Birth - Stillbirth and Perinatal Death

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The distorted world map above shows the relative distribution of early neonatal death by country. Note the over-representation of Africa and Asia compared with Europe, USA and Australia. [1]

Introduction

Worldwide about 2.6 million babies are stillborn, 15 million are preterm births ( less than 37 weeks gestation GA), and 32 million are born small for gestational age.

The perinatal period is the early postnatal period relating to the birth, statistically it includes the period up to 7 days after birth. Neonatal period is the four weeks/month after birth.

Stillbirth and perinatal death can be classified by a number of different systems, all still have "unexplained" or "other" as a potential option. in several systems contribute to many of these deaths. Neonatal deaths include a broader age range of infants who have also died after birth from various causes.

Stillbirths with a gestational age of 28 weeks or more are defined as "late fetal deaths".

There are several death classification systems used in different countries around the world, the most recent are the suggested ReCoDe (UK, 2005), the modified Whitfield (Australia/New Zealand, 2004), and the World Health Organization's International Classification of Disease (ICD-10) systems.


A common stillbirth classification is still "unexplained", with recent analysis of data showing fetal growth restriction is a common antecedent.

Australian categories perinatal and infant death graph.jpg
Australian Categories of Perinatal and Infant Death[2]
Birth Links: birth | Lecture - Birth | caesarean | preterm birth | birth weight | macrosomia | Birth Statistics | Australian Birth Data | Developmental Origins of Health and Disease (DOHAD) | Neonatal Diagnosis | Apgar test | Guthrie test | neonatal | stillbirth and perinatal death | ICD-10 Perinatal Period | Category:Birth
Historic Birth links  
1921 USA Birth Mortality

Some Recent Findings

Neonatal mortality rates 2009
  • Review - Interventions for investigating and identifying the causes of stillbirth[3] "Identification of the causes of stillbirth is critical to the primary prevention of stillbirth and to the provision of optimal care in subsequent pregnancies. A wide variety of investigations are available, but there is currently no consensus on the optimal approach. AUTHORS' CONCLUSIONS: There is currently a lack of RCT evidence regarding the effectiveness of interventions for investigating and identifying the causes of stillbirth. Seeking to determine the causes of stillbirth is an essential component of quality maternity care, but it remains unclear what impact these interventions have on the psychosocial outcomes of parents and families, the rates of diagnosis of the causes of stillbirth, and the care and management of subsequent pregnancies following stillbirth. Due to the absence of trials, this review is unable to inform clinical practice regarding the investigation of stillbirths, and the specific investigations that would determine the causes.Future RCTs addressing this research question would be beneficial, but the settings in which the trials take place, and their design, need to be given careful consideration. Trials need to be conducted with the utmost care and consideration for the needs, concerns, and values of parents and families. Assessment of longer-term psychosocial variables, economic costs to health services, and effects on subsequent pregnancy care and outcomes should also be considered in any future trials."
  • Review - Risk of stillbirth, preterm delivery, and fetal growth restriction following exposure in a previous birth[4] "Little is known about the risk of non-recurrent adverse birth outcomes. We searched MEDLINE, EMBASE, Maternity and Infant Care, and Global Health from inception to 30 November 2016. ... The risk of stillbirth, preterm birth, or small for gestational age (as a proxy for fetal growth restriction) was moderately elevated in women who previously experienced a single exposure, but increased between two- and three-fold when two prior adverse outcomes were combined. Clinical guidelines should consider the inter-relationship of stillbirth, PTB, and SGA, and that each condition is an independent risk factor for the other conditions."
  • Early Pregnancy Losses: Review of Nomenclature, Histopathology, and Possible Etiologies[5] "Miscarriage is a frequent complication of human pregnancy: ∼50% to 70% of spontaneous conceptions are lost prior to the second trimester. Etiology of miscarriage includes genetic abnormalities, infections, immunological and implantation disorders, uterine and endocrine abnormalities, and lifestyle factors. Given such variability, knowledge regarding causes, pathophysiological mechanisms, and morphologies of primary early pregnancy loss has significant gaps; often, pregnancy losses remain unexplained. Pathologic evaluation of miscarriage tissue is an untapped source of knowledge. Although miscarriage specimens comprise a significant part of pathologists' workload, information reported from these specimens is typically of minimal clinical utility for delineating etiology or predicting recurrence risk. Standardized terminology is available, though not universally used. We reintroduce the terminology and review new information about early pregnancy losses and their morphologies. Current clinical terminology is inconsistent, hampering research progress. This review is a resource for diagnostic pathologists studying this complex problem."
  • Stillbirths in Germany 2003 - 2011[6] Searches in the international peer-reviewed literature, retrospective data collection of 168 stillbirths in 8 hospitals, (in the area of Bonn) with subsequent statistical evaluation (descriptive statistics, t-test and binominal test) were undertaken. This study shows considerable deficits in data documentation, interdisciplinary communication and postmortal examination. Only in 51.8% (87/168) of the cases was a certain or uncertain cause of death found (42.3% placental, 1.2% foetal, 3.6% chromosomal, 4.8% umbilical cord abnormalities). Severe foetal growth restriction (<5(th) percentile) was observed in 29.2%; 44.9% (22/49) of them died at the age of ≥36+0 weeks of gestation." Germany Statistics
  • Stillbirths in Australia 1991-2009[2] "In 2009, 2,341 babies were stillborn, accounting for almost three quarters of perinatal deaths. In Australia a 'stillbirth' is defined as the birth of a baby who shows no signs of life after a pregnancy of at least 20 weeks gestation or weighing 400 grams or more. Congenital anomalies, or birth defects, are the most common cause of stillbirth in Australia, accounting for 21% of all stillbirths. From 1991 to 2009, the stillbirth rate in Australia was between 6.4 and 7.8 per 1,000 births. The risk of stillbirth occurring between 28 and 41 weeks gestation dropped between 1991 and 2009, however there was an increase in the risk of stillbirths from 20-27 weeks." Reports Australian Statistics
More recent papers  
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Search term: Stillbirth

Wei Zhao, Xinyu Li, Xinghai Xia, Zhengnan Gao, Cheng Han Iodine Nutrition During Pregnancy: Past, Present, and Future. Biol Trace Elem Res: 2018; PubMed 30218312

Alexa A Freedman, Lauren M Kipling, Katie Labgold, Carmen J Marsit, Carol J Hogue, Augustine Rajakumar, Alicia K Smith, Halit Pinar, Deborah L Conway, Radek Bukowski, Michael W Varner, Robert L Goldenberg, Donald J Dudley, Carolyn Drews-Botsch Comparison of diameter-based and image-based measures of surface area from gross placental pathology for use in epidemiologic studies. Placenta: 2018, 69;82-85 PubMed 30213489

Manoj Murhekar, Ashish Bavdekar, Asha Benakappa, Sridhar Santhanam, Kuldeep Singh, Sanjay Verma, Gajanan N Sapkal, Nivedita Gupta, Valsan Philip Verghese, Rajlakshmi Viswanathan, Asha Mary Abraham, Shyama Choudhary, Gururajrao N Deshpande, Suji George, Garima Goyal, Parul Chawla Gupta, Ishani Jhamb, Deepa John, Swetha Philip, Sandeep Kadam, Ravinder Kaur Sachdeva, Praveen Kumar, Anjali Lepcha, S Mahantesh, S Manasa, Urvashi Nehra, Sanjay Kumar Munjal, Vijaya Lakshmi Nag, Sadanand Naik, Naga Raj, Jagat Ram, R K Ratho, C G Raut, Manoj Kumar Rohit, R Sabarinathan, Sanjay Shah, Pratibha Singh, Mini P Singh, Ashish Tiwari, Neelam Vaid Sentinel Surveillance for Congenital Rubella Syndrome - India, 2016-2017. MMWR Morb. Mortal. Wkly. Rep.: 2018, 67(36);1012-1016 PubMed 30212443

Kadie Anderson, Patricia M Dennis RETROSPECTIVE MORTALITY REVIEW OF SIX CALLITRICHID SPECIES HOUSED AT A SINGLE INSTITUTION (1990-2014). J. Zoo Wildl. Med.: 2018, 49(3);715-721 PubMed 30212336

Suzan L Carmichael, Yair J Blumenfeld, Jonathan A Mayo, Jochen Profit, Gary M Shaw, Susan R Hintz, David K Stevenson Stillbirth and Live Birth at Periviable Gestational Age: A Comparison of Prevalence and Risk Factors. Am J Perinatol: 2018; PubMed 30208499


Search term: Perinatal Death

Hajnalka Barta, Agnes Jermendy, Marton Kolossvary, Lajos R Kozak, Andrea Lakatos, Unoke Meder, Miklos Szabo, Gabor Rudas Prognostic value of early, conventional proton magnetic resonance spectroscopy in cooled asphyxiated infants. BMC Pediatr: 2018, 18(1);302 PubMed 30219051

Marco Podda, Davide Bacciu, Alessio Micheli, Roberto Bellù, Giulia Placidi, Luigi Gagliardi A machine learning approach to estimating preterm infants survival: development of the Preterm Infants Survival Assessment (PISA) predictor. Sci Rep: 2018, 8(1);13743 PubMed 30213963

Teresa Janevic, Jennifer Zeitlin, Nathalie Auger, Natalia N Egorova, Paul Hebert, Amy Balbierz, Elizabeth A Howell Association of Race/Ethnicity With Very Preterm Neonatal Morbidities. JAMA Pediatr: 2018; PubMed 30208467

Rosemary Townsend, Francesco D'Antonio, Filomena Giulia Sileo, Hafsah Kumbay, Basky Thilaganathan, Asma Khalil Perinatal outcome of monochorionic twin pregnancies complicated by selective fetal growth restriction according to management: a systematic review and meta-analysis. Ultrasound Obstet Gynecol: 2018; PubMed 30207011

Torri D Metz Eliminating Preventable Maternal Deaths in the United States: Progress Made and Next Steps. Obstet Gynecol: 2018; PubMed 30204696

Older papers  
  • Perinatal mortality following assisted reproductive technology treatment in Australia and New Zealand, a public health approach for international reporting of perinatal mortality.[7] "There is a need to have uniformed reporting of perinatal mortality for births following assisted reproductive technology (ART) treatment to enable international comparison and benchmarking of ART practice. ...We recommend that reporting of perinatal deaths following ART treatment, should be stratified for three gestation-specific perinatal periods of >= 20, >= 22 and >= 28 completed weeks to < 7 days post-birth; and include plurality specific rates by SET and DET." Assisted Reproductive Technology
  • Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities.[8] " In 2009, an estimated 3.3 million babies died in the first month of life-compared with 4.6 million neonatal deaths in 1990-and more than half of all neonatal deaths occurred in five countries of the world (44% of global livebirths): India 27.8% (19.6% of global livebirths), Nigeria 7.2% (4.5%), Pakistan 6.9% (4.0%), China 6.4% (13.4%), and Democratic Republic of the Congo 4.6% (2.1%)."
  • Effect of screening and management of diabetes during pregnancy on stillbirths[9] "Diabetes during pregnancy is associated with significant risk of complications to the mother, fetus and newborn. We reviewed the potential impact of early detection and control of diabetes mellitus during pregnancy on stillbirths for possible inclusion in the Lives Saved Tool (LiST)."
  • UK study - Time of birth and risk of neonatal death at term[10] "The risk of neonatal death was 4.2 per 10 000 during the normal working week (Monday to Friday, 0900-1700) and 5.6 per 10 000 at all other times (out of hours) (unadjusted odds ratio 1.3, 95% confidence interval 1.1 to 1.6). Adjustment for maternal characteristics had no material effect. The higher rate of death out of hours was because of an increased risk of death ascribed to intrapartum anoxia (adjusted odds ratio 1.7, 1.2 to 2.3)." (See also Swedish study[11])
  • Stillbirth classification - executive summary of a National Institute of Child Health and Human Development workshop.[12] "Stillbirth is a major obstetric complication, with 3.2 million stillbirths worldwide and 26,000 stillbirths in the United States every year. The Eunice Kennedy Shriver National Institute of Child Health and Human Development held a workshop from October 22-24, 2007, to review the pathophysiology of conditions underlying stillbirth to define causes of death."

World High Rate Countries

World infant mortality 01.jpg

Graph shows the number of infant deaths / 1,000 live births for countries above 1%.

Classification Differences

  • World Health Organization - report stillbirths weighing 500g, or born at or after 22 weeks gestational age GA, or 25 cm crown-heel length (CRL), if neither birthweight nor gestational age is known. Restrict stillbirth used for international reporting to those weighing 1,000g (or born at or after 28 weeks gestational age or 35 cm CRL.
  • Australia - a baby who is stillborn must be of at least 20 weeks gestational age or weigh 400g or more.
  • New Zealand - include all fetal deaths from 20 week gestational age or 400g birthweight[13].
  • Canada - includes fetal deaths from 20 week gestational age or 500g birthweight in all provinces except Quebec where only the birthweight criterion applies. [14]
  • United States - states to report fetal deaths of 20 or more weeks gestation, but the definition of a ‘fetal death’ specifically excludes deaths that result from induced termination of pregnancy.[15]
  • United Kingdom - 24 weeks gestational age and includes all fetal deaths that meet this criterion.
  • Europe - the lower limit ranges from 16–26 weeks gestational age and member states vary in their capacity to include late termination of pregnancy that meet their gestation criterion for a stillbirth (Gissler 2012).


Decreased Fetal Movements

Decreased fetal movements (DFM) can occur during the normal fetal period. Pregnancies with multiple occasions of decreased fetal movements are at increased risk of poor perinatal outcomes, including fetal death, intrauterine fetal growth restriction (IUFGR) or preterm birth. An evaluation of women presenting with DFM should involve a thorough history, examination and auscultation of fetal heart, cardiotocography (CTG) and ultrasound if indicated. There are guidelines and position statements available for DFM.

There have been studies using maternal recording of movements, that have limitations of non-compliance and initial analysis shows poor correlation.[16]

A population-based study has also been unable to link, except for some subgroups, maternally perceived DFM to placental pathology.[17]


Links: Fetal Development | Ultrasound | Australia RANZCOG Guideline 2013 PDF | Health 2011 | UK 2011 Guideline No. 57 | USA Reduced fetal movements 2011

Uterine Artery Pulsatility Index

Uterine Artery Pulsatility Index (UT-PI) is a clinical ultrasound technique used for monitoring placental and fetal function. Can be used in second trimester screening in combination with maternal factors and fetal biometry to predict stillbirths and in particular those associated with impaired placentation.[18] Maternal factors can include measurement of maternal serum placental growth factor (PLGF) levels.[19]

Australian Data

Australian Perinatal Deaths
Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Rate 10.1 10.4 9.8 9.8 9.9 10.6 9.2 8.8 8.4 9.0
Number 2,534 2,571 2,475 2,480 2,541 2,769 2,459 2,532 2,501 2,671
  • Perinatal deaths are all fetal deaths (at least 20 weeks gestation or at least 400 grams birth weight) plus all neonatal deaths (death of a live born baby within 28 completed days of birth).
  • Perinatal death rates are calculated per 1,000 all births for the calendar year.
  • Source: ABS Births, Australia, 2009 (cat. no. 3301.0); ABS Perinatal Deaths, Australia, 2009 (cat. no. 3304.0).

NSW

NSW perinatal mortality rate

In New South Wales (2002) 613 perinatal deaths were reported.

  • Unexplained antepartum deaths: 26.3% of perinatal deaths (or 39.2% of stillbirths)
  • Spontaneous preterm labour: 20.6% (less than 37 weeks gestation)
  • Congenital abnormality: 16.8%
  • Antepartum haemorrhage: 8.5%
  • Specific perinatal conditions: 7.3%, of which twin-twin transfusion accounted for 2.3% of deaths
  • Hypertension (high blood pressure): 5.5%
  • Perinatal infection: 4.4%
  • Maternal disease: 4.4%
  • Hypoxic peripartum death: 3.8%

Neonatal deaths (four weeks/month after birth)

  • extreme prematurity was most common cause (39.6%)
  • congenital abnormality (19.3%)
  • neurological disease (13.4%)
  • cardio-respiratory conditions (11.9%)
  • infection (8.4%)

Data: Report of the New South Wales Chief Health Officer, 2004 accessed 19Oct05

USA Data

Leading causes of infant death for 2005:[20]

  1. Congenital malformations, deformations and chromosomal abnormalities
  2. Disorders related to short gestation and low birthweight, not elsewhere classified
  3. Sudden infant death syndrome
  4. Newborn affected by maternal complications of pregnancy
  5. Newborn affected by complications of placenta, cord and membranes
  6. Accidents (unintentional injuries); Respiratory distress of newborn
  7. Bacterial sepsis of newborn
  8. Neonatal hemorrhage
  9. Necrotizing enterocolitis of newborn.

Fetal Death Information

Sample form - fetal death report
  • 2003 Revisions of the U.S. Standard Certificates of Live Birth and Death and the Fetal Death Report. The revision process is generally carried out every 10 to 15 years.
  • Maternal, Paternal and medical and health information is collected.

CAUSE/CONDITIONS CONTRIBUTING TO FETAL DEATH

  • INITIATING CAUSE/CONDITION
  • OTHER SIGNIFICANT CAUSES OR CONDITIONS
  • WEIGHT OF FETUS (grams preferred, specify unit)
  • ESTIMATED TIME OF FETAL DEATH
  • WAS AN AUTOPSY PERFORMED?
  • WAS A HISTOLOGICAL PLACENTAL EXAMINATION PERFORMED?
  • WERE AUTOPSY OR HISTOLOGICAL PLACENTAL EXAMINATION RESULTS USED IN DETERMINING THE CAUSE OF FETAL DEATH?

Links: 2003 Revisions of the U.S. Standard Certificates of Live Birth and Death and the Fetal Death Report

Conditions Associated with Stillbirth

Based upon the 2007 National Institute of Child Health and Human Development workshop. [12]

Infection

  • Severe maternal illness
  • Placental infection leading to hypoxemia
  • Fetal infection leading to congenital deformity
  • Fetal infection leading damage of a vital organ
  • Precipitating preterm labor with the fetus dying in labor

Maternal medical conditions

  • Hypertensive disorders
  • Diabetes mellitus
  • Thyroid disease
  • Renal disease
  • Liver disease
  • Connective tissue disease (systemic lupus erythematosus)
  • Cholestasis

Other

  • Antiphospholipid syndrome
  • Heritable thrombophilias
  • Red cell alloimmunization
  • Platelet alloimmunization
  • Congenital anomaly and malformations
  • Chromosomal abnormalities including confined placental mosaicism
  • Fetomaternal hemorrhage
  • Fetal growth restriction
  • Placental abnormalities including vasa previa and placental abruption
  • Umbilical cord pathology including velamentous insertion, prolapse, occlusion and entanglement
  • Multifetal gestation including twin–twin transfusion syndrome and twin reverse arterial perfusion
  • Amniotic band sequence
  • Central nervous system lesions

References

  1. Dorling D. (2007). Worldmapper: the human anatomy of a small planet. PLoS Med. , 4, e1. PMID: 17411312 DOI.
  2. 2.0 2.1 AIHW: Hilder L, Li Z, Zeki R & Sullivan EA 2014. Stillbirths in Australia 1991-2009. Perinatal statistics series no. 29. Cat. no. PER 63. Canberra: AIHW.
  3. Wojcieszek AM, Shepherd E, Middleton P, Gardener G, Ellwood DA, McClure EM, Gold KJ, Khong TY, Silver RM, Erwich JJH & Flenady V. (2018). Interventions for investigating and identifying the causes of stillbirth. Cochrane Database Syst Rev , 4, CD012504. PMID: 29709055 DOI.
  4. Malacova E, Regan A, Nassar N, Raynes-Greenow C, Leonard H, Srinivasjois R, W Shand A, Lavin T & Pereira G. (2018). Risk of stillbirth, preterm delivery, and fetal growth restriction following exposure in a previous birth: systematic review and meta-analysis. BJOG , 125, 183-192. PMID: 28856792 DOI.
  5. Pinar MH, Gibbins K, He M, Kostadinov S & Silver R. (2018). Early Pregnancy Losses: Review of Nomenclature, Histopathology, and Possible Etiologies. Fetal Pediatr Pathol , , 1-19. PMID: 29737906 DOI.
  6. Hübner J, Gast AS, Müller AM, Bartmann P & Gembruch U. (2015). [Stillbirths in Germany: Retrospective Analysis of 168 Cases between 2003 and 2011]. Z Geburtshilfe Neonatol , 219, 73-80. PMID: 25901868 DOI.
  7. Sullivan EA, Wang YA, Norman RJ, Chambers GM, Chughtai AA & Farquhar CM. (2013). Perinatal mortality following assisted reproductive technology treatment in Australia and New Zealand, a public health approach for international reporting of perinatal mortality. BMC Pregnancy Childbirth , 13, 177. PMID: 24044524 DOI.
  8. Oestergaard MZ, Inoue M, Yoshida S, Mahanani WR, Gore FM, Cousens S, Lawn JE & Mathers CD. (2011). Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Med. , 8, e1001080. PMID: 21918640 DOI.
  9. Syed M, Javed H, Yakoob MY & Bhutta ZA. (2011). Effect of screening and management of diabetes during pregnancy on stillbirths. BMC Public Health , 11 Suppl 3, S2. PMID: 21501437 DOI.
  10. Pasupathy D, Wood AM, Pell JP, Fleming M & Smith GC. (2010). Time of birth and risk of neonatal death at term: retrospective cohort study. BMJ , 341, c3498. PMID: 20634347
  11. Luo ZC & Karlberg J. (2001). Timing of birth and infant and early neonatal mortality in Sweden 1973-95: longitudinal birth register study. BMJ , 323, 1327-30. PMID: 11739216
  12. 12.0 12.1 Reddy UM, Goldenberg R, Silver R, Smith GC, Pauli RM, Wapner RJ, Gardosi J, Pinar H, Grafe M, Kupferminc M, Hulthén Varli I, Erwich JJ, Fretts RC & Willinger M. (2009). Stillbirth classification--developing an international consensus for research: executive summary of a National Institute of Child Health and Human Development workshop. Obstet Gynecol , 114, 901-14. PMID: 19888051 DOI.
  13. Perinatal and Maternal Mortality Review Committee (PMMRC). 2013. Seventh Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2011. Wellington: Health Quality & Safety Commission
  14. Public Health Agency of Canada (PHAC). 2008. Canadian Perinatal Health Report, 2008 Edition. Ottawa.
  15. Kowaleski J. 1997. State definitions and reporting requirements for live births, fetal deaths, and induced terminations of pregnancy (1997 revision). Hyattsville, Maryland: National Center for Health Statistics.
  16. Winje BA, Røislien J, Saastad E, Eide J, Riley CF, Stray-Pedersen B & Frøen JF. (2013). Wavelet principal component analysis of fetal movement counting data preceding hospital examinations due to decreased fetal movement: a prospective cohort study. BMC Pregnancy Childbirth , 13, 172. PMID: 24007565 DOI.
  17. Winje BA, Roald B, Kristensen NP & Frøen JF. (2012). Placental pathology in pregnancies with maternally perceived decreased fetal movement--a population-based nested case-cohort study. PLoS ONE , 7, e39259. PMID: 22723978 DOI.
  18. . (). . , , . PMID: 27601282
  19. . (). . , , . PMID: 27539237
  20. Heron M & Tejada-Vera B. (2009). Deaths: leading causes for 2005. Natl Vital Stat Rep , 58, 1-97. PMID: 20361522

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Cite this page: Hill, M.A. (2018, September 18) Embryology Birth - Stillbirth and Perinatal Death. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Birth_-_Stillbirth_and_Perinatal_Death

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