Stillbirth at Term

Aetiology and trends of rates of stillbirth in a tertiary care hospital in the north of India over 10 years: a retrospective study

OBJECTIVE

To analyse the aetiology of stillbirth and its changing trends in a single tertiary care referral institute of northern India over a 10-year period (2007-2016).

DESIGN

Retrospective study.

SETTING

Tertiary care hospital in the north of India.

SAMPLE

Medical records of all mothers who delivered a stillborn at the institute.

METHODS

Data was collected from monthly and annual perinatal audits and causes of stillbirths were classified using Simplified CODAC classification. Annual reduction rate was calculated by linear regression analysis and Cusick test for the changing trends over 9 years.

MAIN OUTCOME MEASURES

Of 54 160 births, 3678 babies were stillborn. Over 9 years, the annual stillbirth rate has reduced significantly from 73.6 to 62.0 per 1000 total births with an average annual reduction rate of 1%. The most common causes of stillbirths were hypertensive disorders of pregnancy (27.6%), antepartum haemorrhage (19.5%), and congenital anomalies (9.3%).

CONCLUSION

The annual reduction rate (1%) of stillbirth remains low. The aetiology of stillbirths remains unchanged over a 10-year period and hypertensive disorder of pregnancy remains the single most preventable cause of stillbirth.

TWEETABLE ABSTRACT

Analysis of stillbirths over a 10-year period in an Indian institute showed a high but declining trend with annual reduction rate of 1%.

Interventions et techniques de diagnostic prénatal visant l'obtention d'un prélèvement fœtal à des fins diagnostiques : Risques et avantages pour la mère et le fœtus

OBJECTIF

Offrir aux fournisseurs de soins de maternité et à leurs patientes des lignes directrices factuelles contemporaines en ce qui concerne les services de counseling traitant des risques et des avantages maternels propres à la tenue des interventions diagnostiques prénatales orientées par échographie (et/ou des techniques permettant l'établissement d'un diagnostic génétique) nécessaires dans les cas où il a été établi pendant la période prénatale que la grossesse serait exposée à des risques, ainsi qu'en ce qui concerne la prise de décisions subséquentes quant à la prise en charge de la grossesse (questions abordant des aspects tels que le niveau du fournisseur de soins obstétricaux, la surveillance prénatale, le lieu où devraient se dérouler les soins et l'accouchement, et la décision de poursuivre ou d'interrompre la grossesse). La présente directive clinique se limite aux services de counseling traitant des risques et des avantages maternels, et aux décisions en matière de prise en charge de la grossesse pour les femmes qui nécessitent (ou qui envisagent) la mise en œuvre d'une intervention ou d'une technique effractive orientée par échographie aux fins de l'établissement d'un diagnostic prénatal.

POPULATION DE PATIENTES

Femmes enceintes identifiées, à la suite de la mise en œuvre de protocoles établis de dépistage prénatal (taux sériques maternels ± imagerie, résultats d'analyse de l'ADN acellulaire indiquant des risques élevés, résultats anormaux au moment de l'imagerie fœtale diagnostique ou antécédents familiaux de troubles héréditaires), comme étant exposées à un risque accru d'anomalie génétique fœtale. Ces femmes pourraient nécessiter ou demander des services de counseling au sujet des risques et des avantages pour la grossesse de la tenue d'une intervention effractive orientée par échographie visant à déterminer l'étiologie, le diagnostic, et/ou la pathologie de possibles anomalies fœtales. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline, PubMed et The Cochrane Library jusqu'en juin 2014 au moyen d'un vocabulaire contrôlé (« prenatal diagnosis », « amniocentesis », « chorionic villi sampling », « cordocentesis ») et de mots clés (« prenatal screening », « prenatal genetic counselling », « post-procedural pregnancy loss rate ») appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre janvier 1985 et juin 2014. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en juin 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales.

VALEURS

La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). AVANTAGES, DéSAVANTAGES ET COûTS: Consentement éclairé de la patiente, transfert des connaissances, évaluation du risque génétique prénatal, soulagement de l'anxiété, création d'anxiété, défense des droits, compréhension du dépistage fœtal, limites du dépistage fœtal, choix en matière de prise en charge de la grossesse, complication de la grossesse ou fausse couche, soins opportuns et améliorés pour l'accouchement d'un enfant présentant une morbidité reconnue. RECOMMANDATIONS.

Maternal characteristics of pregnancies with intrauterine fetal demise

OBJECTIVE

To identify maternal characteristics independently associated with pregnancies resulting in intrauterine fetal demise (IUFD).

STUDY DESIGN

This was a population-based cohort study of all births taking place at the McGill University Health Centre in Montreal, Canada, between 2001 and 2007, using the McGill University Obstetrics and Neonatal Database. Maternal characteristics were compared between pregnancies that resulted in IUFD and control pregnancies resulting in live newborns. A logistic regression analysis was constructed to identify parameters independently associated with IUFD.

RESULTS

We identified 20,744 births during the study period, 87 of which were complicated by IUFD. Mothers with IUFD were more likely to be younger, with less formal education, higher rates of smoking during pregnancy, and more fetal anomalies (42.5% vs. 7.5%, P<0.001). After exclusion of pregnancies with congenital and/or chromosomal abnormalities, less formal education (7 vs. 13.6 school years, P<0.001) and smoking during pregnancy (24% vs. 7.7%, P<0.001) remained significantly more common in pregnancies resulting in IUFD. In the multivariable regression analysis both smoking and number of maternal school years were independently associated with IUFD pregnancies (OR 2.22 for smoking, P=0.007 and OR 0.865 for number of school years, P<0.001).

CONCLUSION

Lower levels of education and smoking during pregnancy are independent predictors of IUFD.

Placental findings contributing to fetal death, a study of 120 stillbirths between 23 and 40 weeks gestation

BACKGROUND

Intrauterine fetal death is an agonizing, often unpredictable event. Autopsies of stillborn fetuses, including placentas, are performed to clarify the cause of death. Autopsy results are not always easily understood by the patients or their healthcare providers.

OBJECTIVE

To evaluate placental causes of death in stillbirths based on autopsy and placental findings that are related to maternal underperfusion, fetal underperfusion, or inflammatory etiologies in hierarchical order.

METHODS

Retrospective review of 120 autopsy reports of singleton stillborn fetuses and placentas from 23 to 40 weeks of gestation.

RESULTS

Among the placental causes of death there were 54(51%) cases with direct cause or major contributor to death in the etiology of maternal vascular supply abnormalities, 28(26%) cases in the etiology of fetal vascular supply abnormalities and 13(12%) in the etiology of inflammatory lesions. Maternal vascular supply abnormalities were more common in preterm stillbirths and fetal vascular supply abnormalities were more common among term stillbirths. In 88% of stillbirths, the direct cause or a major contributor to death was found in the placentas. The incidence of unexplained death was 8%.

CONCLUSIONS

Pathological analysis of the placenta is essential for clarifying causes of stillbirths. Using specific simplified categories for abnormal placental findings may increase the benefits of the autopsy report.

Etiology of stillbirth at term: a 10-year cohort study

OBJECTIVE

To examine etiological factors contributing to cases of intrauterine fetal demise in term pregnancies over a 10-year period.

METHODS

This was a retrospective cohort analysis of 29 908 term (37(+0) to 41(+6) weeks gestation) infants delivering in a single tertiary-referral university institution over the 10-year period from 1996 to 2005. Cases of stillbirth were identified from a computerized hospital database, and pathological, clinical, and biochemical data were reviewed for all cases. Trends were analyzed using the Cusick test for trend. Categorical data were analyzed using the Fisher's exact test, with the 5% level considered significant.

RESULTS

The incidence of intrauterine fetal demise at term was 1.8 per 1000 at-risk pregnancies. There was no significant downward trend in the rate of term stillbirth between 1996 and 2005 (p = 0.0808). Stillbirths were unexplained in 51% of cases, although in many cases a possible etiological factor was identified but not necessarily proven. There was a significant downward trend in the incidence of unexplained term stillbirths at our institution over the 10-year study period (p = 0.0105). Placental/cord factors accounted for 25% of term stillbirths and did not decrease significantly over the study period (p = 0.0953). Almost 50% of term stillbirths occurred in women who registered late or had no antenatal care. However, suboptimal antenatal care was not predictive of differences in either acceptance of perinatal postmortem or successful identification of stillbirth etiology.

CONCLUSIONS

The incidence of stillbirth at term is 2 per 1000 term pregnancies and has not changed significantly in the past 10 years. Almost 50% of term stillbirths occurred in women with suboptimal antenatal care. More than half of cases are unexplained, often resulting from an incomplete diagnostic work-up. Despite this, there has been a significant downward trend in the rates of unexplained stillbirth at term. It is imperative that a complete diagnostic work-up is performed in cases of term stillbirth, to minimize the incidence of unexplained stillbirth.

Antepartum testing for women with previous stillbirth

Women with past histories of stillbirth have been referred for antepartum surveillance since the inception of electronic fetal monitoring. However, this approach was originally based on mid-twentieth century perinatal studies that noted an increase in adverse outcomes in pregnancies subsequent to stillbirth. When these landmark studies were done, Rh immune globulin, ultrasonography, and other important medical advances had not yet occurred. This article discusses whether women who have suffered a past stillbirth remain at increased risk for perinatal mortality and morbidity in future pregnancies and whether antepartum fetal surveillance can reduce the risk of recurrent stillbirth.