Twin Gestation With Spontaneous Reduction To Singleton.

Twin gestations are at increased risk of single intrauterine fetal death. A first-trimester loss is a common complication in twin gestations. The rate of co-twin morbidity and mortality is higher when a single demise occurs in the second and third trimesters. Monochorionicity strongly influences the prognosis for the surviving co-twin. Fetal ultrasound combined with MRI may be able to help predict neurological injury to the surviving co-twin. The rate of co-twin demise decreases with advancing gestation. After single intrauterine fetal demise, monochorionic gestations should be delivered by 34 weeks and dichorionic by 36 to 37 weeks gestation.

First Nations populations' perceptions, knowledge, attitudes, beliefs, and myths about prevention and bereavement in stillbirth: a mixed methods systematic review protocol.

OBJECTIVE: The objective of this review is to investigate First Nations populations' perceptions, knowledge, attitudes, beliefs, and myths about stillbirth. INTRODUCTION: First Nations populations experience disproportionate rates of stillbirth compared with non-First Nations populations. There has been a surge of interventions aimed at reducing stillbirth and providing better bereavement care, but these are not necessarily appropriate for First Nations populations. As a first step toward developing appropriate interventions for these populations, this review will examine current perceptions, knowledge, attitudes, beliefs, and myths about stillbirth held by First Nations people from the United States, Canada, Aotearoa/New Zealand, and Australia. INCLUSION CRITERIA: The review will consider studies that include individuals of any age (bereaved or non-bereaved) who identify as belonging to First Nations populations. Eligible studies will include the perceptions, knowledge, attitudes, beliefs, and myths about stillbirth among First Nations populations. METHODS: This review will follow the JBI methodology for convergent mixed methods systematic reviews. The review is supported by an advisory panel of Aboriginal elders, lived-experience stillbirth researchers, Aboriginal researchers, and clinicians. PubMed, MEDLINE (Ovid), CINAHL (EBSCOhost), Embase (Ovid), Emcare (Ovid), PsycINFO (EBSCOhost), Indigenous Health InfoNet, Trove, Informit, and ProQuest Dissertations and Theses will be searched for relevant information. Titles and abstracts of potential studies will be screened and examined for eligibility. After critical appraisal, quantitative and qualitative data will be extracted from included studies, with the former "qualitized" and the data undergoing a convergent integrated approach. REVIEW REGISTRATION: PROSPERO CRD42023379627.

Cervical Pessary for Prevention of Preterm Birth in Individuals With a Short Cervix: The TOPS Randomized Clinical Trial.

Importance: A short cervix as assessed by transvaginal ultrasound is an established risk factor for preterm birth. Study findings for a cervical pessary to prevent preterm delivery in singleton pregnancies with transvaginal ultrasound evidence of a short cervix have been conflicting. Objective: To determine if cervical pessary placement decreases the risk of preterm birth or fetal death prior to 37 weeks among individuals with a short cervix. Design, Setting, and Participants: We performed a multicenter, randomized, unmasked trial comparing a cervical pessary vs usual care from February 2017 through November 5, 2021, at 12 centers in the US. Study participants were nonlaboring individuals with a singleton pregnancy and a transvaginal ultrasound cervical length of 20 mm or less at gestations of 16 weeks 0 days through 23 weeks 6 days. Individuals with a prior spontaneous preterm birth were excluded. Interventions: Participants were randomized 1:1 to receive either a cervical pessary placed by a trained clinician (n = 280) or usual care (n = 264). Use of vaginal progesterone was at the discretion of treating clinicians. Main Outcome and Measures: The primary outcome was delivery or fetal death prior to 37 weeks. Results: A total of 544 participants (64%) of a planned sample size of 850 were enrolled in the study (mean age, 29.5 years [SD, 6 years]). Following the third interim analysis, study recruitment was stopped due to concern for fetal or neonatal/infant death as well as for futility. Baseline characteristics were balanced between participants randomized to pessary and those randomized to usual care; 98.9% received vaginal progesterone. In an as-randomized analysis, the primary outcome occurred in 127 participants (45.5%) randomized to pessary and 127 (45.6%) randomized to usual care (relative risk, 1.00; 95% CI, 0.83-1.20). Fetal or neonatal/infant death occurred in 13.3% of those randomized to receive a pessary and in 6.8% of those randomized to receive usual care (relative risk, 1.94; 95% CI, 1.13-3.32). Conclusions and Relevance: Cervical pessary in nonlaboring individuals with a singleton gestation and with a cervical length of 20 mm or less did not decrease the risk of preterm birth and was associated with a higher rate of fetal or neonatal/infant mortality. Trial Registration: ClinicalTrials.gov Identifier: NCT02901626.

The prevalence and perinatal repercussions of preeclampsia after the implementation of a prophylaxis protocol with aspirin.

OBJECTIVES: To evaluate the prevalence and perinatal repercussions of preeclampsia (PE) after the implementation of a prophylaxis protocol with aspirin in singleton pregnancy at Maternity School of Federal University of Rio de Janeiro, Rio de Janeiro, Brazil (2015-2106). METHODOLOGY: PE prevalence according to gestational age (GA) and the prevalence ratio (PR) between PE and prematurity, small for gestational age (SGA), and fetal death were calculated in patients assisted during 2015 and 2016. RESULTS: PE occurred in 373(10.75%) of 3468 investigated cases, where PE < 37 weeks was of 2.79% and PE greater than 37 weeks was of 7.95%. A total of 413 (11.9%) prematurity cases, 320 SGA (9.22%), and 50 fetal deaths (1.44%) occurred. In the PE group, 97 premature newborns (PR 0.90) and 51 SGA (PR 1.16) were born, and two fetal deaths occurred (PR 7.46). Concerning PE < 37 weeks, 27 SGA cases (PR 1.42) and two fetal deaths (PR 2.62) were observed. Regarding PE greater than 37 weeks, 24 SGA (PR 1.09) were born, and no fetal deaths were observed. Our findings were compared to previously published results. CONCLUSIONS: PE was significantly associated with SGA newborns, especially premature PE. Prescribing aspirin for PE prophylaxis based only on clinical risk factors in a real-life scenario does not appear to be effective but resulted in a PE screening and prophylaxis protocol review and update at ME/UFRJ.

Clinical practice guidelines for the antenatal management of dichorionic diamniotic twin pregnancies: a systematic review.

OBJECTIVE: This review aimed to identify guidelines with recommendations applicable to the antenatal management of dichorionic diamniotic twin pregnancies within high-income countries, appraise their methodological quality, and discuss the similarities and variability across guidelines. METHOD: A systematic literature review of electronic databases was performed. Manual searches of guideline repositories and websites of professional organisations were performed to identify additional guidelines. The protocol for this systematic review was registered on PROSPERO (CRD42021248586, 25 June 2021). AGREE II and AGREE-REX tools were applied to assess the quality of eligible guidelines. A narrative and thematic synthesis described and compared the guidelines and their recommendations. RESULTS: Twenty-four guidelines were included, from which 483 recommendations were identified across 4 international organisations and 12 countries. Guidelines addressed eight themes and recommendations were classified accordingly: chorionicity and dating (103 recommendations), fetal growth (105 recommendations), termination of pregnancy (12 recommendations), fetal death (13 recommendations), fetal anomalies (65 recommendations), antenatal care (65 recommendations), preterm labour (56 recommendations) and birth (54 recommendations). Guidelines showed significant variability in recommendations, with conflicting recommendations regarding non-invasive preterm testing, definitions surrounding selective fetal growth restriction, screening for preterm labour and the timing of birth. Guidelines lacked a focus on standard antenatal management of DCDA twins, management of discordant fetal anomaly and single fetal demise. CONCLUSIONS: Specific guidance for dichorionic diamniotic twins is overall indistinct and access to guidance regarding the antenatal management of these pregnancies is currently difficult. Management of discordant fetal anomaly or single fetal demise needs greater consideration.

Molecular Mechanisms Underlying Twin-to-Twin Transfusion Syndrome.

Twin-to-twin transfusion syndrome is a unique disease and a serious complication occurring in 10-15% of monochorionic multiple pregnancies with various placental complications, including hypoxia, anemia, increased oxidative stress, and ischemia-reperfusion injury. Fetoscopic laser photocoagulation, a minimally invasive surgical procedure, seals the placental vascular anastomoses between twins and dramatically improves the survival rates in twin-to-twin transfusion syndrome. However, fetal demise still occurs, suggesting the presence of causes other than placental vascular anastomoses. Placental insufficiency is considered as the main cause of fetal demise in such cases; however, little is known about its underlying molecular mechanisms. Indeed, the further association of the pathogenic mechanisms involved in twin-to-twin transfusion syndrome placenta with several molecules and pathways, such as vascular endothelial growth factor and the renin-angiotensin system, makes it difficult to understand the underlying pathological conditions. Currently, there are no effective strategies focusing on these mechanisms in clinical practice. Certain types of cell death due to oxidative stress might be occurring in the placenta, and elucidation of the molecular mechanism underlying this cell death can help manage and prevent it. This review reports on the molecular mechanisms underlying the development of twin-to-twin transfusion syndrome for effective management and prevention of fetal demise after fetoscopic laser photocoagulation.

Hipotiroidismo subclínico y pérdida de embarazo: una revisión de la literatura / Subclinical Hypothyroidism and Pregnancy Loss: A Literature Review

Existe una alta prevalencia de hipotiroidismo subclínico (SCH) en el embarazo. Está vinculado a una importante morbilidad y mortalidad materna y fetal. Los efectos de SCH sobre el embarazo incluyen mayores riesgos de hipertensión gestacional y ruptura prematura de membranas (PROM). Sus fetos y bebés tenían más probabilidades de sufrir de bajo peso al nacer (LBW) y retraso del crecimiento intrauterino (IUGR). El riesgo de aborto espontáneo se informa alto en varios estudios para SCH no tratado. SCH se asocia directamente con una mayor presencia de anti -cuerpos anti TPO en suero materno. La detección temprana y el tratamiento de SCH han sido testigos de mejores resultados en términos de resultado del embarazo. Esta revisión se centra para establecer la relación de una mayor prevalencia de SCH en los países en desarrollo, así como su asociación con el aumento de los cuerpos anti TPO en suero materna y sacar una conclusión que puede ayudar a reducir las razones y proporcionar una solución. Este estudio concluyó que SCH es más frecuente en los países en desarrollo, ya sea debido a la deficiencia de yodo, una disminución de la conciencia sobre este problema o menos acceso a las instalaciones médicas. Por lo tanto, se sugiere que las hembras con antecedentes de partos prematuros, IUGR anteriores o abortos involuntarios deben someterse a una detección de hipotiroidismo subclínico y niveles de anticuerpos anti TPO durante sus visitas prenatales

There is a high prevalence of subclinical hypothyroidism (SCH) in pregnancy. It is linked to significant maternal and fetal morbidity and mortality. SCH's effects on pregnancy include increased risks of gestational hypertension and premature rupture of membranes (PROM). Their fetuses and infants had been more likely to suffer from low birth weight (LBW) and intrauterine growth retardation (IUGR). The risk of miscarriage is reported high in various studies for untreated SCH. SCH is directly associated with increased presence of anti TPO anti bodies in maternal serum. Early detection and treatment of SCH have witnessed better results in terms of pregnancy outcome. This review focuses to establish the relationship of increased prevalence of SCH in the developing countries as well as its association with increased anti TPO anti bodies in maternal serum and draw a conclusion which can help narrow down the reasons and provide solution. This study concluded that SCH is more prevalent in developing countries, either due to iodine deficiency, decreased awareness about this problem or less access to medical facilities. Therefore, it is suggested that females with history of preterm deliveries, previous IUGRs, or miscarriages should undergo screening for subclinical hypothyroidism and Anti TPO antibody levels during their antenatal visits.

Universal gestational diabetes screening and antepartum stillbirth rates in Austria-A population-based study.

INTRODUCTION: Occult or untreated gestational diabetes (GDM) is a well-known risk factor for adverse perinatal outcomes and may contribute to antepartum stillbirth. We assessed the impact of screening for GDM on the rate of antepartum stillbirths in non-anomalous pregnancies by conducting a population-based study in 974 889 women in Austria. MATERIAL AND METHODS: Our database was derived from the Austrian Birth Registry. Inclusion criteria were singleton live births and antepartum stillbirths ≥24+0 gestational weeks, excluding fetal congenital malformations, terminations of pregnancy and women with pre-existing type 1 or 2 diabetes. Main outcome measures were (a) overall stillbirth rates and (b) stillbirth rates in women at high risk of GDM (i.e., women with a body mass index ≥30 kg/m2 , history of previous intrauterine fetal death, GDM, previous macrosomic offspring) before (2008-2010, "phase I") and after (2011-2019, "phase II") the national implementation of universal GDM screening with a 75 g oral glucose tolerance test in Austrian pregnant women by 2011. RESULTS: In total, 940 373 pregnancies were included between 2008 and 2019, of which 2579 resulted in intrauterine fetal deaths at 33.51 ± 5.10 gestational weeks. After implementation of the GDM screening, a statistically significant reduction in antepartum stillbirth rates among non-anomalous singletons was observed only in women at high risk for GDM (4.10‰ [95% confidence interval (CI) 3.09-5.43] in phase I vs. 2.96‰ [95% CI 2.57-3.41] in phase II; p = 0.043) but not in the general population (2.76‰ [95% CI 2.55-2.99] in phase I vs. 2.74‰ [95% CI 2.62-2.86] in phase II; p = 0.845). The number needed to screen with the oral glucose tolerance test to subsequently prevent one case of (non-anomalous) intrauterine fetal death was 880 in the high-risk and 40 000 in the general population. CONCLUSIONS: The implementation of a universal GDM screening program in Austria in 2011 has not led to any significant reduction in antenatal stillbirths among non-anomalous singletons in the general population. More international data are needed to strengthen our findings.

A Trial of Hyperimmune Globulin to Prevent Congenital Cytomegalovirus Infection.

BACKGROUND: Primary cytomegalovirus (CMV) infection during pregnancy carries a risk of congenital infection and possible severe sequelae. There is no established intervention for preventing congenital CMV infection. METHODS: In this multicenter, double-blind trial, pregnant women with primary CMV infection diagnosed before 24 weeks' gestation were randomly assigned to receive a monthly infusion of CMV hyperimmune globulin (at a dose of 100 mg per kilogram of body weight) or matching placebo until delivery. The primary outcome was a composite of congenital CMV infection or fetal or neonatal death if CMV testing of the fetus or neonate was not performed. RESULTS: From 2012 to 2018, a total of 206,082 pregnant women were screened for primary CMV infection before 23 weeks of gestation; of the 712 participants (0.35%) who tested positive, 399 (56%) underwent randomization. The trial was stopped early for futility. Data on the primary outcome were available for 394 participants; a primary outcome event occurred in the fetus or neonate of 46 of 203 women (22.7%) in the group that received hyperimmune globulin and of 37 of 191 women (19.4%) in the placebo group (relative risk, 1.17; 95% confidence interval [CI] 0.80 to 1.72; P = 0.42). Death occurred in 4.9% of fetuses or neonates in the hyperimmune globulin group and in 2.6% in the placebo group (relative risk, 1.88; 95% CI, 0.66 to 5.41), preterm birth occurred in 12.2% and 8.3%, respectively (relative risk, 1.47; 95% CI, 0.81 to 2.67), and birth weight below the 5th percentile occurred in 10.3% and 5.4% (relative risk, 1.92; 95% CI, 0.92 to 3.99). One participant in the hyperimmune globulin group had a severe allergic reaction to the first infusion. Participants who received hyperimmune globulin had a higher incidence of headaches and shaking chills while receiving infusions than participants who received placebo. CONCLUSIONS: Among pregnant women, administration of CMV hyperimmune globulin starting before 24 weeks' gestation did not result in a lower incidence of a composite of congenital CMV infection or perinatal death than placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Center for Advancing Translational Sciences; ClinicalTrials.gov number, NCT01376778.).

Spatial patterns of fetal mortality: scenario before and after the implementation of surveillance / Padrões espaciais da mortalidade fetal: cenário anterior e posterior à implantação da vigilância

Abstract Objectives: to analyze the spatial distribution of fetal deaths before and after implementation of surveillance for this event in the city of Recife, in the Northeast Region of Brazil. Methods: an ecological study whose spatial analysis unit was the 94 neighborhoods. The gross fetal mortality rates were calculated and the local empirical Bayesian estimator was adopted to smooth out random fluctuations of such rates. To analyze the spatial autocorrelation, the Global Moran's Index was used, and spatial clusters were located by the Local Moran's Index. Results: during the period before implementation of death surveillance, 1,356 fetal deaths were reported, a coefficient of 9.9 deaths per thousand births. During the second period, 1,325 fetal deaths occurred, a coefficient of 9.6 deaths per thousand births. The Global Moran's Indexes (I) were I=0.6 and I=0.4 for the first and second periods, respectively, with statistical significance (p<0.05). For both periods analyzed, spatial clusters of high-risk neighborhoods were identified in the northern and eastern regions of the city. Conclusion: the spatial analysis indicated areas that persist as priorities for planning surveillance and health assistance actions to reduce fetal mortality.

Resumo Objetivos: analisar a distribuição espacial dos óbitos fetais, antes e após a implantação da vigilância deste evento, na cidade do Recife, Nordeste do Brasil. Métodos: estudo ecológico utilizando os 94 bairros existentes como unidade de análise espacial. Foram calculados os coeficientes de mortalidade fetal brutos e empregado o estimador bayesiano empírico local para a suavização de flutuações aleatórias desses coeficientes. A autocorrelação espacial foi analisada com a utilização do Índice de Moran Global e agregados espaciais foram identificados pelo Moran Local. Resultados: foram registrados 1.356 óbitos fetais (coeficiente de mortalidade de 9,9 óbitos por mil nascimentos) e 1.325 óbitos fetais (coeficiente de 9,6 óbitos por mil nascimentos), nos períodos anterior e posterior à implantação da vigilância do óbito, respectivamente. Houve diferença estatisticamente significante (p<0,05) entre os índices de Moran Global (I) dos períodos anterior (I=0,6) e posterior (I=0,4) à implantação da vigilância. Identificaram-se agregados espaciais nos bairros das regiões Norte e Leste da cidade, como maior risco de mortalidade fetal. Conclusão: a análise espacial apontou áreas que persistem como prioritárias para o planejamento de ações de vigilância e assistência à saúde para a redução da mortalidade fetal.

Preventable stillbirths in India and Pakistan: a prospective, observational study.

OBJECTIVE: Stillbirths occur 10-20 times more frequently in low-income settings compared with high-income settings. We created a methodology to define the proportion of stillbirths that are potentially preventable in low-income settings and applied it to stillbirths in sites in India and Pakistan. DESIGN: Prospective observational study. SETTING: Three maternity hospitals in Davangere, India and a large public hospital in Karachi, Pakistan. POPULATION: All cases of stillbirth at ≥20 weeks of gestation occurring from July 2018 to February 2020 were screened for participation; 872 stillbirths were included in this analysis. METHODS: We prospectively defined the conditions and gestational ages that defined the stillbirth cases considered potentially preventable. Informed consent was sought from the parent(s) once the stillbirth was identified, either before or soon after delivery. All information available, including obstetric and medical history, clinical course, fetal heart sounds on admission, the presence of maceration as well as examination of the stillbirth after delivery, histology, and polymerase chain reaction for infectious pathogens of the placenta and various fetal tissues, was used to assess whether a stillbirth was potentially preventable. MAIN OUTCOME MEASURES: Whether a stillbirth was determined to be potentially preventable and the criteria for assignment to those categories. RESULTS: Of 984 enrolled, 872 stillbirths at ≥20 weeks of gestation met the inclusion criteria and were included; of these, 55.5% were deemed to be potentially preventable. Of the 649 stillbirths at ≥28 weeks of gestation and ≥1000 g birthweight, 73.5% were considered potentially preventable. The most common conditions associated with a potentially preventable stillbirth at ≥28 weeks of gestation and ≥1000 g birthweight were small for gestational age (SGA) (52.8%), maternal hypertension (50.2%), antepartum haemorrhage (31.4%) and death that occurred after hospital admission (15.7%). CONCLUSIONS: Most stillbirths in these sites were deemed preventable and were often associated with maternal hypertension, antepartum haemorrhage, SGA and intrapartum demise. TWEETABLE ABSTRACT: Most stillbirths are preventable by better care for women with hypertension, growth restriction and antepartum haemorrhage.

Antepartum Fetal Surveillance: ACOG Practice Bulletin, Number 229.

The goal of antepartum fetal surveillance is to reduce the risk of stillbirth. Antepartum fetal surveillance techniques based on assessment of fetal heart rate (FHR) patterns have been in clinical use for almost four decades and are used along with real-time ultrasonography and umbilical artery Doppler velocimetry to evaluate fetal well-being. Antepartum fetal surveillance techniques are routinely used to assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions (eg, diabetes mellitus) as well as those in which complications have developed (eg, fetal growth restriction). The purpose of this document is to provide a review of the current indications for and techniques of antepartum fetal surveillance and outline management guidelines for antepartum fetal surveillance that are consistent with the best scientific evidence.

Obesity in Pregnancy: ACOG Practice Bulletin, Number 230.

Obstetrician-gynecologists are the leading experts in the health care of women, and obesity is the most common medical condition in women of reproductive age. Obesity in women is such a common condition that the implications relative to pregnancy often are unrecognized, overlooked, or ignored because of the lack of specific evidence-based treatment options. The management of obesity requires long-term approaches ranging from population-based public health and economic initiatives to individual nutritional, behavioral, or surgical interventions. Therefore, an understanding of the management of obesity during pregnancy is essential, and management should begin before pregnancy and continue through the postpartum period. Although the care of the obese woman during pregnancy requires the involvement of the obstetrician or other obstetric care professional, additional health care professionals, such as nutritionists, can offer specific expertise related to management depending on the comfort level of the obstetric care professional. The purpose of this Practice Bulletin is to offer an integrated approach to the management of obesity in women of reproductive age who are planning a pregnancy.

Indications for Outpatient Antenatal Fetal Surveillance: ACOG Committee Opinion, Number 828.

ABSTRACT: The purpose of this Committee Opinion is to offer guidance about indications for and timing and frequency of antenatal fetal surveillance in the outpatient setting. Antenatal fetal surveillance is performed to reduce the risk of stillbirth. However, because the pathway that results in increased risk of stillbirth for a given condition may not be known and antenatal fetal surveillance has not been shown to improve perinatal outcomes for all conditions associated with stillbirth, it is challenging to create a prescriptive list of all indications for which antenatal fetal surveillance should be considered. This Committee Opinion provides guidance on and suggests surveillance for conditions for which stillbirth is reported to occur more frequently than 0.8 per 1,000 (the false-negative rate of a biophysical profile) and which are associated with a relative risk or odds ratio for stillbirth of more than 2.0 compared with pregnancies without the condition. Table 1 presents suggestions for the timing and frequency of testing for specific conditions. As with all testing and interventions, shared decision making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance for individuals with pregnancies at high risk for stillbirth or with multiple comorbidities that increase the risk of stillbirth. It is important to emphasize that the guidance offered in this Committee Opinion should be construed only as suggestions; this guidance should not be construed as mandates or as all encompassing. Ultimately, individualization about if and when to offer antenatal fetal surveillance is advised.

Risk of recurrent stillbirth: a cohort study.

OBJECTIVES: To evaluate the recurrence risk of stillbirth. DESIGN: Retrospective cohort study. SETTING AND POPULATION: All births 1992-2017, Alberta, Canada. METHODS: Retrospective cohort study. MAIN OUTCOME MEASURES: Stillbirth was defined as the death in utero of a fetus with gestational age ≥20 weeks or weighing ≥500 g. Stillbirths were further subdivided into those occurring before labour and those in labour. RESULTS: We identified 744 897 births from 308 478 women. Of these, 3698 women experienced a stillbirth and, of these, 97.7%, experienced only one. For women with a small-for-gestational- age stillbirth in the first birth, their risk of a subsequent antepartum stillbirth was increased substantially: 4.09%, relative risk (RR) 10.39, 95% CI 5.81-18.59. For women with a first birth appropriate-for-gestational-age stillbirth with no risk factors such as pregnancy induced hypertension, the risk with pre-existing diabetes mellitus or hypertension was also increased but to a much lesser degree (RR 2.46, 95% CI 1.23-4.91). For women who had experienced a first birth intrapartum stillbirth, the risk of another intrapartum stillbirth was very high (3.59%, RR 36.50, 95% CI 20.17-66.05). Most of these births also occurred prior to 24 weeks' gestation: 83% (10/12). CONCLUSIONS: The risk of recurrent antepartum stillbirth is low. The increase in risk in instances where the antepartum stillbirth was not growth-restricted is not clinically meaningful. Given the very low risk in any given gestational week, fetal surveillance is unlikely to be effective and may lead to unnecessary interventions. Intrapartum stillbirth has a very high recurrence risk but may not be preventable. TWEETABLE ABSTRACT: Stillbirth recurrence is rare.

Potentially preventable antepartum stillbirths in a high-resource setting: a prospective audit-based study.

OBJECTIVES: The primary objective was the identification of sub-standard care in antepartum stillbirths in Emilia-Romagna Region (Italy), hence the number of potentially preventable cases. Secondly, we seek to evaluate any association between inadequate care and either risk factors for stillbirth or causes of death. STUDY DESIGN: This study was based on prospectively-collected data in an institutional stillbirth audit project, involving all 29 hospital with a maternity unit in Emilia-Romagna Region. For each stillbirth occurred in the area from 2014 to the first semester of 2019 the same diagnostic workup was performed and a clinical record with data about mother and stillborn was completed. Every case was discussed in a multidisciplinary local audit to assess both the cause of death and the quality of care. Two aspects of care quality were evaluated: clinical management and women's access to care. Data were then reviewed by the Regional Audit Group. RESULTS: Elements of inadequate care were identified in 56 out of 524 (10.7 %) fetal deaths. Non-Italian women and pregnancies with fetal growth restriction had double the risk of having received inadequate care during pregnancy, compared to Italian women (aOR 2.0, 95 % CI 1.1-3.6) and a normally developing fetus (aOR 2.0, 95 % CI 1.1-4.1), respectively. Women whose stillbirth was caused by maternal disorders were at higher risk for inadequate care compared to women who had stillbirth explained by other cause (aOR 5.89, 95 %CI 2.2-15.4). Sub-optimal clinical management and barriers to access to care were observed to equal extents. Inappropriate ultrasound monitoring was the most frequent suboptimal care element. CONCLUSIONS: About one out of ten stillbirths was potentially preventable. Interventions to reduce stillbirth occurrence in our high-resource setting should focus on appropriate diagnosis and management of maternal disorders and fetal growth restriction, as well as improving access to antenatal care.

Implementing a modified World Health Organization safe childbirth checklist in health centers of Ethiopia: a pre and post intervention study.

BACKGROUND: Childbirth is a complex process, and checklists are useful tools to remember steps of such complex processes. The World Health Organization safe childbirth checklist is a tool used to improve the quality of care provided to women giving birth. The checklist was modified by Ministry of Health and was introduced to health centers in Ethiopia by the USAID Transform: Primary Health Care Activity. METHODS: A pre and post intervention study design with prospective data collection was employed. The availability of essential childbirth supplies and adherence of health care providers to essential birth practices were compared for the pre and post intervention periods. RESULTS: The pre and post intervention assessments were conducted in 247 and 187 health centers respectively. A statistically significant improvement from 63.6% pre intervention to 83.5% post intervention was observed in the availability of essential childbirth supplies, t (389.7) = - 7.1, p = 0.000. Improvements in adherence of health care providers to essential birth practices were observed with the highest being at pause point three (26.2%, t (306.3) = - 10.6, p = 0.000) followed by pause point four (21.1%, t (282.5) = - 8.0, p = 0.000), and pause point two (18.2%, t (310.8) = - 9.7, p = 0.000). The least and statistically non-significant improvement was observed at pause point one (3.3%, t (432.0) = - 1.5, p = 0.131). CONCLUSION: Improvement in availability of essential childbirth supplies and adherence of health care providers towards essential birth practices was observed after introduction of a modified World Health Organization safe childbirth checklist. Scale up of the use of the checklist is recommended.

Understanding staff views and experiences of a clinical practice change to reduce stillbirth in South Asian women: A cross-sectional survey.

BACKGROUND: In July 2017, Victoria's largest maternity service implemented a new clinical practice guideline to reduce the rates of term stillbirth in women of South Asian background. AIM: To capture the views and experiences of clinical staff following the implementation of the new clinical guideline. METHODS: Cross sectional survey of clinical staff providing maternity care in August 2018, 12 months post implementation. Staff were asked to provide their agreement with ten statements assessing: perceived need for the guideline, implementation processes, guideline clarity, and clinical application. Open-ended questions provided opportunities to express concerns and offer suggestions for improvement. The frequency of responses to each question were tabulated. Open ended responses were grouped together to identify themes. FINDINGS: A total of 120 staff completed the survey, most (n=89, 74%) of whom were midwives. Most staff thought the rationale (n=95, 79%), the criteria for whom they applied (83%, n=99), and the procedures and instructions within the guideline were clear (74%, n=89). Staff reported an increase in workload (72%, n=86) and expressed concerns related to rationale and evaluation of the guidelines, lack of education for both staff and pregnant South Asian women, increased workload and insufficient resources, patient safety and access to care. Challenges relating to shared decision making and communicating with women whose first language is not English were also identified. DISCUSSION: This study has identified key barriers to and opportunities for improving implementation and highlighted additional challenges relating to new clinical guidelines which focus on culturally and linguistically diverse women.

Prompt evaluation and treatment of third-trimester bleeding.

ABSTRACT: Third-trimester bleeding is an obstetric emergency and is associated with significant maternal and fetal morbidity and mortality. The two most common causes for third-trimester bleeding are placental abruption and placenta previa, which account for about half of all cases. Clinicians should have a thorough understanding of the risk factors, clinical presentation, and appropriate management of these conditions. Timely management is necessary for the survival of mother and fetus and to reduce the incidence of neonatal complications.

Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews.

BACKGROUND: Stillbirth is generally defined as a death prior to birth at or after 22 weeks' gestation. It remains a major public health concern globally. Antenatal interventions may reduce stillbirths and improve maternal and neonatal outcomes in settings with high rates of stillbirth. There are several key antenatal strategies that aim to prevent stillbirth including nutrition, and prevention and management of infections. OBJECTIVES: To summarise the evidence from Cochrane systematic reviews on the effects of antenatal interventions for preventing stillbirth for low risk or unselected populations of women. METHODS: We collaborated with Cochrane Pregnancy and Childbirth's Information Specialist to identify all their published reviews that specified or reported stillbirth; and we searched the Cochrane Database of Systematic Reviews (search date: 29 Feburary 2020) to identify reviews published within other Cochrane groups. The primary outcome measure was stillbirth but in the absence of stillbirth data, we used perinatal mortality (both stillbirth and death in the first week of life), fetal loss or fetal death as outcomes. Two review authors independently evaluated reviews for inclusion, extracted data and assessed quality of evidence using AMSTAR (A Measurement Tool to Assess Reviews) and GRADE tools. We assigned interventions to categories with graphic icons to classify the effectiveness of interventions as: clear evidence of benefit or harm; clear evidence of no effect or equivalence; possible benefit or harm; or unknown benefit or harm or no effect or equivalence. MAIN RESULTS: We identified 43 Cochrane Reviews that included interventions in pregnant women with the potential for preventing stillbirth; all of the included reviews reported our primary outcome 'stillbirth' or in the absence of stillbirth, 'perinatal death' or 'fetal loss/fetal death'. AMSTAR quality was high in 40 reviews with scores ranging from 8 to 11 and moderate in three reviews with a score of 7. Nutrition interventions Clear evidence of benefit: balanced energy/protein supplementation versus no supplementation suggests a probable reduction in stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94, 5 randomised controlled trials (RCTs), 3408 women; moderate-certainty evidence). Clear evidence of no effect or equivalence for stillbirth or perinatal death: vitamin A alone versus placebo or no treatment; and multiple micronutrients with iron and folic acid versus iron with or without folic acid. Unknown benefit or harm or no effect or equivalence: for all other nutrition interventions examined the effects were uncertain. Prevention and management of infections Possible benefit for fetal loss or death: insecticide-treated anti-malarial nets versus no nets (RR 0.67, 95% CI 0.47 to 0.97, 4 RCTs; low-certainty). Unknown evidence of no effect or equivalence: drugs for preventing malaria (stillbirth RR 1.02, 95% CI 0.76 to 1.36, 5 RCTs, 7130 women, moderate certainty in women of all parity; perinatal death RR 1.24, 95% CI 0.94 to 1.63, 4 RCTs, 5216 women, moderate-certainty in women of all parity). Prevention, detection and management of other morbidities Clear evidence of benefit: the following interventions suggest a reduction: midwife-led models of care in settings where the midwife is the primary healthcare provider particularly for low-risk pregnant women (overall fetal loss/neonatal death reduction RR 0.84, 95% CI 0.71 to 0.99, 13 RCTs, 17,561 women; high-certainty), training versus not training traditional birth attendants in rural populations of low- and middle-income countries (stillbirth reduction odds ratio (OR) 0.69, 95% CI 0.57 to 0.83, 1 RCT, 18,699 women, moderate-certainty; perinatal death reduction OR 0.70, 95% CI 0.59 to 0.83, 1 RCT, 18,699 women, moderate-certainty). Clear evidence of harm: a reduced number of antenatal care visits probably results in an increase in perinatal death (RR 1.14 95% CI 1.00 to 1.31, 5 RCTs, 56,431 women; moderate-certainty evidence). Clear evidence of no effect or equivalence: there was evidence of no effect in the risk of stillbirth/fetal loss or perinatal death for the following interventions and comparisons: psychosocial interventions; and providing case notes to women. Possible benefit: community-based intervention packages (including community support groups/women's groups, community mobilisation and home visitation, or training traditional birth attendants who made home visits) may result in a reduction of stillbirth (RR 0.81, 95% CI 0.73 to 0.91, 15 RCTs, 201,181 women; low-certainty) and perinatal death (RR 0.78, 95% CI 0.70 to 0.86, 17 RCTs, 282,327 women; low-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. Screening and management of fetal growth and well-being Clear evidence of benefit: computerised antenatal cardiotocography for assessing infant's well-being in utero compared with traditional antenatal cardiotocography (perinatal mortality reduction RR 0.20, 95% CI 0.04 to 0.88, 2 RCTs, 469 women; moderate-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. AUTHORS' CONCLUSIONS: While most interventions were unable to demonstrate a clear effect in reducing stillbirth or perinatal death, several interventions suggested a clear benefit, such as balanced energy/protein supplements, midwife-led models of care, training versus not training traditional birth attendants, and antenatal cardiotocography. Possible benefits were also observed for insecticide-treated anti-malarial nets and community-based intervention packages, whereas a reduced number of antenatal care visits were shown to be harmful. However, there was variation in the effectiveness of interventions across different settings, indicating the need to carefully understand the context in which these interventions were tested. Further high-quality RCTs are needed to evaluate the effects of antenatal preventive interventions and which approaches are most effective to reduce the risk of stillbirth. Stillbirth (or fetal death), perinatal and neonatal death need to be reported separately in future RCTs of antenatal interventions to allow assessment of different interventions on these rare but important outcomes and they need to clearly define the target populations of women where the intervention is most likely to be of benefit. As the high burden of stillbirths occurs in low- and middle-income countries, further high-quality trials need to be conducted in these settings as a priority.