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Underwood K, Reddy UM, Hosier H, Sweeney L, Campbell KH, Xu X. Mode of Delivery in Antepartum Singleton Stillbirths and Associated Risk Factors. Am J Perinatol 2024; 41:e193-e203. [PMID: 35850142 DOI: 10.1055/s-0042-1750795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study was aimed to investigate delivery management of patients with antepartum stillbirth. STUDY DESIGN Using data from fetal death certificates and linked maternal hospital discharge records, we identified a population-based sample of patients with singleton antepartum stillbirth at 20 to 42 weeks of gestation in California in 2007 to 2011. Primary outcomes were intended mode of delivery and actual mode of delivery. We used multivariable regressions to examine the association between patient demographic, clinical, and hospital characteristics and their mode of delivery. Separate analysis was performed for patients who had prior cesarean delivery versus those who did not. RESULTS Of 7,813 patients with singleton antepartum stillbirth, 1,356 had prior cesarean, while 6,457 had no prior cesarean. Labor was attempted in 51.8% of patients with prior cesarean and 93.7% of patients without prior cesarean, with 76.2 and 95.8% of these patients, respectively, delivered vaginally. Overall, 18.9% of patients underwent a cesarean delivery (60.5% among those with prior cesarean and 10.2% among those without prior cesarean). Multivariable regression analysis identified several factors associated with the risk of cesarean delivery that were not medically indicated. For instance, among patients without prior cesarean, malpresentation (of which the vast majority was breech presentation) was associated with an increased likelihood of planned cesarean (adjusted odds ratio [OR] = 3.26, 95% confidence interval [CI]: 2.53-4.22) and cesarean delivery after attempting labor (adjusted OR = 3.09, 95% CI: 2.25-4.25). For both patients with and without prior cesarean, delivery at an urban teaching hospital was associated with a lower likelihood of planned cesarean and a lower likelihood of cesarean delivery after attempting labor (adjusted ORs ranged from 0.28 to 0.56, p < 0.001 for all). CONCLUSION Over one in six patients with antepartum stillbirth underwent cesarean delivery. Among patients who attempted labor, rate of vaginal delivery was generally high, suggesting a potential opportunity to increase vaginal delivery in this population. KEY POINTS · In singleton antepartum stillbirths, 18.9% underwent cesarean delivery.. · Rate of vaginal delivery was high when labor was attempted.. · Both clinical and non-clinical factors were associated with risk of cesarean delivery..
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Affiliation(s)
- Katherine Underwood
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Uma M Reddy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Hillary Hosier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Lena Sweeney
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Katherine H Campbell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Xu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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Sweeney LC, Reddy UM, Campbell K, Xu X. Postpartum readmission risk: a comparison between stillbirths and live births. Am J Obstet Gynecol 2024:S0002-9378(24)00089-9. [PMID: 38367754 DOI: 10.1016/j.ajog.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/29/2024] [Accepted: 02/09/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Stillbirth occurs more commonly among pregnant people with comorbid conditions and obstetrical complications. Stillbirth also independently increases maternal morbidity and imparts a psychosocial hazard when compared with live birth. These distinct needs and burden may increase the risk for postpartum readmission after stillbirth. OBJECTIVE This study aimed to examine the risk for maternal postpartum readmission after stillbirth in comparison with live birth and to identify indications for readmission and the associated risk factors. STUDY DESIGN This was a retrospective cohort of patients with singleton stillbirths or live births, delivered at ≥20 weeks' gestation, who were identified from the 2019 Nationwide Readmissions Database. The primary outcome was all-cause readmission within 6 weeks of discharge from the childbirth hospitalization. The association between stillbirth (vs live birth) and risk for readmission was assessed using multivariable regression models with adjustment for maternal age, sociodemographic characteristics, maternal and obstetrical conditions, and delivery characteristics. Within the stillbirth group, risk factors for readmission were further examined using multivariable regression. The secondary outcomes included principal indication for readmission (categorized based on principal diagnosis code of the readmission hospitalization) and timing of readmission (number of weeks after childbirth hospitalization). Differences in these secondary outcomes were compared between the stillbirth and live birth groups using chi-square tests. All analyses accounted for the complex sample design to generate nationally representative estimates. RESULTS Postpartum readmission occurred in 2.7% of 16,636 patients with stillbirths, whereas it occurred in 1.6% of 2,870,677 patients with live births (unadjusted risk ratio, 1.65; 95% confidence interval, 1.47-1.86). The higher risk for readmission after stillbirth (vs live birth) persisted after adjusting for maternal, obstetrical, and delivery characteristics (adjusted risk ratio, 1.27; 95% confidence interval, 1.11-1.46). The distribution of principal indication for readmission differed after stillbirth and after live birth and included hypertension (30.2% vs 39.5%; unadjusted risk ratio, 0.76; 95% confidence interval, 0.63-0.93), mental health or substance use disorders (6.8% vs 3.6%; unadjusted risk ratio, 1.90; 95% confidence interval, 1.15-3.16), and venous thromboembolism (5.8% vs 2.0%; unadjusted risk ratio, 2.87; 95% confidence interval, 1.60-5.17). Among patients with stillbirths, 56.0% of readmissions occurred within 1 week, 71.8% within 2 weeks, and 88.1% within 4 weeks; the timing of readmission did not differ significantly between the stillbirth and live birth cohorts. Pregestational diabetes (adjusted risk ratio, 1.87; 95% confidence interval, 1.20-2.93), gestational diabetes (adjusted risk ratio, 1.67; 95% confidence interval, 1.03-2.71), hypertensive disorders of pregnancy (adjusted risk ratio, 1.80; 95% confidence interval, 1.31-2.47), obesity (adjusted risk ratio, 1.46; 95% confidence interval, 1.01-2.12), and primary cesarean delivery (adjusted risk ratio, 1.74; 95% confidence interval, 1.17-2.58) were associated with a higher risk for readmission after stillbirth, whereas higher household income was associated with a lower risk for readmission (eg, adjusted risk ratio for income ≥$82,000 vs $1-$47,999, 0.48; 95% confidence interval, 0.30-0.77). CONCLUSION When compared with live births, the risk for postpartum readmission was higher after stillbirths, even after adjustment for differences in the patient demographic and clinical characteristics. Readmission for mental health or substance use disorders and venous thromboembolism is more common after stillbirths than after live births.
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Affiliation(s)
- Lena C Sweeney
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT.
| | - Uma M Reddy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT; Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Katherine Campbell
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| | - Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT; Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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Atkins B, Kindinger L, Mahindra MP, Moatti Z, Siassakos D. Stillbirth: prevention and supportive bereavement care. BMJ MEDICINE 2023; 2:e000262. [PMID: 37564829 PMCID: PMC10410959 DOI: 10.1136/bmjmed-2022-000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/26/2023] [Indexed: 08/12/2023]
Abstract
Around half of the two million stillbirths occurring worldwide each year are preventable. This review compiles the most up-to-date evidence to inform stillbirth prevention. Many general maternal health interventions also reduce the risk of stillbirth, for example, antenatal care attendance. This review focuses on specific aspects of care: glucose metabolism, targeted aspirin prophylaxis, clotting and immune disorders, sleep positions, fetal movement monitoring, and preconception and interconception health. In the past few years, covid-19 infection during pregnancy has emerged as a risk factor for stillbirth, particularly among women who were not vaccinated. Alongside prevention, efforts to address stillbirth must include provision of high quality, supportive, and compassionate bereavement care to improve parents' wellbeing. A growing body of evidence suggests beneficial effects for parents who received supportive care and were offered choices such as mode of birth and the option to see and hold their baby. Staff need support to be able to care for parents effectively, yet, studies consistently highlight the scarcity of specific bereavement care training for healthcare providers. Action is urgently needed and is possible. Action must be taken with the evidence available now, in healthcare settings with high or low resources, to reduce stillbirths and improve training and care.
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Affiliation(s)
- Bethany Atkins
- Institute for Women's Health, University College London, London, UK
- National Institute for Health and Care Research, London, UK
| | - Lindsay Kindinger
- King Edward Memorial Hospital for Women Perth, Perth, WA, Australia
- Fiona Stanley Hospital, Perth, WA, Australia
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Pekkola M, Tikkanen M, Gissler M, Loukovaara M, Paavonen J, Stefanovic V. Delivery characteristics in pregnancies with stillbirth: a retrospective case-control study from a tertiary teaching hospital. J Perinat Med 2022; 50:814-821. [PMID: 33629576 DOI: 10.1515/jpm-2020-0573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/08/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVES We compared delivery characteristics and outcome of women with stillbirth to those with live birth. METHODS This was a retrospective case-control study from Helsinki University Hospital, Finland. The study population comprised 214 antepartum singleton stillbirths during 2003-2015. Two age-adjusted controls giving live birth in the same year at the same institution were chosen for each case from the Finnish Medical Birth Register. Delivery characteristics and adverse pregnancy outcomes were compared between the cases and controls, adjusted for gestational age. RESULTS Labor induction was more common (86.0 vs. 22.0%, p<0.001, gestational age adjusted odds ratio [aOR] 35.25, 95% confidence interval [CI] 12.37-100.45) and cesarean sections less frequent (9.3 vs. 28.7%, p<0.001, aOR 0.21, 95% CI 0.10-0.47) among women with stillbirth. Duration of labor was significantly shorter among the cases (first stage 240.0 min [115.0-365.0 min] vs. 412.5 min [251.0-574.0 min], p<0.001; second stage 8.0 min [0.0-16.0 min] vs. 15.0 min [4.0-26.0 min], p<0.001). Placental abruption was more common in pregnancies with stillbirth (15.0 vs. 0.9%, p<0.001, aOR 8.52, 95% CI 2.51-28.94) and blood transfusion was needed more often (10.7 vs. 4.4%, p=0.002, aOR 6.5, 95% CI 2.10-20.13). The rates of serious maternal complications were low. CONCLUSIONS Most women with stillbirth delivered vaginally without obstetric complications. The duration of labor was shorter in pregnancies with stillbirth but the risk for postpartum interventions and bleeding complications was higher compared to those with live birth.
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Affiliation(s)
- Maria Pekkola
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Minna Tikkanen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Gissler
- THL, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Neurobiology, Care Sciences, and Society, Karolinska Institute, Stockholm, Sweden
| | - Mikko Loukovaara
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jorma Paavonen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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5
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Bailey HD, Adane AA, White SW, Farrant BM, Shepherd CCJ. Caesarean section following antepartum stillbirth in Western Australia 2010-2015: A population-based study. Aust N Z J Obstet Gynaecol 2022; 62:518-524. [PMID: 35170023 DOI: 10.1111/ajo.13494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is scant literature about antepartum stillbirth management but guidelines usually recommend reserving caesarean sections for exceptional circumstances. However, little is known about caesarean section rates following antepartum stillbirth in Australia. AIMS We aimed to describe the onset of labour, mode of birth, and use of analgesia and anaesthesia following antepartum stillbirth and to identify factors associated with caesarean section. MATERIAL AND METHODS In this retrospective cohort study, we used a population-based dataset of all singleton antepartum stillbirths ≥20 weeks gestation in Western Australia between 2010-2015. The overall, primary and repeat caesarean section rates for antepartum stillbirths were calculated and multivariable Poisson regression analyses were performed to identify associated factors, and to calculate relative risks (RRs) and 95% confidence intervals (CIs). RESULTS This study included 634 antepartum stillbirths. Labour was spontaneous for 134 (21.1%), induced for 457 (72.1%), and 43 (6.8%) had a prelabour caesarean section. The overall, primary and repeat caesarean section rates were 8.5%, 4.6% and 23.0% respectively and increased with gestation (P trends all <0.01). Other factors associated with an increased caesarean section risk included: any placenta praevia or placental abruption, birth at a metropolitan private hospital, large-for-gestational-age birthweight, and any maternal chronic condition. During labour, the most frequently used types of analgesia were systemic narcotics (46.0%) and regional blocks (34.7%) while among those who had a caesarean section, 40.7% had a general anaesthetic. CONCLUSIONS In Western Australia between 2010-2015, the caesarean section rates among women with antepartum stillbirths were low, in line with current guidelines.
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Affiliation(s)
- Helen D Bailey
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Akilew A Adane
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,Ngangk Yira Research Centre for Aboriginal Health & Social Equity, Murdoch University, Perth, Western Australia, Australia
| | - Scott W White
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia.,King Edward Memorial Hospital, Maternal Fetal Medicine Service, Perth, Western Australia, Australia
| | - Brad M Farrant
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Carrington C J Shepherd
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,Ngangk Yira Research Centre for Aboriginal Health & Social Equity, Murdoch University, Perth, Western Australia, Australia.,Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
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Ramseyer AM, Whittington JR, Magann EF, Ounpraseuth S, Nembhard WN. Cesarean Delivery Management of Stillbirth: In-Depth Analysis of 75 Cases in a Rural State. South Med J 2021; 114:384-387. [PMID: 34215888 DOI: 10.14423/smj.0000000000001267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To analyze the characteristics surrounding women who underwent cesarean delivery for stillbirth management in the rural, southern US state of Arkansas. METHODS This was a planned secondary analysis of a retrospective descriptive study evaluating mode of delivery following the stillbirth of singleton pregnancies without anomalies or aneuploidy delivered in our state between July 2015 and June 2019. Data were extracted from a statewide reproductive health monitoring system and reviewed by the first three authors. Summary statistics were presented as means and standard deviations for continuous measures and frequencies and percentages for categorical variables. RESULTS There were 861 patients diagnosed as having stillbirth between July 2015 and June 2019 in 44 hospitals in Arkansas. Seventy-five of those patients (8.7%) underwent cesarean delivery and are the basis for this analysis. Common indications for cesarean delivery were prior cesarean delivery (41%), malpresentation (18.7%), and abruption or hemorrhage (13.1%). Sixty-five percent of patients had a prior cesarean delivery. The most common complications were infection and hemorrhage, which accounted for 64.3% of known complications. The overall complication rate was 18.7% among stillbirths delivered via cesarean. CONCLUSIONS This study demonstrates that cesarean delivery remains a common mode of delivery for management of stillbirth and that there is maternal morbidity associated with an abdominal delivery because 22.7% of the women undergoing a cesarean had an operative complication. It also highlights that prior cesarean delivery remains a common indication for a repeat abdominal delivery following a stillbirth despite the lack of fetal benefit.
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Affiliation(s)
- Abigail M Ramseyer
- From the Departments of Obstetrics and Gynecology and Biostatistics, and the Department of Epidemiology in the Fay W. Boozman College of Public Health, University of Arkansas for the Medical Sciences, Little Rock
| | - Julie R Whittington
- From the Departments of Obstetrics and Gynecology and Biostatistics, and the Department of Epidemiology in the Fay W. Boozman College of Public Health, University of Arkansas for the Medical Sciences, Little Rock
| | - Everett F Magann
- From the Departments of Obstetrics and Gynecology and Biostatistics, and the Department of Epidemiology in the Fay W. Boozman College of Public Health, University of Arkansas for the Medical Sciences, Little Rock
| | - Songthip Ounpraseuth
- From the Departments of Obstetrics and Gynecology and Biostatistics, and the Department of Epidemiology in the Fay W. Boozman College of Public Health, University of Arkansas for the Medical Sciences, Little Rock
| | - Wendy N Nembhard
- From the Departments of Obstetrics and Gynecology and Biostatistics, and the Department of Epidemiology in the Fay W. Boozman College of Public Health, University of Arkansas for the Medical Sciences, Little Rock
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Tesema GA, Tessema ZT, Tamirat KS, Teshale AB. Prevalence of stillbirth and its associated factors in East Africa: generalized linear mixed modeling. BMC Pregnancy Childbirth 2021; 21:414. [PMID: 34078299 PMCID: PMC8173886 DOI: 10.1186/s12884-021-03883-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 05/19/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Stillbirth is the most frequently reported adverse pregnancy outcome worldwide, which imposes significant psychological and economic consequences to mothers and affected families. East African countries account for one-third of the 2.6 million stillbirths globally. Though stillbirth is a common public health problem in East African countries, there is limited evidence on the pooled prevalence and associated factors of stillbirth in East Africa. Therefore, this study aimed to investigate the prevalence of stillbirth and its associated factors in East Africa. METHODS This study was based on the most recent Demographic and Health Surveys (DHSs) of 12 East African countries. A total weighted sample of 138,800 reproductive-age women who gave birth during the study period were included in this study. The prevalence of stillbirth with the 95% Confidence Interval (CI) was reported using a forest plot. A mixed-effect binary logistic regression analysis was done to identify significantly associated factors of stillbirth. Since the DHS data has hierarchical nature, the presence of clustering effect was assessed using the Likelihood Ratio (LR) test, and Intra-cluster Correlation Coefficient (ICC), and deviance were used for model comparison. Variables with a p-value of less than 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable mixed-effect binary logistic regression analysis, the Adjusted Odds Ratio (AOR) with 95% CI were reported to declare the strength and significance of the association. RESULTS The prevalence of stillbirth in East Africa was 0.86% (95% CI: 0.82, 0.91) ranged from 0.39% in Kenya to 2.28% in Burundi. In the mixed-effect analysis; country, women aged 25-34 years (AOR = 1.27, 95% CI: 1.11, 1.45), women aged ≥ 35 years (AOR = 1.19, 95% CI: 1.01, 1.44), poor household wealth (AOR = 1.07, 95% CI: 1.02, 1.23), women who didn't have media exposure (AOR = 1.11, 95% CI: 1.01, 1.25), divorced/widowed/separated marital status (AOR = 2.99, 95% CI: 2.04, 4.39), caesarean delivery (AOR = 1.81, 95% CI: 1.52, 2.15), preceding birth interval < 24 months (AOR = 1.15, 95% CI: 1.06, 1.24), women attained secondary education or above (AOR = 0.68, 95% CI: 0.56, 0.81) and preceding birth interval ≥ 49 months (AOR = 1.45, 95% CI: 1.28, 1.65) were significantly associated with stillbirth. CONCLUSIONS Stillbirth remains a major public health problem in East Africa, which varied significantly across countries. These findings highlight the weak health care system of East African countries. Preceding birth interval, county, maternal education media exposure, household wealth status, marital status, and mode of delivery were significantly associated with stillbirth. Therefore, public health programs enhancing maternal education, media access, and optimizing birth spacing should be designed to reduce the incidence of stillbirth.
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Affiliation(s)
- Getayeneh Antehunegn Tesema
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Zemenu Tadesse Tessema
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Koku Sisay Tamirat
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Achamyeleh Birhanu Teshale
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Ramseyer AM, Whittington JR, Magann EF, Warford B, Ounpraseuth S, Nembhard WN. Hospital Annual Delivery Volume and Presence of Graduate Medical Education Influence Mode of Delivery after Stillbirth. South Med J 2020; 113:623-628. [PMID: 33263130 PMCID: PMC8634934 DOI: 10.14423/smj.0000000000001180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To evaluate the statewide experience in mode of delivery for pregnancies complicated by stillbirth by annual delivery volume and presence of graduate medical education programs. METHODS This is a descriptive study of all stillbirths without known congenital anomalies or aneuploidy born in our state from July 1, 2015 to June 30, 2019. Stillbirths were ascertained by the State Reproductive Health Monitoring System, a population-based surveillance system. Stillbirths were identified by the State Reproductive Health Monitoring System from medical facilities and fetal death certificates; trained staff abstracted records. All of the stillbirths with a gestational age of >20 weeks or a birth weight of >500 g if birth weight was unknown and without congenital anomalies or aneuploidy were eligible for this study. RESULTS There were 861 stillbirths from July 2015 through June 2019, 75 (8.7%) of which were delivered by cesarean section. Low-volume hospitals (<1000 deliveries) experienced a higher proportion of their stillbirths delivered by cesarean compared with high-volume hospitals (>1000 deliveries; 13.4% vs 5.5%; P < 0.0001). Before adjusting for maternal characteristics, stillbirths delivered at high-volume hospitals had a 59% lower risk of delivery by cesarean section compared with those delivered at low-volume hospitals (relative risk [RR] 0.41, 95% confidence interval 0.20-0.86, P = 0.02). The cesarean cohort had a higher proportion of Black mothers (44% vs 31.3%, P = 0.025), greater parity (P < 0.0001), and greater gravidity (P < 0.0001) compared with the vaginal group. The gestational age at delivery for stillbirths delivered by cesarean was much higher compared with those who were delivered vaginally (34.8 weeks vs 28.6 weeks; P < 0.0001). The RR of the cesarean delivery of a stillbirth at teaching institutions compared with nonteaching institutions was significantly reduced (RR 0.45, 95% confidence interval 0.28-0.73, P = 0.0011). CONCLUSIONS Annual hospital delivery volumes and residency teaching programs in obstetrics influence the mode of delivery in the management of stillbirth. Advancing gestational age, Black race, and parity are associated with an increased risk of cesarean delivery after stillbirth.
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Affiliation(s)
- Abigail M Ramseyer
- From the Departments of Obstetrics and Gynecology, Biostatistics, and Epidemiology, University of Arkansas for Medical Sciences, Little Rock
| | - Julie R Whittington
- From the Departments of Obstetrics and Gynecology, Biostatistics, and Epidemiology, University of Arkansas for Medical Sciences, Little Rock
| | - Everett F Magann
- From the Departments of Obstetrics and Gynecology, Biostatistics, and Epidemiology, University of Arkansas for Medical Sciences, Little Rock
| | - Brock Warford
- From the Departments of Obstetrics and Gynecology, Biostatistics, and Epidemiology, University of Arkansas for Medical Sciences, Little Rock
| | - Songthip Ounpraseuth
- From the Departments of Obstetrics and Gynecology, Biostatistics, and Epidemiology, University of Arkansas for Medical Sciences, Little Rock
| | - Wendy N Nembhard
- From the Departments of Obstetrics and Gynecology, Biostatistics, and Epidemiology, University of Arkansas for Medical Sciences, Little Rock
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9
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Pekkola M, Tikkanen M, Gissler M, Paavonen J, Stefanovic V. Stillbirth and subsequent pregnancy outcome - a cohort from a large tertiary referral hospital. J Perinat Med 2020; 48:765-770. [PMID: 31926100 DOI: 10.1515/jpm-2019-0425] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/10/2019] [Indexed: 01/15/2023]
Abstract
Objectives This study aimed to assess pregnancy and delivery outcomes in women with a history of stillbirth in a large tertiary referral hospital. Methods This was a retrospective study from Helsinki University Hospital, Finland. The cohort comprised 214 antepartum singleton stillbirths in the period 2003-2015 (case group). Of these, 154 delivered by the end of 2017. Adverse pregnancy outcomes were compared to those in singleton pregnancies of parous women in Finland from the Finnish Medical Birth Register (reference group). Results The rates of adverse pregnancy outcomes were higher among case women for preeclampsia (3.3 vs. 0.9%, P = 0.002), preterm birth (8.5 vs. 3.9%, P = 0.004), small-for-gestational-age (SGA) children (7.8 vs. 2.2%, P < 0.001) and stillbirth (2.7 vs. 0.3%, P < 0.001). There were four preterm recurrent stillbirths. Induction of labor was more common among case women than parous women in the reference group (49.4 vs. 18.3%, P < 0.001). Duration of pregnancy was shorter among case women (38.29 ± 3.20 vs. 39.27 ± 2.52, P < 0.001), and mean birth weight was lower among newborns of the case women (3274 ± 770 vs. 3491 ± 674 g, P < 0.001). Conclusion Although the rates for adverse pregnancy outcomes were higher compared to the parous background population, the overall probability of a favorable outcome was high. The risk of recurrent premature stillbirth in our cohort was higher than that for parous women in general during the study period. No recurrent term stillbirths occurred, however.
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Affiliation(s)
- Maria Pekkola
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Minna Tikkanen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Gissler
- THL, National Institute for Health and Welfare, Information Services Department, Helsinki, Finland.,Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Stockholm, Sweden
| | - Jorma Paavonen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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10
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Rossi RM, Hall ES, DeFranco EA. Mode of delivery in antepartum stillbirths. Am J Obstet Gynecol MFM 2019; 1:156-164.e2. [PMID: 33345821 DOI: 10.1016/j.ajogmf.2019.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/16/2019] [Accepted: 03/20/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Stillbirth complicates 1 in 160 pregnancies in the United States. We sought to determine the rate of cesarean delivery in pregnancies complicated by antepartum stillbirth and to identify characteristics associated with cesarean delivery. STUDY DESIGN This was a population-based retrospective cohort study of all stillbirths in the United States during the year of 2014. Frequency of cesarean delivery was stratified by week of gestation. Maternal, obstetric, and fetal characteristics were compared between women with antepartum stillbirth who underwent cesarean delivery compared with vaginal delivery. Multivariate logistic regression estimated the relative influence of maternal, obstetric, and fetal factors on the outcome of cesarean delivery. RESULTS There were 16,160 nonlaboring women diagnosed with stillbirth during 2014 in the United States. Of the 16,160 stillbirths, 2449 (15.2%) underwent cesarean delivery. At 20-23, 24-27, 28-31, 32-36, and >36 weeks of gestation, the cesarean delivery rate was 4.0%, 16.2%, 23.7%, 30.8%, and 28.8%, respectively. Factors associated with cesarean delivery included gestational diabetes, preeclampsia, use of assisted reproductive technology, history of prior cesarean delivery, and increasing gestational age at delivery. CONCLUSION Approximately 15% of women diagnosed with a stillbirth after 16 weeks of gestation underwent a cesarean delivery in 2014. The stillbirth cesarean delivery rate peaked during the third trimester, during which more than 1 in 4 women underwent a cesarean birth.
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Affiliation(s)
- Robert M Rossi
- Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Eric S Hall
- Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Emily A DeFranco
- Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH
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Route of Delivery in Women With Stillbirth: Results From the Stillbirth Collaborative Research Network. Obstet Gynecol 2017; 129:693-698. [PMID: 28333794 DOI: 10.1097/aog.0000000000001935] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe delivery management of singleton stillbirths in a population-based, multicenter case series. METHODS We conducted a retrospective chart review of 611 women with singleton stillbirths at 20 weeks of gestation or greater from March 2006 to September 2008. Medical and delivery information was abstracted from medical records. Both antepartum and intrapartum stillbirths were included; these were analyzed both together and separately. The primary outcome was mode of delivery. Secondary outcomes included induction of labor and indications for cesarean delivery. Indications for cesarean delivery were classified as obstetric (abnormal fetal heart tracing before intrapartum demise, abruption, coagulopathy, uterine rupture, placenta previa, or labor dystocia) or nonobstetric (patient request, repeat cesarean delivery, or not documented). RESULTS Of the 611 total cases of stillbirth, 93 (15.2%) underwent cesarean delivery, including 43.0% (46/107) of women with prior cesarean delivery and 9.3% (47/504) of women without prior cesarean delivery. No documented obstetric indication was evident for 38.3% (18/47) of primary and 78.3% (36/46) of repeat cesarean deliveries. Labor induction resulted in vaginal delivery for 98.5% (321/326) of women without prior cesarean delivery and 91.1% (41/45) of women with a history of prior cesarean delivery, including two women who had uterine rupture. Among women with a history of prior cesarean delivery who had spontaneous labor, 74.1% (20/27) delivered vaginally, with no cases of uterine rupture. CONCLUSION Women with stillbirth usually delivered vaginally regardless of whether labor was spontaneous or induced or whether they had a prior cesarean delivery. However, 15% underwent cesarean delivery, often without a documented obstetric indication.
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