Recurrence risk of stillbirth in a second pregnancy

Chance of healthy versus adverse outcome in subsequent pregnancy after previous loss beyond 16 weeks: data from a specialized follow-up clinic

PURPOSE

Women with a previous fetal demise have a 2-20 fold increased risk of another stillbirth in a subsequent pregnancy when compared to those who have had a live birth. Despite this, there is limited research regarding the management and outcomes of subsequent pregnancies. This study was conducted to accurately quantify the chances of a woman having a healthy subsequent pregnancy after a pregnancy loss.

METHODS

A retrospective study was conducted at a tertiary-level unit between March 2019 and April 2021. We collected data on all women with a history of previous fetal demise attending a specialized perinatal history clinic and compared the risk of subsequent stillbirth to those with a normal pregnancy outcome. Outcome data included birth outcome, obstetric and medical complications, gestational age and birth weight and mode of delivery. Those who had healthy subsequent pregnancies were compared with those who experienced adverse outcomes.

RESULTS

A total of 101 cases were reviewed. Ninety-six women with subsequent pregnancies after a history of fetal demise from 16 weeks were included. Seventy-nine percent of women (n = 76) delivered a baby at term, without complications. Overall, 2.1% had repeat pregnancy losses (n = 2) and 2.1% delivered babies with fetal growth restriction (n = 2). There were no cases of abruption in a subsequent pregnancy. Eighteen neonates were delivered prematurely (18.4%), 15 of these (83.3%) were due to iatrogenic causes and three (16.7%) were spontaneous. In univariable logistic regression analyses, those with adverse outcomes in subsequent pregnancies had greater odds of pre-eclampsia (Odds ratio *(OR) = 3.89, 95% CI = 1.05-14.43, p = .042) and fetal growth restriction (OR = 4.58, 95% CI = 1.41-14.82, p = 0.011) in previous pregnancies compared to those with healthy outcomes. However, in multivariable logistic regression analyses, neither variable had a significant odds ratio (OR = 2.03, 95% CI = 0.44-9.39, p = .366 and OR = 3.42, 95% CI = 0.90 - 13.09, p = .072 for pre-eclampsia and FGR, respectively).

CONCLUSION

Four in five women had a healthy subsequent pregnancy. This is a reassuring figure for women when contemplating another pregnancy, particularly if cared for in a specialist clinic.

Neonatal and Maternal Outcomes of Pregnancies following Stillbirth

OBJECTIVE

 Prior stillbirth increases risk of subsequent stillbirth but has unclear effect on subsequent liveborn pregnancies. We examined associations between prior stillbirth, adverse neonatal outcomes, and maternal morbidity in subsequent liveborn pregnancies.

STUDY DESIGN

 This is a secondary analysis of a large, National Institutes of Health-funded retrospective cohort study of parturients who delivered a singleton infant at a tertiary-care hospital from January 2002 to March 2013 and had a past medical/obstetric history of diabetic, and/or hypertensive disorders, and/or pregnancy with fetal growth restriction. Our analysis included all multiparous patients from the parent study. The primary outcome was a neonatal morbidity composite (neonatal resuscitation, neonatal birth injury, respiratory distress syndrome, transient tachypnea of the newborn, hypoglycemia, sepsis). Secondary outcomes included a maternal morbidity composite (venous thromboembolism, intensive care unit admission, disseminated intravascular coagulation, sepsis, hysterectomy, pulmonary edema, renal failure, blood transfusion), other maternal/delivery complications, and neonatal intensive care unit (NICU) admission. Outcomes were compared between those with versus without prior stillbirth. Negative binomial regression controlled for maternal comorbidities and delivery year.

RESULTS

 Among 171 and 5,245 multiparous parturients with versus without prior stillbirth, respectively, those with prior stillbirth had higher rates of pregestational diabetes, autoimmune disease, and clotting disorders. After controlling for these differences and delivery year, infants of parturients with prior stillbirth had similar risk of composite neonatal morbidity (adjusted relative ratio [aRR] 1.19; 95% confidence interval [CI] 0.99-1.45) but higher risk of NICU admission (aRR 1.42; 95% CI 1.06-1.91) compared with infants of parturients without prior stillbirth, despite delivering at similar gestational ages. Multiparous patients with prior stillbirth had equal maternal morbidity risk but higher risk of developing preeclampsia with severe features (aRR 2.11; 95% CI 1.19-3.72).

CONCLUSION

 Compared with high-risk multiparous patients without prior stillbirth, those with prior stillbirth have higher risk of NICU admission and preeclampsia with severe features.

KEY POINTS

· Prior stillbirth increases risk in subsequent livebirth for NICU admission and neonatal morbidity.. · Prior stillbirth increased the risk of severe preeclampsia for mothers in subsequent livebirth.. · Additional monitoring of pregnancies of patients with prior history of demise may be warranted..

The effect of low-molecular-weight heparin on live birth rate of patients with unexplained early recurrent pregnancy loss: A two-arm randomized clinical trial

BACKGROUND

The effect of anticoagulant medication in unexplained early recurrent pregnancy loss (RPL) patients is controversial. This clinical trial evaluated the effect of low-molecular-weight heparin (LMWH) on pregnancy outcomes in these patients.

MATERIALS AND METHODS

The study was performed as a single-blind randomized clinical trial between 2016 and 2018. Samples were selected from patients who were referred to Avicenna RPL clinic with a history of at least two previously happened early unexplained miscarriages. The eligibility was defined strictly to select unexplained RPL patients homogenously. One hundred and seventy-three patients who got pregnant recently were allocated randomly into two groups LMWH plus low-dose aspirin treatment (Group A = 85) and low-dose aspirin treatment only (Group B = 88)) and were followed up till their pregnancy termination (delivery/abortion). A per-protocol analysis was carried out and all statistical tests were two-sided with a P < 0.05 significance level.

RESULTS

The live birth rates (LBRs) in Groups A and B were 78% and 77.1%, respectively, which did not show any statistically significant difference between the two groups, neither in rates nor in time of abortion. In subgroup analysis for polycystic ovary syndrome (PCOS) patients, the odds ratio for study outcome (intervention/control) was 2.25 (95% confidence interval: 0.65-7.73). There was no major adverse event whereas minor bleeding was observed in 18% of patients in Group A.

CONCLUSION

LMWH does not improve the LBR in unexplained RPL patients, however, it is recommended to evaluate its effect separately in PCOS patients.

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.

Predicting singleton antepartum stillbirth by the demographic Fetal Medicine Foundation Risk Calculator—A retrospective case-control study

Objective

To assess the risk of singleton intrauterine fetal death (IUFD) in women by the demographic setting of the online Fetal Medicine Foundation (FMF) Stillbirth Risk Calculator.

Methods

Retrospective single-centre case-control study involving 144 women having suffered IUFD and 247 women after delivery of a live-born singleton. Nonparametric receiver operating characteristics (ROC) analyses were performed to predict the prognostic power of the FMF Stillbirth risk score and to generate a cut-off value to discriminate best between the event of IUFD versus live birth.

Results

Women in the IUFD cohort born a significantly higher overall risk with a median FMF risk score of 0.45% (IQR 0.23–0.99) compared to controls [0.23% (IQR 0.21–0.29); p<0.001]. Demographic factors contributing to an increased risk of IUFD in our cohort were maternal obesity (p = 0.002), smoking (p<0.001), chronic hypertension (p = 0.015), antiphospholipid syndrome (p = 0.017), type 2 diabetes (p<0.001), and insulin requirement (p<0.001). ROC analyses showed an area under the curve (AUC) of 0.72 (95% CI 0.67–0.78; p<0.001) for predicting overall IUFD and an AUC of 0.72 (95% CI 0.64–0.80; p<0.001), respectively, for predicting IUFD excluding congenital malformations. The FMF risk score at a cut-off of 0.34% (OR 6.22; 95% CI 3.91–9.89; p<0.001) yielded an 82% specificity and 58% sensitivity in predicting IUFD with a positive and negative predictive value of 0.94% and 99.84%, respectively.

Conclusion

The FMF Stillbirth Risk Calculator based upon maternal demographic and obstetric characteristics only may help identify women at low risk of antepartum stillbirth.

Stillbirth and neonatal mortality in a subsequent pregnancy following stillbirth: a population-based cohort study

BACKGROUND

A history of stillbirth is a risk factor for recurrent fetal death in a subsequent pregnancy. Reported risks of recurrent fetal death are often not stratified by gestational age. In subsequent pregnancies increased rates of medical interventions are reported without evidence of perinatal benefit. The aim of this study was to estimate gestational-age specific risks of recurrent stillbirth and to evaluate the effect of obstetrical management on perinatal outcome after previous stillbirth.

METHODS

A retrospective cohort study in the Netherlands was designed that included 252.827 women with two consecutive singleton pregnancies (1^st and 2^nd delivery) between 1999 and 2007. Data was obtained from the national Perinatal Registry and analyzed for pregnancy outcomes. Fetal deaths associated with a congenital anomaly were excluded. The primary outcome was the occurrence of stillbirth in the second pregnancy stratified by gestational age. Secondary outcome was the influence of obstetrical management on perinatal outcome in a subsequent pregnancy.

RESULTS

Of 252.827 first pregnancies, 2.058 pregnancies ended in a stillbirth (8.1 per 1000). After adjusting for confounding factors, women with a prior stillbirth have a two-fold higher risk of recurrence (aOR 1.96, 95% CI 1.07-3.60) compared to women with a live birth in their first pregnancy. The highest risk of recurrence occurred in the group of women with a stillbirth in early gestation between 22 and 28 weeks of gestation (a OR 2.25, 95% CI 0.62-8.15), while after 32 weeks the risk decreased. The risk of neonatal death after 34 weeks of gestation is higher in women with a history of stillbirth (aOR 6.48, 95% CI 2.61-16.1) and the risk of neonatal death increases with expectant obstetric management (aOR 10.0, 95% CI 2.43-41.1).

CONCLUSIONS

A history of stillbirth remains an important risk for recurrent stillbirth especially in early gestation (22-28 weeks). Women with a previous stillbirth should be counselled for elective induction in the subsequent pregnancy at 37-38 weeks of gestation to decrease the risk of perinatal death.

Can information regarding the index stillbirth determine risk of adverse outcome in a subsequent pregnancy? Findings from a single-center cohort study

INTRODUCTION

Women with a history of stillbirth have an almost five-fold increased risk of stillbirth in a subsequent pregnancy, as well as increased risk of other adverse maternal and neonatal outcomes. The reasons for this association are not well understood but could relate to recurrent causes. We aimed to determine whether information from the time of index stillbirth, including cause, is associated with outcome of a subsequent pregnancy.

MATERIAL AND METHODS

A retrospective cohort study was conducted at a UK tertiary maternity center. Cases were included if stillbirth was investigated, subsequent pregnancy care was provided, and the birth occurred in the same unit. Data on maternal characteristics, findings of investigations, and classification of death using the ReCoDe system were extracted, and logistic regression was performed to determine whether these factors were associated with adverse outcome in the subsequent pregnancy.

RESULTS

In this cohort (n = 266), there were 69 adverse outcomes, including three perinatal deaths. Preterm delivery (16.2%) and birthweight <10th centile (12.4%) were the most common adverse outcomes. Of the preterm births, 69.8% were iatrogenic and 47% of these were due to abnormalities of fetal growth. On multivariate analysis women with a preexisting medical condition (adjusted odds ratio [aOR] 2.12, 95% CI 1.10-4.12) and those who smoked in their subsequent pregnancy (aOR 6.80, 95% CI 1.99-23.30) were at increased risk of adverse outcome. Neither ReCoDe classification of stillbirth (P = .61) nor gestation of stillbirth (P = .36) were associated with subsequent pregnancy outcome. Placental histopathological findings of maternal vascular malperfusion (aOR 11.34, 95% CI 2.20-58.62), fetal vascular malperfusion (aOR 9.27, 95% CI 1.09-78.82), and chorioamnionitis (aOR 6.35, 95% CI 1.16-34.78) in the index stillbirth were associated with adverse outcome in subsequent pregnancy. These associations were independent of maternal characteristics.

CONCLUSIONS

Placental examination at time of stillbirth is important, as certain placental disorders inform the risk of adverse outcome in subsequent pregnancy. In this cohort, information regarding maternal characteristics and classification of cause of stillbirth do not provide significant prognostic information about the risk of adverse outcome in subsequent pregnancies. Optimal management of maternal medical disorders and access to smoking cessation are essential.

Stillbirth: Perceptions among hospital staff in the Middle East and the UK

Objectives Stillbirth is an important and yet relatively unacknowledged public health concern in many parts of the world. Public awareness of stillbirth and its potentially modifiable risk factors is a prerequisite to planning prevention measures. Cultural and regional differences may play an important role in awareness and attitudes to stillbirth prevention. The objective of this study was to evaluate and compare the awareness of stillbirth among hospital staff in Qatar and the UK, representing two culturally different regions.

Study design An online population survey for anonymous completion was sent to the hospital email accounts of all grades of staff (clinical and non-clinical) at two hospitals in Qatar and one tertiary hospital Trust in the UK. The survey was used to gather information on the participants’ demographic background, the experience of stillbirth, knowledge of stillbirth, awareness of information and support sources, as well as attitude towards investigation and litigation. Data were analysed using descriptive and comparative statistics (Chi-Square test and Fisher’s exact test).

Results 1002 respondents completed the survey, including 349 in the Qatar group and 653 in the UK group. There were significant differences in group demographics in terms of language, religion, gender, nationality and experience of stillbirth. The groups also differed significantly in the knowledge of stillbirth, its incidence and risk factors. The two groups took different views on apportioning blame on healthcare services in cases of stillbirth. The Qatar group showed significantly less awareness of available support organisations and relied significantly more on online sources of information for stillbirths (p < 0.001).

Conclusions This comparative study demonstrated significant differences between the two culturally distinct regions in the awareness, knowledge and attitudes towards stillbirths. The complex cultural and other factors that may be contributory should be further studied. The results highlight the need for increasing public awareness around stillbirth as part of effective prevention strategies.

Risk factors for perinatal mortality in Murmansk County, Russia: a registry-based study

Background: Factors contributing to perinatal mortality (PM) in Northwest Russia remain unclear. This study investigated possible associations between selected maternal and fetal characteristics and PM based on data from the population-based Murmansk County Birth Registry.

Objective: This study investigated possible associations between selected maternal and fetal characteristics and PM based on data from the population-based Murmansk County Birth Registry.

Methods: The study population consisted of all live- and stillbirths registered in the Murmansk County Birth Registry during 2006–2011 (n = 52,806). We excluded multiple births, births prior to 22 and after 45 completed weeks of gestation, infants with congenital malformations, and births with missing information regarding gestational age (a total of n = 3,666) and/or the studied characteristics (n = 2,356). Possible associations between maternal socio-demographic and lifestyle characteristics, maternal pre-pregnancy characteristics, pregnancy characteristics, and PM were studied by multivariable logistic regression. Crude and adjusted odds ratios with 95% confidence intervals were calculated.

Results: Of the 49,140 births eligible for prevalence analysis, 338 were identified as perinatal deaths (6.9 per 1,000 births). After adjustment for other factors, maternal low education level, prior preterm delivery, spontaneous or induced abortions, antepartum hemorrhage, antenatally detected or suspected fetal growth retardation, and alcohol abuse during pregnancy all significantly increased the risk of PM. We observed a higher risk of PM in unmarried women, as well as overweight or obese mothers. Maternal underweight reduced the risk of PM.

Conclusions: Our results suggest that both social and medical factors are important correlates of perinatal mortality in Northwest Russia.

Healthcare and wider societal implications of stillbirth: a population-based cost-of-illness study

Objective

To extend previous work and estimate health and social care costs, litigation costs, funeral‐related costs, and productivity losses associated with stillbirth in the UK.

Design

A population‐based cost‐of‐illness study using a synthesis of secondary data.

Setting

The National Health Service (NHS) and wider society in the UK.

Population

Stillbirths occurring within a 12‐month period and subsequent events occurring over the following 2 years.

Methods

Costs were estimated using published data on events, resource use, and unit costs.

Main outcome measures

Mean health and social care costs, litigation costs, funeral‐related costs, and productivity costs for 2 years, reported for a single stillbirth and at a national level.

Results

Mean health and social care costs per stillbirth were £4191. Additionally, funeral‐related costs were £559, and workplace absence (parents and healthcare professionals) was estimated to cost £3829 per stillbirth. For the UK, the annual health and social care costs were estimated at £13.6 million, and total productivity losses amounted to £706.1 million (98% of this cost was attributable to the loss of the life of the baby). The figures for total productivity losses were sensitive to the perspective adopted about the loss of life of the baby.

Conclusion

This work expands the current intelligence on the costs of stillbirth beyond the health service to costs for parents and society, and yet these additional findings must still be regarded as conservative estimates of the true economic costs.

Tweetable abstract

The costs of stillbirth are significant, affecting the health service, parents, professionals, and society.

Plain Language Summary

The costs of stillbirth are significant, affecting the health service, parents, professionals, and society.

A population-based study of the effect of pregnancy history on risk of stillbirth

OBJECTIVE

To examine the effect of pregnancy history on the risk of stillbirth.

METHODS

In a population-based cross-sectional study, data were reviewed from all women aged at least 20 years with singleton pregnancies in Finland between 2000 and 2010. The primary outcome-stillbirth-was defined as fetal death after 22 gestational weeks or death of a fetus weighing at least 500 g.

RESULTS

Among 604 047 singleton pregnancies, the prevalence of stillbirth was 3.17 per 1000 deliveries. Prevalence was lowest for multiparous women without previous pregnancy loss after adjusting for major pregnancy complications associated with stillbirth (placenta previa, placental abruption, and pre-eclampsia) and other confounders. Relative to these women, stillbirth prevalence was higher among multiparous women with previous spontaneous abortion and/or stillbirth (adjusted odds ratio [aOR] 1.20, 95% confidence interval [CI] 1.05-1.36), nulliparous women with no previous pregnancy loss (aOR 1.23, 95% CI 1.10-1.38), and nulliparous women with prior spontaneous abortion (aOR 1.43, 95% CI 1.18-1.74).

CONCLUSION

Previous pregnancy loss was found to be an independent risk factor for stillbirth, irrespective of the number of prior deliveries.

Maternal, Labor, Delivery, and Perinatal Outcomes Associated with Placental Abruption: A Systematic Review

Objective Risk factors for placental abruption have changed, but there has not been an updated systematic review investigating outcomes. Methods We searched PubMed, EMBASE, Web of Science, SCOPUS, and CINAHL for publications from January 1, 2005 through December 31, 2016. We reviewed English-language publications reporting estimated incidence and/or risk factors for maternal, labor, delivery, and perinatal outcomes associated with abruption. We excluded case studies, conference abstracts, and studies that lacked a referent/comparison group or did not clearly characterize placental abruption. Results A total of 123 studies were included. Abruption was associated with elevated risk of cesarean delivery, postpartum hemorrhage and transfusion, preterm birth, intrauterine growth restriction or low birth weight, perinatal mortality, and cerebral palsy. Additional maternal outcomes included relaparotomy, hysterectomy, sepsis, amniotic fluid embolism, venous thromboembolism, acute kidney injury, and maternal intensive care unit admission. Additional perinatal outcomes included acidosis, encephalopathy, severe respiratory disorders, necrotizing enterocolitis, acute kidney injury, need for resuscitation, chronic lung disease, infant death, and epilepsy. Conclusion Few studies examined outcomes beyond the initial birth period, but there is evidence that both mother and child are at risk of additional adverse outcomes. There was also considerable variation in, or absence of, the reporting of abruption definitions.

Healthcare utilisation, induced labour and caesarean section in the pregnancy after stillbirth: a prospective study

OBJECTIVE

To investigate healthcare utilisation, induced labour and caesarean section (CS) in the pregnancy after stillbirth and assess anxiety and dread of childbirth as mediators for these outcomes.

DESIGN

Population-based pregnancy cohort study.

SETTING

The Norwegian Mother and Child Cohort Study.

SAMPLE

A total of 901 pregnant women; 174 pregnant after stillbirth, 362 pregnant after live birth and 365 previously nulliparous.

METHODS

Data from questionnaires answered in the second and third trimesters of pregnancy and information from the Medical Birth Registry of Norway.

MAIN OUTCOME MEASURES

Self-reported assessment of antenatal care, register-based assessment of onset and mode of delivery.

RESULTS

Women with a previous stillbirth had more frequent antenatal visits (mean 10.0; 95% CI 9.4-10.7) compared with women with a previous live birth (mean 6.0; 95% CI 5.8-6.2) and previously nulliparous women (mean 6.3; 95% CI 6.1-6.6). Induced labour and CS, elective and emergency, were also more prevalent in the stillbirth group. The adjusted odds ratio for elective CS was 2.5 (95% CI 1.3-5.0) compared with women with previous live birth and 3.7 (1.8-7.6) compared with previously nulliparous women. Anxiety was a minor mediator for the association between stillbirth and frequency of antenatal visits, whereas dread of childbirth was not a significant mediator for elective CS.

CONCLUSIONS

Women pregnant after stillbirth were more ample users of healthcare services and more often had induced labour and CS. The higher frequency of antenatal visits and elective CS could not be accounted for by anxiety or dread of childbirth.

TWEETABLE ABSTRACT

Women pregnant after stillbirth are ample users of healthcare services and interventions during childbirth.

High Maternal Body Mass Index in Early Pregnancy and Risks of Stillbirth and Infant Mortality-A Population-Based Sibling Study in Sweden

In a population-based case-control study, we investigated whether familial confounding influenced the associations between maternal overweight/obesity and risks of stillbirth and infant mortality by including both population and sister controls. Using nationwide data from the Swedish Medical Birth Register (1992–2011), we included all primiparous women with singleton births who also had a sister with a first birth during that time period. We used logistic regression analyses to calculate odds ratios (and 95% confidence intervals) adjusted for maternal age, height, smoking habits, education, and time period (5-year groups) of child's birth. Body mass index (BMI) was calculated as weight (kg)/height (m)². Compared with population controls with a normal BMI (18.5–24.9), stillbirth risk increased with increasing BMI (BMI 25–29.9: odds ratio (OR) = 1.51 (95% confidence interval (CI): 1.21, 1.89); BMI 30–34.9: OR = 1.77 (95% CI: 1.24, 2.50); BMI ≥35: OR = 3.16 (95% CI: 2.10, 4.76)). The sister case-control analyses revealed similar results. Offspring of obese women (BMI ≥30) had an increased risk of infant mortality when population controls were used (OR = 2.41, 95% CI: 1.83, 3.16), and an even higher risk was obtained when sister controls were used (OR = 4.04, 95% CI: 2.25, 7.25). We conclude that obesity in early pregnancy is associated with increased risks of stillbirth and infant mortality independently of genetic and early environmental risk factors shared within families.

Risk Factors for Stillbirth: Findings from a Population-Based Case-Control Study, Haryana, India

BACKGROUND

Stillbirth is a prevalent adverse outcome of pregnancy in India despite efforts to improve care of women during pregnancy. Risk factors for stillbirths include sociodemographic factors, medical complications during pregnancy, intake of harmful drugs, and complications during delivery. The objective of the study was to examine the risk factors for stillbirth with a focus on sex selection drugs (SSDs).

METHODS

A population-based case-control study was undertaken in Haryana. Cases of stillbirths were identified from the Maternal Infant Death Review System portal of Haryana state for the months of August-September 2014. A consecutive birth from the same geographical area as the case was selected as the control. The sample size was 325 per group. Mothers were interviewed using a validated tool. Bivariate analyses and logistic regression were conducted to examine the association between risk factors and stillbirth. Attributable risk proportions (ARP) and population attributable risk proportions (PARP) were estimated.

RESULTS

The sociodemographic profiles of the cases and controls were similar. History of intake of SSDs [adjusted odds ratio (OR) 2.6, 95% confidence interval (CI) 1.5, 4.5] emerged as a risk factor. Other significant factors were preterm <37 weeks (OR 3.5, 95% CI 2.1, 6.0), history of previous stillbirths (OR 4.0, 95% CI 2.1, 7.8), and complications during labour (OR 3.3, 95% CI 2.1, 5.3). Estimates of the ARP and PARP for intake of SSDs were 0.60 (95% CI 0.32, 0.77) and 0.1 (95% CI -0.13, 0.28), respectively.

CONCLUSIONS

SSDs could be attributed as a risk factor in a fifth of the cases of stillbirths. The number needed to harm for the use of SSDs in causing adverse effect of stillbirths was 5, suggesting thereby that for every five mothers exposed to SSDs, one would have stillbirth. Greater efforts are required to inform people about the harmful effects of SSD consumption during pregnancy.

Elective Delivery at Term after a Previous Unexplained Intra-Uterine Fetal Death: Audit of Delivery Outcome at Tygerberg Hospital, South Africa

Objectives

To assess the delivery outcome in a pregnancy with a previous unexplained intra-uterine death by elective induction of labour at term.

Methods

An audit of the pregnancy outcome of all women within the catchment area with a current singleton pregnancy; and a previous unexplained or unexplored singleton fetal demise ≥24 weeks (or 500 grams birth weight if gestation unknown) after planned routine induction of labour at full term (39-40 weeks).

Results

During the audit period, 306 patients with a previous intra-uterine fetal death were referred for further management. Of these, 161 had a clear indication for earlier intervention and were excluded from the protocol. Of the remaining 145 patients, 9 met further exclusion criteria and there were 2 patients who defaulted. Forty-two of the remaining study patients (with no known previous medical problems) developed complications during their antenatal course that necessitated a change in clinical management and earlier (<39 weeks) delivery. Of the remaining 92 patients in the audit, 47 (51%) went into spontaneous labour before their induction date; all 92 women delivered without major complications. There were no intra-uterine deaths prior to induction.

Conclusions

Careful follow up at a high risk clinic identifies new or concealed maternal or fetal complications in 29% of patients with a previous intra-uterine death and no obvious maternal or fetal disease in the index pregnancy. When all risks are excluded and the pregnancy allowed to progress to full term (39-40 weeks) before an induction is offered, 50% will go into spontaneous labour.

Aetiological Classification of Stillbirths: A Case Control Study

ABSTRACT

Antepartum stillbirths are a major contributor to perinatal mortality. This study was undertaken to assess the role of the ReCoDe (relevant condition at birth) classification system in evaluation of stillbirths in a tertiary teaching hospital in Central Gujarat.

AIM

To determine etiology of stillbirths using the ReCoDe classification system.

MATERIALS AND METHODS

This was a prospective case control study over a period of 1 year from September 1st, 2012 to August 31st, 2013. Sample size was calculated as 243 cases and 486 controls. Two controls (live births) per case were matched for gestational age and birth weight. Odd's ratios with 95 % confidence intervals were calculated using multivariate logistic regression.

RESULTS

Maternal age and parity that appeared to be highly significant factors on univariate analysis were not found to be independent risk factors with multivariate logistic regression. Gestational age and birth weight were not statistically significant risk factors. Other risk factors like previous stillbirth (26.13; 95 % CI 3.23-211.29), antepartum hemorrhage (11.63; 95 % CI 3.83-35.30), and hypertensive disorders (2.09; 95 % CI 1.20-3.63) were found to be highly significant independent risk factors. Major congenital anomaly (P < 0.001), birth asphyxia (P = 0.0037), cord accidents (P = 0.0037), and rupture uterus (P = 0.001) were also highly significant.

CONCLUSION

The stillbirth rate was 87.83 per 1000 live births. The ReCoDe primary classification system enabled 74.1 % of the cases to be assigned a relevant condition, leaving only 25.9 % as unexplained. The single largest condition associated was fetal growth restriction (25.9 %).

Outcome of pregnancy following second- or third-trimester intrauterine fetal death

OBJECTIVE

To investigate the outcomes of a pregnancy after a second- or third-trimester intrauterine fetal death (IUFD).

METHODS

A prospective observational study was conducted at Trousseau Hospital (Paris, France) between 1996 and 2011. The first ongoing pregnancy in women who had had a previous IUFD was monitored. Management of their treatment was according to a standardized protocol. Recurrence of fetal death was the main outcome criterion.

RESULTS

The subsequent pregnancies of 87 women who had experienced at least one previous IUFD were followed up. The cause of previous IUFD was placental in 50 (57%) women, unknown in 19 (22%), adnexal in 12 (14%), metabolic in 2 (2%), and malformative in 4 (5%). Three (3%) participants had another stillbirth. Overall, obstetric complications occurred in 34 (39%) pregnancies (including 22 [25%] preterm births, 5 [6%] small for gestational age, and 6 [7%] maternal vascular complications). Obstetric complications were significantly more common among women whose previous stillbirth had been due to placental causes than among those affected by other causes (P=0.02).

CONCLUSION

Most pregnancies after IUFD resulted in a live birth; however, adverse obstetric outcomes were more common when the previous stillbirth was due to placental causes.

Molecular and cytogenetic analysis in stillbirth: results from 481 consecutive cases

INTRODUCTION

The underlying causes of stillbirth are heterogeneous and in many cases unexplained. Our aim was to conclude clinical results from karyotype and quantitative fluorescence-polymerase chain reaction (QF-PCR) analysis of all stillbirths occurring in Stockholm County between 2008 and 2012. By screening a subset of cases, we aimed to study the possible benefits of chromosomal microarray (CMA) in the analysis of the etiology of stillbirth.

METHODS

During 2008-2012, 481 stillbirths in Stockholm County were investigated according to a clinical protocol including karyotype or QF-PCR analysis. CMA screening was performed on a subset of 90 cases, corresponding to all stillbirths from 2010 without a genetic diagnosis.

RESULTS

Chromosomal aberrations were detected by karyotype or QF-PCR analysis in 7.5% of the stillbirths. CMA analysis additionally identified two known syndromes, one aberration disrupting a known disease gene, and 26 variants of unknown significance. Furthermore, CMA had a significantly higher success rate than karyotyping (100 vs. 80%, p < 0.001).

DISCUSSION

In the analysis of stillbirth, conventional karyotyping is prone to failure, and QF-PCR is a useful complement. We show that CMA has a higher success rate and aberration detection frequency than these methods, and conclude that CMA is a valuable tool for identification of chromosomal aberrations in stillbirth.

Recurrence risk of low Apgar score among term singletons: a population-based cohort study

OBJECTIVE

To examine the risk of recurrence of low Apgar score in a subsequent term singleton pregnancy.

DESIGN

Population-based cohort study.

SETTING

The Netherlands.

POPULATION

A total of 190,725 women with two subsequent singleton term live births between 1999 and 2007.

METHODS

We calculated the recurrence risk of low Apgar score after adjustment for possible confounders. Women with an elective cesarean delivery, fetus in breech presentation or a fetus with congenital anomalies were excluded. Results were reported separately for women with a vaginal delivery or a cesarean delivery at first pregnancy.

MAIN OUTCOME MEASURES

Prevalence of birth asphyxia, a 5-min Apgar score <7.

RESULTS

The risk for an Apgar score of <7 in the first pregnancy was 0.99% and overall halved in the subsequent pregnancies (0.50%). For those with asphyxia in the first pregnancy, the risk of recurrence of a low Apgar score in the subsequent pregnancy was 1.1% (odds ratio 2.1, 95% confidence interval 1.4-3.3). This recurrence risk was present in women with a previous vaginal delivery (odds ratio 2.1, 95% confidence interval 1.2-3.5) and in women with a previous cesarean delivery (odds ratio 3.8, 95% confidence interval 1.7-8.5). Among women with a small-for-gestational-age infant in the subsequent pregnancy and a previous vaginal delivery, the recurrence risk was 4.8% (adjusted odds ratio 5.8, 95% confidence interval 2.0-16.5).

CONCLUSION

Women with birth asphyxia of the first born have twice the risk of renewed asphyxia at the next birth compared to women without birth asphyxia of the first born. This should be incorporated in the risk assessment of pregnant women.

Trends and recurrence of stillbirths in NSW

OBJECTIVE

To examine the trend in stillbirth rates adjusted for the trends in the maternal risk profile, and to use local data to estimate the stillbirth recurrence risk.

METHODS

Linked hospital, birth and perinatal death review data were used to identify risk factors and stillbirths among women giving birth to singletons in NSW between 2001 and 2009. Logistic regression models were developed to predict stillbirth rates based on the changes in the maternal population.

RESULTS

Between 2001 and 2009 there were 3,449 stillbirths (4.4 per 1,000 births), with no significant change in rate overall (p=0.6) or across older gestational age categories (26-33 weeks p=0.67, ≥34 weeks p=0.36), and a slight increase at <26 weeks (p=0.01). However, when changes in the maternal population were taken into account, there was a significant increase in stillbirths at <26 weeks (p<0.001). Women with a stillbirth in a first pregnancy were at increased risk of stillbirth in their second pregnancy (4.3 95%CI 2.4-7.7).

CONCLUSION

There has been no decline in the stillbirth rate in NSW in recent years, which, at late gestations, may be accounted for by changes in the maternal population. At early gestations, there has been an increase in stillbirths where a decrease in rate may be expected based on the maternal population.

IMPLICATIONS

Further focus on addressing risk factors for stillbirths is needed to ensure continued progress is made in reducing stillbirths.

A structured review and exploration of the healthcare costs associated with stillbirth and a subsequent pregnancy in England and Wales

Background

In contrast to other pregnancy complications the economic impact of stillbirth is poorly understood. We aimed to carry out a preliminary exploration of the healthcare costs of stillbirth from the time of pregnancy loss and the period afterwards; also to explore and include the impact of a previous stillbirth on the healthcare costs of the next pregnancy.

Methods

A structured review of the literature including cost studies and description of costs to health-care providers for care provided at the time of stillbirth and in a subsequent pregnancy. Costs in a subsequent pregnancy were compared in three alternative models of care for multiparous women developed from national guidelines and expert opinion: i) “low risk” women who had a live birth, ii) “high risk” women who had a live birth and iii) women with a previous stillbirth.

Results

The costs to the National Health Service (NHS) for investigation immediately following stillbirth ranged from £1,242 (core recommended investigations) to £1,804 (comprehensive investigation). The costs in the next pregnancy following a stillbirth ranged from £2,147 (low-risk woman with a previous healthy child) to £3,751 (Woman with a previous stillbirth of unknown cause). The cost in the next pregnancy following a stillbirth due to a known recurrent or an unknown cause is almost £500 greater than the pregnancy following a stillbirth due to a known non-recurrent cause.

Conclusions

The study has highlighted the paucity of evidence regarding economic issues surrounding stillbirth. Women who have experienced a previous stillbirth are likely to utilise more health care services in their next pregnancy particularly where no cause is found. Every effort should be made to determine the cause of stillbirth to reduce the overall cost to the NHS. The cost associated with identifying the cause of stillbirth could offset the costs of care in the next pregnancy. Future research should concentrate on robust studies looking into the wider economic impact of stillbirth.

Recurrence of perinatal death in Northern Tanzania: a registry based cohort study

Background

Perinatal mortality is known to be high in Sub-Saharan Africa. Some women may carry a particularly high risk which would be reflected in a high recurrence risk. We aim to estimate the recurrence risk of perinatal death using data from a hospital in Northern Tanzania.

Methods

We constructed a cohort study using data from the hospital based KCMC Medical Birth Registry. Women who delivered a singleton for the first time at the hospital between 2000 and 2008 were followed in the registry for subsequent deliveries up to 2010 and 3,909 women were identified with at least one more delivery within the follow-up period. Recurrence risk of perinatal death was estimated in multivariate models analysis while adjusting for confounders and accounting for correlation between births from the same mother.

Results

The recurrence risk of perinatal death for women who had lost a previous baby was 9.1%. This amounted to a relative risk of 3.2 (95% CI: 2.2 - 4.7) compared to the much lower risk of 2.8% for women who had had a surviving baby. Recurrence contributed 21.2% (31/146) of perinatal deaths in subsequent pregnancies. Preeclampsia, placental abruption, placenta previa, induced labor, preterm delivery and low birth weight in a previous delivery with a surviving baby were also associated with increased perinatal mortality in the next pregnancy.

Conclusions

Some women in Tanzanian who suffer a perinatal loss in one pregnancy are at a particularly high risk of also losing the baby of a subsequent pregnancy. Strategies of perinatal death prevention that target pregnant women who are particularly vulnerable or already have experienced a perinatal loss should be considered in future research.

Recurrence of adverse perinatal outcomes in developing countries

OBJECTIVE

To evaluate the risk of recurrence of adverse perinatal outcomes in second pregnancies in developing countries.

METHODS

Data from the 2004-2008 Global Survey on Maternal and Perinatal Health were used to determine the outcomes of singleton second pregnancies for 61 780 women in 23 developing countries. The mother-infant pairs had been followed up until discharge or for 7 days postpartum.

FINDINGS

At the end of their second pregnancies, women whose first pregnancy had ended in stillbirth (n = 1261) or been followed by neonatal death (n = 1052) were more likely than women who had not experienced either outcome to have given birth to a child with a birth weight of < 1500 g (odds ratio, OR: 2.52 and 2.78, respectively) or 1500-2499 g (OR: 1.22 and 1.60, respectively), or to an infant requiring admission to an intensive care unit (OR: 1.64 and 1.68, respectively). At the end of their second pregnancies, those whose first pregnancy had ended in a stillbirth were at increased risk of another stillbirth (OR: 2.35) and those whose first infant had died as a neonate were at increased risk of having the second infant die within the first 7 days of life (OR: 2.82). These trends were found to be largely unaffected by the continent in which the women lived.

CONCLUSION

In the developing world, a woman whose first pregnancy ends in stillbirth or is followed by the death of the neonate is at increased risk of experiencing the same outcomes in her second pregnancy.

Hospital data reporting on postpartum hemorrhage: under-estimates recurrence and over-estimates the contribution of uterine atony

This study aimed to explore whether recording of a prior adverse pregnancy outcome (postpartum hemorrhage) in a medical record increases the likelihood that recurrence of the same event is reported in hospital data. Using a sample of 588 pregnancies [2 consecutive pregnancies for 294 randomly selected women with at least one postpartum hemorrhage (PPH)], we compared 'coded' recurrence rates in hospital data with those obtained from medical record audit. 'Coded' recurrence in a second pregnancy was also compared for women with or without a documented history of prior PPH. We found a 'coded' recurrence rate of 18.5% and an 'audited' recurrence rate of 28.4%. The 'coded' rate of recurrence among women who had a documented history of PPH was 27.4% compared to 19.1% when the previous PPH was not noted in the second pregnancy medical record. Medical record reporting of uterine atony as the cause for postpartum hemorrhages in first and second births was 37.9 and 34.0% while 'coded' hospital data reporting attributed 79.8 and 73.9% respectively to atony. Our study results indicate that a history of postpartum hemorrhage may be a stronger risk factor for subsequent PPH than previously demonstrated. A recorded history of PPH was associated with an increased likelihood of reporting a subsequent PPH, and in such cases recurrence rates approximate true recurrence. The contribution of uterine atony as a cause of postpartum hemorrhage is over-estimated using hospital data.

Stillbirth and fetal growth restriction

OBJECTIVE

To confirm the role of fetal growth restriction (FGR) as a cause of stillbirth, and to compare diagnostic accuracy of customized fetal growth and population-based standards in identifying FGR within a pathological population of early and late stillbirths.

METHODS

Retrospective study on a cohort of 189 stillbirths occurred in single pregnancy between January 2006 and September 2011. Unexplained stillbirths, defined by Aberdeen-Wigglesworth and ReCoDe classifications, were evaluated on the basis of fetal birthweight with both Tuscany population and Gardosi customized standards. Unexplained stillbirths have been classified as early or late depending on the gestational age of occurrence.

RESULTS

Aberdeen-Wigglesworth classification, applied to the 189 cases of stillbirth, left 94 unexplained cases (49.7%), whereas the ReCoDe classification left only 40 (21%). By applying population standards to the 94 unexplained stillbirths we have identified 31 FGRs (33% of sample), while customized standards identified 54 FGRs (57%). Customised standards identified a larger number of FGRs with respect to population standards during the third trimester (i.e. 51% vs. 25% respectively) than in the second trimester (73% vs. 54% respectively) (p = 0.05).

CONCLUSIONS

Customized standards have a higher diagnostic accuracy in identifying FGRs especially during the third trimester.

Do medical certificates of stillbirth provide accurate and useful information regarding the cause of death?

Stillbirth affects one in 200 pregnancies in the UK. Understanding the causes of stillbirth is essential to reducing perinatal mortality. Stillbirth certificates represent a potential source of data on perinatal mortality. We aimed to assess whether the information on stillbirth certificates used in the UK is accurate. A retrospective cross-sectional audit of stillbirth certificates issued in a geographical region of the UK in 2009 was undertaken. Data were recorded from the stillbirth certificate and health records. The cause of death was classified using the ReCoDe system. Two hundred and thirteen stillbirth certificates were issued for stillbirths (feticides for fetal anomaly were excluded). Agreement for the primary factor associated with the stillbirth was fair (Kappa = 0.286). This contrasts with the gestation of stillbirth, which was almost complete agreement (Kappa = 0.883). The majority of stillbirths (58.7%) were classified on the certificate as 'unknown cause'. A proportion of 9.4% of stillbirths were classified as congenital anomaly and 8.0% as placental abruption. Only 0.5% of stillbirth certificates cited fetal growth restriction as a relevant condition contributing to death. A total of 49.6% of 'unexplained' stillbirths were associated with fetal growth restriction on review. Errors were present in 77.9% of certificates, including missing co-morbidities (55.9%) and the wrong cause of death (40.4%). The cause(s) of death is (are) not recorded accurately on the UK medical certificate of stillbirth, and the majority of certificates contain one or more errors. Training is required to improve understanding of the causes of stillbirth and completion of medical certificates. Data recorded directly from medical certificate of stillbirths are not sufficiently reliable for descriptive studies of causation and epidemiology.

A model for prediction of spontaneous preterm birth in asymptomatic women

BACKGROUND

Preterm birth is a complex health problem with social, environmental, behavioral, and genetic determinants of an individual's risk and remains a major challenge in obstetrics. Recent research has caused improvements in predicting preterm birth; however, there is still controversy about the prediction of preterm birth in asymptomatic women. The purpose of this study was to determine if Bayesian filtering can be used in a clinical setting to predict spontaneous preterm birth in asymptomatic women.

METHODS

A model of predicting spontaneous preterm birth using PopBayes based on a Bayesian filtering algorithm was developed using a previously collected dataset, then applied to a prospectively collected cohort of asymptomatic women who delivered singleton live newborns at or after 24 weeks of gestation. Cases complicated with major congenital malformations were excluded.

RESULTS

The proportion of patients with spontaneous preterm birth was 18.4% (96 of 522) at <37 weeks gestation, 5.4% (28 of 522) at <34 weeks gestation, and 2.7% (14 of 522) at <32 weeks gestation. The match rates with the combination of demographic, clinical, and genetic factors using a Bayesian filtering method (PopBayes) were higher than the match rates using demographic and clinical factors only, including maternal age, maternal body mass index (BMI), prior preterm birth, education, occupation, income, and active and passive smoking. The match rates in preterm delivery before 32 weeks of gestation were higher than the match rates in preterm delivery before 37 and 34 weeks of gestation (94.3% vs. 84.7% and 82.0%, respectively). The negative predictive values for demographic, clinical, and genetic factors in predicting preterm delivery using PopBayes were consistently >90%.

CONCLUSIONS

We suggest that Bayesian filtering (PopBayes) is a customizable and useful tool in establishing a model for the prediction of preterm birth.