Effect of proactive MFM care on the incidence of stillbirth

Abstract

ODED LANGER, ANDREJZ LYSIKIEWICZ, BARAK ROSENN, NICOLE GELLER, St. Luke’s Roosevelt Hospital Center, Obstetrics & Gynecology, New York, New York, St. Luke’s Roosevelt Hospital Center, Obstetrics and Gynecology, New York, New York, St. Luke’s Roosevelt Hospital Center, Obstetrics & MFM, New York, New York, St. Luke’s-Roosevelt Hospital Center, Obstetrics and Gynecology, New York, New York OBJECTIVE: To determine the rate of potentially avoidable stillbirths. STUDY DESIGN: All consecutive stillbirths were identified over a 5yr period (2000-2005) from a computerized database at an inner city, Obstetric and Gynecology Department. All cases were evaluated by the Quality Assurance Committee and independent assessment by two Maternal-Fetal Medicine Specialists. Stillbirths were stratified into 3 groups: 1) Nonavoidable: when all evaluators when all evaluators agreed that the cause of stillbirth could not be modified; 2) Avoidable: All evaluators identified risk factors that could be modified thereby changing the outcome; 3) Undetermined: There was not a general consensus of cause. RESULTS: The overall stillbirth rate was 4.2/1000 (112/26,385). Of the 112 stillbirths, 17.4% were deemed avoidable, 54% unavoidable and 28% cause undetermined. Overall, 48% of the stillbirths were clinic and 52% were private patients. The rate of avoidable stillbirths, was 22% in the clinic population and 17% in the private population (P=.56). Of the avoidable stillbirths, 69% were due to patient factor (i.e. noncompliance with fetal testing, inadequate prenatal care), 25% were physician error (i.e. delayed delivery, misdiagnosis), and 6% were both the patient and the physicians fault. Maternal-Fetal Specialists were involved in 47% of the avoidable, 31% of the unavoidable and 24% of the undetermined groups of stillbirths (P=NS). Stratified by risk factors, the rate of avoidable cases in each diagnosis group was: Postdates 6%, Fetal Growth Restriction 13%, Maternal Chorioamnionitis 7%, Decreased Fetal Movement 50%, Pregestational Diabetes 13%, GDM 13%, Preeclampsia 28% (all ‘‘mild’’ cases), Chronic Hypertension 13%. CONCLUSION: The stillbirth rate has been reduced significantly due to advances in obstetrics. However, it appears from our data that there is still room for improvement by early identification of at-risk patients, more intensive patient evaluation and patient education.