Glenn Gardener

An evaluation of classification systems for stillbirth.

BackgroundAudit and classification of stillbirths is an essential part of clinical practice and a crucial step towards stillbirth prevention. Due to the limitations of the ICD system and lack of an international approach to an acceptable solution, numerous disparate classification systems have emerged. We assessed the performance of six contemporary systems to inform the development of an internationally accepted approach.MethodsWe evaluated the following systems: Amended Aberdeen, Extended Wigglesworth; PSANZ-PDC, ReCoDe, Tulip and CODAC. Nine teams from 7 countries applied the classification systems to cohorts of stillbirths from their regions using 857 stillbirth cases. The main outcome measures were: the ability to retain the important information about the death using the InfoKeep rating; the ease of use according to the Ease rating (both measures used a five-point scale with a score <2 considered unsatisfactory); inter-observer agreement and the proportion of unexplained stillbirths. A randomly selected subset of 100 stillbirths was used to assess inter-observer agreement.ResultsInfoKeep scores were significantly different across the classifications (p ≤ 0.01) due to low scores for Wigglesworth and Aberdeen. CODAC received the highest mean (SD) score of 3.40 (0.73) followed by PSANZ-PDC, ReCoDe and Tulip [2.77 (1.00), 2.36 (1.21), 1.92 (1.24) respectively]. Wigglesworth and Aberdeen resulted in a high proportion of unexplained stillbirths and CODAC and Tulip the lowest. While Ease scores were different (p ≤ 0.01), all systems received satisfactory scores; CODAC received the highest score. Aberdeen and Wigglesworth showed poor agreement with kappas of 0.35 and 0.25 respectively. Tulip performed best with a kappa of 0.74. The remainder had good to fair agreement.ConclusionThe Extended Wigglesworth and Amended Aberdeen systems cannot be recommended for classification of stillbirths. Overall, CODAC performed best with PSANZ-PDC and ReCoDe performing well. Tulip was shown to have the best agreement and a low proportion of unexplained stillbirths. The virtues of these systems need to be considered in the development of an international solution to classification of stillbirths. Further studies are required on the performance of classification systems in the context of developing countries. Suboptimal agreement highlights the importance of instituting measures to ensure consistency for any classification system.

Causes of death and associated conditions (Codac) – a utilitarian approach to the classification of perinatal deaths

A carefully classified dataset of perinatal mortality will retain the most significant information on the causes of death. Such information is needed for health care policy development, surveillance and international comparisons, clinical services and research. For comparability purposes, we propose a classification system that could serve all these needs, and be applicable in both developing and developed countries. It is developed to adhere to basic concepts of underlying cause in the International Classification of Diseases (ICD), although gaps in ICD prevent classification of perinatal deaths solely on existing ICD codes.We tested the Causes of Death and Associated Conditions (Codac) classification for perinatal deaths in seven populations, including two developing country settings. We identified areas of potential improvements in the ability to retain existing information, ease of use and inter-rater agreement. After revisions to address these issues we propose Version II of Codac with detailed coding instructions.The ten main categories of Codac consist of three key contributors to global perinatal mortality (intrapartum events, infections and congenital anomalies), two crucial aspects of perinatal mortality (unknown causes of death and termination of pregnancy), a clear distinction of conditions relevant only to the neonatal period and the remaining conditions are arranged in the four anatomical compartments (fetal, cord, placental and maternal).For more detail there are 94 subcategories, further specified in 577 categories in the full version. Codac is designed to accommodate both the main cause of death as well as two associated conditions. We suggest reporting not only the main cause of death, but also the associated relevant conditions so that scenarios of combined conditions and events are captured.The appropriately applied Codac system promises to better manage information on causes of perinatal deaths, the conditions associated with them, and the most common clinical scenarios for future study and comparisons.

Neurodevelopmental outcome and risk factors for disability for twin-twin transfusion syndrome treated with laser surgery

OBJECTIVE This study was performed to report the neurodevelopmental outcome of survivors of twin-twin transfusion syndrome (TTTS) treated with laser surgery and to determine the risk factors for neurodevelopmental disability. STUDY DESIGN A prospective study of TTTS cases treated with laser was performed. Survivors were assessed at 2 years corrected for prematurity. Neurodevelopmental disability was defined as the presence of cerebral palsy, deafness, blindness, or cognitive impairment with a developmental score >2 SDs below the mean. RESULTS A total of 75 TTTS pregnancies were treated with a perinatal survival rate of 79.3%. A total of 113 survivors were assessed. The rate of cerebral palsy was 4.4% and cognitive impairment was 8%, with a neurodevelopmental disability rate of 12.4%. Quintero stage was the only independent risk factor for neurodevelopmental disability. CONCLUSION The incidence of neurodevelopmental disability in TTTS survivors treated with laser is considerable, with Quintero stage being an independent risk factor.

Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial.

Congenital diaphragmatic hernia (CDH) may be isolated or associated with other structural anomalies, the latter with poor prognosis. The defect allows viscera to herniate through the defect into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. When isolated, survival chances can be predicted by antenatal measurement of lung size and liver herniation. Chromosomal microarrays and exome sequencing contribute to understanding genetic factors underlying isolated CDH. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion (FETO) under local anesthesia. The Tracheal Occlusion To Accelerate Lung growth trial (www.totaltrial.eu) is an international randomized trial investigating the role of fetal therapy for severe and moderate pulmonary hypoplasia. Despite an apparent increase in survival following FETO, the search for lesser invasive and more potent prenatal interventions must continue.

Detection and management of decreased fetal movements in Australia and New Zealand: a survey of obstetric practice.

Background:  Decreased fetal movement (DFM) is associated with increased risk of adverse pregnancy outcome. However, there is limited research to inform practice in the detection and management of DFM.

Selective fetoscopic laser ablation in 100 consecutive pregnancies with severe twin–twin transfusion syndrome

Aims: To report the perinatal outcomes of a large series of twin pregnancies with severe twin–twin transfusion syndrome (TTTS) managed with laser ablation surgery in an Australian tertiary perinatal centre and to compare the outcome with other large cohorts.

Anti‐D in pregnant women with the RHD(IVS3+1G>A)‐associated DEL phenotype

BACKGROUND: Pregnant women with the DEL phenotype appear to be D– by routine serology. Women with DEL phenotypes that show a partial D‐like epitope loss may develop anti‐D. It has been proposed that this alloantibody could have a deleterious effect with respect to hemolytic disease in the fetus and newborn.

Influence of polyhydramnios on perinatal outcome in pregestational diabetic pregnancies

This study was carried out to evaluate the perinatal outcomes of pregnancy with pregestational diabetes mellitus complicated by polyhydramnios.

Early onset, severe fetal growth restriction with absent or reversed end-diastolic flow velocity waveform in the umbilical artery: Perinatal and long-term outcomes

Objective: To assess perinatal and long‐term outcomes for pregnancies complicated by early onset, severe fetal growth restriction with absent or reverse end‐diastolic flow velocity waveform (AREDF) in the umbilical artery.

Noninvasive fetal RHD genotyping by microfluidics digital PCR using maternal plasma from two alloimmunized women with the variant RHD(IVS3+1G>A) allele

Whats already known about this topic? Noninvasive prenatal RHD typing can be achieved by using cell-free fetal DNA in the plasma of RhD-negative mothers. For RhD-negative mothers carrying intact but dysfunctional RHD gene variants, the abundant maternal RHD sequences in maternal plasma could interfere with the fetal RHD allele detection. What does this study add? Digital PCR provides a high analytical specificity to noninvasively determine the fetal inheritance of RHD allele in alloimmunized pregnancies involving maternal RHD variants.