Infection-related stillbirths (original) (raw)
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Maternal infection and stillbirth: a review
The Journal of Maternal-Fetal & Neonatal Medicine, 2020
Introduction: Maternal infections likely are an important cause of stillbirths, especially in sub-Saharan Africa and south Asia, where the burden is highest. Due to the lack of routine testing for infection, which can be complex and often expensive, the prevalence of infection during pregnancy and the association of many infections with stillbirth are not well-documented, especially in low-resource countries. Methods: Following an extensive literature review of infection and stillbirth initially published in 2010, we conducted a review of literature in the last 10 years to identify infections associated with stillbirth, focused on those in low-resource settings. Results: During the last 10 years, over 40 bacterial, viral and other pathogens have been associated with stillbirth. Newly emerging viral infections such as Denge as well as several well-established, but not yet eliminated infections such as rubella have been associated with stillbirth. Two of the maternal infections most strongly associated with stillbirth, each with about a 2-fold risk, are malaria and syphilis but others have been associated with risk in a range of studies. With a lack of routine antenatal screening, many pathogens are identified as associated with stillbirth only through case reports. Infection remains an important, yet understudied, cause of stillbirth. Conclusion: Research studies to determine definitive associations between various infections and stillbirth are important to better understand the role of infections and strategies to reduce infection-related stillbirth. Summary This review explores the association between infections and stillbirths focusing on low-income country studies published in the last 10 years. Much information about these relationships comes from case reports. Research resulting in a better understanding of the causes and strategies to reduce infection-related stillbirth is necessary.
Seminars in Fetal and Neonatal Medicine, 2009
s u m m a r y Infection may cause stillbirth by several mechanisms, including direct infection, placental damage, and severe maternal illness. Various organisms have been associated with stillbirth, including many bacteria, viruses, and protozoa. In developed countries, between 10% and 25% of stillbirths may be caused by an infection, whereas in developing countries, which have much higher stillbirth rates, the contribution of infection is much greater. In developed countries, ascending bacterial infection, both before and after membrane rupture, with organisms such as Escherichia coli, group B streptococci, and Ureaplasma urealyticum is usually the most common infectious cause of stillbirth. However, in areas where syphilis is prevalent, up to half of all stillbirths may be caused by this infection alone. Malaria may be an important cause of stillbirth in women infected for the first time in pregnancy. The two most important viral causes of stillbirth are parvovirus and Coxsackie virus, although a number of other viral infections appear to be causal. Toxoplasma gondii, Listeria monocytogenes, and the organisms that cause leptospirosis, Q fever, and Lyme disease have all been implicated as etiologic for stillbirth. In certain developing countries, the stillbirth rate is high and the infection-related component so great that achieving a substantial reduction in stillbirth should be possible by reducing maternal infections. However, because infection-related stillbirth is uncommon in developed countries, and because those that do occur are caused by a wide variety of organisms, reducing this etiologic component of stillbirth much further will be difficult.
Reducing stillbirths in low-income countries
Acta obstetricia et gynecologica Scandinavica, 2015
Worldwide, 98% of stillbirths occur in low-income countries (LIC), where stillbirth rates are 10-fold higher than in high-income countries (HIC). While most HIC stillbirths occur in the prenatally, in LIC most stillbirths occur at term and during labor/delivery. Conditions causing stillbirths include those of maternal origin (obstructed labor, trauma, antepartum hemorrhage, preeclampsia/eclampsia, infection, diabetes, other maternal diseases), and fetal origin (fetal growth restriction, fetal distress, cord prolapse, multiples, malpresentations, congenital anomalies). In LIC, aside from infectious origins, most stillbirths are caused by fetal asphyxia. Stillbirth prevention requires recognition of maternal conditions, and care in a facility where fetal monitoring and expeditious delivery are possible, usually by cesarean section. Of major causes, only syphilis and malaria can be managed prenatally. Targeting single conditions or interventions is unlikely to substantially reduce stil...
Gates open research, 2023
Stillbirth, one of the most common adverse pregnancy outcomes, is especially prevalent in low and middle-income countries (LMICs). Understanding the causes of stillbirth is crucial to developing effective interventions. In this commentary, investigators working across several LMICs discuss the most useful investigations to determine causes of stillbirths in LMICs. Useful data were defined as 1) feasible to obtain accurately and 2) informative to determine or help eliminate a cause of death. Recently, new tools for LMIC settings to determine cause of death in stillbirths, including minimally invasive tissue sampling (MITS)-a method using needle biopsies to obtain internal organ tissue from deceased fetuses for histology and pathogen identification in those tissues have become available. While placental histology has been available for some time, the development of the Amsterdam Criteria in 2016 has provided a useful framework to categorize placental lesions. The authors recommend focusing on the clinical history, the placental evaluation, the external examination of the fetus, and, when available, fetal tissue obtained by MITS, especially of the lung (focused on histology and microbiology) and brain/cerebral spinal fluid (CSF)
Causes of stillbirths among women from South Africa: a prospective, observational study
The Lancet Global Health, 2019
Background About 2•6 million third-trimester stillbirths occur annually worldwide, mostly in low-income and middleincome countries, where the causes of these deaths are rarely investigated. Methods We did a prospective, hospital-based, observational study in Soweto, South Africa, to investigate the causes of stillbirths in fetuses of at least 22 weeks' gestational age or with a birthweight of at least 500 g. Maternal clinical information was abstracted from medical records. Investigations included placental macroscopic and histopathological examination and fetal blood culture (including screening for pathogenic bacteria associated with stillbirth). Cases missing one or more of these investigations were considered to have incomplete samples and were excluded from the analysis of cause of stillbirth. Causes of stillbirths were assessed by individual case reviews by at least two obstetricians, and classified with a modified Stillbirth Collaborative Research Network classification system. Findings Between Oct 9, 2014, and Nov 8, 2015, we enrolled 354 stillbirths (born to 350 women). Among the women with available data, 133 (38%) of 350 had hypertension, median age was 27 years (IQR 23-33), 51 (18%) of 291 were obese, six (2%) of 344 had syphilis, and 94 (27%) of 350 had HIV. 63 (18%) of 341 fetuses showed intrauterine growth restriction. Of 298 cases (born to 294 mothers) with complete samples, the most common causes of stillbirth were maternal medical conditions (64 [21%] cases; among them 56 [19%] with hypertensive disorders and six [2%] with diabetes), placental or fetal infections (58 [19%]; 47 [16%] with fetal invasive bacterial infection), pathological placental conditions (57 [19%]; among them 27 [9%] with fetal membrane and placental inflammation and 26 [9%] with circulatory abnormalities), and clinical obstetric complications (54 [18%]; 45 [15%] with placental abruption). Six (2%) stillbirths were attributed to fetal, genetic, or structural abnormalities. In 55 (18%) cases, no cause of death was identified. The most common bacteria to which stillbirths due to fetal invasive infections were attributed were group B streptococcus (15 [5%] cases), E coli (12 [4%]), E faecalis (six [2%]), and S aureus (five [2%]). Interpretation Targeted investigation of stillbirths (even without fetal autopsy) can ascertain a cause of stillbirth in most cases. Further studies using such investigations are needed to inform the prioritisation of interventions to reduce stillbirths globally. Funding Novartis and GlaxoSmithKline.
Epidemiology of stillbirth in low-middle income countries: A Global Network Study
Acta Obstetricia et Gynecologica Scandinavica, 2011
Objective. To determine population-based stillbirth rates and to determine whether the timing and maturity of the stillbirths suggest a high proportion of potentially preventable deaths. Design. Prospective observational study. Setting. Communities in six low-income countries (Democratic Republic of Congo, Kenya, Zambia, Guatemala, India, and Pakistan) and one site in a mid-income country (Argentina). Population. Pregnant women residing in the study communities. Methods. Over a five-year period, in selected catchment areas, using multiple methodologies, trained study staff obtained pregnancy outcomes on each delivery in their area. Main outcome measures. Pregnancy outcome, stillbirth characteristics. Results. Outcomes of 195 400 deliveries were included. Stillbirth rates ranged from 32 per 1 000 in Pakistan to 8 per 1 000 births in Argentina. Three-fourths (76%) of stillbirth offspring were not macerated, 63% were ≥37 weeks and 48% weighed 2 500g or more. Across all sites, women with no education, of high and low parity, of older age, and without access to antenatal care were at significantly greater risk for stillbirth (p<0.001). Compared to those delivered by a physician, women delivered by nurses and traditional birth attendants had a lower risk of stillbirth. Conclusions. In these low-middle income countries, most stillbirth offspring were not macerated, were reported as ≥37 weeks' gestation, and almost half weighed at least 2 500g. With access to better medical care, especially in the intrapartum period, many of these stillbirths could likely be prevented.
Commentary: reducing the world's stillbirths
BMC Pregnancy and Childbirth, 2009
The 3.2 million stillbirths that occur worldwide each year are largely absent from global data tracking, policy dialogue and programmes. Limitations of global stillbirth data and a lack of consensus surrounding priority interventions render stillbirths invisible in policy and programmes. This supplement provides an in-depth analysis of the burden and evidence base for potential interventions to avert stillbirths. Lead investigators from the Aga Khan University (Karachi, Pakistan), supported by colleagues from Johns Hopkins University (Baltimore, USA) and Saving Newborn Lives (South Africa), reviewed evidence for impact of interventions to prevent stillbirths and strategies for delivering them.
Stillbirths: Epidemiology, Evidence, and Priorities for Action
Seminars in Perinatology, 2010
The annual global burden of stillbirths amounts to an estimated 3.2 million%, 98% of which occur in low-and middle-income countries (LMICs). Of these, 1.02 million (32%) are intrapartum, ie, taking place during labor. The most important causes of stillbirths in LMICs include obstructed or prolonged labor, hypertensive diseases of pregnancy, syphilis and gram-negative infections, malaria in endemic areas, and undernutrition. Interventions that target these causes can play an important role in reducing stillbirths. There is a clear benefit of emergency obstetrical care, particularly Cesarean delivery, on intrapartum rates in LMICs when Cesarean rates are less than 8% to 10%. Provision of a skilled birth attendant is another important intervention whereby labor complications can be prevented, identified, managed, and/or referred. Among interventions for infections, syphilis screening and treatment can prevent as many as 50% of all stillbirths in areas with high syphilis prevalence, reducing the risk of stillbirths among treated women to that of untreated women. Intermittent preventive treatment of malaria and insecticide-treated mosquito nets are also interventions with strong recommendation, especially in the first 2 pregnancies. Balanced energy protein supplementation is an important nutritional intervention to prevent stillbirths in undernourished women, especially in LMICs. Creation of increased demand for health services within communities and increasing their uptake also can play a role in averting stillbirths. Other potential social and behavioral interventions include birth spacing, smoking cessation and indoor air pollution control, although the evidence for these is weak. Semin Perinatol 34:387-394
BMC Public Health, 2011
Background Infection 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. Methods We 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. Results A total of 25 studies were included in the review. A random-effects meta-analysis of observati...