Risk Factors For Stillbirth Research Articles

Miscarriage Risk Factors and Causes: Review Article

Miscarriage Risk Factors and Causes: Review Article

Risk factors of miscarriage among pregnant women attending Omdurman maternity hospital

Background: Around 56 million miscarriages are performed each year in the world, with about 45% are done unsafely. Miscarriage poses great risks and complications that contribute to long-term physical and psychological problems. Good knowledge and practice related to pregnancy follow-up and avoiding the causes of miscarriage will reduce its risks significantly. Aim of current study was to determine and identify the rate and risk factors of miscarriage and the common causes of miscarriage among women in Omdurman Maternity Hospital, Sudan. In addition, to evaluate the level of awareness of the risks and complications of miscarriage among women attending the maternity hospital, Sudan. Methods: A quantitative, cross sectional study using questionnaires (N=100) was used in this study to determine the risk factors of miscarriage in women attending the maternity hospital in Omdurman, Sudan Results: The study revealed that miscarriages were not very frequent, and there was no significant family history of miscarriages. However, those who had a miscarriage were in the first trimester of pregnancy. One of the main causes of miscarriage is the presence of severe stress from work, illness and food poisoning. Conclusions: The findings of this study suggest different interventions to reduce the risks of miscarriages such as educating mothers about antenatal care and to take precautions during the first trimester to avoid miscarriages and educating families about the risks of being in consanguineous relationships. In addition, raising awareness about contraceptive methods to reduce the rates of induced miscarriages.

Clinical Risk Factors affecting the Pregnancy Outcome using Pakistan Maternal Mortality Survey (PMMS) 2019

Background: South Asia is the world's most populous region, and it also has the highest rate of pregnancy loss. It is necessary to understand the risk factors for pregnancy loss in South Asian countries like Pakistan for reducing the global burden of pregnancy loss. Aim: To determine the potential clinical factors affecting pregnancy outcomes of Pakistani women aged 15-49 years during 2016-2019. Study design: This study was conducted using Pakistan Maternal Mortality Survey (PMMS 2019) during 2020-2021. All eligible ever-married women (n=7096) aged 15-49 were selected for this study. In this study, the clinical risk factors considered are fever, unconsciousness, high blood pressure, diabetes, vaginal bleeding, problems associated with the placenta, problems associated with the position of the baby, and preeclampsia. The response variable was pregnancy outcome comprising four categories that are live-birth, stillbirth, miscarriage, and abortion. A multinomial logistic regression model was applied to test the relationship between the dependent variable and each of the eight risk factors. Results: Multinomial logistic regression model identified that fever (OR=0.723), vaginal bleeding(OR=1.614), high blood pressure (OR=1.473), and problems associated with the position of the baby (OR=0.396)are significantly associated with a stillbirth at a 10% level of significance. Additionally, unconsciousness (OR=1.019) appears as a potential risk factor for abortion. Practical implication: Understanding the most significant risk factors that contribute to negative pregnancy outcomes, it can prioritize resources to improve maternal health. Also, assistance to healthcare providers and policymakers in making informed decisions regarding maternal health in Pakistan can be provided. Conclusion: Fever, vaginal bleeding, high blood pressure, problems associated with the position of the baby are significant risk factors of stillbirth. However, unconsciousness identified a risk factor of abortion. It is concluded that in Pakistan pregnancy loss can be reduced by controlling the prevalence of diseases during pregnancy. Keywords: Abortion, Clinical risk factors, Miscarriage, Multinomial logistic model, Pregnancy loss, Stillbirth

Predictors of Miscarriage in the West of Iran: A Case-Control Study

Background: Since the risk factors for miscarriage vary in different societies, the present study was conducted to investigate the effect of the related factors on miscarriage in the west of Iran (Zanjan city). We aimed to determine the modifiable and non-modifiable predictors of miscarriage.
 
 
 
 
 Methods: In this case-control study, 219 cases and 420 controls were selected among those living in the Zanjan (a city located in western Iran) in 2019. Data were collected by a 25-item checklist of medical records available in the comprehensive urban health service center. For assessing the effects of explanatory variables on miscarriage, the multiple logistic regression model was used at a 95% confidence interval. All analysis was conducted by Stata 14 software.
 Results: Short birth interval (less than 36 months) (OR=2.4, p<0.001) and ectopic pregnancy (OR=3.5, p<0.011) increase the odds of miscarriage. In other words, high education reduced the odds of miscarriage (OR:0.07,p<0.001).
 Conclusion: In the present study, increasing age, low education level, history of previous coagulation, previous spontaneous abortion, history of previous ectopic pregnancy and short birth intervals (less than 36 month) were associated directly with miscarriage.
 
 
 

Stillbirth and fetal growth restriction

Aim: to estimate the rate of early-onset and late-onset fetal growth restriction (FGR) in stillbirth, identify features of placentaassociated complications and determine respective risk factors of stillbirth (especially at early gestational age).Materials and Methods. There were retrospectively studied 61 stillbirth cases in 2016–2019 that occurred in the III level obstetric hospitals: 32 early (23–31 weeks of gestation) and late (32–39 weeks) cases; 156 live births with 8–10 Apgar scores delivered at 36–41 weeks of gestation used as controls. Quantitative parameters were compared using the mean values and standard deviation; nominal parameters were analyzed using odds ratio (OR) and adjusted OR (aOR) with 95 % confidence interval (CI).Results. More than half of stillbirths are associated with FGR with almost 60 % of early-onset phenotype of this pathology. Both in stillbirths and live births, 2/3 of FGR have extremely low weight (OR = 1.8; 95 % CI = 0.6–6.9); 1/3 of growth restricted fetuses were detected shortly before delivery (OR = 1.3; 95 % CI = 0.7–2.4); 1/4 of pregnancies complicated by placental insufficiency are not associated with FGR (OR = 1.4; 95 % CI = 0.7–2.7). Risk factors of stillbirth in pregnancy complicated by FGR are the early-onset growth restriction phenotype (aOR = 3.2; 95 % CI = 1.0–10.3), maternal age over 28 years (aOR = 6.0; 95 % CI = 1.2–29.4), miscarriages and multiple induced abortions (aOR = 3.6; 95 % CI = 1.1–11.2), non-compliance in regular clinics visiting and correction of threatening conditions (aOR = 10.9; 95 % CI = 1.3–91.6), toxoplasma infection (aOR = 6.0; 95 % CI = 1.5–24.5). Early stillbirth with FGR is associated with an older mother's age (aOR = 5.8; 95 % CI = 1.0–34.4), greater parity (aOR = 3.3; 95 % CI = 1.0–10.4), uterine diseases including endometrial polyps, endometriosis, cervix cervicitis, cervix dysplasia (aOR = 4.0; 95 % CI = 0.9–17.2), diabetes mellitus (aOR = 3.1; 95 % CI = 0.8–13.2) and preeclampsia.Conclusion. The rate of early-onset FGR in stillbirth comprises almost 60 % that is twice higher than in live birth, with the rate of late-onset phenotype being less than 30 %. In late stillbirths the early-onset phenotype also prevails. There are no prominent features for stillbirths with FGR compared to previously known risk factors regardless of hypotrophy. Early vs. late stillbirth with FGR is more associated with gynecological pathologies as well as with diabetes mellitus and preeclampsia.

Applying Scientific Rationale to the Current Perceptions and Explanations of Massage and Miscarriage in the First Trimester.

Miscarriage is a relatively common occurrence, impacting 8-15% of clinically recognised pregnancies, and up to 30% of all conceptions. The public perception of the risk factors associated with miscarriage does not match the evidence. Evidence indicates that there are very few modifiable factors to prevent miscarriage, and the majority of the time little could have been done to prevent a spontaneous miscarriage. However, the public perception is that consuming drugs, lifting a heavy object, previous use of an intrauterine device, or massage can all contribute to miscarriage. While misinformation about the causes and risk factors of miscarriage continues to circulate, pregnant women will experience confusion about what activities they can (and cannot) do in early pregnancy, including receiving a massage. Pregnancy massage is an important component of massage therapy education. The resources that underpin pregnancy massage coursework consist of educational print content that includes direction and caution that massage in the first trimester, if done 'incorrectly' or in the 'wrong' location, can contribute to adverse outcomes such as miscarriage. The most common statements, perceptions and explanations for massage and miscarriage cover three broad areas: 1) maternal changes from massage affects the embryo/fetus; 2) massage leads to damage of the fetus/placenta; and 3) aspects of the massage treatment in the first trimester initiate contractions. The goal of this paper is to use scientific rationale to critically consider the validity of the current perceptions and explanations of massage therapy and miscarriage. Whilst direct evidence from clinical trials was lacking, considerations of physiological mechanisms regulating pregnancy and known risk factors associated with miscarriage provide no evidence that massage in pregnancy would increase a patient's risk of miscarriage. This scientific rationale should be addressed when teaching pregnancy massage courses.

Trends and risk factors of stillbirth among women of reproductive age in Pakistan: A multivariate decomposition analysis.

Every year, 2 million babies are stillborn in the world. Globally, there has been a decline in the stillbirth rate of 2%. Despite advancements in prenatal care and the implementation of new medical technologies, the incidence of early stillbirths remains unchanged. A slight decrease in the rate of late-term stillbirth has been observed. Pakistan ranked third in South Asia for having the highest stillbirth rate. Compared to its neighbors and other developing nations, Pakistan has shown a lack of progress in reducing maternal and neonatal fatalities. Therefore, the purpose of this study is to use a multivariate decomposition analysis to examine the trends and factors that have contributed to the change in the stillbirth rate over time. To conduct this study, we used a secondary data analysis approach and analyzed data from the Pakistan Demographic and Health Survey (PDHS) of 2012-2013 and 2017-2018). For the analysis, a total sample of 15,068 births in 2017-2018 and 13,558 births in the PDHS from 2012 to 2013 were taken into account. Using the MVDCMP function within STATA version 15 statistical software, a logit-based multivariate decomposition model was fitted to determine the variables that influence the change in stillbirth. The current study used two cross-sectional surveys to identify important risk factors for stillbirths. Over the past 5 years, Pakistan's stillbirth rate has risen from 3.98 to 5.75%. According to the total multivariate decomposition analysis, the change in coefficient (change in the effect of attributes) accounted for 81.17% of the overall change in the proportion of stillbirths. In contrast, the change in endowment was not statistically significant. Changes in maternal education, individual and community-level wealth status, and mode of delivery all significantly impacted the rate of stillbirths over time. Stillbirths increased in Pakistan from 2012 to 2017. Stillbirths are observed more frequently for women residing in Punjab, Sindh, and rural areas. A major concern that is directly related to the prevalence of stillbirths in Pakistan is the lack of accessible, affordable, and high-quality maternal healthcare facilities. Older, overweight, and uneducated women are more likely to have stillbirths than women who deliver vaginally. High parity and short birth intervals also accelerated the rate of stillbirths. An effective remedy to control stillbirths is the provision of accessible and affordable healthcare services. Awareness campaigns for the health education of pregnant women should focus on raising awareness to support better pregnancy outcomes for poor women living in communities with higher education levels. The risk of stillbirth can be reduced by offering free diagnostics for early detection of birth complications in low-resource settings and referring these cases to knowledgeable gynecologists for safe delivery.

Review of the evidence of the effects of human papillomavirus infection and Gardnerella vaginalis, and their co-infection on infertility.

A prevalent sexually transmitted infection, the human papillomavirus (HPV) is typically obtained just after the first sexual activity. The majority of HPV infections are asymptomatic and temporary. Cervical, anal, penile, vaginal, vulvar, and oropharyngeal cancers can occur due to recurrent infections with high-risk (hr)-HPV strains, generally decades later. Infections with HPV are significantly associated with reproductive function abnormalities. Per recent research, HPV infections may result in male infertility by reducing sperm motility. The hr-HPV infection was a risk factor for miscarriage, and the indiscriminate HPV genotype increased the probability of premature labor unexpectedly. Women's endometrial trophoblastic cell implantation is decreased by HPV. Gardnerella vaginalis (GV), an anaerobic bacterium that is a component of the natural vaginal flora, can be associated with bacterial vaginosis (BV) when it starts to overgrow and emerge as the dominant species. Reduced Lactobacillus species abundance and GV are linked to female infertility. Data from in vitro studies suggests that sialidase produced by GV may facilitate the entry and growth of papilloma and other sexually transmitted viruses. Also, based on some studies conducted in the past, it can be said that GV and BV are associated with the development of uterine cancer. However, there is still not enough information about the exact mechanism of GV and HPV in causing infertility, which requires more research.

Determining the risk of miscarriage in genetic forms of thrombophilia

The aim: to study the distribution and influence of coagulation factor gene polymorphisms and endothelial dysfunction on the development of recurrent pregnancy loss.
 Materials and methods: a prospective case-control study included 109 pregnant women in the 1st trimester with habitual miscarriage and 34 conditionally healthy pregnant women with an uncomplicated obstetrical anamnesis without risk factors for miscarriage. Genetic polymorphisms of coagulation and fibrinolysis factors (1691 G→A FVL, 20210 G→A prothrombin, 675 5G/4G PAI-1, 455 G→A fibrinogen β), as well as endothelial dysfunctions (192 Q→R PON-1, 677 C → T MTHFR) were investigated using allele-specific polymerase chain reaction.
 Results: Pathological polymorphisms of the genes of the hemostasis system and endothelial dysfunction play a significant role in the development of miscarriage, namely such pathological genotypes as 1691 GA of factor V Leiden - increases the risk by 5.3 times (95 % CI 1.5-18.5), 20210 GA of prothrombin - by 26.47 times (1.6-445.7), 675 4G/4G PAI-1 - by 7, 5 times (1.7-33.79), -455AA fibrinogen β - 9.7 times (1.3-74.16), 677 CT MTHFR - 2.6 times (1.0-6.2), 677 TT MTHFR - 21.7 times (1.3-368.6). Multigenic forms of thrombophilia predominate in the majority of patients with miscarriage and account for 76.1 % (p<0.001, OR=12.31, 95 % CI 4.8-31.55). It was determined that the simultaneous presence of two pathological polymorphisms increases the risk of miscarriage by 3.88 times (OR 3.38; 95 % CI 1.26-9.97), and three ones - more than 2.5 times (OR 2.66; 95 % CI 1.02-7.19).
 Conclusions: the course of pregnancy against the background of pathological polymorphisms of the genes of the hemostasis system and endothelial dysfunction significantly increases the risk of habitual miscarriage, which should be considered when planning a pregnancy in women with habitual miscarriage

Implementation of Uterine Artery Doppler Scanning: Improving the Care of Women and Babies High Risk for Fetal Growth Restriction.

While stillbirth rates have declined in many countries, these declines are less marked in the UK. Fetal growth restriction (FGR) affects about 3% to 7% of all pregnancies and is by far the single strongest risk factor for stillbirth. FGR implies a pathological restriction of the genetic growth potential and is not synonymous with small-for-gestational age (SGA). The Royal College of Obstetricians and Gynaecologists (RCOG) defines SGA as an estimated fetal weight (EFW) or abdominal circumference (AC) less than the 10th centile. The likelihood of FGR is higher in severe SGA defined as an EFW or AC less than the 3rd centile. The second version of Saving Babies' Lives Care Bundle (SBLCBv2) recommends the second trimester uterine artery Doppler (UtAD) pulsatility index (PI) screening for pregnancies at high risk of FGR. This study was aimed at determining the prevalence of FGR and assess pregnancy outcomes following the implementation of UtAD at the United Lincolnshire Hospitals NHS Trust (ULHT). One-year retrospective cohort study (1st September 2020-31st August 2021) was conducted across both ULHT hospitals in the UK (Lincoln County Hospital in Lincoln and Pilgrim Hospital in Boston). During the study period, 5197 women were booked at ULHT. Of 5197, 349 were identified as high risk for FGR. When numbers were compared for the two hospitals, FGR rate was higher in Lincoln 8.10% vs. 4.51% in Boston. In addition, an increased proportion of abnormal UtAD scans was observed in Lincoln (35.7%) vs. in Boston (22%) (P = 0.014). Of the 349 UtAD scans, 237 were normal (67.9%), 41 showed unilateral notching (11.7%), 43 bilateral notching (12.3%), and 28 raised PI (8%). Babies in the bilateral notching group exhibited the lowest birth weight (P = 0.005), born at an earlier gestation (P = 0.029), and with low Apgar scores at 1 (P = 0.007) and 5 minutes (P < 0.001). Discussion. UtAD is a useful second trimester screening tool for women identified as high risk for FGR and helps stratify the intensity of surveillance. However, the findings call into question a focus solely on the UtAD PI for improving FGR detection without taking into account bilateral notching.

Determination of the Predictive Roles and Potentially Pathogenic Antigen Epitopes of α-Enolase Related to the Development of Miscarriage in Females with Autoimmune Thyroiditis.

Autoimmune thyroiditis (AIT) is a common endocrine disease which causes a significantly increased risk of miscarriage. Our recent study has shown that the increased ENO1 autoantibody (ENO1Ab) expression in an experimental AIT mouse model was induced by thyroglobulin (Tg) immunization only. In this study, we explored the potential roles of ENO1Ab in miscarriage occurrence among AIT women, and the specific epitopes of ENO1 targeted by ENO1Ab. A total of 432 euthyroid pregnant participants were selected from the project of Subclinical Hypothyroid during Early Pregnancy, including 48 women with AIT and miscarriage, 96 with miscarriage but no AIT, 96 with AIT but no miscarriage, and 192 without either AIT or miscarriage. The enzyme-linked immunosorbent assay was used to determine the serum levels of total IgG against ENO1 and 18 predicted antigen epitopes of ENO1. The results showed that women with AIT and miscarriage had the highest serum levels of ENO1Ab compared to the other groups. Logistic regression analysis showed that the serum ENO1Ab was an independent risk factor for miscarriage, especially among AIT females. The serum level of total IgG against the predicted epitope peptide 6 (i.e., P6 and aa168-183) of ENO1 was significantly increased in women with AIT and miscarriage when compared with those of both the AIT non-miscarriage group and non-AIT miscarriage group. This pilot study suggests that serum ENO1Ab may have a fair predictive value for AIT-related miscarriage, and the autoantibody specific to P6 epitope may especially be more specifically related to this disorder.

Vaginal Bacterial Infection Is Associated With the Occurrence of Spontaneous Abortion during the First Trimester

Background: Recurrent spontaneous abortion (RSA) is a serious disorder that may be detrimental to a woman's health. Bacterial vaginosis (BV) is a vaginal microsystem disorder that seems to be connected to a higher risk of abortion, early birth, and puerperal endometritis. 60 percent of all vaginitis types are caused by BV. The purpose of this research is to explore whether vaginal bacterial infection is connected to spontaneous abortion during the first trimester. Methods: This was a cross sectional study on 120 pregnant women on the first trimester diagnosed with spontaneous abortion during the first trimester. Results: No significant difference in clinical data of included subjects in both groups. Significant high prevalence of symptoms in pregnancy loss group. Significant increase in lactobacilli in all grades in abortion group compared with evolving pregnancy group. Significant increase in pathogenic bacteria in abortion group. No significant difference in enteric bacteria. A high significant association between infection and abortion occurrence. All pathogens were significantly associated with pregnancy loss occurrence. Also B. Streptococci were significantly associated with abortion occurrence. Conclusion: To exclude out chronic infections, all RSA patients should be evaluated according on their personal infection risk, which involves a thorough history as well as physical and laboratory examinations. Despite the fact that many RSA patients are healthy, monogamous, and have a minimal risk of STDs, they should be checked. During the first trimester, vaginal infection may be a risk factor for spontaneous abortion.

Maternal and fetal risk factors for stillbirth in Otjozondjupa Region, Namibia: a case-control study.

stillbirth is defined as a baby born with no signs of life. Globally, around 3.2 million stillbirths occur annually, of which, 98% are experienced in low and middle-income countries. Otjozondjupa Region topped the list of regions with high burden of stillbirth in Namibia in 2016. This study sought to elucidate risk factors for stillbirth. an unmatched 1:2 case-control study was conducted. A sample of 285, 95 cases and 190 controls were chosen using simple random sampling method. Bivariate and multivariate analyses were done to assess the risk factors of stillbirth. maternal medical and obstetric factors significantly associated with stillbirth are: premature delivery (aOR 0.13 95% CI 0.05, 0.33, P < 0.001), gestational age (aOR 0.04, 95% CI 0.00, 0.25, P < 0.001), high-risk pregnancy (aOR 3.59, 95% CI 1.35, 9.55, P = 0.01), duration of labor (aOR 4.04, 95% CI 1.56, 10.43, P = 0.003) and antenatal care (ANC) attendance (aOR 0.07, 95% CI 0.00, 0.79, P = 0.03). Only low birth weight (≤ 2500 g) was associated with stillbirth amongst fetal related factors (aOR 16.58, 95% CI 8.71, 31.55, P < 0.001). this study concludes that stillbirth in Otjozondjupa Region was mostly associated with maternal medical and obstetric factors. It also concluded that attending antenatal care in Otjozondjupa did not improve birth outcome.

Maternal, Fetal and Service-Related Risk Factors for Stillbirths During Conflict Situation, Yemen, 2015-2016

Background: Stillbirth is a silent traumatic canker, which is a major concern to individuals, health institutions countries worldwide and continues to be a major global problem responsible for nearly three million deaths each year. To estimate the stillbirth rate (SBR) and to identify the potential risk factors for stillbirth. Subjects and Method: A community-based prospective cohort study was undertaken between August 2015 and December 2016 in which 980 pregnant women in Sana’a city of Yemen were identified. A multi-stage cluster sampling was used to select participants from community households. The independent variables were socio-demographic, prenatal and past obstetric, special habit, birth and fetal. The dependent variable was stillbirth. The data collection of this study used a questionnaire. Binomial regression together with generalized linear models, were employed in this study. Results: The results identified that the stillbirth rate (SBR) was presently between 46.2 per 1000 and 45.2 per 1000 cases. The multivariable analysis identified teenage mothers aged &lt; 20 years, with their first childbirth, had a (aOR= 3.70; 95% CI= 1.76 to 7.76; p&lt;0.001) women with anemia (aOR = 2.23; 95% CI= 1.67 to 2.98; p&lt;0.001), smoking snuff (aOR = 4.27; 95% CI= 1.17 to 15.55; p= 0.028), prolonged labor (&gt; 24 hours) (aOR= 2.02; 95% CI= 1.38 to 2.96; p&lt; 0.001), prolonged rupture of membranes (≥ 24 hours) (aOR= 2.22; 95% CI= 1.66 to 2.98; p&lt;0.001), fetal malposition (aOR= 4.60; 95% CI= 2.97 to 7.12; p&lt;0.001), low birth weight (aOR= 14.90; 95% CI= 4.30 to 51.75; p&lt;0.001) and fetal gestational age (in weeks) (aOR = 5.60; 95% CI= 2.52 to 12.41; p&lt;0.001). These factors were associated with an increased risk of stillbirths. Conclusion: This study is encouraging pregnant women to deliver at health facilities, providing better management of obstetrical complications, proper antenatal care, and prompt referral services are essential for the reduction of stillbirths in Yemen. Keywords: stillbirth, risk factors, community-based study, cohort study, Sana’a city, Yemen Correspondence: Ahmed H. Al-Shahethi. National Center for Epidemiology and Diseases Surveillance, Ministry of Public Health and Population, Yemen. P.O. box: 299. Fax: +9671564720. Phone: +967771922712. Email: alshahethi71@yahoo.com, ahmedhamood71@gmail.com.

COVID-19 is not a causal risk for miscarriage: evidence from a Mendelian randomization study.

Coronavirus disease 2019 (COVID-19) has caused a global pandemic in the last three years. The lack of reliable evidence on the risk of miscarriage due to COVID-19 has become a concern for patients and obstetricians. We sought to identify rigorous evidence using two-sample Mendelian randomization (MR) analysis. Seven single-nucleotide polymorphisms (SNPs) associated with COVID-19 were used as instrumental variables to explore causality by two-sample MR. The summary data of genetic variants were obtained from the Genome Wide Association Study (GWAS) among European populations in the UK Biobank and EBI database. Inverse variance weighting (IVW) method was taken as the gold standard for MR results, and other methods were taken as auxiliary. We also performed sensitivity analysis to evaluate the robustness of MR. The MR analysis showed there was no clear causal association between COVID-19 and miscarriage in the genetic prediction [OR 0.9981 (95% CI, 0.9872-1.0091), p = 0.7336]. Sensitivity analysis suggested that the MR results were robust [horizontal pleiotropy (MR-Egger, intercept = 0.0001592; se = 0.0023; p = 0.9480)]. The evidence from MR does not support COVID-19 as a causal risk factor for miscarriage in European populations. The small probability of direct placental infection, as well as the inability to stratify the data may explain the results of MR. These findings can be informative for obstetricians when managing women in labor.

Risk Factors of Spontaneous Abortion

Spontaneous abortion is defined as a pregnancy loss at the gestational age of under 20 weeks or within the first trimester, which is usually marked by intravaginal bleeding and expulsion of conceptus through the cervix. In 20% of pregnancies, vaginal bleeding occurs prior to 20 weeks of gestational age, and 50% of these cases develop into spontaneous abortion. More than 80% of spontaneous abortion occurs before 12 weeks of gestational age. There are many factors contributing to the incidence of spontaneous abortion such as prior miscarriage and maternal age. Several chronic diseases are also known to trigger spontaneous abortion, such as diabetes and autoimmune diseases. Immediate postpartum conception and infections, such as cervicitis, vaginitis, HIV, syphilis and malaria are also common risk factors. In some cases, fetal chromosomal abnormalities may also cause spontaneous abortion. Environmental contaminants such as arsenic, lead, and organic solvents are thought to be factors that may induce spontaneous abortion.

Causes of death in stillbirth and quality of care—an example of a local audit

AbstractIntroductionNeonatal deaths have decreased steadily in Sweden since the 1960s, but the stillbirth rate has been stable at around 4 per 1000 births, for the last 40 years. Risk factors of stillbirth are well studied; however, the cause of death is unclear in many cases. The purpose of this study was to examine causes of death in stillbirth using a classification system. In addition, we aimed to assess substandard care factors and identify areas for quality improvement.Materials and MethodsWe performed a retrospective clinical audit of all stillbirths delivered between January 2006 and December 2019. We performed a detailed investigation of medical records and classified the causes of death according to ‘The Stockholm classification of stillbirth’. Unclear cases were discussed in a multidisciplinary local audit group. Substandard care factors were identified and classified as probable, possible, or unlikely, with respect to the cause of death.ResultsIn total, there were 64 cases of stillbirth. It was possible to determine a cause of death in 91% (95% confidence interval [CI]: 81.02–95.63) of the cases. The leading cause of death was intrauterine growth restriction (IUGR)/placental insufficiency (45%) (95% CI: 33.73–57.43), followed by infection (13%) (95% CI: 6.47–22.8) and placental abruption (9%) (95% CI: 4.37–18.98). Factors of substandard care were identified in 49% (95% CI: 37.06–61.4) of the cases, but in only 10% the substandard care factor had a probable association with the cause of death.ConclusionIntroducing a local audit group and using a validated classification system made it possible to find a cause of death in about 90% of the cases of stillbirth. Since IUGR/placental insufficiency is the leading cause of death, it is important to improve current strategies to identify pregnancies at risk for IUGR, antenatally. Our results suggest that there is a possibility to improve the quality of care in many areas, particularly regarding symphysis‐fundus measurements.Tweetable AbstractA validated classification system and local audits are valuable tools to determine the causes of IUFD. This enables directed preventive actions toward IUFD.

Does a short luteal phase correlate with an increased risk of miscarriage? A cohort study.

Miscarriage is defined as spontaneous loss of pregnancy prior to 20 weeks gestation. With an estimated risk of 15% of clinically confirmed pregnancies ending in miscarriage, it is the most common adverse event in pregnancy. Woman's age is the primary risk factor for miscarriage, while medical conditions, including hormonal abnormalities, are also associated. Progesterone is essential for maintaining pregnancy. A short luteal phase may reflect inadequate levels of progesterone production, but it is unclear whether a short luteal phase correlates with an increase in the risk of miscarriage. Using a cohort study design, we conducted a secondary data analysis from four cohorts of couples who used a standardized protocol to track biomarkers of the female cycles. A short luteal phase was defined as less than 10days, with < 11, < 9, and < 8days as alternate definitions in sensitivity analyses. We included women who experienced a pregnancy with a known outcome, identified the length of the luteal phase in up to 3 cycles prior to conception and assessed the relationship with miscarriage using a modified Poisson regression analysis, adjusting for demographic characteristics, smoking, alcohol use and previous pregnancy history. In our sample of 252 women; the overall miscarriage rate was 18.7%. The adjusted incident risk ratio of miscarriage in women who had at least one short luteal phase < 10 days, compared to those who had none, was 1.01 (95% CI: 0.57, 1.80) Similar null risk was found when assessing alternative lengths of short luteal phase. Women who had short luteal phases < 10 days in all 3 cycles prior to the conception cycle had an incident risk ratio of 2.14 (95% CI: 0.7, 6.55). Our study found that a short luteal phase in the three cycles prior to conception was not associated with higher rates of miscarriage in an international cohort of women tracking their cycles, but our sample size was limited. Further research to determine if short luteal phases or luteal phase deficiency is associated with early pregnancy losses among preconception cohorts with daily tracking of cycle parameters, in addition to progesterone and human chorionic gonadotropin levels, is warranted. Additionally, future studies should include women with recurrent short luteal phases as a more likely risk factor than isolated short luteal phases.

Stillbirth rates and its spatial patterns in India: an exploration of HMIS data

High prevalence of stillbirths is a significant concern for the health system of India. This necessitates a closer scrutiny of the prevalence, spatial pattern and the risk factors of stillbirth at both national and local level. We analysed stillbirth data of three financial years (April 2017-March 2020) from Health Management Information System (HMIS) of India which provides majorly public facility level data for stillbirths up to the district level on a monthly basis. National and state level prevalence of stillbirth rate (SBR) were estimated. Spatial patterns of SBR at district level was identified using local indicator of spatial association (LISA). Risk factors of stillbirths were studied by triangulation of HMIS and National Family Health Survey (NFHS-4) data using bivariate LISA. National average of SBR in 2017-18, 2018-2019 and 2019-2020 are 13.4 [4.2-24.2], 13.1 [4.2-22.2] and 12.4 [3.7-22.5] respectively. Districts of Odisha, Madhya Pradesh, Rajasthan and Chhattisgarh (OMRC) form a contiguous east-west belt of high SBR. Body mass index (BMI) of the mother, antenatal care (ANC), maternal anemia, iron-folic acid (IFA) supplementation and institutional delivery show significant spatial autocorrelation with SBR. Maternal and child health programme delivery should prioritise targeted intervention in the hotspot clusters of high SBR, considering the locally significant determinants. The findings show inter alia, the need to focus on ANC to reduce stillbirth in India. The study is not funded.

Testing the acceptability of stillbirth awareness messages in an SMS program for fathers.

To raise expectant fathers' awareness of risk factors for stillbirth. A set of brief text messages was developed addressing recognised risk factors for stillbirth: avoidance of maternal cigarette smoking, maternal going to sleep on side messaging, awareness of the importance of noticing and reporting changes in foetal movement and fathers' involvement in shared decision making for timing of birth. Eight messages were inserted into the SMS4dads pilot program being conducted by NSW Health. Feedback on the messages was requested. Participants rated the quality of the messages on a three-point Likert scale and provided comments. Overall, 2528 messages were sent to 626 fathers' mobile phones, 45% of fathers replied with 666 ratings and 115 comments evaluating the texts. The quantitative ratings indicated substantial overall approval of the messages. Within the coding category "Evaluation of Message Content," three themes described fathers' reactions and feelings about the smoking, movement, side sleeping and birth timing messages: "important-good information," "not appropriate/anxiety provoking" and "not relevant-obvious." Three themes reflecting the attributes of the messages within the "Service Quality" category were "need more information," "complements public health" and "child voice fit." Results indicate that the messages are an acceptable way to provide information and suggested actions addressing stillbirth risk factors to fathers-to-be. SO WHAT?: Fathers' awareness of the risk factors for stillbirth can assist mothers to take appropriate actions for a healthy birth. Information on risk factors can be provided to fathers via a father-focused text messaging service.