Antepartum Fetal Death Research Articles

Maternal Morbidity following Trial of Labor after Cesarean in Women Experiencing Antepartum Fetal Death

This study aims to investigate whether trial of labor after cesarean delivery (TOLAC) in women with antepartum fetal death, is associated with an elevated risk of maternal morbidity. A retrospective multicenter. TOLAC of singleton pregnancies following a single low-segment incision were included. Maternal adverse outcomes were compared between women with antepartum fetal death and women with a viable fetus. Controls were matched with cases in a 1:4 ratio based on their previous vaginal births and induction of labor rates. Univariate analysis was followed by multiple logistic regression modeling. During the study period, 181 women experienced antepartum fetal death and were matched with 724 women with viable fetuses. Univariate analysis revealed that women with antepartum fetal death had significantly lower rates of TOLAC failure (4.4% vs. 25.1%, p < 0.01), but similar rates of composite adverse maternal outcomes (6.1% vs. 8.0%, p = 0.38) and uterine rupture (0.6% vs. 0.3%, p = 0.56). Multivariable analyses controlling for confounders showed that an antepartum fetal death vs. live birth isn't associated with the composite adverse maternal outcomes (aOR 0.96, 95% CI 0.21–4.44, p = 0.95). TOLAC in women with antepartum fetal death is not associated with an increased risk of adverse maternal outcomes while showing high rates of successful vaginal birth after cesarean (VBAC).

Impact of cord entanglement on perinatal outcome

ObjectiveTo evaluate the impact of umbilical cord entanglement around various fetal organs on perinatal outcomes. Study designA retrospective population-based study of all deliveries between 1988 and 2016 at a tertiary medical center. Immediate perinatal outcomes of newborns with and without cord entanglement were compared. ResultsThe prevalence of any cord entanglement in our population was 16.62 % (45,312 cases out of 272,713 deliveries during the study period). Cord entanglement was found to be significantly associated with antepartum fetal death (OR = 2.13, 95 % CI 1.77–2.57, p < 0.001) and one-minute Apgar score less than 7 (OR = 1.21, 95 % CI 1.16–1.27, p < 0.001). There was no association between cord entanglement and small for gestational age (SGA) babies. ConclusionCord entanglement is associated with antepartum fetal death, but not with SGA.

СОВРЕМЕННЫЙ ПОДХОД К ОЦЕНКЕ ПЕРИНАТАЛЬНОГО РИСКА, ОСНОВАННЫЙ НА ИСПОЛЬЗОВАНИИ ПРОГНОСТИЧЕСКИХ КРИТЕРИЕВ АНТЕНАТАЛЬНЫХ, ИНТРАНАТАЛЬНЫХ И РАННИХ НЕОНАТАЛЬНЫХ ПОТЕРЬ

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.

ПОЛ ПЛОДА В ОЦЕНКЕ РИСКА АНТЕНАТАЛЬНЫХ, ИНТРАНАТАЛЬНЫХ И РАННИХ НЕОНАТАЛЬНЫХ ПОТЕРЬ

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.

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

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. Population-based cohort study. The Swedish Medical Birth registry. Women with their first and second singletons between 1982 and 2012. 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). Stillbirth (antepartum and intrapartum fetal death). 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. 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.

Development of a multivariate predictive nomogram among women with antepartum fetal death diagnosed at ≥ 34 weeks of gestation for outcome of TOLAC.

The present study was planned to develop a nomogram that will give a priori estimate on the probability of vaginal birth from maternal features in women with antepartum fetal death diagnosed at ≥ 34week's gestation and previous one low transverse cesarean section (LTCS). This will help to reduce maternal complications and increase confidence when planning a trial of labor after cesarean section (TOLAC). A prospective observational study was planned where participants underwent induction of labor with Foley's catheter (unless already in spontaneous labor) within 24h of enrolment. Participants with absent or inadequate contractions, oxytocin infusion as an additional agent was used. Data was collected on maternal predelivery features. Outcome of participants was categorized into two classes-vaginal and cesarean delivery. Classifiers were trained with data on maternal features and the accuracy of predicting outcome class determined. The classifier with maximum accuracy was used to develop a nomogram. Three hundred and one women underwent treatment as per protocol. Two hundred and twenty women attained successful vaginal delivery and eighty-one women underwent caesarean section. Factors having a significant impact on outcome were maternal body mass index (BMI), bishop score, duration of augmentation, estimated foetal weight, interval from previous LTCS, admission to active labor interval, vaginal delivery after LTCS and gestational age. The Naïve -Bayes model gave the highest prediction accuracy (0.88). Non-linear classifiers by using selective features could predict the outcome of TOLAC among women with intra-uterine fetal death attempting vaginal birth at or beyond 34weeks gestation with high accuracy.

Parents' descriptions of labouring with an antepartum fetal death: Findings from the Birthing in Grief study.

Evidence to guide intrapartum care when an unborn baby has died is limited. To explore parents' experiences of care during labour of an antepartum stillbirth. Semi-structured interviews with 18 bereaved parents from across Australia. Content analysis was conducted. Two broad themes were identified: 'explaining every step' and 'helping us feel like parents.' Sub-themes under the first broad theme, 'explaining every step', were 'how and when information was given' and 'what happens next.' 'Like any other parent', 'feeling the pain' and 'everything is clouded' were sub-themes of the second broad theme. These findings mapped to current Australian clinical practice guidelines for bereavement care around stillbirth and neonatal death, ie good communication, recognition of parenthood, shared decision making and effective support. This study on parents' experiences of labour with a fetal death in utero brings an important perspective to intrapartum care for this group. As far as we are aware, this study is the first to focus solely on this aspect of care. Our findings could be readily mapped to the four perinatal bereavement care goals. Parents wanted care providers to facilitate their choices, their sense of control, their autonomy and their agency. They wanted to feel that they had received the 'best' care available.

The Role of First Trimester Ultrasound in the Detection of Vasa Previa: a Systematic Review

Vasa previa is a rare disorder in which fetal blood vessels are left unprotected in the membranes and cross the internal os of the cervix. The risk of vessel tearing causing antepartum bleeding and fetal death due to exsanguination is highly increased. Prenatal detection drastically improves fetal outcome. The aim of this study is to scrutinize the recent evidence for the use of first trimester prenatal ultrasonography to improve the detection of vasa previa. We conducted a systematic literature review in the computerized databases Pubmed, Embase, CINAHL and Web of Science from inception to September 2022. Two first trimester sonographic markers are associated with vasa previa later in pregnancy: umbilical cord insertion in the lower one-third of the uterine cavity and a velamentous insertion. We conclude the evaluation of the umbilical cord insertion in the first trimester is feasible, not time-consuming and may identify the population at increased risk for vasa previa.

Fetal heart block: Vaginal delivery an option.

Fetal heart block (FHB) occurs in approximately 1:20 000 births and is associated with significant morbidity and mortality. Vaginal delivery with intrapartum fetal scalp lactate monitoring is offered as an option at our centre for selected cases, in contrast with the published literature advocating caesarean birth. To review perinatal outcomes at delivery for FHB at a tertiary referral hospital. Ours was a retrospective cohort study from 1 January, 2007 to 30 June, 2020. The infant outcomes are summarised in three delivery groups: vaginal delivery, planned caesarean section (CS) and unplanned CS. There were 23 newborns in the study period, with a median gestation at birth of 37.2 weeks and there was one antepartum fetal death in this cohort. Vaginal delivery was planned in 12 women: eight had normal births, three of these women progressed to an intrapartum (unplanned) CS and one woman had a planned CS. All live babies in the vaginal delivery cohort had an Apgar score greater than seven at five minutes. Of the 22 newborns, six required intubation, of which five had been delivered by a planned CS. Our data suggest that planned vaginal delivery is a safe option for selected women carrying a fetus with FHB. Managing labour with serial fetal scalp lactates, and the involvement of senior clinicians are important factors in achieving a successful outcome.

Application of the international classification of diseases-perinatal mortality (ICD-PM) system to stillbirths: A single center experience in a middle income country

ObjectiveThe present study is intended to investigate the causes of stillbirth and its relationship with maternal conditions using the International Classification of Diseases-Perinatal Mortality (ICD-PM) system. Material and methodsAll early and late fetal deaths between 2015 and 2020 were analyzed. Time of death, fetal causes, and the maternal conditions involved were identified using the ICD-PM classification system. ResultsDuring the study period, out of 74,102 births a total of 475 stillbirths were recorded (6.4 per 1000 births), of which 83.6% of the cases were antepartum and 11.8% were intrapartum fetal deaths, and the time of death could not be determined in 4.6% of the cases. Fetal developmental disorder was the most common cause of antepartum fetal death (24.2%). Intrapartum deaths were mostly due to extremely low birth weight (44.6%). The most common maternal conditions involved were complications of placenta, cord, and membranes (19.8%). ConclusionThe applicability of the ICD-PM classification system for stillbirths is easy. It was observed that fetal deaths mostly occurred in the antepartum period and the cause of death could not be identified in over half of these antepartum fetal deaths. In over half of the stillbirths, there is at least one maternal condition involved. The most common maternal conditions involved are complications of placenta, cord, and membranes. The most common maternal medical problem is hypertensive diseases of pregnancy.

Reduced fetal growth velocity precedes antepartum fetal death.

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.

Современный подход к стратификации перинатального риска

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

Risk factors for antepartum death in term pregnancies

Objective To identify risk factors for antepartum fetal death (APD) in term pregnancies while considering maternal, pregnancy and fetal characteristics. Materials and methods Our study took place between the years 1988–2013. A total of 272,527 singleton births at term were recorded during this time period, including 524 cases of APD (0.2%). Cases of known chromosomal or other fetal abnormalities and cases with poor prenatal care were excluded. In order to identify independent risk factors contributing to antepartum fetal death in term we conducted a multivariate analysis using logistic regression. Results The main risk factors found to be significantly associated with APD in term were suspected intrauterine growth restriction (OR = 2.70, p < .001), diabetes (OR = 1.37, p = .05), hypertensive disorders (OR = 1.59, p = .01), advanced maternal age (OR = 1.03, p < .001) and grand-multiparity (OR = 1.79, p < .001). Advanced gestational age was not significantly associated with APD (38.95 vs. 39.44, p < .001). Conclusions Most of the risk factors for antepartum fetal death in term pregnancies found in this study coincide with known risk factors for APD as described in previous studies. We believe that in the presence of these risk factors, closer surveillance and careful medical management of the pregnancy are required, in order to reduce the incidence of APD, including induction of labor at advanced gestational age.

Brasilian List of Avidable Causes of Death that can be avoided by National Health System interventions, and its applicability for analysis of perinatal deaths in municipalities in the states of Rio de Janeiro and São Paulo, Brazil, 2011.

Objective to assess the applicability of the Brazilian List of Avoidable Causes of Death (BAL) to perinatal mortality in public maternity hospitals in the states of Rio de Janeiro (RJ) and São Paulo (SP) in 2011. Methods this was a descriptive case series study of perinatal deaths using primary data from the Mortality Information System; the BAL was applied, with adaptations (codes P20.9 and P70-74) and, in addition in Rio de Janeiro the Extended Wigglesworth (EW) Classification was also used. Results according to the BAL, 61.2% of the 98 perinatal deaths were avoidable, mainly by providing adequate attention to women in pregnancy; 'Ill-defined causes of death' accounted for 26.6% of cases, mainly fetal deaths; use of EW in RJ indicated that the 'Antepartum Fetal Death' category was predominant and was related to inadequate prenatal care; this was in line with the BAL. Conclusions after reallocating some codes, the BAL can improve fetal death evaluation, whereby studies with a larger number of participants are needed.

Association between maternal serum homocysteine concentrations in early pregnancy and adverse pregnancy outcomes.

Background:There is still conflicting evidence on the extent to which maternal hyperhomocysteinemia is a risk factor for pregnancy complications.Aims:The study aimed to investigate the impact of elevated maternal homocysteine concentrations on adverse pregnancy outcomes among Nigerian women in Lagos.Materials and Methods:This was a prospective cohort study conducted at the Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria. Participants were enrolled during the first trimester of pregnancy following which relevant data were obtained by the interview. Fasting blood samples were collected for the measurement of maternal homocysteine concentration using the enzyme-linked immunosorbent assay method. Pregnancy outcomes and complications were obtained by abstracting the antenatal, delivery, and newborn medical records. Preterm births, low-birth weight (LBW), and antepartum fetal death were used as confirmatory outcome variables in the final analysis. Descriptive statistics for all data were computed using SPSS version 22.0. The associations between the variables were tested and multivariate analyses were used to study the effects of the major baseline characteristics on the pregnancy outcome. P < 0.05 was considered statistically significant.Results:Hyperhomocysteinemia was recorded in 41 (24.6%) patients. Women with a high homocysteine concentration and those with a normal homocysteine level did not differ significantly in terms of age (P = 0.684), level of education (P = 0.866), and parity (P = 0.647). Women with hyperhomocysteinemia had an approximately twelve-fold higher risk of preterm birth (P = 0.001) and a ten-fold higher risk of delivering a term neonate with LBW (P = 0.004), but had no risk of antepartum fetal death (P = 0.118) compared to women with a normal homocysteine concentration.Conclusions:The prevalence of hyperhomocysteinemia among mothers in Lagos was relatively low. The associations between hyperhomocysteinemia and adverse pregnancy outcomes could have implications in future for the prevention of these adverse outcomes.

Perinatal mortality: epidemiological profile, causes and avoidable factors at a reference public maternity hospital in the State of Santa Catarina, Brazil, 2011-2015.

Background This study aimed to identify the perinatal mortality coefficient, the epidemiological profile, causes and avoidable factors at a reference public maternity hospital in southern Brazil. Methods In this cross-sectional study, 334 medical records of postpartum women and newborns were evaluated between January 1st, 2011 and December 31st, 2015. The Expanded Wigglesworth Classification was used to assess the causes of perinatal mortality and the International Statistical Classification of Diseases and Related Health Problems (ICD-10/SEADE Foundation) was used for the preventable perinatal mortality analysis. Absolute numbers and percentages were used for data analysis. The perinatal mortality formula was used to calculate the perinatal mortality rate. Results The perinatal mortality rate was 13.2/1000 total births, with a predominance of white race/color; mothers were 21-30 years of age, had experienced their first pregnancy and had completed their high school education. Conclusion The main factors associated with perinatal death were antepartum fetal death in 182 (54.49%) cases, and avoidable death through appropriate prenatal care in 234 (70.05%) cases.

Unrecognized maternal heart rate artefact in cases of perinatal mortality reported to the United States Food and Drug Administration from 2009 to 2019: a critical patient safety issue

BackgroundMaternal heart rate artefact is a signal processing error whereby the fetal heart rate is masked by the maternal pulse, potentially leading to danger by failure to recognize an abnormal fetal heart rate or a pre-existing fetal death. Maternal heart rate artefact may be exacerbated by autocorrelation algorithms in modern fetal monitors due to smooth transitions between maternal and fetal heart rates rather than breaks in the tracing. In response, manufacturers of cardiotocography monitors recommend verifying fetal life prior to monitoring and have developed safeguards including signal ambiguity detection technologies to simultaneously and continuously monitor the maternal and fetal heart rates. However, these safeguards are not emphasized in current cardiotocography clinical practice guidelines, potentially leading to a patient safety gap.MethodsThe United States Food and Drug Administration Manufacturer and User Facility Device Experience database was reviewed for records with event type “Death” for the time period March 31, 2009 to March 31, 2019, in combination with search terms selected to capture all cases reported involving cardiotocography devices. Records were reviewed to determine whether maternal heart rate artefact was probable and/or whether the report contained a recommendation from the device manufacturer regarding maternal heart rate artefact.ResultsForty-seven cases of perinatal mortality were identified with probable maternal heart rate artefact including 14 with antepartum fetal death prior to initiation of cardiotocography, 14 with intrapartum fetal death or neonatal death after initiation of cardiotocography, and 19 where the temporal relationship between initiation of cardiotocography and death cannot be definitively established from the report. In 29 cases, there was a recommendation from the manufacturer regarding diagnosis and/or management of maternal heart rate artefact.ConclusionsThis case series indicates a recurring problem with undetected maternal heart rate artefact leading to perinatal mortality and, in cases of pre-existing fetal death, healthcare provider confusion. In response, manufacturers frequently recommend safeguards which are found in their device’s instructions for use but not in major intrapartum cardiotocography guidelines. Cardiotocography guidelines should be updated to include the latest safeguards against the risks of maternal heart rate artefact. An additional file summarizing key points for clinicians is included.

Neonatal outcomes in term pregnancies treated with antenatal corticosteroids for suspected pre-term labor.

To evaluate the association between antenatal corticosteroid treatment and neonatal outcome when delivery occurs at term. A retrospective cohort study of all women with singleton gestations who delivered at term (37 + 0 to 41 + 6weeks) in a tertiary medical center (2012-2015). Women with diabetes, suspected fetal growth restriction, antepartum fetal death, and fetal structural or chromosomal anomalies were excluded. The cohort was divided according to prior preterm (24 + 0 to 33 + 6weeks) antenatal corticosteroids treatment due to threatened preterm labor (study group), vs. no such treatment (control group). Primary outcome was birthweight at delivery. Secondary outcomes were composites neonatal adverse outcomes. Logistic regression analysis was utilized to adjust results for potential confounders. Of 25,872 women who were included in the study, 722 (3%) were treated with antenatal corticosteroids. Women in the treatment group had higher rates of nulliparity compared to controls (43% vs. 38%, p = 0.002). Birth weight was significantly lower in the corticosteroid treatment group (3077g vs. 3264g, p = 0.001), with higher rates of small for gestational age (11% vs. 6%, p = 0.001). Multivariate analysis adjusting for parity and gestational age demonstrated that corticosteroid treatment was associated with lower birth weight (B = - 93g, 95% CI - 123 to - 66, p = 0.001). Treatment was not found to be associated with adverse neonatal outcomes composites. Antenatal corticosteroid treatment is associated with lower birth weight and higher rates of small for gestational age neonates among women who eventually deliver at term. However, it is not associated with short-term adverse neonatal outcomes.

Co-infection with Zika and Chikungunya viruses associated with fetal death—A case report

We describe a case of fetal death associated with a recent infection by Chikungunya virus (CHIKV) in a Brazilian pregnant woman (positive RT-PCR in blood and placenta). Zika virus (ZIKV) infection during pregnancy was also identified, based on a positive RT-PCR in a fetal kidney specimen. The maternal infection caused by the ZIKV was asymptomatic and the CHIKV infection had a classical clinical presentation. The fetus had no apparent anomalies, but her weight was between the 3rd and 10th percentile for the gestational age. This is the second case report of congenital arboviral co-infection and the first followed by antepartum fetal death.

Cup detachment during vacuum-assisted vaginal delivery and birth outcome.

To determine the perinatal outcome associated with cup detachment during vacuum-assisted vaginal delivery (VAVD). A retrospective cohort study of all women attempting VAVD in a tertiary hospital (2012-2014). Singleton-term pregnancies were included. Antepartum fetal death and major fetal structural or chromosomal abnormalities were excluded. Primary outcome was neonatal birth trauma (subgaleal hematoma, subarachnoid hematoma, subdural hematoma, skull fracture, and/or erb's palsy). Secondary outcomes were maternal complications or other neonatal morbidities. Outcomes were compared between women after ≥1 cup detachment (study group) and the rest (control group). Logistic regression analysis was utilized to adjust results to potential confounders. Overall, 1779 women attempted VAVD during study period. Of them, in 146 (8.2%), the cup detached prior to delivery; 130/146 (89%) had a single detachment. After detachment, 4 (2.7%) delivered by cesarean section, 77 (52.7%) delivered after cup reapplication, and 65 (44.6%) delivered spontaneously. Women in the study group were more likely to undergo VAVD due to prolonged second stage, and were characterized by lower rates of metal cup use. Neonates in the detachment group had higher rates of subarachnoid hematoma and composite neonatal birth trauma (2.7 vs. 0.1% and 4.8 vs. 1.8%, respectively, p<0.05). This remained significant after adjustment to potential confounders (subarachnoid hematoma aOR=45.44, 95% CI 6.42-321.62 and neonatal birth trauma aOR=2.62, 95% CI 1.1-6.22, p<0.05 for all). Other neonatal and maternal morbidities were similar between groups. Cup detachment is associated with a higher rate of adverse neonatal outcome. Cup reapplication should be considered carefully.