Effect of screening and management of diabetes during pregnancy on stillbirths

Stillbirth: we can do better

Stillbirth is far too common, occurring in millions of pregnancies per year globally. The rate of stillbirth (defined as death of a fetus prior to birth at 20 weeks' gestation or more) in the United States is 5.73 per 1000. This is approximately 1 in 175 pregnancies accounting for about 21,000 stillbirths per year. Although rates are much higher in low-income countries, the stillbirth rate in the United States is much higher than most high resource countries. Moreover, there are substantial disparities in stillbirth, with rates twice as high for non-Hispanic Black and Native Hawaiian or Other Pacific Islanders compared to non-Hispanic Whites. There is considerable opportunity for reduction in stillbirths, even in high resource countries such as the United States. In this article, we review the epidemiology, risk factors, causes, evaluation, medical and emotional management, and prevention of stillbirth. We focus on novel data regarding genetic etiologies, placental assessment, risk stratification, and prevention.

Anaesthetic Management of Diabetic Ketoacidosis (DKA) in a Cesarean Section: A Case Report

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus that poses unique challenges during pregnancy. We present a case of a 36-year-old pregnant woman with a history of type 1 diabetes mellitus who developed severe DKA at 33.5 weeks of gestation, necessitating an emergency cesarean section. Despite a known history of diabetes, the patient's infrequent clinic attendance and suboptimal disease management contributed to her critical condition. DKA was promptly diagnosed, and a multidisciplinary team comprising obstetricians, endocrinologists, anesthesiologists, and neonatologists collaborated to provide comprehensive care. The preoperative assessment revealed dehydration and electrolyte imbalances, necessitating meticulous planning for IV fluid administration and hemodynamic stability during the cesarean section. Regional anaesthesia was chosen as the anaesthetic approach, and close postoperative monitoring was initiated. The neonate, delivered with satisfactory Apgar scores, was transferred to the neonatal ICU for observation. The patient's gradual clinical improvement over 48 hours demonstrated the importance of ongoing care. This case highlights the significance of early recognition, multidisciplinary teamwork, and meticulous perioperative care in managing DKA during pregnancy, ensuring favourable outcomes for both the mother and the neonate.

Clinical analysis of diabetes in pregnancy with stillbirth

We analyzed the clinical characteristics of patients with diabetes in pregnancy (DIP) associated with stillbirth and explored strategies to reduce its incidence. We retrospectively analyzed 71 stillbirths associated with DIP (group A) and 150 normal pregnancies (group B) during 2009 to 2018. The incidence of the following was higher in group A (P < .05): hypertensive disorders (38.03% vs 6.00%), placenta previa (14.08% vs 2.67%), placental abruption (5.63% vs 0.67%), fetal malformation (8.45% vs 0.67%), fasting plasma glucose (FPG) ≥ 7.0 mmol/L (46.48% vs 0.67%), 2-h postprandial plasma glucose ≥ 11.1 mmol/L (57.75% vs 6.00%), HbA1c ≥ 6.5% (63.38% vs 6.00%), and polyhydramnios (11.27% vs 4.67). The incidence of oligohydramnios (4.23% vs 6.67%) was lower in group A than in group B (P < .05). According to the gestational age at the time of stillbirth, Group-A cases were subgrouped into miscarriages (20-27+6 weeks), premature deliveries (28-36+6 weeks), and full-term deliveries (≥37 weeks). Age, parity, and DIP type did not differ among the subgroups (P > .05). Among patients with DIP, antenatal FPG, 2-h postprandial plasma glucose, and HbA1c were significantly associated with stillbirth (P < .05). Stillbirth was first detected at 22 weeks and typically occurred at 28-36+6 weeks. DIP was associated with a higher incidence of stillbirth, and FPG, 2-h postprandial plasma glucose, and HbA1c were potential indicators of stillbirth in DIP. Age (odds ratio [OR]: 2.21, 95% confidence interval [CI]: 1.67-2.74), gestational hypertension (OR: 3.44, 95% CI: 2.21-4.67), body mass index (OR: 2.86, 95% CI: 1.95-3.76), preeclampsia (OR: 2.29, 95% CI: 1.45-3.12), and diabetic ketoacidosis (OR: 3.99, 95% CI: 1.22-6.76) were positively correlated with the occurrence of stillbirth in DIP. Controlling perinatal plasma glucose, accurately detecting and managing comorbidities/complications, and timely termination of pregnancy can reduce the incidence of stillbirths associated with DIP.

Diabetes and anti-diabetic interventions and the risk of gynaecological and obstetric morbidity: an umbrella review of the literature

BACKGROUND

Diabetes has reached epidemic proportions in recent years with serious health ramifications. The aim of this study was to evaluate the strength and validity of associations between diabetes and anti-diabetic interventions and the risk of any type of gynaecological or obstetric conditions.

METHODS

Design: Umbrella review of systematic reviews and meta-analyses.

DATA SOURCES

PubMed, Medline, Embase, Cochrane Database of Systematic Reviews, manual screening of references.

ELIGIBILITY CRITERIA

Systematic reviews and meta-analyses of observational and interventional studies investigating the relationship between diabetes and anti-diabetic interventions with gynaecological or obstetric outcomes. Meta-analyses that did not include complete data from individual studies, such as relative risk, 95% confidence intervals, number of cases/controls, or total population were excluded.

DATA ANALYSIS

The evidence from meta-analyses of observational studies was graded as strong, highly suggestive, suggestive or weak according to criteria comprising the random effects estimate of meta-analyses and their largest study, the number of cases, 95% prediction intervals, I² heterogeneity index between studies, excess significance bias, small study effect and sensitivity analysis using credibility ceilings. Interventional meta-analyses of randomised controlled trials were assessed separately based on the statistical significance of reported associations, the risk of bias and quality of evidence (GRADE) of included meta-analyses.

RESULTS

A total of 117 meta-analyses of observational cohort studies and 200 meta-analyses of randomised clinical trials that evaluated 317 outcomes were included. Strong or highly suggestive evidence only supported a positive association between gestational diabetes and caesarean section, large for gestational age babies, major congenital malformations and heart defects and an inverse relationship between metformin use and ovarian cancer incidence. Only a fifth of the randomised controlled trials investigating the effect of anti-diabetic interventions on women's health reached statistical significance and highlighted metformin as a more effective agent than insulin on risk reduction of adverse obstetric outcomes in both gestational and pre-gestational diabetes.

CONCLUSIONS

Gestational diabetes appears to be strongly associated with a high risk of caesarean section and large for gestational age babies. Weaker associations were demonstrated between diabetes and anti-diabetic interventions with other obstetric and gynaecological outcomes.

TRIAL REGISTRATION

Open Science Framework (OSF) (Registration https://doi.org/10.17605/OSF.IO/9G6AB ).

Maternal serum fructosamine levels and stillbirth: a case-control study of the Stillbirth Collaborative Research Network

OBJECTIVE

To evaluate the association between maternal fructosamine levels at the time of delivery and stillbirth.

DESIGN

Secondary analysis of a case-control study.

SETTING

Multicentre study of five geographic catchment areas in the USA.

POPULATION

All singleton stillbirths with known diabetes status and fructosamine measurement, and representative live birth controls.

MAIN OUTCOME MEASURES

Fructosamine levels in stillbirths and live births among groups were adjusted for potential confounding factors, including diabetes. Optimal thresholds of fructosamine to discriminate stillbirth and live birth.

RESULTS

A total of 529 women with a stillbirth and 1499 women with a live birth were included in the analysis. Mean fructosamine levels were significantly higher in women with a stillbirth than in women with a live birth after adjustment (177 ± 3.05 versus 165 ± 2.89 μmol/L, P < 0.001). The difference in fructosamine levels between stillbirths and live births was greater among women with diabetes (194 ± 8.54 versus 162 ± 3.21 μmol/L), compared with women without diabetes (171 ± 2.50 versus 162 ± 2.56 μmol/L). The area under the curve (AUC) for fructosamine level and stillbirth was 0.634 (0.605-0.663) overall, 0.713 (0.624-0.802) with diabetes and 0.625 (0.595-0.656) with no diabetes.

CONCLUSIONS

Maternal fructosamine levels at the time of delivery were higher in women with stillbirth compared with women with live birth. Differences were substantial in women with diabetes, suggesting a potential benefit of glycaemic control in women with diabetes during pregnancy. The small differences noted in women without diabetes are not likely to justify routine screening in all cases of stillbirth.

TWEETABLE ABSTRACT

Maternal serum fructosamine levels are higher in women with stillbirth than in women with live birth, especially in women with diabetes.

Clinical, metabolic and neurological disorders in full-term newborns from mothers with gestational diabetes mellitus

Objective. To determine the clinical and metabolic changes in children born from mothers with gestational diabetes mellitus and to predict perinatal injury of the central nervous system (CNS), taking into account the level of maternal hyperglycemia.Material and methods. The period of early postnatal adaptation was analyzed in 258 full-term infants, who were divided into two groups, depending on the glucose level in the mother’s venous blood during pregnancy: Group 1: 5,1–5,6 mmol/L, Group 2: 5,7–7,0 mmol/L.Results. Based on clinical, functional and laboratory markers (electrolyte balance and carbohydrate metabolism in the blood of a newborn) there was established a correlation between the severity of maternal hyperglycemia and the severity of neonatal disorders. In Group II infants born from mothers with more severe hyperglycemia are more likely to have a respiratory distress syndrome and ischemic-hypoxic injury of the central nervous system in combination with excess birth weight which significantly complicates postnatal adaptation.Conclusion. The concentration of neuron-specific enolase of 4,9 ng/ml in the fetal amniotic fluid is an antenatal marker of perinatal damage to the central nervous system in a newborn.

Diabetes during Pregnancy: A Maternal Disease Complicating the Course of Pregnancy with Long-Term Deleterious Effects on the Offspring. A Clinical Review

In spite of the huge progress in the treatment of diabetes mellitus, we are still in the situation that both pregestational (PGDM) and gestational diabetes (GDM) impose an additional risk to the embryo, fetus, and course of pregnancy. PGDM may increase the rate of congenital malformations, especially cardiac, nervous system, musculoskeletal system, and limbs. PGDM may interfere with fetal growth, often causing macrosomia, but in the presence of severe maternal complications, especially nephropathy, it may inhibit fetal growth. PGDM may also induce a variety of perinatal complications such as stillbirth and perinatal death, cardiomyopathy, respiratory morbidity, and perinatal asphyxia. GDM that generally develops in the second half of pregnancy induces similar but generally less severe complications. Their severity is higher with earlier onset of GDM and inversely correlated with the degree of glycemic control. Early initiation of GDM might even cause some increase in the rate of congenital malformations. Both PGDM and GDM may cause various motor and behavioral neurodevelopmental problems, including an increased incidence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Most complications are reduced in incidence and severity with the improvement in diabetic control. Mechanisms of diabetic-induced damage in pregnancy are related to maternal and fetal hyperglycemia, enhanced oxidative stress, epigenetic changes, and other, less defined, pathogenic mechanisms.

Identification of the functional pathways altered by placental cell exposure to high glucose: lessons from the transcript and metabolite interactome

The specific consequences of hyperglycaemia on placental metabolism and function are incompletely understood but likely contribute to poor pregnancy outcomes associated with diabetes mellitus (DM). This study aimed to identify the functional biochemical pathways perturbed by placental exposure to high glucose levels through integrative analysis of the trophoblast transcriptome and metabolome. The human trophoblast cell line, BeWo, was cultured in 5 or 25 mM glucose, as a model of the placenta in DM. Transcriptomic analysis using microarrays, demonstrated 5632 differentially expressed gene transcripts (≥± 1.3 fold change (FC)) following exposure to high glucose. These genes were used to generate interactome models of transcript response using BioGRID (non-inferred network: 2500 nodes (genes) and 10541 protein-protein interactions). Ultra performance-liquid chromatography-mass spectrometry (MS) and gas chromatography-MS analysis of intracellular extracts and culture medium were used to assess the response of metabolite profiles to high glucose concentration. The interactions of altered genes and metabolites were assessed using the MetScape interactome database, resulting in an integrated model of systemic transcriptome (2969 genes) and metabolome (41 metabolites) response within placental cells exposed to high glucose. The functional pathways which demonstrated significant change in response to high glucose included fatty acid β-oxidation, phospholipid metabolism and phosphatidylinositol phosphate signalling.

Modelling stillbirth mortality reduction with the Lives Saved Tool

BACKGROUND

The worldwide burden of stillbirths is large, with an estimated 2.6 million babies stillborn in 2015 including 1.3 million dying during labour. The Every Newborn Action Plan set a stillbirth target of ≤12 per 1000 in all countries by 2030. Planning tools will be essential as countries set policy and plan investment to scale up interventions to meet this target. This paper summarises the approach taken for modelling the impact of scaling-up health interventions on stillbirths in the Lives Saved tool (LiST), and potential future refinements.

METHODS

The specific application to stillbirths of the general method for modelling the impact of interventions in LiST is described. The evidence for the effectiveness of potential interventions to reduce stillbirths are reviewed and the assumptions of the affected fraction of stillbirths who could potentially benefit from these interventions are presented. The current assumptions and their effects on stillbirth reduction are described and potential future improvements discussed.

RESULTS

High quality evidence are not available for all parameters in the LiST stillbirth model. Cause-specific mortality data is not available for stillbirths, therefore stillbirths are modelled in LiST using an attributable fraction approach by timing of stillbirths (antepartum/ intrapartum). Of 35 potential interventions to reduce stillbirths identified, eight interventions are currently modelled in LiST. These include childbirth care, induction for prolonged pregnancy, multiple micronutrient and balanced energy supplementation, malaria prevention and detection and management of hypertensive disorders of pregnancy, diabetes and syphilis. For three of the interventions, childbirth care, detection and management of hypertensive disorders of pregnancy, and diabetes the estimate of effectiveness is based on expert opinion through a Delphi process. Only for malaria is coverage information available, with coverage estimated using expert opinion for all other interventions. Going forward, potential improvements identified include improving of effectiveness and coverage estimates for included interventions and addition of further interventions.

CONCLUSIONS

Known effective interventions have the potential to reduce stillbirths and can be modelled using the LiST tool. Data for stillbirths are improving. Going forward the LiST tool should seek, where possible, to incorporate these improving data, and to continually be refined to provide an increasingly reliable tool for policy and programming purposes.

Adolescent Health and Well-Being: Background and Methodology for Review of Potential Interventions

Owing to child survival initiatives around the world in the 1970s and 1980s, a dramatic rise in the population of adolescents has been seen, especially in the developing countries. A quarter of world's population in 2012 comprised adolescents and young adults; of these, 90% lived in low- and middle-income countries. More recently, there has been a consensus on investing in adolescent health and development for the success of post-2015 developmental agenda. In this series of articles, we aimed to assess various interventions identified in our conceptual framework to evaluate their effectiveness in improving adolescent health. We took a systematic approach to consolidate the existing evidence. This article is an introductory article detailing the background, conceptual framework, and methodology used for synthesizing evidence, followed by seven articles summarizing evidence on interventions for sexual/reproductive health, nutrition, immunization, mental health, substance abuse, and accidents/injury. The concluding article of the series summarizes the findings of the all the previous articles in the series and the relevance of the evidence for action in the post-2015 Millennium Development Goals era along with evidence gaps and future research priorities.

Gestational age specific stillbirth risk among Indigenous and non-Indigenous women in Queensland, Australia: a population based study

Background

In Australia, significant disparity persists in stillbirth rates between Aboriginal and Torres Strait Islander (Indigenous Australian) and non-Indigenous women. Diabetes, hypertension, antepartum haemorrhage and small-for-gestational age (SGA) have been identified as important contributors to higher rates among Indigenous women. The objective of this study was to examine gestational age specific risk of stillbirth associated with these conditions among Indigenous and non-Indigenous women.

Methods

Retrospective population-based study of all singleton births of at least 20 weeks gestation or at least 400 grams birthweight in Queensland between July 2005 and December 2011 using data from the Queensland Perinatal Data Collection, which is a routinely-maintained database that collects data on all births in Queensland. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95 % confidence intervals, adjusting for maternal demographic and pregnancy factors.

Results

Of 360987 births analysed, 20273 (5.6 %) were to Indigenous women and 340714 (94.4 %) were to non-Indigenous women. Stillbirth rates were 7.9 (95 % CI 6.8–9.2) and 4.1 (95 % CI 3.9–4.3) per 1000 births, respectively. For both Indigenous and non-Indigenous women across most gestational age groups, antepartum haemorrhage, SGA, pre-existing diabetes and pre-existing hypertension were associated with increased risk of stillbirth. There were mixed results for pre-eclampsia and eclampsia and a consistently raised risk of stillbirth was not seen for gestational diabetes.

Conclusion

This study highlights gestational age specific stillbirth risk for Indigenous and non-Indigenous women; and disparity in risk at term gestations. Improving access to and utilisation of appropriate and responsive healthcare may help to address disparities in stillbirth risk for Indigenous women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0943-7) contains supplementary material, which is available to authorized users.

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

OBJECTIVE

To compare the rates and aetiologies of stillbirth over the past 50 years.

STUDY DESIGN

We reviewed all autopsy reports for stillbirths occurring between 1989 and 2009 at the McGill University Health Centre to determine the pathological aetiology of stillbirths. We also reviewed maternal characteristics. We compared our results with a previous study published in 1992 on aetiologies of stillbirth from 1961 to 1988 at the same institution.

RESULTS

From among the 79 410 births between 1989 and 2009, 217 stillbirths were included in our study. The mean maternal age was 31.05 (±5.8) years. In 28.1% of cases, there was a history of subfertility. The mean gestational age at diagnosis was 32.69 (±5.58) weeks, with a birthweight of 1888 (±1084) g. The main causes of stillbirth were unknown (26.7%), placental factors (19.8%) and abruptio placentae (12.9%). Other causes included haematogenous or ascending infection (10.6%), fetal malformations (8.3%), maternal hypertension (3.2%), intrauterine growth restriction (2.8%), diabetes (1.8%) and intrapartum asphyxia (1.4%). Other fetal causes were found in 12.4% of cases.

CONCLUSIONS

Owing to detailed pathological examination of most stillbirth cases over the past five decades at our tertiary obstetrical centre, we could study the trends in the aetiology of stillbirths in a cohort of more than 150 000 births. In 50 years, the rate of stillbirth has decreased from 115 to 32 cases/10 000 births from the 1960s to 2000s, which represents a reduction of 72%. Stillbirth from unknown cause remains the most common contributor, with 40% of these cases occurring in late pregnancy.

An update on diabetic women obstetrical outcomes linked to preconception and pregnancy glycemic profile: a systematic literature review

Women with type 2 diabetes were less likely to have diabetes related complications than women with type 1. Women with type 1 diabetes had a high prepregnancy care and showed a worse glycemic control than women with type 2 both in the preconception period and during pregnancy. Obstetrical outcomes showed that preeclampsia and stillbirth rate is almost doubled in type 1 patients while perinatal deaths and SGA importantly increased in type 2 diabetes. In modern obstetrical care it is mandatory to maintain glucose levels as close to normal as possible particularly in diabetic population. HbA1C no higher than 6% before pregnancy and during the first trimester seems to decrease the risk of adverse obstetrical outcomes. Both the preconceptional counseling and glycemic profile optimization represent a fundamental step to improve pregnancy outcomes in women with preexisting diabetes. A systematic approach to family planning and the availability of preconception care for all diabetic women who desire pregnancy could be an essential step for diabetic management program.

Obstructive Sleep Apnoea in Pregnancy - More Questions than Answers

The role of obstructive sleep apnoea (OSA) in pregnancy is not well studied, but an increasing body of literature appears to indicate that there may be adverse maternal and foetal health effects of the disease. OSA is associated with a twofold risk of pre-eclampsia. The small size of the existing investigations still leave unanswered questions about the consequences of OSA as it relates to some other clinically relevant outcomes such as eclampsia, stillbirth and maternal mortality. A consistent body of literature has emerged demonstrating an increased risk of insulin resistance and diabetes associated with OSA. However, among pregnant women, the association appears to be related to short sleep duration. Well-designed and adequately powered studies are needed to further delineate the role of OSA and sleep duration on pregnancy outcome and the mechanisms of those effects.

Attitudes towards preconception care in Maltese women with type 1 diabetes mellitus

INTRODUCTION

The aim of this study was to assess the level of knowledge and awareness related to preconception care among Maltese women of reproductive age with type 1 diabetes mellitus (T1DM).

METHODS

Thirty-seven T1DM women, aged 12-30 years, were self-administered a questionnaire related to diabetes self-management and preconception care. The participants then underwent an educational intervention and re-took the same questionnaire.

RESULTS

Before the intervention, 26 participants (70%) claimed they did not have any knowledge about the preconception care of diabetes. Of the remaining 11 participants, the main reported source of information about diabetes care was the diabetologist (n = 8; 6.7%). The response rate was 70% (26 out of 37 participants completed the questionnaire after the educational intervention). Six of the participants who initially reported no preconception care knowledge claimed an increased awareness after the event. There was a statistically significant increase in the knowledge scores after the intervention.

CONCLUSION

It is evident that there is a lack of awareness of the importance of pre-pregnancy planning to avoid pregnancy-related complications with diabetes. This emphasizes the need for more education and it is imperative for healthcare professionals to address these issues with adolescent female patients.

Pre-existing diabetes mellitus and adverse pregnancy outcomes

Background

Pregnancies complicated by pre-existing diabetes mellitus (PDM) are associated with a high rate of adverse outcomes, including an increased miscarriage rate, preterm delivery, preeclampsia, perinatal mortality and congenital malformations; compared to the background population. The objectives of this study are to determine the prevalence of PDM and to investigate the maternal and the neonatal outcomes of women with PDM.

Methods

This is a retrospective cohort study for women who delivered in King Khalid University Hospital (KKUH) during the period of January 1^st to the 31^st of December 2008. The pregnancy outcomes of the women with PDM were compared to the outcomes of all non-diabetic women who delivered during the same study period.

Results

A total of 3157 deliveries met the inclusion criteria. Out of the study population 116 (3.7%) women had PDM. There were 66 (57%) women with type 1 diabetes mellitus (T1DM) and 50 (43%) women with type 2 diabetes mellitus (T2DM). Compared to non-diabetic women those with PDM were significantly older, of higher parity, and they had more previous miscarriages. Women with PDM were more likely to be delivered by emergency cesarean section (C/S), OR 2.67, 95% confidence intervals (CI) (1.63-4.32), P < 0.001, or elective C/S, OR 6.73, 95% CI (3.99-11.31), P < 0.001. The neonates of the mothers with PDM were significantly heavier, P < 0.001; and more frequently macrosomic; OR 3.97, 95% CI (2.03-7.65), P = 0.002. They more frequently have APGAR scores <7 in 5 minutes, OR 2.61, 95% CI (0.89-7.05), P 0.057 and more likely to be delivered at <37 gestation weeks, OR 2.24, 95% CI (1.37- 3.67), P 0.003. The stillbirth rate was 2.6 times more among the women with PDM; however the difference did not reach statistical significance, P 0.084.

Conclusion

PDM is associated with increased risk for C/S delivery, macrosomia, stillbirth, preterm delivery and low APGAR scores at 5 min.

Association between stillbirth and risk factors known at pregnancy confirmation

CONTEXT

Stillbirths account for almost half of US deaths from 20 weeks' gestation to 1 year of life. Most large studies of risk factors for stillbirth use vital statistics with limited data.

OBJECTIVE

To determine the relation between stillbirths and risk factors that could be ascertained at the start of pregnancy, particularly the contribution of these factors to racial disparities.

DESIGN, SETTING, AND PARTICIPANTS

Multisite population-based case-control study conducted between March 2006 and September 2008. Fifty-nine US tertiary care and community hospitals, with access to at least 90% of deliveries within 5 catchment areas defined by state and county lines, enrolled residents with deliveries of 1 or more stillborn fetuses and a representative sample of deliveries of only live-born infants, oversampled for those at less than 32 weeks' gestation and those of African descent.

MAIN OUTCOME MEASURE

Stillbirth.

RESULTS

Analysis included 614 case and 1816 control deliveries. In multivariate analyses, the following factors were independently associated with stillbirth: non-Hispanic black race/ethnicity (23.1% stillbirths, 11.2% live births) (vs non-Hispanic whites; adjusted odds ratio [AOR], 2.12 [95% CI, 1.41-3.20]); previous stillbirth (6.7% stillbirths, 1.4% live births); nulliparity with (10.5% stillbirths, 5.2% live births) and without (34.0% stillbirths, 29.7% live births) previous losses at fewer than 20 weeks' gestation (vs multiparity without stillbirth or previous losses; AOR, 5.91 [95% CI, 3.18-11.00]; AOR, 3.13 [95% CI, 2.06-4.75]; and AOR, 1.98 [95% CI, 1.51-2.60], respectively); diabetes (5.6% stillbirths, 1.6% live births) (vs no diabetes; AOR, 2.50 [95% CI, 1.39-4.48]); maternal age 40 years or older (4.5% stillbirths, 2.1% live births) (vs age 20-34 years; AOR, 2.41 [95% CI, 1.24-4.70]); maternal AB blood type (4.9% stillbirths, 3.0% live births) (vs type O; AOR, 1.96 [95% CI, 1.16-3.30]); history of drug addiction (4.5% stillbirths, 2.1% live births) (vs never use; AOR, 2.08 [95% CI, 1.12-3.88]); smoking during the 3 months prior to pregnancy (<10 cigarettes/d, 10.0% stillbirths, 6.5% live births) (vs none; AOR, 1.55 [95% CI, 1.02-2.35]); obesity/overweight (15.5% stillbirths, 12.4% live births) (vs normal weight; AOR, 1.72 [95% CI, 1.22-2.43]); not living with a partner (25.4% stillbirths, 15.3% live births) (vs married; AOR, 1.62 [95% CI, 1.15-2.27]); and plurality (6.4% stillbirths, 1.9% live births) (vs singleton; AOR, 4.59 [95% CI, 2.63-8.00]). The generalized R(2) was 0.19, explaining little of the variance.

CONCLUSION

Multiple risk factors that would have been known at the time of pregnancy confirmation were associated with stillbirth but accounted for only a small amount of the variance in this outcome.

Stillbirths: what difference can we make and at what cost?

Worldwide, 2·65 million (uncertainty range 2·08 million to 3·79 million) stillbirths occur yearly, of which 98% occur in countries of low and middle income. Despite the fact that more than 45% of the global burden of stillbirths occur intrapartum, the perception is that little is known about effective interventions, especially those that can be implemented in low-resource settings. We undertook a systematic review of randomised trials and observational studies of interventions which could reduce the burden of stillbirths, particularly in low-income and middle-income countries. We identified several interventions with sufficient evidence to recommend implementation in health systems, including periconceptional folic acid supplementation or fortification, prevention of malaria, and improved detection and management of syphilis during pregnancy in endemic areas. Basic and comprehensive emergency obstetric care were identified as key effective interventions to reduce intrapartum stillbirths. Broad-scale implementation of intervention packages across 68 countries listed as priorities in the Countdown to 2015 report could avert up to 45% of stillbirths according to a model generated from the Lives Saved Tool. The overall costs for these interventions are within the general estimates of cost-effective interventions for maternal care, especially in view of the effects on outcomes across maternal, fetal, and neonatal health.