The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH‐21^st Project

Abstract

ObjectivesTo identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well‐dated pregnancies and access to antenatal care.DesignPopulation‐based, prospective, observational study.SettingEight international urban populations.PopulationPregnant women and their babies enrolled in the Newborn Cross‐Sectional Study of the INTERGROWTH‐21st Project.MethodsCox proportional hazard models were used to compare risks among antepartum stillborn and liveborn babies.Main outcome measuresAntepartum stillbirth was defined as any fetal death after 16 weeks’ gestation before the onset of labour.ResultsOf 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio‐economic status, hazard ratio (HR): 1.6 (95% CI, 1.2–2.1); single marital status, HR 2.0 (95% CI, 1.4–2.8); age ≥40 years, HR 2.2 (95% CI, 1.4–3.7); essential hypertension, HR 4.0 (95% CI, 2.7–5.9); HIV/AIDS, HR 4.3 (95% CI, 2.0–9.1); pre‐eclampsia, HR 1.6 (95% CI, 1.1–3.8); multiple pregnancy, HR 3.3 (95% CI, 2.0–5.6); and antepartum haemorrhage, HR 3.3 (95% CI, 2.5–4.5). Birth weight <3rd centile was associated with antepartum stillbirth [HR, 4.6 (95% CI, 3.4–6.2)]. The greatest risk was seen in babies not suspected to have been growth restricted antenatally, with an HR of 5.0 (95% CI, 3.6–7.0). The population‐attributable risk of antepartum death associated with small‐for‐gestational‐age neonates diagnosed at birth was 11%.ConclusionsAntepartum stillbirth is a complex syndrome associated with several risk factors. Although small babies are at higher risk, current growth restriction detection strategies only modestly reduced the rate of stillbirth.Tweetable abstractInternational stillbirth study finds individual risks poor predictors of death but combinations promising.

Using fetal abdominal circumference growth velocity in the prediction of adverse outcome in near‐term small‐for‐gestational‐age fetuses

“…The limitations of this practice are increasingly appreciated. As SGA is just one manifestation of FGR, even the universal detection of SGA will have limited effects on stillbirth and neonatal morbidity. As some SGA fetuses are constitutionally small, and probably not at increased perinatal risk, iatrogenic delivery may be harmful.…”

Predictive accuracy of cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction: systematic review and meta‐analysis

“…(3) assessed CPR in the general population as a screening tool; (4) were case-control studies without complete information for cases with suspected FGR, case series or reports, editorials, comments, reviews or letters without original data; (5) reported data for CPR only as mean or median values; (6) did not publish test accuracy estimates, or sufficient information to calculate them could not be retrieved.…”

“…Small-for-gestational age (SGA) at birth, based on different cut-off values, is a commonly used proxy measure of FGR 3 . FGR is associated with an increased risk of short-and long-term morbidity and mortality, as well as impaired neurological and cognitive development [4][5][6][7][8][9][10][11] .…”

Feasibility of using self‐reported ethnicity in pregnancy according to the gestation‐related optimal weight classification: a cross‐sectional study

“…A major goal of antenatal care is the detection of fetal growth restriction (FGR), a leading risk factor for stillbirth and long‐term morbidity . Antenatal identification of a fetus that is small for gestational age (SGA) has been shown to reduce the risk of stillbirth, yet a continuing clinical challenge is differentiating the constitutionally small fetus from the growth‐restricted fetus.…”

“…A major goal of antenatal care is the detection of fetal growth restriction (FGR), a leading risk factor for stillbirth and longterm morbidity. [1][2][3][4][5] Antenatal identification of a fetus that is small for gestational age (SGA) has been shown to reduce the risk of stillbirth, 1 yet a continuing clinical challenge is differentiating the constitutionally small fetus from the growth-restricted fetus. Improved identification of the pathologically small fetus forms the basis of the gestation-related optimal weight (GROW) customised growth charts developed by the Gestation Network.…”