The Tulip classification of perinatal mortality: introduction and multidisciplinary inter-rater agreement

Placental Pathology Findings in Unexplained Pregnancy Losses

There are approximately 5 million pregnancies per year in the USA, with 1 million ending in miscarriage (a loss occurring prior to 20 weeks of gestation) and over 20,000 ending in stillbirth at or beyond 20 weeks of gestation. As many as 50% of these losses are unexplained. Our objective was to evaluate the effect of expanding the placental pathology diagnostic categories to include the explicit categories of (1) dysmorphic chorionic villi and (2) small placenta in examining previously unexplained losses. Using a clinical database of 1256 previously unexplained losses at 6-43 weeks of gestation, the most prevalent abnormality associated with each loss was determined through examination of its placental pathology slides. Of 1256 cases analyzed from 922 patients, there were 878 (69.9%) miscarriages and 378 (30.1%) antepartum stillbirths. We determined the pathologic diagnoses for 1150/1256 (91.6%) of the entire series, 777/878 (88.5%) of the miscarriages (< 20 weeks' gestation), and 373/378 (98.7%) of the stillbirths (≥ 20 weeks' gestation). The most common pathologic feature observed in unexplained miscarriages was dysmorphic chorionic villi (757 cases; 86.2%), a marker associated with genetic abnormalities. The most common pathologic feature observed in unexplained stillbirths was a small placenta (128 cases; 33.9%). Our classification system reinforced the utility of placental examination for elucidating potential mechanisms behind pregnancy loss. The improved rate of diagnosis appeared to be the result of filling a gap in previous pregnancy loss classification systems via inclusion of the categories of dysmorphic chorionic villi and small placenta.

Stillbirth diagnosis and classification: comparison of ReCoDe and ICD-PM systems

OBJECTIVES

The identification of causes of stillbirth (SB) can be a challenge due to several different classification systems of SB causes. In the scientific literature there is a continuous emergence of SB classification systems, not allowing uniform data collection and comparisons between populations from different geographical areas. For these reasons, this study compared two of the most used SB classifications, aiming to identify which of them should be preferable.

METHODS

A total of 191 SBs were retrospectively classified by a panel composed by three experienced-physicians throughout the ReCoDe and ICD-PM systems to evaluate which classification minimizes unclassified/unspecified cases. In addition, intra and inter-rater agreements were calculated.

RESULTS

ReCoDe defined: the 23.6% of cases as unexplained, placental insufficiency in the 14.1%, lethal congenital anomalies in the 12%, infection in the 9.4%, abruptio in the 7.3%, and chorioamnionitis in the 7.3%. ICD-PM defined: the 20.9% of cases as unspecified, antepartum hypoxia in the 44%, congenital malformations, deformations, and chromosomal abnormalities in the 11.5%, and infection in the 11.5%. For ReCoDe, inter-rater was agreement of 0.58; intra-rater agreements were 0.78 and 0.79. For ICD-PM, inter-rater agreement was 0.54; intra-rater agreements were of 0.76 and 0.71.

CONCLUSIONS

There is no significant difference between ReCoDe and ICD-PM classifications in minimizing unexplained/unspecified cases. Inter and intra-rater agreements were largely suboptimal for both ReCoDe and ICD-PM due to their lack of specific guidelines which can facilitate the interpretation. Thus, the authors suggest correctives strategies: the implementation of specific guidelines and illustrative case reports to easily solve interpretation issues.

Stillbirths preceded by reduced fetal movements are more frequently associated with placental insufficiency: a retrospective cohort study

OBJECTIVES

Maternal report of reduced fetal movements (RFM) is a means of identifying fetal compromise in pregnancy. In live births RFM is associated with altered placental structure and function. Here, we explored associations between RFM, pregnancy characteristics, and the presence of placental abnormalities and fetal growth restriction (FGR) in cases of stillbirth.

METHODS

A retrospective cohort study was carried out in a single UK tertiary maternity unit. Cases were divided into three groups: 109 women reporting RFM, 33 women with absent fetal movements (AFM) and 159 who did not report RFM before the diagnosis of stillbirth. Univariate and multivariate logistic regression was used to determine associations between RFM/AFM, pregnancy characteristics, placental insufficiency and the classification of the stillbirth.

RESULTS

AFM or RFM were reported prior to diagnosis of stillbirth in 142 (47.2%) of cases. Pregnancies with RFM prior to diagnosis of stillbirth were independently associated with placental insufficiency (Odds Ratio (OR) 2.79, 95% Confidence Interval (CI) 1.84, 5.04) and were less frequently associated with maternal proteinuria (OR 0.16, 95% CI 0.07, 0.62) and previous pregnancy loss <24 weeks (OR 0.20, 95% CI 0.07, 0.70). When combined, AFM and RFM were less frequently reported in twin pregnancies ending in stillbirth and in intrapartum stillbirths.

CONCLUSIONS

The association between RFM and placental insufficiency was confirmed in cases of stillbirth. This provides further evidence that RFM is a symptom of placental insufficiency. Therefore, investigation after RFM should aim to identify placental dysfunction.

Universal gestational diabetes screening and antepartum stillbirth rates in Austria-A population-based study

INTRODUCTION

Occult or untreated gestational diabetes (GDM) is a well-known risk factor for adverse perinatal outcomes and may contribute to antepartum stillbirth. We assessed the impact of screening for GDM on the rate of antepartum stillbirths in non-anomalous pregnancies by conducting a population-based study in 974 889 women in Austria.

MATERIAL AND METHODS

Our database was derived from the Austrian Birth Registry. Inclusion criteria were singleton live births and antepartum stillbirths ≥24⁺⁰ gestational weeks, excluding fetal congenital malformations, terminations of pregnancy and women with pre-existing type 1 or 2 diabetes. Main outcome measures were (a) overall stillbirth rates and (b) stillbirth rates in women at high risk of GDM (i.e., women with a body mass index ≥30 kg/m² , history of previous intrauterine fetal death, GDM, previous macrosomic offspring) before (2008-2010, "phase I") and after (2011-2019, "phase II") the national implementation of universal GDM screening with a 75 g oral glucose tolerance test in Austrian pregnant women by 2011.

RESULTS

In total, 940 373 pregnancies were included between 2008 and 2019, of which 2579 resulted in intrauterine fetal deaths at 33.51 ± 5.10 gestational weeks. After implementation of the GDM screening, a statistically significant reduction in antepartum stillbirth rates among non-anomalous singletons was observed only in women at high risk for GDM (4.10‰ [95% confidence interval (CI) 3.09-5.43] in phase I vs. 2.96‰ [95% CI 2.57-3.41] in phase II; p = 0.043) but not in the general population (2.76‰ [95% CI 2.55-2.99] in phase I vs. 2.74‰ [95% CI 2.62-2.86] in phase II; p = 0.845). The number needed to screen with the oral glucose tolerance test to subsequently prevent one case of (non-anomalous) intrauterine fetal death was 880 in the high-risk and 40 000 in the general population.

CONCLUSIONS

The implementation of a universal GDM screening program in Austria in 2011 has not led to any significant reduction in antenatal stillbirths among non-anomalous singletons in the general population. More international data are needed to strengthen our findings.

Placental Findings Contributing to Perinatal Death: A 15-Year Retrospective Review from a Teaching Hospital in Thailand

Introduction: The placenta is infrequently examined in developing countries. This study examined the role of placental pathology in perinatal deaths at Chulalongkorn University Hospital, Bangkok. Methods: Included were singleton intrauterine deaths after gestational week 20 and live-born infants up to 1 week old, over a 15-year period. Placental lesions were classified as: inflammatory-immune, maternal stromal-vascular, fetal stromal-vascular, umbilical cord complications and other. Results: 208 such cases had the placenta available. A placental cause of death was found in 96 (46%), non-placental causes in 28% and the cause of death was unknown in 26%. Of those 96 placentas, 44% were categorized as inflammatory-immune, 30% maternal stromal-vascular, 13% fetal stromal-vascular, 7% umbilical cord complications and 6% other. Conclusions: Placental causes of death were less common than in many Western studies, but inflammatory-immune processes more common. These differences may relate to how cases were accrued, and/or local socioeconomic factors, and warrant further study.

Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review

BACKGROUND

This systematic review aimed to provide an updated summary of studies investigating depression, anxiety, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD) in parents after stillbirth (from 20 weeks gestational age until birth).

METHODS

A literature search was conducted in the databases Web of Science and PsychINFO. Main inclusion criteria were 1) peer-reviewed, quantitative, English-language articles published from 1980; (2) studies investigating depression, anxiety, PTSD, or OCD among parents following stillbirth; and (3) studies defining stillbirth as equal to or after 20 weeks of gestation.

RESULTS

Thirteen quantitative, peer-reviewed articles were eligible for inclusion. Selected articles investigated depression, anxiety, and PTSD, while no studies on OCD met our inclusion criteria. The majority of studies investigated women, while only two studies included men. The results indicated heightened short- and long-term levels of depression, anxiety, and PTSD in parents after stillbirth compared to those of parents with live birth. Studies investigating predictors found that social support, marital status, negative appraisals, and variables related to care and management after stillbirth affected levels of symptoms.

CONCLUSIONS

Parents who experience stillbirth have a considerably higher risk of reporting symptoms of depression, anxiety, and PTSD compared with parents with live births. More longitudinal studies are needed to increase our knowledge of how symptoms develop over time, and more research on fathers, transgender, non-binary and gender fluid individuals is needed. Research on the association between stillbirth and OCD is also warranted. Knowledge of the severity of anxiety, depression, and PTSD after stillbirth, and predictors associated with symptom severity could provide healthcare professionals with valuable information on how to provide beneficial postpartum care.

Facilitators and Strategies for Breaking the News of an Intrauterine Death-A Mixed Methods Study among Obstetricians

(1) Background: The death of a baby in utero is a very sad event for both the affected parents and the caring doctors. By this study, we aimed to assess the tools, which may help obstetricians to overcome this challenge in their profession. (2) Methods: We conducted a cross-sectional online survey in 1526 obstetricians registered with the Austrian Society of Obstetrics and Gynecology between September and October 2020. (3) Results: With a response rate of 24.2% (n = 439), our study shows that diagnosing fetal death was associated with a moderate to high degree of stress, regardless of position (p = 0.949), age (p = 0.110), gender (p = 0.155), and experience (p = 0.150) of physicians. Coping strategies for delivering the news of intrauterine death to affected parents were relying on clinical knowledge and high levels of self-confidence (55.0%; 203/369), support from colleagues (53.9%; 199/369), and debriefing (52.8%; 195/369). In general, facilitators for breaking bad news were more commonly cultivated by female obstetricians [OR 1.267 (95% CI 1.149-1.396); p < 0.001], residents [χ²(3;369) = 9.937; p = 0.019], and obstetricians of younger age [41 (34-50) years vs. 45 (36-55) years; p = 0.018]. External facilitators were most frequently mentioned, including professional support, training, professional guidance, time, parents' leaflets, follow-up consultations, a supporting consultation atmosphere, and preparation before delivering the bad news. Internal facilitators included knowledge, empathy, seeking silence, reflection, privacy, and relief of guilt. (4) Conclusions: Communicating the diagnosis of fetal death evokes moderate to high levels of stress among obstetricians. Resources from both the professional and private environment are required to deal with this professional challenge on a personal level.

Timing of hospital admission for stillbirth delivery on maternal and obstetric outcome: a retrospective cohort study

The effect of timing of hospital admission for stillbirth delivery following late intrauterine fetal death (IUFD) has not yet been described. By this study, we aimed to gain an understanding of the impact of “immediate” (i.e., on the same day of IUFD diagnosis) versus “delayed” hospital admission (i.e., on the subsequent day or two days after IUFD diagnosis) on maternal and delivery outcome parameters. This retrospective cohort study comprised all women who suffered a singleton IUFD ≥ 21 gestational weeks and delivered the stillborn at our tertiary referral center between 2003 and 2019. We excluded all terminations of pregnancy and women presenting with acute symptoms on the day of IUFD diagnosis. In total, 183 women were included of whom 69.4% (n = 127) were immediately admitted and 30.6% (n = 56) had delayed admission. Median gestational age of IUFD was 30⁺³ (21⁺⁰–41⁺³) weeks. Whilst women with early signs of labor were more frequently admitted immediately (87.5%; 14/16), neither maternal demographic and obstetric parameters, nor day of the week or presenting symptoms influenced the timing of hospital admission. 77.6% (142/183) of women after IUFD diagnosis delivered within the first 3 days after admission. Women after immediate admission equally often delivered on admission day and the day after (26.0%; 33/127 each), women after delayed admission most commonly delivered the day after admission (39.3%; 22/56). Stillbirth delivery on the day of diagnosis was more common upon immediate admission (p = 0.006), especially in early gestational weeks (p = 0.003) and with small fetal weight (p < 0.001), requiring less induction of labor. No significant difference regarding delivery mode, labor duration, use of intrapartum analgesia, need for episiotomy and risk of perineal injury was observed between the groups. Also rate of intrapartum hemorrhage was independent of admission timing, although immediately admitted women experienced greater median blood loss after vaginal delivery. Maternal laboratory parameters (hemoglobin, thrombocytes and CRP) were independent of admission timing, except for higher levels of leucocytes, neutrophils and lymphocytes in immediately admitted women. Our study shows no clinical superiority of immediate hospital admission for stillbirth delivery. Under stable medical circumstances, it, therefore, seems feasible to allow the woman delayed admission for labor and delivery.

Abnormal umbilical cord insertions in singleton deliveries: placental histology and neonatal outcomes

AIMS

This study aimed to identify any microscopic features associated with abnormal (membranous/velamentous or marginal) placental cord insertions and to analyse their adverse neonatal outcomes.

METHODS

We retrospectively analysed the records-including pathological findings, clinical information and pregnancy outcomes-for 1060 singleton pregnancies, involving newborn delivered after 24 weeks of gestation.

RESULTS

Marginal cord insertions were identified in 26.60% of cases and membranous cord insertions in 2.64%. Subchorionic vessel thrombus was more prevalent in marginal or membranous insertions (0.97%) than in normal cord insertions (0.27%) (p=0.129). Intervillous thrombi (13.73% vs 8.41%, p<0.05) and chorioamnionitis (8.53% vs 5.48%, p=0.089) were more prevalent in normal cord insertions. Premature rupture of membranes was significantly more commonly associated with abnormal (marginal 15.25% and membranous 17.86%) than with normal (9.87%) insertions (p<0.05). Pre-eclampsia was more common in the group with membranous cord insertions (7.14%) than in the other groups (marginal 0.35%; normal 0.80%) (p<0.05). Marginal and membranous placental cord insertions were associated with earlier gestational age at delivery and smaller fetuses than in the group with normal insertions. Intrauterine fetal demise, cardiac malformations and pregestational diabetes were also more common among cases of abnormal cord insertions.

CONCLUSIONS

Subchorionic vessel thrombus and adverse pregnancy-related outcomes were more prevalent in cases of marginal/membranous cord insertion than for normal insertions.

Cardio-pathogenic variants in unexplained intrauterine fetal death: a retrospective pilot study

To describe the prevalence and spectrum of cardio-pathogenic variants in singleton fetuses after unexplained intrauterine fetal death (IUFD). DNA from post-mortem fibroblastic tissue samples of 16 fetuses after unexplained IUFD was retrieved at two tertiary university hospitals for clinical exome sequencing with subsequent filtering of 122 cardio-specific genes to elucidate underlying cardio-pathogenic variants. In total, we included 12 (75%) male and four (25%) female fetuses who were stillborn at a median gestational age of 34⁺⁶ (23⁺²–40⁺⁵) weeks. In two (12.5%) fetuses no cardio-pathogenic variants were found. In 14 (87.5%) fetuses, overall 33 variants were detected in 22 cardio-specific genes, involving 14 (63.63%) genes associated with cardiomyopathy, six (27.27%) arrhythmogenic susceptibility genes and two (9.09%) arrhythmia and cardiomyopathy associated genes. Among the 33 variants, five (15.2%) were classified as likely benign according to the American College of Medical Genetics and Genomics; 28 (84.8%) variants were considered as variants of uncertain significance. Compared to a cohort of explained IUFDs, the cases with and without fetal variants in cardiac genes differed not significantly regarding maternal age, previous history of stillbirth, time of stillbirth or fetal sex. Unexplained stillbirth may be caused by cardio-genetic pathologies, yet a high number of variants of uncertain significance merit a more detailed post-mortem examination including family segregation analysis.

Placenta Pathology From Term Born Neonates With Normal or Adverse Outcome

BACKGROUND

The incidence of umbilical cord or placental parenchyma abnormalities associated with mortality or morbidity of term infants is lacking.

METHODS

Placentas of 55 antepartum stillbirths (APD), 21 intrapartum stillbirths (IPD), 12 neonatal deaths (ND), and 80 admissions to a level 3 neonatal intensive care unit (NS) were studied and compared with 439 placentas from neonates from normal term pregnancies and normal outcome after vaginal delivery (NPVD) and with 105 placentas after an elective caesarian sections (NPEC).

RESULTS

NPVD and NPEC placentas showed no or one abnormality in 70% and placentas from stillbirth showed two or more abnormalities in 80% of cases. APD placentas more frequently had a low weight and less formation of terminal villi. Hypercoiling was more often present in all study groups. Severe chronic villitis was almost exclusively present in APD placentas. Chorioamnionitis was significantly more frequent in APD, IPD and NS placentas and funisitis was more often observed in IPD and NS placentas.

CONCLUSION

Multiple placental abnormalities are significantly more frequent in placentas from term neonates with severe perinatal morbidity and mortality. These placental abnormalities are thought to be associated with disturbed oxygen transfer or with inflammation.

Stillbirth is associated with increased risk of long-term maternal renal disease: a nationwide cohort study

Background

Stillbirth is a devastating adverse pregnancy outcome that may occur without any obvious reason or may occur in the context of fetal growth restriction, preeclampsia, or other obstetric complications. There is increasing evidence that women who experience stillbirths are at greater risk of long-term cardiovascular disease, but little is known about their risk of chronic kidney disease and end-stage renal disease. We conducted the largest study to date to investigate the subsequent risk of maternal chronic kidney disease and end-stage renal disease following stillbirth.

Objective

To identify whether pregnancy complicated by stillbirth is associated with subsequent risk of maternal chronic kidney disease and end-stage renal disease, independent of underlying medical or obstetric comorbidities.

Study Design/Methods

We conducted a population-based cohort study using nationwide data from the Swedish Medical Birth Register, National Patient Register, and Swedish Renal Register. We included all women who had live births and stillbirths from 1973 to 2012, with follow-up to 2013. Women with preexisting renal disease were excluded. Cox proportional hazard regression models were used to estimate adjusted hazard ratios and 95% confidence intervals for associations between stillbirth and maternal chronic kidney disease and end-stage renal disease respectively. We controlled for maternal age, year of delivery, country of origin, parity, body mass index, smoking, gestational diabetes, preeclampsia, and small for gestational age deliveries. Women who had a history of medical comorbidities, which may predispose to renal disease (prepregnancy cardiovascular disease, hypertension, diabetes, lupus, systemic sclerosis, hemoglobinopathy, or coagulopathy), were excluded from the main analysis and examined separately.

Results

There were 1,941,057 unique women who had 3,755,444 singleton pregnancies, followed up over 42,313,758 person-years. The median follow-up time was 20.7 years (interquartile range, 9.9–30.0 years). 13,032 women (0.7%) had at least 1 stillbirth. Women who had experienced at least 1 stillbirth had a greater risk of developing chronic kidney disease (adjusted hazard ratio, 1.26; 95% confidence interval, 1.09–1.45) and end-stage renal disease (adjusted hazard ratio, 2.25; 95% confidence interval, 1.55–3.25) compared with women who only had live births. These associations persisted after removing all stillbirths that occurred in the context of preeclampsia, and small for gestational age or congenital malformations (for chronic kidney disease, adjusted hazard ratio, 1.33; 95% confidence interval, 1.13–1.57; for end-stage renal disease, adjusted hazard ratio, 2.95; 95% confidence interval, CI 1.86–4.68). There was no significant association observed between stillbirth and either chronic kidney disease or end-stage renal disease in women who had preexisting medical comorbidities (chronic kidney disease, adjusted hazard ratio, 1.13; 95% confidence interval, 0.73–1.75 or end-stage renal disease, adjusted hazard ratio, 1.49; 95% confidence interval, 0.78–2.85).

Conclusion

Women who have a history of stillbirth may be at increased risk of chronic kidney disease and end-stage renal disease compared with women who have only had live births. This association persists independently of preeclampsia, and small for gestational age, maternal smoking, obesity, and medical comorbidities. Further research is required to determine whether affected women would benefit from closer surveillance and follow-up for future renal disease.

Improving Diagnostic Classification of Stillbirths and Neonatal Deaths Using ICD-PM (International Classification of Diseases for Perinatal Mortality) Codes: Validation Study

Background

Stillbirths and neonatal deaths have long been imperfectly classified and recorded worldwide. In Hong Kong, the current code system is deficient (>90% cases with unknown causes) in providing the diagnoses of perinatal mortality cases.

Objective

The objective of this study was to apply the International Classification of Diseases for Perinatal Mortality (ICD-PM) system to existing perinatal death data. Further, the aim was to assess whether there was any change in the classifications of perinatal deaths compared with the existing classification system and identify any areas in which future interventions can be made.

Methods

We applied the ICD-PM (with International Statistical Classification of Diseases and Related Health Problems, 10th Revision) code system to existing perinatal death data in Kwong Wah Hospital, Hong Kong, to improve diagnostic classification. The study included stillbirths (after 24 weeks gestation) and neonatal deaths (from birth to 28 days). The retrospective data (5 years) from May 1, 2012, to April 30, 2017, were recoded by the principal investigator (HML) applying the ICD-PM, then validated by an overseas expert (EA) after she reviewed the detailed case summaries. The prospective application of ICD-PM from May 1, 2017, to April 30, 2019, was performed during the monthly multidisciplinary perinatal meetings and then also validated by EA for agreement.

Results

We analyzed the data of 34,920 deliveries, and 119 cases were included for analysis (92 stillbirths and 27 neonatal deaths). The overall agreement with EA of our codes using the ICD-PM was 93.2% (111/119); 92% (78/85) for the 5 years of retrospective codes and 97% (33/34) for the 2 years of prospective codes (P=.44). After the application of the ICD-PM, the overall proportion of unknown causes of perinatal mortality dropped from 34.5% (41/119) to 10.1% (12/119) of cases (P<.001).

Conclusions

Using the ICD-PM would lead to a better classification of perinatal deaths, reduce the proportion of unknown diagnoses, and clearly link the maternal conditions with these perinatal deaths.

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.

Cause of intrauterine and neonatal death in twin pregnancies (CoDiT): development of a novel classification system

OBJECTIVE

Twin pregnancies have a significantly higher perinatal mortality than singleton pregnancies. Current classification systems for perinatal death lack twin-specific categories, potentially leading to loss of important information regarding cause of death. We introduce and test a classification system designed to assign a cause of death in twin pregnancies (CoDiT).

DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary maternity unit in England with a perinatal pathology service.

POPULATION

Twin pregnancies in the West Midlands affected by fetal or neonatal demise of one or both twins between 1 January 2005 and 31 December 2016 in which postmortem examination was undertaken.

METHODS

A multidisciplinary panel designed CoDiT by adapting the most appropriate elements of singleton classification systems. The system was tested by assigning cause of death in 265 fetal and neonatal deaths from 144 twin pregnancies. Cause of death was validated by another obstetrician blinded to the original classification.

MAIN OUTCOME MEASURES

Inter-rater, intra-rater, inter-disciplinary agreement and cause of death.

RESULTS

Cohen's Kappa demonstrated 'strong' (>0.8) inter-rater, intra-rater and inter-disciplinary agreement (95% CI 0.70-0.91). The commonest cause of death irrespective of chorionicity was the placenta; twin-to-twin transfusion syndrome (TTTS) was the commonest placental cause in monochorionic twins and acute chorioamnionitis in dichorionic twins.

CONCLUSIONS

This novel classification system records causes of death in twin pregnancies from postmortem reports with high inter-user agreement. We highlight differences in aetiology of death between monochorionic and dichorionic twins.

TWEETABLE ABSTRACT

New classification system for #twin cause of death 'CoDiT' shows high rater agreement.

Genetic innovations and our understanding of stillbirth

Stillbirth after 20 weeks gestation happens in 1 in 200 pregnancies and occurs more commonly than neonatal loss and sudden infant death syndrome (SIDs) combined. The stillbirth rate is several times greater in low as opposed to high-resource countries. However, among high-resource countries, although a lower overall stillbirth rate exists, there has been little change for several decades. Molecular genetic technologies are emerging as important contributors to our understanding of stillbirth. Initially, genetic etiologies included alterations in chromosome number or structure such as aneuploidy and microduplications and deletions. More recently, next-generation sequencing analysis in two genetic conditions, Smith Lemli Optiz Syndrome (SLOs) and the channelopathy disorders (such as long QT syndrome (LQTS)) provide examples into the association of pathogenic gene variants with stillbirth. Although these specific conditions individually account for only a small number of stillbirths, investigating these disorders provides a new and innovative approach for further understanding genetic contributors to adverse pregnancy outcomes. Our knowledge of the role of genetic disease as an etiology for stillbirth is elementary. Genomic interrogation of maternal-fetal genotypes, gene-gene, and genotype-environment interaction is lacking in stillbirth research. At the DNA sequence level, further investigation of variants of unknown significance is an opportunity for exploration of biologic pathways of importance to pregnancy loss. This review concentrates on SLO as an example of a single gene disorder with a high carrier but low affected liveborn proband rate. The channelopathy disorders are included as initial examples of genetic conditions with variable presentation including an association with sudden infant death syndrome. Highlighted are the challenges when numerous genes and variants are involved, and the task of assigning pathogenicity. The advantages and limitations of genetic evaluations are presented and avenues for further research considered.

Mothers with long QT syndrome are at increased risk for fetal death: findings from a multicenter international study

BACKGROUND

Most fetal deaths are unexplained. Long QT syndrome is a genetic disorder of cardiac ion channels. Affected individuals, including fetuses, are predisposed to sudden death. We sought to determine the risk of fetal death in familial long QT syndrome, in which the mother or father carries the long QT syndrome genotype. In addition, we assessed whether risk differed if the long QT syndrome genotype was inherited from the mother or father.

OBJECTIVE

This was a retrospective review of pregnancies in families with the 3 most common heterozygous pathogenic long QT syndrome genotypes in KCNQ1 (LQT1), KCNH2 (LQT2), or SCN5A (LQT3), which occur in approximately 1 in 2000 individuals. The purpose of our study was to compare pregnancy and birth outcomes in familial long QT syndrome with the normal population and between maternal and paternal carriers of the long QT syndrome genotype. We hypothesized that fetal death before (miscarriage) and after (stillbirths) 20 weeks gestation would be increased in familial long QT syndrome compared with the normal population and that the parent of origin would not affect birth outcomes.

STUDY DESIGN

Our study was a multicenter observational case series of 148 pregnancies from 103 families (80 mothers, 23 fathers) with familial long QT syndrome (60 with LQT1, 29 with LQT2, 14 with LQT3) who were recruited from 11 international centers with expertise in hereditary heart rhythm diseases, pediatric and/or adult electrophysiology, and high-risk pregnancies. Clinical databases from these sites were reviewed for long QT syndrome that occurred in men or women of childbearing age (18-40 years). Pregnancy outcomes (livebirth, stillbirth, and miscarriage), birthweights, and gestational age at delivery were compared among long QT syndrome genotypes and between maternal vs paternal long QT syndrome-affected status with the use of logistic regression analysis.

RESULTS

Most offspring (80%; 118/148) were liveborn at term; 66% of offspring (73/110) had long QT syndrome. Newborn infants of mothers with long QT syndrome were delivered earlier and, when the data were controlled for gestational age, weighed less than newborn infants of long QT syndrome fathers. Fetal arrhythmias were observed rarely, but stillbirths (fetal death at >20 weeks gestation) were 8 times more frequent in long QT syndrome (4% vs approximately 0.5%); miscarriages (fetal death at ≤20 weeks gestation) were 2 times that of the general population (16% vs 8%). The likelihood of fetal death was significantly greater with maternal vs paternal long QT syndrome (24.4% vs 3.4%; P=.036). Only 10% of all fetal deaths underwent postmortem long QT syndrome testing; 2 of 3 cases were positive for the family long QT syndrome genotype.

CONCLUSION

This is the first report to demonstrate that mothers with long QT syndrome are at increased risk of fetal death and to uncover a previously unreported cause of stillbirth. Our results suggest that maternal effects of long QT syndrome channelopathy may cause placental or myometrial dysfunction that confers increased susceptibility to fetal death and growth restriction in newborn survivors, regardless of long QT syndrome status.

Men's grief following pregnancy loss and neonatal loss: a systematic review and emerging theoretical model

BACKGROUND

Emotional distress following pregnancy loss and neonatal loss is common, with enduring grief occurring for many parents. However, little is known about men's grief, since the majority of existing literature and subsequent bereavement care guidelines have focused on women. To develop a comprehensive understanding of men's grief, this systematic review sought to summarise and appraise the literature focusing on men's grief following pregnancy loss and neonatal loss.

METHODS

A systematic review was undertaken with searches completed across four databases (PubMed, PsycINFO, Embase, and CINAHL). These were guided by two research questions: 1) what are men's experiences of grief following pregnancy/neonatal loss; and 2) what are the predictors of men's grief following pregnancy/neonatal loss? Eligible articles were qualitative, quantitative or mixed methods empirical studies including primary data on men's grief, published between 1998 and October 2018. Eligibility for loss type included miscarriage or stillbirth (by any definition), termination of pregnancy for nonviable foetal anomaly, and neonatal death up to 28 days after a live birth.

RESULTS

A final sample of 46 articles were identified, including 26 qualitative, 19 quantitative, and one mixed methods paper. Findings indicate that men's grief experiences are highly varied, and current grief measures may not capture all of the complexities of grief for men. Qualitative studies identified that in comparison to women, men may face different challenges including expectations to support female partners, and a lack of social recognition for their grief and subsequent needs. Men may face double-disenfranchised grief in relation to the pregnancy/neonatal loss experience.

CONCLUSION

There is a need to increase the accessibility of support services for men following pregnancy/neonatal loss, and to provide recognition and validation of their experiences of grief. Cohort studies are required among varied groups of bereaved men to confirm grief-predictor relationships, and to refine an emerging socio-ecological model of men's grief.

TRIALS REGISTRATION

PROSPERO registration number: CRD42018103981.

Relation of Pregnancy Loss to Risk of Cardiovascular Disease in Parous Postmenopausal Women (From the Women's Health Initiative)

Women with history of pregnancy loss (PL) have higher burden of cardiovascular disease (CVD) later in life, yet it is unclear whether this is attributable to an association with established CVD risk factors (RFs). We examined whether PL is associated with CVD RFs and biomarkers in parous postmenopausal women in the Women's Health Initiative, and whether the association between PL and CVD RFs accounted for the association between PL and incident CVD. Linear and logistic regressions were used to estimate associations between baseline history of PL and CVD RFs. Cox proportional hazards regression models were used to estimate the associations between baseline history of PL and incident CVD after adjustment for baseline RFs. Of 79,121 women, 27,272 (35%) had experienced PL. History of PL was associated with higher body mass index (p < 0.0001), hypertension (p < 0.0001), diabetes (p = 0.003), depression (p < 0.0001), and lower income (p < 0.0001), physical activity (p = 0.01), poorer diet (p < 0.0001), smoking (p < 0.0001), and alcohol use (p < 0.0001). After adjustment for CVD RFs, PL was significantly associated with incident CVD over mean follow up of 16 years (hazard ratio 1.11, 95% confidence interval 1.06 to 1.16). In conclusion, several CVD RFs are associated with PL, but they do not entirely account for the association between PL and incident CVD.

Risk factors and classification of stillbirth in a Middle Eastern population: a retrospective study

OBJECTIVE

To estimate the incidence of stillbirth, explore the associated maternal and fetal factors and to evaluate the most appropriate classification of stillbirth for a multiethnic population.

METHODS

This is a retrospective population-based study of stillbirth in a large tertiary unit. Data of each stillbirth with a gestational age >/=24 weeks in the year 2015 were collected from electronic medical records and analyzed.

RESULTS

The stillbirth rate for our multiethnic population is 7.81 per 1000 births. Maternal medical factors comprised 52.4% in which the rates of hypertensive disorders, diabetes and other medical disorders were 22.5%, 20.8% and 8.3%, respectively. The most common fetal factor was intrauterine growth restriction (IUGR) (22.5%) followed by congenital anomalies (21.6%). All cases were categorized using the Wigglesworth, Aberdeen, Tulip, ReCoDe and International Classification of Diseases-perinatal mortality (ICD-PM) classifications and the rates of unclassified stillbirths were 59.2%, 46.6%, 16.6%, 11.6% and 7.5%, respectively. An autopsy was performed in 9.1% of cases reflecting local religious and cultural sensitivities.

CONCLUSION

This study highlighted the modifiable risk factors among the Middle Eastern population. The most appropriate classification was the ICD-PM. The low rates of autopsy prevented a detailed evaluation of stillbirths, therefore it is suggested that a minimally invasive autopsy [postmortem magnetic resonance imaging (MRI)] may improve the quality of care.

Placenta and Umbilical Cord Cause in Antepartum Deaths

Stillbirth is a sudden and painful event for parents and obstetrical specialists as well. It is, therefore, of greatest importance to be able to give answers for the cause in order to plan a subsequent pregnancy. The aim of this retrospective study is to estimate the placental and umbilical cord cause of intrauterine death in relation to different gestational ages. The study took place on the Medical Birth Registry of Aretaieio Hospital, National and Kapodistrian University, Athens, Greece. We include a total of 19,283 pregnancies from 1998 to 2012. In this study period, 431 embryonic deaths occurred. The clinical history was documented on admission at delivery. Conditions thought to be associated with the intrauterine fetal death were recorded. Gestational age was calculated from the last menstrual period as well as with the three-trimester system. The autopsy, placenta and umbilical cord examination were performed by the same laboratory of pathology in Aretaieio University Hospital. We found that the majority of stillbirths occurred in the second trimester. We examined placenta and umbilical cord in all cases. The most frequent histologic abnormalities were those indicated placental vascular insufficiency. As far as the umbilical cord is concerned we found that the inflammatory disorder was the most common in antepartum deaths. A single umbilical artery was significantly related to gestational diabetes and congenital embryonic anomalies. Finally, our results showed steady declines in antepartum deaths during 1998-2012. As a result, we reached the conclusion that in order to reduce the fetal death rate, we have to insist on the autopsy of the placenta and umbilical cord in order to gain the appropriate information in counseling the parents.

Taxonomy of clinical encounters during the first 90 days post-delivery of an initial lower limb prosthesis

BACKGROUND

The incidence and etiology of prosthetic services utilization is poorly understood during the first 90 days post-delivery of the initial lower limb prosthesis. This period is of critical importance, as prevailing policy dictates limits on the reimbursement for certain services provided during this time period. The first step in understanding the financial ramifications of such policy is to examine the taxonomy behind clinical encounters during this tenuous time period.

OBJECTIVES

Quantify and categorize clinical encounters by incidence and etiology.

STUDY DESIGN

Retrospective chart review.

METHODS

A central database containing data on prosthetic services was examined. Incidence and etiology were extracted through independent review of each patient chart.

RESULTS

A total of 537 unique patients were identified, with 109 meeting the inclusion criteria. Chi-square testing showed that comfort ( p < 0.05), cosmesis ( p < 0.01), and mechanical failure ( p < 0.001) yielded statistical significance in scheduled versus unscheduled visits. Stepwise regression analysis demonstrated that both sex and K-level were important predictors of unscheduled visits.

CONCLUSION

Taxonomization of clinical encounters experienced during the first 90 days provides a framework for future studies to be conducted. The data provided can serve as a basis for informing reimbursement policy, workforce planning, and advocacy. Clinical relevance Comfort is the most frequent reason for a clinical encounter during the first 90 days after delivering a lower limb prosthesis. The data on the taxonomy behind the clinical encounters can be used to guide workforce planning and advocate for just reimbursement policy that better reflect patient's needs.

Impact of fetal maceration grade on risk of maternal disseminated intravascular coagulation after intrauterine fetal death - A retrospective cohort study

Disseminated intravascular coagulation (DIC) is a life-threatening event that is the endpoint of a pathologically activated cascade leading to excessive consumption of platelets culminating in bleeding. Several diseases are known to be associated with DIC, some of which may also occur during pregnancy or the puerperium. One of the potential risk factors that have been considered as a potential trigger for DIC is the retention of a highly macerated fetus after intrauterine fetal death (IUFD). However, sparse evidence exists on its clinical implication on hemostasis parameters. In this retrospective single-center study, we investigated the role of fetal maceration grades 0-III on the risk of DIC in 91 women following IUFD between gestational weeks (+days) 22 + 0 and 41 + 6 between 2003 and 2017. We calculated the Erez DIC-score after consideration of maternal platelet count (PC), prothrombin time (PT) and fibrinogen (Fib) and correlated the findings with fetal maceration grade. Mean (±SD) age of women was 32.1 ± 6.7 years. Neither maternal hemostasis parameters (PC, PT, Fib), nor the Erez score showed a statistically significant difference between maceration grades 0-III with median values of 1 for all four grades (maceration grade I: range 0 to 27; I: 0 to 51; II: 0 to 52; III: 0 to 39). We therefore conclude, that the pathophysiology of DIC in women after singleton IUFD is unrelated to the degree of fetal maceration.

Making stillbirths visible: a systematic review of globally reported causes of stillbirth

BACKGROUND

Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention.

OBJECTIVES

To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM.

SEARCH STRATEGY

We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016.

SELECTION CRITERIA

Reports of stillbirth causes in unselective cohorts.

DATA COLLECTION AND ANALYSIS

Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC).

MAIN RESULTS

Eighty-five reports from 50 countries (489 089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes.

CONCLUSIONS

There is a paucity of quality information on causes of stillbirth globally. Improving investigation of stillbirths and standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings.

FUNDING

HR, SH, SHL, and AW were supported by an NHMRC-CRE grant (APP1116640). VF was funded by an NHMRC-CDF (APP1123611).

TWEETABLE ABSTRACT

Urgent need to improve data on causes of stillbirths across all settings to meet global targets.

PLAIN LANGUAGE SUMMARY

Background and methods Nearly three million babies are stillborn every year. These deaths have deep and long-lasting effects on parents, healthcare providers, and the society. One of the major challenges to preventing stillbirths is the lack of information about why they happen. In this study, we collected reports on the causes of stillbirth from high-, middle-, and low-income countries to: (1) Understand the causes of stillbirth, and (2) Understand how to improve reporting of stillbirths. Findings We found 85 reports from 50 different countries. The information available from the reports was inconsistent and often of poor quality, so it was hard to get a clear picture about what are the causes of stillbirth across the world. Many different definitions of stillbirth were used. There was also wide variation in what investigations of the mother and baby were undertaken to identify the cause of stillbirth. Stillbirths in all income settings (low-, middle-, and high-income countries) were most frequently reported as Unexplained, Other, and Haemorrhage (bleeding). Unexplained and Other are not helpful in understanding why a baby was stillborn. In low-income countries, stillbirths were often attributed to Infection and Complications during labour and birth. In middle- and high-income countries, stillbirths were often reported as Placental complications. Limitations We may have missed some reports as searches were carried out in English only. The available reports were of poor quality. Implications Many countries, particularly those where the majority of stillbirths occur, do not report any information about these deaths. Where there are reports, the quality is often poor. It is important to improve the investigation and reporting of stillbirth using a standardised system so that policy makers and healthcare workers can develop effective stillbirth prevention programs. All stillbirths should be investigated and reported in line with the World Health Organization standards.

Fetal death: an extreme manifestation of maternal anti-fetal rejection

OBJECTIVE

The aim of this study was to determine the association between chronic placental inflammation and amniotic fluid (AF) markers of maternal anti-fetal rejection as well as the presence of microorganisms in the AF fluid of patients with fetal death.

STUDY DESIGN

This cohort study included 40 patients with fetal death whose placentas were examined for chronic inflammatory lesions and whose AF chemokine ligand (CXCL)10 and interleukin (IL)-6 concentrations were determined by immunoassays. AF was processed for bacteria, mycoplasmas and viruses using cultivation and molecular microbiologic techniques (i.e. PCR-ESI/MS).

RESULTS

(1) The most prevalent placental findings were maternal vascular underperfusion (63.2%, 24/38), followed by chronic inflammatory lesions (57.9%, 22/38); (2) chronic chorioamnionitis (18/38) was three times more frequent than villitis of unknown etiology (6/38); (3) an elevated AF CXCL10 concentration (above the 95th centile) was present in 60% of the cases, and a receiver operating characteristics (ROC)-derived cut-off of 2.9 ng/mL had a sensitivity of 73% and a specificity of 75% in the identification of chronic placental inflammatory lesions; (4) only five cases had microbial invasion of the amniotic cavity, and the presence of microorganisms did not correlate with chronic placental inflammation.

CONCLUSION

In women with unexplained fetal death, there is an association between elevated AF CXCL10 and chronic placental inflammatory lesions. Therefore, we conclude that a subset of patients with fetal death may have endured a breakdown of maternal-fetal tolerance, which cannot be attributed to microorganisms in the amniotic cavity.

Cause of and factors associated with stillbirth: a systematic review of classification systems

INTRODUCTION

An estimated 2.6 million stillbirths occur worldwide each year. A standardized classification system setting out possible cause of death and contributing factors is useful to help obtain comparative data across different settings. We undertook a systematic review of stillbirth classification systems to highlight their strengths and weaknesses for practitioners and policymakers.

MATERIAL AND METHODS

We conducted a systematic search and review of the literature to identify the classification systems used to aggregate information for stillbirth and perinatal deaths. Narrative synthesis was used to compare the range and depth of information required to apply the systems, and the different categories provided for cause of and factors contributing to stillbirth.

RESULTS

A total of 118 documents were screened; 31 classification systems were included, of which six were designed specifically for stillbirth, 14 for perinatal death, three systems included neonatal deaths and two included infant deaths. Most (27/31) were developed in and first tested using data obtained from high-income settings. All systems required information from clinical records. One-third of the classification systems (11/31) included information obtained from histology or autopsy. The percentage where cause of death remained unknown ranged from 0.39% using the Nordic-Baltic classification to 46.4% using the Keeling system.

CONCLUSION

Over time, classification systems have become more complex. The success of application is dependent on the availability of detailed clinical information and laboratory investigations. Systems that adopt a layered approach allow for classification of cause of death to a broad as well as to a more detailed level.

Perinatal mortality classification: an analysis of 112 cases of stillbirth

This was a retrospective cohort analysis of stillbirths that occurred from January 2004 to December 2013 in our institution. We compared Tulip and Wigglesworth classification systems on a cohort of stillbirths and analysed the main differences between these two classifications. In this period, there were 112 stillbirths of a total of 31,758 births (stillbirth rate of 3.5 per 1000 births). There were 99 antepartum deaths and 13 intrapartum deaths. Foetal autopsy was performed in 99 cases and placental histopathological examination in all of the cases. The Wigglesworth found 'unknown' causes in 47 cases and the Tulip classification allocated 33 of these. Fourteen cases remained in the group of 'unknown' causes. Therefore, the Wigglesworth classification of stillbirths results in a higher proportion of unexplained stillbirths. We suggest that the traditional Wigglesworth classification should be substituted by a classification that manages the available information.

Perinatal death investigations: What is current practice?

Perinatal death (PD) is a devastating obstetric complication. Determination of cause of death helps in understanding why and how it occurs, and it is an indispensable aid to parents wanting to understand why their baby died and to determine the recurrence risk and management in subsequent pregnancy. Consequently, a perinatal death requires adequate diagnostic investigation. An important first step in the analysis of PD is to identify the case circumstances, including relevant details regarding maternal history, obstetric history and current pregnancy (complications are evaluated and recorded). In the next step, placental examination is suggested in all cases, together with molecular cytogenetic evaluation and fetal autopsy. Investigation for fetal-maternal hemorrhage by Kleihauer is also recommended as standard. In cases where parents do not consent to autopsy, alternative approaches such as minimally invasive postmortem examination, postmortem magnetic resonance imaging, and fetal photographs are good alternatives. After all investigations have been performed it is important to combine findings from the clinical review and investigations together, to identify the most probable cause of death and counsel the parents regarding their loss.

Classification of causes and associated conditions for stillbirths and neonatal deaths

Accurate and consistent classification of causes and associated conditions for perinatal deaths is essential to inform strategies to reduce the five million which occur globally each year. With the majority of deaths occurring in low- and middle-income countries (LMICs), their needs must be prioritised. The aim of this paper is to review the classification of perinatal death, the contemporary classification systems including the World Health Organization's International Classification of Diseases - Perinatal Mortality (ICD-PM), and next steps. During the period from 2009 to 2014, a total of 81 new or modified classification systems were identified with the majority developed in high-income countries (HICs). Structure, definitions and rules and therefore data on causes vary widely and implementation is suboptimal. Whereas system testing is limited, none appears ideal. Several systems result in a high proportion of unexplained stillbirths, prompting HICs to use more detailed systems that require data unavailable in low-income countries. Some systems appear to perform well across these different settings. ICD-PM addresses some shortcomings of ICD-10 for perinatal deaths, but important limitations remain, especially for stillbirths. A global approach to classification is needed and seems feasible. The new ICD-PM system is an important step forward and improvements will be enhanced by wide-scale use and evaluation. Implementation requires national-level support and dedicated resources. Future research should focus on implementation strategies and evaluation methods, defining placental pathologies, and ways to engage parents in the process.

Causes and temporal changes in nationally collected stillbirth audit data in high-resource settings

Few high-income countries have an active national programme of stillbirth audit. From the three national programmes identified (UK, New Zealand, and the Netherlands) steady declines in annual stillbirth rates have been observed over the audit period between 1993 and 2014. Unexplained stillbirth remains the largest group in the classification of stillbirths, with a decline in intrapartum-related stillbirths, which could represent improvements in intrapartum care. All three national audits of stillbirths suggest that up to half of all reviewed stillbirths have elements of care that failed to follow standards and guidance. Variation in the classification of stillbirth, cause of death and frequency of risk factor groups limit our ability to draw meaningful conclusions as to the true scale of the burden and the changing epidemiology of stillbirths in high-income countries. International standardization of these would facilitate direct comparisons between countries. The observed declines in stillbirth rates over the period of perinatal audit, a possible consequence of recommendations for improved antenatal care, should serve to incentivise other countries to implement similar audit programmes.

The Stillbirth Classification System for the Safe Passage Study

Objective Describe the classification system for assigning the cause of stillbirth in the Safe Passage Study, an international, multi-institutional, prospective analysis conducted by the NIAAA/NICHD-funded Prenatal Alcohol in SIDS and Stillbirth (PASS) Research Network. The study mission is to determine the role of prenatal alcohol and/or cigarette smoke exposure in adverse pregnancy outcomes, including stillbirth, in a high-risk cohort of 12,000 maternal/fetal dyads. Methods The PASS Network classification system is based upon 5 "sites of origin" for cause of stillbirth, further subdivided into mechanism subcategories; both are employed to assign an ultimate cause of death. Each PASS stillbirth was assigned a cause of death and status of sporadic versus recurrent. Adjudication involved review of maternal and obstetrical records; fetal autopsy and placental findings; and required complete consensus in each case. Two published classification systems, ie, INCODE and ReCoDe, were used for comparison. Results Causes of stillbirth classified were fetal (26%), placental (53%), external (5%), and undetermined (16%). Nine cases (47%) had placental causes of death due to maternal disorders that carry recurrence risks. There was full agreement for cause of death across the 3 classification systems in 26% of cases and partial agreement among them in 42% of cases. Conclusions The proposed PASS schema employs a user-friendly classification that provides comparable information to previously published systems. Advantages include its simplicity, mechanistic formulations, tight clinicopathologic integration, provision for an undetermined category, and its wide applicability to perinatal mortality review boards with access to information routinely collected during clinicopathologic evaluations.

Stillbirth and intrauterine fetal death: factors affecting determination of cause of death at autopsy

OBJECTIVES

There have been several attempts to classify cause of death (CoD) in stillbirth; however, all such systems are subjective, allowing for observer bias and making comparisons between systems challenging. This study aimed to examine factors relating to determination of CoD using a large dataset from two specialist centers in which observer bias had been reduced by classifying findings objectively and assigning CoD based on predetermined criteria.

METHODS

Detailed autopsy reports from intrauterine deaths in the second and third trimesters during 2005-2013 were reviewed and findings entered into a specially designed database, in which CoD was assigned using predefined objective criteria. Data regarding CoD categories and factors affecting determination of CoD were examined.

RESULTS

There were 1064 intrauterine deaths, including 246 early intrauterine fetal deaths (IUFD) (< 20 weeks), 179 late IUFDs (20-23 weeks) and 639 stillbirths (≥ 24 weeks' gestation). Overall, around 40% (n = 412) had a clear CoD identified, whilst around 60% (n = 652) were classified as 'unexplained', including around half with identified risk factors or lesions of uncertain significance, with the remaining half (n = 292 (45%)) being entirely unexplained. A stepwise increase in the proportion of unexplained deaths was observed with increasing maceration. Black and Asian women had significantly greater proportions of deaths due to ascending infection, whilst women aged over 40 years had significantly increased placenta-related CoDs. There was no significant difference in CoD distribution according to maternal body mass index or with increasing postmortem interval. Around half of those with an identifiable CoD could be identified from clinical review and external fetal examination or imaging, with most of the remainder being determined following placental examination.

CONCLUSIONS

Based on objective criteria, many intrauterine deaths throughout gestation remain unexplained despite autopsy examination. The rate of unexplained death varies from around 30% to 60% depending on interpretation of the significance of features. CoD determination is dependent on both the classification system used and subjective interpretation, such that variation in the proportion of 'unexplained' cases is based largely on speculation regarding mechanisms of death. Novel methods to determine objectively the mechanism of death at postmortem examination are required. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Stillbirth and intrauterine fetal death: role of routine histopathological placental findings to determine cause of death

OBJECTIVES

Placental abnormalities are a common cause of death in stillbirth, ranking second only to unexplained deaths, though there is wide variation in the proportion attributed to placental disease. In clinical practice, interpretation of the significance of placental findings is difficult, since many placental features in stillbirths overlap with those in live births. Our aim was to examine objectively classified placental findings from a series of > 1000 autopsies following intrauterine death in order to evaluate the role of placental histological examination in determining the cause of death.

METHODS

As part of a larger study evaluating several aspects of autopsy findings in intrauterine death, a dedicated database was used to collate antenatal and postmortem examination details for all cases examined between 2005 and 2013 at two tertiary specialist centers in London, UK. Histological findings for placentas were evaluated in relation to the final cause of death.

RESULTS

Among 1064 intrauterine deaths, 946 (89%) cases had the placenta submitted for examination as part of the autopsy. Of these, 307 (32%) cases had the cause of death assigned to abnormalities of the placenta, cord or membranes. Around one third of stillbirths (≥ 24 weeks) had some isolated placental histological abnormality identified, many of uncertain significance, a significantly greater proportion than in cases of second-trimester intrauterine fetal demise (P < 0.0001). The cause of death was ascending infection in 176/946 (19%) cases, peaking at 22 weeks' gestation, with significantly more black mothers having ascending infection compared with other ethnicities (P < 0.0001). Maternal vascular malperfusion was the largest category of placental abnormalities in stillbirth, with peak prevalence in the early third trimester. There were 18 (2%) cases with specific histological abnormalities, including chronic histiocytic intervillositis and massive perivillous fibrin deposition.

CONCLUSIONS

Placental pathologies represent the largest category of cause of intrauterine death. Placental histological examination is the single most useful component of the autopsy process in this clinical setting. A minority of cases are associated with specific placental pathologies, often with high recurrence rates, that can be diagnosed only on microscopic examination of the placenta. Many deaths remain unexplained, although placental histological lesions may be present which are of uncertain significance. A rigorous, systematic approach to placental pathology research and classification may yield better understanding of the significance of placental findings and reduce the rate of unexplained intrauterine deaths. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Seeking order amidst chaos: a systematic review of classification systems for causes of stillbirth and neonatal death, 2009-2014

BACKGROUND

Each year, about 5.3 million babies die in the perinatal period. Understanding of causes of death is critical for prevention, yet there is no globally acceptable classification system. Instead, many disparate systems have been developed and used. We aimed to identify all systems used or created between 2009 and 2014, with their key features, including extent of alignment with the International Classification of Diseases (ICD) and variation in features by region, to inform the World Health Organization's development of a new global approach to classifying perinatal deaths.

METHODS

A systematic literature review (CINAHL, EMBASE, Medline, Global Health, and PubMed) identified published and unpublished studies and national reports describing new classification systems or modifications of existing systems for causes of perinatal death, or that used or tested such systems, between 2009 and 2014. Studies reporting ICD use only were excluded. Data were independently double-extracted (except from non-English publications). Subgroup analyses explored variation by extent and region.

RESULTS

Eighty-one systems were identified as new, modifications of existing systems, or having been used between 2009 and 2014, with an average of ten systems created/modified each year. Systems had widely varying characteristics: (i) comprehensiveness (40 systems classified both stillbirths and neonatal deaths); (ii) extent of use (systems were created in 28 countries and used in 40; 17 were created for national use; 27 were widely used); (iii) accessibility (three systems available in e-format); (iv) underlying cause of death (64 systems required a single cause of death); (v) reliability (10 systems tested for reliability, with overall Kappa scores ranging from .35-.93); and (vi) ICD alignment (17 systems used ICD codes). Regional databases were not searched, so system numbers may be underestimated. Some non-differential misclassification of systems was possible.

CONCLUSIONS

The plethora of systems in use, and continuing system development, hamper international efforts to improve understanding of causes of death. Recognition of the features of currently used systems, combined with a better understanding of the drivers of continued system creation, may help the development of a truly effective global system.

Classification of stillbirths is an ongoing dilemma

AIM

To compare different classification systems in a cohort of stillbirths undergoing a comprehensive workup; to establish whether a particular classification system is most suitable and useful in determining cause of death, purporting the lowest percentage of unexplained death.

METHODS

Cases of stillbirth at gestational age 22-41 weeks occurring at the Department of Gynecology and Obstetrics of Foggia University during a 4 year period were collected. The World Health Organization (WHO) diagnosis of stillbirth was used. All the data collection was based on the recommendations of an Italian diagnostic workup for stillbirth. Two expert obstetricians reviewed all cases and classified causes according to five classification systems.

RESULTS

Relevant Condition at Death (ReCoDe) and Causes Of Death and Associated Conditions (CODAC) classification systems performed best in retaining information. The ReCoDe system provided the lowest rate of unexplained stillbirth (14%) compared to de Galan-Roosen (16%), CODAC (16%), Tulip (18%), Wigglesworth (62%).

CONCLUSION

Classification of stillbirth is influenced by the multiplicity of possible causes and factors related to fetal death. Fetal autopsy, placental histology and cytogenetic analysis are strongly recommended to have a complete diagnostic evaluation. Commonly employed classification systems performed differently in our experience, the most satisfactory being the ReCoDe. Given the rate of "unexplained" cases, none can be considered optimal and further efforts are necessary to work out a clinically useful system.

Classification systems for causes of stillbirth and neonatal death, 2009-2014: an assessment of alignment with characteristics for an effective global system

Background

To reduce the burden of 5.3 million stillbirths and neonatal deaths annually, an understanding of causes of deaths is critical. A systematic review identified 81 systems for classification of causes of stillbirth (SB) and neonatal death (NND) between 2009 and 2014. The large number of systems hampers efforts to understand and prevent these deaths. This study aimed to assess the alignment of current classification systems with expert-identified characteristics for a globally effective classification system.

Methods

Eighty-one classification systems were assessed for alignment with 17 characteristics previously identified through expert consensus as necessary for an effective global system. Data were extracted independently by two authors. Systems were assessed against each characteristic and weighted and unweighted scores assigned to each. Subgroup analyses were undertaken by system use, setting, type of death included and type of characteristic.

Results

None of the 81 systems were aligned with more than 9 of the 17 characteristics; most (82 %) were aligned with four or fewer. On average, systems were aligned with 19 % of characteristics. The most aligned system (Frøen 2009-Codac) still had an unweighted score of only 9/17. Alignment with individual characteristics ranged from 0 to 49 %. Alignment was somewhat higher for widely used as compared to less used systems (22 % v 17 %), systems used only in high income countries as compared to only in low and middle income countries (20 % vs 16 %), and systems including both SB and NND (23 %) as compared to NND-only (15 %) and SB-only systems (13 %). Alignment was higher with characteristics assessing structure (23 %) than function (15 %).

Conclusions

There is an unmet need for a system exhibiting all the characteristics of a globally effective system as defined by experts in the use of systems, as none of the 81 contemporary classification systems assessed was highly aligned with these characteristics. A particular concern in terms of global effectiveness is the lack of alignment with “ease of use” among all systems, including even the most-aligned. A system which meets the needs of users would have the potential to become the first truly globally effective classification system.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1040-7) contains supplementary material, which is available to authorized users.

Characteristics of a global classification system for perinatal deaths: a Delphi consensus study

BACKGROUND

Despite the global burden of perinatal deaths, there is currently no single, globally-acceptable classification system for perinatal deaths. Instead, multiple, disparate systems are in use world-wide. This inconsistency hinders accurate estimates of causes of death and impedes effective prevention strategies. The World Health Organisation (WHO) is developing a globally-acceptable classification approach for perinatal deaths. To inform this work, we sought to establish a consensus on the important characteristics of such a system.

METHODS

A group of international experts in the classification of perinatal deaths were identified and invited to join an expert panel to develop a list of important characteristics of a quality global classification system for perinatal death. A Delphi consensus methodology was used to reach agreement. Three rounds of consultation were undertaken using a purpose built on-line survey. Round one sought suggested characteristics for subsequent scoring and selection in rounds two and three.

RESULTS

The panel of experts agreed on a total of 17 important characteristics for a globally-acceptable perinatal death classification system. Of these, 10 relate to the structural design of the system and 7 relate to the functional aspects and use of the system.

CONCLUSION

This study serves as formative work towards the development of a globally-acceptable approach for the classification of the causes of perinatal deaths. The list of functional and structural characteristics identified should be taken into consideration when designing and developing such a system.

Thyroid function testing in women who had a stillbirth

CONTEXT

Thyroid dysfunction is thought to be associated with stillbirth. Therefore, thyroid function is often recommended in the diagnostic investigations for stillbirth.

OBJECTIVE

We aimed to evaluate the added value of thyroid function testing in the diagnostic investigations for stillbirth.

DESIGN AND PATIENTS

A nationwide multicentre prospective cohort study in 1025 women who suffered stillbirth >20 weeks of gestation performed between 2002 and 2008. In each woman, an extensive diagnostic work-up was performed, including placental examination and autopsy. TSH and FT4 values below the 2·5th percentile or above the 97·5th percentile according local laboratory reference values were regarded as abnormal. Women with a history of thyroid disease were evaluated separately.

MAIN OUTCOME MEASURES

Thyroid function abnormalities in women with stillbirth.

RESULTS

Of 1025 included women, 21 had a history of thyroid disease (2%). In the 875 with TSH and FT4 results and no history of thyroid disease, 10% had hypothyroxinemia, 4·6% subclinical hypothyroidism, 1·6% overt hypothyroidism and 1·5% subclinical hyperthyroidism. Women with a subclinical hyperthyroidism more often had a foetal death caused by foetal hydrops: 23% vs 2·9% (adjusted OR 10·3, 95% CI 2·5-42).

CONCLUSIONS

Women with a stillbirth had a slightly higher prevalence of overt hypothyroidism, subclinical hypothyroidism and hypothyroxinaemia compared to previous studies on thyroid dysfunction in pregnant women. Given the absence of a strong associations with the cause of stillbirth, and no demonstrated beneficial effects of treating thyroid dysfunction in these women, routine screening after stillbirth is not justified.

Quantitative assessment of placental morphology may identify specific causes of stillbirth

BACKGROUND

Stillbirth is frequently the result of pathological processes involving the placenta. Understanding the significance of specific lesions is hindered by qualitative subjective evaluation. We hypothesised that quantitative assessment of placental morphology would identify alterations between different causes of stillbirth and that placental phenotype would be independent of post-mortem effects and differ between live births and stillbirths with the same condition.

METHODS

Placental tissue was obtained from stillbirths with an established cause of death, those of unknown cause and live births. Image analysis was used to quantify different facets of placental structure including: syncytial nuclear aggregates (SNAs), proliferative cells, blood vessels, leukocytes and trophoblast area. These analyses were then applied to placental tissue from live births and stillbirths associated with fetal growth restriction (FGR), and to placental lobules before and after perfusion of the maternal side of the placental circulation to model post-mortem effects.

RESULTS

Different causes of stillbirth, particularly FGR, cord accident and hypertension had altered placental morphology compared to healthy live births. FGR stillbirths had increased SNAs and trophoblast area and reduced proliferation and villous vascularity; 2 out of 10 stillbirths of unknown cause had similar placental morphology to FGR. Stillbirths with FGR had reduced vascularity, proliferation and trophoblast area compared to FGR live births. Ex vivo perfusion did not reproduce the morphological findings of stillbirth.

CONCLUSION

These preliminary data suggest that addition of quantitative assessment of placental morphology may distinguish between different causes of stillbirth; these changes do not appear to be due to post-mortem effects. Applying quantitative assessment in addition to qualitative assessment might reduce the proportion of unexplained stillbirths.

Management of stillbirth delivery

Stillbirth is a common adverse outcome of pregnancy. Management should be individualized based on gestational age, maternal condition, prior uterine surgery, availability of skilled professionals, and maternal desires. This article discusses available data on management by gestational age and prior uterine surgery. Expectant management is a viable option for women and families who desire it and do not have any contraindications. In the second trimester, misoprostol induction and dilatation and evacuation are effective in the evacuation of the uterus. In the third trimester, induction of labor with prostaglandins, mechanical dilators, and augmentation with oxytocin is appropriate. Care should be taken with women with prior cesarean delivery; prostaglandins ideally should be avoided. Delivery by cesarean section should be performed selectively, i.e., when there is a maternal indication.

Classification of substandard factors in perinatal care: development and multidisciplinary inter-rater agreement of the Groningen-system

Background

Perinatal audit is an established method for improving the quality of perinatal care. In audit meetings substandard factors (SSF) are identified in cases of perinatal mortality and morbidity. To our knowledge there is no classification system specifically designed for the classification of substandard factors. Such a classification may help to standardise allocation of substandard factors to categories. This will help to prioritise, guide and implement actions in quality improvement programs.

Methods

A classification system of 284 substandard factors (SSF) identified in perinatal audit meetings between 2007 and 2011 was drawn up using the WHO Conceptual Framework for the International Classification for Patient Safety as a starting point. Discussions were held on inter-rater disagreements, inclusion of items, format and organisation and definitions of the main- and subcategories. A guideline was developed. An independent multidisciplinary group tested the classification. Independent of inter-rater agreement the allocations to categories were counted. For the counts in the subcategories one and two, we used the allocations in the main category as reference. The chance corrected agreement between classifiers was tested with Cohen's kappa statistic.

Results

The classification consists of 9 main categories with one or two subcategories. The main categories are (1) Equipment and Materials, (2) Medication, (3) Additional tests/ investigations, (4) Transportation , (5) Documentation, (6) Communication, (7) Medical practice, (8) Other and (9) non classifiable. Of 3663 allocations by 13 classifiers 1452 SSF’s were allocated (40 %) to ‘medical practice’ and 1247 (34 %) to ‘documentation’. 118 (3 %) times SSF’s were not classifiable, mainly due to unclear phrasing of the SSF. The chance corrected agreement of 284 substandard factors in the main category was 0.68 (95 % CI 0.66-0.70) and 0.57 (95 % CI 0.54-0.59) for the CDG and the IGD respectively.

Conclusions

Classifying substandard factors has given insight into problem area's in perinatal care and can give direction to medical, political and financial quality improvement measures.

The Groningen-system has well defined categories and subcategories and the guidelines and examples are clear. The multidisciplinary inter-rater agreement is moderate to good. Improvement of the phrasing of the substandard factors is expected to improve inter-rater agreement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0638-5) contains supplementary material, which is available to authorized users.

The role of preterm placental calcification on assessing risks of stillbirth

INTRODUCTION

Stillbirth is an important issue in antenatal care and much remains unknown. This cohort study aims to explore the previously un-identified risk factor of third-trimester stillbirth to determine if Grade III preterm placental calcification (PPC) is associated with stillbirth.

METHODS

At a tertiary teaching hospital, obstetric ultrasonography was performed at 28 weeks' gestation to establish a diagnosis of PPC. Pregnancies with multifetal gestations, major fetal congenital anomalies, termination, cord accidents, apparent intrauterine infection, and antepartum complications were excluded.

RESULTS

15,122 eligible pregnancies were categorized as stillbirth (n = 99) and livebirth (n = 15,023) groups. Between these two groups, there were no significant differences in maternal age, BMI, and parity, but significant differences in smoking and in PPC (35.4% vs 6.3%, p < 0.001) were observed. The peak occurrence of stillbirths was at 30 and 37 weeks' gestation, with a bimodal distribution of 11 and 17 stillbirths, respectively. For pregnancies with or without PPC, the incidences of stillbirths per-1000-births were 35.9 and 4.5, respectively. Using Kaplan-Meier survival analysis, at 40 weeks' gestation the cumulative stillbirth risk for pregnancies with PPC was higher compared to those without PPC. Logistic regression revealed that after adjusting for the effects of smoking and demographic factors, the risk of stillbirth (adjusted OR:7.62; 95% CI:5.00-11.62) was much higher when PPC was present.

DISCUSSION

Grade III PPC is associated with a higher incidence of stillbirth, and identified an independent risk factor. Being a pathologic implication, it may precede this negative outcome and can serve as a warning sign or marker when noted on ultrasonography.

Umbilical hypercoiling in 2nd- and 3rd-trimester intrauterine fetal death

Cases of unexplained intrauterine fetal death (IUFD) can be reduced by full placental examination, with or without autopsy. Determination of the umbilical coiling index (UCI) is considered to be a part of full placental examination. Umbilical hypercoiling (UCI above 0.30 coils/cm) is associated with IUFD. In a large retrospective study, we found an incidence of 18% umbilical hypercoiling in IUFD. We explored the association between umbilical hypercoiling and 2nd- and 3rd-trimester IUFD in 77 cases. There was a significant negative correlation between the UCI and gestational age of IUFD (P<0.001). More severe cases of hypercoiling were observed in the categories of IUFD at a younger age and with a longer duration. Signs of fetal thrombosis were significantly more present in IUFDs with umbilical hypercoiling. An umbilical cord stricture and hypercoiling seem to be significantly more common in IUFD. The severity of hypercoiling was of no influence on the presence or absence of an umbilical cord stricture. Furthermore, there was no significant difference in signs of cardiac failure between the groups of IUFD with and without umbilical hypercoiling. Our findings may be explained by the theory that hypercoiling leads to a disturbed fetal-placental circulation. Therefore, determination of the UCI should be part of the routine placental examination of cases of IUFD.

IFPA Gábor Than Award Lecture: Recognition of placental failure is key to saving babies' lives

In high-income countries, placental failure is implicated in up to 65% of cases of stillbirth. Placental failure describes the situation where the placenta cannot meet the fetus' needs and may be the end-result of a variety of underlying pathological processes evident in the placental disc, membranes and umbilical cord. These include lesions with genetic, environmental, infectious, inflammatory, mechanical, metabolic, traumatic or vascular origin. Investigation of placental tissue from stillbirths and from pregnancies at an increased risk of stillbirth has demonstrated changes in macroscopic and microscopic structure which are themselves related to abnormal placental function. A better understanding and identification of placental failure may improve the management of pregnancy complications and of pregnancies after stillbirth (which have a 5-fold increased risk of stillbirth). The majority of current antenatal tests focus on the fetus and its response to the intrauterine environment; few of these investigations reduce stillbirths in low-risk pregnancies. However, some currently used investigations reflect placental development, structure and vascular function, while other investigations employed in clinical research settings such as the evaluation of placental structure and shape have a good predictive value for adverse fetal outcome. In addition, recent studies suggest that biomarkers of placental inflammation and deteriorating placental function can be detected in maternal blood suggesting that holistic evaluation of placental structure and function is possible. We anticipate that development of reliable tests of placental structure and function, coupled to assessment of fetal wellbeing offer a new opportunity to identify pregnancies at risk of stillbirth and to direct novel therapeutic strategies to prevent it.

Term perinatal mortality audit in the Netherlands 2010-2012: a population-based cohort study

OBJECTIVE

To assess the implementation and first results of a term perinatal internal audit by a standardised method.

DESIGN

Population-based cohort study.

SETTING

All 90 Dutch hospitals with obstetric/paediatric departments linked to community practices of midwives, general practitioners in their attachment areas, organised in perinatal cooperation groups (PCG).

POPULATION

The population consisted of 943 registered term perinatal deaths occurring in 2010-2012 with detailed information, including 707 cases with completed audit results.

MAIN OUTCOME MEASURES

Participation in the audit, perinatal death classification, identification of substandard factors (SSF), SSF in relation to death, conclusive recommendations for quality improvement in perinatal care and antepartum risk selection at the start of labour.

RESULTS

After the introduction of the perinatal audit in 2010, all PCGs participated. They organised 645 audit sessions, with an average of 31 healthcare professionals per session. Of all 1102 term perinatal deaths (2.3/1000) data were registered for 86% (943) and standardised anonymised audit results for 64% (707). In 53% of the cases at least one SSF was identified. Non-compliance to guidelines (35%) and deviation from usual professional care (41%) were the most frequent SSF. There was a (very) probable relation between the SSF and perinatal death for 8% of all cases. This declined over the years: from 10% (n=23) in 2010 to 5% (n=10) in 2012 (p=0.060). Simultaneously term perinatal mortality decreased from 2.3 to 2.0/1000 births (p<0.00001). Possibilities for improvement were identified in the organisation of care (35%), guidelines or usual care (19%) and in documentation (15%). More pregnancies were antepartum selected as high risk, 70% in 2010 and 84% in 2012 (p=0.0001).

CONCLUSIONS

The perinatal audit is implemented nationwide in all obstetrical units in the Netherlands in a short time period. It is possible that the audit contributed to the decrease in term perinatal mortality.