Comparison of the aetiology of stillbirth over five decades in a single centre: a retrospective study

Etiology of stillbirth in a tertiary care center: a retrospective cohort study assessing ultrasound, laboratory, and pathology investigations

BACKGROUND

Canadian stillbirth data are limited, and a significant proportion of pregnancies resulting in stillbirth have no attributable cause. The objective of this study was to characterize stillbirth case investigations and management at a tertiary care hospital in Ontario, Canada.

METHODS

This was a retrospective chart review study of all cases of singleton stillbirth at The Ottawa Hospital between 1 January 2012 and 31 December 2017. Terminations and multiples stillbirths were excluded. Chart reviews were conducted to extract maternal sociodemographic, obstetrical, and fetal characteristics, including results from antenatal ultrasounds, autopsy, placenta pathology, and laboratory investigations.

RESULTS

A total of 155 eligible cases of stillbirth were identified, resulting in a 6-year stillbirth rate of 4.2 per 1000 total births. The median maternal age was 31.0 years (IQR: 29.0, 35.0) and the median gestational age at delivery was 28 weeks (IQR: 24, 35). A total of 9 (5.8%) pregnant individuals had a history of previous stillbirth. Of the 155 stillbirths, 35% underwent the full suite of post-loss laboratory, placental, and fetal autopsy investigations. 63.2% of cases had post-loss laboratory investigations completed. 76% and 71% of cases had fetal autopsy and placenta pathology evaluations completed, respectively. Antenatal characteristics associated with stillbirth included fetal anomalies/genetic markers (27.1%), umbilical cord and placental anomalies (24.5%), fetal growth abnormalities (27.7%), cervical/uterine abnormalities (11.6%), and amniotic fluid abnormalities (25.1%). The most common autopsy findings included evidence of infection (22.7%), fetal anomalies (12.6%), and fetal hypoxia (10%). The most common placental pathology findings included features of placental insufficiency (21.8%), retroplacental abnormalities (16.3%), and umbilical cord accident/infarct (15.4%).

CONCLUSIONS

Our findings demonstrate that as many as two-thirds of singleton stillbirth cases at our center did not receive the post-perinatal loss investigations recommended by clinical practice guidelines. More thorough collection of post-stillbirth data at all levels (institutional, provincial, national) is warranted to improve our understanding of stillbirth epidemiology, etiology, and management in Canada.

Exploring the role of a time-efficient MRI assessment of the placenta and fetal brain in uncomplicated pregnancies and these complicated by placental insufficiency

INTRODUCTION

The development of placenta and fetal brain are intricately linked. Placental insufficiency is related to poor neonatal outcomes with impacts on neurodevelopment. This study sought to investigate whether simultaneous fast assessment of placental and fetal brain oxygenation using MRI T2* relaxometry can play a complementary role to US and Doppler US.

METHODS

This study is a retrospective case-control study with uncomplicated pregnancies (n = 99) and cases with placental insufficiency (PI) (n = 49). Participants underwent placental and fetal brain MRI and contemporaneous ultrasound imaging, resulting in quantitative assessment including a combined MRI score called Cerebro-placental-T2*-Ratio (CPTR). This was assessed in comparison with US-derived Cerebro-Placental-Ratio (CPR), placental histopathology, assessed using the Amsterdam criteria [1], and delivery details.

RESULTS

Pplacental and fetal brain T2* decreased with increasing gestational age in both low and high risk pregnancies and were corrected for gestational-age alsosignificantly decreased in PI. Both CPR and CPTR score were significantly correlated with gestational age at delivery for the entire cohort. CPTR was, however, also correlated independently with gestational age at delivery in the PI cohort. It furthermore showed a correlation to birth-weight-centile in healthy controls.

DISCUSSION

This study indicates that MR analysis of the placenta and brain may play a complementary role in the investigation of fetal development. The additional correlation to birth-weight-centile in controls may suggest a role in the determination of placental health even in healthy controls. To our knowledge, this is the first study assessing quantitatively both placental and fetal brain development over gestation in a large cohort of low and high risk pregnancies. Future larger prospective studies will include additional cohorts.

Epidemiological characteristics and risk factors of obstetric infection after the Universal Two-Child Policy in North China: a 5-year retrospective study based on 268,311 cases

BACKGROUND

Obstetrical infection is one of the causes of maternal death and a difficult problem for many clinicians. Changes in the demographic and obstetric background of pregnant women following the Universal Two-Child Policy may have an impact on some fertility phenomena. And with the increase in the number of deliveries, the limited medical resources become more scarce. How will China's health system quickly adapt to the growing needs and expectations for maternal health and ensure the provision of qualified and accessible medical services? In addition, what social support measures should be provided to reduce preventable obstetric complications? Given the relatively low per capita share of medical resources in China, how should China deal with the impact of the Universal Two-Child Policy? Therefore, more studies based on the change of fertility policy are needed. We try to analyze the epidemiological characteristics and risk factors of obstetric infection before and after the Universal Two-Child Policy, with a view to providing reference for the prevention and control of obstetric infection in regions after the change of fertility policy, and also hope to make corresponding contributions to the solution of the above problems through relevant studies.

METHODS

The subjects of the survey were 268,311 pregnant women from Hebei Province Maternal Near Miss Surveillance System (HBMNMSS) of Hebei Women and Children's Health Center from January 1, 2013 to December 31, 2017. We analyzed the region, time and population distribution characteristics of obstetric infection, compared the epidemiological factors of obstetric infection before and after the Universal Two-Child Policy, and analyzed the relevant risk factors of obstetric infection.

RESULTS

The incidence of obstetric infection increased nearly twice after the Universal Two-Child Policy. The incidence of obstetric infection was highest in Chengde (1.9%), a city with a northward geographical distribution, Baoding (1.6%), Cangzhou (1.5%) followed; The higher the hospital grade, the higher the incidence; The incidence of obstetric infections in hospitals at all levels has increased; The age of onset before the Universal Two-Child Policy was (27.82 ± 5.047) years old, and the age after the Universal Two-Child Policy was (28.97 ± 4.880) years old; The incidence of obstetric infections is higher in winter. The rate of abortion-related infection (increased from 0.61 to 1.65%) and the rate of pregnant women with high school education (increased from 0.35 to 0.74%) increased significantly. The results of multivariate Logistic regression analysis after the Universal Two-Child Policy showed that anemia (OR = 1.249, 95%CI: 1.071-1.458), chronic hypertension (OR = 1.934, 95%CI: 1.375-2.722), mild preeclampsia (OR = 2.103, 95%CI: 1.323-3.344) and severe preeclampsia (OR = 2.228, 95%CI: 1.703-2.916) were independent risk factors for obstetric infection. Gestational age ≥ 37 weeks was a protective factor.

CONCLUSION

After the Universal Two-Child Policy, the prevention and control of obstetric infections should be strengthened, especially for abortion-related infections and elderly maternal with obstetric complications and complication in high-grade hospitals in winter. Educational background is also one of the factors that should be considered in the prevention of obstetric sensation. Prolonging gestational age is helpful to reduce the incidence of obstetric infection.

Effect of individualized medical nutrition guidance on pregnancy outcomes in older pregnant women

OBJECTIVE

We aimed to explore the effect of individualized medical nutrition guidance on pregnancy outcomes among older pregnant women.

METHODS

This was a prospective study using a randomized controlled trial design. We selected 820 older pregnant women and randomly divided them into a study group and control group (410 women each). The control group was given routine health education and nutrition guidance; the study group was provided individualized medical nutrition guidance. Gestational diabetes mellitus, hypertensive disorders of pregnancy, vaginal delivery rate, postpartum hemorrhage rate, gestational body weight, neonatal birth weight, and neonate transfer to the neonatal intensive care unit (NICU) were compared between the groups.

RESULTS

The incidence of gestational diabetes in the study group was significantly lower and the rate of vaginal delivery was significantly higher than those in the control group. The incidence of macrosomia, rate of neonatal transfer to the NICU, and rate of neonatal hyperbilirubinemia were significantly lower in the study group than those in the control group.

CONCLUSIONS

Individualized nutritional intervention for older pregnant women can effectively reduce the incidence of complications during pregnancy and childbirth and improve maternal and child outcomes.

The trend and characteristics of stillbirth delivery in a university teaching hospital in Lagos, Nigeria

Background:

The burden of stillbirth is so huge in sub-Saharan Africa, especially in Nigeria where many mothers and mothers-to-be are denied the joy of motherhood. Despite the frequent occurrence of this obstetric problem in our environment, little priority is placed on it.

Objectives:

The study aims to bring to the fore, the burden, trend, and characteristics of stillbirth delivery in Lagos, Nigeria.

Subjects and Methods:

This was a 5-year descriptive retrospective study of the case records of women who had stillbirth delivery at Lagos University Teaching Hospital from January 2009 to December 2013. Relevant information was obtained using a study pro forma, and data analysis was carried out using SPSS version 20.0.

Results:

The prevalence of stillbirth was 6.2%, and the rate was 61.8/1000 total births. Women who did not book for antenatal care accounted for 76.2% of the cases, and the antenatal and intrapartum stillbirths accounted for 64.6% and 35.4%, respectively. The mean gestational age was 35.5 ± 1.2 weeks, while the mean birth weight was 2.9 ± 1.0 kg. Majority of the stillbirths were male fetuses (54.5%). Previous history of stillbirth (36.0%), hypertensive disorders in pregnancy (33.0%), placental abruption (28.8%), intrauterine growth restriction (13.0%), and ruptured uterus (11.3%) were the common clinical risk factors identified.

Conclusion:

The burden of stillbirth is high in our environment, and majority is due to preventable or manageable obstetric conditions. There is a need to encourage early referral of complicated pregnancies and labor to specialized centers that can cater for them, so as to avoid unnecessary and preventable deaths.

An annotated data set for identifying women reporting adverse pregnancy outcomes on Twitter

Despite the prevalence in the United States of miscarriage [1], stillbirth [2], and infant mortality associated with preterm birth and low birthweight [3], their causes remain largely unknown [4], [5], [6]. To advance the use of social media data as a complementary resource for epidemiology of adverse pregnancy outcomes, we present a data set of 6487 tweets that mention miscarriage, stillbirth, preterm birth or premature labor, low birthweight, neonatal intensive care, or fetal/infant loss in general. These tweets are a subset of 22,912 tweets retrieved by applying hand-written regular expressions to a database containing more than 400 million public tweets posted by more than 100,000 women who have announced their pregnancy on Twitter [7]. Two professional annotators labeled the 6487 tweets in a binary fashion, distinguishing those potentially reporting that the user has personally experienced the outcome ("outcome" tweets) from those that merely mention the outcome ("non-outcome" tweets). Inter-annotator agreement was κ = 0.90 (Cohen's kappa). The tweets annotated as "outcome" include 1318 women reporting miscarriage, 94 stillbirth, 591 preterm birth or premature labor, 171 low birthweight, 453 neonatal intensive care, and 356 fetal/infant loss in general. These "outcome" tweets can be used to explore patient experiences and perceptions of adverse pregnancy outcomes, and can direct researchers to the users' broader timelines-tweets posted by a user over time-for observational studies. Our past work demonstrates the analysis of timelines for selecting a study population [8] and conducting a case-control study [9] of users reporting that their child has a birth defect. For larger-scale studies, the full annotated corpus can be used to train supervised machine learning algorithms to automatically identify additional users reporting adverse pregnancy outcomes on Twitter. We used the annotated corpus to train feature-engineered and deep learning-based classifiers presented in "A natural language processing pipeline to advance the use of Twitter data for digital epidemiology of adverse pregnancy outcomes" [10].

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.

Automatically Identifying Comparator Groups on Twitter for Digital Epidemiology of Pregnancy Outcomes

Despite the prevalence of adverse pregnancy outcomes such as miscarriage, stillbirth, birth defects, and preterm birth, their causes are largely unknown. We seek to advance the use of social media for observational studies of pregnancy outcomes by developing a natural language processing pipeline for automatically identifying users from which to select comparator groups on Twitter. We annotated 2361 tweets by users who have announced their pregnancy on Twitter, which were used to train and evaluate supervised machine learning algorithms as a basis for automatically detecting women who have reported that their pregnancy had reached term and their baby was born at a normal weight. Upon further processing the tweet-level predictions of a majority voting-based ensemble classifier, the pipeline achieved a user-level F1-score of 0.933 (precision = 0.947, recall = 0.920). Our pipeline will be deployed to identify large comparator groups for studying pregnancy outcomes on Twitter.

A natural language processing pipeline to advance the use of Twitter data for digital epidemiology of adverse pregnancy outcomes

BACKGROUND

In the United States, 17% of pregnancies end in fetal loss: miscarriage or stillbirth. Preterm birth affects 10% of live births in the United States and is the leading cause of neonatal death globally. Preterm births with low birthweight are the second leading cause of infant mortality in the United States. Despite their prevalence, the causes of miscarriage, stillbirth, and preterm birth are largely unknown.

OBJECTIVE

The primary objectives of this study are to (1) assess whether women report miscarriage, stillbirth, and preterm birth, among others, on Twitter, and (2) develop natural language processing (NLP) methods to automatically identify users from which to select cases for large-scale observational studies.

METHODS

We handcrafted regular expressions to retrieve tweets that mention an adverse pregnancy outcome, from a database containing more than 400 million publicly available tweets posted by more than 100,000 users who have announced their pregnancy on Twitter. Two annotators independently annotated 8109 (one random tweet per user) of the 22,912 retrieved tweets, distinguishing those reporting that the user has personally experienced the outcome ("outcome" tweets) from those that merely mention the outcome ("non-outcome" tweets). Inter-annotator agreement was κ = 0.90 (Cohen's kappa). We used the annotated tweets to train and evaluate feature-engineered and deep learning-based classifiers. We further annotated 7512 (of the 8109) tweets to develop a generalizable, rule-based module designed to filter out reported speech-that is, posts containing what was said by others-prior to automatic classification. We performed an extrinsic evaluation assessing whether the reported speech filter could improve the detection of women reporting adverse pregnancy outcomes on Twitter.

RESULTS

The tweets annotated as "outcome" include 1632 women reporting miscarriage, 119 stillbirth, 749 preterm birth or premature labor, 217 low birthweight, 558 NICU admission, and 458 fetal/infant loss in general. A deep neural network, BERT-based classifier achieved the highest overall F₁-score (0.88) for automatically detecting "outcome" tweets (precision = 0.87, recall = 0.89), with an F₁-score of at least 0.82 and a precision of at least 0.84 for each of the adverse pregnancy outcomes. Our reported speech filter significantly (P < 0.05) improved the accuracy of Logistic Regression (from 78.0% to 80.8%) and majority voting-based ensemble (from 81.1% to 82.9%) classifiers. Although the filter did not improve the F₁-score of the BERT-based classifier, it did improve precision-a trade-off of recall that may be acceptable for automated case selection of more prevalent outcomes. Without the filter, reported speech is one of the main sources of errors for the BERT-based classifier.

CONCLUSION

This study demonstrates that (1) women do report their adverse pregnancy outcomes on Twitter, (2) our NLP pipeline can automatically identify users from which to select cases for large-scale observational studies, and (3) our reported speech filter would reduce the cost of annotating health-related social media data and can significantly improve the overall performance of feature-based classifiers.

Review of Stillbirth in a Canadian Tertiary Care Centre

OBJECTIVE

Because literature on stillbirth in Canada and its related factors is scarce, the objective of this study was to determine the causes of stillbirth in a Canadian tertiary care centre and to identify the risk factors present in these deliveries.

METHODS

The charts of 180 stillbirth deliveries with a gestational age greater than or equal to 20 weeks or a birth weight greater than or equal to 500 g between 2011 and 2016 were reviewed. Information collected from maternal charts included maternal demographics, known risk factors for stillbirth during pregnancy, delivery parameters, and pathologic examination (Canadian Task Force Classification III).

RESULTS

The autopsy rate was 42.5%, placental pathology rate was 100%, and karyotype was completed in 20.2% of the reviewed cases. Often, the cause of stillbirth was unexplained (43.2%). The most common causes were preterm birth (9.8%) and abruption (9.3%). The most common risk factors in this population were maternal obesity (37.6%), late prenatal care (35.0%), and maternal smoking (22.4%).

CONCLUSION

Most stillbirths were unexplained in this Canadian tertiary care centre, and the rates of autopsy and karyotype were low. Identified risk factors present in this population may contribute to the significantly higher rate of stillbirth in this centre compared with the provincial rate.

An audit on a routine antenatal nonstress testing program in pregnant women with preexisting diabetes

INTRODUCTION

The objective was to evaluate the effectiveness of routine (planned) antenatal nonstress tests (NSTs) in pregnant women with preexisting diabetes.

MATERIAL AND METHODS

A retrospective single-center study of 642 consecutive pregnancies in women with preexisting diabetes who gave birth to a singleton ≥22 weeks. Weekly planned NSTs were commenced at 33-35 weeks. In pregnancies with maternal-fetal complications, the initiation and frequency of the planned NST were individualized. Daily maternal assessment of fetal activity was recommended from 28 weeks, and decreased fetal activity indicated an unplanned NST. Data were collected from medical records, and local and regional databases.

RESULTS

In total, 3016 planned NSTs were performed, with a median of five (range 0-12) tests per pregnancy. Ninety-five planned NSTs (3.1%) were abnormal, a finding confirmed by retesting the same day in eight cases (8.4%), thus leading to delivery. Complications were present in seven of these eight pregnancies, whereas no fetal movements for the last 3 days were reported when the planned NST was performed in the eighth pregnancy. When specifically asked, five of the eight women stated that they had observed decreased fetal activity preceding the planned NST. In 86 pregnancies (13.4%), maternal perception of decreased fetal activity indicated in total 127 unplanned NSTs. The combination of decreased fetal activity and further obstetrical assessment led to delivery in 10 of these pregnancies (11.6%). One stillbirth occurred at 37 weeks in a pregnancy complicated by fetal achondroplasia and polyhydramnios, where the weekly planned NSTs had been normal. The overall stillbirth rate was thus 1.6/1000.

CONCLUSIONS

Routine use of planned antenatal NSTs does not appear to be indicated in pregnancies in women with preexisting diabetes in the absence of maternal-fetal complications.

Causes of stillbirths in diabetic and gestational diabetes pregnancies at a NSW tertiary referral hospital

BACKGROUND

Diabetes in pregnancy may result in stillbirth or neonatal death.

AIM

This audit examined stillbirths of mothers with pre-existing diabetes in pregnancy (DIP) and gestational diabetes (GDM) to determine maternal and diabetic characteristics implicated in these deaths.

MATERIALS AND METHODS

A retrospective cohort study was conducted to identify stillbirths occurring in diabetic pregnancies at Westmead Hospital during 2006-2017. Medical records were reviewed to obtain data relating to maternal factors, diabetes history, glycaemic control and cause of death.

RESULTS

There were 37 women (seven with type 1 diabetes [T1DM], 11 with type 2 diabetes [T2DM] and 19 with GDM) who had 38 stillbirths. The leading cause of stillbirth was lethal congenital malformations in nine cases, followed by placental and umbilical abnormalities in six, intra-uterine growth restriction (IUGR) in six, and obstetric factors in four cases. Malformations were predominantly cardiovascular (n = 7), musculoskeletal (n = 5) and gastrointestinal (n = 4). There was no difference in the proportion of stillbirths related to malformations between the DIP and GDM groups (P = 0.22). In the pre-conception period or first trimester, all T1DM subjects and all but two T2DM subjects had HbA1c >7% or there was no measurement. HbA1c was >7% in 6/7 T1DM subjects and 7/11 T2DM subjects at some stage during the pregnancy.

CONCLUSION

Stillbirth remains a problem in diabetic pregnancy in the 21st century. Lethal malformations, placental abnormalities and IUGR were the leading causes of stillbirth related to diabetes. Pre-conception counselling and planning to achieve better glycaemic control in pregnancy needs to be improved.

Two denominators for one numerator: the example of neonatal mortality

Preterm delivery is one of the strongest predictors of neonatal mortality. A given exposure may increase neonatal mortality directly, or indirectly by increasing the risk of preterm birth. Efforts to assess these direct and indirect effects are complicated by the fact that neonatal mortality arises from two distinct denominators (i.e. two risk sets). One risk set comprises fetuses, susceptible to intrauterine pathologies (such as malformations or infection), which can result in neonatal death. The other risk set comprises live births, who (unlike fetuses) are susceptible to problems of immaturity and complications of delivery. In practice, fetal and neonatal sources of neonatal mortality cannot be separated-not only because of incomplete information, but because risks from both sources can act on the same newborn. We use simulations to assess the repercussions of this structural problem. We first construct a scenario in which fetal and neonatal factors contribute separately to neonatal mortality. We introduce an exposure that increases risk of preterm birth (and thus neonatal mortality) without affecting the two baseline sets of neonatal mortality risk. We then calculate the apparent gestational-age-specific mortality for exposed and unexposed newborns, using as the denominator either fetuses or live births at a given gestational age. If conditioning on gestational age successfully blocked the mediating effect of preterm delivery, then exposure would have no effect on gestational-age-specific risk. Instead, we find apparent exposure effects with either denominator. Except for prediction, neither denominator provides a meaningful way to define gestational-age-specific neonatal mortality.

Making stillbirths visible: a systematic review of globally reported causes of stillbirth

BACKGROUND

Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention.

OBJECTIVES

To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM.

SEARCH STRATEGY

We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016.

SELECTION CRITERIA

Reports of stillbirth causes in unselective cohorts.

DATA COLLECTION AND ANALYSIS

Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC).

MAIN RESULTS

Eighty-five reports from 50 countries (489 089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes.

CONCLUSIONS

There is a paucity of quality information on causes of stillbirth globally. Improving investigation of stillbirths and standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings.

FUNDING

HR, SH, SHL, and AW were supported by an NHMRC-CRE grant (APP1116640). VF was funded by an NHMRC-CDF (APP1123611).

TWEETABLE ABSTRACT

Urgent need to improve data on causes of stillbirths across all settings to meet global targets.

PLAIN LANGUAGE SUMMARY

Background and methods Nearly three million babies are stillborn every year. These deaths have deep and long-lasting effects on parents, healthcare providers, and the society. One of the major challenges to preventing stillbirths is the lack of information about why they happen. In this study, we collected reports on the causes of stillbirth from high-, middle-, and low-income countries to: (1) Understand the causes of stillbirth, and (2) Understand how to improve reporting of stillbirths. Findings We found 85 reports from 50 different countries. The information available from the reports was inconsistent and often of poor quality, so it was hard to get a clear picture about what are the causes of stillbirth across the world. Many different definitions of stillbirth were used. There was also wide variation in what investigations of the mother and baby were undertaken to identify the cause of stillbirth. Stillbirths in all income settings (low-, middle-, and high-income countries) were most frequently reported as Unexplained, Other, and Haemorrhage (bleeding). Unexplained and Other are not helpful in understanding why a baby was stillborn. In low-income countries, stillbirths were often attributed to Infection and Complications during labour and birth. In middle- and high-income countries, stillbirths were often reported as Placental complications. Limitations We may have missed some reports as searches were carried out in English only. The available reports were of poor quality. Implications Many countries, particularly those where the majority of stillbirths occur, do not report any information about these deaths. Where there are reports, the quality is often poor. It is important to improve the investigation and reporting of stillbirth using a standardised system so that policy makers and healthcare workers can develop effective stillbirth prevention programs. All stillbirths should be investigated and reported in line with the World Health Organization standards.

[Fetal autopsies : Relic or still a gold standard?]

BACKGROUND

Fetal autopsy rates are decreasing in Western countries although post-mortem examinations render important information for the parents concerning the cause of abortion and risk of recurrence in future pregnancies.

OBJECTIVE

The intention of the presented study was to analyze the development of fetal autopsies in Germany during the last decade and to review accessible information obtained by fetal autopsy.

MATERIAL AND METHODS

Reports of fetal autopsies conducted in two German university Institutes of pathology between 2005 and 2014 were evaluated retrospectively. Demographic data and the correlation between clinical diagnoses and autopsy findings were assessed. In addition, differences between spontaneous and induced cases of abortion and differences between the institutes were also documented.

RESULTS

Overall, 428 fetal autopsies were performed, whereby the number of autopsies decreased by 24.2% during the study period. Of the examined fetuses 29.7% were induced abortions which as expected exhibited different malformations compared to cases of spontaneous abortion (p < 0.001). There was no evidence of a malformation or other cause of death in 27.1% of the cases and 95.7% of these abortions occurred spontaneously. A discrepancy between clinical and autopsy findings was evident in 6.8% of cases and 3.5% of the autopsy examinations revealed at least one additional malformation compared to the prenatal clinical data.

CONCLUSION

Despite improvements in prenatal diagnostics, fetal autopsies remain an important diagnostic tool even today contributing additional information in a considerable number of cases potentially revising clinical diagnoses.

Fetomaternal hemorrhage complicated pregnancy: risks, identification, and management

PURPOSE OF REVIEW

This article aims not only to review recent literature about the clinical features of massive fetomaternal hemorrhage (FMH) and identification of risk factors, but also to alert obstetricians and pediatricians to this underdiagnosed and underestimated severe obstetrical issue. In addition, a simplified flow chart for the antenatal management of suspected FMH is proposed.

RECENT FINDINGS

Improvements in obstetrical and neonatal care have decreased perinatal morbidity and mortality and the rate of stillbirth. Unfortunately, because of the nonspecific signs on presentation, adverse outcome associated with massive FMH has not followed this trend and still has devastating consequences. As even the definition varies among publications and there is lack of universal screening, the real nature still remains obscure. Improvements in the diagnosis of fetal anemia, laboratory and intrauterine transfusion techniques, and the implementation of prenatal and postnatal neuroprotection give some hope for the better outcome in the most severe cases. Unfortunately, obstetricians' awareness of the massive FMH remains still at an unacceptably low level.

SUMMARY

There is an urgent need for the internationally accepted definition, standardized pregnancy management protocol, and structured follow-up of neonates from such pregnancies. We suggest the international registry of massive FMH cases.

Classification systems for causes of stillbirth and neonatal death, 2009-2014: an assessment of alignment with characteristics for an effective global system

Background

To reduce the burden of 5.3 million stillbirths and neonatal deaths annually, an understanding of causes of deaths is critical. A systematic review identified 81 systems for classification of causes of stillbirth (SB) and neonatal death (NND) between 2009 and 2014. The large number of systems hampers efforts to understand and prevent these deaths. This study aimed to assess the alignment of current classification systems with expert-identified characteristics for a globally effective classification system.

Methods

Eighty-one classification systems were assessed for alignment with 17 characteristics previously identified through expert consensus as necessary for an effective global system. Data were extracted independently by two authors. Systems were assessed against each characteristic and weighted and unweighted scores assigned to each. Subgroup analyses were undertaken by system use, setting, type of death included and type of characteristic.

Results

None of the 81 systems were aligned with more than 9 of the 17 characteristics; most (82 %) were aligned with four or fewer. On average, systems were aligned with 19 % of characteristics. The most aligned system (Frøen 2009-Codac) still had an unweighted score of only 9/17. Alignment with individual characteristics ranged from 0 to 49 %. Alignment was somewhat higher for widely used as compared to less used systems (22 % v 17 %), systems used only in high income countries as compared to only in low and middle income countries (20 % vs 16 %), and systems including both SB and NND (23 %) as compared to NND-only (15 %) and SB-only systems (13 %). Alignment was higher with characteristics assessing structure (23 %) than function (15 %).

Conclusions

There is an unmet need for a system exhibiting all the characteristics of a globally effective system as defined by experts in the use of systems, as none of the 81 contemporary classification systems assessed was highly aligned with these characteristics. A particular concern in terms of global effectiveness is the lack of alignment with “ease of use” among all systems, including even the most-aligned. A system which meets the needs of users would have the potential to become the first truly globally effective classification system.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1040-7) contains supplementary material, which is available to authorized users.

Human Placental Histopathology in Preterm Stillbirth: One Center's Experience

Our aim is to identify maternal risk factors and to determine placental histopathologies in preterm stillbirths. We designed a prospective study involving a patient population (n = 136) composed of singleton stillbirth (n = 40) and singleton live-born neonates (n = 96) between 23 0/7 and 36 6/7 weeks of gestation. We divided the stillbirths into groups of early (n = 21) and late (n = 19) stillbirths. Statistical analyses were performed using SPSS version 15 software. Small birth weight for gestational age and oligo-anhydramnios were significantly higher in the early stillbirth group (p = 0.001, p = 0.002 respectively). Antenatal follow up was significantly lower in the late stillbirth group (p = 0.001). Placental weight was statistically lower in the early stillbirth group (p = 0.001). We found no significant differences in maternal vascular underperfusion, fetal vascular obstruction, inflammation and villitis of unknown etiology. Placental pathologies causing preterm labor may play an important role in the etiology of stillbirths and antenatal follow up is essential for each pregnancy.

Reproductive Health Issues for Adults with a Common Genomic Disorder: 22q11.2 Deletion Syndrome

22q11.2 deletion syndrome (22q11.2DS) is the most common microdeletion syndrome in humans. Survival to reproductive age and beyond is now the norm. Several manifestations of this syndrome, such as congenital cardiac disease and neuropsychiatric disorders, may increase risk for adverse pregnancy outcomes in the general population. However, there are limited data on reproductive health in 22q11.2DS. We performed a retrospective chart review for 158 adults with 22q11.2DS (75 male, 83 female; mean age 34.3 years) and extracted key variables relevant to pregnancy and reproductive health. We present four illustrative cases as brief vignettes. There were 25 adults (21 > age 35 years; 21 female) with a history of one or more pregnancies. Outcomes for women with 22q11.2DS, compared with expectations for the general population, showed a significantly elevated prevalence of small for gestational age liveborn offspring (p < 0.001), associated mainly with infants with 22q11.2DS. Stillbirths also showed elevated prevalence (p < 0.05). Not all observed adverse events appeared to be attributable to transmission of the 22q11.2 deletion. Recurring issues relevant to reproductive health in 22q11.2DS included the potential impact of maternal morbidities, inadequate social support, unsafe sexual practices, and delayed diagnosis of 22q11.2DS and/or lack of genetic counseling. These preliminary results emphasize the importance of early diagnosis and long term follow-up that could help facilitate genetic counseling for men and women with 22q11.2DS. We propose initial recommendations for pre-conception management, educational strategies, prenatal planning, and preparation for possible high-risk pregnancy and/or delivery.