Current Stillbirth Classifications · Specific purposes of stillbirth ... English language....
Transcript of Current Stillbirth Classifications · Specific purposes of stillbirth ... English language....
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