The application of the ICD-10 for antepartum stillbirth patients in a referral centre of Eastern China: a retrospective study from 2015 to 2022.

BACKGROUND: The causes of some stillbirths are unclear, and additional work must be done to investigate the risk factors for stillbirths. OBJECTIVE: To apply the International Classification of Disease-10 (ICD-10) for antepartum stillbirth at a referral center in eastern China. METHODS: Antepartum stillbirths were grouped according to the cause of death according to the International Classification of Disease-10 (ICD-10) criteria. The main maternal condition at the time of antepartum stillbirth was assigned to each patient. RESULTS: Antepartum stillbirths were mostly classified as fetal deaths of unspecified cause, antepartum hypoxia. Although more than half of the mothers were without an identified condition at the time of the antepartum stillbirth, where there was a maternal condition associated with perinatal death, maternal medical and surgical conditions and maternal complications during pregnancy were most common. Of all the stillbirths, 51.2% occurred between 28 and 37 weeks of gestation, the main causes of stillbirth at different gestational ages also differed. Autopsy and chromosomal microarray analysis (CMA) were recommended in all stillbirths, but only 3.6% received autopsy and 10.5% underwent chromosomal microarray analysis. CONCLUSIONS: The ICD-10 is helpful in classifying the causes of stillbirths, but more than half of the stillbirths in our study were unexplained; therefore, additional work must be done. And the ICD-10 score may need to be improved, such as by classifying stillbirths according to gestational age. Autopsy and CMA could help determine the cause of stillbirth, but the acceptance of these methods is currently low.

Risk of stillbirth after a previous caesarean delivery: A Swedish nationwide cohort study.

OBJECTIVES: To investigate the risk of stillbirth in relation to (1) a previous caesarean delivery (CD) compared with those following a vaginal birth (VB); and (2) vaginal birth after caesarean (VBAC) compared with a repeat CD. DESIGN: Population-based cohort study. SETTING: The Swedish Medical Birth registry. POPULATION: Women with their first and second singletons between 1982 and 2012. METHODS: Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association between CD in the first pregnancy and stillbirth in the second pregnancy and the association between VBAC and stillbirth. Sub-group analyses were performed by types of CD and timing of stillbirth (antepartum and intrapartum). MAIN OUTCOME MEASURES: Stillbirth (antepartum and intrapartum fetal death). RESULTS: Of the 1 771 700 singleton births from 885 850 women, 117 114 (13.2%) women had a CD in the first pregnancy, and 51 755 had VBAC in the second pregnancy. We found a 37% increased odds of stillbirth (aOR 1.37; 95% CI 1.23-1.52) in women with a previous CD compared with VB. The odds of intrapartum stillbirth were higher in the previous pre-labour CD group (aOR 2.72; 95% CI 1.51-4.91) and in the previous in-labour CD group (aOR 1.35; 95% CI 0.76-2.40), although not statistically significant in the latter case. No increased odds were found for intrapartum stillbirth in women who had VBAC (aOR 0.99; 95% CI 0.48-2.06) compared with women who had a repeat CD. CONCLUSIONS: This study confirms that a CD is associated with an increased risk of subsequent stillbirth, with a greater risk among pre-labour CD. This association is not solely mediated by increases in intrapartum asphyxia, uterine rupture or attempted VBAC. Further research is needed to understand this association, but these findings might help healthcare providers to reach optimal decisions regarding mode of birth, particularly when CD is unnecessary.

Burden, Differentials and Causes of Stillbirths in India: A Systematic Review and Meta Analysis.

India contributes the highest absolute number of stillbirths in the world. This systematic review and meta-analysis was conducted to synthesize the burden, timing and causes of stillbirths in India. Forty-nine reports from 46 studies conducted in 21 Indian states and Union Territories were included. It was found that there was no uniformity/standardization in the definition of stillbirths and in the classification system used to assign the cause. The share of antepartum stillbirths was estimated to be two-third while remaining were intrapartum stillbirths. Maternal conditions and fetal causes were found to be the leading cause of stillbirth in India. The maternal condition was assigned as the commonest cause (25%) followed by fetal (14%), placental cause (13%), congenital malformation (6%) and intrapartum complications (4%). Approximately 20% of the stillbirths were assigned as unknown or unexplained. This review demonstrates that there is a paucity of quality stillbirth data in India. Other than the state level differences in stillbirth rates, no other data is available on inequities in stillbirths in India. There is an urgent need for strengthening availability and quality of stillbirth data in India on both stillbirth rates as well as the causes. There is a need to conduct additional research to know the timing of the stillbirths, causes of death and actual burden. India needs to strengthen stillbirth audits along with registry to find out the modifiable factors and delays for making country specific preventive strategies. The policy makers, academic community and researchers need to work together to ensure accelerated and equitable reduction in stillbirths in India.

Antepartum stillbirth rates during the COVID-19 pandemic in Austria: A population-based study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has had dramatic effects on the pregnant population worldwide, increasing the risk of adverse perinatal outcomes. OBJECTIVE: To assess the incidence of antepartum stillbirth (aSB) during the COVID-19 pandemic in Austria. METHODS: We collected epidemiological data from the Austrian Birth Registry and compared the rate of aSB (i.e., fetal death at or after 24+0 gestational weeks) during the pandemic period (March-December 2020) and in the respective pre-pandemic months (2015-2019). RESULTS: In total, 65 660 pregnancies were included, of which 171 resulted in aSB at 33.7 ± 4.8 gestational weeks. During the pandemic, the aSB rate increased from 2.49‰ to 2.60‰ (P = 0.601), in contrast to the significant decline in preterm deliveries at or before 37 gestational weeks from 0.61‰ to 0.56‰ (relative risk [RR] 0.93; 95% confidence interval [CI] 0.91-0.96; P < 0.001). During the first lockdown, the aSB rate significantly increased from 2.38‰ to 3.52‰ (P = 0.021), yielding an adjusted odds ratio of 1.57 (95% CI 1.08-2.27; P = 0.018). The event of aSB during the COVID-19 pandemic was strongly related with increased fetal weight and maternal obesity. CONCLUSION: In Austria, there has been an overall increase in the incidence of aSB during the pandemic with a significant peak during the first lockdown.

Risk of stillbirth among Zambian women with a prior cesarean delivery.

OBJECTIVE: Cesarean delivery (CD) may be associated with stillbirth in future pregnancies. We investigated prior CD as a risk factor for stillbirth in Lusaka, Zambia. METHODS: We conducted a retrospective cohort analysis of women with only one prior pregnancy who delivered between February 1, 2006, and May 31, 2013. We analysed data from the Zambia Electronic Perinatal System. Maternal and infant characteristics were analyzed for association with stillbirth using Pearson's χ2 test or the Wilcoxon rank-sum test. We calculated risk ratios for the relationship between stillbirth (antepartum vs intrapartum) and prior CD, with a log Poisson model to adjust for confounding. RESULTS: Of 57 320 women in our cohort, 1933 (3.4%) reported a prior CD. There were 1012 (1.8%) stillbirths in the no prior CD group and 81 (4.2%) in the prior CD group (P<0.001). In multivariate models adjusting for stillbirth risk factors, prior CD was associated with antepartum (adjusted risk ratio 1.56, 95% confidence interval 1.08-2.24) and intrapartum (adjusted risk ratio 3.26, 95% confidence interval 2.40-4.42) stillbirth compared with no prior CD. The difference between groups was most apparent at 36-37 weeks' gestation (log-rank P<0.001). CONCLUSION: Prior CD was associated with increased risk of stillbirth. Improved monitoring during labor and safe methods for induction are urgently needed in low-resource settings.

Delivery at Term: When, How, and Why.

There is growing evidence from randomized trials that induction of labor at or near term does not increase cesarean delivery; observational data show that the optimal gestation for spontaneous delivery for the baby is 39 weeks. Elective cesarean at these gestations is also sometimes considered, but evaluating the associated risks is complex. For the baby, although cesarean obviates the risks of labor, it carries a risk of respiratory problems, which may be severe. For the mother, cesarean is more dangerous than vaginal and emergency cesarean is more dangerous than elective. The authors consider the evidence base for near-term induction of labor and cesarean for a range of scenarios.

The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21st Project.

OBJECTIVES: To identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well-dated pregnancies and access to antenatal care. DESIGN: Population-based, prospective, observational study. SETTING: Eight international urban populations. POPULATION: Pregnant women and their babies enrolled in the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. METHODS: Cox proportional hazard models were used to compare risks among antepartum stillborn and liveborn babies. MAIN OUTCOME MEASURES: Antepartum stillbirth was defined as any fetal death after 16 weeks' gestation before the onset of labour. RESULTS: Of 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio-economic status, hazard ratio (HR): 1.6 (95% CI, 1.2-2.1); single marital status, HR 2.0 (95% CI, 1.4-2.8); age ≥40 years, HR 2.2 (95% CI, 1.4-3.7); essential hypertension, HR 4.0 (95% CI, 2.7-5.9); HIV/AIDS, HR 4.3 (95% CI, 2.0-9.1); pre-eclampsia, HR 1.6 (95% CI, 1.1-3.8); multiple pregnancy, HR 3.3 (95% CI, 2.0-5.6); and antepartum haemorrhage, HR 3.3 (95% CI, 2.5-4.5). Birth weight <3rd centile was associated with antepartum stillbirth [HR, 4.6 (95% CI, 3.4-6.2)]. The greatest risk was seen in babies not suspected to have been growth restricted antenatally, with an HR of 5.0 (95% CI, 3.6-7.0). The population-attributable risk of antepartum death associated with small-for-gestational-age neonates diagnosed at birth was 11%. CONCLUSIONS: Antepartum stillbirth is a complex syndrome associated with several risk factors. Although small babies are at higher risk, current growth restriction detection strategies only modestly reduced the rate of stillbirth. TWEETABLE ABSTRACT: International stillbirth study finds individual risks poor predictors of death but combinations promising.

A mouse model of antepartum stillbirth.

BACKGROUND: Many stillbirths of normally formed fetuses in the third trimester could be prevented via delivery if reliable means to anticipate this outcome existed. However, because the etiology of these stillbirths is often unexplained and although the underlying mechanism is presumed to be hypoxia from placental insufficiency, the placentas often appear normal on histopathological examination. Gestational age is a risk factor for antepartum stillbirth, with a rapid rise in stillbirth rates after 40 weeks' gestation. We speculate that a common mechanism may explain antepartum stillbirth in both the late-term and postterm periods. Mice also show increasing rates of stillbirth when pregnancy is artificially prolonged. The model therefore affords an opportunity to characterize events that precede stillbirth. OBJECTIVE: The objective of the study was to prolong gestation in mice and monitor fetal and placental growth and cardiovascular changes. STUDY DESIGN: From embryonic day 15.5 to embryonic day 18.5, pregnant CD-1 mice received daily progesterone injections to prolong pregnancy by an additional 24 hour period (to embryonic day 19.5). To characterize fetal and placental development, experimental assays were performed throughout late gestation (embryonic day 15.5 to embryonic day 19.5), including postnatal day 1 pups as controls. In addition to collecting fetal and placental weights, we monitored fetal blood flow using Doppler ultrasound and examined the fetoplacental arterial vascular geometry using microcomputed tomography. Evidence of hypoxic organ injury in the fetus was assessed using magnetic resonance imaging and pimonidazole immunohistochemistry. RESULTS: At embryonic day 19.5, mean fetal weights were reduced by 14% compared with control postnatal day 1 pups. Ultrasound biomicroscopy showed that fetal heart rate and umbilical artery flow continued to increase at embryonic day 19.5. Despite this, the embryonic day 19.5 fetuses had significant pimonidazole staining in both brain and liver tissue, indicating fetal hypoxia. Placental weights at embryonic day 19.5 were 21% lower than at term (embryonic day 18.5). Microcomputed tomography showed no change in quantitative morphology of the fetoplacental arterial vasculature between embryonic day 18.5 and embryonic day 19.5. CONCLUSION: Prolongation of pregnancy renders the murine fetus vulnerable to significant growth restriction and hypoxia because of differential loss of placental mass rather than any compromise in fetoplacental blood flow. Our data are consistent with a hypoxic mechanism of antepartum fetal death in human term and postterm pregnancy and validates the inability of umbilical artery Doppler to safely monitor such fetuses. New tests of placental function are needed to identify the late-term fetus at risk of hypoxia to intervene by delivery to avoid antepartum stillbirth.

Causes of antepartum stillbirth in women of advanced maternal age.

OBJECTIVES: To breakdown the causes of antepartum stillbirth by maternal age. STUDY DESIGN: Observational study. SETTING: UK. SAMPLE: Anonymised national data on 2850 cases of antepartum stillbirth in 2009. STATISTICAL ANALYSIS: The association between cause of stillbirth and maternal age was examined using an adjusted multinomial logistic regression model. Risk ratios were calculated relative to stillbirth due to haemorrhage. MAIN OUTCOME MEASURES: Antepartum stillbirths classified by the Centre for Maternal and Child Enquiries (CMACE) classification. RESULTS: Stillbirths in women aged 35 years and over are more likely to be due to major congenital anomalies (relative risk ratio (RRR) 2.0, 95% CI 1.3-3.0), mechanical causes (RRR 1.6, 95% CI 1.0-2.6), maternal disorders (RRR 2.1, 95% CI 1.2-3.6) or associated obstetric factors (RRR 2.1, 95% CI 1.1-3.9) than women less than 35. Women aged 35 years and over have a statistically significant increased risk of stillbirth due to major congenital anomalies (OR relative to live birth 1.6, 95% CI 1.3-1.9) and maternal disorders (OR 1.7, 95% CI 1.2-2.4) than younger women. Women aged 35 years and over were 30% more likely to experience a term stillbirth than women <35 years (OR 1.3, 95% CI 1.1-1.5). Stillbirth due to congenital anomaly was statistically significantly more likely in women ≥ 35 years. CONCLUSIONS: Advanced maternal age is a significant risk factor for antepartum stillbirth particularly at term. Attention should be given to stillbirth due to mechanical causes, maternal disorders and associated obstetric factors in such women.

To what extent do English language RCT meta-analysis justify induction of low-risk pregnancy for postdates?

Induction for postdates in low-risk pregnancy was adopted with the intent to prevent post-term antepartum stillbirth, the most common cause of perinatal death, based on evidence derived in English language RCT meta-analysis. Systematic English language meta-analysis of RCT studies of induction for postdates in low-risk pregnancy report perinatal mortality rates (PMRs) for low-risk pregnancy ranging from 2.6 to 7.6/1000, based on 2-5 stillbirths among 13-16 perinatal deaths, including diabetic pregnancies as well as other high-risk pregnancies irrelevant to the study question. Baseline PMR≥41 weeks in large international databases for high and low risk pregnancies before routine induction 1998-2003 range from 0.9 to 2.4/1000 or about 300% lower than the reported PMR rates for postdate pregnancies in the expectant management arm in English language RCT meta-analysis. Deaths in the first week far exceed stillbirths in the RCT meta-analysis, the opposite of what is expected. These 2 implausible results bring into question the evidence used to justify induction for postdates≥41 weeks.

Muerte fetal intrauterina: ¿podemos actuar en su prevención? / Intrauterine fetal death: Can we act on prevention?

Objetivos: Análisis de los factores etiopatogénicos, maternos, fetales y placentarios, asociados a la muerte fetal intrauterina (MFIU). Análisis de los avances en el diagnóstico causal de la MFIU tras instauración de un protocolo específico. Métodos: Estudio descriptivo retrospectivo. Análisis de todos los casos de muerte fetal tardía en gestaciones únicas acontecidas en el Complejo Hospitalario Universitario de Vigo (2005- 2010). Resultados: Hubo 56 casos de muerte fetal tardía. De las gestantes estudiadas, 4 eran menores de 17 años y 19 mayores de 35 años, un 21,4 por ciento fumaban, el 60 por ciento tenía un IMC > 25 kg/m2 y el 18 por ciento no controlaron el embarazo. La patología materna predominante fue la tiroidea, mientras que las patologías gestacionales principales fueron diabetes gestacional, preeclampsia y amenaza de parto prematuro. El principal motivo de consulta fue la disminución de movimientos fetales. Se realizó estudio anatomopatológico placentario en el 82 por ciento y necropsia en el 73 por ciento. El porcentaje de causa desconocida en el grupo de no protocolo fue 20 por ciento y con protocolo 15 por ciento. Conclusión: El establecimiento de la causa de MFIU es difícil y en algunos casos no posible, aunque sí el reconocimiento de factores de riesgo. La implantación de un protocolo permitió un mayor acercamiento a la causa de la muerte fetal y mejor manejo posterior. La autopsia, el estudio de la placenta, los análisis citogenéticos y el estudio de trombosis materna son la base para el diagnóstico de MFIU.

Objective: Analysis of the pathogenetic maternal fetal and placental factors associated with stillbirth. Analysis of progress in the diagnoses of the cause of stillbirth after the establishment of a specific protocol. Methods: Retrospective descriptive study. Analysis of the cases of late fetal death in singleton pregnancies occurred at the University Hospital of Vigo during the period 2005-2010. Results: We found 56 late fetal deaths. Four were under 17 and 19 above 35 years old, 21percent were smokers, 60 percent had a BMI > 25 kg/m2 and 18 percent had not prenatal care. Thyroid disease was the most prevalent whereas gestational diabetes, preeclampsia and threatened preterm labour were the main obstetric pathologies. The main reason of consultation was decrease of fetal movements. Pathological exam of the placenta was made in 82 percent of cases and necropsy in 73 percent. Rate of unknown cause in the cases of no protocol was 20 percent while in the protocol group was 15 percent. Conclusion: The cause of intrauterine fetal death is difficult to establish. The recognition of certain risk factors is possible. The implementation of a study protocol allowed a better approach to the cause of fetal death and its management. Autopsy, placental examination, cytogenetic analysis, maternal thrombosis study was basic tests for the diagnosis of intrauterine fetal death.

A retrospective cohort study of maternal and perinatal risk factors on intrauterine fetal death / 대한산부인과학회지

OBJECTIVES: The purpose of this study was to investigate the clinical characteristics and the risk factors of Intrauterine fetal death (IUFD). METHODS: We did retrospective review and investigated the risk factors from medical records of the 62 pregnancies with IUFD between January 2000 and December 2007. Also we statistically analyzed that maternal and perinatal risk factors compared with 3,887 live-birth pregnancies. RESULTS: The overall incidence of IUFD was 1.57%. The age distribution of mother with IUFD was between 21 to 41, and was highest in the 30 to 34 year old age group (41.94%). There were 29 cases (46.78%) with nulliparous and 5 cases (8.06%) with previous IUFD. IUFD was the most prevalent (48.39%) at 20-29 weeks of gestation and the sex ratio of male versus female fetus was 1.03:1. Most of cases (80.64%) were delivered vaginally (spontaneous labor: 62.90%, labor induction: 17.74%), and laparotomy was 19.35%. Risk factors were maternal obesity, infection, placental abnormality, advanced maternal age (> or =35), and unexplained cause in that order. 50 cases included more than two risk factors. The risk analysis showed statistically significant risk in preeclampsia (OR 2.733; 95% CI 1.408-5.306) and placental abruption (OR 5.190; 95% CI 2.165-12.441). CONCLUSION: Identification of risk factors for IUFD assists the clinician in performing a risk assessment for each patient. Clinicians need to be able to assess each patient's risk for IUFD and to have a low threshold to evaluate fetal growth in at-risk pregnancies.