Risk factors for antepartum death in term pregnancies

Context: Antepartum fetal death is a significant contributor to perinatal mortality and challenges the adequacy of antenatal surveillance. Identifying the causes and risk factors for death may aid its prevention. Aim: To determine the causes of antepartum fetal death and identify associated risk factors. Subjects and Methods: All antepartum fetal deaths, with fetuses weighing 1 kg or more, delivered at Wesley Guild Hospital, Ilesa between January 1996 and December 2000 were the subjects. The controls were all live births delivered immediately before and after every index fetal death. Information on maternal demographic details, past obstetric history and antenatal complications were retrieved from the case notes of both the subjects and the controls for analysis. Results: The total number of births during the study period was 5,050 with 266 stillbirths. Of the stillbirths, 111 (41.7%) were antepartum out of which 70 (63.1%) weighed 1 kg and above. The main causes of death were antepartum haemorrhage (20%), maternal disease (14.3%) and pre-eclampsia/eclampsia (11.4%). The cause of death was unknown in 38.8% of cases. The main risk factors identified for antepartum death were lack of antenatal care and low birthweight. Maternal age and parity did not seem to be risk factors for antepartum fetal loss. Conclusion: Maternal disease is still a major cause of antepartum deaths in our society. Improved antenatal care and better surveillance of fetal growth may reduce the current high stillbirth rate in our society. Key Words: Perinatal Mortality, Stillbirth, Intrauterine Death [Trop J Obstet Gynaecol, 2003, 20: 134-136]

To determine whether decreased fetal growth velocity precedes antepartum fetal death and to evaluate whether fetal growth velocity is a better predictor of antepartum fetal death compared to a single fetal biometric measurement at the last available ultrasound scan prior to diagnosis of demise. This was a retrospective, longitudinal study of 4285 singleton pregnancies in African-American women who underwent at least two fetal ultrasound examinations between 14 and 32 weeks of gestation and delivered a liveborn neonate (controls; n = 4262) or experienced antepartum fetal death (cases; n = 23). Fetal death was defined as death diagnosed at ≥ 20 weeks of gestation and confirmed by ultrasound examination. Exclusion criteria included congenital anomaly, birth at < 20 weeks of gestation, multiple gestation and intrapartum fetal death. The ultrasound examination performed at the time of fetal demise was not included in the analysis. Percentiles for estimated fetal weight (EFW) and individual biometric parameters were determined according to the Hadlock and Perinatology Research Branch/Eunice Kennedy Shriver National Institute of Child Health and Human Development (PRB/NICHD) fetal growth standards. Fetal growth velocity was defined as the slope of the regression line of the measurement percentiles as a function of gestational age based on two or more measurements in each pregnancy. Cases had significantly lower growth velocities of EFW (P < 0.001) and of fetal head circumference, biparietal diameter, abdominal circumference and femur length (all P < 0.05) compared to controls, according to the PRB/NICHD and Hadlock growth standards. Fetuses with EFW growth velocity < 10th percentile of the controls had a 9.4-fold and an 11.2-fold increased risk of antepartum death, based on the Hadlock and customized PRB/NICHD standards, respectively. At a 10% false-positive rate, the sensitivity of EFW growth velocity for predicting antepartum fetal death was 56.5%, compared to 26.1% for a single EFW percentile evaluation at the last available ultrasound examination, according to the customized PRB/NICHD standard. Given that 74% of antepartum fetal death cases were not diagnosed as small-for-gestational age (EFW < 10th percentile) at the last ultrasound examination when the fetuses were alive, alternative approaches are needed to improve detection of fetuses at risk of fetal death. Longitudinal sonographic evaluation to determine growth velocity doubles the sensitivity for prediction of antepartum fetal death compared to a single EFW measurement at the last available ultrasound examination, yet the performance is still suboptimal. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Objective. To develop a new approach to perinatal risk stratification based on the determination of prognostic criteria for antepartum and intrapartum fetal death, and early neonatal death to improve the efficiency of predicting adverse perinatal outcomes. Patients and methods. A retrospective case-control study with the participation of patients with antepartum (n = 134) and intrapartum (n = 41) fetal death, early neonatal death (n = 61), and favorable perinatal outcome (n = 50) was carried out. The Bayes–Wald–Gubler method was used to determine prognostic criteria. Comparative evaluation of the efficacy of the proposed prognostic method and the generally accepted determination of perinatal risk was performed retrospectively in patients with perinatal loss (n = 102) and favorable perinatal outcome (n = 100); ROC analysis was performed. Results. Forty-two risk factors were identified and divided into three groups: universal for all types of perinatal loss, common for two of them, and specific for each of them (antepartum and intrapartum fetal death, early neonatal death). The prognostic value of factors in their presence and absence was determined. It was found that universal and common risk factors for each type of perinatal loss had different prognostic value. The method of differential prediction of perinatal loss was presented. The sensitivity of the new and generally accepted prognostic methods was 95.1 and 69.6%, the specificity was 80 and 53%, and the accuracy of predicting adverse outcomes was 87.6 and 61.4%, respectively. Conclusion. The conducted study allowed to suggest a new approach to perinatal risk stratification based on differential prediction of perinatal loss, which is superior to the traditional risk assessment methods in terms of the effectiveness of predicting adverse perinatal outcomes. Key words: antepartum fetal death, intrapartum fetal death, perinatal outcomes, prediction, early neonatal death

Data on maternal characteristics that could predict antepartum fetal death in women receiving antenatal care in resource-constrained settings are limited. To identify maternal sociodemographic and clinical risk factors for antepartum fetal death among women receiving antenatal care in a developing country setting. Case-control analyses of risk factors in the occurrence of singleton fetal death before labour at two university hospitals in south-west Nigeria over 4-5 years. A total of 46 cases and 184 controls were compared for 31 sociodemographic and clinical risk factors. Unconditional multivariate logistic regression analysis was applied to determine independent risk factors. Level of significance was set at P < 0.05. The incidence of antepartum fetal death among women receiving antenatal care was 10.8 per 1000 total births during the period. Significant risk factors at univariate level include proteinuria, pregnancy-induced hypertension, pre-existing hypertension, reduced weight gain per week, previous antepartum fetal death, antepartum haemorrhage, previous miscarriage, symphysiofundal height-gestational age disparity = 4 cm and perception of reduced fetal movements. The independent risk factors were proteinuria (adjusted OR 4.23, CI: 1.57-11.42), pregnancy-induced hypertension (adjusted OR 8.24, CI: 3.01-22.51) and perceived reduction in fetal movements (adjusted OR 7.17, CI: 1.57-45.76). The identified factors should serve as potential targets for antenatal interventions to prevent antepartum fetal death in these institutions. Awareness of these factors should stimulate appropriate risk assessment geared towards the prevention of antepartum fetal deaths by clinicians in these centres and centres in similar setting.

Risk factors for unexplained antepartum fetal death in Norway 1967-1998.

To assess risk factors for antepartum fetal deaths. A population-based case-control study was carried out in the city of São Paulo from August 2000 to January 2001. Subjects were selected from a birth cohort from a linked birth and death certificate database. Cases were 164 antepartum fetal deaths and controls were drawn from a random sample of 313 births surviving at least 28 days. Information was collected from birth and death certificates, hospital records and home interviews. A hierarchical conceptual framework guided the logistic regression analysis. Statistically significant factors associated with antepartum fetal death were: mother without or recent marital union; mother's education under four years; mothers with previous low birth weight infant; mothers with hypertension, diabetes, bleeding during pregnancy; no or inadequate prenatal care; congenital malformation and intrauterine growth restriction. The highest population attributable fractions were for inadequacy of prenatal care (40%), hypertension (27%), intrauterine growth restriction (30%) and absence of a long-standing union (26%). Proximal biological risk factors are most important in antepartum fetal deaths. However, distal factors - mother's low education and marital status - are also significant. Improving access to and quality of prenatal care could have a large impact on fetal mortality.

Unexpected fetal death during pregnancy—a problem of unrecognized fetal disorders during antenatal care?

Fatal antepartum fetomaternal hemorrhage is a relatively uncommon clinical presentation, though one that appears quickly and without warning. The pathophysiology of this disease is unclear, and the incidence does not appear to be decreasing in line with overall antepartum mortality. This study was undertaken to analyse trends in antepartum fetal death from fetomaternal hemorrhage over a 25-year period in a single maternity hospital in Dublin, Ireland. A cross-sectional study of 192 132 nonanomalous infants weighing 500 g or more, delivered in a single tertiary-referral university institution between 1987 and 2011. Data was compared using Fisher's exact test, univariate analysis, and Cuzick's test for trend. There was no decrease in the rate of fatal fetomaternal hemorrhage over the past 25 years (p = 0.29), despite a decline in overall antepartum deaths (p = 0.0049). Fetomaternal hemorrhage accounted for 4.1% (34/828) of antepartum stillbirths. A higher proportion of these stillbirths occurred at term gestations (74%; 25/34) compared with other causes (40%; 321/794; p = 0.0003). Female infants were statistically more likely to be involved than males [odds ratio (OR) 2.33, 95% confidence interval (CI) 1.08-5.47, p = 0.02). Multiple gestations were up to six times as likely to be affected as singleton pregnancies (OR 6.52, 95% CI 1.67-18.50, p = 0.005). Over the past 25 years there has been no reduction in rates of fatal fetomaternal hemorrhage. Female infants and multiple gestations remain at higher risk of antepartum death from fatal fetomaternal hemorrhage.

An evaluation of the importance of formal, maternal fetal movement counting as a measure of fetal well-being

To identify mortality trends and risk factors associated with stillbirths and neonatal deaths 1982-2011. Population-based cross-sectional study based on reported pregnancy history in Iganga-Mayuge Health and Demographic Surveillance Site (HDSS) in Uganda. A pregnancy history survey was conducted among women aged 15-49 years living in the HDSS during May-July 2011 (n = 10 540). Time trends were analysed with cubic splines and linear regression. Potential risk factors were examined with multilevel logistic regression with adjusted odds ratios (AOR) and 95% confidence intervals (CI). 34 073 births from 1982 to 2011 were analysed. The annual rate of decrease was 0.9% for stillbirths and 1.8% for neonatal mortality. Stillbirths were associated with several risk factors: multiple births (AOR 2.57, CI 1.66-3.99), previous adverse outcome (AOR 6.16, CI 4.26-8.88) and grand multiparity among 35- to 49-year-olds (AOR 1.97, CI 1.32-2.89). Neonatal deaths were associated with multiple births (AOR 6.16, CI 4.80-7.92) and advanced maternal age linked with parity of 1-4 (AOR 2.34, CI 1.28-4.25) and grand multiparity (AOR 1.44, CI 1.09-1.90). Education, marital status and household wealth were not associated with the outcomes. The slow decline in mortality rates and easily identifiable risk factors calls for improving quality of care at birth and a rethinking of how to address obstetric risks, potentially a revival of the risk approach in antenatal care.

Risk factors associated with antepartum fetal death

ROUTINE FORMAL FETAL MOVEMENT COUNTING AND RISK OF ANTEPARTUM LATE DEATH IN NORMALLY FORMED SINGLETONS

Unfavorable demographic trends, combined with unstable dynamics of perinatal mortality rates, require improvement of the perinatal forecasting system. The search for new perinatal risk factors is also becoming relevant. The appearance of publications on the influence of sexual dimorphism on the course of pregnancy and childbirth indicates the need to study the possibility of using this factor in predicting perinatal losses. Objective of the study: to study the role of fetal sex as a risk factor for antepartum and intrapartum fetal death, early neonatal death of a newborn. Materials and research methods. A retrospective study was conducted with the participation of patients with antepartum (n=70) and intrapartum (n=40) fetal death, early neonatal death of a newborn (n=50) and a favorable perinatal outcome (n=50) as a control. We studied the structure of patients by fetal sex, conducted its comparative analysis in these groups, determined the prognostic value of fetal sex in antepartum, intrapartum fetal death and early neonatal death of a newborn. We used the program "Statistica 10.0" for statistical processing of the obtained data and the Bayes model of prediction with analysis by A. Wald, method of E.V. Gubler and the criterion of S. Kullback. Results. The male sex of the fetus prevailed over the female in all groups of perinatal risk. In the group with a favorable perinatal outcome, on the contrary, female fetuses were more common. We found a statistically significant difference in fetal sex between the antepartum risk and control groups: the male sex of the fetus occurred at antenatal losses 1.5 times more often than at favorable perinatal outcomes (p=0.028). We have calculated prognostic coefficients and indicators of the informativeness of fetal sex in antepartum, intrapartum and early neonatal losses. We have determined the prognostic value of fetal sex and established the nature of its effect on perinatal prognosis for each of the risk groups. Conclusion. The conducted study allows us to consider the sex of the fetus as a factor of differentiated risk of antepartum, intrapartum and early neonatal losses. The obtained results clearly demonstrate the prognostic role of fetal sex and indicate the need to include this factor in the perinatal risk assessment system at each stage of the perinatal period.

Introduction: The most available screening method for detecting intrauterine fetal growth restriction is a graph of uterine fundal height (FH) during pregnancy (gravidogram). Сustomized charts with indicators adjusted for ethnicity, age, parity, maternal anthropometric characteristics (height, weight, BMI), parity, pregnancy complications, morbid background, social factors. Aim: To investigate the effect of maternal characteristics (age and parity) on (FH) during pregnancy, to detect fetal growth restriction. Materials and Methods: The study design was a single-stage retrospective cross-sectional study. Inclusion criteria for the study were: presence of first trimester ultrasound screening at 10-14 weeks' gestation, uncomplicated pregnancy, singleton pregnancy. Exclusion criteria:multiple pregnancies, breech presentation, malposition (transverse, oblique), fetal weight up to 2500 grams and over 4000 grams, premature birth, hypertensive states, antepartum fetal death, abnormal fetal growth, abundant water, small water, extragenital pathology. Results: We sampled 3,886 cases of term pregnancies in the cephalic presentation, which ended with a live birth weight of 2,500 to 4,000 grams. When the mean FH values were assessed by age group, significant differences were found at 26, 28, 31-32, 35, and 38 weeks of gestation. It was also found that with an increase in maternal age by 1 year one should expect an increase in FH at weeks 26, 28, 31, 35, 38 and 41 by 0.047 cm; 0.055 cm; 0.049 cm; 0.063 cm; 0.049 cm; 0.057 cm and 0.067 cm. When comparing the mean FH values by maternal parity group, the FH values were found to be higher at 26 to 27, 30 to 35, 37 to 38, and 41 weeks of gestation, and the FH values increased with each successive pregnancy. Using linear regression, it was found that at weeks 31 - 33, 35 weeks of gestation an increase in FH of 0.208 cm; 0.254 cm; 0.154 cm; 0.189 cm should be expected at weeks 38, 40 - 42 weeks, an increase in FH of 0.189 cm; 0.188 cm; 0.576 cm; 7.845 cm should be expected at weeks 38, 40 - 42 weeks. Conclusions: Maternal age and maternal parity variables are influential factors on uterine fundal height during pregnancy after 31 weeks gestation. Введение: Наиболее доступным скрининговым методом выявления задержки внутриутробного развития плода является график роста высоты стояния дна матки (ВДМ) во время беременности (гравидограмма). Персонализированные графики, показатели которых скорректированы с учетом этнической принадлежности, возраста, паритета, антропометрических характеристик матери (рост, вес, индекс массы тела), осложнений беременности, морбидного фона, социальных факторов. Цель: Изучить влияние характеристик матери (возраста и паритета) на ВДМ во время беременности, для выявления нарушений роста плода. Материалы и методы: Дизайн исследования - одномоментное ретроспективное поперечное исследование. Критериями включения в исследование являлись: наличие УЗИ скрининга первого триместра беременности в сроке 10-14 недель, неосложненное течение беременности, одноплодная беременность. Критерии исключения: многоплодная беременность, тазовое предлежание плода, неправильные положения плода (поперечное, косое), вес плода до 2500 грамм и свыше 4000 граммов, преждевременные роды, гипертензивные состояния, антенатальная гибель плода, ВПР плода, многоводие, маловодие, экстрагенитальная патология. Результаты: Нами были отобраны 3886 случаев доношенной беременности в головном предлежании, закончившейся рождением живого плода с массой от 2500 до 4000 граммов. При оценке средних величин ВДМ в зависимости от возрастных групп были выявлены значимые различия в сроках 26, 28, 31 – 32, 35, 38 недель беременности. Также были выявлено, что при увеличении возраста матери на 1 год следует ожидать увеличение ВДМ в сроках 26, 28, 31, 35, 38 и 41 недель на 0,047 см; 0,055 см; 0,049 см; 0,063 см; 0,049 см; 0,057 см и 0,067 см. При сравнении средних величин ВДМ по группам паритета матери, было обнаружено, что в сроках 26 – 27, 30 – 35, 37 – 38, 41 недель беременности величины ВДМ были выше, и с каждой последующей беременностью величины ВДМ повышались. С помощью линейной регрессии выявлено, что при увеличении паритета на 1 роды следует ожидать увеличение ВДМ 31-33, 35 неделях на 0,208 см; 0,254 см; 0,154 см; 0,189 см, а в сроках 38, 40-42 неделях - на 0,189 см; 0,188 см; 0,576 см; 7,845 см. Выводы: Переменные возраст и паритет матери являются влияющими факторами на высоту стояния дна матки во время беременности после 31 недель гестации. Кіріспе: Ұрықтың жатырішілік дамуының тежелуінің ең қолжетімді скрининг әдісіне жүктілік кезінде жатыр түбінің тұру биіктігінің (ЖТТБ) өсу графигі (гравидограмма) жатады. Жекеленген графиктер көрсеткіштері анасының этносына, жасына, паритетіне, антрометриялық сипатына (бойы, салмағы, дене салмақ индексі), жүктілік асқынулары, морбидті фоны, әлеуметтік факторларына байланысты ескеріп тұрғызылады. Мақсаты: Ұрықтың даму бұзылыстарын анықтау үшін жүктілік кезінде ЖТТБ анасының сипаттамаларының (жасы мен паритет) әсерін зерттеу. Материалдар мен тәсілдер: Зерттеу дизайны – бір мезетті ретроспективті көлденең зерттеу. Зерттеуге қосу критерийлеріне жатады: жүктіліктің алғашқы үш айында 10-14 апта мерзімдегі УДЗ скрининг болуы, жүктіліктің асқынбаған ағымы, бір ұрықты жүктілік. Зерттеуге қоспау критерийлері: көп ұрықты жүктілік, ұрықтың жамбаспен орналасуы, ұрықтың дұрыс емес жағдайда орналасуы (көлденең, қиғаш), ұрықтың салмағы 2500 грамм дейін немесе 4000 граммнан жоғары, уақытынан ерте босану, гипертензиялық жағдайлар, ұрықтың антенаталды өлуі, ұрықтың жатырішілік ақаулары, қағанақ суының көптігі, қағанақ суының аздығы, экстрагениталды патология. Нәтижелер: Біз дене салмағы 2500 мен 4000 грамм арасында тірі ұрық тууымен аяқталған ұрық басымен орналасқан толық жетілген жүктіліктің 3886 жағдайын таңдап алдық. Анасының жасы топтары бойынша ЖТТБ орташа өлшемдерін салыстырған кезде жүктіліктің 26, 28, 31 – 32, 35, 38 апталарында айқын айырмашылықтар анықталды. Сонымен қатар, анасының жасы 1 жылға артқан кезде жүктіліктің 26, 28, 31, 35, 38 мен 41 апталарында ЖТТБ өлшемдері 0,047 см; 0,055 см; 0,049 см; 0,063 см; 0,049 см; 0,057 см мен 0,067 см артатыны анықталды. Анасының паритет топтары бойынша ЖТТБ орташа өлшемдерін салыстырған кезде жүктіліктің 26 – 27, 30 – 35, 37 – 38, 41 апта мерзімдерінде ЖТТБ өлшемі артқан, яғни әрбір келесі жүктілікпен ЖТТБ өлшемі артқан. Сызықты регрессия көмегімен анасының 1 босануға артқан кезде жүктіліктің 31-33, 35 апталарында ЖТТБ өлшемдерінің 0,208 см; 0,254 см; 0,154 см; 0,189 см артуын, ал 38, 40-42 апталарда - 0,189 см; 0,188 см; 0,576 см; 7,845 см артуын болжауға мүмкіндік беретіні анықталды. Қорытынды: Анасының жасы мен паритеті ауысымдары жүктілік кезінде гестацияның 31 аптасынан кейін жатыр түбінің тұру биіктігіне әсер ететін факторларға жатады.

The problem of perinatal losses is still actual in obstetrics today. At the same time there are cases of non-estimation or extra-estimation of perinatal risk in obstetrical practice. The usage of famous prognostic systems gives the opportunity to select pregnant women into groups of high risk and provide the necessary organizational and tactic measures. But to define the character of possible complications, to establish the degree of their severity and time of appearance is really impossible. Objective of the study: to develop a new approach to estimation of perinatal risk based on the determination of prognostic criteria for antepartum and intrapartum fetal death, early neonatal death of a newborn in order to increase the efficacy of predicting of unfavourable perinatal outcomes. Materials and research methods. The retrospective case-control study in patients with antepartum (n=134) and intrapartum (n=41) fetal death, early neonatal death of the newborn (n=61) and favourable perinatal outcome (n=50) was conducted. There was used the Bayes algorhythm with Wald's consecutive analysis in the modification of Genkin-Gubler to determine prognostic criteria. The comparative estimation of the efficacy of the proposed prognostic method and traditional method of determining perinatal risk was performed retrospectively in patients with perinatal losses (n=102) and favourable perinatal outcome (n=100). ROC analysis was performed. Results. There were identified 42 risk factors divided into three groups: universal for all types of perinatal losses, common for two of them and specific for each of them (antepartum and intrapartum fetal death, early neonatal death of a newborn). There was determined the prognostic influence of factors in their presence and absence. It was found that universal and common risk factors had different prognostic influence for each type of perinatal losses. There was presented the method for differential predicting of perinatal losses. The sensitivity of the new and traditional prognostic methods was 95.1% and 69.6%, specificity was 80% and 53%, and the accuracy of predicting of unfavourable outcome was 87.6% and 61.4% respectively. Conclusion. The investigation permitted to propose the new approach to estimation of perinatal risk, based on differential predicting of perinatal losses being is more effective than traditional method in predicting adverse perinatal outcomes.