activated MAPK and PI3K pathways in PDXs with upregulation of IGF1 and IGF2, suggesting that the hormone actions on MED12-LM are mediated by the IGF pathway. When hormones were removed, MED12-LM PDXs lost approximately 60% of volume within 3 days through reduction in cell size. However, in contrast to general belief, the survival of LM cells was independent of E2 and/or P4, and apoptosis was not involved in the tumor regression. Furthermore, it was postulated that abnormal collagen fibers promote the growth of LMs. However, collagen fibers of actively growing PDXs were well aligned. The disruption of collagen fibers, as found in human LM specimens, occurred only when the volume of PDXs had grown to over 20 times the volume of unstimulated PDXs, indicating disruption is the result of growth not the cause. Hence, this study revises generally accepted theories on the growth and regression of LMs.

Intrapartum fetal deaths and unexpected neonatal deaths in the Republic of Ireland: 2011 - 2014; a descriptive study

BACKGROUND

Intrapartum fetal death, the death of a fetus during labour, is a tragic outcome of pregnancy. The intrapartum death rate of a country is reflective of the care received by mothers and babies in labour and it is through analysing these cases that good aspects of care, as well as areas for improvement can be identified. Investigating unexpected neonatal deaths that may be associated with an intrapartum event is also helpful to fully appraise intrapartum care. This is a descriptive study of intrapartum fetal deaths and unexpected neonatal deaths in Ireland from 2011 to 2014.

METHODS

Anonymised data pertaining to all intrapartum fetal deaths and unexpected neonatal deaths for the study time period was obtained from the national perinatal epidemiology centre. All statistical analyses were conducted using Statistical package for the Social Sciences (SPSS).

RESULTS

There were 81 intrapartum fetal deaths from 2011 to 2014, and 36 unexpected neonatal deaths from 2012 to 2014. The overall intrapartum death rate was 0.29 per 1000 births and the corrected intrapartum fetal death rate was 0.16 per 1000 births. The overall unexpected neonatal death rate was 0.17 per 1000 live births. Major Congenital Malformation accounted for 36/81 intrapartum deaths, chorioamnionitis for 18/81, and placental abruption accounted for eight babies' deaths. Intrapartum asphyxia accounted for eight of the intrapartum deaths. With respect to the neonatal deaths over half (21/36, 58.3%) of the babies died as a result of hypoxic ischaemic encephalopathy. Information is also reported on both maternal and individual baby demographics.

CONCLUSIONS

This is the first detailed descriptive analysis of intrapartum deaths and unexpected intrapartum event related neonatal deaths in Ireland. The corrected intrapartum fetal death rate was 0.16 per 1000 births. Despite our results being based on the best available national data on intrapartum deaths and unexpected neonatal deaths, we were unable to identify if any of these deaths could have been prevented. A more formal confidential inquiry based system is necessary to fully appraise these cases.

Ambient Temperature and Stillbirth: A Multi-Center Retrospective Cohort Study

BACKGROUND

Climate change is expected to have adverse health effects, but the association between extreme ambient temperatures and stillbirth is unclear.

OBJECTIVES

We investigated acute and chronic associations between extreme ambient temperatures and stillbirth risk, and estimated the attributable risk associated with local temperature extremes in the United States.

METHODS

We linked 223,375 singleton births ≥23 weeks of gestation (2002–2008) from 12 U.S. sites to local temperature. Chronic exposure to hot (>90th percentile), cold (<10th percentile), or mild (10th–90th percentile) temperatures was defined using window- and site-specific temperature distributions for three-months preconception, first and second trimester, and whole-pregnancy averages. For acute exposure, average temperature for the week preceding delivery was compared to two alternative control weeks in a case-crossover analysis.

RESULTS

In comparison with mild, whole-pregnancy exposure to cold [adjusted odds ratio (aOR) = 4.75; 95% confidence interval (CI): 3.95, 5.71] and hot (aOR = 3.71; 95% CI: 3.07, 4.47) were associated with stillbirth risk, and preconception and first and second trimester exposures were not. Approximately 17–19% of stillbirth cases were potentially attributable to chronic whole-pregnancy exposures to local temperature extremes. This is equivalent to ∼1,116 cold-related and ∼1,019 hot-related excess cases in the United States annually. In the case-crossover analysis, a 1°C increase during the week preceding delivery was associated with a 6% (3–9%) increase in stillbirth risk during the warm season (May–September). This incidence translates to ∼4 (2–6) additional stillbirths per 10,000 births for each 1°C increase.

CONCLUSIONS

Extremes of local ambient temperature may have chronic and acute effects on stillbirth risk, even in temperate zones. Temperature-related effects on pregnancy outcomes merit additional investigation. https://doi.org/10.1289/EHP945.

Fetal heart rate monitoring: from Doppler to computerized analysis

The monitoring of fetal heart rate (FHR) status is an important method to check well-being of the baby during labor. Since the electronic FHR monitoring was introduced 40 years ago, it has been expected to be an innovative screening test to detect fetuses who are becoming hypoxic and who may benefit from cesarean delivery or operative vaginal delivery. However, several randomized controlled trials have failed to prove that electronic FHR monitoring had any benefit of reducing the perinatal mortality and morbidity. Also it is now clear that the FHR monitoring had high intra- and interobserver disagreements and increased the rate of cesarean delivery. Despite such limitations, the FHR monitoring is still one of the most important obstetric procedures in clinical practice, and the cardiotocogram is the most-used equipment. To supplement cardiotocogram, new methods of computerized FHR analysis and electrocardiogram have been developed, and several clinical researches have been currently performed. Computerized equipment makes us to analyze beat-to-beat variability and short term heart rate patterns. Furthermore, researches about multiparameters of FHR variability will be ongoing.

Computerized analysis of fetal heart rate variability signal during the stages of labor

AIM

To analyze computerized cardiotocographic (cCTG) parameters (baseline fetal heart rate, baseline FHR; short term variability, STV; approximate entropy, ApEn; low frequency, LF; movement frequency, MF; high frequency, HF) in physiological pregnancy in order to correlate them with the stages of labor. This could provide more information for understanding the mechanisms of nervous system control of FHR during labor progression.

METHODS

A total of 534 pregnant women were monitored on cCTG from the 37th week before the onset of spontaneous labor and during the first and the second stage of labor. Statistical analysis was performed using Kruskal-Wallis test and Wilcoxon rank-sum test with the Bonferroni adjusted α (< 0.05).

RESULTS

Statistically significant differences were seen between baseline FHR, MF and HF (P < 0.001), in which the first two were reduced and the third was increased when compared between pre-labor, and the first and second stages of labor. Differences between some of the stages were found for ApEn, LF and for LF/(HF + MF), where the first and the third were reduced and the second was increased.

CONCLUSIONS

cCTG modifications during labor may reflect the physiologic increased activation of the autonomous nervous system. Using computerized fetal heart rate analysis during labor it may be possible to obtain more information from the fetal cardiac signal, in comparison with the traditional tracing.

Litigation related to intrapartum fetal surveillance

The role of intrapartum care including cardiotocography (CTG) monitoring in cases of perinatal neurological injury receives considerable debate in both clinical and medicolegal settings. The debate, however, has distracted attention from fundamental questions about the timing, mechanism, and preventability of perinatal injury. CTG tracings are used as a surrogate for asphyxia with the timing of intervention ("rescue") predicated on the presumed severity of asphyxia. Using CTG in this way has prevented intrapartum stillbirth, but it has not reduced the long-term injury in part, because, contrary to popular belief, the majority of intrapartum fetal injuries are unassociated with severe hypoxia or severe neonatal depression. This article describes the timing and mechanisms, including mechanical factors, of intrapartum perinatal injury and the benefit of using the CTG, not for the purpose of "rescue", but for identifying risk factors for fetal injury and keeping the fetus out of harm's way.

A modified fetal heart rate tracing interpretation system for prediction of cesarean section

OBJECTIVE

To investigate whether a modified version of the 2008 National Institute of Child Health and Human Development (NICHD) interpretation system upon admission decreases cesarean delivery risk.

METHODS

This retrospective cohort study ascribed a modified category to the first 30 min of fetal heart rate (FHR) tracings in labor. Category I was divided into two subsets (Ia and Ib) by the presence of accelerations. Category II was divided into four subsets (IIa-IId) based on baseline FHR, variability, response to stimulation and decelerations. Log-binomial regression was used to calculate risk ratios (RR) and 95% confidence intervals (CI).

RESULTS

A category was ascribed to 910 women. Most FHR tracings were Category Ia (65.8%), Ib (7.7%), IIb (11.8%) and IId (14.0%). Category Ib tracings (fewer than two accelerations) were 2.26 (95% CI: 1.13-4.52) times more likely to result in cesarean delivery for abnormal FHR tracing than Category Ia tracings. A similar increase in risk was seen when comparing Category IIb and Category IId with Category Ia.

CONCLUSION

Application of a modified version of the 2008 NICHD FHR interpretation system to the initial 30 min of labor can identify women at increased risk of cesarean delivery for abnormal FHR tracing.

Blocking Epidermal Growth Factor Receptor Signaling in HTR-8/SVneo First Trimester Trophoblast Cells Results in Dephosphorylation of PKBα/AKT and Induces Apoptosis

We identified a major peptide signaling target of EGF/EGFR pathway and explored the consequences of blocking or activating this pathway in the first trimester extravillous trophoblast cells, HTR-8/SVneo. A global analysis of protein phosphorylation was undertaken using novel technology (Kinexus Kinetworks) that utilizes SDS-polyacrylamide minigel electrophoresis and multi-lane immunoblotting to permit specific and semiquantitative detection of multiple phosphoproteins. Forty-seven protein phosphorylation sites were queried, and the results reported based on relative phosphorylation at each site. EGF- and Iressa-(gefitinib, ZD1839, an inhibitor of EGFR) treated HTR-8/SVneo cells were subjected to immunoblotting and flow cytometry to confirm the phosphoprotein screen and to assess the effects of EGF versus Iressa on cell cycle and apoptosis. EGFR mediates the phosphorylation of important signaling proteins, including PKBα/AKT. This pathway is likely to be central to EGFR-mediated trophoblast survival. Furthermore, EGF treatment induces proliferation and inhibits apoptosis, while Iressa induces apoptosis.

Risk factors for intrapartum fetal death and trends over the years

OBJECTIVE

To determine the time trends and risk factors for intrapartum fetal death (IPFD).

STUDY DESIGN

A case-control study comparing pregnancies with and without IPFD between the years 1988 and 2008 was conducted. A multiple logistic regression model was used to determine the risk factors for IPFD.

RESULTS

During the study period, 204,102 singleton births were analyzed; of these, 110 IPFD cases occurred. The following independent risk factors were identified: Bedouin ethnicity (OR = 1.85, 95% CI 1.22-2.8), malpresentations (OR = 2.76, 95% CI 1.71-4.47), gestational age (OR = 0.72, 95% CI 0.69-0.76), polyhydramnios (OR = 3.49, 95% CI 1.94-6.26), meconium-stained amniotic fluid (OR = 3.18, 95% CI 2.01-5.05), umbilical cord prolapse (OR = 6.64, 95% CI 2.79-15.78), placental abruption (OR = 3.24, 95% CI 1.73-6.04), uterine rupture (OR = 38.59, 95% CI 10.58-140.71) and congenital malformations (OR = 2.41, 95% CI 1.47-3.97). A gradual decline over the years in the rate of IPFD was noted in the Bedouin population. No significant association was noted in the prevalence of IPFD during the weekends as compared to the week days (OR = 0.85; 95% CI 0.54-1.32; P = 0.475).

CONCLUSION

Independent risk factors for IPFD are preterm birth, malpresentation, polyhydramnios, meconium-stained amniotic fluid, umbilical cord prolapse, placental abruption, uterine rupture, congenital malformations and Bedouin ethnicity. Weekends do not pose additional risk for the occurrence of IPFD.

Investigation of the role of computed tomography as an adjunct to autopsy in the evaluation of stillbirth

INTRODUCTION

The number of parents agreeing to autopsy following stillbirth is declining, which has undermined clinicians' ability to assess causes of intrauterine death and can impact counselling regarding recurrence. Post-mortem radiological imaging is a potential alternative method of investigating perinatal loss. The aim of this study was to assess the role of multi-detector computed tomography (MDCT) in the investigation of stillbirth.

STUDY DESIGN

Following ethical approval and written consent, parents were offered MDCT of the stillborn infant. MDCT was performed with 3D reconstruction, and images were analysed for image quality, anthropomorphic measurements and pathologic findings. Body part and organ-specific measurements were performed; including head, chest and abdominal circumferences, and muscle and liver mass was also measured. Findings were correlated with obstetric history, post-mortem skeletal survey (plain radiography), and formal autopsy.

RESULTS

Fourteen third-trimester stillborn infants were scanned. Image quality was moderate to excellent for most body structures. CT was better than plain radiography for imaging skeletal structures and large solid organs and demonstrated a range of pathologies including renal vein thrombosis, mesenteric calcification and skeletal hyperostosis that were not seen on plain radiographs. MDCT did not overlook autopsy findings and provided some additional information.

CONCLUSION

This study confirms the feasibility of MDCT in the investigation of third trimester stillbirth. MDCT image quality is acceptable and the examination can demonstrate a range of anatomic and pathologic findings. Initially, its value may be as an important adjunct to conventional autopsy.

Electronic fetal monitoring as a public health screening program: the arithmetic of failure

Electronic fetal monitoring has failed as a public health screening program. Nevertheless, most of the four million low-risk women giving birth in the United States each year continue to undergo this screening. The failure of this program should have been anticipated and thus avoided had the accepted principles of screening been considered before its introduction. All screening tests have poor positive predictive value when searching for rare conditions such as fetal death in labor or cerebral palsy. This problem is aggravated when the screening test does not have good validity as is the case with electronic fetal monitoring. Because of low-prevalence target conditions and mediocre validity, the positive predictive value of electronic fetal monitoring for fetal death in labor or cerebral palsy is near zero. Stated alternatively, almost every positive test result is wrong. To avoid such costly errors in the future, the prerequisites for any screening program must be fulfilled before the program is begun.

Support after stillbirth and its effect on parental grief over time

In this study the authors describe parents' experiences of support over a 2-year period after a stillbirth and its effect on parental grief. Data was collected by questionnaire from 33 mothers and 22 fathers at 3 months, 1 year, and 2 years after a stillbirth. Midwives, physicians, counselors, and priests--at the hospital where the stillbirth occurred--are those on the front line providing professional support. The support from family and friends was seen to be important 2 years after the stillbirth. The need for professional support after stillbirth can differ, depending on the support provided by family, friends, and social networks. They may not fully realize the value of their support and how to be supportive. Printed educational materials given to individuals in the social network or family might therefore be helpful.

The impact of maternal age on fetal death: does length of gestation matter?

OBJECTIVE

The objective of the investigation was to study the association of fetal death with maternal age by length of gestation.

STUDY DESIGN

This was a population study including all ongoing pregnancies after 16 weeks of gestation in Norway during the period 1967-2006 (n = 2,182,756).

RESULTS

The risk of fetal death was 1.4 times higher in women 40-44 years old than in women aged 20-24 years in midpregnancy but 2.8 times higher at term. In term pregnancies the relative importance of maternal age increased by additional pregnancy weeks. In gestational weeks 42-43, the crude risk was 5.1 times higher in mothers 40 years old or older. In the recent period, the elevated risk of fetal death in elderly mothers at term has been attenuated.

CONCLUSION

Women 40 years old or older had the highest risk of fetal death throughout pregnancy, particularly in term and postterm pregnancies. Improved obstetric care may explain the attenuation of risk associated with age in recent time.

Low perinatal autopsy rate in Malaysia: time for a change

Our objectives were to determine the perinatal autopsy rate in a tertiary hospital in Malaysia and to quantify the value of the perinatal autopsy. All stillbirths, miscarriages, therapeutic abortions, and neonatal deaths between January 1, 2004, and August 31, 2009, were identified from the archives. The autopsy findings were compared with the clinical diagnoses. The autopsy reports were also reviewed to determine if it would be possible to improve the quality of the autopsies. There were 807 perinatal deaths, of which 36 (4.5%) included an autopsy. There were ethnic differences in the rate of autopsy, with the lowest rate among the Malays. The autopsy provided the diagnosis, changed the clinical diagnosis, or revealed additional findings in 58.3% of cases. Ancillary testing, such as microbiology, chromosomal analysis, and biochemistry, could improve the quality of the autopsy. This study provides further data on the perinatal autopsy rate from an emerging and developing country. It reaffirms the value of the perinatal autopsy. Attempts must be made to improve on the low autopsy rate while recognizing that the performance of autopsies can be enhanced through the use of ancillary testing.

Making stillbirths count, making numbers talk - issues in data collection for stillbirths

BACKGROUND

Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care.

DISCUSSION

In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings.

SUMMARY

Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.