An European concerted action investigating the validity of perinatal mortality as an outcome indicator for the quality of antenatal and perinatal care

Perinatal Outcomes in Premature Placental Calcification and the Association of a Color Doppler Study: Report from a Tertiary Care Hospital in Eastern India

Introduction: Placental calcification, identified before the 36th week of gestational age, is known as premature placental calcification (PPC). PPC could be a clue for the poor fetal outcome. However, its association with adverse perinatal outcomes is yet to be confirmed. Objective: The primary objective was to determine and compare the perinatal outcomes in pregnancies with and without documented premature placental calcification. Methodology: The present study was a prospective cohort study performed from October 2017 to September 2019. We consecutively enrolled 494 antenatal women who presented to our antenatal OPD after taking consent to participate in our study. Transabdominal sonographies were conducted between 28-36 weeks of gestation to document placental maturity. We compared maternal and fetal outcomes between those who were identified with grade III placental calcification (n = 140) and those without grade III placental calcification (n = 354). Results: The incidence of preeclampsia, at least one abnormal Doppler index, obstetrics cholestasis, placental abruption, and FGR (fetal growth restriction) pregnancies were significantly higher in the group premature placental calcification. We also found a significantly increased incidence of Low APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) scores, NICU (Neonatal Intensive Care Unit) Admission, Abnormal CTG (cardiotocography), meconium-stained liquor, and low birth weight babies in those with grade III placental calcification. Conclusion: Clinicians should be aware of documenting placental grading while performing ultrasonography during 28 to 36 weeks. Ultrasonographically, the absence of PPC can define a subcategory of low-risk pregnant populations which probably need no referral to specialized centers and can be managed in these settings.

Perinatal care in Portugal: effects of 15 years of a regionalized system

AIM

To share information on the organization of perinatal care in Portugal.

METHODS

Data were derived from the Programme of the National Committee for Mother and Child Health 1989, National Institute for Statistics, and Eurostat.

RESULTS

In 1989, perinatal care in Portugal was reformed: the closure was proposed of maternity units with less than 1500 deliveries per year; hospitals were classified as level I (no deliveries), II (low-risk deliveries, intermediate care units) or III (high-risk deliveries, intensive care units), and functional coordinating units responsible for liaison between local health centres and hospitals were established. A nationwide system of neonatal transport began in 1987, and in 1990 postgraduate courses on neonatology were initiated. With this reform, in-hospital deliveries increased from 74% before the reform to 99% after. Maternal death rate decreased from 9.2/100,000 deliveries in 1989 to 5.3 in 2003 and, in the same period, the perinatal mortality rate decreased from 16.4 to 6.6/1000 (live births + stillborn with > or = 22 wk gestational age), the neonatal mortality rate decreased from 8.1 to 2.7/1000 live births, and the infant mortality rate from 12.2/1000 live births to 4/1000.

CONCLUSION

Regionalization of perinatal care and neonatal transport are key factors for a successful perinatal health system.

Maternal and paternal thrombophilia: risk factors for perinatal mortality

BACKGROUND

Although some paternal components to the predisposition to pre-eclampsia have been demonstrated recently, it is not known whether such paternal factors play a role to thrombophilia-related perinatal mortality.

OBJECTIVE

To compare the paternal and maternal contribution to perinatal mortality.

STUDY DESIGN

Data from a prospective registry of perinatal mortality in a Dutch healthcare region were used. Between December 1999 and May 2000, the prevalence of thrombophilia was studied in 74 women with a history of perinatal mortality (female cases) and 54 of their male partners (male cases). Seventy-one healthy unrelated women after uneventful pregnancies only and 66 of their male partners were used as controls.

SETTING

Obstetric outpatient clinic in a regional hospital (Remierde Graaf Group, Deflt).

METHODS

Presence of various coagulation abnormalities, hyperhomocysteinaemia and anticardiolipins was investigated.

RESULTS

The frequency of antithrombin deficiency (12% vs 0%), increased activated protein C (APC) resistance (32% vs 6%), total protein S deficiency (11% vs 1%) and elevated factor VIII:C activity (43% vs 17%) was significantly higher in female cases compared with controls. In male cases, the frequency of increased APC resistance was significantly higher compared with controls (22% vs 0%). In 30 of the 54 couples with a history of perinatal mortality, more than one thrombophilic abnormality was found (55%) compared with 10 of the 62 control couples (17%).

CONCLUSION

The risk of having thrombophilia is doubled in men who have fathered pregnancies which ended in perinatal death as well as in the mothers of such pregnancies.

Are intrapartum and neonatal deaths in breech delivery at term potentially avoidable?--a blinded controlled audit

The aim of the study was to investigate whether deaths in term breech deliveries could have been avoided with improved care during pregnancy and delivery. All cases of intrapartum/early neonatal death of nonmalformed infants in breech presentation delivered at term in Denmark in the period 1982-92 were studied. For each of the 12 deaths two controls matched by presentation and planned mode of delivery were selected. Eleven obstetricians assessed the care through narratives that ended when the infant was delivered to umbilicus and stated if the infant died, and whether the "possible death" was potentially avoidable. The majority thought that 42% of cases and 9% of the controls had died. Antenatal and intrapartum care was suboptimal respectively in 17% and 25% of cases and 4% and 26% of controls. The assumed death was found to have been potentially avoidable in 58% of cases and 17% of controls. Care in pregnancies with IUGR, pre-eclampsia, placental abruption, post-maturity, the time from decision to performance of cesarean section, and compliance between patient and professionals were more often criticized in cases than in controls. Controlled audit seemed to be a valuable tool for quality improvement and for validation of litigation activities. In conclusion, infant death at term breech delivery was to a large extent potentially avoidable. However, even in controls, suboptimal care was not uncommon.

The influence of prenatal screening and termination of pregnancy on perinatal mortality rates

OBJECTIVES

This study concerns the possible effect of practice of prenatal screening of congenital anomalies followed by termination of pregnancy on the perinatal mortality between European countries.

METHODS

Data of nine region-specific EUROCAT registries from five European countries were used to compare the pregnancy termination rate and perinatal mortality due to congenital anomalies between the registries. The impact of pregnancy terminations on the perinatal mortality rate was estimated using a calculated lethality for each congenital anomaly in the hypothetical case that no pregnancy terminations had been performed and was expressed in the 'natural' perinatal mortality rate.

RESULTS

There are large differences between the EUROCAT registries in the number of pregnancy terminations for congenital anomalies. The difference between the 'natural' and regular perinatal mortality rate vary between 3.7 and 14.1 per 10 000 live births and stillbirths. The difference is greater in regions where prenatal screening is more common than in regions where this is not common.

CONCLUSION

Differences in practice of prenatal screening and termination of pregnancy of congenital anomalies contribute to the variations in the overall perinatal mortality rate between European regions and countries.

Birth weight and perinatal mortality: a comparison of "optimal" birth weight in seven Western European countries

BACKGROUND

Previous studies have suggested that a population's entire birth weight distribution may be shifted towards higher or lower birth weights, and that optimal birth weight may be lower in populations with a lower average birth weight. We evaluated this hypothesis for seven western European countries.

METHODS

We obtained data on all singleton births (N = 1,372,092) and extended perinatal deaths (stillbirths plus neonatal deaths; N = 7,900) occurring in Finland, Sweden, Norway, Denmark, Scotland, the Netherlands, and Flanders (Belgium) in 1993-1995. We assessed whether countries differed in the mode of their birth weight distribution and in the birth weight associated with the lowest perinatal mortality, and then correlated the two.

RESULTS

Substantial international differences were found in the mode of the birth weight distribution, which ranged between 3384 gm in Flanders and 3628 gm in Finland. The position of the minimum of the perinatal mortality curve also differed considerably, ranging between 3755 gm in Flanders and 4305 gm in Norway. There was a strong relation between the two: for every 100 gm increase in modal birth weight, optimal birth weight was 170 gm higher (95% confidence interval = 104-236 gm).

CONCLUSIONS

Our results confirm those of previous studies that compared two populations. To improve the identification of small babies at high risk of perinatal death, population-specific standards for birth weight should be developed and used.

Comparability of published perinatal mortality rates in Western Europe: the quantitative impact of differences in gestational age and birthweight criteria

OBJECTIVE

To quantify the impact of publication criteria on differences in published national perinatal mortality rates among Western European countries.

DESIGN

Descriptive study of perinatal mortality rates in Western European countries with adjustments for international differences in publication data.

POPULATION

All live births and perinatal deaths in 1994 in Western European countries.

METHODS

The 1994 perinatal mortality rates were obtained from national and Eurostat publications for Belgium, Denmark, Finland, France, Germany, Greece, The Netherlands. Norway, Portugal, Spain, Sweden, United Kingdom (England, Wales, Scotland, Northern Ireland). Two methods, one direct and one indirect, were used for adjusting these officially published rates for differences in registration laws or publication practices. For the indirect method adjustment factors were derived from an analysis of a large Finnish database using different cutoff points for gestational age and birthweight. For the direct method a common cutoff point was imposed for birthweight (1000g) and gestational age (28 completed weeks) on national perinatal mortality data, obtained from civil registration or hospital/obstetrics databases in each country.

RESULTS

The published perinatal mortality rates ranged from 5.4 per 1000 total births in Sweden and Finland to 9.7 in Greece and Northern Ireland. The indirect adjustment method showed that some countries apply cutoff points for registration or publication of perinatal mortality which may raise the perinatal mortality rate by up to 17% above the most commonly used threshold for including live and stillbirths. The direct adjustment method showed that a common lower limit of 1000g for birthweight or 28 weeks for gestational age would reduce the perinatal mortality rate, but by a differing extent ranging from 14% to 40%. Both adjustment methods reduced the contrast between the countries' perinatal mortality rates, and changed their rank order.

CONCLUSION

These quantitative results confirm that international differences in countries' published perinatal mortality rates partly reflect differences between countries' criteria for registration and publication of perinatal deaths.