Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services?

Objective To test the hypothesis that suboptimal factors in perinatal care services resulting in perinatal deaths were more common among immigrant mothers from the Horn of Africa, when compared with Swedish mothers.
Design A perinatal audit, comparing cases of perinatal deaths among children of African immigrants residing in Sweden, with a stratified sample of cases among native Swedish women.
Population and setting Sixty-three cases of perinatal deaths among immigrant east African women delivered in Swedish hospitals in 1990–1996, and 126 cases of perinatal deaths among native Swedish women. Time of death and type of hospital were stratified.
Main outcome measures Suboptimal factors in perinatal care services, categorised as maternal, medical care and communication.
Results The rate of suboptimal factors likely to result in potentially avoidable perinatal death was significantly higher among African immigrants. In the group of antenatal deaths, the odds ratio (OR) was 6.2 (95% CI 1.9–20); the OR for intrapartal deaths was 13 (95% CI 1.1–166); and the OR for neonatal deaths was 18 (95% CI 3.3–100), when compared with Swedish mothers. The most common factors were delay in seeking health care, mothers refusing caesarean sections, insufficient surveillance of intrauterine growth restriction (IUGR), inadequate medication, misinterpretation of cardiotocography (CTG) and interpersonal miscommunication.
Conclusions Suboptimal factors in perinatal care likely to result in perinatal death were significantly more common among east African than native Swedish mothers, affording insight into socio-cultural differences in pregnancy strategies, but also the suboptimal performance of certain health care routines in the Swedish perinatal care system.     

Confidential enquiry of stillbirths in current obstetric practice.

OBJECTIVE: Confidential panel enquiry into sub-optimal factors relating to stillbirths. METHOD: All 121 stillbirths in KK Women's and Children's Hospital in the years 1995 and 1996 were studied. Three assessors reviewed the case records of each death, and panel consensus was reached regarding sub-optimal antenatal care and factors leading to stillbirths. RESULT: The incidence rate of stillbirth was 4.04 per 1000 deliveries. A total of 76 cases (62.8%) were found to have grade II and III sub-optimal factors in their management. Patients themselves were involved in the sub-optimal management of their own pregnancy in 52.9% of the stillbirths. Primary healthcare givers were involved in 8.3% of all stillbirths, specialist caregivers 12.4% and antenatal care system 4.1%. CONCLUSION: The study has identified sub-optimal antenatal management in over 60% of cases. As patients' factors form the major contribution towards sub-optimal care, management strategy aimed towards improving patients' education and compliance to antenatal care should be a priority.     

Are risk factors for stillbirths in low-income countries associated with sensorineural hearing loss in survivors?

Objectives.?To determine associated risk factors for stillbirths in Lagos, Nigeria and to examine possible relationships between these factors and the risk of sensorineural hearing loss (SNHL).

Methods.?Stillbirths in an inner-city maternity hospital from June 2005 to May 2007 were matched with live-birth controls at ratio 1:2. Risk factors and their associated adjusted odds ratio (OR) at 95% confidence interval (CI) were first determined by multiple logistic regression and then correlated with hearing screening failure among survivors who received a two-stage hearing screening with automated otoacoustic emissions and auditory brainstem response.

Results.?Of 201 cases examined and matched with 402 live births, 101 (50.2%) were fresh stillbirths and 100 (49.8%) macerated. Multiparity (OR: 1.92; CI: 1.16–3.20), lack of antenatal care (OR: 7.23; CI: 3.94–13.26), hypertensive conditions (OR: 6.48; CI: 2.94–14.29), antepartum haemorrhage (OR:18.84; CI: 6.96–51.00), premature rupture of membrane (OR:3.36; CI: 1.40–8.05), prolonged obstructed labour (OR: 22.25; CI: 10.07–49.16) and prematurity (OR: 2.30; CI: 1.2–4.01) were associated with increased risk of stillbirths whereas caesarean section (OR: 0.24; CI: 0.12–0.48) was associated with lower risk of stillbirths. Infants delivered by mothers with hypertensive conditions during pregnancy were at risk of SNHL (OR: 2.97; CI: 1.15–7.64).

Conclusion.?Hypertensive conditions during pregnancy increase the risk of stillbirths and place survivors at greater risk of SNHL.     

Changing childbirth: lessons from an Australian survey of 1336 women

Objective To investigate the views and experiences of care in labour and birth of a representative sample
Design Cross-sectional survey mailed to women 6–7 months after giving birth.
Population All women who gave birth in a two week period in Victoria, Australia in September 1993, except those who had a stillbirth or neonatal death.
Results After adjusting for parity, the risk status of the pregnancy, and social and obstetric factors, specific aspects of care with the greatest negative impact on the overall rating of intrapartum care were: caregivers perceived as unhelpful (midwives: adjusted OR 12.03 [95% CI 7–8–1 8.1, doctors: adjusted OR 6.76 [95% CI 4.–10.31); and having an active say in decisions only sometimes, rarely or not at all (adjusted OR 8.0 [95% CI 4.–16–11). In a separate regression analysis including parity, risk status, obstetric and social factors, but not specific aspects of care, factors associated with dissatisfaction with intrapartum care included participation in a shared antenatal care programme (adjusted OR 1.9 [95% CI 1.–3.1) and being of nonEnglish speaking background (adjusted OR 1.0 [95% CI 1.–2.1). The following factors lowered the odds of dissatisfaction: attending a birth centre (adjusted OR 0.34 [95% CI 0.–1.]) and knowing the midwives before going into labour (adjusted OR 0.8 [95% CI 0.–0.]).
Conclusion The survey demonstrates the potential for 'new' models of care to have either positive or negative effects on women's experiences of care. Evaluation of innovations in perinatal care taking into account women's views is a prerequisite for improvements in maternity care. of women who gave birth in Victoria, Australia in 1993.     

11. Perinatal mortality

Summary. The perinatal mortality rate in all singleton births was 103 per 1000; 67% of all perinatal deaths were stillbirths and in 77% of stillbirths, intrauterine death had already occurred before admission to hospital. Nine per cent of live births but 40% of stillbirths and 50% of neonatal deaths were of low birthweight (≤2.5 kg). The principal obstetric causes of perinatal deaths were obstructed labour and its consequences, anaemia, antepartum haemorrhage, eclampsia and low fetal birthweight. Nearly half of all perinatal deaths were associated with complicated deliveries of which vaginal breech delivery was by far the most hazardous. Both the proportion of babies with low birthweight and the perinatal mortality rates rose dramatically and progressively with haematocrit <0.30. A raised perinatal mortality rate was also associated with raised haematocrit >0.40. Of the biosocial factors influencing perinatal health, lack of antenatal care, residence outside Zaria, early teenage pregnancy and high parity exerted the most deleterious effect and literacy and antenatal care the most favourable effect on pregnancy outcome.     

Maternal risk factors associated with fetal death during antenatal care in low-resource tertiary hospitals

BACKGROUND: Data on maternal characteristics that could predict antepartum fetal death in women receiving antenatal care in resource-constrained settings are limited. Aims: To identify maternal sociodemographic and clinical risk factors for antepartum fetal death among women receiving antenatal care in a developing country setting. METHODS: Case-control analyses of risk factors in the occurrence of singleton fetal death before labour at two university hospitals in south-west Nigeria over 4-5 years. A total of 46 cases and 184 controls were compared for 31 sociodemographic and clinical risk factors. Unconditional multivariate logistic regression analysis was applied to determine independent risk factors. Level of significance was set at P < 0.05. RESULTS: The incidence of antepartum fetal death among women receiving antenatal care was 10.8 per 1000 total births during the period. Significant risk factors at univariate level include proteinuria, pregnancy-induced hypertension, pre-existing hypertension, reduced weight gain per week, previous antepartum fetal death, antepartum haemorrhage, previous miscarriage, symphysiofundal height-gestational age disparity = 4 cm and perception of reduced fetal movements. The independent risk factors were proteinuria (adjusted OR 4.23, CI: 1.57-11.42), pregnancy-induced hypertension (adjusted OR 8.24, CI: 3.01-22.51) and perceived reduction in fetal movements (adjusted OR 7.17, CI: 1.57-45.76). CONCLUSIONS: The identified factors should serve as potential targets for antenatal interventions to prevent antepartum fetal death in these institutions. Awareness of these factors should stimulate appropriate risk assessment geared towards the prevention of antepartum fetal deaths by clinicians in these centres and centres in similar setting.     

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.     

False-positive 1-hour glucose challenge test and adverse perinatal outcomes

OBJECTIVE: To determine whether a false-positive 1-hour glucose challenge test (GCT) is associated with perinatal complications. METHODS: We performed a retrospective cohort study of 1825 eligible pregnant women among a cohort of 1998 patients. Patients were screened for gestational diabetes mellitus (GDM) with the 1-hour 50-g GCT at 24-28 gestational weeks. A false-positive GCT was defined as a result greater than or equal to 135 mg/dL followed by a normal 3-hour glucose tolerance test (GTT). We compared the negative GCT and false-positive GCT cohorts for a composite perinatal outcome variable that included fetal macrosomia, antenatal death, shoulder dystocia, chorioamnionitis, preeclampsia, intensive care nursery admission, and postpartum endometritis. Secondary outcomes included cesarean delivery and each component variable of the composite. Unadjusted, stratified, and multiple logistic regression analyses were used to investigate the association between a false-positive GCT and the development of perinatal complications. RESULTS: We identified 164 patients with a false-positive GCT and 50 patients with GDM. The false-positive GCT cohort on average was older, of higher parity, had a higher body mass index, and more frequently had chronic hypertension, sickle cell trait, and elevated midtrimester human chorionic gonadotropin levels. The false-positive GCT cohort more frequently had adverse perinatal outcomes, including the composite perinatal outcome (odds ratio [OR] 5.96, 95% confidence interval[CI]1.47,24.16), macrosomia greater than 4500 g (OR 3.66, 95% CI 1.30, 10.32), antenatal death (OR 4.61, 95% CI 0.77, 27.48), shoulder dystocia (OR 2.85, 95% CI 1.25, 6.51), endometritis (OR 2.18, 95% CI 1.03, 4.63), and cesarean delivery (OR 1.76, 95% CI 0.99, 3.14). CONCLUSION: A false-positive GCT is an independent risk factor for adverse perinatal outcomes.     

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.     

Effectiveness of referral system for antenatal and intra-partum problems in Gutu district, Zimbabwe.

We conducted a population-based cohort study to determine the prevalence of antenatal and intra-partum referrals, compliance with advice and perinatal outcomes in referred pregnant women in Gutu district, Zimbabwe. The cohort was composed of 10,572 women who received antenatal care in 23 rural health centres (RHC) in Gutu district between January 1995 and June 1998. Pregnancy records of women with antenatal or intra-partum referral were analysed for indication, compliance and perinatal outcomes. Using women who had no antenatal referral or those who complied as referents, the association of referral with perinatal outcome was expressed as relative risk (RR) with 95% confidence intervals (CI). A total of 30% of women (3,094/10,572) had an antenatal referral. Among women attending RHC in labour, 13% (694/5,338) were referred intra-partum. Nulliparous and women younger than 20 years were more likely to be referred. Nurse - midwives' compliance with referral recommendations was low as 59% women with historical risk factors and 52% with raised blood pressure (>140/90 mmHg) were not referred. Women complied with referral advice except when indication was high parity. Women with antenatal referral were more likely to have hospital delivery, 70% vs 18% (p < 0.001). A total of 13% (993/7,478) of women referred themselves for hospital delivery. The risk of perinatal death was elevated among intra-partum referrals (RR 3.4; 95% CI 1.7 - 6.8), self-referrals (RR 2.6; 95% CI 1.5 - 4.5) and also among women with historical risk factors who were not referred (RR 4.8; 95% CI 2.5 - 9.2). We concluded that although there was a functional referral system in Gutu district its efficiency was reduced by failure of health personnel to comply with referral recommendations. Women took appropriate action for most referral indications.     

A case-control study of intrapartum stillbirths.

OBJECTIVE: To determine antenatal and intrapartum risk factors for intrapartum stillbirths in a total population. DESIGN: Matched case-control study. SETTING: Western Australia 1980-1983. SUBJECTS: Intrapartum stillbirths of > or = 1000 g birthweight (cases) and liveborn infants (controls) individually matched for year of birth, plurality, sex and birthweight of infant and race of mother. RESULTS: Intrapartum stillbirths were more likely than controls to have had placental abruption (OR = 9.55, CI = 2.09-43.69), fetal distress (OR = 4.64, CI = 1.92-11.19), cord prolapse (OR = 10.00, CI = 1.17-85.60) and unhealthy placentas (OR = 2.26, CI = 1.13-4.52), and more likely to have been born by vaginal breech manoeuvre (OR = 3.51, CI = 1.40-8.80) and emergency caesarean section (OR = 2.15, CI = 1.13-4.10); mothers of intrapartum stillbirths were less likely to have had no labour (OR = 0.14, CI = 0.04-0.55) and to have been delivered normally (OR = 0.20, CI = 0.10-0.40). Mothers of cases born by emergency caesarean section had longer labours than mothers of controls born by this method. All intrapartum stillbirths with breech presentation were born by vaginal breech manoeuvre compared with only 53% of the controls; the remainder of the controls were born by caesarean section. CONCLUSIONS: Results indicate that little could have been done early in pregnancy to prevent the intrapartum stillbirths as no antenatal risk factors predicted these deaths. Most of the risk factors identified related to labour and delivery problems. Considering cases born by emergency caesarean section, delivery of the mother earlier in labour may have prevented some of the deaths.     

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.     

Trends in adverse maternal outcomes during childbirth: a population-based study of severe maternal morbidity

Background

Women experiencing decreased fetal movements (DFM) are at increased risk of adverse outcomes, including stillbirth. Fourteen delivery units in Norway registered all cases of DFM in a population-based quality assessment. We found that information to women and management of DFM varied significantly between hospitals. We intended to examine two cohorts of women with DFM before and during two consensus-based interventions aiming to improve care through: 1) written information to women about fetal activity and DFM, including an invitation to monitor fetal movements, 2) guidelines for management of DFM for health-care professionals.

Methods

All singleton third trimester pregnancies presenting with a perception of DFM were registered, and outcomes collected independently at all 14 hospitals. The quality assessment period included April 2005 through October 2005, and the two interventions were implemented from November 2005 through March 2007. The baseline versus intervention cohorts included: 19,407 versus 46,143 births and 1215 versus 3038 women with DFM, respectively.

Results

Reports of DFM did not increase during the intervention. The stillbirth rate among women with DFM fell during the intervention: 4.2% vs. 2.4%, (OR 0.51 95% CI 0.32–0.81), and 3.0/1000 versus 2.0/1000 in the overall study population (OR 0.67 95% CI 0.48–0.93). There was no increase in the rates of preterm births, fetal growth restriction, transfers to neonatal care or severe neonatal depression among women with DFM during the intervention. The use of ultrasound in management increased, while additional follow up visits and admissions for induction were reduced.

Conclusion

Improved management of DFM and uniform information to women is associated with fewer stillbirths.     

Pre-eclampsia: maternal risk factors and perinatal outcome

OBJECTIVE: The aim of this study was to throw light on the incidence of pre-eclampsia (PE) in women attending for care and delivery at a hospital in Saudi Arabia, and analyze the maternal risk factors and outcome of mothers and neonates in pregnancies complicated by PE. METHODS: This retrospective study involved almost all women (n = 27,787) who delivered at King Fahad Hospital of the University in a 10-year period (1992-2001). The maternal records were reviewed for age, parity, gestational age, mode of delivery, antenatal care, onset of PE, severity of proteinuria, and the frequency of antenatal and intrapartum complications. The neonatal records were reviewed for perinatal outcome including birth weight, frequency of stillbirths, and neonatal deaths. RESULTS: Among the study cohort of pregnancies, 685 women, i.e. 2.47%, were diagnosed as having PE among whom a high proportion (42.0%) were nulliparous women. Similarly, PE was encountered at a high percentage (40.0%) in women at the extreme of their reproductive age (< 20 and >40 years), and more women with PE delivered prematurely (30.2%) as compared to healthy controls (13.5%). Spontaneous vaginal deliveries were less frequent in women with PE (69.2%) as compared with healthy controls (86.2%). Instrumental deliveries, with spontaneous labor, amounted to 15.9% in women with PE, but they comprised only 2.9% in healthy women. The deliveries were more likely to be induced (22.8%) or be performed by cesarean section (14.9%) in women with PE than in healthy controls (6.8% and 9.6%). Placental abruption was the most common maternal complication (12.6%) in women with PE, followed by oligouria (7.9%), coagulopathy (6.0%), and renal failure (4.1%). The perinatal outcome of pregnancies with PE shows that stillbirths (2.34%) and early neonatal deaths (1.02%) comprised an overall mortality rate of 33.6 per 1,000. More stillbirths and neonatal deaths showed a tendency to be associated with the severe form of PE (diastolic BP > or =120), as compared with the mild form (diastolic BP 90-110). Stillbirths and neonatal deaths appear to be associated with women who had no or irregular antenatal care and whose proteinuria amounted to or exceeded 3 g per 24 h, when delivery occurred at 28th gestational week or less, and when the birth-weight of the neonates was between 500 and 1,000 g. CONCLUSION: We document a hospital-based incidence rate of PE of 2.47%, with a high proportion of PE cases occurring among nulliparous women and those at the extreme ends of the reproductive age. More maternal and neonatal complications were encountered in women with PE when the PE was severe, when the pregnancy had to be terminated early, when there was no regular antenatal care, the birth-weight was low, or the proteinuria was severe.     

Effect of the interpregnancy interval on perinatal outcomes in Latin America

OBJECTIVE: To estimate whether interpregnancy interval is independently associated with increased risk of perinatal death and other adverse perinatal outcomes. METHODS: We investigated the effect of interpregnancy interval on perinatal outcomes in 1,125,430 pregnancies recorded in the Perinatal Information System database of the Latin American Center for Perinatology and Human Development, Montevideo, Uruguay, between 1985 and 2004. Odds ratios (ORs) were adjusted for 16 major confounding factors using multiple logistic regression models. RESULTS: Compared with infants with interpregnancy intervals of 18-23 months, those born to women with intervals shorter than 6 months had an increased risk of early neonatal death (adjusted OR 1.49, 95% confidence interval [CI] 1.06-1.96), fetal death (adjusted OR 1.54, 95% CI 1.28-1.83), low birth weight (adjusted OR 1.88, 95% CI 1.78-1.90), very low birth weight (adjusted OR 2.01, 95% CI 1.73-2.31), preterm birth (adjusted OR 1.80, 95% CI 1.71-1.89), very preterm birth (adjusted OR 1.95, 95% CI 1.67-2.26), and small for gestational age (adjusted OR 1.30, 95% CI 1.25-1.36). Intervals of 6-11 months and 60 months and longer were also associated with a significantly greater risk for the 7 adverse perinatal outcomes. CONCLUSION: In Latin America, interpregnancy intervals shorter than 12 months and longer than 59 months are independently associated with increased risk of adverse perinatal outcomes. These data suggest that spacing pregnancies appropriately could prevent perinatal deaths and other adverse perinatal outcomes in the developing world.     

Stillbirth in diabetic pregnancies

Pregnancy in women with pregestational diabetes is associated with high perinatal morbidity and mortality. Stillbirth accounts for the majority of cases with perinatal death. Intrauterine growth restriction, pre-eclampsia, foetal hypoxia and congenital malformations may be contributing factors, but more than 50% of stillbirths are unexplained. Majority of stillbirths are characterised by suboptimal glycaemic control during pregnancy. Foetal hypoxia and cardiac dysfunction secondary to poor glycaemic control are probably the most important pathogenic factors in stillbirths among pregnant diabetic women. There is thus a need for new strategies for improving glycaemic control to near-normal levels throughout pregnancy and for preventing and treating hypertensive disorders in pregnancy. Antenatal surveillance tests including ultrasound examinations of the foetal growth rate, kick counting and non-stress testing of foetal cardiac function are widely used. However, future research should establish better antenatal surveillance tests to identify the infants susceptible to stillbirth before it happens.     

子痫前期患者胎盘早剥发病危险因素分析

目的 探讨子痫前期患者胎盘早剥发病的危险因素.方法 对1994年1月至2008年12月的15年间,在北京大学第三医院住院并分娩的219例患者的临床资料进行回顾性分析,根据病情分为3组:子痫前期早剥组,52例,为重度子痫前期发生胎盘早剥的患者;子痫前期组,130例,为重度子痫前期未发生胎盘早剥的患者;原因不明早剥组,37例,为非子痫前期发生胎盘早剥的患者.选择同期无并发症的正常分娩产妇178例为对照组(按1∶2病例对照研究方法选择).采用单因素及多因素回归分析方法,分析子痫前期患者胎盘早剥的发病危险因素.结果 (1)与对照组比较,单因素分析结果显示,孕次、产次、子痫前期病史、中晚期妊娠丢失史、自身免疫性疾病史、慢性高血压病史、此次孕期无规律产前检查、胎儿生长受限(FGR)及脐动脉收缩期最大血流速度(S)与舒张末期血流速度(D)的比值(S/D)异常是子痫前期患者胎盘早剥发病的危险因素;多因素回归分析显示,孕期无规律产前检查(OR=45.348,95%CI为17.096～120.288,P=0.000)、FGR(OR=27.087,95%CI为5.585～131.363,P=0.000)及中晚期妊娠丢失史(OR=16.068,95% CI为1.698～152.029,P=0.015)是子痫前期患者胎盘早剥发病的独立危险因素.(2)与子痫前期组比较,子痫前期病史(OR=3.715,95% CI为1.096～12.596,P=0.035)及孕期无规律产前检查(OR=2.509,95%CI为1.173～5.370,P=0.018)是子痫前期患者胎盘早剥发病的独立危险因素.结论 孕期无规律产前检查、子痫前期病史、中晚期妊娠丢失史及FGR是影响子痫前期患者胎盘早剥发病的危险因素.     

Restricted fetal growth in sudden intrauterine unexplained death

BACKGROUND: Unexplained antepartum stillbirth is a common cause of perinatal death, and identifying the fetus at risk is a challenge for obstetric practice. Intrauterine growth restriction (IUGR) is associated with a variety of adverse perinatal outcomes, but reports on its impact on unexplained stillbirths by population-based birthweight standards have been varying, including both unexplained and unexplored stillbirths. AIM: We have studied IUGR, assessed by individually adjusted fetal weight standards, in antepartum deaths that remained unexplained despite thorough postmortem investigations. METHODS: Antenatal health cards from a complete population-based 10-year material of 76 validated sudden intrauterine unexplained deaths were compared to those of 582 randomly selected liveborn controls. Birthweight <10th percentile of the individualized standard adjusted for gestational age, maternal height, weight, parity, ethnicity, and fetal gender was defined as growth restriction. RESULTS: 52% of unexplained stillbirths were growth restricted, with a mean gestational age at death of 35.1 weeks. Suboptimal growth was the most important fetal determinant for sudden intrauterine unexplained death (odds ratio 7.0, 95% confidence interval 3.3-15.1). Concurrent maternal overweight or obesity, high age, and low education further increase the risk. Overweight and obesity increase the risk irrespective of fetal growth, and while high maternal age increases the risk of the normal weight fetus, it is not associated to growth restriction as a precursor of sudden intrauterine unexplained death. CONCLUSIONS: IUGR is an important risk factor of sudden intrauterine unexplained death, and this should be excluded in pregnancies with any other risk factor for sudden intrauterine unexplained death.     

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.     

Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand

Background

Although a number of antenatal and intrapartum interventions have shown some evidence of impact on stillbirth incidence, much confusion surrounds ideal strategies for delivering these interventions within health systems, particularly in low-/middle-income countries where 98% of the world's stillbirths occur. Improving the uptake of quality antenatal and intrapartum care is critical for evidence-based interventions to generate an impact at the population level. This concluding paper of a series of papers reviewing the evidence for stillbirth interventions examines the evidence for community and health systems approaches to improve uptake and quality of antenatal and intrapartum care, and synthesises programme and policy recommendations for how best to deliver evidence-based interventions at community and facility levels, across the continuum of care, to reduce stillbirths.

Methods

We systematically searched PubMed and the Cochrane Library for abstracts pertaining to community-based and health-systems strategies to increase uptake and quality of antenatal and intrapartum care services. We also sought abstracts which reported impact on stillbirths or perinatal mortality. Searches used multiple combinations of broad and specific search terms and prioritised rigorous randomised controlled trials and meta-analyses where available. Wherever eligible randomised controlled trials were identified after a Cochrane review had been published, we conducted new meta-analyses based on the original Cochrane criteria.

Results

In low-resource settings, cost, distance and the time needed to access care are major barriers for effective uptake of antenatal and particularly intrapartum services. A number of innovative strategies to surmount cost, distance, and time barriers to accessing care were identified and evaluated; of these, community financial incentives, loan/insurance schemes, and maternity waiting homes seem promising, but few studies have reported or evaluated the impact of the wide-scale implementation of these strategies on stillbirth rates. Strategies to improve quality of care by upgrading the skills of community cadres have shown demonstrable impact on perinatal mortality, particularly in conjunction with health systems strengthening and facilitation of referrals. Neonatal resuscitation training for physicians and other health workers shows potential to prevent many neonatal deaths currently misclassified as stillbirths. Perinatal audit systems, which aim to improve quality of care by identifying deficiencies in care, are a quality improvement measure that shows some evidence of benefit for changes in clinical practice that prevent stillbirths, and are strongly recommended wherever practical, whether as hospital case review or as confidential enquiry at district or national level.

Conclusion

Delivering interventions to reduce the global burden of stillbirths requires action at all levels of the health system. Packages of interventions should be tailored to local conditions, including local levels and causes of stillbirth, accessibility of care and health system resources and provider skill. Antenatal care can potentially serve as a platform to deliver interventions to improve maternal nutrition, promote behaviour change to reduce harmful exposures and risk of infections, screen for and treat risk factors, and encourage skilled attendance at birth. Following the example of high-income countries, improving intrapartum monitoring for fetal distress and access to Caesarean section in low-/middle-income countries appears to be key to reducing intrapartum stillbirth. In remote or low-resource settings, families and communities can be galvanised to demand and seek quality care through financial incentives and health promotion efforts of local cadres of health workers, though these interventions often require simultaneous health systems strengthening. Perinatal audit can aid in the development of better standards of care, improving quality in health systems. Effective strategies to prevent stillbirth are known; gaps remain in the data, the evidence and perhaps most significantly, the political will to implement these strategies at scale.