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Prospective risk of unexplained stillbirth in singleton pregnancies at term: population based analysis

Christina S Cotzias, research registrar ^a,  Sara Paterson-Brown, consultant ^b,  Nicholas M Fisk, professor ^a. 

^a Institute of Obstetrics and Gynaecology, Imperial College School of Medicine, Queen Charlotte's and Chelsea Hospital, London W6 0XG, ^b Queen Charlotte's and Chelsea Hospital

Correspondence to: Sara Paterson-Brown s.paterson-brown{at}rpms.ac.uk

Unexpected late fetal death is tragic but not uncommon, most such fetal deaths being unexplained. Although five times more common than sudden infant death,¹ they have attracted scant public attention.

Delivery is recommended when the risks to the fetus in utero are greater than those to the baby after birth; in high risk pregnancies this is generally believed to be around 38 weeks. The risk of unexplained stillbirth near term is, however, relevant to all pregnancies. Current numerical estimates do not detail risk by gestation,¹ and the few studies that have done so are no longer applicable in the United Kingdom in the late 1990s. Yudkin et al calculated the total risk of stillbirth by gestation using population data that are currently over 15 years old,² while Feldman calculated a prospective risk using data from a New York City population, including multiple pregnancies and a high proportion of women with no antenatal care.³ We calculated prospective risks of unexplained stillbirth by gestation in singleton pregnancies near term.

	Methods and results

Top Methods and results Comment References

We reviewed published data on 171 527 births in the North East Thames region in 1989-91⁴ and derived the number of ongoing pregnancies and stillbirths at or beyond each gestational week from 35 to 43 weeks. The prospective stillbirth rate per 1000 ongoing pregnancies was calculated as the number of stillbirths at or beyond week n divided by the number of pregnancies at or beyond week n multiplied by 1000, where n is the week of gestation from 35 to 43 weeks.

As the original dataset included all stillbirths (explained and unexplained and those in multiple pregnancies), we applied correction factors to derive gestation specific risks of unexplained stillbirth in singleton pregnancies near term as follows. We used data from the Office for National Statistics for 1994 to estimate the proportion of all births (live births and stillbirths) that were singleton (650 826/659 545=0.9868) and the proportion of overall stillbirths that were in singleton pregnancies (3465/3813=0.9087). We used data from the 1994 confidential enquiry into stillbirths and deaths in infancy¹ to estimate the proportion of total stillbirths of fetuses >2500 g that were unexplained (833/1137=0.7326).

The table shows the risk of stillbirth in ongoing pregnancies. At or beyond 38 weeks one in 730 singleton pregnancies were complicated by an unexplained stillbirth at term and one in 529 by stillbirth of any cause. Stillbirths of any cause may be more relevant because all stillbirths beyond 38 weeks are arguably unexpected since fetuses with recognised risk factors have usually been delivered by this time.

	Comment

Top Methods and results Comment References

We acknowledge that the risks we report are approximations, being derived from three sources of data, but they provide the first quantifiable estimate of risk in continuing singleton pregnancies near term. This information is relevant to modern obstetric practice, where women want to be informed and have high expectations about the safety of their unborn child. Most women would want a caesarean section if the risk of fetal death or damage to their child exceeded one in 4000.⁵ Our calculations show that the risk of stillbirth at term is five to eight times higher than this.

Interestingly, at 38 weeks the risks of stillbirth near term exceed those at 42 weeks, when delivery is usually recommended. Delivering women routinely at 38 weeks would lead to a high incidence of caesarean section with its attendant risks, either primarily or from failed induction, in addition to a small risk of iatrogenic neonatal respiratory morbidity.

Antepartum stillbirth is a major public health problem, accounting for a greater contribution to perinatal mortality than either deaths as a consequence of prematurity or the sudden infant death syndrome.¹ Research into the underlying mechanisms and aetiological factors of this problem to identify pregnancies at risk must remain a prerequisite for any selective strategy to prevent these deaths.

	Acknowledgments

   Contributors: CSC refined the methodology, collected and analysed the data, and drafted the paper. SP-B contributed to the study design, analysis, and paper drafts. NMF had the original idea for the study and contributed to drafting and revising the paper. CSC is guarantor for the study.

	Footnotes

Funding: None.

Competing interests: None declared.

	References

Top Methods and results Comment References

1.	Confidential Enquiry into Stillbirths and Deaths in Infancy. Fourth and fifth annual reports. London: Stationery Office , 1996 and 1998.
2.	Yudkin PL, Wood L, Redman CWG. Risk of unexplained stillbirth at different gestational ages. Lancet 1987; i: 1192-1194
3.	Feldman G. Prospective risk of stillbirth. Obstet Gynecol 1992; 79: 547-552[Medline].
4.	Hilder L, Costeloe K, Thilaganathan B. Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality. Br J Obstet Gynaecol 1998; 105: 169-173[Medline].
5.	Thornton J, Lilford R. The caesarean section decision: patients' choices are not determined by immediate emotional reactions. J Obstet Gynaecol 1989; 9: 283-288.

(Accepted 25 February 1999)