Current Stillbirth Classifications Current Stillbirth Classifications

Vicki Flenady, Frederik Froen, Adrian Charles, Halit Pinar

Purpose of this studyPurpose of this study

To describe the characteristics of current To describe the characteristics of current classification systems for stillbirths to inform classification systems for stillbirths to inform

the development of an internationally the development of an internationally acceptable stillbirth classification.acceptable stillbirth classification.

The aim of any classification must be to derive strategies to understand the reasons for, and ultimately prevent perinatal mortality.

Keeling et al 1989

Why classify?Why classify?

Counselling parents: alleviate anxiety – “what went wrong”, future pregnancies

Education: training and practice improvement

Epidemiology: identification of groups for closer investigation; and ongoing monitoring

Public health: policy development prevention, health service utilisation

Research: finding the answers to reduce the risk

Specific purposes of stillbirth Specific purposes of stillbirth classificationclassification

“The basic problem in the classification of perinatal deaths is the complexity of the clinical situation within which the fetus (…) dies.”

Jonathan Jonathan WigglesworthWigglesworth on on ascertaining the main cause of deathascertaining the main cause of death

What makes a good classification?What makes a good classification?Classification CriteriaClassification Criteria by De Galan-Roosen

Ease of use by clinicians and perinatal pathologists with uniform definitions;

Ease of expansion in terms of sub classification; Good level of agreement (low inter-observer

variability); Based on clinical factors and autopsy findings

including histology of the placenta; Explain the underlying cause of death; Suitable in stillbirth as well as neonatal death; Result in a high percentage of classifiable cases and

a low percentage of unexplained cases

One more: ABILITY TO RETAIN ALL IDENTIFIED SIGNIFICANT INFORMATION ABOUT THE DEATH

MethodsMethodsSystematic literature search

Sources:

Electronic databases and expert informants. English language.

Inclusion criteria: Unique classifications systems to determine causes of stillbirth (+/-neonatal)

Published cohorts occurring 1996 onwards

Exclusions: “informal” groupings of deaths, minor modifications of existing classifications

ResultsResults

Potentially eligible for inclusion: 11

Excluded: 7 •Revisions of included systems - 2

•Cohorts <1996 - 4

Included studies: 5

Current classificationsCurrent classificationsClassification Country Population Factors

Amended Aberdeen

(1969) UK SB, NND Maternal, fetal

Extended

Wigglesworth (1986)

UK SB, NND Maternal, fetal

PSANZ-PDC

(2004) Australia SB (20wks),

NND Maternal, fetal,

limited placental pathology

ReCode (2005)

UK SB Maternal, fetal, some placental

pathology

Tulip (2006)

Netherlands SB (16wks), NND, PNND*

Maternal, fetal, some placental

pathology

Aberdeen To identify the factor that probably initiated the train of events leading to the death for the purpose of prevention.

Wigglesworth To identify the cause of perinatal death to

improve understanding for the purposes of prevention.

PSANZ To identify the factor that initiated the sequence

of events leading to the death – for the purposes of prevention.

ReCode To identify the relevant condition at the time of

death. “What went wrong , ….not necessarily why”. For teaching, counselling, public health policy.

Tulip To identify the underlying cause and

mechanism of death for the purpose of counselling and prevention.

User friendliness and validity….User friendliness and validity…. Categories

Major -Total Hierarchy Definitions

Guides Agreement

Aberdeen 8 - 22 Yes No/Minimal Good Wigglesw. 9-3 Yes No/Minimal Fair PSANZ 11-118 Mostly Yes Excellent ReCode 37-39 Yes Minimal ? Tulip 6-42 “Not

strictly” Yes Excellent

Includes categories for …..Includes categories for ….. FGR Unexplained

AP death Unclassifiable

Assoc. Cond.

IP death

Aberdeen No Partially

includes, IP deaths, NND

Yes No No

Wigglesw. No Yes Yes

(“last resort”) No Yes

PSANZ Yes Yes Partially Yes Yes ReCode Yes Yes Yes Yes Yes Tulip No Partially

includes NND

Yes No No

Risk for unexplained stillbirth

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

23 29 31 34 36 38 40 42

Gestational age

Risk

per

100

0 on

goin

g pr

egna

ncie

s FrøenHuangSingerYudkin

Risk factors for unexplained stillbirth

Late gestation

Overweight / obesity (OR 2.5)

Maternal Age 35+ (OR 3-5)SmokersLow edu./ socioecon. status

Multiparity(OR 3-5)

Intrauterine growth restriction(OR 3)

Reduced fetal movements

Potentially Preventable

0 10 20 30 40 50 60 70

Ireland 93 (Walsh 1995)Wales (Tuthill 1999)UK (Cesdi 2001)Sweden (Winbo 2001)UK (Gardosi 1998)Australia (Alessandri 1992)New Z (Westgate 1985)UK (Wagaarachchi 2002)UK (Shankar 2002)UK (Yudkin 1987)USA (Ananth 1995)USA (Lammer 1989)France (Goffinet 1996)France (Coujard 1975)Norway (Rasmussen 2003)USA (Brans 1984)USA (Incerpi 1998)Saudi Arabia (Meshle 2001)Australia & NZ (Flenady 2003)Australia (Robson 2001)Canada (Huang 2000)Norway (Frøen 2001)Queensland (Flenady 2003)Denmark (Kesmodel 2002)India (Naidu 2001)Sweden (Ahlenius 1995)Ireland 70ies (Walsh 1995)Sweden (Petersson 2002)

Unexplained: proportion of stillbirthsUnexplained: proportion of stillbirths

Main categories of stillbirthsMain categories of stillbirths Unexplained

SB %

CA %

Spont. Preterm

%

APH %

FGR %

Total major

Aberdeen (CESDI)

50 12 12 74

Wiggles. (CESDI)

70 13 80

PSANZ 28 20 10 8 64 ReCode 15 15 43 73 Tulip na na na na

Sub optimal care: Sub optimal care: EuroNatalEuroNatal studystudy

See you at the round table!

Thank youThank you

Amended Aberdeen Classification (1969)

Whitfield et al Classification (1986)

PSANZ-PDC Classification (2000)

Fetal deformity Fetal abnormality Congenital abnormality Infection of the fetus or neonate

Infection Perinatal infection

Toxaemia Hypertension Hypertension Antepartum haemorrhage (APH)

APH APH

Maternal disease Maternal disease Maternal conditions Mechanical causes Birth trauma Specific perinatal

conditions (includes Birth trauma,

Serological incompatibility Hemolytic disease Alloimmune disease, Twin-twin transfusion)

Intrapartum asphyxia Hypoxic peripartum death Deaths of unknown origin IUGR (Intrauterine

Growth Retardation) Fetal growth restriction

Premature (5½lb/2500g or less) Spontaneous preterm Spontaneous preterm Mature (more than 5½lb/2500g) Unexplained

intrauterine death Unexplained antepartum death

Miscellaneous Unclassified

Other causes No obstetric antecedent (includes Unknown, SIDS and postnatally acquired infection)

Extended Wigglesworth

Revised Aberdeen

Fetal and Neonatal Classification

1954 Aberdeen Maternity 1954 Aberdeen Maternity Hospital ClassificationHospital Classification

1. Cause unknown: Premature (5½lb or less) (20%), Mature (14%);

2. Trauma – mechanical stress during labour (19%);

3. Fetal deformity (15%) 4. Antepartum haemorrhage (11%); 5. Toxaemia (10%); 6. Maternal disease (6%); 7. Other causes (5%).

UK obstetric antecedent classificationsUK obstetric antecedent classifications

Amended Aberdeen Classification (1969) Fetal deformity Infection of the fetus or neonate Toxaemia Antepartum haemorrhage Maternal disease Mechanical causes Serological incompatibility Deaths of unknown origin Premature (5½lb/2500g or less) Mature (more than 5½lb/2500g) Miscellaneous Unclassified

PSANZ PSANZ Guidelines and training casesGuidelines and training cases

Thank youThank you

CESDI 8CESDI 8THTH ReportReport

Causes of Late Fetal Death (>28wks) Causes of Late Fetal Death (>28wks)

PSANZPSANZ--PDCPDCMMH 1994MMH 1994--20042004

Specific perinatal conditions

11%

Antepartum haemorrhage

9%

Perinatal infection0%

Congenital abnormality

14%

Hypertension3%

No obstetric antecedent

0%

Maternal conditions5%

Spontaneous preterm4%

Unexplained antepartum death

44%

Fetal growth restriction

8%

Hypoxic peripartum death2%

Purpose of the ClassificationsPurpose of the Classifications

PSANZ- Perinatal death classification To identify the single most important factor which led to the chain of events which resulted in the death.

PSANZ-Neonatal death classificationUsed in addition to the PDC to identify the single most important factor in the neonatal period which led to the chain of events which resulted in the death.

To consider potentially preventable factors in perinatal To consider potentially preventable factors in perinatal mortalitymortality

Perinatal Society of Australia and New Zealand (of Perinatal Society of Australia and New Zealand (of Perinatal Death Classification (PSANZPerinatal Death Classification (PSANZ--PDC)PDC)

1. CONGENITAL ABNORMALITY

2. PERINATAL INFECTION

3. HYPERTENSION

4. ANTEPARTUM HAEMORRHAGE

5. MATERNAL CONDITIONS

6. SPECIFIC PERINATAL CONDITIONS

7. HYPOXIC PERIPARTUM DEATH

8. FETAL GROWTH RESTRICTION

9. SPONTANEOUS PRETERM

10. UNEXPLAINED ANTEPARTUM DEATH

11. NO OBSTETRIC ANTECEDENT

Used across ANZ and reported in Used across ANZ and reported in Australia's Mothers and BabiesAustralia's Mothers and Babies

Clinical Practice Guidelines for Perinatal Mortality AuditClinical Practice Guidelines for Perinatal Mortality AuditIncorporating Incorporating

Psychosocial and Social Aspects of Perinatal Bereavement Psychosocial and Social Aspects of Perinatal Bereavement

Perinatal Society of Australia and New Zealand Perinatal Mortality Group

PSANZ PSANZ Training casesTraining cases -- answersanswers

PSANZ Perinatal Mortality Group WebsitePSANZ Perinatal Mortality Group Websitewww.psanzpnmsig.orgwww.psanzpnmsig.org

Specific perinatal conditions

9%

Maternal conditions6%

Antepartum haemorrhage6%

Spontaneous preterm18%

Congenital abnormality25%

Unexplained antepartum death20%

Fetal growth restriction6%

Hypertension3%Hypoxic peripartum death

3%

No obstetric antecedent1%

Perinatal infection3%

Cause of Perinatal Death by PSANZCause of Perinatal Death by PSANZ--PDC: PDC: QLD, SA, VIC 2000QLD, SA, VIC 2000

n=1303n=1303

PSANZPSANZ--PDCPDC

3. HYPERTENSION

3.1 Chronic hypertension: essential3.2 Chronic hypertension: secondary, eg renal disease3.3 Chronic hypertension: unspecified3.4 Gestational hypertension3.5 Pre-eclampsia3.6 Pre-eclampsia superimposed on chronic hypertension3.8 Unspecified hypertension

Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, Peek MJ, Rowan JA, Walters BNJ. Consensus Statement. The detection, investigation and management of hypertension in pregnancy: executive summary. Aust NZ J Obstet Gynaecol2000;40:133-138

PSANZ PDC/NDC AgreementPSANZ PDC/NDC Agreement

Classification Major Category Agreement

Perinatal Fetal deaths n = 70

Neonatal deaths n= 30

Total deaths n=100

Kappa

n (%)

58(83)

26 (87)

84 (84)

0.83 to 0.95

(p<0.01) Neonatal

Neonatal deaths n=28

n (%)

-

24 (86)

-

0.85 to 0.90

(p <0.01)

How does PSANZHow does PSANZ--PDC shape up?PDC shape up?

Ease of use by clinicians and perinatal pathologists with uniform definitions;

Good level of agreement (low inter-observer variability);Ease of expansion in terms of sub classification;Based on clinical factors and autopsy findings including

histology of the placenta;Explain the underlying cause of death;Suitable in stillbirth as well as neonatal death;Result in a high percentage of classifiable cases and a low

percentage of unexplained cases

PSANZPSANZ--PDCPDC2. PERINATAL INFECTION

2.1 Bacterial 2.11 Group B Streptococcus 2.12 E coli 2.13 Listeria monocytogenes 2.18 Other bacterial 2.19 Unspecified bacterial 2.2 Viral 2.21 Cytomegalovirus 2.22 Parvovirus 2.23 Herpes simplex virus 2.24 Rubella virus 2.28 Other viral 2.29 Unspecified viral 2.3 Protozoal eg Toxoplasma 2.4 Spirochaetal eg Syphilis 2.5 Fungal 2.8 Other

2.9 Unspecified organism

How does PSANZHow does PSANZ--PDC shape up?PDC shape up?

Ease of use by clinicians and perinatal pathologists with uniform definitions;

Good level of agreement (low inter-observer variability);Ease of expansion in terms of sub classification;Based on clinical factors and autopsy findings

including histology of the placenta;Explain the underlying cause of death;Result in a high percentage of classifiable cases and a

low percentage of unexplained cases Suitable in stillbirth as well as neonatal death;

PSANZPSANZ--PDCPDC

10 UNEXPLAINED ANTEPARTUM DEATH

10.1With evidence of uteroplacental insufficiency, eg significant infarction, acute atherosis, maternal and/or fetal vascular thrombosis or maternal floor infarction

10.2 With chronic villitis 10.3 Without the above placental pathology

10.4 No examination of placenta 10.9 Unspecified unexplained antepartum death or not

known whether placenta examined

Unexplained Unexplained AntepartumAntepartumFetal DeathFetal Death

“ Death of a normally formed fetus prior to the onset of labour where no predisposing factors are considered likely to have caused the death eg FGR or any other primary complication such as spontaneous preterm ROM”

Unexplained (Unexplored?) Unexplained (Unexplored?) AntepartumAntepartum Fetal DeathFetal Death

Perinatal Autopsy Rates by StatePerinatal Autopsy Rates by StateQLD, VIC , SA 2000QLD, VIC , SA 2000

PSANZ PSANZ –– ClassificationClassification

0

10

20

30

40

50

60

70

80

90

100

Congenitalabnormality

Unexplainedantepartum death

Spontaneouspreterm

Specific perinatalconditions

Antepartumhaemorrhage

Maternal conditions Overall

State 1

State 2

State 3

PSANZPSANZ--PDCPDC

8. FETAL GROWTH RESTRICTION (FGR)

8.1 With evidence of uteroplacental insufficiency eg significant infarction, acute atherosis, maternal and/or fetal vascular thrombosis or maternal floor infarction

8.2 with chronic villitis 8.3 Without the above placental pathology

8.4 No examination of placenta 8.8 Unspecified FGR or not known whether placenta examined

Australian birthweight percentiles for singleton girls

0

1000

2000

3000

4000

5000

22 24 26 28 30 32 34 36 38 40 42 44

Gestational age (weeks)

Weight (grams) Percentile

3

97

75502510

90

From: Roberts CL & Lancaster PAL. Australian national birthweight percentiles by gestational age. MJA 1999;170: 114-118. ©Copyright 1999. The Medical Journal of Australia - reproduced with permission.

20 APPENDIX 1B

Courtesy of Jason Gardosi

Causes of Fetal DeathQLD,WA, VIC 2000-2003

n=3530

1.38

0.18

0.23

0.51

0.84

0.58

0.14

0.45

0.82

1.90

0.04

0.00 0.50 1.00 1.50 2.00

Congenital anomaly

Perinatal infection

Hypertension

Antepartum haemorrhage

Maternal conditions

Specific perinatal conditions

Hypoxic peripartum death

Fetal growth restriction

Spontaneous preterm

Unexplained antepartum death

No obstetric antecedent

Causes of Fetal Death, multiple and singletons QLD,WA, VIC 2000-2003

n=3530

0 1 2 3 4 5 6 7 8

Congenital anomaly

Perinatal infection

Hypertension

Antepartum haemorrhage

Maternal conditions

Specific perinatal conditions

Hypoxic peripartum death

Fetal growth restriction

Spontaneous preterm

Unexplained antepartum death

No obstetric antecedent

Unexplained Fetal Death (n=948)QLD,WA, VIC 2000-2003

Unexplained fetal death contribution to fetal death rate by gestation singleton (n=3180) versus multiple (n=350) pregnancies

0

10

20

30

40

50

60

70

20-21 22-23 24-27 28-31 32-34 35-36 37-41 42+ OverallGestation at birth

% o

f fet

al d

eath

rate

Singleton

Multiple

How does PSANZHow does PSANZ--PDC shape up?PDC shape up?

Ease of use by clinicians and perinatal pathologists with uniform definitions;

Good level of agreement (low inter-observer variability);Ease of expansion in terms of sub classification;Based on clinical factors and autopsy findings including

histology of the placenta;Explain the underlying cause of death;Result in a high percentage of classifiable cases and a low

percentage of unexplained cases Suitable in stillbirth as well as neonatal death;

0.0

0.5

1.0

1.5

2.0

2.5

Cong

enita

l abn

orm

ality

Unex

plai

ned

ante

partu

m d

eath

Spon

tane

ous p

rete

rmSp

ecifi

c pe

rinat

al co

nditi

ons

Ante

partu

m h

aem

orrh

age

Mat

erna

l con

ditio

nsFe

tal g

rowt

h re

stric

tion

Hype

rtens

ion

Perin

atal

infe

ctio

nHy

poxic

per

ipar

tum

dea

thNo

obs

tetri

c an

tece

dent

PSANZ-PDC

per 1

000

Birt

hs Neonatal deathFetal death

Cause of Perinatal Death by ANZACPM: Cause of Perinatal Death by ANZACPM: QLD, SA, VIC 2000QLD, SA, VIC 2000

Births n=129752, Perinatal deaths n=1303

Perinatal Society of Australia and New Zealand Perinatal Society of Australia and New Zealand Neonatal Death Classification(PSANZNeonatal Death Classification(PSANZ--NDC)NDC)

1. CONGENITAL ABNORMALITY

2. EXTREME PREMATURITY

3. CARDIO-RESPIRATORY DISORDERS

4. INFECTION

5. NEUROLOGICAL

6. GASTROINTESTINAL

7. OTHER

International systemsInternational systems

Recently developed International Recently developed International systemssystems

ReCode: Stillbirth only Identifies the relevant condition at the time of death in

utero. Hierarchical. Starting with fetal condition Secondary factors identified Focus on growth restriction 47% FGR – 50% with no apparent cause 15% unexplained (ie 38% unexplained) Difficult to identify clinically relevant conditions those

which triggered the chian of events ( eg no spontaneous preterm category)

Recently developed International Recently developed International systemssystems

Tulip: Late fetal loss, Stillbirth, Neonatal deaths

and deaths before discharge Not Hierarchical, 3 layers of coding Identifies the Cause, Mechanisms and

Pathway of the death Focus on placental pathology - difficult to

identify clinically relevant conditions (eg no category for pre-eclampsia)

International Stillbirth Alliance International Stillbirth Alliance Conference Japan June1Conference Japan June1--4 20064 2006

http://www.isaconference2006.com/http://www.isaconference2006.com/

Would PSANZ consider an international Would PSANZ consider an international classification system for stillbirths?classification system for stillbirths?

How does PSANZHow does PSANZ--PDC shape up? PDC shape up?

Ease of use by clinicians and perinatal pathologists with uniform definitions;

Good level of agreement (low inter-observer variability);

Ease of expansion in terms of sub classification; Based on clinical factors and autopsy findings including

histology of the placenta; Explain the underlying cause of death; Suitable in stillbirth as well as neonatal death; Result in a high percentage of classifiable cases and a

low percentage of unexplained cases

Clinical Practice Guidelines for Perinatal Clinical Practice Guidelines for Perinatal Mortality Audit Mortality Audit

Incorporating Incorporating Psychosocial and Social Aspects of Perinatal BereavementPsychosocial and Social Aspects of Perinatal Bereavement

Perinatal Society of Australia and New Zealand Perinatal Society of Australia and New Zealand Perinatal Mortality Group Perinatal Mortality Group

http://www.psanzpnmsig.org/

PSANZ Perinatal Mortality Audit PSANZ Perinatal Mortality Audit GuidelinesGuidelines

The guideline is presented in 7 sections as follows:

Section 1: Overview & summary of recommendations;Section 2: Institutional perinatal mortality audit;Section 3: Psychological and social aspects of perinatal

bereavement;Section 4: Perinatal post-mortem examination;Section 5: Investigation of stillbirths;Section 6: Investigation of neonatal deaths;Section 7: Perinatal mortality classifications

ObjectivesObjectives

ooBackground classification systems Background classification systems ooDevelopment of the PSANZ ClassificationDevelopment of the PSANZ ClassificationooExample cases Example cases ooCauses of perinatal death Causes of perinatal death

Fetal, Neonatal and Perinatal Mortality Fetal, Neonatal and Perinatal Mortality QLD, SA, VIC 2000 and Australia 1999QLD, SA, VIC 2000 and Australia 1999

State Births Livebirths FD NND PND n rate 1 n rate 2 n rate 1

SA 17872 17766 106 5.9 57 3.2 163 9.1 QLD 49318 48960 358 7.3 184 3.8 542 11.0 VIC 62562 62146 416 6.6 182 2.9 598 9.6

Total 129752 128872 880 6.8 423 3.3 1303 10.0

Australia 257394 255605 1789 7.0 822 3.2 2611 10.1

1per 1 000 births, 2 per 1 000 livebirths

Neonatal Deaths by NDCNeonatal Deaths by NDCQLD, SA, VIC 2000, QLD, SA, VIC 2000,

n=423n=423

34.8

25.5

14.9

9.56.9

5.23.3

0

5

10

15

20

25

30

35

40

Congen

ital a

bnorm

ality

Extreme p

rematu

rity

Cardio-

respira

tory diso

rders

Neuro

logical

Infectio

nOther

Gastro

intestin

al

PSANZ-NDC

% o

f Neo

nata

l Dea

ths

Cause of Perinatal Death by Indigenous Cause of Perinatal Death by Indigenous Status: PSANZStatus: PSANZ--PDCPDC

Indigenous n=81, Not Indigenous n=1220

3.4

2.2

0.00 1.00 2.00 3.00 4.00 5.00 6.00

Spontaneous Preterm

Unexplained Antepartum Death

Congenital Abnormality

Specific Perinatal Conditions

Hypertension

Maternal Conditions

Antepartum Hemorrhage

Perinatal Infection

Fetal Growth Restriction

No Obstetrical Antecedent

Hypoxic Peripartum Deaths

IndigenousNot Indigenous

4.7

3.4

9.84.1

2.7

Cause of fetal death by plurality Cause of fetal death by plurality QLD, WA, VIC 2000QLD, WA, VIC 2000--20032003

n=3530n=3530

Multiple fetal death

Singleton fetal death

PSANZ Perinatal Death Classification

n % rate1 n % rate1 Relative Risk (95%CI)

Congenital abnormality 38 10.9 2.3 650 20.4 1.4 1.71 (1.23, 2.37) Perinatal infection 2 0.6 0.1 90 2.8 0.2 0.65 (0.16, 2.63) Hypertension 13 3.7 0.8 104 3.3 0.2 3.65 (2.05, 6.49) Antepartum haemorrhage

15 4.3 0.9 239 7.5 0.5 1.83 (1.94, 2.15)

Maternal conditions 10 2.9 0.6 408 12.8 0.9 0.72 (0.38, 1.34) Specific perinatal conditions

124

35.4

7.5

165

5.2

0.3 21.95 (19.39, 27.68)

Hypoxic peripartum death

1 0.3 0.1 68 2.1 0.1 0.43 (0.60, 3.09)

Fetal growth restriction 9 2.6 0.5 217 6.8 0. 5 1.21 (0.62, 2.36) Spontaneous preterm 83 23.7 5.0 324 10.2 0. 7 7.48 (5.88, 9.52) Unexplained antepartum

51 14.6 3.1 897 28.2 1.9 1.66 (1.25, 2.20)

No obstetric antecedent 4 1.1 0.2 18 0.6 0.04 6.49 (2.20, 19.17) Total 350 100 21.2 3180 100 6.6 3.21 2.99, 3.59

Future for PSANZ PDC&NDC

National collaboration: Annual reporting Australia’s Mother’s and Babies

Review and updating PSANZ SIG

International collaboration – meaningful comparisons across countries

PSANZ ClassificationsPSANZ Classifications

Developed by perinatal clinicians, over a 15 year period Hierarchical- ie, categories mutually

exclusive and unambiguous Categories clinically relevant Easy to apply Reproducible

Why not ICD?Why not ICD?

553 perinatal deaths in Queensland for the year 1997

Classified by three clinicians (VF, JK, DT) according to the Perinatal classification system.

The same cases were also assigned ICD9 (CM) codes by professional coders in Queensland Health.

Jason Gardosi – CESDI 8Th report

PSANZ classification developmentPSANZ classification development

•March 2003 endorsed by the Perinatal Society of Australia and New Zealand

•Adopted across all Sates and Territories in Australia -increasing use in NZ.

•Accepted by the Australian National Perinatal Statistics Unit for national reporting

•Clinical classifications of perinatal deaths since 1986 - 1996 call for consensus

•1999 Consensus reached - increasingly used

Unexplained antepartum deathUnexplained antepartum deathExamples:Classify here: Intrauterine Fetal Death (IUFD) at 27

weeks, with membranes intact, before onset of labour, no explanation. No autopsy or examination of placenta. Classify as Unexplained Antepartum Death, Category 10.4.

Do not classify here: Spontaneous ROM at 27 weeks, no significant maternal conditions present, subsequent IUFD prior to onset of labour. No chorioamnionitis. Classify as Spontaneous Preterm (Category 9.32).

PSANZPSANZ-- NDC classification developmentNDC classification development

Wigglesworth Classification

(1980)†

Fetal and Neonatal Factors Classification

(1986) (Hey, Lloyd,

Wigglesworth)

PSANZ-NDC (2000)

Normally formed stillbirths Congenital malformations Congenital abnormalities Congenital abnormality Immaturity Severe pulmonary immaturity Extreme prematurity Hyaline membrane disease Cardio-respiratory disorders Asphyxia Asphyxia before birth

(antepartum or intrapartum) Neurological

Birth trauma Intracranial haemorrhage Other (Specific conditions) Infection Infection Gastrointestinal (eg Necrotising

enterocolitis)

Miscellaneous Other (eg SIDS, Accidents)

Isoimmunisation Unclassified/Unknown

Perinatal InfectionClassify here: Term prelabour rupture

of the membranes, delivery following > 24hours of membrane rupture, neonatal pneumonia identified within 48 hours of birth, subsequent neonatal death, Group B Streptococcus identified on vaginal culture and in gastric aspirate. Classify as Category 2.11 – GBS.

Classify here: Antepartum fetal death at 27weeks gestation following maternal pyrexia. Autopsy confirmed overwhelming fetal sepsis with E coli isolated from blood cultures, placental swab, liver swab and lung swab. Acute villitis and chorioamnionitis were also present..

Death type Criteria of Infection Fetal 1. Histological confirmation of infection in cord (funisitis)

or fetus (pneumonitis or pneumonia) with or without microbiological evidence of infection. OR 2a. Convincing clinical evidence of primary maternal infection AND 2b. Positive culture of a pathogen from mother or placenta

Neonatal Congenital infection Early onset infection (within 48 hours of birth), defined as: 1.Clinical signs in neonate consistent with sepsis AND 2.Haematological changes consistent with sepsis AND ONE OR MORE OF 3a – 3d 3a. Positive culture of a pathogen (bacterial or viral) from the neonate OR 3b. Pathological evidence at autopsy OR 3c. Positive serology OR 3d. Positive culture of a pathogen from the mother or the placenta. NB: Some congenital viral infections may have onset later than 48 hours after birth. For neonatal deaths occurring within a few hours of birth, especially those for which resuscitation was not attempted, where infection is presumed to be the cause of death, the infection criteria for fetal death may be used.

PDC and ICD 9 RankingsPDC and ICD 9 RankingsClassification % ICD 9 % Major fetal abnormality 19 Diseases relating to short

gestation and lowbirthweight 20

Unexplained antepartum death

19 Other ill defined conditions in the perinatal period

19

Spontaneous preterm 13 Congenital abnormality 19 Multiple pregnancy 13 Foetus or newborn affected

by comps of placenta,cord and members

10

Antepartum haemorrhage

12 Intrauterine hypoxia and birth asphyxia

8

No obstetric antecedent 8 Infections specific to the perinatal period

4

Specific obstetric conditions

7 Sudden death, cause unknown

3

Hypertension 3 Other respiratory conditions of the fetus and newborn

3

Perinatal infection 2 Birth trauma 2 Hypoxic peripartum death

2 Foetal and neonatal haemorrhage

2

Intrauterine growth restriction

2 Conditions involving the integument and temperature regulation

2

PSANZPSANZ--PDCPDC

4. Antepartum Haemorrhage

4.1 Placental abruption4.2 Placenta praevia4.3 Vasa praevia4.4 Other APH4.8 APH of undetermined origin

PSANZPSANZ--PDCPDC1. CONGENITAL ABNORMALITY (including terminations

for congenital abnormalities) 1.1 Central nervous system 1.2 Cardiovascular system 1.3 Urinary tract 1.4 Gastrointestinal tract 1.5 Chromosomal 1.6 Metabolic 1.7 Multiple 1.8 Other congenital abnormality 1.81 Musculoskeletal 1.82 Respiratory 1.83 Diaphragmatic hernia 1.88 Other specified congenital abnormality 1.9 Unspecified congenital abnormality

UK obstetric antecedent classificationsUK obstetric antecedent classifications

Amended Aberdeen Classification (1969)

Whitfield et al Classification (1986)

Fetal deformity Fetal abnormality Infection of the fetus or neonate Infection Toxaemia Hypertension Antepartum haemorrhage (APH)

APH

Maternal disease Maternal disease Mechanical causes Birth trauma Serological incompatibility Hemolytic disease Intrapartum asphyxia Deaths of unknown origin IUGR (Intrauterine Growth

Retardation) Premature (5½lb/2500g or less)

Spontaneous preterm

Mature (more than 5½lb/2500g)

Unexplained intrauterine death

Miscellaneous Other causes Unclassified

Causes of Fetal Death, multiple and singletons QLD,WA, VIC 2000-2003

n=3530

0

1

2

3

4

5

6

7

8

Congen

ital a

nomaly

Perinata

l infec

tion

Hyperten

sion

Antepartu

m haemorr

hage

Maternal

conditio

ns

Specific

perina

tal co

nditions

Hypoxic

peripart

um death

Fetal g

rowth restr

iction

Spontaneo

us pret

erm

Unexplai

ned an

tepart

um death

No obstet

ric ante

ceden

t

PSANZ-PDC

Rat

e pe

r 100

0

SINGELTON rate MULTIPLE rate

Classification CriteriaClassification Criteria++Ease of use by clinicians and perinatal pathologists

with uniform definitions;++ Good level of agreement (low inter-observer

variability);++ Ease of expansion in terms of sub classification;+ Based on clinical factors and autopsy findings

including histology of the placenta;+ Explain the underlying cause of death;+ Result in a high percentage of classifiable cases and

a low percentage of unexplained cases + Suitable in stillbirth as well as neonatal death;

Stillbirth Still Happening……. StillStillbirth Still Happening……. Still

Care ImprovementCare ImprovementPotentially Contributing FactorsPotentially Contributing FactorsThe determination of potentially contributing factor in the death does not mean that death was certainly preventable, but that if a preferable course of action had been followed, the risk of death would be likely to have been reduced.

Classification:Classification:o maternal/socialo infrastructure/service organisation o professional care delivery

Definitions of stillbirth in ANZDefinitions of stillbirth in ANZ

400or20PSANZ Guideline

400or20National Health Data Dictionary

Only if birthweight is unavailable

500or22WHO National reporting

Only if birthweight is unavailable

1000or28WHO International comparisons

83.15.1and 7.1

If birthweight unavailableBased on year of registration

400or20NPSU

82.85.3Only if birthweight is unavailable

400or20ABS

10.40.57.4Residents and non residents400And/or20NZ

Rate per 1000OtherWeightAnd/orGA

ABS: 5/1000= 1300State and Territories: 7/1000 = 1750

450??

So how many stillbirths in So how many stillbirths in Australia?Australia?

Causes of Fetal DeathQLD,WA, VIC 2000-2003

n=3530

1.38

0.18

0.23

0.51

0.84

0.58

0.14

0.45

0.82

1.90

0.04

0.00 0.50 1.00 1.50 2.00

Congenital anomaly

Perinatal infection

Hypertension

Antepartum haemorrhage

Maternal conditions

Specific perinatal conditions

Hypoxic peripartum death

Fetal growth restriction

Spontaneous preterm

Unexplained antepartum death

No obstetric antecedent

Cause of Perinatal Death by Indigenous Status, SA, QLD PSANZ-PDC

n=2000

3.4

2.2

0.00 1.00 2.00 3.00 4.00 5.00 6.00

Spontaneous Preterm

Unexplained Antepartum Death

Congenital Abnormality

Specific Perinatal Conditions

Hypertension

Maternal Conditions

Antepartum Hemorrhage

Perinatal Infection

Fetal Growth Restriction

No Obstetrical Antecedent

Hypoxic Peripartum Deaths

IndigenousNot Indigenous

CESDI 8CESDI 8THTH ReportReport

CESDI 8CESDI 8THTH ReportReport