Causes of stillbirth: an analysis of 77 cases

OBJECTIVE: To devise preventive measures for stillbirths, which account for more than 70% of perinatal deaths in Japan. METHODS: We retrospectively reviewed the medical records of 77 women with singleton pregnancies who gave birth to stillborn infants at > or = 30 weeks between 1979 and 1996 at our hospital. RESULTS: Major malformations were present in 21 (27%) of 77 infants, including 11 infants with anencephaly. Two infants (2.6%) were severely hydropic. Preeclampsia preceded the stillbirth and might have been an indirect cause of stillbirth in 21 (39%) of 54 women whose infants had normal formations. The cause of stillbirth in 33 non-preeclamptic women was unclear in 15 (28%), abruptio placentae in 9, fetal growth retardation in 3, the HELLP syndrome in 3, chorioamnionitis in 2, and cord accident in 1. Abruptio placentae also occurred in 9 of 21 preeclamptic patients. Thus, abruptio placentae was responsible for 18 (33%) of 54 stillborn infants with a grossly normal appearance. An autopsy was performed on only 13 (24%) of 54 infants with grossly normal appearance and did not provide new information relating to deaths. CONCLUSIONS: The causes of stillbirth were many and varied, with a large proportion having no obvious cause, although autopsies were underused. Increased monitoring for women with preeclampsia and early diagnosis and prompt delivery for women with abruptio placentae might be helpful in reducing the number of stillbirths.     

Maternal blood pressure in pregnancy and stillbirth: a case-control study of third-trimester stillbirth

An immense body of literature on the effects of hypertension on perinatal morbidity and mortality exists, but only a handful of studies have reported adverse outcomes associated with low maternal blood pressure during pregnancy. This study aimed to investigate if there is an increased risk of fetal loss associated with hypotension during pregnancy. A matched case-control study of stillbirth and maternal blood pressure was conducted in which maternal blood pressures for a total of 124 pregnancies culminating in stillbirth were compared with maternal blood pressures in 243 (matched) pregnancies resulting in a liveborn infant. Women whose diastolic blood pressures fell in a borderline range (60 to 70 mm Hg) were consistently at greater risk of stillbirth relative to normotensive pregnancies. Women who had three or more mean arterial pressure values < or = 83 mm Hg during the course of their pregnancy were at nearly twice the risk of stillbirth (odds ratio 1.78; 95% confidence interval [CI] 1.06 to 2.99; P = 0.03). Systolic hypotension was not significantly associated with stillbirth, but proportionately more control women were noted to have systolic hypertension (SBP > or = 130 mmHg) than cases, and the adjusted odds of stillbirth in women who were hypertensive at either their first or last antenatal visit or whose antenatal average SBP was > or = 130 mm Hg were all very close to 0.4 (95% CI 0.37 to 0.43; P = 0.02 to 0.03) relative to normotensives. We concluded that maternal hypotension, particularly borderline hypotension, may be a contributory risk factor for stillbirth. Women with hypertension in pregnancy may now be at a decreased risk of stillbirth as a result of the close care and treatment they receive.     

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

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

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

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

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

Torsion of ovarian tumors: a clinicopathological study

Torsion of ovarian tumors occurred predominantly in the reproductive age group. The majority of the cases presented in pregnant (22.7%) than in non-pregnant (6.1%) women. The major presenting symptom was pain but an abdominal mass was palpable in 79.4% of cases. Torsion was more common on the right ovary and 50% were gangrenous at laparotomy. Most of the tumors were benign cystic teratomas. Only 8.7% of the tumors were malignant.     

Risk factors for antepartum and intrapartum stillbirth: a population-based study

To examine disparities in risk factors for stillbirths and its occurrence in the antepartum versus intrapartum periods. A population-based, cross-sectional study using data on women that delivered singleton births between 20 and 43 weeks in Missouri (1989-1997) was conducted (n = 626,883). Hazard ratios and 95% confidence intervals were derived from regression models and population attributable fractions were estimated to examine the impact of risk factors on stillbirth. Among African Americans, risks of antepartum and intrapartum stillbirth were 5.6 and 1.1 per 1,000 singleton births, respectively; risks among whites were 3.4 and 0.5 per 1,000 births, respectively. Maternal age > or = 35 years, lack of prenatal care, prepregnancy body mass index (BMI) > or = 30 kg/m2, and prior preterm or small-for-gestational age birth were significantly associated with increased risk for antepartum stillbirth among whites, but not African Americans. BMI < or = 18.5 kg/m2 was associated with antepartum and intrapartum stillbirth among African Americans, but not whites. The presence of any congenital anomaly, abruption, and cord complications were associated with antepartum stillbirth in both races. Premature rupture of membranes was associated with intrapartum stillbirth among whites and African Americans, but intrapartum fever was associated with intrapartum stillbirth among African Americans. These risk factors were implicated in 54.9% and 19.7% of antepartum and intrapartum stillbirths, respectively, among African American women, and in a respective 46.6% and 11.9% among white women. Considerable heterogeneity in risk factors between antepartum and intrapartum stillbirths is evident. Knowledge on timing of stillbirth specific risk factors may help clinicians in decreasing antepartum and intrapartum stillbirth risks through monitoring and timely intervention.     

Hereditary ovarian cancer: a clinicopathological study.

Hereditary ovarian cancer (HOC) is rare and little recognized. Over the years, we have identified 37 HOC patients from HOC syndrome kindreds with documented cancers of ovary, breast, colon, or endometrium in two or more first-degree relatives. The age and clinical stage at diagnosis and overall 5-year survival of HOC patients were compared with those of ovarian cancers in the unselected patients. The gross and microscopic features of the tumors are compared with a set of 34 consecutively chosen ovarian cancer cases with documented negative family histories. The mean age of HOC patients at diagnosis was significantly lower (50.2 years) than that of the unselected control population (59 years) (p less than 0.001). Detailed pedigree analysis breaks down the HOC group into (a) site-specific ovarian cancer, 5 cases, 56.4 years mean age; (b) breast-ovarian cancer syndrome, 28 cases, 50.46 years mean age; and (c) Lynch syndrome II (colon/endometrial cancer), 4 cases, mean age 41 years. The age differences were statistically significant (p = 0.050). The most prevalent International Federation of Gynecology and Obstetrics clinical stage at diagnosis of HOC (stage III) was the same as for the control group. Histologically, all (100%) HOC tumors were surface epithelial cancers with predominance of serous papillary type moderate to high grade (89 versus 71% in control, p = 0.07). No other pathologic features appeared to be significant. In conclusion, HOC is a serous papillary tumor and characterized by early age of onset and excess of breast/ovary/colon-endometrial cancers in first-degree relatives of patients with specific HOC syndromes.     

Villous oedema of the placenta: a clinicopathological study

Villous oedema was observed in 259 placentae among 1925 consecutive singleton pregnancies of greater than 19 weeks gestation. It was present in 11 per cent of term placentae in which significant associations with fetal and neonatal death (P less than 0.03), and absence of maternal cigarette smoking (P less than 0.002) were found. In preterm placentae, the oedema was usually more severe, and its prevalence increased from 20 per cent for 33-37 weeks to 40 per cent for less than 33 weeks. Our analysis showed that for a given gestational age, villous oedema was not significantly related to chorioamnionistis, Apgar scores of less than 7 at 1 and 5 min, or neonatal death, an exception was for 33-37 weeks gestation, in the absence of chorioamnionitis, villous oedema was associated with low 1 min Apgar score. Immature intermediate villi are present in premature placentae as a normal developmental stage and in dysmature placentae as a result of villous maldevelopment. Since villous oedema closely resembles the 'stromal channels' in this villous type and shows significant association with prematurity and villous dysmaturity, we postulate that villous oedema is a lesion primarily of the immature intermediate villi. Both fetal and maternal factors are involved in its pathogenesis.     

Tuberculous endometritis: a clinicopathological study of 1000 cases

Summary. A histopathological diagnosis of tuberculous endometritis was made in 2.3% of 42 770 specimens of non-pregnant endometrial curet-tings and biopsies examined in Delhi. A retrospective analysis of the women with tuberculous endometriosis showed that 62% were in their third decade and the commonest presenting symptoms were infertility (47%) and amenorrhoea (26%). Discrete granulomas were seen in 60%. In the absence of a typical granuloma dilatation of glands, active destruction of epithelium and inflammatory exudate in the lumen suggested tubercular aetiology.     

Vaginal cysts: a clinicopathological study of 41 cases

The clinicopathological features of 43 vaginal cysts in 41 patients treated at Magee-Womens Hospital between 1972 and 1982 were evaluated. Thirty-five of the patients were white and six black; their ages ranged from 19 to 68 years with an average of 37.6 years. Most patients complained of a swelling or mass in the vagina, accompanied in some by stress incontinence, dyspareunia, dysfunctional uterine bleeding, or a history of episiotomies or vaginal lacerations. The majority of the cysts were located in the lateral and posterior walls of the vagina. The most frequent cyst type was mucus-secreting müllerian (19; or 44%), followed by ten (23%) epidermal inclusion cysts; three of the latter were located in a previous episiotomy site. The remainder were five (11%) of Gartner's duct type, three (7%) of Bartholin's duct type, and three (7%) of endometriotic type. The remaining three were unclassified for lack of an epithelial lining in two, and one cystourethrocele was confused with a vaginal cyst. None disclosed atypical epithelial hyperplasia or malignant change.     

Fallopian tube carcinoma: a clinicopathological study of 17 cases

From 1969 through 1986, 17 patients with primary adenocarcinoma of the fallopian tube were treated at the Loma Linda University Medical Center. Stages I, II, and III of the disease were present in 6, 5, and 6 patients, respectively. The mean age of the patients was 59.9 years. Vaginal bleeding or discharge (57%), followed by abdominal pain or discomfort (29%), was the most common symptom in our patients. A palpable pelvic mass was detected in two-thirds of the patients. One case of carcinosarcoma, one case of mixed mesodermal tumor, and one case of endometrioid carcinoma are included. No patient in this series had a correct preoperative diagnosis. Therapy consisted of surgical resection, usually followed by various combinations of adjuvant radiation therapy and/or chemotherapy. The overall 5-year survival rate was 31%. Five patients (29%) are alive without evidence of disease. This study supports the need for collaboration among large centers to define the optimal adjuvant therapy of this disease. In the absence of the desired treatment protocols, such lesions should be approached in a manner similar to that used for ovarian cancers.     

Androgen-producing ovarian tumors: a clinicopathological study of 3 cases

The clinical course and pathological findings of 3 rare cases of androgen-producing ovarian tumors are presented. The ages of the 3 patients (Cases 1, 2, and 3, respectively) were 43, 34, and 57 years, respectively. Their preoperative serum testosterone levels were 506, 491, and 231 ng/dl, respectively. The pathological diagnoses of Cases 1, 2, and 3 were a Sertoli-stromal cell tumor of intermediate differentiation, a stromal tumor containing Leydig cells, and a stromal tumor with minor sex cord elements, respectively. Patient 1 experienced a recurrence, of a lesion at the vaginal stump 1 year and 2 months after the initial surgery. The clinical courses of Cases 2 and 3 have been non-contributory.     

Measuring errors and non-participation in a nation-wide study of stillbirth.

BACKGROUND: An observational study in which data are being collected by an anonymous questionnaire is an alternative when an intervention cannot be investigated by a controlled clinical trial. If used, measuring errors and non-participation may decrease validity. METHODS: We compared data retrieved with an anonymous questionnaire in a nation-wide study on stillbirth with information from the Swedish Medical Birth Register. In the original study population with 759 women, four groups were formed comprising participants and non-participants among subjects (stillbirth in 1991) and controls (live birth the same year). To assess misclassification, we compared information provided by the questionnaire to the data for the corresponding group in the Swedish Medical Birth Register. Comparing background information on participants and non-participants elucidated misrepresentation. RESULTS: The figures from the questionnaire and the register were almost identical for hypertension, albumin and sugar in the urine during pregnancy, while anemia and tiredness were reported more often in the questionnaire. Similar results were found in the two data sources regarding the type and frequency of analgesia during the delivery, birth order, gender and weight of the index child. On average, all women reported a larger number of gestation weeks in the questionnaire than was indicated in the register-based information. A higher percentage of the participants than the non-participants, both among subjects and controls, were born in Sweden, had Swedish citizenship and were married or cohabiting. CONCLUSION: Information on many variables derived from an anonymous questionnaire can be used in a scientific context. The validity of a study in the investigated population would probably be enhanced if it were restricted to subjects born in Sweden.