Perinatal Mortality at the Armed Forces Hospital, Riyadh, Saudi Arabia: Five-Year Review of 22,203 Births
1990; King Faisal Specialist Hospital and Research Centre; Volume: 10; Issue: 3 Linguagem: Inglês
10.5144/0256-4947.1990.268
ISSN0975-4466
Autores Tópico(s)Injury Epidemiology and Prevention
ResumoOriginal ArticlesPerinatal Mortality at the Armed Forces Hospital, Riyadh, Saudi Arabia: Five-Year Review of 22,203 Births Abdul-Aziz AlgwiserFachartz Abdul-Aziz Algwiser Address reprint requests and correspondence to Dr. Algwiser: Department of Obstetrics and Gynaecology, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159, Saudi Arabia. From the Department of Obstetrics and Gynecology, Riyadh Armed Forces Hospital, Riyadh Published Online:1 May 1990https://doi.org/10.5144/0256-4947.1990.268SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractA study was conducted of the perinatal deaths that occurred at the Armed Forces Hospital between 1983 and 1987. Congenital anomalies accounted for 104 (35.6%) of the 292 perinatal deaths. Of the 188 normally formed infants who died, 64 died within the first week of life, 25 died during labor, and 99 died ante partum. The perinatal mortality was 13.1 per 1,000 total births; stillbirth rate, 6.6 per 1,000 total births, and neonatal death rate, 6.6 per 1,000 live births. Among normally formed infants, birth weight was less than 1500 g in 22.6% of the stillbirth cases and in 70.3% of the cases of early neonatal death. Of the 64 neonatal deaths, 70.3% occurred within 24 hours of delivery. Survival occurred in 23.8% of those infants weighing 500 to 749 g and in 87.9% of those weighing 750 to 999 g. Those infants born by cesarean section who weighed less than 1000 g exhibited a 71.4% survival rate compared with 46.7% in infants born vaginally. Improved antenatal supervision and monitoring, early detection of fetal and maternal complications, and better neonatal care should help to further reduce perinatal mortality.IntroductionPerinatal mortality rates are important for identifying problems in obstetrical and early neonatal care. Large national perinatal mortality surveys conducted in Western countries have had a major influence in outlining problem areas and stimulating efforts toward reducing perinatal loss.1–3 The definition of fetal death differs among various public health authorities, however, and this makes international comparison difficult.4–15 Sociological and biological differences between countries and regions within countries further depreciate perinatal mortality figures as indicators of the adequacy of maternity services.4,8,16–19 For the purpose of study, International Federation of Obstetrics and Gynaecology and the World Health Organization20–24 recommended definitions were applied.Several hospital-based perinatal mortality studies25–32 have been conducted in Saudi Arabia. The first two reports,32,33 also originating from the Riyadh Armed Forces Hospital, served as a basis for further examining perinatal mortality in the context of birth weight and mode of delivery. The information gained can then serve as the basis for outlining measures that will further reduce perinatal mortality.MATERIAL AND METHODSAll babies born at the Riyadh Armed Forces Hospital between 1 January 1983 and 31 December 1987 comprised the study population. Data collected included birth weight, cause of death, time of death, mode of delivery, and the effect of mode of delivery on the survival of very-low-birth-weight infants. All newborns and stillborns weighing 500 g and over at or after 22 weeks of gestation were included in the study. Gestational ages were calculated from the menstrual history and sonographic assessment of fetal biparietal diameter, abdominal girth, thoracic diameter, and femoral length. Three infants weighing less than 500 g were excluded. Very low birth weight was defined as 1,500 g or less.All perinatal deaths were reviewed monthly at a perinatal mortality meeting attended by both obstetricians and neonatologists. Because autopsy is not permitted in Saudi Arabia, cause of death was diagnosed from clinical observations. Causes of death were classified according to a modified version of the Aberdeen classification.2,3,34 The causes of death were listed according to the fetal or maternal condition that was most likely to be directly involved in the fetal death. Prematurity was defined as gestation below 37 weeks whereas infants over 42 weeks were considered postmature. Preeclampsia was diagnosed when blood pressure rose to at least 140/90 mm Hg on more than one occasion after the 24th week of gestation in a patient with previously normal blood pressure.RESULTSThe total number of infants delivered at the Riyadh Armed Forces Hospital has increased from 3615 in 1983 to 5019 in 1987 (Table 1). After decreasing to 10.8 per thousand in 1985, the perinatal mortality rose to 13.1 per thousand in 1987. Of the 22,203 infants with a birth weight of 500 g and over, 147 were stillborn and 145 died within the first week of life, yielding a perinatal mortality of 13.1 per thousand total births, stillbirth rate of 6.6 per thousand total births, and neonatal death rate of 6.6 per thousand live births.Table 1. Total number of patients, births, and perinatal mortality during the study period.Table 1. Total number of patients, births, and perinatal mortality during the study period.Table 2 shows the time of death in relation to birth weight in both normal and congenitally malformed infants. Birth weight in 38.8% of the normally formed infants who died was less than 1500 g. Of the 64 deaths among normally formed infants, 45 (70.3%) died in the first 24 hours of life. Multiple anomalies and neural tube defects accounted for the majority of congenital malformations in infants who died: 36.5% and 29.8%, respectively (Table 3). Table 4 shows the causes of death in relation to birth weight in normally formed infants.Table 2. Birth weights and times of death (in relation to labor) of normally formed infants and birth weights of infants dying from fetal abnormality.Table 2. Birth weights and times of death (in relation to labor) of normally formed infants and birth weights of infants dying from fetal abnormality.Table 3. Site of anomaly.Table 3. Site of anomaly.Table 4. Causes of death in relation to birth weight and labor in normally formed infants.Table 4. Causes of death in relation to birth weight and labor in normally formed infants.Survival in normally formed newborn infants according to gestational age is given in Figure 1 and according to birth weight in Figure 2. Maternal disease was the predisposing factor in 14 (7.4%) deaths; all of which were stillbirths. Diabetes was present in ten, renal hypertension in one, essential hypertension in one, acute brucellosis occurring at 39 weeks' gestation in one, and a brain tumor in one.Figure 1. Survival in live born infants according to gestational age.Download FigureFigure 2. Survival of live born infants according to birth weight.Download FigureMechanical factors accounted for 20 (10.6%) of the deaths among the normally formed infants: eight antepartum, ten intrapartum, and two neonatal. Thirteen babies weighed over 2500 g. The cord was tied around the neck in seven of the antepartum deaths and thrombosis of the umbilical cord was the cause of death in the eighth infant. Of the ten intrapartum deaths resulting from mechanical factors, four were related to difficult breech delivery, two to cord prolapse, and one to abruptio placentae following external cephalic version. The remaining three were due to difficult forceps delivery, two of which were associated with ruptured uterus. The two neonatal deaths were related to severe birth asphyxia, one an undiagnosed twin and one a difficult breech delivery through an incompletely dilated cervix.Four deaths were due to severe rhesus isoimmunization, two of which were unbooked.Eighteen deaths in normally formed infants were attributed to antepartum hemorrhage and this was due to abruptio placentae in eight cases, placenta previa in three cases, and an unknown site of bleeding in seven cases. Severe hypoxia was the cause of the eight neonatal deaths, two of which were associated with hyaline membrane disease and one with intraventricular hemorrhage. The ten intrapartum deaths were related to intrapartum asphyxia. Preeclampsia caused ten deaths: five stillbirths, two intrapartum deaths (both of which were complicated by abruptio placentae), and three neonatal deaths (one of which was complicated by abruptio placentae).There were no maternal complications in 122 perinatal deaths occurring in normally formed infants (Table 4). Eight-five infants weighed less than 2500 g and 37 weighed over 2500 g. Of the 85 very-low-birth-weight and low-birth-weight infants who died, there were 43 neonatal deaths, two intrapartum deaths, and 40 stillbirths. Of the total 122, 71 were preterm, 17 of whom were severely growth retarded. Of 14 mature infants, ten were severely growth retarded. The causes of the 43 neonatal deaths in very-low-birth-weight and low-birth-weight infants were intrauterine hypoxia in two cases, respiratory distress syndrome in 22 cases, intraventricular hemorrhage in three cases, intraventricular hemorrhage associated with respiratory distress syndrome in six cases, infection in six cases, nonhemolytic hydrops fetalis in one, cot death in two, and intractable metabolic acidosis in one. Two infants died of severe birth hypoxia intrapartum and could not be saved by cesarean section.Very-low-birth-weight infants (500 to 1499 g) constituted a large proportion of neonatal deaths in normally formed infants (70.3%). During the period of study there were 239 very-low-birth-weight infants; 45 died within the first week of life, giving a mortality rate of 188.3 per thousand live births among this group (Tables 5 and 6). The relationship of mode of delivery to survival in very-low-birth-weight infants is illustrated in Table 5 and this is further broken down by gestational age in Table 6. Table 7 shows the cause of death and Table 8 the Apgar scores at 1 and 5 minutes by weight and mode of delivery in very-low-birth-weight infants.Table 5. Effect of birth weight and mode of delivery on survival of very-low-birth-weight infants.Table 5. Effect of birth weight and mode of delivery on survival of very-low-birth-weight infants.Table 6. Effect of gestational age and mode of delivery on survival of very low birth weight infants.Table 6. Effect of gestational age and mode of delivery on survival of very low birth weight infants.Table 7. Causes of early neonatal death of very-low-birth-weight infants by mode of delivery.Table 7. Causes of early neonatal death of very-low-birth-weight infants by mode of delivery.Table 8. Mean Apgar score at one and five minutes in very-low-birth-weight infants.Table 8. Mean Apgar score at one and five minutes in very-low-birth-weight infants.The causes of the 40 stillbirths were second twin in five cases, nonhemolytic hydrops fetalis in one case, and severe prematurity in 23 cases (of which 11 were severely growth retarded); the remaining 11 babies were full term but small for gestational age (eight were severely growth retarded).Of the 37 perinatal deaths in infants weighing over 2500 g, six were neonatal, six occurred intrapartum, and 25 occurred before onset of delivery. The causes of the six neonatal deaths were birth asphyxia in three cases and one each of septicemia, recurrent convulsions, and cot death. The six intrapartum deaths were related to intrapartum asphyxia. Cesarean section was carried out in four cases but failed to save the baby. The causes of the 25 antepartum deaths were nonhemolytic hydrops fetalis in two cases, postmaturity in three, and undetermined cause in the remaining 20 cases.DISCUSSIONThe most frequent cause of perinatal mortality in the present study was fetal abnormality, which accounted for 35.6% of the deaths. The incidence of fatal congenital anomalies was 4.7 per 1,000 total births. This rate is higher than that reported by others3,11,15,16,26,35 but similar to that reported in Scotland for Avon and the Mersey region.2,36,37 The high rate in the present study may be explained by the high incidence of consanguineous marriages among Saudis. Of the patients attending antenatal clinics of the Armed Forces Hospital, 25% were married to their first cousin.Of normally formed infants, 52.7% died before the onset of labor, which agrees with the figures reported by Buckell3 (49%) and Mcllwaine2 (41%). Of normally formed newborn infants, 70.3% died during the first 24 hours of life. Buckell3 reported 52% and Mutch36 57%.Almost half of the neonatal deaths in the present study were due to extreme prematurity. Despite the progress made in introducing pharmacological agents to stop premature labor, their overall impact in reducing the number of births before 28 weeks of gestation has been disappointing. Infants weighing less than 1500 g accounted for 38.3% of the deaths in normally formed infants. The neonatal mortality rate in this group was 188.3 per 1000 live births. This is similar to the figures cited by others.38–42 Survival is closely related to birth weight. Babies weighing 500 to 1499 g have an 89.5% chance of being born alive and 81.2% chance of surviving the neonatal period. Those babies weighing 1000 to 1499 g have an 89.4% chance of survival as compared to a 64.1 % chance of survival in babies weighing 500 to 999 g.Mode of delivery seems to play a role in the survival of very small babies. Cesarean section seems to improve the chance of survival.41 This was seen in the present study for those infants with birth weight of 500 to 999 g, but no significant difference was demonstrated between vertex and cesarean delivery for infants with a birth weight of 1,000 to 1,499 g. Cesarean section has been advised for breech presentation babies with a potential birth weight of under 1500 g.38,40,43,49 Although the present report includes a relatively small number of infants in this birth weight range, compared to numbers considered in other studies,42,47,50,51 there was significantly decreased survival in infants with breech presentation delivered vaginally for the 500 to 749 g and 750 to 999 g birth weight groups. An attempt to relate survival to mode of delivery or presentation of very-low-birth-weight infants may be statistically valid but may not be clinically applicable because of the need for cesarean section. Those infants with a low 5-minute Apgar score suffered intrapartum asphyxia. Thus perinatal asphyxia may have precipitated the subsequent development or increasing severity of respiratory distress syndrome52 and intraventricular hemorrhage,53 both factors shown to significantly increase mortality. The high proportion of neonatal deaths seen during the first 24 hours of life in the present study, and observed in other studies as well,3,36 reinforces the need for expert care during that vital time. However, many more infants are lost before onset of labor. 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Google Scholar53. Papile LA, Burstein J, Burstein R, Koffler H. "Incidence and evolution of subependymal and intraventricular haemorrhage: a study of infants with birthweight less than 1500 grams" . J Paediatr. 1978; 92: 529–34. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byEnglish J (1994) Perinatal Mortality at the North West Armed Forces Hospital, Tabuk, Saudi Arabia and the Potential Benefits of the Biophysical Profile Score, Annals of Saudi Medicine , 15:2, (133-136), Online publication date: 1-Mar-1995.Jaiyesimi O and Ruberu D (1994) Noncardiac Defects in Children With Congenital Heart Disease, Annals of Saudi Medicine , 14:3, (183-186), Online publication date: 1-May-1994. Volume 10, Issue 3May 1990 Metrics History Accepted5 August 1989Published online1 May 1990 ACKNOWLEDGMENTI am grateful to Miss Julie Zdanowicz for her help in typing this paper. I am also indebted to Dr. W.G. Paterson, Senior Consultant, for his valuable advice and criticism and to all colleagues in the Department of Obstetrics and Gynaecology for access to the records of patients under their care.InformationCopyright © 1990, Annals of Saudi MedicinePDF download
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