Predictors Of Perinatal Mortality Research Articles

OP07.22: Do changes in systolic and end‐systolic blood flow in ductus venosus and right hepatic vein give additional information of cardiac decompensation and in prediction of perinatal mortality?

OP07.22: Do changes in systolic and end‐systolic blood flow in ductus venosus and right hepatic vein give additional information of cardiac decompensation and in prediction of perinatal mortality?

1018: What is new in IUGR Doppler?

In this lecture, we will compare the performance of middle cerebral artery (MCA), ductus venosus (DV) and umbilical artery (UA) Doppler in the prediction of perinatal mortality. We will include patients diagnosed to have SGA (EFW or AC < 10th percentile) and an abnormal umbilical artery pulsatility index (PI). Middle cerebral artery peak systolic velocity (PSV), DV-PI and UA-PI for each fetus will be considered abnormal when they are outside the reference range. The presence, absence (A) and reversed flow (RF) of DV and UA will also be determined.

Predictors of adverse perinatal outcome in twins delivered at

Objective: Multiple gestations are at increased risk for prematurity as well as perinatal mortality and morbidity. The aim of this study was to identify the independent risk factors for adverse perinatal outcome in a large uniform population of twins delivered preterm. Methods: We accessed a cohort of twin gestations for the period 1990-2000 delivered at < 37.0 weeks gestation. Chorionicity was established by ultrasound assessment of the dividing membrane, neonatal gender and histologic examination of the placenta at birth. Adverse perinatal outcome was defined as stillbirth, neonatal death, or major neonatal complications. Statistical analysis used contingency tables, Student's t test, one-way ANOVA and logistic regression, with a two-tailed p < 0.05 considered significant. Results: A total of 356 twin gestations (712 twins) were included in the database, and 183 twins (25.7%) had adverse perinatal outcome. Logistic regression analysis demonstrated that gestational age at delivery (p < 0.001), premature rupture of membranes (PROM) (p = 0.004), birth weight discordance (p = 0.009), and 5-min Apgar scores (p = 0.001) were significant and independent predictors of adverse perinatal outcome, whereas monochorionicity and twin-twin transfusion syndrome were not. Conclusions: Gestational age at delivery and birth weight discordance are the most important independent predictors of perinatal mortality or morbidity among preterm twins.

The importance of quality of care in perinatal mortality: a case-control study in Chiapas, Mexico

This study was undertaken in order to ascertain the relative importance of different risk factors for perinatal mortality (PM) in a community of Chiapas, Mexico stressing the importance of antenatal and neonatal medical care. Cases were stillbirth and early neonatal death (END). Two children born in the same hospital and/or day as the case were randomly selected as controls, in Tapachula, Chiapas, Mexico. Socioeconomic, cultural, maternal, pregnancy, delivery, product and medical care factors were recorded. Two analyses were performed using multiple logistic regression: one for stillbirths, the other for END. PM rate was 46.7/1000; 142 cases and 284 controls were studied. Fifteen cases were excluded due to congenital malformations; 62 stillbirth and 65 END were analyzed. For stillbirth, pregnancy-delivery and maternal medical care factors resulted in the most strongly associated risk factors for PM (OR=27.5 95% CI 6.4-116.8), and within this index insufficient prenatal care had the strongest impact on PM (%population attributable risk (%PAR)=24%). For END, fetal conditions and the newborn medical care index had the strongest association with PM (OR=9.5 95% CI 1.5-60.3), and within the index inappropriate medical care of the newborn (%PAR=27%) was the most important variable. Our results support the fact that insufficient prenatal care and failure to comply with the standards of care for labor, delivery and for the care of the newborn are strong predictors of PM.

P05.07: Absence or reverse flow in end diastolic velocity of umbilical artery (AEDV), still the easiest and the best predictor of perinatal mortality ever described

The aim of this study is to determine the perinatal outcome of fetuses with AEDV following an protocol of management in one perinatal center. Patients with AEDV were included in a protocol as follows: 1) under 28 weeks of gestation, decisions of interruption were based on the finding of an absence of flow in “a “wave in ductus venosus; 2) between 28 and 32 w, interruption with the addition of any deterioration in antenatal surveillance test; 3) after 32 w or in the presence of severe maternal deterioration were always an interruption criteria. Doppler measurements were performed with an Voluson 730 (GE Medical systems). Fetuses with congenital anomalies and twins were excluded. 92 patients were included. Maternal age and gestational age were 27 y (15–46) and 29 y (15–42), and 30 w (24–39) and 29 w (26–39. Abnormal ductus venosus was seen in 13/59 and 6/33 patients respectively. Fetal and neonatal death were 7/59 (11.8%), 10/52 (19.3%) and 2/33 (6%), 12/31 (38.7%) for active and expectant management respectively. (NS). Alive newborns were 42/59 (71.2%) and 19/33 (57.6%). The decrease in perinatal mortality in this experience in relation of the first reports from 1994 should be explained associated with a more active management of this extremely risk condition.

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Prognostic factors for survival of growth-restricted fetuses with absent end-diastolic velocity in the umbilical artery.

The aim of the study was to evaluate the prognostic factors for survival of growth-restricted fetuses with absent end-diastolic velocity in the umbilical artery. Forty-five intrauterine growth-restricted fetuses with either absent end-diastolic (34 fetuses) or reverse flow (11 fetuses) in the umbilical artery were studied. The clinical characteristics of these pregnancies were determined. Logistic regression analysis was conducted to find the relative value of gestational age at birth, thoracic artery and middle cerebral artery Doppler velocimetry, and short-term variability determined by cardiotochography in the prediction of perinatal mortality. The mean gestational age at birth and birth weight were 30.8+/-2.4 weeks and 972+/-337 g, respectively. The perinatal mortality was 40%. Gestational age at birth was found to have the only significant contribution to the prediction of perinatal deaths. Fetuses with a gestational age at delivery less than 29 weeks died and more than 31 weeks survived. Thoracic artery pulsatility index had the best screening efficiency for predicting perinatal mortality between 29 and 31 weeks gestational age. Absent end-diastolic velocity in the umbilical artery is mainly a problem of severe preterm growth-restricted fetuses and is associated with high perinatal mortality. The major and dominant influence on survival is gestational age at birth.

Fetal umbilical doppler in a population of 541 high-risk pregnancies: prediction of perinatal mortality and morbidity

Objective: To evaluate the usefulness of systematic umbilical Doppler in the assessment of high-risk pregnancies. Method: In a prospective multicentre study, a group of high-risk pregnancies (intrauterine growth retardation, hypertension during pregnancy, abnormal obstetric history) was systematically studied by Doppler exploration of the fetal umbilical artery between 28 and 34 weeks. All the details of pregnancy development to the first postnatal days were collected and analysed a posteriori. Results: Three groups were formed according to Doppler results (Index S-D/S) A, index < 90th percentile ( n = 458, 84.6%); B, index ≥ 90th percentile and diastole over zero ( n = 67, 12.4%); C, zero diastole ( n = 16, 2.9%). There was a strong correlation between Doppler results and pregnancy development. Group C corresponded to a greatly altered prognosis (hypotrophy, < 3rd percentlile in 69%; intrauterine deaths in 9 16 ). In group B, relative to group A, the prognosis was significantly altered (hypotrophy, 24% versus 6%, P < 0.01; prematurity rate, 25% versus 11%, P < 0.001) but these repercussions were not as severe as in group C. Conclusion: In high-risk pregnancies, fetal umbilical artery Doppler study is of interest for prognostic assessment. Normal results should provide temporary reassurance. Abnormal umbilical Doppler indicates that chronic suffering will occur or is onset in at least one-third of cases.

Factors related to birth weight and perinatal mortality.

)reliable statistical reporting systems for a few countries extending back to World War II show that perinatal mortality rates have continuously fallen. To understand the reasons for this trend, 2 kinds of studies must be distinguished: studies which relate observed perinatal mortality rates or changes in rates to social, demographic, and other factors; and studies which set out "experimentally" to manipulate related factors and to study the effect on perinatal mortality rates. This discussion focuses exclusively on observational studies, covering factors associated with birth weight; components of the birth weight distribution; population studies; joint effects of several factors; birth weight, gestation, and mortality; and perinatal mortality. There are 2 distinct approaches to the study of birth weight: one that uses a threshold value, usally 2500 gm, and studies the proportion of births below that value; and one that studies differences in mean birth weight. Since, for many purposes, there is a particular interest in the very light babies, a direct measurement of their number is often the most appropriate approach. Which component procedures may be able to provide useful summary graduations of a birth weight distribution, their claims to represent substantive reality need ot be viewed critically. There are numerous studies of birth weight and perinatal mortality, but there are relatively few which have used adequate random sampling techniques allowing valid statements to be made about well defined populations. Attention is directed to results from a few large scale population studies, particularly the resultsof the 1958 British Perinatal Mortality survey. For both age and parity there was a change in the spread of birth weights as the mean birth weight rises, and this is reflected in the relationship between these factors and perinatal mortalty. The common practice of presenting percentiles of birth wieght for given gestation length is questionble since it suggests that babies at the same percentile value are in some sense equivalent. The use of birth weight alone gives a better prediction of perinatal mortality as can be seen by the manner in which the high mortality contours tend to become parallel to the gestation axis. For purposes of comparability, the 1973 World Health Organization (WHO) studies shows clearly that the use of separate late fetal death rates and neonatal death rates can be misleading. The use of a perinatal rate overcomes this problem. A table shows how perinatal mortality rates vary across the categories of several factors for Cuba, New Zealan, and Sweden in the 1973 WHO study. From the point of view of predicting high perinatal mortality risk, the data suggest that twins, high age and high parity mothers, and short interpregnancy intervals are common to all countries.

Antepartum fetal heart rate monitoring in multiple pregnancy.

The assessment of fetal wellbeing in patients with multiple pregnancy by nonstressed antepartum cardiotocography is technically feasible and of clinical value. In 50 patients (101 babies) who were monitored during the antepartum period, there were five patients in whom one of a pair of twins showed a non-reactive cardiotogram. Four of these babies died (two intrauterine deaths and two neonatal deaths). All of these five babies were growth retarded at birth. The cardiotocograms from the other 96 fetuses were 'reactive' and these babies were normal. Cardiotocography seems to be a better predictor of perinatal mortality and morbidity than serial urinary oestrogens or serial biparietal diameter measurements in multiple pregnancy.

Prediction of perinatal mortality in early pregnancy.

The detection of high-risk pregnancies has become one of the major concerns of physicians and midwives in charge of pregnant women. Detection must be made very early, and it would be highly desirable for certain factors of risk to be discovered before the beginning of pregnancy, and even before any pregnancy in any given woman. In the work reported here, our objective was to predict perinatal mortality during the first three months of pregnancy in order to discover the groups at risk requiring particular care. Predictions will be based not only on pathological findings, but also on characteristics, the importance of which is sometimes less well known, such as age, social and economic Status, and circumstances of life during pregnancy. On the basis of an analytical study of these factors, an attempt at predicting stillbirth and neonatal death is made.