南非女性死胎的原因：一项前瞻性、观察性研究。
Causes of stillbirths among women from South Africa: a prospective, observational study.
机构信息
Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Department of Science/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Department of Science/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
出版信息
Lancet Glob Health. 2019 Apr;7(4):e503-e512. doi: 10.1016/S2214-109X(18)30541-2.
BACKGROUND
About 2·6 million third-trimester stillbirths occur annually worldwide, mostly in low-income and middle-income countries, where the causes of these deaths are rarely investigated.
METHODS
We did a prospective, hospital-based, observational study in Soweto, South Africa, to investigate the causes of stillbirths in fetuses of at least 22 weeks' gestational age or with a birthweight of at least 500 g. Maternal clinical information was abstracted from medical records. Investigations included placental macroscopic and histopathological examination and fetal blood culture (including screening for pathogenic bacteria associated with stillbirth). Cases missing one or more of these investigations were considered to have incomplete samples and were excluded from the analysis of cause of stillbirth. Causes of stillbirths were assessed by individual case reviews by at least two obstetricians, and classified with a modified Stillbirth Collaborative Research Network classification system.
FINDINGS
Between Oct 9, 2014, and Nov 8, 2015, we enrolled 354 stillbirths (born to 350 women). Among the women with available data, 133 (38%) of 350 had hypertension, median age was 27 years (IQR 23-33), 51 (18%) of 291 were obese, six (2%) of 344 had syphilis, and 94 (27%) of 350 had HIV. 63 (18%) of 341 fetuses showed intrauterine growth restriction. Of 298 cases (born to 294 mothers) with complete samples, the most common causes of stillbirth were maternal medical conditions (64 [21%] cases; among them 56 [19%] with hypertensive disorders and six [2%] with diabetes), placental or fetal infections (58 [19%]; 47 [16%] with fetal invasive bacterial infection), pathological placental conditions (57 [19%]; among them 27 [9%] with fetal membrane and placental inflammation and 26 [9%] with circulatory abnormalities), and clinical obstetric complications (54 [18%]; 45 [15%] with placental abruption). Six (2%) stillbirths were attributed to fetal, genetic, or structural abnormalities. In 55 (18%) cases, no cause of death was identified. The most common bacteria to which stillbirths due to fetal invasive infections were attributed were group B streptococcus (15 [5%] cases), E coli (12 [4%]), E faecalis (six [2%]), and S aureus (five [2%]).
INTERPRETATION
Targeted investigation of stillbirths (even without fetal autopsy) can ascertain a cause of stillbirth in most cases. Further studies using such investigations are needed to inform the prioritisation of interventions to reduce stillbirths globally.
FUNDING
Novartis and GlaxoSmithKline.
背景
全世界每年约有 260 万例死于妊娠晚期的死胎，主要发生在低收入和中等收入国家，这些国家很少对这些死亡原因进行调查。
方法
我们在南非索韦托进行了一项前瞻性、基于医院的观察性研究，以调查至少 22 周妊娠龄或出生体重至少为 500 克的胎儿死胎的原因。从病历中提取产妇临床信息。检查包括胎盘大体和组织病理学检查以及胎儿血液培养（包括筛查与死胎相关的致病性细菌）。如果一个或多个检查缺失，则认为病例样本不完整，并从死胎原因分析中排除。通过至少两名产科医生进行单独的病例回顾评估死胎的原因，并使用改良的Stillbirth Collaborative Research Network 分类系统进行分类。
结果
在 2014 年 10 月 9 日至 2015 年 11 月 8 日期间，我们纳入了 354 例死胎（来自 350 名妇女）。在有可用数据的妇女中，133 名（38%）患有高血压，中位年龄为 27 岁（IQR 23-33），51 名（18%）肥胖，6 名（2%）患有梅毒，94 名（27%）患有 HIV。341 例胎儿中有 63 例（18%）存在宫内生长受限。在 298 例（来自 294 名母亲）完整样本中，最常见的死胎原因是母体医疗状况（64 例[21%]；其中 56 例[19%]为高血压疾病，6 例[2%]为糖尿病）、胎盘或胎儿感染（58 例[19%]；其中 47 例[16%]为胎儿侵袭性细菌感染，57 例[19%]为病理性胎盘情况（其中 27 例[9%]为胎膜和胎盘炎症，26 例[9%]为循环异常），临床产科并发症（54 例[18%]；其中 45 例[15%]为胎盘早剥）。6 例（2%）死胎归因于胎儿、遗传或结构异常。在 55 例（18%）病例中，未确定死亡原因。导致胎儿侵袭性感染的死胎最常见的细菌是 B 群链球菌（15 例[5%]）、大肠杆菌（12 例[4%]）、粪肠球菌（6 例[2%]）和金黄色葡萄球菌（5 例[2%]）。
结论
即使没有胎儿尸检，针对死胎的有针对性调查也可以确定大多数死胎的原因。需要使用此类调查进一步研究，以确定全球减少死胎的干预措施的优先次序。
资助
诺华公司和葛兰素史克公司。
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