Multivariate analysis of risk factors for stillbirth in Leon, Mexico

BACKGROUND: To identify sociodemographic and clinical risk factors for antenatal fetal death in a developing country setting. METHODS: A case-control study was carried out, including 753 women: 251 had a stillbirth (cases) and 502 had a healthy live birth (controls). Stillbirths were considered as antenatal fetal death after 21 weeks of gestation. Seventeen sociodemographic and clinical risk factors for stillbirth were analyzed. Statistical analysis. Student's t-test or the Mann-Whitney U-test for continuous data and the chi2-test or Fisher's exact test for categorical variables were used. Logistic regression analysis was used to find significant predictors for stillbirth. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. RESULTS: Three risk factors were significant in the logistic regression model: maternal age (OR 1.04, 95% CI 1.00-1.08), antenatal care (OR 0.1, 95% CI 0.0-0.2) and umbilical cord complication (OR 5.8, 95% CI 3.2-10.2). The whole model had a determination coefficient of 0.280, with a chi2-value of 246.2 (p < 0.001). CONCLUSIONS: In our setting antenatal care should be considered as the cornerstone in the prevention of stillbirth. With adequate antenatal care both women with advanced maternal age and umbilical cord complication could be identified. This finding could be useful for developing as well as developed country settings to avoid the occurrence of stillbirth.     

Determinants of unexplained antepartum fetal deaths

OBJECTIVE: To assess fetal, maternal, and pregnancy-related determinants of unexplained antepartum fetal death. METHODS: We conducted a hospital-based cohort study of 84,294 births weighing 500 g or more from 1961-1974 and 1978-1996. Unexplained fetal deaths were defined as fetal deaths occurring before labor without evidence of significant fetal, maternal, or placental pathology. RESULTS: One hundred ninety-six unexplained antepartum fetal deaths accounted for 27.2% of 721 total fetal deaths. Two thirds of the unexplained fetal deaths occurred after 35 weeks' gestation. The following factors were independently associated with unexplained fetal death: maternal prepregnancy weight greater than 68 kg (adjusted odds ratio [OR] 2.9; 95% confidence interval [CI] 1.85, 4.68), birth weight ratio (defined as ratio of birth weight to mean weight for gestational age) between 0.75 and 0.85 (OR 2.77; 95% CI 1.48, 5.18) or over 1.15 (OR 2.36; 95% CI 1.26, 4.44), fewer than four antenatal visits in women whose fetuses died at 37 weeks or later (OR 2.21; 95% CI 1.08, 4.52), primiparity (OR 1.74; 95% CI 1.26, 2.40), parity of three or more (OR 2.01; 95% CI 1.26, 3.20), low socioeconomic status (OR 1.59; 95% CI 1.14, 2.22), cord loops (OR 1.75; 95% CI 1.04, 2.97) and, for the 1978-1996 period only, maternal age 40 years or more (OR 3.69; 95% CI 1.28, 10.58). Trimester of first antenatal visit, low maternal weight, postdate pregnancy, fetal-to-placental weight ratio, fetal sex, previous fetal death, previous abortion, cigarette smoking, and alcohol use were not significantly associated with unexplained fetal death. CONCLUSION: In this study, we identified several factors associated with an increased risk of unexplained fetal death.     

Epidemiology of fetal death in Latin America

BACKGROUND: To identify risk factors associated with fetal death, and to measure the rate and the risk of fetal death in a large cohort of Latin American women. METHODS: We analyzed 837,232 singleton births recorded in the Perinatal Information System Database of the Latin American Center for Perinatology and Human Development (CLAP) between 1985 and 1997. The risk factors analyzed included fetal factors and maternal sociodemographic, obstetric, and clinical characteristics. Adjusted relative risks were obtained, after adjustment for potential confounding factors, through multiple logistic regression models based on the method of generalized estimating equations. RESULTS: There were 14,713 fetal deaths (rate=17.6 per 1000 births). The fetal death risk increased exponentially as pregnancy advanced. Thirty-seven percent of all fetal deaths occurred at term, and 64% were antepartum. The main risk factors associated with fetal death were lack of antenatal care (adjusted relative risk [aRR]=4.26; 95% confidence interval, 3.84-4.71) and small for gestational age (aRR=3.26; 95% CI, 3.13-3.40). In addition, the risk of death during the intrapartum period was almost tenfold higher for fetuses in noncephalic presentations. Other risk factors associated with stillbirth were: third trimester bleeding, eclampsia, chronic hypertension, preeclampsia, syphilis, gestational diabetes mellitus, Rh isoimmunization, interpregnancy interval<6 months, parity > or =4, maternal age > or =35 years, illiteracy, premature rupture of membranes, body mass index > or =29.0, maternal anemia, previous abortion, and previous adverse perinatal outcomes. CONCLUSIONS: There are several preventable factors that should be dealt with in order to reduce the gap in fetal mortality between Latin America and developed countries.     

Maternal Hypertension and Spontaneous Preterm Births Among Black Women

Objective: To examine effects of maternal hypertension on spontaneous preterm birth (birth at less than 37 weeks’ gestation) among black women.Methods: Using hospital discharge summary records from the National Hospital Discharge Survey between 1988 and 1993, we conducted a case-control study to assess the risk of spontaneous preterm birth among black women with chronic hypertension preceding pregnancy and pregnancy-induced hypertension. Logistic regression was used to derive odds ratios (ORs) and 95% confidence intervals (CIs).Results: Preterm births were almost two times more likely for women with pregnancy-induced hypertension (OR = 1.8; 95% CI, 1.5, 2.2), more than 1.5 times more likely for women with chronic hypertension preceding pregnancy (OR = 1.6; 95% CI, 1.3, 2.1), and more than four times more likely for women with pregnancy-aggravated hypertension (OR = 4.4; 95% CI, 2.9, 6.7) compared with normotensive women. Preterm births also were associated significantly with antepartum hemorrhage, poor fetal growth, marital status, and source of payment. The odds of preterm birth by maternal hypertension were increased among women with chronic hypertension and genitourinary infection, whereas the odds of preterm birth were reduced among women with pregnancy-induced hypertension and genitourinary infection.Conclusion: These findings are important in demonstrating the relation between type of hypertension in pregnancy and preterm birth. The relationships between maternal hypertension and preterm birth need to be further investigated to provide some guidelines in the management of hypertension in pregnancy and assessment of prenatal care compliance for black women, particularly when genitourinary infection is present.     

Unexplained antepartum fetal deaths: what are the determinants?

Objective The objective was to assess fetal, antenatal, and pregnancy determinants of unexplained antepartum fetal death.Methods This is a hospital-based cohort study of 34,394 births weighing 500 g or more from January 1995 to December 2002. Unexplained fetal deaths were defined as fetal deaths occurring before labor, without evidence of significant fetal, maternal or placental pathology.Results Ninety-eight unexplained antepartum fetal deaths accounted for 27.2% of 360 total fetal deaths. Two-thirds of these deaths occurred after 36 weeks gestation. The following factors are independently associated with unexplained fetal deaths: primiparity (OR 1.74; 95% CI 1.21, 2.86); parity of five or more (OR 1.19; 95% CI 1.26, 3.26); low socioeconomic status (OR 1.22; 95% CI 1.14, 2.86); maternal age 40 years or more (OR 3.62; 95% CI 1.22, 4.52); maternal age of 18 years or less (OR 1.79; 95% CI 0.82, 2.89); maternal prepregnancy weight greater than 70 kg (OR 2.20; 95% CI 1.85, 3.68); fewer than three antenatal visits in women whose fetuses died at 31 weeks or more (OR 1.11; 95% CI 1.08, 2.48); birth weight ratio (defined as ratio of birth weight to mean birth weight for gestational age) between 0.85 and 0.94 (OR 1.77; 95% CI 1.28, 4.18) or over 1.45 (OR 2.92; 95% CI 1.75, 3.21); trimester of first antenatal visit. Previous fetal death, previous abortion, cigarette smoking, fetal sex, low maternal weight, fetal-to-placenta weight, and post date pregnancy were not significantly associated with unexplained fetal deaths.Conclusion Several factors were identified that are associated with an increased risk of unexplained fetal deaths.     

Obstetric history and the risk of placenta previa

OBJECTIVE: To evaluate secular trends in the occurrence of placenta previa and whether placenta previa is associated with the outcome of previous pregnancies, cesarean section, and sociodemographic factors. DESIGN: A cohort study based on the Medical Birth Registry of Norway. Placenta previa in the second pregnancy was investigated for associations with outcomes in the first pregnancy and sociodemographic factors. RESULTS: In birth orders 1 and 2 the occurrence of placenta previa was 1.2 and 2.2 per 1,000, respectively, with no secular trend. The occurrence increased with maternal age and was lowest in women aged 20-29 years. The recurrence rate was 23 per 1,000 (adjusted odds ratio (OR) of recurrence=9.7). In women with prior delivery at < or =25 gestational weeks the risk of placenta previa was 6.7 per 1,000 (adjusted OR=3.0). In women with prior placental abruption the risk was 5.8 per 1,000 (OR=2.6). In women with prior perinatal death the risk was 4.4 per 1,000 (adjusted OR= 1.8). No independent relationship emerged with socio-economic factors, previous birthweight, and a history of pregnancy induced hypertension. Cesarean section was associated with subsequent development of placenta previa (adjusted OR= 1.3). CONCLUSIONS: We found no secular trends in the occurrence of placenta previa. Placenta previa is associated with previously described risk factors for placental abruption. The increased risk of placenta previa subsequent to placental abruption supports the theory of a shared etiologic factor. However, placenta previa and placental abruption do not share a common etiology in relation to a history of pregnancy induced hypertension, fetal growth retardation, and socio-economic factors.     

An evaluation of the importance of formal, maternal fetal movement counting as a measure of fetal well-being.

Maternal perception of fetal movements has, over the years, become recognised as a valuable tool for early detection of fetal compromise. Several studies published in the mid-1970s have demonstrated that a reduction or cessation in maternally perceived fetal movements may precede antepartum late fetal death by a day or longer. From these findings formal fetal movement counting emerged as a valuable, non-invasive method of assessing fetal well-being; the belief being that clinical actions taken on the basis of reduced fetal movement counting may prevent antepartum death or morbidity. Conversely, more recent studies have failed to demonstrate that there is a beneficial effect of a formal, fetal movement counting policy on antepartum death. It is not disputed that fetal movements are of clinical importance but it seems that routine daily counting of fetal movements by women followed by appropriate action when movements are reduced offers no advantages over formal inquiry about fetal movements during standard antenatal care. Thus, the application of formal, maternal fetal movement counting as a method of fetal surveillance to reduce late antepartum death must be questioned.     

Racial Disparities in Comorbidities,Complications, and Maternal and Fetal Outcomes in Women With Preeclampsia/eclampsia

Objective: The mechanisms leading to worse outcomes in African-American (AA) women with preeclampsia/eclampsia remain unclear. Our objective was to identify racial differences in maternal comorbidities, peripartum characteristics, and maternal and fetal outcomes. Methods/Results: When compared to white women with preeclampsia/eclampsia, AA women had an increased unadjusted risk of inpatient maternal mortality (OR 3.70, 95% CI: 2.19–6.24). After adjustment for covariates, in-hospital mortality for AA women remained higher than that for white women (OR 2.85, 95% CI: 1.38–5.53), while the adjusted risk of death among Hispanic women did not differ from that for white women. We also found an increased risk of intrauterine fetal death (IUFD) among AA women. When compared to white women with preeclampsia, AA women had an increased unadjusted odds of IUFD (OR 2.78, 95% CI: 2.49–3.11), which remained significant after adjustment for covariates (adjusted OR 2.45, 95% CI: 2.14–2.82). In contrast, IUFD among Hispanic women did not differ from that for white women after adjusting for covariates. Conclusions and Relevance: Our data suggest that African-American women are more likely to have risk factors for preeclampsia and more likely to suffer an adverse outcome during peripartum care. Future research should examine whether controlling co-morbidities and other risk factors will help to alleviate racial disparities in outcomes in this cohort of women.     

Avoidable risk factors in perinatal deaths: a perinatal audit in South Australia

OBJECTIVES: To analyse risk factors of perinatal death, with an emphasis on potentially avoidable risk factors, and differences in the frequency of suboptimal care factors between maternity units with different levels of care. METHODS: Six hundred and eight pregnancies (2001-2005) in South Australia resulting in perinatal death were described and compared to 86 623 live birth pregnancies. RESULTS: Two hundred and seventy cases (44.4%) were found to have one or more avoidable maternal risk factors, 31 cases (5.1%) had a risk factor relating access to care, while 68 cases (11.2%) were associated with deficiencies in professional care. One hundred and four women (17.1% of cases) presented too late for timely medical care: 85% of these did have a sufficient number of antenatal visits. The following independent maternal risk factors for perinatal death were found: assisted reproductive technology (adjusted odds ratio (AOR) 3.16), preterm labour (AOR 22.05), antepartum haemorrhage (APH) abruption (AOR 6.40), APH other/unknown cause (AOR 2.19), intrauterine growth restriction (AOR 3.94), cervical incompetence (AOR 8.89), threatened miscarriage (AOR 1.89), pre-existing hypertension (AOR 1.72), psychiatric disorder (AOR 1.85) and minimal antenatal care (AOR 2.89). The most commonly found professional care deficiency in cases was the failure to act on or recognise high-risk pregnancies/complications, found in 49 cases (8.1%). CONCLUSION: Further improvements in perinatal mortality may be achieved by greater emphasis on the importance of antenatal care and educating women to recognise signs and symptoms that require professional assessment. Education of maternity care providers may benefit from a further focus on how to recognise and/or manage high-risk pregnancies.     

Adequacy of prenatal care and neonatal mortality in infants born to mothers with and without antenatal high-risk conditions

BACKGROUND: Previous studies have found that inadequate prenatal care was associated with increased neonatal mortality in the general pregnant women. AIMS: To examine the association between adequacy of prenatal care and neonatal mortality in the presence and absence of antenatal high-risk conditions. METHODS: We conducted a retrospective cohort study of infants based on 1995-2000 vital statistics data in the USA. The relative risk for neonatal death associated with adequacy of prenatal care was estimated by multivariate logistic regressions with adjustment of confounding factors. RESULTS: Inadequate prenatal care was associated with increased neonatal mortality when pregnancies were complicated by anaemia, cardiac disease, lung disease, chronic hypertension, diabetes, renal disease, pregnancy-induced hypertension, and previous preterm/small-for-gestational-age birth. The observed association also existed in the absence of these antenatal high-risk conditions. Overutilisation of prenatal care was associated with increased risk of neonatal deaths in both the presence and the absence of antenatal high-risk conditions. When gestational age at delivery and birthweight were further adjusted, the observed association between inadequate prenatal care and neonatal mortality was not significant in pregnancies with various high-risk conditions. CONCLUSIONS: Inadequate prenatal care is associated with increased neonatal death in both the presence and the absence of antenatal high-risk conditions. The observed association between inadequate prenatal care and neonatal mortality may be mediated by increased risk of preterm delivery and low birthweight in these pregnancies. Overutilisation of prenatal care is associated with potential risks for fetal and neonatal development, leading to increased neonatal mortality.     

Failure to obtain desired postpartum sterilization: risk and predictors

OBJECTIVE: The aim of this study was to assess the rate of and risk factors for not obtaining postpartum sterilization among women who expressed a desire for sterilization during antepartum care. METHODS: In this retrospective study, we identified a cohort of women who expressed desire for postpartum sterilization at our center between March 2002 and November 2003. We compared women who did and those who did not undergo the procedure, based on demographic, antenatal, and intrapartum factors. RESULTS: Of the 712 women who expressed desire for postpartum sterilization during antepartum care, 327 (46%) did not undergo the procedure. In multivariable analysis, women who were between the ages of 21 and 25 years (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.35-0.89), were African American (OR 0.68, 95% CI 0.47-1.00), requested sterilization in the second trimester (OR 0.50, 95% CI 0.29-0.86)), and had a vaginal delivery (OR 0.21, 95% CI 0.14-0.32) rather than cesarean delivery were least likely to undergo postpartum sterilization. CONCLUSION: Despite their initial request, only 54% of women in our sample underwent sterilization. Young age, African-American race, request in the second trimester, and vaginal delivery were significantly associated with not undergoing sterilization. Our data suggest that providers should counsel all women who desire postpartum sterilization about the wide array of contraceptive methods available, with the understanding that approximately half of all women may not undergo the sterilization procedure. LEVEL OF EVIDENCE: II-2.     

Assessment of risk factors for stillbirth among pregnant women in Jamaica.

A case - control study was conducted to assess the risk factors of stillbirth among pregnant women in Jamaica. A total of 314 women participated (160 with stillborn babies and 154 with live-born babies). A questionnaire designed to collect information on sociodemographic characteristics, antenatal care, medical and sexually transmitted disease (STD) history, method of delivery and infant birth and health status was administered to each woman. Medical records were reviewed to verify medical history. Six variables were found to be significant predictors of stillbirth by multivariate logistic regression. Low birth weight (OR = 4.3, CI = 2.4 - 7.7), complications during pregnancy or delivery (OR = .19, CI = 0.09 - 0.41), method of delivery (caesarean section; OR = 7.2, CI = 1.6 - 33.2), number of living children (OR = 0.54, CI = 0.40 - 0.73), number of antenatal visits (less than three; OR = 2.0, CI = 1.3 - 3.1), and presence of unfavourable and /or adverse fetal outcome (OR = 4.0, CI = 1.8 - 9.2) were found to be associated with stillbirth. These findings have important implications in establishing policies for prenatal care in Jamaica.     

Suboptimal care in stillbirths - a retrospective audit study

BACKGROUND: Stillbirth rates have decreased radically over the last decades. One reason for this is improved perinatal care. The aim of this study was to explore whether sub-optimal factors in stillbirths were more frequent among non-western than western women. METHODS: Population-based perinatal audit of 356 stillbirths after gestational week 23, in 2 Norwegian counties during 1998-2003 (4.2 per 1,000 deliveries); of these 31% were born to non-western women. By audit, the stillbirths were attributed to optimal or sub-optimal care factors. Multivariate methods were used to analyse the data. RESULTS: Sub-optimal factors were identified in 37% of the deaths. When compared to western women, non-western women had an increased risk of stillbirth (OR: 2.2; 95% CI: 1.3-3.8), and an increased risk of sub-optimal care (OR: 2.4; 95% CI: 1.5-3.9). More often, non-western women received sub-optimal obstetric care (p<0.001), as e.g. failure to act on non-reassuring fetal status or incorrect assessment of labour progression. A common failure in antenatal care for both groups was unidentified or inadequate management of intrauterine growth restriction or decreased fetal movements. Non-western women were less prone to attend the program for antenatal care or to take the consequences of recommendations from health professionals. Inadequate communication was documented in 47% of non-western mothers; an interpreter was used in 29% of these cases. CONCLUSIONS: Non-western women constituted a risk group for sub-optimal care factors in stillbirths. Possibilities for improvements include a reduction of language barriers, better identification and management of growth restriction for both origin groups, and adequate intervention in complicated vaginal births; with increased vigilance towards non-western women.     

Interaction between risk factors for fetal growth retardation associated with abnormal umbilical artery Doppler studies

BACKGROUND: The role of antenatal risk factors associated with the occurrence of fetal growth restriction complicated by abnormal umbilical artery Doppler studies has not yet been studied extensively. We evaluated the role and the interactions of antenatal antecedents of fetal growth restriction complicated by abnormal umbilical artery end-diastolic velocities. METHODS: We compared antenatal variables in 183 pregnancies complicated by fetal growth retardation and abnormal umbilical artery Doppler studies and 549 appropriately grown fetuses with normal end-diastolic velocity waveform in the umbilical artery. Logistic regression was used to evaluate the association between antenatal variables and fetal growth retardation and to test for interaction. RESULTS: In logistic models, increasing maternal age [odds ratio (OR) 1.06, 95% confidence interval (CI) 1.01-1.11], nulliparity (OR 2.2, 95% CI 1.37-3.5), smoking during pregnancy (OR 2.56, 95% CI 1.56-4.22), preeclampsia (OR 27.5, 95% CI 15.1-49.9), first-trimester hemorrhage (OR 2.25, 95% CI 1.32-3.82) and low (< 0.2 kg/week) weight gain in pregnancy (OR 3.48, 95% CI 1.71-3.05) were significantly associated with an increased risk of fetal growth restriction complicated by abnormal Doppler studies. These risk factors were also significantly correlated with the occurrence of absent/reversed end-diastolic blood flow in the umbilical artery. Maternal smoking during pregnancy interacted negatively with preeclampsia but positively with a low weight gain in pregnancy. CONCLUSIONS: The results of this study have shown that antenatal risk factors for intrauterine growth retardation (IUGR) complicated by abnormal Doppler studies are similar to those associated with the birth of a small-for-gestational-age infant. Preeclampsia, maternal smoking and low weight gain in pregnancy play a significant causal role in the origin of fetal growth restriction associated with abnormal uteroplacental blood flow.     

Do women with recurrent miscarriage constitute a high-risk obstetric population?

The aim of this study was to examine if women with history of recurrent miscarriage have a higher risk of maternal and foetal complications in future pregnancies. This was a retrospective case control study that analysed data collected prospectively between 2001 and 2007 from 400 women with history of recurrent miscarriage who achieved pregnancies progressing beyond 24 weeks gestation compared to 39,860 deliveries from the general obstetric database within the same time period. Results showed that women with recurrent miscarriage had significantly increased odds of low Apgar scores at one (odds ratios (OR) 1.57, 95% CI 1.20–2.05) and five?minutes (OR 2.0, 95% CI 1.23–3.27), small for gestational age (OR 1.96, 95% CI 1.12–3.43), preterm delivery (OR 1.64, 95% CI 1.22–2.19) and antepartum haemorrhage (OR 7.67, 95% CI 4.23–13.91). The risks were increased in the presence of a male foetus but no difference was observed between primary and secondary miscarriage patients. In conclusion, women with recurrent miscarriage have an increased risk of several maternal and foetal complications and therefore may require closer monitoring during the antenatal period particularly when pregnant with a male foetus.     

The impact of prenatal care on postneonatal deaths in the presence and absence of antenatal high-risk conditions

OBJECTIVE: This study was undertaken to determine the association, if any, between prenatal care and postneonatal death in the presence and absence of high-risk pregnancy conditions. STUDY DESIGN: Data were derived from the national linked birth/infant death data set for the years 1995 to 1997 provided by the National Center for Health Statistics. Analyses were restricted to singleton live births that occurred after 23 completed weeks of gestation. Multiple births, congenital malformations, chromosomal abnormalities, missing data on gestational age, and birth weight less than 500 g were excluded. Multivariable logistic regression analyses were used to adjust for various antenatal high-risk conditions, maternal age, gravidity, gestational age at delivery, birth weight, maternal education, marital status, smoking, and alcohol use. Postneonatal death rate was defined as the number of deaths between 28 and 365 days of life per 1,000 neonatal survivors. RESULTS: For 10,512,269 singleton live births analyzed, 21,962 (2.1 per 1,000) resulted in postneonatal death. Postneonatal death rates were higher for African American women than white women in the presence (3.8 vs 1.7 per 1,000) and absence (11.2 vs 5.3 per 1,000) of prenatal care. Lack of prenatal care was associated with increased relative risk (RR) for postneonatal death, 1.8-fold in African American women and 1.6-fold in white women. Lack of prenatal care was associated with increased postneonatal death rates to a similar degree for the individual high-risk pregnancy conditions for both African American and white women. Lack of prenatal care was associated with increased postneonatal death rates, especially in the presence of postterm pregnancy (RR 2.3, 95% CI 1.6, 3.1), pregnancy-induced hypertension (RR 2.2, 95% CI 1.5, 3.4), intrapartum fever (RR 2.1, 95% CI 1.2, 3.5), and small-for-gestational-age infant (RR 1.6, 95% CI 1.3, 2.0). CONCLUSION: Lack of prenatal care should be considered as a high-risk factor for postneonatal death for both African American and white women, especially if the pregnancy has been complicated by postdates, pregnancy-induced hypertension, intrapartum fever or small-for-gestational-age infant.     

Chronic hypertension as a risk factor for offspring to be born small for gestational age

BACKGROUND: Chronic hypertension during pregnancy is associated with an increased risk for birth of small for gestational age offspring. The aim of this study was to determine whether the risk remains after consideration of maternal characteristics and superimposed pre-eclampsia. METHOD: A population-based cohort study based on the Swedish Medical Birth Register 1992-98 and comprising 560 188 women aged 15-44 years with singleton pregnancies including 2,754 women with chronic hypertension. The register contains data of maternal characteristics besides maternal and fetal complications. Multiple logistic regression analysis was used. Small for gestational age was defined as birth weight less than -2SD adjusted for gestational age and sex. RESULTS: Chronic hypertensive women have an independent risk for small for gestational age (OR 3.1; 95% CI 2.7-3.7) when controlling for confounding of maternal characteristics such as age, parity, BMI, smoking, and ethnic origin. After introducing superimposed pre-eclampsia in the model the risk remains but decreases (OR 2.4; 95% CI 2.1-2.9). CONCLUSION: Chronic hypertension is an independent risk factor for birth of small for gestational age offspring. Pre-eclampsia is a strong mediating factor.     

Socio-economic, demographic and obstetric risk factors for late fetal death of unknown etiology in Lithuania: a case--referent study

BACKGROUND: The purpose of this study was to evaluate the association between third trimester unexplained prelabor fetal deaths and various socio-economic, demographic and obstetric factors in Lithuania. METHODS: A case-referent study on 58 women with third trimester fetal death and 116 women with live fetus at term was carried out. Inclusion criteria for women in the first group (cases) were: prelabor fetal death of unknown etiology, singleton pregnancy >26 weeks of gestation and intact fetal membranes. For each case two referent women were recruited, admitted during the same period in active phase of labor at term (>37 weeks of gestation) with intact fetal membranes and fetus alive. Data were obtained by interview, anthropometry and by reviewing the medical records. Several potential socio-economic, demographic and obstetrical risk factors for unexplained fetal death were investigated. RESULTS: Univariate analyses determined several factors that were associated with fetal death of unknown etiology: low educational level, single marital status, low income, etc. After secondary logistic regression analysis only three independent variables remained significantly associated with otherwise unexplained stillbirth: small for gestational age fetus (OR 29.6; 95% CI 6.2-141.6), low income (OR 7.4; 95% CI 3.1-17.6), and maternal white blood cell count more than 16,000/mm3 (OR 5.4; 95% CI 1.4-21.6). Body mass index, smoking, occupation of women and other evaluated parameters were not confirmed to be significant risk factors. CONCLUSION: Small for gestational age fetus, low income and elevated maternal white blood cell count are factors significantly associated with late prelabor fetal death in Lithuania.     

Maternal and perinatal outcome in nulliparous women aged 35 and older

OBJECTIVE: To compare the maternal and perinatal outcome of nulliparous women 35 years and older at the time of delivery with nulliparous women 25-29 years old. METHODS: A retrospective review of maternal and newborn records of singleton gestations only for first birth in women aged 35 and older (study group n = 143) were compared with pregnancies of women aged 25-29 (control group, n = 148) delivered at the same period with respect to pregnancy complications and outcome. The study was performed at the Princess Badeea Teaching Hospital in North Jordan between January 1, 1996 and July 1, 2000. RESULTS: Most of the elderly nulliparous women were professionals (60%) and 20% had a history of infertility. Compared with women aged 20-29 years, women delivering their first child at or >35 years were at increased risk of weight gain, obesity, chronic and pregnancy-induced hypertension, antepartum haemorrhage, multiple gestation, malpresentation, and premature rupture of membranes. Women aged 35 years and older were also substantially more likely to have preterm labour, oxytocin use, and caesarean births. The older women differed significantly in neonatal outcomes: gestational age, birth weight, preterm delivery, low birth weight, small for gestational age, fetal distress and neonatal intensive care unit admissions. CONCLUSION: It is concluded that nulliparous women 35 years and older had higher risk of antepartum, intrapartum, and neonatal complications than nulliparous women aged 25-29 years, but these risks, for the most part, are manageable in the context of modern obstetrics. The excess rate of caesarean sections is only partially accounted for by gestational complications. Despite the increased risk of complications, perinatal death of the study group was similar to that of the control group. There were no maternal deaths.     

Improved outcome of preterm infants when delivered in tertiary care centers

OBJECTIVE: Previous studies that compared outcomes of infants born outside tertiary care centers (outborn) with those born in tertiary care centers (inborn) did not account for admission illness severity and perinatal risks. The objective of this study was to examine whether outborn status is associated with higher mortality and morbidity, after adjustment for perinatal risks and admission illness severity (using the Score for Neonatal Acute Physiology, Version II [SNAP-II]) among preterm infants who were admitted to Neonatal Intensive Care Units (NICUs). METHODS: Logistic regression analysis was used to compare the risk-adjusted outcomes of 3769 singleton infants born at or before 32 weeks' gestation, who were admitted to 17 Canadian NICUs during 1996-1997. RESULTS: Outborn and inborn infants had significantly different gestational ages, perinatal risk factors (maternal hypertension, prenatal care, antenatal corticosteroid therapy, 5-minute Apgar score, delivery type, small for gestational age) and admission SNAP-II. Outborn infants were at higher risk of death (adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2, 2.5), grade III or IV intraventricular hemorrhage (adjusted OR 2.2, 95% CI 1.5, 3.2), patent ductus arteriosus (adjusted OR 1.6, 95% CI 1.2, 2.1), respiratory distress syndrome (adjusted OR 4.8, 95% CI 3.6, 6.3), and nosocomial infection (adjusted OR 2.5, 95% CI 1.9, 3.3), even after adjusting for perinatal risks and admission illness severity. CONCLUSIONS: Outborn infants were less mature and more ill than inborn infants at NICU admission. However, even after adjustment for perinatal risks and admission illness severity, inborn infants had better outcomes than outborn infants. Our results support in-utero transfer of high-risk pregnancies to a tertiary level facility.