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Ramji N, Corsi DJ, Gad M, Dimanlig-Cruz S, Miao Q, Guo Y, Rybak N, White RR, Wen SW, Walker MC, Gaudet LM. The impact of isolated obesity compared with obesity and other risk factors on risk of stillbirth: a retrospective cohort study. CMAJ 2024; 196:E250-E259. [PMID: 38438153 PMCID: PMC10911866 DOI: 10.1503/cmaj.221450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Maternal obesity is associated with stillbirth, but uncertainty persists around the effects of higher obesity classes. We sought to compare the risk of stillbirth associated with maternal obesity alone versus maternal obesity and additional or undiagnosed factors contributing to high-risk pregnancy. METHODS We conducted a retrospective cohort study using the Better Outcomes Registry and Network (BORN) for singleton hospital births in Ontario between 2012 and 2018. We used multivariable Cox proportional hazard regression and logistic regression to evaluate the relationship between prepregnancy maternal body mass index (BMI) class and stillbirth (reference was normal BMI). We treated maternal characteristics and obstetrical complications as independent covariates. We performed mediator analyses to measure the direct and indirect effects of BMI on stillbirth through major common-pathway complications. We used fully adjusted and partially adjusted models, representing the impact of maternal obesity alone and maternal obesity with other risk factors on stillbirth, respectively. RESULTS We analyzed data on 681 178 births between 2012 and 2018, of which 1956 were stillbirths. Class I obesity was associated with an increased incidence of stillbirth (adjusted hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.35-1.78). This association was stronger for class III obesity (adjusted HR 1.80, 95% CI 1.44-2.24), and strongest for class II obesity (adjusted HR 2.17, 95% CI 1.83-2.57). Plotting point estimates for odds ratios, stratified by gestational age, showed a marked increase in the relative odds for stillbirth beyond 37 weeks' gestation for those with obesity with and without other risk factors, compared with those with normal BMI. The impact of potential mediators was minimal. INTERPRETATION Maternal obesity alone and obesity with other risk factors are associated with an increased risk of stillbirth. This risk increases with gestational age, especially at term.
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Affiliation(s)
- Naila Ramji
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont.
| | - Daniel J Corsi
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Monica Gad
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Sheryll Dimanlig-Cruz
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Qun Miao
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Yanfang Guo
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Natalie Rybak
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Ruth Rennicks White
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Shi Wu Wen
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Mark C Walker
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
| | - Laura M Gaudet
- Department of Obstetrics & Gynecology (Ramji), Dalhousie University, Fredericton, NB; Department of Bioethics (Ramji), Dalhousie University, Halifax, NS; Better Outcomes Registry and Network Ontario (Corsi, Dimanlig-Cruz, Miao, Walker), Children's Hospital of Eastern Ontario (CHEO); CHEO Research Institute (Corsi, Miao), Ottawa, Ont.; Nicotine Dependence Service (Gad), Centre of Addiction and Mental Health, Toronto, Ont.; Clinical Epidemiology Program (Dimanlig-Cruz, Guo, Rybak, Rennicks White, Wen, Walker), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Guo, Wen), University of Ottawa; Department of Obstetrics, Gynecology & Newborn Care (Rybak, Rennicks White), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Queen's University; Department of Obstetrics and Gynecology, Kingston Health Sciences Centre (Gaudet), Kingston, Ont
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Osborne B, Mitra S, Karol D, Azzi P, Ou K, Alibhai KM, Murphy MSQ, El-Chaâr D. Etiology of stillbirth in a tertiary care center: a retrospective cohort study assessing ultrasound, laboratory, and pathology investigations. J Matern Fetal Neonatal Med 2023; 36:2277131. [PMID: 37926910 DOI: 10.1080/14767058.2023.2277131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Canadian stillbirth data are limited, and a significant proportion of pregnancies resulting in stillbirth have no attributable cause. The objective of this study was to characterize stillbirth case investigations and management at a tertiary care hospital in Ontario, Canada. METHODS This was a retrospective chart review study of all cases of singleton stillbirth at The Ottawa Hospital between 1 January 2012 and 31 December 2017. Terminations and multiples stillbirths were excluded. Chart reviews were conducted to extract maternal sociodemographic, obstetrical, and fetal characteristics, including results from antenatal ultrasounds, autopsy, placenta pathology, and laboratory investigations. RESULTS A total of 155 eligible cases of stillbirth were identified, resulting in a 6-year stillbirth rate of 4.2 per 1000 total births. The median maternal age was 31.0 years (IQR: 29.0, 35.0) and the median gestational age at delivery was 28 weeks (IQR: 24, 35). A total of 9 (5.8%) pregnant individuals had a history of previous stillbirth. Of the 155 stillbirths, 35% underwent the full suite of post-loss laboratory, placental, and fetal autopsy investigations. 63.2% of cases had post-loss laboratory investigations completed. 76% and 71% of cases had fetal autopsy and placenta pathology evaluations completed, respectively. Antenatal characteristics associated with stillbirth included fetal anomalies/genetic markers (27.1%), umbilical cord and placental anomalies (24.5%), fetal growth abnormalities (27.7%), cervical/uterine abnormalities (11.6%), and amniotic fluid abnormalities (25.1%). The most common autopsy findings included evidence of infection (22.7%), fetal anomalies (12.6%), and fetal hypoxia (10%). The most common placental pathology findings included features of placental insufficiency (21.8%), retroplacental abnormalities (16.3%), and umbilical cord accident/infarct (15.4%). CONCLUSIONS Our findings demonstrate that as many as two-thirds of singleton stillbirth cases at our center did not receive the post-perinatal loss investigations recommended by clinical practice guidelines. More thorough collection of post-stillbirth data at all levels (institutional, provincial, national) is warranted to improve our understanding of stillbirth epidemiology, etiology, and management in Canada.
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Affiliation(s)
- Brenden Osborne
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Medicine, University of Galway, Galway, Ireland
| | - Sohini Mitra
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
| | - Dalia Karol
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
| | - Pierre Azzi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Science, University of Ottawa, Ottawa, Canada
| | - Kelsie Ou
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Kameela M Alibhai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Malia S Q Murphy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Darine El-Chaâr
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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