Risk factors for stillbirth at term: an Italian area-based, prospective cohort study.

BACKGROUND: Stillbirth at term has great emotional impact on both parents and professionals. In developed countries, efforts to identify risk factors are mandatory to plan area-specific prevention strategies. OBJECTIVE: The aim of the study was to identify independent risk factors that contribute to stillbirth at 37 weeks' gestation or later. STUDY DESIGN: This was an area-based, prospective cohort study on pregnancy at term with enrolled from 2014 to 2021 in Emilia-Romagna, a north Italian region. Data were retrieved from both birth certificates and the Stillbirth Surveillance system database. To identify independent risk factors, a multivariate analysis using logistic regression was performed. A descriptive analysis of the causes of stillbirth is also reported. RESULTS: In the observation period, 246,437 babies born at term (including 260 stillbirths, giving a rate of 1.06/1000) were considered. The risk factors independently associated with stillbirth were small for gestational age babies (odds ratio, 2.58; 95% confidence interval, 1.88-3.53), pregnancy achieved though fertility treatments (odds ratio, 2.01; 95% confidence interval, 1.15-3.51), and delayed access to pregnancy services (odds ratio, 1.56; 95% confidence interval, 1.10-2.22). In multipara, the presence of a previous stillbirth (odds ratio, 3.91; 95% confidence interval, 1.98-7.72) was also associated with an increased risk for recurrence. Early- rather than late-term was an additional risk factor. The most frequent causes of death were placental and cord disorders (61/260 and 56/260, respectively). However, 28.1% of cases remain unexplained. CONCLUSION: The risks for stillbirth at term are known early in pregnancy or could be identified through tailored antenatal management, allowing effective preventive strategies to reduce preventable cases.

Women's perception of fetal movements and perinatal outcomes: results of a prospective cohort study.

BACKGROUND: Active fetal movements (AFMs) are a sign of the well-being of the baby during pregnancy and suggests the integrity of the cardiovascular, musculoskeletal, and nervous systems of the fetus. The abnormal perception of AFMs is associated with an increased risk of adverse perinatal outcomes such as stillbirth (SB) and brain damage. Several definitions of " decreased fetal movements" have been proposed, but none of them has been universally accepted. The aim of the study is to investigate the perinatal outcomes in relation to AFMs frequency and perception in term pregnancy with an ad hoc questionnaire administered to the women before delivery. STUDY DESIGN: This was a prospective case-control study on pregnant women at term referring to the Obstetric Unit of the University Hospital of Modena, Italy, between January 2020 and March 2020. A validated questionnaire was administered to women who agreed to participate in the study. Therefore, women were subdivided into the case and control groups: cases included women who experienced adverse perinatal outcomes (APO) such as perinatal mortality (SB and early neonatal mortality), operative delivery (cesarean section or vacuum) due to fetal distress, Apgar 5' < 7, neonatal resuscitation at birth and NICU Admission, while controls were women who experienced delivery and birth without APO in the same period. RESULTS: Seventy-seven cases and 178 controls that compiled the questionnaire were included in the analysis. Characteristics significantly associated with APO were low education (OR 1.57, CI 95% 1.11-2.22), nulliparity (OR 1.76, CI 95% 1.20-2.58), obesity (OR 1.55, CI 95% 1.10-2.17), neonatal male gender (OR 1.92 CI95% 1.33-2.78) and centile at birth (< 10° and >90°) (OR 2.77, 95%CI 2.17, 3.55). There was no association between any answer about strengths, frequency and vigor of perceived fetal movements and APO. Even any maternal perception of fetal hiccups or uterine contractions wasn't associated with APO. On the other hand, women who referred to frequent change positions during sleep (OR 1.55 CI95% 1.05-2.30) and women who snore (OR 1.43 CI95% 1.01-2.05) showed a statistically significant increase of APO. CONCLUSIONS: Our data confirm the significant association between modifiable risk factors (such as obesity and low education) and APO. Thus, healthcare providers should be aware of the importance of intervention in reducing obesity, therefore snoring and related sleep apnea syndrome. Finally, changing position during sleep while not the perception of modified/reduced fetal movements significantly could induce the worst obstetric outcomes.

Stillbirth occurrence during COVID-19 pandemic: a population-based prospective study.

OBJECTIVES: Data collected worldwide on stillbirth (SB) rates during the Covid-19 pandemic are contradictory. Variations may be due to methodological differences or population characteristics. The aim of the study is to assess the changes in SB rate, risk factors, causes of death and quality of antenatal care during the pandemic compared to the control periods. METHODS: This prospective study is based on the information collected by the Emilia-Romagna Surveillance system database. We conducted a descriptive analysis of SB rate, risk factors, causes of death and quality of cares, comparing data of the pandemic (March 2020-June 2021) with the 16 months before. RESULTS: During the pandemic, the SB rate was 3.45/1,000 births, a value in line with the rates of previous control periods. Neonatal weight >90th centile was the only risk factor for SB that significantly changed during the pandemic (2.2% vs. 8.0%; p-value: 0.024). No significant differences were found in the distribution of the causes of death groups. Concerning quality of antenatal cares, cases evaluated with suboptimal care (5.2%) did not change significantly compared to the control period (12.0%), as well as the cases with less than recommended obstetric (12.6% vs. 14%) and ultrasound evaluations (0% vs. 2.7%). CONCLUSIONS: During the COVID-19 pandemic, no significant differences in SB rates were found in an area that maintained an adequate level of antenatal care. Thus, eventual associations between SB rate and the COVID-19 infection are explained by an indirect impact of the virus, rather than its direct effect.

Impact of endocrine disorders on stillbirth: a prospective cohort study.

OBJECTIVE: Among risk factors for SB, maternal endocrine diseases (ED), such as thyroids dysfunction and gestational diabetes mellitus (GDM), are the most frequent. This study aimed to investigate the rate of ED in a population of SB cases collected prospectively, and the relationship between these and causes of death. METHODS: This is an area-based, prospective cohort study conducted in Emilia-Romagna, Italy between January 2014 and December 2020. Data included all cases of SB (>22 weeks). RESULTS: From 2014 to 2020, 766 SB occurred out of a total of 232.506 births (SB rate:0.3/1000). The ED were present in 197/766 cases of SB (25.7%), respectively, 104 thyroid disease (52.8%), 74 GDM (37.5%), and 19 cases of concomitant GDM and thyroid disease (9.6%). Women who had SB associated with ED presented significantly higher mean maternal age (p < 0.001), BMI (p < 0.001), obesity (p < 0.001) and lower smoking habit (p = 0.02) respect with control group. Neonatal and placental weight of stillborn women with ED was significantly higher (p < 0.001) in respect to stillborn of the control group. Women with ED as associated condition (ReCODE classification), present significantly higher cases of SB caused by placenta pathologies (p = 0.009) namely abruptio placentae (p = 0.001) respect than control group. CONCLUSIONS: ED was more frequent in older and obese women experiencing SB. The main cause of death was abruptio placentae. This information can be helpful when counseling mothers with ED and planning antenatal management to prevent SB.

Chronic deciduitis in stillbirths: are there any specific clinical associations?

INTRODUCTION: Placental chronic deciduitis is a lesion consistent with the presence of plasma cells within the placental basal plate. It could be associated with adverse pregnancy outcomes, including stillbirth. METHODS: We retrospectively evaluated a cohort of 180 antepartum stillborn cases from singleton pregnancies, with the aim of investigating the clinical-histopathological relationship. Placental slides were reviewed following the standard protocol proposed by the "Amsterdam consensus statement". RESULTS: We observed an association between chronic deciduitis and lesions consistent with maternal vascular malperfusion, delayed villous maturation, villitis of unknown etiology and maternal autoimmunity. CONCLUSIONS: The observed clinical-histopathological associations suggest that an extensive maternal investigation could improve the comprehension of factors interfering with the placental development and the increasing risk of adverse pregnancy outcomes. HighlightsChronic deciduitis is associated with lesions consistent with maternal vascular malperfusionChronic deciduitis is associated with delayed villous maturationChronic deciduitis is associated with villitis of unknown etiologyChronic deciduitis is associated with maternal autoimmunity.

Intrapartum stillbirth for sepsis complicating Arabin cervical pessary placement in a twin pregnancy.

There is little evidence regarding the best treatment in case of dilated cervix and exposed membranes in twins. Current options for its management include vaginal progesterone, cervical cerclage and cervical pessary, but none of them had shown effectiveness compared to expectant management. We presented a case of twin pregnancy at 22 6/7 weeks' gestation admitted to the hospital because of cervical insufficiency with bulging of membranes. An Arabin pessary was positioned after a failed attempt of cervical cerclage and no antibiotic was given in absence of signs of infection. Cesarean delivery was performed at 24 weeks' gestation because of spontaneous preterm labor and spontaneous rupture of membranes with the first baby in a transverse lie position. At the uterus section, the first baby was stillborn, with Arabin pessary strictly adherent to his ecchymotic head, while the second baby was born alive. After diagnostic histopathological and microbiological investigations, we hypothesized that the first twin died for funisitis/sepsis and mechanical insult due to the strict adhesion of the pessary to the fetal head. We concluded that in case of bulging membranes and dilated cervix, antibiotic treatment should be evaluated, also in absence of signs/symptoms of infection or suspicion of rupture of the membranes, and pessary insertion should be avoided, namely at second trimester, because of the risk of its dislocation inside the uterus when contractions start and potential hurt to extremely preterm fetus.

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.

The Burden of Placental Histopathology in Stillbirths Associated With Maternal Obesity.

OBJECTIVES: Obesity is an increasing health problem that has become a common medical disorder among women of childbearing age, representing worldwide a risk factor for stillbirth. The aim of the study is to evaluate the association between placental histopathologic findings and obesity in stillbirth. METHODS: Placentas were analyzed according to the Amsterdam consensus statement. Histologic findings in stillbirth from obese and lean mothers were analyzed and compared with those observed in liveborn controls. RESULTS: Stillbirth in obese mothers displayed placental pathology in all gestational ages, mostly at term of pregnancy. The most observed placental lesions were those consistent with maternal vascular malperfusion of the placental bed. Decidual arteriopathy and placental infarcts appeared specifically associated with maternal obesity. Moreover, obese women with stillbirth showed the highest cumulative number of placental lesions. CONCLUSIONS: Considering the significant association between stillbirth, maternal obesity, and placental histopathologic findings, health care providers should be aware about the importance of placental examination in obese women, especially in stillborn cases. The high prevalence of lesions consistent with vascular malperfusion of the placental bed suggests that stillbirth prevention strategies in obese women should rely on the development of tools to study and improve decidual artery functioning early in pregnancy.