Aetiology of stillbirths and adverse newborn outcomes at Queen Elizabeth central hospital, Blantyre, Malaw

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Death of an infant in utero or at birth is a devastating experience for the mother and of concern in clinical practice. Developing countries struggle to provide comprehensive care to pregnant mothers and the new born. Stillbirths are common in poor countries that their occurrence is perceived inevitable. We aimed to characterize factors associated with stillbirth in our referral hospital population.Intrapartum birth asphyxia is a major contributor of high perinatal mortality in resource limited countries like Malawi. In low and middle income countries, about 59 % of the stillbirths are intrapartum unlike in developed countries where it is significantly lower than 10%. Studies done in Malawi have shown that birth asphyxia is a common cause of stillbirth. Furthermore, babies born with asphyxia may have increased long-term morbidity such as cerebral palsy, hence the need to identify new-borns at risk. The analysis of umbilical cord blood gases has been shown to be the gold standard for diagnosis of near-birth metabolic acidosis. Lactate has emerged as the preferred marker of acidosis in clinical practice. To determine the aetiology of stillbirths and adverse new-born outcomes among women delivering at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi This was a cross-section study done in two phases. In the first phase, data on all stillbirths that occurred at QECH between 1st August 2016 and 31st September 2016 was collected from the labour ward and Chatinkha operating theatre registries and patients’ files. All mothers of stillborn babies during the study period gave informed consent to participate in the study and have their blood samples collected and tested for VDRL, malaria, haemoglobin and fasting blood sugar on the bedside using point of care syphilis testing kit (Determine), malaria rapid diagnostic testing kit, Hemacue and glucometer respectively. The stillbirths were classified using the RECODE system The second phase was undertaken during April 2017. Data on all 401 births that occurred at QECH were collected from the labour ward and operating theatre registries and patients’ files. For all live births, umbilical arterial blood was drawn from a double clamped segment into heparinised plastic syringes. Lactate concentration in Umbilical cord arterial blood was analysed using Nova biomedical point of care devices within 15 minutes. All mothers had their blood samples collected and tested for VDRL, malaria, haemoglobin and fasting blood sugar at the bedside using point of care syphilis testing kit (Determine), malaria rapid diagnostic testing kit, Hemacue and glucometer respectively. During the first phase of the study, there were 54 stillbirths among 2149 deliveries translating to 25.1/1000births with 61% fresh stillbirths and 35% macerated stillbirth. 34% of the stillbirths were delivered through Caesarean section that was done after more than an hour from decision to undertake the procedure. Common relevant conditions at delivery were anaemia (52%), asphyxia (40%), hypertensive disorders (29%), placenta abruption ix (27%), HIV (25%) and syphilis (15%). None of the mothers had malaria or diabetes Mellitus. In phase two, the perinatal mortality was 44.9/1000births. The leading documented cause of nursery admission was birth asphyxia (41.7%). Shortage of theatre space accounted for all delays to do emergency Caesarean sections. Hyperlactatemia was associated with emergency caesarean sections, meconium stained liquor and vertex vaginal deliveries. There was no association between Hyperlactatemia and antepartum haemorrhage, gestational age, multiple gestation, PPROM, anaemia or malaria. Logistic regression modelling revealed that the odds of a composite adverse outcome (early neonatal death or admission to the neonatal unit) were significantly elevated in the presence of maternal hypertension (OR=2.9, P=0.019(95% C.I. 1.19-7.26)) after adjusting for the degree of hyperlactatemia. The study highlighted the risk factors for stillbirths at QECH. The risk factors for stillbirths at QECH include; preeclampsia, abruption placenta, anaemia, syphilis, and asphyxia. Poor intrapartum care attributed to lack of theatre capacity was the single most important cause of fresh stillbirths. None of the participating mothers had diabetes mellitus or malaria contrary to findings from other studies where both conditions were associated with increased risk of stillbirth. The ANC coverage was adequate, however, the quality of care provided in the centres needs improvement especially with regard to blood pressure testing and syphilis screening. Birth asphyxia is the most common cause of admission to the nursery and high perinatal mortality. The Apgar score at one minute is a good predictor of hyperlactatemia, however, x it over-diagnoses acidosis. Hypertensive mothers had 19% higher risk of having poor neonatal outcome for any given level of umbilical cord arterial lactate so additional attention to intrapartum and newborn monitoring for hypertensive mothers is required