Effectiveness of interventions to screen and manage infections during pregnancy on reducing stillbirths: a review

Abstract

BackgroundInfection is a well acknowledged cause of stillbirths and may account for about half of all perinatal deaths today, especially in developing countries. This review presents the impact of interventions targeting various important infections during pregnancy on stillbirth or perinatal mortality.MethodsWe undertook a systematic review including all relevant literature on interventions dealing with infections during pregnancy for assessment of effects on stillbirths or perinatal mortality. The quality of the evidence was assessed using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach by Child Health Epidemiology Reference Group (CHERG). For the outcome of interest, namely stillbirth, we applied the rules developed by CHERG to recommend a final estimate for reduction in stillbirth for input to the Lives Saved Tool (LiST) model.ResultsA total of 25 studies were included in the review. A random-effects meta-analysis of observational studies of detection and treatment of syphilis during pregnancy showed a significant 80% reduction in stillbirths [Relative risk (RR) = 0.20; 95% confidence interval (CI): 0.12 - 0.34) that is recommended for inclusion in the LiST model. Our meta-analysis showed the malaria prevention interventions i.e. intermittent preventive treatment (IPTp) and insecticide-treated mosquito nets (ITNs) can reduce stillbirths by 22%, however results were not statistically significant (RR = 0.78; 95% CI: 0.59 – 1.03). For human immunodeficiency virus infection, a pooled analysis of 6 radomized controlled trials (RCTs) failed to show a statistically significant reduction in stillbirth with the use of antiretroviral in pregnancy compared to placebo (RR = 0.93; 95% CI: 0.45 – 1.92). Similarly, pooled analysis combining four studies for the treatment of bacterial vaginosis (3 for oral and 1 for vaginal antibiotic) failed to yield a significant impact on perinatal mortality (OR = 0.88; 95% CI: 0.50 – 1.55).ConclusionsThe clearest evidence of impact in stillbirth reduction was found for adequate prevention and treatment of syphilis infection and possibly malaria. At present, large gaps exist in the growing list of stillbirth risk factors, especially those that are infection related. Potential causes of stillbirths including HIV and TORCH infections need to be investigated further to help establish the role of prevention/treatment and its subsequent impact on stillbirth reduction.

Effect of Highly Active Antiretroviral Treatment (HAART) During Pregnancy on Pregnancy Outcomes: Experiences from a PMTCT Program in Western India

“…40 However, limited research is available on the effect of HAART on fetal death 41 and a recent pooled analysis of studies showed that HAART did not reduce the possibility of stillbirths. 42 In our study, in spite of the better CD4 counts at the time of pregnancy due to treatment (HAART), the group of women who received HAART might be clinically different than the women who received AZT. However, a recent study by Baroncelli and colleagues 43 among women who were diagnosed before pregnancy and undergoing ART at conception reported that women who have not experienced AIDS-defining events have similar maternal and neonatal outcomes as compared to women with more advanced stage of the disease.…”

Stillbirths: what difference can we make and at what cost?

“…63 In practical terms, however, both interventions are used in combination in endemic populations, which reduces the risk of stillbirths in women in their fi rst or second pregnancy by an estimated 22% (table 1). 21 …”

Maternal group B Streptococcus‐related stillbirth: a systematic review

“…3 Antenatal screening and treatment of maternal infection can substantially reduce stillbirth rates, as evidenced by programmes to prevent congenital syphilis that are estimated to have reduced syphilis-related stillbirth rates by up to 80%. [3][4][5] The role of other in utero fetal infections in stillbirths, however, is less well documented, and would be important to delineate to further improve pregnancy outcomes.…”