Perinatal mortality at King Fahd Hospital of the University Al-Khobar, Saudi Arabia

The perinatal deaths of all singleton births that occurred at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia during a 4-year period are analysed. The causes of death are classified into 12 groups using an extended modification of the Aberdeen classification. There were 165 perinatal deaths in 8057 singleton births, giving a perinatal mortality rate of 20.47 per 1000 total births. Fetal malformations occurred in 29 (17.57%) cases. Of the remaining 136 normal infants, 77 (56.6%) were stillbirths and 59 (43.4%) died within 1 week of delivery. Spontaneous premature labor was the commonest cause of death (23.52%) followed by birth trauma (11%) and maternal diseases (9.55%). The cause of death was not known in 22 (16.17%) cases. In conclusion, prevention of premature labor, better intrapartum fetal monitoring, early recognition of fetal distress and improvement of neonatal care should reduce the perinatal mortality rate.     

A model for the prospective analysis of perinatal deaths in a perinatal network

This prospective study assesses factors that contribute to perinatal mortality. The study population includes the 1362 perinatal deaths that occurred among 85,402 live births between 1983 and 1987 at hospitals of the University of Chicago Perinatal Network. After peer review of demographic, clinical, and pathologic data, each perinatal death was classified in one of the following categories: (1) the result of congenital malformation incompatible with life, (2) unavoidable, (3) potentially avoidable by patient, by health provider, or by both, or (4) of undetermined responsibility. Of 1362 deaths, 12.3% involved congenital malformations incompatible with life, 56.9% were classified as unavoidable, 28.1% were judged potentially avoidable, and 2.7% due to undetermined causes. Of potentially avoidable deaths, 36% were due to patient factors (primarily noncompliance), 59% to health provider factors, and 15% to combined patient and provider factors. There was a significant reduction in the potentially avoidable cases during the study period. The maximum attainable reduction in perinatal mortality under optimal conditions is calculated. Intervention plans to achieve this goal are discussed.     

Clinical causes and classification of perinatal mortality in Lagos

Perinatal deaths in singleton births at the Lagos University Teaching Hospital during a 5-year period were reviewed. Causes of deaths were classified into eight groups using a modified form of the Aberdeen classification. Perinatal mortality was high (42.5/1000 total births). The stillbirth rate was 32.5/1000 total births. The major causes of perinatal mortality were trauma (30.5%), low birth weight (23.9%), hemorrhage (13.7%), toxemia of pregnancy (10.3%) and mature, cause unknown (10%). Congenital malformation (4.3%) was not a major cause of perinatal deaths in this study.     

The impact of multiple pregnancies and malformations on perinatal mortality

AIM: To evaluate the impact of the rate of multiple pregnancies and congenital malformations on perinatal mortality. METHODS: The study is based on data from the perinatal audit in Vejle County Denmark. Fetal deaths with gestational age > or = 22 weeks and deaths in livebirths within the first 28 days after birth were included in the calculated perinatal mortality. Total number of births was 30,181 and 252 pregnancies and 268 fetuses/infants were evaluated. The study period was 1995-2000. There was no routine ultrasound screening for congenital malformations in the county, though midtrimester ultrasound was used to assess gestational age. RESULTS: Perinatal mortality was 8.9 per 1000 births with no significant change over time. Rate of multiple pregnancies was 1.94% ranging from 1.81% during the first 3 years to 2.06% for the last 3 years (not significant). Fetuses and infants from multiple pregnancies contributed 18% of all deaths. Perinatal mortality for single births was 7.6 per 1000 births and for multiple births 42.2/1000 (P<0.0001). The distribution of gestational age for single and multiple births was highly significant (P<0.0001) with 67% of multiple pregnancies with GA < 28 weeks compared to 26% of single pregnancies. Nineteen percent of all deaths were caused by congenital malformations and the majority of these were potentially detectable by ultrasound investigation. CONCLUSIONS: The increasing rate of multiple pregnancies makes it difficult to see improvements in perinatal mortality. Calculated from the perinatal mortality in single and multiple pregnancies in Vejle County assisted conceptions contribute with an an excess of 45 perinatal deaths per year in Denmark. The difference between countries in rate of multiple pregnancies and in prenatal ultrasound screening recommendations for malformations makes it difficult to compare perinatal mortality.     

Acute and Subacute Polyhydramnios in Singleton Pregnancies

Over a 10-year period when 51,022 singleton infants were delivered, 19 pregnancies (1 in 2,685) were complicated by acute polyhydramnios 17 (1 in 3,000) by subacute polyhydramnios and 501 (1 in 102) by chronic polyhydramnios. The incidence of major congenital malformations in singleton pregnancies associated with acute polyhydramnios was 63% and the perinatal mortality rate was 74%. When subacute polyhydramnios occurred in singleton pregnancies, the incidence of major congenital malformations was 65%, similar to acute polyhydramnios, but the perinatal mortality rate was only 35%. The comparable figures for chronic polyhydramnios in singleton pregnancies were a major malformation incidence of 14% and perinatal mortality rate of 10%. The type of onset of polyhydramnios, acute, subacute or chronic is therefore the most important indicator of prognosis. In patients with gross polyhydramnios, acute renal failure must be specifically excluded.     

The Egypt National Perinatal/Neonatal Mortality Study 2000.

OBJECTIVES: To estimate stillbirth, perinatal (PMR) and neonatal mortality rates (NMR) in Egypt and to assign main causes of death. STUDY DESIGN: Data were collected from a representative sample of women who gave birth from 17,521 households which were included in the Egypt Demographic and Health Survey (EDHS) 2000. Comparisons were made between three systems for classifying causes of death. RESULTS: The NMR was 25 per 1000 live births (17 early and eight late). Half the deaths occurred in the first two days of life. Neonatal causes of death were pre-maturity (39%), asphyxia (18%), infections (7%), congenital malformation (6%) and unclassified (29%). The PMR was 34 per 1000 births, mainly attributed to: asphyxia (44%) and prematurity (21%). The revised Wigglesworth classification agreed well with the physicians except the panel attributed more deaths to infections (20%). The WHO verbal autopsy algorithm left 48% of deaths unclassified. CONCLUSIONS: Infant mortality in Egypt is showing an epidemiological transition with a significant decrease in mortality, resulting in a disproportionate percentage of deaths in the first week of life. Infant mortality in Egypt declined 64% from 124 per 1000 between 1974 and 1978 to 44 per 1000 between 1995 and 1999, the decline being greatest among older infants; 55% of all infant deaths occurred during the neonatal period. The neonatal mortality rate in this study was estimated to be 25 per 1000 live births.     

Can Anything Be Done About Mid-Trimester Fetal Wastage?

In Victoria in the triennium 1982-1984, perinatal losses between 22 and 28 weeks' gestation accounted for 32% of the overall perinatal wastage of 12.7 per 1,000 births. Over the same period only 1.2% of babies were delivered weighing less than 1,500g, but this group made up 40% of the total stillbirths and 50% of the neonatal deaths. By contrast the perinatal wastage was only 7 per 1,000 births in babies born weighing more than 1,500g and this included lethal congenital malformations. The major antenatal risk factors contributing to the high mid-trimester fetal wastage were premature labour (17.7%), multiple pregnancy (13.9%), cervical incompetence (12.9%), antepartum haemorrhage (12.9%), premature rupture of the membranes (11.5%), lethal congenital malformations (10.6%) and hypertensive disorders (7.4%). Cognizant of the frequency of preventable factors, the Consultative Council on Maternal and Perinatal Mortality and Morbidity in Victoria recommends that, where feasible, the mother of these high-risk pregnancies be transferred to a centre where facilities are available to monitor the pregnancy and labour, and which offers intensive care facilities for the baby.     

Perinatal mortality in a large perinatal center: five-year review of 31,000 births

The perinatal mortality rate for 30,928 babies born at Medical Center Hospital, San Antonio, Texas, between 1978 and 1982, was 20.3/1,000 births. Neonatal and fetal mortality rates were, respectively, 10.1/1,000 live births and 10.4/1,000 births. Exclusion of babies who weighed less than 500 gm yielded adjusted fetal, neonatal, and perinatal mortality rates of, respectively, 9.2, 9.8, and 17.9. Birth weight-specific mortality rates were calculated by groups of 250 gm birth weight for all neonates and by increments of 100 gm for babies who weighed 500 to 1,499 gm. Male infants, intrauterine growth-retarded babies, and babies whose mothers were less than 15 years old contributed more deaths than would be expected from the characteristics of the obstetric population. Presumptive cause of fetal death was unknown in 32%, fetal anoxia in 21%, maternal pathologic conditions in 20%, inappropriate fetal growth in 13%, congenital malformations in 8%, and systemic fetal infections in 6%. Leading presumptive causes of neonatal death were immaturity (29%), congenital malformations (18%), hemorrhages (16%), and systemic infections (10%). Hyaline membrane disease and necrotizing enterocolitis contributed, respectively, 7% and 6% of deaths. Past and future trends of perinatal mortality are discussed.     

Analysis of perinatal mortality at a teaching hospital in Dar es Salaam, Tanzania, 1999-2003

We conducted a retrospective analysis of perinatal mortality at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania 1999-2003 in order to categorise/classify perinatal deaths as well as to identify key factors in perinatal care that could be improved. Data were retrieved from the MNH obstetric database and causes of early neonatal deaths were traced from the neonatal ward register. The study includes all foetuses weighing =500g. A modified Nordic-Baltic classification was used for classification of perinatal deaths. Over a 5-year period there were 77,815 babies born with a perinatal mortality rate of 124 per 1000 births, 78% of which was labour related stillbirth. The PMR was 913/1000 for singleton births and 723/1000 for multiple births for babies weighing less than 1500 grams and 65/1000 for singleton births and 116/1000 for multiple births for babies weighing 2500 grams or more. Babies weighing less than 1500 grams contributed 26% of PMR, whereas 41% occurred in babies weighing 2500 grams or more. The majority (79%) of neonatal deaths had Apgar score <7 at 5 minutes and the most common causes of neonatal mortality were birth asphyxia (37%) and prematurity (29%). Labour related deaths were more common in multiple pregnancies. The majority of the perinatal deaths should be essentially avoidable through improved quality of intrapartum care. Establishment of perinatal audit at MNH can help identify key actions for improved care.     

Congenital malformations in infants conceived following assisted reproductive technology in comparison with spontaneously conceived infants

Abstract

Objective: To evaluate the risk for congenital malformations diagnosed at birth following assisted reproductive technology (ART) treatments compared with live births conceived spontaneously.

Methods: A retrospective cohort study including 9042 live births following ART and 213?288 spontaneously conceived (SC) live births during the period 1997–2004.The cohort was linked to the national live birth registry to determine the outcome of the pregnancies including congenital malformations.

Results: An increased adjusted risk for all congenital malformations was observed in ART compared with SC infants [2.4% versus 1.9%; OR_adj?=?1.45; 95% CI: 1.26, 1.68]. The increased risk was observed in singleton births [2.4% versus 1.8%; OR_adj?=?1.41; 95% CI: 1.14, 1.71] but not in the ART conceived multiple births [2.5% versus 2.6%.; OR_adj?=?1.15; 95% CI: 0.90, 1.46]. Significantly increased adjusted risks for nervous, circulatory, digestive and genital system malformations were evident in the ART singleton group compared to SC infants. In addition, increased risks were also observed in separate comparisons of IVF births versus SC [OR_adj?=?1.28; 95% CI: 1.00, 1.63] and ICSI births versus SC [OR_adj?=?1.56; 95% CI: 1.31, 1.84]. Data regarding pregnancy termination or congenital malformation diagnosed later in life were not included.

Conclusion: Infants born following ART were at significantly increased risk for congenital malformations compared to live birth conceived spontaneously.     

Congenital visceral malformations--role of perinatal autopsy in diagnosis

OBJECTIVES: Congenital malformations are one of the leading causes of perinatal deaths and infant mortality. The objective of the present study is to detect visceral malformations in perinatal autopsies. DESIGN: A retrospective analysis of perinatal autopsies performed between 1998 and 2001 was done. Various visceral malformations were noted and categorized as urologic, cardiac, respiratory, gastrointestinal and miscellaneous. RESULTS: Out of a total of 62 perinatal autopsies performed, congenital malformations were present in 38.7% of cases. Visceral malformations were observed in 24.1% of cases. Urologic malformations were the commonest (14.1%), followed by cardiac (8%) malformations. Associated external malformations were present in 6/15 cases, cardiac malformations being commonly associated with skeletal malformations. CONCLUSIONS: In all the cases, internal malformations were not suspected clinically. Thus, autopsy is an invaluable tool for detecting visceral malformations, adding to the clinical diagnosis and providing a feedback to the parents.     

Diabetes in pregnancy: a population-based study of incidence, referral for care, and perinatal mortality

During 1979 and 1980 in Washington State, 260 infants (live births plus fetal deaths greater than or equal to 20 weeks' gestation) were born to women with preexisting diabetes mellitus, the equivalent to a population-based incidence of 2.1 per 1000 total births. One quarter of these women had non-insulin-dependent diabetes prior to pregnancy. The perinatal mortality rate for all infants of diabetic mothers in this series was 108 per 1000, which was eight times the state perinatal mortality rate. Only 45% of births occurred in the five tertiary centers in the state, whereas 39% occurred in hospitals that had fewer than six deliveries per year complicated by overt diabetes. The mortality rate was slightly, but not significantly, lower among infants born in referral hospitals than among those born in primary-level hospitals. Congenital malformations accounted for 43% of the 28 perinatal deaths, and fetal losses between 20 and 27 weeks' gestation accounted for another 21%. During the 2-year study period there were only three cases in which antepartum care in nonspecialty centers may have contributed to a perinatal loss.     

Systematic multidisciplinary approach to reporting perinatal mortality: Lessons from a five-year regional review

Background:  Because of differences in reporting criteria throughout the world, comparing perinatal mortality rates and identifying areas of concern can be complicated and imprecise.
Aims:  To detail the systematic approach to reporting perinatal deaths and to identify any significant differences in outcomes in the Australian Capital Territory (ACT).
Methods:  Review of perinatal deaths from 2001 to 2005 in the ACT using the Australian and New Zealand Antecedent Classification of Perinatal Mortality (ANZACPM) and the Australian and New Zealand Neonatal Death Classification (ANZNDC) systems.
Results:  ACT residents' perinatal mortality rate was 10.6 per 1000 total births, fetal death rate 7.5 per 1000 total births and neonatal death rate 3.2 per 1000 live births. The three leading antecedent causes of perinatal death were congenital anomalies, spontaneous preterm birth and unexplained antepartum death. The three leading causes of neonatal death were extreme prematurity, cardiorespiratory disorders and congenital anomalies. Multiple births attributed to 20% (65 of 321) of perinatal deaths. Perinatal autopsy was performed in 50% of cases, but in only 64% of unexplained antepartum deaths.
Conclusions:  Causes of perinatal death for the ACT and surrounding New South Wales region are similar to other states using this classification system. The following are considered important lessons to promote accurate perinatal mortality reporting: (i) a universal reporting system for Australia utilising a multidisciplinary team; (ii) a high perinatal autopsy rate, especially in the critical area of antepartum death with no identifiable cause; and (iii) standardised definitions for avoidability. Attention to these areas may prompt further research and changes in practice to further reduce perinatal mortality.     

Breech delivery at term: do the perinatal results justify a trial of labour?

This is a retrospective study conducted at Princess Badee'a Teaching Hospital in North Jordan to compare neonatal loss and morbidity in term singleton breech infants delivered either vaginally or by caesarean section. In this study, all singleton term breech presentation at 37 completed weeks' gestation were reviewed. Three hundred and eight singleton term babies, presenting by the breech were studied. Intrapartum deaths, neonatal deaths and Apgar scores in vaginal and caesarean delivery were compared. After exclusion of infants with lethal congenital malformations and antenatal stillbirths, the incidence of intrapartum and neonatal deaths associated with vaginal births was 3.5% compared with 1.3% in infants born abdominally. The number of low Apgar scores were similar in both groups. We concluded that caesarean section for term singleton breech presentation is associated with good neonatal outcome and this may influence the decision of obstetricians about the mode of delivery.     

Monoamniotic twin pregnancies: antenatal management and perinatal results of 19 consecutive cases

Objective   To describe the obstetric management and perinatal outcome of antenatally diagnosed monoamniotic twin pregnancies (MATP) in a tertiary level maternity unit.
Setting   Port-Royal Maternity Hospital, Paris, France.
Population   MATP that progressed beyond 22 weeks seen from 1993 to 2001.
Methods   A retrospective chart review of all twin pregnancies. Diagnosis of MATP was made by ultrasonography and confirmed by placental pathology.
Main outcome measure   Perinatal mortality.
Results   Among the 1242 twins pregnancies delivered during the study period, 19 were monoamniotic. Four fetuses (10% of all births) had malformations. Perinatal mortality was high ( n = 12, 32%) because of fetal deaths (nine cases) and very preterm births (three neonatal deaths). No fetal deaths occurred after 29 weeks. Of the 15 women with at least one live fetus before labour, 6 gave birth by vaginal delivery (40%). No obstetric accidents occurred during vaginal deliveries.
Conclusion   Perinatal mortality of MATP is still very high, even with accurate, early antenatal diagnosis, intensified surveillance and delivery provided in a tertiary level hospital. The main causes of perinatal deaths are cord accidents in utero , congenital anomalies and very preterm births.     

Perinatal outcome of ICSI pregnancies compared with a matched group of natural conception pregnancies in Flanders (Belgium): a cohort study

A retrospective cohort study was conducted with an intracytoplasmic sperm injection (ICSI) group and a naturally conceived comparison group. A total of 1655 singleton and 1102 twin ICSI births were studied with regard to perinatal outcome. Control subjects (naturally conceived pregnancies) were selected from a regional registry and were matched for maternal age, parity, place of delivery, year of birth and fetal sex. The main outcome measures were duration of pregnancy, birth weight, Apgar score <5 after 5 min, neonatal complications, perinatal death and congenital malformations. Twin births, when compared with singletons, carry a much higher risk of poor perinatal outcome. For both ICSI singletons and ICSI twins, no significant difference was found between ICSI and naturally conceived pregnancies for all investigated parameters. After excluding like-sex twin pairs, ICSI twin pregnancies were at increased risk for perinatal mortality (OR = 2.74, CI = 1.26-5.98), prematurity (OR = 1.38, CI = 1.10-1.75) and low birth weight (OR = 1.34, CI = 1.06-1.69) compared with spontaneously conceived different-sex twin pairs. In conclusion, the perinatal outcome of ICSI singleton and twin pregnancies was very similar to that of spontaneously conceived pregnancies in this large cohort study. After excluding like-sex twin pairs, ICSI twins were at increased risk for prematurity, low birth weight and higher perinatal mortality compared with the natural conception comparison group.     

A parsimonious explanation for intersecting perinatal mortality curves: understanding the effect of plurality and of parity

BACKGROUND: Birth weight- and gestational age-specific perinatal mortality curves intersect when compared across categories of maternal smoking, plurality, race and other factors. No simple explanation exists for this paradoxical observation. METHODS: We used data on all live births, stillbirths and infant deaths in Canada (1991-1997) to compare perinatal mortality rates among singleton and twin births, and among singleton births to nulliparous and parous women. Birth weight- and gestational age-specific perinatal mortality rates were first calculated by dividing the number of perinatal deaths at any given birth weight or gestational age by the number of total births at that birth weight or gestational age (conventional calculation). Gestational age-specific perinatal mortality rates were also calculated using the number of fetuses at risk of perinatal death at any given gestational age. RESULTS: Conventional perinatal mortality rates among twin births were lower than those among singletons at lower birth weights and earlier gestation ages, while the reverse was true at higher birth weights and later gestational ages. When perinatal mortality rates were based on fetuses at risk, however, twin births had consistently higher mortality rates than singletons at all gestational ages. A similar pattern emerged in contrasts of gestational age-specific perinatal mortality among singleton births to nulliparous and parous women. Increases in gestational age-specific rates of growth-restriction with advancing gestational age presaged rising rates of gestational age-specific perinatal mortality in both contrasts. CONCLUSIONS: The proper conceptualization of perinatal risk eliminates the mortality crossover paradox and provides new insights into perinatal health issues.     

Review of causes of perinatal mortality in a regional perinatal center, 1980 to 1984

During 1980 to 1984, 279 deaths occurred among 15,306 births in a regional perinatal unit. Survival to discharge corrected for lethal malformations was 81% or better in infants with a birth weight above 749 gm. Congenital malformations (23.2%), infections (21.3%), asphyxia (19.8%), and hyaline membrane disease (11%) caused most perinatal deaths.     

Perinatal study in Tientsin: 1978

Clinical records of a total of 3320 singleton births, representing the year 1978, at the two Tientsin Medical College Hospitals, Tientsin, People's Republic of China, were studied to ascertain (a) reproductive parameters such as the average age of the mothers at first and successive births and (b) the relationships between perinatal deaths, prematurity and birth weight and the mothers's age, number of previous pregnancies, parity, maternal conditions in the prenatal and delivery period and operative procedures of delivery.