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... Two studies link the presence of a nuchal cord during pregnancy with mild chronic pre-labour hypoxia ) and a lower birth weight (Miser 1992, Rhoades et al, 1999). Other studies were unable to find an association between nuchal cords and mor- bidity during pregnancy (Carey and Rayburn, 2000;Aksoy, 2003;Clapp III et al, 2003;Gonzalez-Quintero et al, 2004). Most research in this area focuses on the effect of a nuchal cord during labour and birth. ...
... The dependent variable examined in this study was "having experienced a stillbirth or not". The binary model of logistic regression was used in this study to control the variables that are likely to have confounding effects (14). ...
... Two studies link the presence of a nuchal cord during pregnancy with mild chronic pre-labour hypoxia (Hashimoto and Clapp, 2003) and a lower birth weight (Miser 1992, Rhoades et al, 1999). Other studies were unable to find an association between nuchal cords and morbidity during pregnancy (Carey and Rayburn, 2000; Aksoy, 2003; Clapp III et al, 2003; Gonzalez-Quintero et al, 2004). Most research in this area focuses on the effect of a nuchal cord during labour and birth. ...
The presence of a nuchal cord, where the umbilical cord is around the neck at the point of birth is a common occurrence, and checking for, and managing a nuchal cord has become
part of routine midwifery practice. Whilst a tight nuchal cord is associated with some short-term morbidity, it is unclear whether such outcomes are actually a result of the presence of the nuchal cord itself, or as a result of clamping and cutting the cord. The action of looping a loose nuchal cord over the baby’s head before the emergence of the body may also interfere with the normal physiology of birth. In addition women’s experience of birthing a baby with a nuchal cord has not been explored.
The association of nuchal cords with danger is embedded within our culture and influences parent’s perceptions. Therefore, childbirth education needs to address the issues surrounding this commonly occurring situation.
... Our results thus strengthen the evidence that the coexistence of clinical and placental UC abnormalities may indeed play a part in perinatal morbidity and, particularly, in the rate of macerated stillbirth [5,7,48,49]. Of these stillbirths, a proportion shows features of FTV, which are more likely to be seen in unexplained stillbirths . ...
To assess the usefulness and limitations of placental histology when morphological umbilical cord (UC) abnormality coexists with clinical UC compromise, 5634 consecutive placentas were divided into four groups and statistically compared: group 1—182 placentas from pregnancies with clinical features of UC compromise (variable decelerations, UC entanglement, prolapse, or true knot at delivery); group 2—1355 placentas with abnormal UC morphology or insertion; group 3—152 placentas with at least one phenotype from group 1 and one from group 2; group 4—3945 placentas with no clinical or morphological UC-related phenotypes (control group).Differences were analyzed by ANOVA or χ
2. Of 68 phenotypes studied, 13 clinical and 18 placental phenotypes were statistically significant. In group 1, 2 phenotypes were most common (oligohydramnios and abnormal fetal heart rate tracing). In group 2, 6 phenotypes were most common, including 4 clinical (abnormal umbilical artery Dopplers, nonmacerated stillbirth, multiple pregnancy, and fetal growth restriction) and 2 placental. In group 3, 23 phenotypes were most common, including 7 clinical (gestational hypertension, polyhydramnios, induction of labor, cesarean section, macerated stillbirth, congenital malformations, and abnormal 3rd stage of labor) and 16 placental. The existence of clinical signs of UC compromise alone was associated with the absence of pathomorphological placental abnormalities. However, the coexistence of clinical and abnormal morphological UC phenotypes was statistically significantly associated with placental histological signs of decreased fetal blood flow, hypoxia (acute and chronic post uterine), shallow placental implantation, and/or amnion nodosum. Thus, confirmation of clinical UC compromise should not be expected on placental examination if no morphological UC abnormality or abnormal UC insertion has been found.
... The most common genetic etiology for stillbirth is due to karyotype abnormalities, however many stillborn fetuses with normal karyotypes also have genetic abnormalities . -Placental causes include placental abruption, premature rupture of membranes, vasa previa, chorioamnionitis, vascular malformations and umbilical cord accidents such as knots or abnormal placement [21,40]. -External causes: Some common examples are: antepartum mother's injuries/trauma or delivery/labor incidents such as birth asphyxia and obstetric trauma. ...
... One series found that single nuchal cords were present in one quarter of deliveries and multiple nuchal cords were present in 3.7 percent 46 . An increase in blood flow resistance has been noted with even a single nuchal coil, oxygen saturation of umbilical cord blood can be altered, and a persistent nuchal cord can be associated with reduction in the middle cerebral artery S/D ratio (suggesting redistribution of blood flow to the brain) 44,46 . ...
Introduction: Intrauterine Foetal Death (IUFD) is one of the final pathways of adverse pregnancy outcome. It is a public health problem with increasing prevalence across diverse populations, especially in Sub-Saharan Africa. Objective: This population-based study was aimed at determining the rate and risk factors for IUFD in a secondary-level medical center in southern Nigeria Methodology: This was a retrospective age-matched case control study carried out among 402 women who were on admission in the maternity ward of General Hospital Anua, Akwa Ibom State, Nigeria between January 2006 and December 2016. They were selected using incidental non-probability sampling method from the hospital records. Data was analyzed using Statistical Package for the Social Sciences, version 23. Results: Average maternal age was 24.26 years among the case and 23.56 among the control participants. The age group 18-29 had the most participants (49.8%). The risk of intrauterine foetal death was statistically significant when assoiated with adverse perinatal outcome[OR = 1.05 (95%CI: 1.01-1.09, p value < 0.001)] ; malpresentation [OR = 0.16 (95%CI: 0.12-0.27, p value < 0.001)]; previous caesarean section[OR = 2.06 (95%CI: 1.31-2.61, p value < 0.001)] ; fetal macrosomia[OR = 3.71 (95%CI: 3.06-4.91, p value < 0.001)]; preeclampsia [OR = 1.34 (95%CI: 0.71-1.69, p value < 0.001)] ; ecclampsia [OR = 2.96 (95%CI: 1.92-3.61, p value < 0.001)] ; oligohydramnios[OR = 1.54 (95%CI: 1.12-1.94, p value < 0.001)] ; polyhydramnios [OR = 1.49 (95%CI: 1.34-1.76, p value < 0.001)] ;placenta abruption[OR = 3.84 (95%CI: 1.71-5.61, p value < 0.001)] ; placenta praevia[OR = 1.05 (95%CI: 1.62-2.19, p value < 0.001)] ; cord prolapse[OR = 4.69 (95%CI: 2.17-6.19, p value < 0.001)] ; true knot [OR = 3.16 (95%CI: 2.89-4.61, p value < 0.001)] ;and gestational diabetes [OR = 1.01 (95%CI: 1.94-2.05, p value < 0.001)]. Conclusion: Intrauterine fetal demise is associated with several risk factors which can be maternal, fetal or placental. This underscores the need for adequate antenatal surveillance, birth preparedness and complication readiness to avert the misfortune.
... No stillbirth occurred. Carey and Rayburn observed an overall rate of stillbirth of 0.7% in a cohort of 13,757 deliveries which excels our cohort by far . Furthermore, in his analysis, he could not find any connection between umbilical cord entanglement and stillbirth. ...
Neonaticide is a serious allegation that needs a complete chain of criminal investigations. In this context, a nuchal cord is considered to be responsible for an infant’s death, but there is a clear lack of evidence. The purpose of our study is to reveal if a nuchal cord can be responsible for stillbirth, poor perinatal outcome, or neonatal death in the forensic aspect. We conducted a prospective study in collaboration with the Augustinian Sisters’ Hospital in Cologne, Germany in the period from February 2014 to May 2016. Four-hundred eighty-six children were enrolled. All births were assessed regarding the occurrence of an umbilical cord entanglement, and perinatal outcome was measured by arterial blood gas analysis, Apgar after 1, 5, and 10 min after birth as well as the general vitality. The prevalence of a nuchal cord was 16.87%. Apgar decrease and acidosis were significantly associated with a nuchal cord. No adverse perinatal outcome was recorded in this constellation. There was no child death regarding the first 24 h, and no mother experienced a syncope while giving birth. We can conclude that a nuchal cord is not associated with adverse perinatal outcome.
... The growing body of evidence from previous observational studies suggests that the mere presence of nuchal cord is not associated with any clinically significant increment in the incidence of any clinically important adverse fetal/neonatal outcomes; as reported by Henry et al.  in their retrospective analysis of 219,337 live births during 6-year period with documented tight nuchal cord in 6.6% and loose nuchal cord in 21.6% and also in the analysis of 182,492 births by Cohain . This doesn't negate the several reported cases of stillbirths with umbilical cord loop(s) surrounding the fetal neck, indentation marks on the fetal neck, and petechial hemorrhages of the head and neck characteristic of strangulation ; although the cumulative large retrospective studies failed to demonstrate any increased risk of stillbirth in pregnancies complicated by nuchal cords [5,8,11]. It also doesn't nullify the two large retrospective studies including about 38,000 fetuses with nuchal cords that showed an increment of 60-80% in the incidence of abnormal intrapartum fetal heart rate patterns compared to those without nuchal cords [2,12]; in contrast to many prospective studies that failed to show any increased incidence of abnormal intrapartum fetal heart rate patterns . ...
Background/objective: The purpose of this study is to investigate the use of a more biologic parameter for evaluation of the effect of nuchal cord tightness; the study of blood flow in the umbilical arteries of nuchal cord using Doppler ultrasonography.
Methods: This prospective cohort study was conducted at Ain Shams University Maternity Hospital, Cairo, Egypt in the period between August 2015 and August 2017. Hundred primigravidas were recruited with nuchal cord diagnosed by Doppler ultrasonography; whereas the rest of the study population was included in the “Control group”. Doppler velocimetry study was then performed on a free-floating loop of the umbilical cord and Doppler indices were calculated. Both groups were followed up during labor: intrapartum events, mode of delivery and neonatal outcome were recorded.
Results: Intrapartum fetal heart rate abnormalities were significantly more common in the nuchal cord group compared to the control group. The overall CTG category was significantly more commonly reflecting abnormal FHR patterns in the nuchal cord group compared to the control group with 46.74% of the nuchal group patients falling within the “suspicious – pathological – need urgent intervention” categories. Intervention rate was significantly higher in the nuchal cord group than the control group (33.69 versus 21.84%). Moreover, incidence of intrapartum fetal heart rate abnormalities and intervention rate were significantly higher in the nuchal cord with abnormal Doppler subgroup compared to both nuchal cord with normal Doppler subgroup and the control group; with a calculated number needed to harm of 2.11.
Conclusions: In view of these results, it might be concluded that umbilical cord tightness affecting fetal hemodynamics (expressed by changes in umbilical artery Doppler) might be a determinate factor affecting the intrapartum course.
... A 2020 study on a group of nearly a quarter of a million patients showed no differences in mortality between patients diagnosed with NC vs. those without NC diagnosis . An increased risk of fetal or neonatal death in the event of intrauterine NC was also not indicated by several other large retrospective studies [1,8,13,17], even in tight nuchal cord situations . A 2020 meta-analysis including 145 studies showed an increased risk of stillbirth in the event of true umbilical cord knots (OR 4.65, 95% CI 2.09, 10.37) . ...
The twisting of the umbilical cord around the fetal neck is a common phenomenon in the delivery room, and despite the lack of univocal evidence of its negative impact on perinatal events, it causes anxiety and stress in patients. The aim of the study was to assess the prevalence of nuchal cord and its impact on adverse obstetric and neonatal outcomes.
We conducted a retrospective cohort study. All patients who gave birth in the clinic within one year (n = 1467) were included in the study group. We compared the prevalence of nuchal cord in distinct subgroups of patients. In the next stage, we estimated the chance of specific perinatal outcomes and compared the neonatal outcomes between groups with and without nuchal cord.
Nuchal cord was present in 24% of labors. It was twice as common among patients giving birth vaginally (32.14%) than among patients giving birth by a caesarean section (16.78%, p < 0.001). Nuchal cord was also more frequent in births with meconium-stained amniotic fluid (33.88% vs. 23.34%, p = 0.009). In the group of patients with nuchal cord, we observed a slight increase in the risk of a non-reassuring fetal heart rate trace (OR = 1.55, CI 95% 1.02-2.36) as an indication of the completion of labor by caesarean delivery. We did not note an increase in the risk of completing natural childbirth by vacuum extraction. In the group of nuchal cord patients, there was a higher chance of a serious or moderate neonatal condition in the first minute of life (Apgar 0-7 points) (OR = 2.00, 95% CI = 1.14-3.49).
Nuchal cord increases the risk of a caesarean delivery due to a non-reassuring fetal heart rate trace. Nuchal cord increases the chance of a reduced Apgar score (0-7 points) in the first minute of life. The observed relationships do not translate to neonatal arterial blood gas testing.
... Although a nuchal cord has been associated with several markers of poor neonatal outcome and some groups have reported an increase in perinatal mortality 16,17 , these studies were retrospective. Most studies have found no increase in the risk of stillbirth, especially if risk factors such as hypertension, abruption, diabetes, premature rupture of the membranes, oligohydramnios and major fetal anomalies are controlled for 13,14,38,48 . ...
To investigate the ability of ultrasound to detect the presence of a nuchal cord immediately prior to induction of labor and the association of its presence with delivery by Cesarean section.
A transabdominal ultrasound scan using gray-scale and color Doppler imaging was performed immediately prior to induction of labor in 289 women in a prospective study to assess the presence of a nuchal cord. The presence of a nuchal cord was classified as present, absent or uncertain. The outcomes of labor, delivery and the neonates were obtained from the patient notes after delivery.
A nuchal cord was present at 18% of deliveries. The incidence was not affected by parity, fetal position or reduced amniotic fluid volume. The sensitivity of ultrasound in diagnosing a nuchal cord was 37.5%, with specificity, positive and negative predictive values of 80%, 29% and 85%, respectively. The presence of a nuchal cord did not significantly increase the risk of delivery by Cesarean section (35% vs. 28%; relative risk = 1.22; 95% CI, 0.80-1.87), instrumental delivery for fetal distress, an abnormal cardiotocograph in labor or at delivery, an Apgar score < 7 at 1 min, arterial cord pH < 7.1 or neonatal unit admission.
The sensitivity of the ultrasound diagnosis of a nuchal cord is low prior to induction of labor at term. A nuchal cord does not appear to increase the risk of Cesarean section or of poor neonatal outcome. The low ultrasound detection rate of a nuchal cord limits its use in decision making prior to induction of labor in high-risk pregnancies.
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. The optimal classification system would identify the pathophysiologic entity initiating the chain of events that irreversibly led to death. Because the integrity of the classification is based on available pathologic, clinical, and diagnostic data, experts emphasized that a complete stillbirth workup should be performed. Experts developed evidence-based characteristics of maternal, fetal, and placental conditions to attribute a condition as a cause of stillbirth. These conditions include infection, maternal medical conditions, antiphospholipid syndrome, heritable thrombophilias, red cell alloimmunization, platelet alloimmunization, congenital malformations, chromosomal abnormalities including confined placental mosaicism, fetomaternal hemorrhage, placental and umbilical cord abnormalities including vasa previa and placental abruption, complications of multifetal gestation, and uterine complications. In all cases, owing to lack of sufficient knowledge about disease states and normal development, there will be a degree of uncertainty regarding whether a specific condition was indeed the cause of death.
Sadly, the death of a fetus may occur at any stage of a pregnancy, including during the labour process. A pregnancy loss will be devastating for the expectant parents. Obstetricians should be familiar with the management of intrauterine fetal death as prompt and appropriate counselling will aid the couple’s grief process. Understandably, couples wish to know the cause and chances of recurrence; thus, the full investigation of possible aetiological factors using a pragmatic approach will help in the postnatal counselling and management of future pregnancies. This review also explores the legal and ethical aspects of postmortem consent.
Presence of nuchal cord (NC) is associated with transient decrease of umbilical cord blood flow. However, the exact perinatal effect of presence of NC in a newborn is still under debate. The aim of this study was to evaluate the perinatal complications and umbilical cord blood gases of deliveries complicated with NC and summarize the associated literature. Gestational age-matched term singleton pregnancies complicated with NC (n=160) were compared with neonates without NC (n=160). Patients' files and Labor and Delivery Unit database were used to extract maternal age, gestational age, presence of NC, number of nuchal loops around fetal neck, intrapartum complications and umbilical cord blood gases. pH, pO2, pCO2, HCO3-, O2 saturation, and base excess were determined in all patients. Mean maternal age, mean gestational age, and birth weight were not significantly different between the two groups (p > 0.05). Occurrence of oligohydramnios, intrauterine growth retardation (IUGR), intrapartum abnormalities and Apgar scores < 7 at 1 minute were not significantly different between the groups (p>0.05). However, umbilical cord blood pH (7.32 vs. 7.30, p = 0.048), pO2 (37.4 +/- 18.1 vs. 31.7 +/- 14.4, p = 0.01) and O2 saturation (57.4 +/- 21.8 vs. 48.3 +/- 20.4, p = 0.005) were significantly lower in the NC group compared with the controls. Furthermore, the number of Apgar scores < 7 at 1 minute was significantly higher in neonates with multiple NC (28.1% vs. 9.2%, p = 0.007), and intrapartum abnormalities were more frequently seen in newborns with multiple NC (31.3% vs.15.6%, p = 0.04). The results of this study suggest that presence of single NC may negatively affect the umbilical cord blood gases without significant perinatal complications. However, multiple NC may also increase the development of intrapartum complications and lower Apgar scores. Perinatal effects of NC should be investigated with a large prospective study.
To identify by an inductive statistical analysis mutually similar and clinically relevant clinicoplacental clusters.
Twenty-nine maternofetal and 49 placental variables have been retrospectively analyzed in a 3382 case clinicoplacental database using a hierarchical agglomerative Ward dendrogram and multidimensional scaling.
The exploratory cluster analysis identified 9 clinicoplacental (macerated stillbirth, fetal growth restriction, placenta creta, acute fetal distress, uterine hypoxia, severe ascending infection, placental abruption, and mixed etiology [2 clusters]), 5 purely placental (regressive placental changes, excessive extravillous trophoblasts, placental hydrops, fetal thrombotic vasculopathy, stem obliterative endarteritis), and 1 purely clinical (fetal congenital malformations) statistically significant clusters/subclusters. The clusters of such variables like clinical umbilical cord compromise, preuterine and postuterine hypoxia, gross umbilical cord or gross chorionic disk abnormalities did not reveal statistically significant stability.
Although clinical usefulness of several well-established placental lesions has been confirmed, claims about high predictability of others have not.
Research is needed to determine the cause of unexplained stillbirth. Sudden antenatal death syndrome is an important national issue that requires more scrutiny. Umbilical cord accidents as a causative factor of stillbirth need intensive investigation. Evidence supports a role of the umbilical cord in a portion of stillbirth cases, and theory suggests additional causes. This article summarizes the known information relating umbilical cord accidents and stillbirth and highlights the research needs.
In many parts of the developed world the role of the perinatal necropsy has diminished in status, for a number of reasons. There may be a touching faith in the accuracy of noninvasive technology to provide all answers. There may be a suspicion that clinicians wish to experiment on deceased fetuses and newborns. These understandable beliefs may in part have stemmed both from the failure of obstetricians and neonatologists to explain to families the limitations of sophisticated equipment and from secrecy around the process of necropsy. Such secrecy was often well intentioned, and generally stemmed from a misguided wish to protect vulnerable parents from the details of the examination of their baby ' s body. In 2003 the British Medical Journal devoted an issue to the subject of death. It included fi ve editorials and fi ve original articles on mortality: the subject of necropsy was not mentioned once (Anon 2003).
There is an easy path for all clinicians. We can avoid asking for autopsies because the “baby has suffered enough” and suggest that our clinical skills, imaging, phlebotomy, microbiology, and histological capabilities have already given us the complete answer to the causes of the demise of the fetus or neonate. To take this line is to abrogate our responsibilities to the family. It is essential that we as clinicians should persuade our professional colleagues of the high value of necropsy, especially to bereaved families. Professionals should emphasize to parents that it is their opportunity and right to have a necropsy carried out on their baby. Only then can the most appropriate counseling be entered into with accuracy, confi -dence, and in a spirit of trust.
Umbilical cord around neck, a common obstetric complication, affects fetal hemodynamics. Does it influence fetal cardiac functions? The purpose of this study was to investigate the left and right ventricular systolic and diastolic functions of fetuses with umbilical cord around neck in the third trimester by applying velocity vector imaging (VVI).
Thirty-five cases of fetuses with umbilical cord around neck whose gestational ages from 35 to 40 weeks were selected, including 20 cases of umbilical artery ratio of the highest systolic velocity (S) to the lowest diastolic velocity (D) (S/D) < 3.0 and 15 cases of umbilical artery S/D ≥ 3.0, while 20 cases of normal fetuses of 35 - 40 gestational weeks were selected as the control group. The changes in longitudinal velocity, strain, and strain rate of fetal left and right ventricle in systole and diastole in two groups, and the changes in fetal cardiac function under the situation of umbilical cord around neck were analyzed.
Longitudinal strain and strain rate overall of fetal left and right ventricle in systole and diastole were less in fetuses with umbilical artery S/D (3)3.0 and umbilical cord around neck than those in fetuses with umbilical artery S/D < 3.0 and those in control group (P < 0.05); there was no significant difference (P > 0.05) in longitudinal strain and strain rate overall of fetal left and right ventricle in systole and diastole between fetuses with umbilical artery S/D < 3.0 and those in control group.
Left and right ventricular systolic and diastolic dysfunction was detected in fetuses with umbilical cord around neck and umbilical artery S/D (3)3.0. VVI could sensitively respond to cardiac function changes in fetuses with umbilical cord around neck, which provides another valuable method in the evaluation of fetal cardiac function.
The aim of this study was to determine the frequency of adverse maternal and fetal outcomes of both external cephalic version (ECV) and persisting breech presentation at term. We conducted a systematic review of the literature using Medline, Embase and All Evidence Based Medicine (EBM) Reviews databases. Data were extracted from studies that compared women who had an ECV from 36 weeks' gestation with a similar control group of women enrolled at the same gestational age, eligible for, but who did not have an ECV. Eleven studies with a total of 2503 women were included. Adverse outcomes related to ECV were rarely reported and in most studies there was no evidence that relevant outcomes were ascertained among similar women who did not have an ECV. There was no increased risk of antepartum fetal death associated with ECV, but numbers were small. There were no reported cases of uterine rupture, placental abruption, prelabour rupture of membranes or cord prolapse, but these outcomes were not examined among controls. Onset of labour within 24 h and nuchal cord was non-significantly higher among women who had an ECV compared with those with a persisting breech. Despite limited reporting and small numbers, the results of our review suggest that adverse maternal and fetal outcomes of both ECV and persisting breech presentation are rare. Only with improved reporting and collection of safety data on ECV and persisting breech presentation can we provide high-quality information to assist informed decision making by pregnant women with a breech presentation at term.
Probabilistic information on outcomes of breech presentation is important for clinical decision-making. We aim to quantify adverse maternal and fetal outcomes of breech presentation at term.
We conducted an audit of 1,070 women with a term, singleton breech presentation who were classified as eligible or ineligible for external cephalic version or diagnosed in labor at a tertiary obstetric hospital in Australia, 1997-2004. Maternal, delivery and perinatal outcomes were assessed and frequency of events quantified.
Five hundred and sixty (52%) women were eligible and 170 (16%) were ineligible for external cephalic version, 211 (20%) women were diagnosed in labor and 134 (12%) were unclassifiable. Seventy-one percent of eligible women had an external cephalic version, with a 39% success rate. Adverse outcomes of breech presentation at term were rare: immediate delivery for prelabor rupture of membranes (1.3%), nuchal cord (9.3%), cord prolapse (0.4%), and fetal death (0.3%); and did not differ by clinical classification. Women who had an external cephalic version had a reduced risk of onset-of-labor within 24 h (RR 0.25; 95%CI 0.08, 0.82) compared with women eligible for but who did not have an external cephalic version. Women diagnosed with breech in labor had the highest rates of emergency cesarean section (64%), cord prolapse (1.4%) and poorest infant outcomes.
Adverse maternal and fetal outcomes of breech presentation at term are rare and there was no increased risk of complications after external cephalic version. Findings provide important data to quantify the frequency of adverse outcomes that will help facilitate informed decision-making and ensure optimal management of breech presentation.
com-mon adverse pregnancy out-comes in the United States and affects approximately 1 in 160 pregnancies. 1 These approximately 26 000 still-births per year are equivalent to the number of infant deaths. 2 The still-birth rate in the United States is higher than that of many other developed countries. 3-5 From 1990-2003, the still-birth rate declined slowly but steadily, by an average of 1.4% per year. In con-trast, the infant mortality rate de-clined twice as fast by an average of 2.8% per year. 1 Since 2003 the still-birth rate in the United States has re-mained stagnant at 6.2 stillbirths per 1000 births, 1 59% higher than the Healthy People 2010 target goal of 4.1 fetal deaths per 1000 births. 6 US stillbirth prevalence shows sig-nificant racial disparity. The stillbirth rate for non-Hispanic black women is 2.3-fold higher than that of non-Hispanic white women (11.13 com-pared with 4.79 fetal deaths per 1000 live births and fetal deaths). 1 The rate for Hispanic women is 14% higher than for non-Hispanic white women (5.44 per 1000 live births and fetal deaths). Much of the racial disparity in still-birth remains unexplained. 7-11 The Stillbirth Collaborative Re-search Network (SCRN) was initiated by the Eunice Kennedy Shriver Na-tional Institute of Child Health and Hu-man Development (NICHD) to ad-dress this major public health issue. A workshop of experts convened by NICHD in 2001 concluded that vital records were inadequate to address the Context Stillbirth affects 1 in 160 pregnancies in the United States, equal to the num-ber of infant deaths each year. Rates are higher than those of other developed coun-tries and have stagnated over the past decade. There is significant racial disparity in the rate of stillbirth that is unexplained.
We report the management of a fetus with breech presentation and double nuchal cord in a mother desiring external cephalic version (ECV). The patient was a 26-year-old woman, gravida 1, para 0, with an unremarkable prenatal course, who was found to have a breech presentation at 34 weeks 1 day. She consented for external cephalic version (ECV) and upon evaluation at 36 weeks 2 days, the fetus was found to have double nuchal coils of the umbilical cord. ECV was not attempted. Subsequent fetal surveillance consisted of fetal movement counts, non-stress tests and Doppler ultrasound of the umbilical artery. At 38 weeks 1 day, ultrasound revealed absence of the nuchal coils. ECV was attempted and was successful. The fetus maintained the cephalic presentation and the patient delivered uneventfully. This case report illustrates the value of follow-up ultrasound in a patient who desires an ECV and for whom such a procedure was declined due to the presence of double nuchal coils. Cesarean delivery was successfully avoided.
The umbilical cord acts as the critical lifeline of the developing fetus by providing nutrients and oxygen to it. Umbilical cord abnormalities are considered the leading cause of stillbirth in humans, but information on stillbirths associated with umbilical cord abnormalities is very scant in the clinical practice of animals. Here, we described a case of fetal demise in camels indicated to be caused by fetal death from strangulation by its umbilical cord, which is commonly known as the nuchal cord. A pregnant camel at its 36 weeks of gestation spontaneously aborted a single fetus. The camel was 5 years old and nullipara. A 6-day-old cloned embryo was transferred transcervically to the recipient. Pregnancy was confirmed 50 days after embryo transfer by ultrasonography, and the pregnant camel was maintained under a standard nutritional plan. The neck of the aborted fetus was strangulated tightly by a double loop of the umbilical cord. There was no congenital anomaly or other malformation in the fetus. We concluded that the nuchal cord was tightly coiled around the neck of the fetus and interfered with the blood flow in the fetus by collapsing the umbilical vein and subsequently causing fetal death and abortion. To the authors' knowledge, this is the first reported case of a nuchal cord in camels.
Stillbirth is an important public health concern and its rate indicates the sanitary development of society. The purpose of this study is to determine the trend of stillbirth rates and its risk factors in Babol.
A retrospective study was conducted based on the data of hospital charts of two major Gynecological wards in Shahid Yahyanejat and Babol clinic hospitals in Babol, Northern Iran. In the first phase, the frequencies of stillbirths and live birth deliveries were collected for the period of 1999-2008. In the second phase, a case-control study of 150 stillbirths cases and 300 live births as controls was conducted. The risk factors data included maternal age, gestational age, gravity, history of stillbirth, abortion, diabetes mellitus, preeclampsia, fetal sex, residence area, birth interval and prenatal care. The odds ratio for risk factors with 95% confidence interval for stillbirths was calculated using the logistic regression model.
Stillbirth rate was reduced significantly from 10.51 in 1999 to 8.57 per 1000 deliveries in 2008 (p=0.001). A significant association was found between preterm delivery (p=0.001) and preeclampsia (p=0.01) with stillbirths. Although the proportion of stillbirths was higher among mothers with history of diabetes, abortion and maternal age of more than 35 years, the odds ratio was not statistically significant.
There is a relationship between stillbirth, preterm delivery and preeclampsia. Thus, we can considerably prevent stillbirths with sanitary remedial interference on these risk factors.
Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depends on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.
Current data on the role of the umbilical cord in pregnancy complications are conflicting; estimates of the proportion of stillbirths due to cord problems range from 3.4 to 26.7%. A systematic review and meta-analysis were undertaken to determine which umbilical cord abnormalities are associated with stillbirth and related adverse pregnancy outcomes.
MEDLINE, EMBASE, CINAHL and Google Scholar were searched from 1960 to present day. Reference lists of included studies and grey literature were also searched. Cohort, cross-sectional, or case-control studies of singleton pregnancies after 20 weeks' gestation that reported the frequency of umbilical cord characteristics or cord abnormalities and their relationship to stillbirth or other adverse outcomes were included. Quality of included studies was assessed using NIH quality assessment tools. Analyses were performed in STATA.
This review included 145 studies. Nuchal cords were present in 22% of births (95% CI 19, 25); multiple loops of cord were present in 4% (95% CI 3, 5) and true knots of the cord in 1% (95% CI 0, 1) of births. There was no evidence for an association between stillbirth and any nuchal cord (OR 1.11, 95% CI 0.62, 1.98). Comparing multiple loops of nuchal cord to single loops or no loop gave an OR of 2.36 (95% CI 0.99, 5.62). We were not able to look at the effect of tight or loose nuchal loops. The likelihood of stillbirth was significantly higher with a true cord knot (OR 4.65, 95% CI 2.09, 10.37).
True umbilical cord knots are associated with increased risk of stillbirth; the incidence of stillbirth is higher with multiple nuchal loops compared to single nuchal cords. No studies reported the combined effects of multiple umbilical cord abnormalities. Our analyses suggest specific avenues for future research.
Umbilical cord abnormalities are commonly cited as a cause of stillbirth, but details regarding these stillbirths are rare. Our objective was to characterize stillbirths associated with umbilical cord abnormalities using rigorous criteria and to examine associated risk factors.
The Stillbirth Collaborative Research Network conducted a case-control study of stillbirth and live births from 2006 to 2008. We analyzed stillbirths that underwent complete fetal and placental evaluations and cause of death analysis using the INCODE (Initial Causes of Fetal Death) classification system. Umbilical cord abnormality was defined as cord entrapment (defined as nuchal, body, shoulder cord accompanied by evidence of cord occlusion on pathologic examination); knots, torsions, or strictures with thrombi, or other obstruction by pathologic examination; cord prolapse; vasa previa; and compromised fetal microcirculation, which is defined as a histopathologic finding that represents objective evidence of vascular obstruction and can be used to indirectly confirm umbilical cord abnormalities when suspected as a cause for stillbirth. We compared demographic and clinical factors between women with stillbirths associated with umbilical cord abnormalities and those associated with other causes, as well as with live births. Secondarily, we analyzed the subset of pregnancies with a low umbilical cord index.
Of 496 stillbirths with complete cause of death analysis by INCODE, 94 (19%, 95% CI 16-23%) were associated with umbilical cord abnormality. Forty-five (48%) had compromised fetal microcirculation, 27 (29%) had cord entrapment, 26 (27%) knots, torsions, or stricture, and five (5%) had cord prolapse. No cases of vasa previa occurred. With few exceptions, maternal characteristics were similar between umbilical cord abnormality stillbirths and non-umbilical cord abnormality stillbirths and between umbilical cord abnormality stillbirths and live births, including among a subanalysis of those with hypo-coiled umbilical cords.
Umbilical cord abnormalities are an important risk factor for stillbirth, accounting for 19% of cases, even when using rigorous criteria. Few specific maternal and clinical characteristics were associated with risk.
This retrospective analysis was performed to find out if clusters of mineralized chorionic villi can be regarded as an independent feature of fetal vascular malperfusion (FVM).
Of all 1698 placentas reviewed by the author during the last 10 years, 39 (2.3%) showed clusters of mineralized chorionic villi (Group 1), 100 cases (5.9%) showed randomly scattered mineralized chorionic villi with without clustering (Group 2), and the remaining 1559 placentas showed no villous mineralization (comparative Group 3). In doubtful cases, histochemistry stains were performed to determine the pattern of villous mineralization. Twenty three independent clinical and 43 placental variables were statistically compared among the groups: descriptive statistics (Chi-square, Fisher test or signed rank test), and logistics regression model.
Clinically, Group 1 featured shorter gestational age than Group 2, and in addition to shorter gestational age, more common oligohydramnios, polyhydramnios, induction of labor, macerated stillbirth and fetal growth restriction than Group 3. Of placental variables, fetal vascular ectasia, and clusters of avascular chorionic villi were more common in Group 1 than in Group 2, and in addition, segmental villous stromal vascular karyorrhexis was more common than in Group 3. By the logistics regression mode, segmental villous mineralization was independently associated with other histological features of FVM as a group and particularly with clusters of sclerotic chorionic villi.
FVM is characterized by temporal heterogeneity, i.e. coexistence of lesions of various duration, and strongly and independently correlates with clusters of mineralized chorionic villi. Therefore, segmental villous mineralization should be included into the category of segmental FVM. It can be seen even in totally fibrotic placentas of prolonged stillbirth when other histological features of segmental vascular malperfusion can be obscured by global villous sclerosis.
To retrospectively statistically compare clinical and placental phenotypes of nonmacerated fetuses and live-born perinatal deaths in 3rd trimester pregnancies.
Twenty-five clinical and 47 placental phenotypes were statistically compared among 93 cases of nonmacerated (intrapartum, or recent antepartum death) 3rd trimester fetal deaths (Group 1), 118 3rd trimester neonatal deaths (Group 2) and 4285 cases without perinatal mortality (Group 3).
Sixteen clinical and placental phenotypes were statistically significantly different between Group 3 and the two groups of perinatal deaths, which included eight placental phenotypes of fetal vascular malperfusion and eight other placental phenotypes of various etiology (amnion nodosum, 2-vessel umbilical cord, villous edema, increased extracellular matrix of chorionic villi, erythroblasts in fetal blood and trophoblastic lesions of shallow placentation). Statistically significant differences between Groups 1 and 2 were scant (oligohydramnios, fetal malformations, cesarean sections, hypercoiled umbilical cord and amnion nodosum being more common in the latter, and retroplacental hematoma more common in the former).
Placental examination in neonatal mortality shows thrombotic pathology related to umbilical cord compromise and features of shallow placental implantation that are similar to those in nonmacerated stillbirth; however, the features of placental abruption were more common in recent antepartum death, as were the features related to neonatal congenital malformations in neonatal deaths.
Stillbirth is a common and devastating pregnancy complication. The aim of this study was to review and compare the recommendations of the most recently published guidelines on the investigation and management of this adverse outcome. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), the Perinatal Society of Australia and New Zealand (PSANZ), the Society of Obstetricians and Gynecologists of Canada (SOGC) on stillbirth was carried out. Regarding investigation, there is consensus that medical history and postmortem examination are crucial and that determining the etiology may improve care in a subsequent pregnancy. All guidelines recommend histopathological examination of the placenta, genetic analysis and microbiology of fetal and placental tissues, offering less invasive techniques when autopsy is declined and a Kleihauer test to detect large feto–maternal hemorrhage, whereas they discourage routine screening for inherited thrombophilias. RCOG and SOGC also recommend a complete blood count, coagulopathies’ testing, anti-Ro and anti-La antibodies’ measurement in cases of hydrops and parental karyotyping. Discrepancies exist among the reviewed guidelines on the definition of stillbirth and the usefulness of thyroid function tests and maternal viral screening. Moreover, only ACOG and RCOG discuss the management of stillbirth. They agree that, in the absence of coagulopathies, expectant management should be considered and encourage vaginal birth, but they suggest different labor induction protocols and different management in subsequent pregnancies. It is important to develop consistent international practice protocols, in order to allow effective determination of the underlying causes and optimal management of stillbirths, while identifying the gaps in the current literature may highlight the need for future research.
Les objectifs de ce chapitre sont multiples : étudier les données épidémiologiques concernant la mort fœtale in utero (MFIU), ses facteurs de risques et étiologies associées ainsi que d’évaluer les actions de prévention primaire et secondaire des MFIU. Nous étudierons aussi dans ce chapitre l’utilité de l’examen fœto-placentaire et de l’autopsie virtuelle par IRM et déterminerons une prise en charge pour l’inhibition de la lactation chez ces patientes.
Stillbirth occurring after 28 weeks gestation affects between 1.5-4.5 per 1,000 births in high-income countries. The majority of stillbirths in this setting occur in women without risk factors. In addition, many established risk factors such as nulliparity and maternal age are not amenable to modification during pregnancy. Identification of other risk factors which could be amenable to change in pregnancy should be a priority in stillbirth prevention research. Therefore, this study aimed to utilise an online survey asking women who had a stillbirth about their pregnancy in order to identify any common symptoms and experiences.
A web-based survey.
A total of 1,714 women who had experienced a stillbirth >3 weeks prior to enrolment completed the survey. Common experiences identified were: perception of changes in fetal movement (63% of respondents), reports of a "gut instinct" that something was wrong (68%), and perceived time of death occurring overnight (56%). A quarter of participants believed that their baby's death was due to a cord issue and another 18% indicated that they did not know the reason why their baby died. In many cases (55%) the mother believed the cause of death was different to that told by clinicians.
This study confirms the association between altered fetal movements and stillbirth and highlights novel associations that merit closer scrutiny including a maternal gut instinct that something was wrong. The potential importance of maternal sleep is highlighted by the finding of more than half the mothers believing their baby died during the night. This study supports the importance of listening to mothers' concerns and symptoms during pregnancy and highlights the need for thorough investigation of stillbirth and appropriate explanation being given to parents.
Nuchal cord type A and type B need to be distinguished at delivery. Type A encircles the neck in an unlocked pattern. Type B encircles the neck in a locked pattern. In a prospective review of nuchal cords the type B pattern occurred in 1 in 50 births. Cesarean section and stillbirth were associated with type B nuchal cord.
We sought to investigate what aspects of the stillbirth evaluation are considered to be essential and what tests can potentially be eliminated.
A retrospective analysis of 745 stillbirths occurring from January 1990 to December 1994 was conducted. A stillbirth was defined by an estimated gestational age >20 weeks' gestational age or fetal weight >500 gm. We attempted to arrive at an apparent cause for each stillbirth after evaluation of genetic or chromosomal abnormalities, obstetric history, maternal medical illnesses, laboratory tests, autopsy findings, and placental pathologic conditions.
We found that the most important aspects of stillbirth evaluation were placental pathologic conditions and autopsy. When the placenta was examined, a significant abnormality was detected in 30% (160 of 529) of the cases. When autopsy was performed, only 31% of fetal deaths (142 of 462) were unexplained; however, when no autopsy was performed, 44% (125 of 283) were unexplained (p = 0.0002). The following laboratory evaluations that were routinely performed were found to yield little definitive information: antinuclear antibody testing, Kleihauer-Betke test, and screening for congenital infections (toxoplasmosis, other viruses, rubella, cytomegalovirus, and herpes simplex virus). Overall, 36% (267 of 745) of stillbirths still remained unexplained despite a thorough evaluation in most cases.
The causes of stillbirth are many and varied, with a large proportion having no obvious cause. As this study demonstrates, certain laboratory tests can be eliminated in the workup of fetal death. In the evaluation of stillbirth a complete systematic method that incorporates placental pathologic conditions, as well as autopsy findings, should prove to be beneficial.