Causes and risk factors for singleton stillbirth in Japan: Analysis of a nationwide perinatal database, 2013-2014

Value of CODAC classification in identifying causes of stillbirths

PURPOSE

Stillbirth is a public health problem and one of the main obstetrical complications of pregnancy that practitioners can ever witness. A careful etiological investigation and a search for risk factors is necessary. The main objective of our study was to identify the causes of stillbirths using the CODAC classification system.

METHODS

It was a monocentric retrospective descriptive study conducted over 5 years in our gynecology department. We collected 114 cases.

RESULTS

The overall frequency was 8.26 ‰. The average age of women was 32.19 years. Women came from an urban environment in 48.2% and had a low level of education in 54.4% of cases. Our patients were moderately obese (48%). A history of stillbirth was found in 33 cases (28.9%), and the average term of pregnancy was 32 weeks' gestation. Pregnancy was poorly monitored in 2/3 of the population studied. The most frequent reason for consultation was a decrease/absence of fetal movement perception (30%). Labor was induced in 53.5% of deliveries. Delivery was by vaginal route in 58% of cases and the male sex was predominant (61%). For funicular anomalies, a placental abruption was found in 21.1% of cases, and a cord loop in 11.4%. For the etiological investigation via the CODAC classification, maternal pathologies were the most frequent with 28.07% of cases dominated by hypertension. Placental pathologies (placental abruption) and cord abnormalities (cord loop) represented, respectively, 22 and 21.05%. An unexplained cause was found in 20.17%.

CONCLUSIONS

For the etiological investigation, we relied on the CODAC classification to minimize unexplained causes. This etiological investigation is essential not only to provide answers for the bereaved couple but also to prevent the recurrence of such incidents in subsequent pregnancies.

Maternal Exposure to Per- and Polyfluoroalkyl Substances and Offspring Chromosomal Abnormalities: The Japan Environment and Children's Study

BACKGROUND

Although recent in vitro experimental results have raised the question of whether maternal exposure to per- and polyfluoroalkyl substances (PFAS) may be a potential environmental risk factor for chromosomal abnormalities, epidemiological studies investigating these associations are lacking.

OBJECTIVES

This study examined whether prenatal PFAS exposure is associated with a higher prevalence of chromosomal abnormalities among offspring.

METHODS

We used data from the Japan Environment and Children's Study, a nationwide birth cohort study, and employed logistic regression models to examine the associations between maternal plasma PFAS concentrations in the first trimester and the diagnosis of chromosomal abnormalities in all births (artificial abortions, miscarriages, stillbirths, and live births) up to 2 years of age. In addition, we examined associations with mixtures of PFAS using multipollutant models.

RESULTS

The final sample consisted of 24,724 births with singleton pregnancies, of which 44 confirmed cases of chromosomal abnormalities were identified (prevalence: 17.8/10,000 births). When examined individually, exposure to perfluorononanoic acid (PFNA) and perfluorooctane sulfonic acid (PFOS) showed positive associations with any chromosomal abnormalities with age-adjusted odds ratios of 1.81 (95% CI: 1.26, 2.61) and 2.08 (95% CI: 1.41, 3.07) per doubling in concentration, respectively. These associations remained significant after Bonferroni correction, although they did not reach the adjusted significance threshold in certain sensitivity analyses. Furthermore, the doubling in all PFAS included as a mixture was associated with chromosomal abnormalities, indicating an age-adjusted odds ratio of 2.25 (95% CI: 1.34, 3.80), with PFOS as the predominant contributor, followed by PFNA, perfluoroundecanoic acid (PFUnA), and perfluorooctanoic acid (PFOA).

DISCUSSION

The study findings suggested a potential association between maternal exposure to PFAS, particularly PFOS, and chromosomal abnormalities in offspring. However, the results should be interpreted cautiously, because selection bias arising from the recruitment of women in early pregnancy may explain the associations. https://doi.org/10.1289/EHP13617.

Incidence and first trimester risk factors of stillbirth in Indonesia

OBJECTIVES

To determine the incidence and the risk factors of stillbirth from maternal biophysical, ultrasound, and biochemical markers at 11-13 weeks of gestation in the Indonesian population.

METHODS

This was a retrospective cohort study of pregnant women for first-trimester preeclampsia screening at 11-13 weeks of gestation in some clinics and hospital in Jakarta. Maternal characteristics and history, mean arterial pressure (MAP) measurement, uterine artery pulsatility index (UtA-PI) ultrasound, maternal ophthalmic peak ratio (Oph-PR) Doppler, and placental growth factor (PlGF) serum were collected during the visit. Stillbirth was classified into placental dysfunction-related when it occurred with preeclampsia or birth weight <10th percentile and non-placental dysfunction-related. Bivariate and multivariate logistic regression analyses were employed to determine the risk factors associated with stillbirth.

RESULTS

Of 1,643 eligible participants, 13 (0.79 %) stillbirth cases were reported. More than half of the stillbirths (7) were placental dysfunction-related. After adjusted with maternal age, body mass index (BMI), and parity status, chronic hypertension (aOR (adjusted odds ratio)) 24.41, 95 % CI {confidence interval} 5.93-100.43), previous pregnancy with preeclampsia (aOR 15.79, 95 % CI 4.42-56.41), MAP >101.85 (aOR 26.67, 95 % CI 8.26-86.06), UtA-PI >1.90 (aOR 10.68, 95 % CI 2.34-48.58, and PlGF <28.77 pg/mL (aOR 18.60, 95 % CI 5.59-61.92) were associated with stillbirth.

CONCLUSIONS

The incidence of stillbirth in the population is comparable to studies conducted in developed countries. Most routine variables assessed at the 11-13 weeks combined screening for preeclampsia are associated with the risk of stillbirth.

Maternal and fetal factors associated with stillbirth in singleton pregnancies in 13 hospitals across six states in India: A prospective cohort study

OBJECTIVE

This study aimed to investigate the incidence of and risk factors for stillbirth in an Indian population.

METHODS

We conducted a secondary data analysis of a hospital-based cohort from the Maternal and Perinatal Health Research collaboration, India (MaatHRI), including pregnant women who gave birth between October 2018-September 2023. Data from 9823 singleton pregnancies recruited from 13 hospitals across six Indian states were included. Univariable and multivariable Poisson regression analysis were performed to examine the relationship between stillbirth and potential risk factors. Model prediction was assessed using the area under the receiver-operating characteristic (AUROC) curve.

RESULTS

There were 216 stillbirths (48 antepartum and 168 intrapartum) in the study population, representing an overall stillbirth rate of 22.0 per 1000 total births (95% confidence interval [CI]: 19.2-25.1). Modifiable risk factors for stillbirth were: receiving less than four antenatal check-ups (adjusted relative risk [aRR]: 1.75, 95% CI: 1.25-2.47), not taking any iron and folic acid supplementation during pregnancy (aRR: 7.23, 95% CI: 2.12-45.33) and having severe anemia in the third trimester (aRR: 3.37, 95% CI: 1.97-6.11). Having pregnancy/fetal complications such as hypertensive disorders of pregnancy (aRR: 1.59, 95% CI: 1.03-2.36), preterm birth (aRR: 4.41, 95% CI: 3.21-6.08) and birth weight below the 10th percentile for gestational age (aRR: 1.35, 95% CI: 1.02-1.79) were also associated with an increased risk of stillbirth. Identified risk factors explained 78.2% (95% CI: 75.0%-81.4%) of the risk of stillbirth in the population.

CONCLUSION

Addressing potentially modifiable antenatal factors could reduce the risk of stillbirths in India.

Obesity as a potential risk factor for stillbirth: The Japan Environment and Children's Study

The relationship between high body mass index (BMI) >25 kg/m2 and risk for stillbirth in the Japanese population remains unclear. This study aimed to estimate the impact of maternal obesity on the risk of stillbirth in a Japanese population. This prospective cohort study used data from the Japan Environment and Children's Study, which recruited pregnant individuals between 2011 and 2014. A total of 93,772 fetuses were considered eligible for inclusion in this study. Stillbirth (fetal death before or during labor at ≥22 completed weeks of gestation) rates were compared among four pre-pregnancy BMI groups: underweight (<18.5 kg/m2), reference (18.5 to <25.0 kg/m2), overweight (25.0 to <30.0 kg/m2), and obese (≥30.0 kg/m2). The association between pre-pregnancy BMI and the risk of stillbirth was estimated using multiple logistic regression analyses. The overall stillbirth incidence was 0.33% (305/93,722). Compared with the reference group, the risk of stillbirth was significantly higher in the overweight group (adjusted odds ratio [aOR]: 1.55; 95% confidence interval [CI]: 1.08-2.23) and the obese group (aOR: 2.60; 95% CI: 1.59-4.24). The overall incidence of early stillbirth (i.e., <28 weeks) was 0.17% (155/93,722). Similarly, after adjusting for potential confounding factors, the risk of early stillbirth was significantly higher in the obese group (aOR: 4.33; 95% CI: 2.44-7.70). Increased maternal BMI was associated with an increased risk of stillbirth in the Japanese population. Therefore, counselling women planning for pregnancy on the importance of an appropriate pre-pregnancy BMI to minimize the risk of stillbirth is important.

Evaluating the impact of maternal health care policy on stillbirth and perinatal mortality in Ghana; a mixed method approach using two rounds of Ghana demographic and health survey data sets and qualitative design technique

BACKGROUND

Stillbirth and perinatal mortality issues continue to receive inadequate policy attention in Ghana despite government efforts maternal health care policy intervention over the years. The development has raised concerns as to whether Ghana can achieve the World Health Organization target of 12 per 1000 live births by the year 2030.

PURPOSE

In this study, we compared stillbirth and perinatal mortality between two groups of women who registered and benefitted from Ghana's 'free' maternal health care policy and those who did not. We further explored the contextual factors of utilization of maternal health care under the 'free' policy to find explanation to the quantitative findings.

METHODS

The study adopted a mixed method approach, first using two rounds of Ghana Demographic and Health Survey data sets, 2008 and 2014 as baseline and end line respectively. We constructed outcome variables of stillbirth and perinatal mortality from the under 5 mortality variables (n = 487). We then analyzed for association using multiple logistics regression and checked for sensitivity and over dispersion using Poisson and negative binomial regression models, while adjusting for confounding. We also conducted 23 in-depth interviews and 8 focus group discussions for doctors, midwives and pregnant women and analyzed the contents of the transcripts thematically with verbatim quotes.

RESULTS

Stillbirth rate increased in 2014 by 2 per 1000 live births. On the other hand, perinatal mortality rate declined within the same period by 4 per 1000 live births. Newborns were 1.64 times more likely to be stillborn; aOR: 1.64; 95% [CI: 1.02, 2.65] and 2.04 times more likely to die before their 6th day of life; aOR: 2.04; 95% [CI: 1.28, 3.25] among the 'free' maternal health care policy group, compared to the no 'free' maternal health care policy group, and the differences were statistically significant, p< 0.041; p< 0.003, respectively. Routine medicines such as folic acid and multi-vitamins were intermittently in short supply forcing private purchase by pregnant women to augment their routine requirement. Also, pregnant women in labor took in local concoction as oxytocin, ostensibly to fast track the labor process and inadvertently leading to complications of uterine rapture thus, increasing the risk of stillbirths.

CONCLUSION

Even though perinatal mortality rate declined overall in 2014, the proportion of stillbirth and perinatal death is declining slowly despite the 'free' policy intervention. Shortage of medicine commodities, inadequate monitoring of labor process coupled with pregnant women intake of traditional herbs, perhaps explains the current rate of stillbirth and perinatal death.

Analysis of Maternal and Neonatal Complications in a Group of Patients with Gestational Diabetes Mellitus

Background and Objectives: Gestational diabetes mellitus (GDM) represents one of the most common complications during pregnancy, being associated with numerous maternal and neonatal complications. The study aimed to analyze maternal and neonatal complications associated with GDM. The risk factors of GDM and of the maternal and neonatal complications were studied in order to prevent their occurrence. Materials and Methods: The study included 97 women in the study, who underwent an oral glucose tolerance test (OGTT) between weeks 24-28 of pregnancy, consequently being divided into two groups: pregnant women with and without GDM. Statistical analysis was performed using the SPSS 26.0 software and MATLAB fitglm, the results being considered statistically significant if p < 0.05. Results: We observed statistically significant differences between the group of women with and without GDM, regarding gestational hypertension (17.6% vs. 0%), preeclampsia (13.72% vs. 0%), and cesarean delivery (96.1% vs. 78,3%). Data on the newborn and neonatal complications: statistically significant differences were recorded between the two groups (GDM vs. no GDM) regarding the average weight at birth (3339.41 ± 658.12 g vs. 3122.83 ± 173.67 g), presence of large for gestational age (21.6% vs. 0%), macrosomia (13.7% vs. 0%), excessive fetal growth (35.3% vs. 0%), respiratory distress (31.4% vs. 0%), hospitalization for at least 24 h in the Neonatal Intensive Care Unit (9.80% vs. 0%), and APGAR score <7 both 1 and 5 min following birth (7.8% vs. 0%). Additionally, the frequency of neonatal hypoglycemia and hyperbilirubinemia was higher among newborns from mothers with GDM. Conclusions: The screening and diagnosis of GDM is vital, and appropriate management is required for the prevention of maternal and neonatal complications associated with GDM. It is also important to know the risk factors for GDM and attempt to prevent their appearance.

An Analysis of the Trend of Fetal Mortality Rates among Working and Jobless Households in Japan, 1995-2019

This study aimed to identify differences in the trends of artificial and spontaneous fetal mortality rates between working and jobless households depending on ages, periods, and birth cohorts in Japan. Vital Statistics data from 1995 to 2019 and age groups in 5–year increments from 15 to 19 years through 45 to 49 years were used. Bayesian age–period–cohort analysis was used to evaluate changes in each of the outcomes. As a result, the difference in maternal age–standardized rate of both the artificial and spontaneous fetal mortality rates between the two types of households decreased in the periods analyzed. However, there was a statistically significant difference in the mortality rate between jobless and working households, regardless of maternal ages, periods, and cohorts for the artificial fetal mortality rate. A statistically significant difference was also observed for the spontaneous fetal mortality rates in some maternal ages, periods, and cohorts. In addition, the trend of birth cohort effects was particularly different between the two types of households for both the artificial and spontaneous fetal mortality rates.

Fetal heart rate pattern in term or near-term cerebral palsy: a nationwide cohort study

BACKGROUND

It is crucial to interpret fetal heart rate patterns with a focus on the pattern evolution during labor to estimate the relationship between cerebral palsy and delivery. However, nationwide data are not available.

OBJECTIVE

The aim of our study was to demonstrate the features of fetal heart rate pattern evolution and estimate the timing of fetal brain injury during labor in cerebral palsy cases.

STUDY DESIGN

In this longitudinal study, 1069 consecutive intrapartum fetal heart rate strips from infants with severe cerebral palsy at or beyond 34 weeks of gestation, were analyzed. They were categorized as follows: (1) continuous bradycardia (Bradycardia), (2) persistently nonreassuring, (3) reassuring-prolonged deceleration, (4) Hon's pattern, and (5) persistently reassuring. The clinical factors underlying cerebral palsy in each group were assessed.

RESULTS

Hypoxic brain injury during labor (those in the reassuring-prolonged deceleration and Hon's pattern groups) accounted for 31.5% of severe cerebral palsy cases and at least 30% of those developed during the antenatal period. Of the 1069 cases, 7.86% were classified as continuous bradycardia (n=84), 21.7% as persistently nonreassuring (n=232), 15.6% as reassuring-prolonged deceleration (n=167), 15.9% as Hon's pattern (n=170), 19.8% as persistently reassuring (n=212), and 19.1% were unclassified (n=204). The overall interobserver agreement was moderate (kappa 0.59). Placental abruption was the most common cause (31.9%) of cerebral palsy, accounting for almost 90% of cases in the continuous bradycardia group (64 of 73). Among the cases in the Hon's pattern group (n=67), umbilical cord abnormalities were the most common clinical factor for cerebral palsy development (29.9%), followed by placental abruption (20.9%), and inappropriate operative vaginal delivery (13.4%).

CONCLUSION

Intrapartum hypoxic brain injury accounted for approximately 30% of severe cerebral palsy cases, whereas a substantial proportion of the cases were suspected to have either a prenatal or postnatal onset. Up to 16% of cerebral palsy cases may be preventable by placing a greater focus on the earlier changes seen in the Hon's fetal heart rate progression.

Impact of free maternal health care policy on maternal health care utilization and perinatal mortality in Ghana: protocol design for historical cohort study

Background

Ghana introduced what has come to be known as the 'Free’ Maternal Health Care Policy (FMHCP) in 2008 via the free registration of pregnant women to the National Health Insurance Scheme to access healthcare free of charge. The policy targeted every pregnant woman in Ghana with a full benefits package covering comprehensive maternal healthcare.

Purpose

This study seeks to measure the contribution of the FMHCP to maternal healthcare utilization; antenatal care uptake, and facility delivery and determine the utilization impact on stillbirth, perinatal, and neonatal deaths using quasi-experimental methods. The study will also contextualize the findings against funding constraints and operational bottlenecks surrounding the policy operations in the Upper East Region of Ghana.

Methods

This study adopts a mixed-method design to estimate the treatment effect using variables generated from historical data of Ghana and Kenya Demographic and Health Survey data sets of 2008/2014, as treatment and comparison groups respectively. As DHS uses complex design, weighting will be applied to the data sets to cater for clustering and stratification at all stages of the analysis by setting the data in STATA and prefix Stata commands with ‘svy’. Thus, the policy impact will be determined using quasi-experimental designs; propensity score matching, and difference-in-differences methods. Prevalence, mean difference, and test of association between outcome and exposure variables will be achieved using the Rao Scot Chi-square. Confounding variables will be adjusted for using Poisson and multiple logistics regression models. Statistical results will be reported in proportions, regression coefficient, and risk ratios. This study then employs intrinsic-case study technique to explore the current operations of the ‘free’ policy in Ghana, using qualitative methods to obtain primary data from the Upper East Region of Ghana for an in-depth analysis.

Discussion

The study discussions will show the contributions of the ‘free’ policy towards maternal healthcare utilization and its performance towards stillbirth, perinatal and neonatal healthcare outcomes. The discussions will also centre on policy designs and implementation in resource constraints settings showing how SDG3 can be achievement or otherwise. Effectiveness of policy proxy and gains in the context of social health insurance within a broader concept of population health and economic burden will also be conferred.

Protocol approval

This study protocol is registered for implementation by the Ghana Health Service Ethical Review Committee, number: GHS-ERC 002/04/19.

Interferon therapy for pregnant patients with essential thrombocythemia in Japan

Essential thrombocythemia (ET) mainly affects the elderly, but can also develop in women of childbearing age. The risk of miscarriage and other complications during pregnancy in ET patients are reported to be higher than that compared to the general population. Therefore, management of pregnancy in ET patients requires special considerations. Several groups recommend interferon (IFN) therapy for ET patients with high-risk pregnancies, but currently no guidelines are available in Japan. We report the outcomes of nine ET patients with ten consecutive high-risk pregnancies. All patients were successfully managed with IFN-α during their pregnancies. All patients also received aspirin and switched to unfractionated heparin around 36 weeks of gestation. As for the seven pregnancies in which IFN-α was started after detection of pregnancy, median platelet counts decreased from 910 to 573 × 10⁹/L after 2 months of IFN-α therapy, and median platelet counts at the time of delivery for all ten pregnancies was 361 × 10⁹/L. All patients gave birth to healthy children. IFN-α was well tolerated, safe, and effective as a cytoreductive therapy for all patients. Although evidence is limited and the use of IFN is not approved in Japan, we suggest considering IFN therapy for high-risk ET pregnancies.

Retrospective study 2005-2015 of all cases of fetal death occurred at ≥23 gestational weeks, in Friuli Venezia Giulia, Italy

Background

Intrauterine fetal death (IUFD) is a tragic event and, despite efforts to reduce rates, its incidence remains difficult to reduce. The objective of the present study was to examine the etiological factors that contribute to the main causes and conditions associated with IUFD, over an 11-year period in a region of North-East Italy (Friuli Venezia Giulia) for which reliable data in available.

Methods

Retrospective analysis of all 278 IUFD cases occurred between 2005 and 2015 in pregnancies with gestational age ≥ 23 weeks.

Results

The incidence of IUFD was 2.8‰ live births. Of these, 30% were small for gestational age (SGA), with immigrant women being significantly over-represented. The share of SGA reached 35% in cases in which a maternal of fetal pathological condition was present, and dropped to 28% in the absence of associated pathology. In 78 pregnancies (28%) no pathology was recorded that could justify IUFD. Of all IUFDs, 11% occurred during labor, and 72% occurred at a gestational age above 30 weeks.

Conclusion

The percentage of IUFD cases for which no possible cause can be identified is quite high. Only the adoption of evidence-based diagnostic protocols, with integrated immunologic, genetic and pathologic examinations, can help reduce this diagnostic gap, contributing to the prevention of future IUFDs.

Understanding high rates of stillbirth and neonatal death in a disadvantaged, high-migrant district in France: A perinatal audit

INTRODUCTION

The objective of this study is to investigate factors associated with risks of perinatal death in a disadvantaged, high-migrant French district with mortality rates above the national average.

MATERIAL AND METHODS

The study design is a perinatal audit in 2014 in all 11 maternity units in the Seine-Saint-Denis district (25 037 births). The data come from medical chart abstraction, maternal interviews and peer assessor confidential review of deaths. A representative sample of live births in the same district, from the 2010 French Perinatal Survey, was used for comparisons (n = 429). The main outcome measures were stillbirth and neonatal death (0-27 days) at ≥22 weeks of gestation.

RESULTS

The audit included 218 women and 227 deaths (156 stillbirths, 71 neonatal deaths); 75 women were interviewed. In addition to primiparity and multiple pregnancy, overweight and obesity increased mortality risks (50% of cases, adjusted odds ratios [aOR] 1.7, 95% confidence interval [CI] 1.1-2.8, and aOR 1.9 [95% CI 1.1-3.2], respectively) as did the presence of preexisting medical/obstetric conditions (28.6% of cases, aOR 3.2, 95% CI 2.0-5.3). Problems accessing or complying with care were noted in 25% of medical records and recounted in 50% of interviews. Assessors identified suboptimal factors in 73.2% of deaths and judged 33.9% to be possibly or probably preventable. Care not adapted to risk factors and poor healthcare coordination were frequent suboptimal factors. Possibly preventable deaths were higher (P < .05) for women with gestational diabetes or hypertension (44.6%) than women without (29.0%).

CONCLUSIONS

Preventive actions to improve healthcare referral and coordination, especially for overweight and obese women and women with medical and obstetrical risk factors, could reduce perinatal mortality in disadvantaged areas.

Maternal Risk Factors for Stillbirth: A Registry-Based Study

Background and Objectives: The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals. Placental pathologies and infection associated with preterm birth are linked to a substantial proportion of stillbirths. Appropriate preconception care and quality antenatal care that is accessible to all women has the potential to reduce stillbirth rates. The aim of the present study was to assess potential risk factors associated with stillbirth within maternal medical diseases and obstetric complications. Materials and Methods: Retrospective cohort study (2001-2014) was used to analyse data from the Medical Birth Register on stillbirth and live births as controls. Adjusted Odds ratios (aOR) with 95% confidence intervals (CI) were estimated. Multiple regression model adjusted for maternal age, parity and gestational age. Results: The stillbirth rate was 6.2 per 1000 live and stillbirths. The presence of maternal medical diseases greatly increased the risk of stillbirth including diabetes mellitus (aOR = 2.5; p < 0.001), chronic hypertension 3.1 (aOR = 3.1; p < 0.001) and oligohydromnios/polyhydromnios (aOR = 2.4; p < 0.001). Pregnancy complications such as intrauterine growth restriction (aOR = 2.2; p < 0.001) was important risk factor for stillbirth. Abruption was associated with a 2.8 odds of stillbirth. Conclusions: Risk factors most significantly associated with stillbirth include maternal history of chronic hypertension and abruptio placenta which is a common cause of death in stillbirth. Early identification of potential risk factors and appropriate perinatal management are important issues in the prevention of adverse fetal outcomes and preventive strategies need to focus on improving antenatal detection of fetal growth restriction.