Stillbirth: are we making more progress than we think? A retrospective cohort study

Elective induction of labour at full-term gestations and childhood school outcomes

AIM

To explore the association between induction of labour at full-term gestations in low-risk nulliparous women and childhood school outcomes.

METHODS

A retrospective whole-of-population cohort study linking perinatal data to educational test scores at grades 3, 5 and 7 in Victoria, Australia. Low-risk nulliparous women with singleton pregnancies induced at 39 and 40 weeks without a medical indication were compared to those expectantly managed from that week of gestation. Multivariable logistic regressions were used as well as generalised estimating equations on longitudinal data.

RESULTS

At 39 weeks, there were 3687 and 103 164 infants in the induction and expectant arms, respectively. At 40 weeks' gestation, there were 7914 and 70 280 infants, respectively. Infants born to nulliparous women induced at 39 weeks' gestation had significantly poorer educational outcomes at grade 3 (adjusted odds ratio (aOR) = 1.39, 95% confidence interval (CI): 1.13-1.70) but not grades 5 (aOR = 1.05, 95% CI: 0.84-1.33) and 7 (aOR = 1.07, 95% CI: 0.81-1.40) compared to those expectantly managed. Infants born to nulliparous women induced at 40 weeks had comparable educational outcomes at grade 3 (aOR = 1.06, 95% CI: 0.90-1.25) but poorer educational outcomes at grades 5 (aOR = 1.23, 95% CI: 1.05-1.43) and 7 (aOR = 1.23, 95% CI: 1.03-1.47) compared to those expectantly managed.

CONCLUSIONS

There were inconsistent associations between elective induction of labour at full-term gestations in low-risk nulliparous women and impaired childhood school outcomes.

Causes of perinatal deaths in Australia: Slow progress in the preterm period

AIM

The majority of perinatal deaths occur in the preterm period; however, current approaches predominantly focus on prevention in the term period. Reducing perinatal deaths in the preterm period is, therefore, key to reducing the rates of perinatal death overall in Australia. The aim was to understand the classifications of causes of preterm stillbirth and neonatal death in Victoria over time and by gestation.

MATERIALS AND METHODS

Retrospective study using state-wide, publicly available data. All births in Victoria between 2010 and 2018 included in the Victorian Perinatal Data Collection, excluding terminations of pregnancy for maternal psychosocial indications, were studied. Differences in causes of preterm perinatal mortality gestation group and over time were determined.

RESULTS

Out of 7977 perinatal deaths reported, 85.9% (n = 6849) were in the preterm period. The most common cause of preterm stillbirths was congenital anomalies (n = 1574, 29.8%), followed by unexplained antepartum deaths (n = 557, 14.2%). The most common cause of preterm neonatal death was spontaneous preterm birth (sPTB; n = 599, 38.2%), followed by congenital anomalies (n = 493, 31.4%). The rate of preterm stillbirths due to hypertension (-14.9% (95% CI -27.1% to -2.7%; P = 0.02)), maternal conditions (-24.1% (95% CI -44.2% to -4.0%; P = 0.03)) and those that were unexplained (-5.4% (95% CI -9.8% to -1.2%; P = 0.02)) decreased per annum between 2010 and 2018. All other classifications did not change significantly over time.

CONCLUSION

Prevention of congenital anomalies and sPTB is critical to reducing preterm perinatal mortality. Greater emphasis on understanding causes of preterm deaths through mortality investigations may reduce the proportion of those considered 'unexplained'.

Reducing health inequality in Black, Asian and other minority ethnic pregnant women: impact of first trimester combined screening for placental dysfunction on perinatal mortality

OBJECTIVE

To assess the impact of the Fetal Medicine Foundation (FMF) first trimester screening algorithm for pre-eclampsia on health disparities in perinatal death among minority ethnic groups.

DESIGN

A retrospective cohort study from July 2016 to December 2020.

SETTING

A large London teaching hospital.

PATIENTS AND METHODS

All women who underwent first trimester pre-eclampsia risk assessment using either the NICE screening checklist or the FMF multimodal approach. Women considered at high-risk in the FMF cohort were offered 150 mg aspirin before 16 weeks' gestation, serial growth scans and elective birth at 40 weeks.

MAIN OUTCOME MEASURES

Stillbirth, neonatal death and perinatal death rates stratified by screening method and maternal ethnicity.

RESULTS

In the NICE cohort, the perinatal death rate was significantly higher in non-white than white women (7.95 versus 2.63/1000 births, OR 3.035, 95% CI 1.551-5.941). Following the introduction of FMF screening, the perinatal death rate in non-white women fell from 7.95 to 3.22/1000 births (OR 0.403, 95% CI 0.206-0.789), such that it was no longer significantly different from the perinatal mortality rate in white women (3.22 versus 2.55/1000 births, OR 1.261, 95% CI 0.641-2.483).

CONCLUSIONS

First trimester combined screening for placental dysfunction is associated with a significant reduction in perinatal death in minority ethnic women. Health disparities in perinatal death among ethnic minority women demand urgent attention from both clinicians and health policy makers. The data of this study suggest that this ethnic health inequality may be avoidable.

Association Between First-Trimester Maternal Cytomegalovirus Infection and Stillbirth: A Prospective Cohort Study

BACKGROUND

Given that the time lag between cytomegalovirus (CMV) screening and diagnosed testing, a better knowledge of the association between pregnant women with CMV screening test positive and stillbirth in an epidemiological perspective was required to assist people being counseled reframe their pregnancy and birth plans based on the magnitude of the risk.

METHODS

This study recruited 44048 eligible pregnant women from March 13, 2013 to December 31, 2019. Serological tests including CMV-specific IgM and IgG, and IgG avidity index were used to screen for maternal CMV infection and were measured by automated chemiluminescence immunoassay. The association was assessed using the inverse probability of group-weighted multivariate-adjusted log-binomial models.

RESULTS

A total of 540 infants ended with a stillbirth (12.3 per 1000 pregnancies), and 2472 pregnancies with maternal CMV infection were screened out (56.1 per 1000 pregnancies) among all eligible pregnancies. In the comparison analysis, 326 infants ended with a stillbirth (86.6 per 1000 pregnancies) in the maternal CMV infection group compared with 214 infants (7.8 per 1000 pregnancies) in the group where mothers were not infected with CMV (RR 12.17; 95% CI 9.43-15.71). After excluding the pregnancies of stillbirth with birth defects, a strong association between the two groups was still observed (RR 9.38; 95% CI 6.92-12.70).

CONCLUSION

Our findings quantified the risk of a woman having a baby with stillbirth if she had a positive serologic CMV screening test in her first trimester, and supported the value of using CMV serologic tests as part of regular testing in pregnant women.

TRIAL REGISTRATION

Registered in Chinese Clinical Trial Registry Center; registration number, ChiCTR1800016635; registration date, 06/14/2018 (Retrospectively registered); URL of trial registry record, https://www.chictr.org.cn/showproj.aspx?proj=28300.

Outpatient labour induction

The inexorable rise in induction rates over the past two decades, in parallel with increasing medical costs and pressure to reduce length of stay, has led to marked logistic difficulties for health care workers, managers and planners. Maternity services are being overwhelmed by the need to allocate staff and delivery suite space for the scheduling and undertaking of induction processes, rather than focussing care for women in spontaneous labour. Induction of labour according to the majority of current protocols and guidelines necessitates increased length of stay and relatively aggressive use of oxytocin (to reduce the time expended in the labour ward from artificial rupture of membranes (AROM) to establishment of labour). This increased oxytocin usage requires increased use of continuous electronic foetal monitoring, and may also increase epidural usage, further increasing the complexity of labour for the woman and her health care workers. Outpatient care after cervical priming and even outpatient care after AROM may help to ease these pressures and may reduce the medicalisation of the birth experience when induction is indicated, with a potential to reduce oxytocin use and associated interventions. If the period between cervical priming to AROM is managed as outpatient care, then the woman may be able to find better psychological and social support at home, as well as maintain autonomy and get better rest prior to the onset of labour. Inpatient AROM could also be followed by outpatient care until the pregnant person returns to the hospital, either in spontaneous labour, or for initiation of syntocinon after 12-18 h. High-quality research has already demonstrated that outpatient care for cervical ripening is acceptable to mothers and caregivers, has economic benefits and has an acceptable safety profile in appropriately selected low-risk inductions.