The application of the ICD-10 for antepartum stillbirth patients in a referral centre of Eastern China: a retrospective study from 2015 to 2022.

BACKGROUND: The causes of some stillbirths are unclear, and additional work must be done to investigate the risk factors for stillbirths. OBJECTIVE: To apply the International Classification of Disease-10 (ICD-10) for antepartum stillbirth at a referral center in eastern China. METHODS: Antepartum stillbirths were grouped according to the cause of death according to the International Classification of Disease-10 (ICD-10) criteria. The main maternal condition at the time of antepartum stillbirth was assigned to each patient. RESULTS: Antepartum stillbirths were mostly classified as fetal deaths of unspecified cause, antepartum hypoxia. Although more than half of the mothers were without an identified condition at the time of the antepartum stillbirth, where there was a maternal condition associated with perinatal death, maternal medical and surgical conditions and maternal complications during pregnancy were most common. Of all the stillbirths, 51.2% occurred between 28 and 37 weeks of gestation, the main causes of stillbirth at different gestational ages also differed. Autopsy and chromosomal microarray analysis (CMA) were recommended in all stillbirths, but only 3.6% received autopsy and 10.5% underwent chromosomal microarray analysis. CONCLUSIONS: The ICD-10 is helpful in classifying the causes of stillbirths, but more than half of the stillbirths in our study were unexplained; therefore, additional work must be done. And the ICD-10 score may need to be improved, such as by classifying stillbirths according to gestational age. Autopsy and CMA could help determine the cause of stillbirth, but the acceptance of these methods is currently low.

Causes of and factors associated with stillbirth in low- and middle-income countries: a systematic literature review.

BACKGROUND: Annually, 2.6 million stillbirths occur worldwide, 98% in developing countries. It is crucial that we understand causes and contributing factors. METHODS: We conducted a systematic review of studies reporting factors associated with and cause(s) of stillbirth in low- and middle-income countries (2000-13). Narrative synthesis to compare similarities and differences between studies with similar outcome categories. MAIN RESULTS: A total of 142 studies with 2.1% from low-income settings were investigated; most report on stillbirths occurring at health facility level. Definition of stillbirth varied; 10.6% of studies (mainly upper middle-income countries) used a cut-off point of ≥22 weeks of gestation and 32.4% (mainly lower income countries) used ≥28 weeks of gestation. Factors reported to be associated with stillbirth include poverty and lack of education, maternal age (>35 or <20 years), parity (1, ≥5), lack of antenatal care, prematurity, low birthweight, and previous stillbirth. The most frequently reported cause of stillbirth was maternal factors (8-50%) including syphilis, positive HIV status with low CD4 count, malaria and diabetes. Congenital anomalies are reported to account for 2.1-33.3% of stillbirths, placental causes (7.4-42%), asphyxia and birth trauma (3.1-25%), umbilical problems (2.9-33.3%), and amniotic and uterine factors (6.5-10.7%). Seven different classification systems were identified but applied in only 22% of studies that could have used a classification system. A high percentage of stillbirths remain 'unclassified' (3.8-57.4%). CONCLUSION: To build capacity for perinatal death audit, clear guidelines and a suitable classification system to assign cause of death must be developed. Existing classification systems may need to be adapted. Better data and more data are urgently needed.

Predictive Model for Late Stillbirth Among Antenatal Hypertensive Women.

Objective: To develop a predictive model for late stillbirth among women with hypertensive disorders of pregnancy (HDP) in low- and middle-income countries. Materials and Methods: Study was part of the WHO newborn birth defect (NBBD) project and included all stillbirths occurring in the facility from November 2015 to December 2020. The age and parity matched subjects with HDP having live birth were taken as controls. All significant predictors were analyzed and a predictive model was developed. Results: Out of 69,007 deliveries, 1691(24.5/1000) were stillborn. HDP was seen in (390/1691, 23.0%), in 265/390 (67.4%) cases it occurred at or after 28 weeks of gestation and were included as cases. On comparing the cases with controls, the significant factors were estimated fetal weight less than 2000 gms (P < 0.001, OR 10.3), poor antenatal care (p < 0.001, OR-5.9), family history of hypertension (p < 0.018, OR-4.4) and the presence of gestational hypertension (p = 0.001, OR 2.2). The predictive model had sensitivity and specificity of 80.3% and 70.03%, respectively, the receiver operating curve showed the area under the curve(AUC) in the range of good prediction (0.846). Conclusion: The predictive model could play a potential role in stillbirth prevention in women with HDP in low- and middle-income countries. Supplementary Information: The online version contains supplementary material available at 10.1007/s13224-021-01561-3.

Stillbirths and the COVID-19 pandemic: Looking beyond SARS-CoV-2 infection.

OBJECTIVE: To study the impact of the COVID-19 outbreak and subsequent lockdown on the incidence, associated causes, and modifiable factors of stillbirth. METHODS: An analytical case-control study was performed comparing stillbirths from March to September 2020 (cases) and March to September 2019 (controls) in a tertiary care center in India. Modifiable factors were observed as level-I, level-II, and level-III delays. RESULTS: A significant difference in the rate of stillbirths was found among cases (37.4/1000) and controls (29.9/1000) (P = 0.045). Abruption in normotensive women was significantly higher in cases compared to controls (P = 0.03). Modifiable factors or preventable causes were noted in 76.1% of cases and 59.6% of controls; the difference was highly significant (P < 0.001, relative risk [RR] 1.8). Level-II delays or delays in reaching the hospital for delivery due to lack of transport were observed in 12.7% of cases compared to none in controls (P < 0.006, RR 47.7). Level-III delays or delays in providing care at the facility were observed in 31.3% of cases and 11.5% of controls (P < 0.001, RR 2.7). CONCLUSION: Although there was no difference in causes of stillbirth between cases and controls, level-II and level-III delays were significantly impacted by the pandemic, leading to a higher rate of preventable stillbirths in pregnant women not infected with COVID-19.

Hypertension during pregnancy and risk of stillbirth: challenges in a developing country.

OBJECTIVE: To explore the factors associated with hypertensive disorders of pregnancy (HDP) in women experiencing stillbirth (SB). MATERIAL AND METHODS: It was an observational, analytical case-control study, done as part of the World Health Organization South-East Asian Region Office SB project. The epidemiological profile, history, clinical features, and investigations of stillborn cases having HDP were noted, an equal number of age and parity matched subjects with HDP having livebirth were taken as controls. RESULTS: Out of 46,816 deliveries, 1239 (26.2/1000) were stillborn. The maternal causes contributed 374/1239 (30.2%) stillbirths according to the CODAC classification, HDP was the most common maternal cause (304/1239, 24.9%). Subjects with HDP were included as cases. On comparing the cases with controls it was found that significantly more number of cases had inadequate antenatal visits (p < .001, OR -4.8), two or more abortions (p < .001, OR -1.9), early onset of hypertension (p < .0001, OR -5.6) and complications such as fetal growth restriction (FGR) (p < .001, OR -2.3) and abruption (p < .001, OR -4.0). Women with preeclampsia were less likely to have SB compared to those with gestational or chronic hypertension (p = .0001, OR -2.3). The birth weight/placental weight ratio of more than eight had the highest odds ratio regarding contribution to SB among hypertensive women (p = .0001 OR -6.7). CONCLUSION: In women with HDP, adequate antenatal care would lead to the prevention of complications such as anemia, abruption, and FGR, and thus prevent SB. The high BW/PW ratio is a potential marker of risk of SB.

Factors contributing to late stillbirth among women with pregnancy hypertension in a developing country.

OBJECTIVE: To investigate the factors associated with late stillbirth among women with hypertensive disorders of pregnancy (HDP). MATERIAL AND METHODS: The clinical details of women with HDP having late stillbirth were compared with controls having livebirth. RESULTS: Total 208 cases and 288 controls were included in the study. Inadequate antenatal visits (p < 0.001, OR-5.92). birth weight < 2000 gms (p < 0.001, OR 10.3) and BW/PW ratio > 8 contributed significantly (p = 0.0001, OR-5.6) to stillbirth. CONCLUSION: Poor antenatal care, birth weight below 2000gms and high BW/PW ratio was associated with a higher risk of stillbirth.

An Analysis of Cause of Stillbirth in a Tertiary Care Hospital of Delhi: A Contribution to the WHO SEARO Project.

BACKGROUND: Over 98% of the world's total stillbirths are believed to occur in developing countries and still have received very little research, programmatic or policy attention. AIMS AND OBJECTIVE: To collect data on epidemiological profile of cases experiencing stillbirths, to assess the associated antenatal high risk factors present and to find out the probable cause of stillbirth. MATERIALS AND METHODS: This was a cross-sectional, observational study, which was done as part of WHO SEARO project after ethical clearance. The study included all stillbirths which occurred in the hospital during the study period August 2015-February 2017. Antenatal records were reviewed; maternal investigations were done. Baby was examined after delivery. Pre-structured pro forma was filled for every case. Finally, the relevant condition found was classified under CODAC system of stillbirth classification. RESULT: Out of 20,580 deliveries, 600 (2.9%) were stillborn. Maternal cause was noted in 145/600 (24.2%) cases, fetal cause was noted in 181/600 (30.2%), and placental and cord origins were suspected in 128/600 (21.3%) and 12/600 (2%) cases, respectively. In 72/600 (12.0%) cases the reason for stillbirth was unknown and unclassifiable. Among the maternal causes the most common was hypertension (89/600, 14.8%) followed by infection including fever (5.7%); the most common infection was hepatitis. Among the fetal causes birth defect was the most common (106/600, 17.7%) followed by extreme prematurity in 42/600 (7.0%). CONCLUSION: Birth defects were the most important fetal cause of stillbirth; hypertension in pregnancy and fetal growth restriction were important associated factors.

An evaluation of stillbirths in Istanbul by examining death certificates.

AIM: Despite the fact that the frequency of stillbirth is estimated to be about the same as that of early neonatal deaths, stillbirth records and statistics are not kept on a regular basis worldwide and their causes cannot be determined. The aim of our study was to examine the causes and characteristics of stillbirths in Istanbul. MATERIAL AND METHODS: All death certificates of 2011 archived in 8 District Cemetery Directorships, which manage 322 cemeteries within the boundaries of Istanbul Metropolitan Municipality, were examined. Based on the burial licences, weight, gestational weeks, the main cause and causes of death related to stillbirth were analyzed. Cervical insufficieny, placenta abnormalities, preeclampsia, complications of multiple pregnancy, chronic diseases of mothers, conditions including malignancy in mothers were evaluated under the title of "maternal and gestational causes." Intrapartum infections, meconium aspiration, and asphyxia were evaluated under the title of "perinatal causes." RESULTS: A total of 2078 stillbirths and 128 abortus records were found among the death certificates. Nineteen of the abortus records and 109 stillbirths were misidentified. A total of 1988 stillbirth records were examined, of which 68.4% were low-birth-weight babies (<2 500 g). Approximately three quarters of the stillbirths were mild preterm and extremely preterm babies, whereas 10% were at or more than 37 gestastional weeks. The cause of death was not known in 30% of the stillbirths. CONCLUSIONS: The cause of death was not known in a significant portion of stillbirths in Istanbul. Recordings should be made more meticulosuly directed to the cause of death. The cause of stillbirth in term babies is another research subject. Regional and global epidemiologic studies are needed to understand the causes of stillbirths and thus to take necessary precautions.