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Perinatal mortality at King Fahd Hospital of The University Al-Khobar, Saudi Arabia
Znt. J. Gynecoi. Obstet., 1988,26: 399-407 International Federation of Gynecology & Obstetrics
399
Perinatal mortality at King Fahd Hospital of The University Al-Khobar , Saudi Arabia Mazen Y. El-Zibdeh,
Suleiman
A. Al-Suleiman
and Mohammad
H. Al-Sibai
Department of Obstetrics & Gynecology, King Fakal University and King Fahd Hospital of the University, AI-Khobar (Saudi Arabia) (Received December 19th, 1986) (Revised and accepted June 9th. 1987)
Abstract
Introduction
The perinatal deaths of all singleton births that occurred at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia during a I-year period are analysed. The causes of death are classified into 12 groups using an extended modification of the Aberdeen classification. There were 165 perinatal deaths in 8057 singleton births, giving a perinatal mortality rate of 20.47per 1000 total births. Fetal malformations occurred in 29 (17.57Vo) cases. Of the remaining 136 normal infants, 77 (56.6%) were stillbirths and 59 (43.4%) died within I week of delivery. Spontaneous premature labor was the commonest cause of death (23.52qo) followed by birth trauma (II %) and maternal diseases (9.55%). The cause of death was not known in 22 (16.170/0/ cases. In conclusion, prevention of premature labor, better intrapartum fetal monitoring, early recognition of fetal distress and improvement of neonatal care should reduce theperinatal mortality rate.
The perinatal mortality (PNM) rates reflect the quality of obstetric and neonatal services. Comparisons of PNM data between different regions and hospitals are used to give an idea about the health status of a given population WI. Methods of enquiry into perinatal death are numerous and varies from regular informal clinical review of the individual cases, to the more formal analysis of uncontrolled cases based on hospital cases or on a geographically defined population [6,12]. In developing countries, statistics at national level are still lacking and geographically based PNM statistics are unreliable. Most of the statistics available from such countries are based on individual hospital data. Saudi Arabia is a developing country. The health care and facilities are advancing rapidly in most regions. There are few documented perinatal statistics available from hospitals in this country [20,30]. The King Fahd Hospital of the University (KFHU) in Al-Khobar opened in May 198 1. The number of deliveries has increased from 1173 in the first year to 2526 in the fourth year. This PNM survey was undertaken to identify the causes and the predisposing factors of perinatal deaths, so
Keywords: Perinatal deaths; Prematurity; Congenital malformations; Birth trauma; Maternal diseases; Intrapartum fetal monitoring. 0020-7292/88/$03.50 0 1988 International Federation of Gynecology & Obstetrics Published and Printed in Ireland
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et al.
that specific deficiencies are recognised order to reduce the death rate.
in
Materials and methods All babies born at KFHU Al-Khobar between June 1, 1981 and May 31, 1985 are included in this survey of perinatal deaths (PND). This study includes: (a) (b) (c)
stillbirths of 24 weeks gestation or more; stillbirths weighing 500 g or more when gestational age was not stated; all babies born alive and were of any gestation or weight but who died within the first 7 days of life.
The PNM rate is defined as the number of PND per 1000 total births. Data about each PND were obtained soon after delivery from the clinical records of the mother and the baby and were coded in a specially designed form for the study. This form included information about the mother’s medical history, her antenatal period, the course of labor and the outcome of the fetus in terms of antepartum, intrapartum and postpartum death. The information about the infant included the sex, birth weight, Apgar scoring, and the resuscitation procedures in pertinent cases. External congenital abnormalities, X-ray findings and ultrasonographic results when carried out were recorded. Postpartum examination of the dead fetus was not done in all cases of PND because this it not allowed in Saudi Arabia as routine except in certain special circumstances. Detailed information about the placenta included the weight, appearance, length of the cord and any abnormalities such as retroplacental clot or single umbilical artery. In cases of neonatal death, information included the pediatric assessment of gestational age, neonatal complications and the age at death in days. Gestational age was calculated from the last menstrual period and in patients attendInt J Gynecol Obstet 26
ing an antenatal clinic it was confirmed by ultrasonographic examination. In live-born infants the gestational age was confirmed by physical examination using the criteria of Dubowitz [9]. Intrauterine growth retardation (IUGR) of the infant, diagnosed when the infants birthweight was below the 10th percentile of the normal intrauterine growth for deliveries occurring at KFHU AL-Khobar [l 11, or when the infant delivered after 37 weeks gestation, weighed less than 2.5 kg. A gestational age of less than 37 completed weeks was defined as prematurity, and of 42 weeks or more as postmaturity. Each death was classified according to a modified version of the Aberdeen classification [28]: (1) Congenital abnormalities. These included only major abnormalities incompatible with life. (2) Prematurity. This group included normally formed infants that died due to premature labor or its complications. (3) Intrauterine growth retardation (IUGR). The death of the normally formed infants that could not be explained by ,any maternal complication other than IUGR were included in this group. (4) Antepartum hemorrhage (APH). The fetal loss was attributed to APH in pertinent cases (placenta previa, placental abruption, and undetermined origin) provided there was no history of toxemia or hypertension. (5) Pre-ecfamptic toxemia (PET). The hypertensive component of toxemia in this study was defined as a rise of blood pressure in pregnancy on more than one occasion after 24 weeks gestation to 140/90 mmHg, provided there was no past history of hypertension before or during early pregnancy. (6) Birth trauma. This included the death of the normally formed infant weighing 1.8 kg or above and associated with mechanical obstruction or sustained damage during labor. When the infant weighed less than 1.8 kg the traumatic death of such babies was considered under prematurity. (7) Intrapartum asphyxia. This group
Perinatal mortality, Saudi Arabia
included intrapartum and early neonatal death of the normally formed infant, in an apparently normal pregnancy preceded by evidence of birth asphyxia (e.g. monitored fetal heart rate changes, meconium passage and fetal scalp pH less than 7.2). In the live born infant the occurrence of hypoxia was confirmed by Apgar score of less than 3 at 1 min, vigorous resuscitation requirement and umbilical artery pH of less than 7.25. (8) Rhesus isoimmunization. Death due to Rh isoimmunization was based on evidence of Rh blood group incompatibility, antibodies titre, suggestive clinical history and postnatal findings in the infant. (9) Maternal diseases. This group included infant losses attributable to any maternal medical or surgical disorders, e.g. diabetes, cardiac disease, renal disease, hepatic disease, cerebra-vascular accident and severe anemia. (10) Maternal and fetal infection. All bacterial, viral or protozoal infection occurring as a primary factor and directly or indirectly causing infant’s death were included in this group. (11) Mature normal infant no maternal complication. This group included normally formed infants weighing 2.5 kg or more at birth and whose death could not be explained by any maternal complications or causes listed above. (12) Others. This category included miscellaneous causes of death other than those
Table 1.
Relation between perinatal mortality in normal and malformed infants and time of death. stillbirths (%)
First week deaths (%)
Total (@A)
Normal infants Malformed infants
77 (56.61)
59 (43.38)
136 (82.42)
8 (27.58)
21 (72.41)
29 (17.57)
Total
85 (51.5)
80 (48.5)
165
defined above. hydrops fetalis.
It
included
401
non-immune
Results
During the Cyear period of the study 8126 patients delivered at KFHU, Al-Khobar, 8057 singleton births, 68 twins and one set of triplets. Perinatal death occurred in 165 singleton and in 7 of the twin deliveries. The PNM rate was 20.47 per 1000 singleton births and 20.98 per 1000 total births. Among the 165 PND in the singleton pregnancies, 29 (17.57%) deaths were due to congenital abnormalities. Seventy-seven (56.61Vo) of the remaining 136 normally formed infants were stillbirths and 59 (43.38%) were neonatal deaths (Table I). About 65% of the patients delivered at KFHU had antenatal care (ANC). The PNM rate was three times more in pregnancies that had no ANC (Table II), and this was statistically significant (P-value < 0.0001 using Ztest). The PNM rate was lower in women between 20 and 24 years and higher in those below 19 and above 24 years. The PNM rate was lower in para 2 women and higher in primigravida and para 1 patients. The mortality rate then increased reaching the highest level among women who were para 7 and above. Table III summarises the causes of stillbirth (SB) and first-week neonatal death in the normally formed infants.
Relation between perinatal mortality and antenatal Tabk II. (ANC) care in singleton pregnancy. Calculated Z-value = 7.1323; P-vahre
No. of PND
PNM/lO@l births
5237
64
12.22
2820
101
35.81
8057
165
20.47
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Tnbk III.
Causes of perinatal death in normally formed
infants. No. of
Cause of PNJI
Still-
births Prematurity Intrauterine growth retardation Antepartmn hemorrhage Pre-eclamptic toxemia Birth trauma Birth asphyxia Hemolytjc disease Maternal diseases Mature infant, no maternal complication Fetal infection Others Total 070
No. of Fist week deaths
Total
“IO
1 9
31 2
32 11
23.52 8.08
9
2
11
8.08
9
1
10
1.35
9 7 4 9 20
6 5 1 4 2
15 12 5 13 22
11.02 8.82 3.36 9.55 16.17
-
3 2
3 2
2.20 1.47
77 56.61
59 43.38
136
Prematurity (32 cases) Of the 136 normally formed infants, 32 (23.5%) died due to prematurity. In 18 of 32 cases the mothers had no ANC. Predisposing factors were present in 18 cases. Twenty-three of the 32 cases had normal vaginal delivery, two had cesarean section (CS) and seven vaginal breech delivery. During this study period there were 52 premature babies delivered vaginally as breech.
Intrauterine growth retardation (II cases) Only four mothers of 11 cases attended ANC regularly. Two of these four mothers had intrauterine fetal death (IUFD) at 36 weeks gestation, while the remaining two delivered at 37 weeks gestation; one vaginally and the other by CS. The two live-born infants weighed 1.8 and 1.9 kg and both had neonatal death due to severe meconium aspiration and pneumonia.
100
An tepartum hemorrhage Congenital abnormalities accounted for 29 (17.57%) deaths. Details of the abnormalities are shown in Table IV. The PND rate due to fetal abnormalities was 3.59 per 1000 singleton births. Eight cases of fetal abnormalities were stillborn, while 21 cases died in the neonatal period. In eight of the 11 patients who attended antenatal clinic, fetal abnormalities were discovered by 20 weeks gestation on routine ultrasonography. Table IV.
Perinatal deaths due to fetal abnormalities.
Type of fetal abnormality
No. of deaths
070
Central nervous system Multiple deformities Congenital heart disease Biaphragmatic hernia Potter’s syndrome Achondroplasia Exomphalocele
10 7 5 2 2 2 1
34.4 24.1 17.2 6.8 6.8 6.8 3.4
Total
29
99.5
Int J Gynecol Obstet 26
This condition caused 11 PND; all were due to abruptio placenta. In six cases the mothers were 35 years of age and above and had more than 10 children. Severe APH was present in nine cases and they were admitted to the hospital with IUFD. The other two cases had APH at 36 weeks and were delivered by CS but the infants died within 24 h due to severe hypoxia.
Pre-eclamptic toxemia Pre-eclampsia accounted for 10 PND. Six patients had no ANC and the infants were dead when admitted in labor. Two of the remaining four mothers developed severe PET at 26 weeks and 28 weeks gestation causing intrauterine death. One of the remaining two was a grandmultiparous women who had spontaneous labor at 36 weeks gestation and the baby died during labor. The remaining one was induced at 34 weeks and the baby died 2 days after delivery.
Birth trauma Fifteen infants died due to birth trauma.
Perinatal mortality, Saudi Arabia Table V.
Causes and time of perinatal death due to birth
trauma. Cause of death
No. of stillbirths
No. of first week deaths
Total no. of cases
Cord complication Breech delivery Shoulder presentation Forceps delivery Ruptured uterus
4 2 2 1
1 4 1 -
5 6 2 1 1
Total
9
6
15
Table V shows the causes and the time of death in this group. The cord complications accounted for five deaths. Three had prolapsed non-pulsating cords on admission. Breech delivery was responsible for six PND. All mothers were multiparous and the babies weighed between 2800 and 3700 g. Two babies were fresh stillbirths. The other four infants died within 24 h after delivery due to severe asphyxia and intracranial hemorrhage. Shoulder presentation with arm and cord prolapse was the cause of death in two cases. The mothers in both cases were multiparous and had emergency CS. One case had a difficult forceps delivery and the baby died 3 h after birth due to birth trauma. Ruptured uterus was the cause of death in one case. This mother had two previous cesarean sections and on admission she was found to have ruptured uterus and a dead infant. In trapartum asphyxia This accounted for 12 PND; seven died during labor and five after delivery. Seven mothers were admitted to the hospital after they had been in labor at home for a considerable period of time. In three cases the fetal heart was absent on admission. The other four had emergency cesarean sections but the badies died after delivery due to severe asphyxia.
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Retrospective study of the other five mother’s charts showed that the signs of fetal distress such as fetal bradycardia, late decelerations and meconium stained liquor were present in labor. Prolonged labor of more than 15 h occurred in two cases. Of these five cases, three infants died during labor, one died in the first neonatal day and the fifth delivered by emergency CS but could not be revived and died soon after birth. Rhesus isoimmunization There were five perinatal deaths in multiparous patients due to Rh-isoimmunization. Three mothers had no ANC and attended the hospital at 36-38 weeks gestation with IUFD. The fourth case was referred from another hospital at 36 weeks gestation with severe Rh-isoimmunization and the baby was delivered by CS but died 6 h after birth. In the fifth case severe isoimmunization was detected at 24 weeks gestation and the baby died in utero at 28 weeks gestation. Maternal diseases Nine PND were due to maternal diabetes (6.6% of PND of normally formed infants). Six of these mothers attended ANC. In three of them IUFD occurred at around 37 weeks gestation. In the other three, the babies were delivered at 36-38 weeks gestation but died in the first neonatal week due to hyaline membrane disease and pneumonia. One mother was admitted in coma due to subarachnoid hemorrhage at 30 weeks gestation. A live infant was delivered by CS but he died 2 days later due to hypoxia and prematurity. Another woman was admitted at 32 weeks gestation with severe jaundice, hepatosplenomegaly and anemia, and the baby was found to be dead on admission. Two IUFD occurred at 30 and 34 weeks gestation, one to a cardiac patient, and the other to a patient who suffered from chronic pyelonephritis and developed hypertension at 24 weeks gestation.
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Mature normal infant, no maternal complication All babies in this group weighed 2500 g or more and appeared normal. The cause of death was not obvious. Fifteen mothers in this group had no ANC. Postmaturity was suspected in three cases. Maternal and fetal infections Three infants died during the neonatal period due to infection. Two were born at 38 weeks gestation and developed pneumonia, streptococcal septicemia and consumptive coagulopathy. The third infant was delivered in the emergency room (3.2 kg) and died after 6 days due to septicemia and renal failure. Others Two infants in this group died due to nonimmune hydrops fetalis. The mothers were primigravidae and had Rh-positive blood group without any circulating antibodies. Both infants were alive at birth with generalised edema, pericardial effusion and hepatomegaly and died within 3 h of birth. Discussion The result of this study based on the patients of a teaching hospital may not represent the true perinatal problems in the general population but gives some estimate of the causes of PNM in the country. Such a study identifies the major causes of PND and focuses attention on those that are avoidable and preventable. The PNM rate at KFHU-Al-Khobar in the singleton pregnancies (20.47 per 1000 births) is slightly higher than that reported from Riyadh, Saudi Arabia [30]. Congenital malformation was the second major cause of PND. Recognition of these abnormalities in early pregnancy will not reduce the PNM because termination of pregnancy is not allowed in Saudi Arabia for fetal abnormalities. In the normally formed infants, prematurity was the commonest cause of perinatal Znt J Gym-cot Obstet 26
death. Fetal death due to prematurity was closely related to the gestational age and birth weight. Predisposing factors were present in 18 (56%) cases. The failure of a large number of patients delivered in our hospital to attend ANC or to adhere to regular follow-up made early recognition of the predisposing factors difficult. This feature is common in our country as many women consider pregnancy and childbirth as a natural process and require no intervention by the medical staff. Changing this attitude requires an extensive health education program and an increase in the number of primary health care centers. Prevention of preterm labor should be an important objective of prenatal care. However, some investigators have attempted to identify prospectively those women most likely to be delivered before 37 weeks gestation [7,25]. A program which identifies these patients early in pregnancy would provide adequate time for preterm labor prevention. Also, the presence of good ,hospital facilities for the care of the premature infant during labor and in the immediate neonatal period will undoubtedly/ reduce PND caused by prematurity. IUGR in the absence of maternal complications accounted for 11 deaths. The babies of four mothers who attended antenatal care could have been saved if delivery was planned at an earlier stage. As IUGR is detectable clinically and by sonography [26,27,34], so, most deaths from IUGR are avoidable by careful monitoring and timely intervention. Birth trauma accounted for 11% of PND. This factor is now negligible in the developed world [4,5], while much higher incidence has been reported in the developing countries [2,24]. Breech delivery carries a considerable risk to the fetus and frequently requires operative delivery [32]. Current obstetric literature has shown that selected term breech infants can be delivered safely per vaginum particularly when the presentation is either full or frank breech. Some obstetricians opt for CS in the belief that this is the best for the baby. CS carries certain immediate and long term risks for the mother and the obstetrician must
Perinatal mortality, Saudi Arabia
take these into account when he decides between vaginal or abdominal delivery particularly in a community like Saudi Arabia where parity is usually high. The safety of breech delivery requires acccurate assessment of the infant’s weight, the position of the limbs, the degree of the babies head .extension and the pelvic measurements [13,23]. The decision to attempt vaginal delivery must be continuously re-evaluated even if the second stage of labor has already begun [3]. In our study deaths due to vaginal breech delivery could have been avoided if CS was performed at the right time. Birth asphyxia is still a major cause of PND in developing countries. This is mainly because of the delayed arrival of the laboring mothers to hospital and due to inadequate intrapartum fetal monitoring facilities. In this study, seven mothers arrived late in labor and PND may have been avoided if they had been admitted at an earlier stage. The PNM is expected to decrease if birth asphyxia is recognised and managed early [ 191. All deaths associated with antepartum hemorrhage were due to placental abruption. Increased maternal age, grandmultiparity and lack of antenatal care as seen in this study may be relevant associated factors. Fetal loss from abruptio placentae is inevitably high and correlates with the severity of placental separation, gestational age and the amount of concealed hemorrhage [l,lO]. When the fetus is alive on admission to hospital, fetal loss correlates well with diagnosis to delivery interval [21]. Prompt delivery by CS in cases of moderate and severe abruption is associated with reduced perinatal loss [ 17,211. The incidence of pre-eclamptic toxemia in Saudi Arabia is less than that reported in Western countries [311. Pre-eclampsia accounted for 10 (7.3%) perinatal deaths, and only four mothers attended ANC. In two cases PET developed as early as 24 weeks gestation, and the obstetricians were reluctant to deliver these babies by CS because of severe prematurity. Delivery by CS in such cases may save the babies only when
405
good neonatal facilities are available. In a population like that of Saudi Arabia, where parity is usually high, and because of the risks associated with a scarred uterus, the obstetrician’s reluctance for doing CS is justified, particularly when the outcome of the baby is not certain due to severe prematurity. In the other two cases, the babies may have been saved if they had been monitored carefully in labor and timely CS carried out. Deaths from Rh-incompatibility is now declining all over the world. The continuing incidence is due to isoimmunization before the use of anti-D immunoglobulin or due to failure to receive the injection particularly after abortion. In this study, Rh-incompatibility was the only hemolytic disease causing fetal loss. Failure of the first three patients to attend antenatal care and late referral of the fourth, made these avoidable outside factors solely responsible for these fetal losses. Diabetes mellitus is a common problem in Saudi Arabia. It is estimated that 3.1% of our antenatal patients have clinical or chemical diabetes, and it accounted for 6.5% of PND in the normally formed infants. Grandmultiparity, increased maternal age and failure of the patient to attend ANC regularly are the associated factors. Early and regular antenatal visits, adequate control of diabetes and monitoring of fetal well-being in pregnancy and labor will reduce the perinatal losses in these cases. Sixteen percent of PND were mature infants with no maternal complications. The number of unexplained fetal deaths in this study is much higher than that reported in other surveys [16]. The high incidence of unexplained fetal death may be exaggerated, because the majority of the mothers in this group (68%) did not attend ANC, and autopsy was not performed on these infants. Complications such as anemia, leaking membranes, transient hypertension or bacteruria may have been present and would have been recognised had these women attended ANC. Clinical and Clinical Research
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Autopsy is not routinely performed in Saudi Arabia due to social and religious reasons. Perinatal autopsy would have probably identified some unrecognized fetal deformities and genetic factors for appropriate counselling [16,29]. Serious neonatal infections have a considerable mortality and some survivors may be seriously handicapped. The three infants that died from infection may have been saved by early diagnosis and antibiotic treatment. The two infants with non-immune hydrops could not be saved. In such cases the mortality is usually high. Recent studies showed that diagnosis of non-immune hydrops can be achieved as early as 28 weeks of gestation or less, enabling institution of antenatal therapy in some cases particularly in fetuses with cardiac arrhythmias [14]. If modern methods of antenatal diagnosis and neonatal intensive care are applied, it is estimated that between 23 and 35% of infants could survive without disability [ 18,331. In conclusion, PNM rate at KFHU, AlKhobar is relatively low in comparison to other reports from developing countries [8,22,24]. Prematurity is the major cause of PND in the normally formed infants. PNM rate should improve if the pregnant women comply with regular ANC. Efforts should be made in improving the health status of the population and in preventing the spontaneous premature labor. Better facilities for monitoring fetal conditions during pregnancy, labor and the neonatal period should help in lowering the perinatal mortality rate. Acknowledgments The authors wish to thank Professor T.K. Chatterjee for his useful comments during the preparation of this manuscript, and for Dr. J. Absood from the Community Department for the statistical analysis. References
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1 Abdella TN, Sibai BM, Hays JM, Anderson CD: Relationship of hypertensive disease to abruptio placentae. Obstet Gynecol63: 365, 1984.
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Abudu 0, Akinkugbe A: Clinical causes and classification of perinatal mortality in Lagos. Int J Gynaecol Obstet20: 443,1982. Bonnie E, Fleischer A, Schulman H, Jagani N: Fetal acidosis and the abnormal fetal heart rate tracing. The term breech fetus. Obstet Gynecol63: 233,1984. Brans YW, Escobedo MB, Hayashi RI-I, Huff RW. Kagan-Hallet KS, Ramamurthy RS: Perinatal mortality in a large perinatal centre. Five years review of 31,000 births. Am J Obstet GynecolZ48: 284,1984. Buckell EWC. Wood BSB: Wessex perinatal mortality survey 1982. Br J Obstet Gynaecol92: 550,1985. Chalmers I: Enquiry into perinatal death. Br J Obstet Gynaecol 92: 545, 1985. Creasy RK, Gummer BA, L&gins GC: System for predicting spontaneous preterrn birth. Obstet Gynecol 55: 692, 1980. Dawudo AH, Adewunmi OA. Marinho AO: Perinatal mortality surveys in an African teaching hospital, the past and the present statistics. E Afr Med J 62: 243,1985. Dubowitz LMS, Dubowitz V, Goldberg C: Clinical assessment of gestational age on the newborn infant. J Pediatr 77: 1, 1970. Egley C, Cefalo R: Abruptio placenta. In Progress in Obstetrics and Gynecology (ed J Studd), Vol. 5, p 108. Churchill Livingstone, Edinburgh, London, Melbourne and New York, 1985. El-Zibdeh MY: The birth weight percentile for gestational age of single births, King Fahd Hospital of the University, Al-Khobar for 198311984 (unpublished data). Enkin M, Chalmers I: Inquiries into perinatal deaths at Area Health Authority Level (A status report Winter 1979/80). Commun Med 2: 219,198O. Gimovsky ML, Paul RH Singleton breech presentation in labor. Experience in 1980. Am J Obstet Gynecol143: 733, 1982. Harrigan JT. Kangos JJ, Sikka A. Spisso KR, Natarajan N, Rosenfeld D, Leiman S, Korn D: Successful treatment of fetal congestive heart failure secondary to tachycardia. N Engl J Med 304: 1527.1981. Hein HA, Lathrop SS, Papke KR: Comparing perinatal mortality. Obstet Gynecol66: 346, 1985. Hovatta 0, Lipasti A, Rapola J. Karjalainen 0: Causes of stillbirth: a clinico-pathological study of 243 patients. Br J Obstet Gynaecol90: 691,1983. Hurd WW, Miodovnik M, Hertzberg V, Lavin JP: Selective management of abruptio placentae: A prospective study. Obstet Gynecol61: 467,1983. Hutchinson AA, Drew JH, Yu VYH, Williams ML, Fortune DW, Beischier NA: Nonimmunologic hydrops fetalis: a review of 61 cases. Obstet Gynecol59: 347,1982. Ingemarsson E: Routine electronic fetal monitoring during labor. Acta Obstet Gynecol Stand Suppl99: 1, 1981. John P. Study of perinatal and infant deaths in 1%7, in Dhahran. Saudi Arabia. J Trop Pediatr 16: 43,197O. Knab DR: Abruptio placentae. Obstet Gynecol 52: 625, 1978.
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Kohli KL, Alomaim M: Infant and child mortality in Kuwait. J Biosoc Sci 15: 339,1985. Kopelman JN, Duff P, Karl RT, Schipul AH, Read JA: Computed tomographic pelvimetry in the evaluation of breech presentation. Obstet Gynecol68: 455,1986. Lister UG, Rossiter CE, Chong H: Perinatal mortality. Br J Obstet Gynaecol Suppl5: 86.1985. Main DM, Gabbe SG, Richardson D, Strong S: Can preterm deliveries be prevented? Am J Obstet Gynecol 151: 892.1985. Manning FA. Morrison I, Lange IR. Harman C: Antepar-turn determination of fetal health: composite biophysical profile scorhrg. Chn Perinatol9: 285,1982. Manning FA, Morrison I, Lange IR. Harman C: Antepartum evaluation of fetal health. In Recent Advances in Perinatal Medicine (ed ML Chiswick) Vol. 3, p 41. Churchill Livingstone, Edinburgh, 1983. McIlwaine GM, Howat RCL, Dunn F, MacNaughton MC: The Scottish perinatal mortality survey. Br Med J 2: 1103,1979. Meier PR, Manchester DK, Robert SH. Clewell WH,
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Stewart M: Perinatal autopsy: its clinical value. Obstet Gynecol67: 349.1986. Mosleh R: Perhratal mortality at the Riyadh Armed Forces Hospital, Riyadh. Saudi Med J 6: 135,1985. Pugh CK. Ledward RA: Pregnancy induced hypertension in Saudi Arabia. Trop Doct 11: 74,198l. Rosen MG, Lawrence C: The effect of delivery route on outcome in breech presentation. Am J Obstet Gynecol 148: 909,1984. Watson J, Campbell S: Antenatal evaluation and management in Nonimmune Hydrops Fetalis. Obstet Gynecol 67: 589,1986. Whitfield CR, Smith NC, Cockbum F, Gibson AAM: Perinatally related wastage: a proposed classification of primary obstetric factors. Br J Obstet Gynaecol93: 694, 1986.
Address for reprints: M. Y. El-zibdeh, MD P.O. Box 910101 Jordan
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Perinatal mortality at King Fahd Hospital of The University Al-Khobar , Saudi Arabia Mazen Y. El-Zibdeh,
Suleiman
A. Al-Suleiman
and Mohammad
H. Al-Sibai
Department of Obstetrics & Gynecology, King Fakal University and King Fahd Hospital of the University, AI-Khobar (Saudi Arabia) (Received December 19th, 1986) (Revised and accepted June 9th. 1987)
Abstract
Introduction
The perinatal deaths of all singleton births that occurred at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia during a I-year period are analysed. The causes of death are classified into 12 groups using an extended modification of the Aberdeen classification. There were 165 perinatal deaths in 8057 singleton births, giving a perinatal mortality rate of 20.47per 1000 total births. Fetal malformations occurred in 29 (17.57Vo) cases. Of the remaining 136 normal infants, 77 (56.6%) were stillbirths and 59 (43.4%) died within I week of delivery. Spontaneous premature labor was the commonest cause of death (23.52qo) followed by birth trauma (II %) and maternal diseases (9.55%). The cause of death was not known in 22 (16.170/0/ cases. In conclusion, prevention of premature labor, better intrapartum fetal monitoring, early recognition of fetal distress and improvement of neonatal care should reduce theperinatal mortality rate.
The perinatal mortality (PNM) rates reflect the quality of obstetric and neonatal services. Comparisons of PNM data between different regions and hospitals are used to give an idea about the health status of a given population WI. Methods of enquiry into perinatal death are numerous and varies from regular informal clinical review of the individual cases, to the more formal analysis of uncontrolled cases based on hospital cases or on a geographically defined population [6,12]. In developing countries, statistics at national level are still lacking and geographically based PNM statistics are unreliable. Most of the statistics available from such countries are based on individual hospital data. Saudi Arabia is a developing country. The health care and facilities are advancing rapidly in most regions. There are few documented perinatal statistics available from hospitals in this country [20,30]. The King Fahd Hospital of the University (KFHU) in Al-Khobar opened in May 198 1. The number of deliveries has increased from 1173 in the first year to 2526 in the fourth year. This PNM survey was undertaken to identify the causes and the predisposing factors of perinatal deaths, so
Keywords: Perinatal deaths; Prematurity; Congenital malformations; Birth trauma; Maternal diseases; Intrapartum fetal monitoring. 0020-7292/88/$03.50 0 1988 International Federation of Gynecology & Obstetrics Published and Printed in Ireland
Clinical and Clinical Research
400
El-Zibdeh
et al.
that specific deficiencies are recognised order to reduce the death rate.
in
Materials and methods All babies born at KFHU Al-Khobar between June 1, 1981 and May 31, 1985 are included in this survey of perinatal deaths (PND). This study includes: (a) (b) (c)
stillbirths of 24 weeks gestation or more; stillbirths weighing 500 g or more when gestational age was not stated; all babies born alive and were of any gestation or weight but who died within the first 7 days of life.
The PNM rate is defined as the number of PND per 1000 total births. Data about each PND were obtained soon after delivery from the clinical records of the mother and the baby and were coded in a specially designed form for the study. This form included information about the mother’s medical history, her antenatal period, the course of labor and the outcome of the fetus in terms of antepartum, intrapartum and postpartum death. The information about the infant included the sex, birth weight, Apgar scoring, and the resuscitation procedures in pertinent cases. External congenital abnormalities, X-ray findings and ultrasonographic results when carried out were recorded. Postpartum examination of the dead fetus was not done in all cases of PND because this it not allowed in Saudi Arabia as routine except in certain special circumstances. Detailed information about the placenta included the weight, appearance, length of the cord and any abnormalities such as retroplacental clot or single umbilical artery. In cases of neonatal death, information included the pediatric assessment of gestational age, neonatal complications and the age at death in days. Gestational age was calculated from the last menstrual period and in patients attendInt J Gynecol Obstet 26
ing an antenatal clinic it was confirmed by ultrasonographic examination. In live-born infants the gestational age was confirmed by physical examination using the criteria of Dubowitz [9]. Intrauterine growth retardation (IUGR) of the infant, diagnosed when the infants birthweight was below the 10th percentile of the normal intrauterine growth for deliveries occurring at KFHU AL-Khobar [l 11, or when the infant delivered after 37 weeks gestation, weighed less than 2.5 kg. A gestational age of less than 37 completed weeks was defined as prematurity, and of 42 weeks or more as postmaturity. Each death was classified according to a modified version of the Aberdeen classification [28]: (1) Congenital abnormalities. These included only major abnormalities incompatible with life. (2) Prematurity. This group included normally formed infants that died due to premature labor or its complications. (3) Intrauterine growth retardation (IUGR). The death of the normally formed infants that could not be explained by ,any maternal complication other than IUGR were included in this group. (4) Antepartum hemorrhage (APH). The fetal loss was attributed to APH in pertinent cases (placenta previa, placental abruption, and undetermined origin) provided there was no history of toxemia or hypertension. (5) Pre-ecfamptic toxemia (PET). The hypertensive component of toxemia in this study was defined as a rise of blood pressure in pregnancy on more than one occasion after 24 weeks gestation to 140/90 mmHg, provided there was no past history of hypertension before or during early pregnancy. (6) Birth trauma. This included the death of the normally formed infant weighing 1.8 kg or above and associated with mechanical obstruction or sustained damage during labor. When the infant weighed less than 1.8 kg the traumatic death of such babies was considered under prematurity. (7) Intrapartum asphyxia. This group
Perinatal mortality, Saudi Arabia
included intrapartum and early neonatal death of the normally formed infant, in an apparently normal pregnancy preceded by evidence of birth asphyxia (e.g. monitored fetal heart rate changes, meconium passage and fetal scalp pH less than 7.2). In the live born infant the occurrence of hypoxia was confirmed by Apgar score of less than 3 at 1 min, vigorous resuscitation requirement and umbilical artery pH of less than 7.25. (8) Rhesus isoimmunization. Death due to Rh isoimmunization was based on evidence of Rh blood group incompatibility, antibodies titre, suggestive clinical history and postnatal findings in the infant. (9) Maternal diseases. This group included infant losses attributable to any maternal medical or surgical disorders, e.g. diabetes, cardiac disease, renal disease, hepatic disease, cerebra-vascular accident and severe anemia. (10) Maternal and fetal infection. All bacterial, viral or protozoal infection occurring as a primary factor and directly or indirectly causing infant’s death were included in this group. (11) Mature normal infant no maternal complication. This group included normally formed infants weighing 2.5 kg or more at birth and whose death could not be explained by any maternal complications or causes listed above. (12) Others. This category included miscellaneous causes of death other than those
Table 1.
Relation between perinatal mortality in normal and malformed infants and time of death. stillbirths (%)
First week deaths (%)
Total (@A)
Normal infants Malformed infants
77 (56.61)
59 (43.38)
136 (82.42)
8 (27.58)
21 (72.41)
29 (17.57)
Total
85 (51.5)
80 (48.5)
165
defined above. hydrops fetalis.
It
included
401
non-immune
Results
During the Cyear period of the study 8126 patients delivered at KFHU, Al-Khobar, 8057 singleton births, 68 twins and one set of triplets. Perinatal death occurred in 165 singleton and in 7 of the twin deliveries. The PNM rate was 20.47 per 1000 singleton births and 20.98 per 1000 total births. Among the 165 PND in the singleton pregnancies, 29 (17.57%) deaths were due to congenital abnormalities. Seventy-seven (56.61Vo) of the remaining 136 normally formed infants were stillbirths and 59 (43.38%) were neonatal deaths (Table I). About 65% of the patients delivered at KFHU had antenatal care (ANC). The PNM rate was three times more in pregnancies that had no ANC (Table II), and this was statistically significant (P-value < 0.0001 using Ztest). The PNM rate was lower in women between 20 and 24 years and higher in those below 19 and above 24 years. The PNM rate was lower in para 2 women and higher in primigravida and para 1 patients. The mortality rate then increased reaching the highest level among women who were para 7 and above. Table III summarises the causes of stillbirth (SB) and first-week neonatal death in the normally formed infants.
Relation between perinatal mortality and antenatal Tabk II. (ANC) care in singleton pregnancy. Calculated Z-value = 7.1323; P-vahre
No. of PND
PNM/lO@l births
5237
64
12.22
2820
101
35.81
8057
165
20.47
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Tnbk III.
Causes of perinatal death in normally formed
infants. No. of
Cause of PNJI
Still-
births Prematurity Intrauterine growth retardation Antepartmn hemorrhage Pre-eclamptic toxemia Birth trauma Birth asphyxia Hemolytjc disease Maternal diseases Mature infant, no maternal complication Fetal infection Others Total 070
No. of Fist week deaths
Total
“IO
1 9
31 2
32 11
23.52 8.08
9
2
11
8.08
9
1
10
1.35
9 7 4 9 20
6 5 1 4 2
15 12 5 13 22
11.02 8.82 3.36 9.55 16.17
-
3 2
3 2
2.20 1.47
77 56.61
59 43.38
136
Prematurity (32 cases) Of the 136 normally formed infants, 32 (23.5%) died due to prematurity. In 18 of 32 cases the mothers had no ANC. Predisposing factors were present in 18 cases. Twenty-three of the 32 cases had normal vaginal delivery, two had cesarean section (CS) and seven vaginal breech delivery. During this study period there were 52 premature babies delivered vaginally as breech.
Intrauterine growth retardation (II cases) Only four mothers of 11 cases attended ANC regularly. Two of these four mothers had intrauterine fetal death (IUFD) at 36 weeks gestation, while the remaining two delivered at 37 weeks gestation; one vaginally and the other by CS. The two live-born infants weighed 1.8 and 1.9 kg and both had neonatal death due to severe meconium aspiration and pneumonia.
100
An tepartum hemorrhage Congenital abnormalities accounted for 29 (17.57%) deaths. Details of the abnormalities are shown in Table IV. The PND rate due to fetal abnormalities was 3.59 per 1000 singleton births. Eight cases of fetal abnormalities were stillborn, while 21 cases died in the neonatal period. In eight of the 11 patients who attended antenatal clinic, fetal abnormalities were discovered by 20 weeks gestation on routine ultrasonography. Table IV.
Perinatal deaths due to fetal abnormalities.
Type of fetal abnormality
No. of deaths
070
Central nervous system Multiple deformities Congenital heart disease Biaphragmatic hernia Potter’s syndrome Achondroplasia Exomphalocele
10 7 5 2 2 2 1
34.4 24.1 17.2 6.8 6.8 6.8 3.4
Total
29
99.5
Int J Gynecol Obstet 26
This condition caused 11 PND; all were due to abruptio placenta. In six cases the mothers were 35 years of age and above and had more than 10 children. Severe APH was present in nine cases and they were admitted to the hospital with IUFD. The other two cases had APH at 36 weeks and were delivered by CS but the infants died within 24 h due to severe hypoxia.
Pre-eclamptic toxemia Pre-eclampsia accounted for 10 PND. Six patients had no ANC and the infants were dead when admitted in labor. Two of the remaining four mothers developed severe PET at 26 weeks and 28 weeks gestation causing intrauterine death. One of the remaining two was a grandmultiparous women who had spontaneous labor at 36 weeks gestation and the baby died during labor. The remaining one was induced at 34 weeks and the baby died 2 days after delivery.
Birth trauma Fifteen infants died due to birth trauma.
Perinatal mortality, Saudi Arabia Table V.
Causes and time of perinatal death due to birth
trauma. Cause of death
No. of stillbirths
No. of first week deaths
Total no. of cases
Cord complication Breech delivery Shoulder presentation Forceps delivery Ruptured uterus
4 2 2 1
1 4 1 -
5 6 2 1 1
Total
9
6
15
Table V shows the causes and the time of death in this group. The cord complications accounted for five deaths. Three had prolapsed non-pulsating cords on admission. Breech delivery was responsible for six PND. All mothers were multiparous and the babies weighed between 2800 and 3700 g. Two babies were fresh stillbirths. The other four infants died within 24 h after delivery due to severe asphyxia and intracranial hemorrhage. Shoulder presentation with arm and cord prolapse was the cause of death in two cases. The mothers in both cases were multiparous and had emergency CS. One case had a difficult forceps delivery and the baby died 3 h after birth due to birth trauma. Ruptured uterus was the cause of death in one case. This mother had two previous cesarean sections and on admission she was found to have ruptured uterus and a dead infant. In trapartum asphyxia This accounted for 12 PND; seven died during labor and five after delivery. Seven mothers were admitted to the hospital after they had been in labor at home for a considerable period of time. In three cases the fetal heart was absent on admission. The other four had emergency cesarean sections but the badies died after delivery due to severe asphyxia.
403
Retrospective study of the other five mother’s charts showed that the signs of fetal distress such as fetal bradycardia, late decelerations and meconium stained liquor were present in labor. Prolonged labor of more than 15 h occurred in two cases. Of these five cases, three infants died during labor, one died in the first neonatal day and the fifth delivered by emergency CS but could not be revived and died soon after birth. Rhesus isoimmunization There were five perinatal deaths in multiparous patients due to Rh-isoimmunization. Three mothers had no ANC and attended the hospital at 36-38 weeks gestation with IUFD. The fourth case was referred from another hospital at 36 weeks gestation with severe Rh-isoimmunization and the baby was delivered by CS but died 6 h after birth. In the fifth case severe isoimmunization was detected at 24 weeks gestation and the baby died in utero at 28 weeks gestation. Maternal diseases Nine PND were due to maternal diabetes (6.6% of PND of normally formed infants). Six of these mothers attended ANC. In three of them IUFD occurred at around 37 weeks gestation. In the other three, the babies were delivered at 36-38 weeks gestation but died in the first neonatal week due to hyaline membrane disease and pneumonia. One mother was admitted in coma due to subarachnoid hemorrhage at 30 weeks gestation. A live infant was delivered by CS but he died 2 days later due to hypoxia and prematurity. Another woman was admitted at 32 weeks gestation with severe jaundice, hepatosplenomegaly and anemia, and the baby was found to be dead on admission. Two IUFD occurred at 30 and 34 weeks gestation, one to a cardiac patient, and the other to a patient who suffered from chronic pyelonephritis and developed hypertension at 24 weeks gestation.
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El-Zibdeh et al.
Mature normal infant, no maternal complication All babies in this group weighed 2500 g or more and appeared normal. The cause of death was not obvious. Fifteen mothers in this group had no ANC. Postmaturity was suspected in three cases. Maternal and fetal infections Three infants died during the neonatal period due to infection. Two were born at 38 weeks gestation and developed pneumonia, streptococcal septicemia and consumptive coagulopathy. The third infant was delivered in the emergency room (3.2 kg) and died after 6 days due to septicemia and renal failure. Others Two infants in this group died due to nonimmune hydrops fetalis. The mothers were primigravidae and had Rh-positive blood group without any circulating antibodies. Both infants were alive at birth with generalised edema, pericardial effusion and hepatomegaly and died within 3 h of birth. Discussion The result of this study based on the patients of a teaching hospital may not represent the true perinatal problems in the general population but gives some estimate of the causes of PNM in the country. Such a study identifies the major causes of PND and focuses attention on those that are avoidable and preventable. The PNM rate at KFHU-Al-Khobar in the singleton pregnancies (20.47 per 1000 births) is slightly higher than that reported from Riyadh, Saudi Arabia [30]. Congenital malformation was the second major cause of PND. Recognition of these abnormalities in early pregnancy will not reduce the PNM because termination of pregnancy is not allowed in Saudi Arabia for fetal abnormalities. In the normally formed infants, prematurity was the commonest cause of perinatal Znt J Gym-cot Obstet 26
death. Fetal death due to prematurity was closely related to the gestational age and birth weight. Predisposing factors were present in 18 (56%) cases. The failure of a large number of patients delivered in our hospital to attend ANC or to adhere to regular follow-up made early recognition of the predisposing factors difficult. This feature is common in our country as many women consider pregnancy and childbirth as a natural process and require no intervention by the medical staff. Changing this attitude requires an extensive health education program and an increase in the number of primary health care centers. Prevention of preterm labor should be an important objective of prenatal care. However, some investigators have attempted to identify prospectively those women most likely to be delivered before 37 weeks gestation [7,25]. A program which identifies these patients early in pregnancy would provide adequate time for preterm labor prevention. Also, the presence of good ,hospital facilities for the care of the premature infant during labor and in the immediate neonatal period will undoubtedly/ reduce PND caused by prematurity. IUGR in the absence of maternal complications accounted for 11 deaths. The babies of four mothers who attended antenatal care could have been saved if delivery was planned at an earlier stage. As IUGR is detectable clinically and by sonography [26,27,34], so, most deaths from IUGR are avoidable by careful monitoring and timely intervention. Birth trauma accounted for 11% of PND. This factor is now negligible in the developed world [4,5], while much higher incidence has been reported in the developing countries [2,24]. Breech delivery carries a considerable risk to the fetus and frequently requires operative delivery [32]. Current obstetric literature has shown that selected term breech infants can be delivered safely per vaginum particularly when the presentation is either full or frank breech. Some obstetricians opt for CS in the belief that this is the best for the baby. CS carries certain immediate and long term risks for the mother and the obstetrician must
Perinatal mortality, Saudi Arabia
take these into account when he decides between vaginal or abdominal delivery particularly in a community like Saudi Arabia where parity is usually high. The safety of breech delivery requires acccurate assessment of the infant’s weight, the position of the limbs, the degree of the babies head .extension and the pelvic measurements [13,23]. The decision to attempt vaginal delivery must be continuously re-evaluated even if the second stage of labor has already begun [3]. In our study deaths due to vaginal breech delivery could have been avoided if CS was performed at the right time. Birth asphyxia is still a major cause of PND in developing countries. This is mainly because of the delayed arrival of the laboring mothers to hospital and due to inadequate intrapartum fetal monitoring facilities. In this study, seven mothers arrived late in labor and PND may have been avoided if they had been admitted at an earlier stage. The PNM is expected to decrease if birth asphyxia is recognised and managed early [ 191. All deaths associated with antepartum hemorrhage were due to placental abruption. Increased maternal age, grandmultiparity and lack of antenatal care as seen in this study may be relevant associated factors. Fetal loss from abruptio placentae is inevitably high and correlates with the severity of placental separation, gestational age and the amount of concealed hemorrhage [l,lO]. When the fetus is alive on admission to hospital, fetal loss correlates well with diagnosis to delivery interval [21]. Prompt delivery by CS in cases of moderate and severe abruption is associated with reduced perinatal loss [ 17,211. The incidence of pre-eclamptic toxemia in Saudi Arabia is less than that reported in Western countries [311. Pre-eclampsia accounted for 10 (7.3%) perinatal deaths, and only four mothers attended ANC. In two cases PET developed as early as 24 weeks gestation, and the obstetricians were reluctant to deliver these babies by CS because of severe prematurity. Delivery by CS in such cases may save the babies only when
405
good neonatal facilities are available. In a population like that of Saudi Arabia, where parity is usually high, and because of the risks associated with a scarred uterus, the obstetrician’s reluctance for doing CS is justified, particularly when the outcome of the baby is not certain due to severe prematurity. In the other two cases, the babies may have been saved if they had been monitored carefully in labor and timely CS carried out. Deaths from Rh-incompatibility is now declining all over the world. The continuing incidence is due to isoimmunization before the use of anti-D immunoglobulin or due to failure to receive the injection particularly after abortion. In this study, Rh-incompatibility was the only hemolytic disease causing fetal loss. Failure of the first three patients to attend antenatal care and late referral of the fourth, made these avoidable outside factors solely responsible for these fetal losses. Diabetes mellitus is a common problem in Saudi Arabia. It is estimated that 3.1% of our antenatal patients have clinical or chemical diabetes, and it accounted for 6.5% of PND in the normally formed infants. Grandmultiparity, increased maternal age and failure of the patient to attend ANC regularly are the associated factors. Early and regular antenatal visits, adequate control of diabetes and monitoring of fetal well-being in pregnancy and labor will reduce the perinatal losses in these cases. Sixteen percent of PND were mature infants with no maternal complications. The number of unexplained fetal deaths in this study is much higher than that reported in other surveys [16]. The high incidence of unexplained fetal death may be exaggerated, because the majority of the mothers in this group (68%) did not attend ANC, and autopsy was not performed on these infants. Complications such as anemia, leaking membranes, transient hypertension or bacteruria may have been present and would have been recognised had these women attended ANC. Clinical and Clinical Research
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El-Zibdeh et al.
Autopsy is not routinely performed in Saudi Arabia due to social and religious reasons. Perinatal autopsy would have probably identified some unrecognized fetal deformities and genetic factors for appropriate counselling [16,29]. Serious neonatal infections have a considerable mortality and some survivors may be seriously handicapped. The three infants that died from infection may have been saved by early diagnosis and antibiotic treatment. The two infants with non-immune hydrops could not be saved. In such cases the mortality is usually high. Recent studies showed that diagnosis of non-immune hydrops can be achieved as early as 28 weeks of gestation or less, enabling institution of antenatal therapy in some cases particularly in fetuses with cardiac arrhythmias [14]. If modern methods of antenatal diagnosis and neonatal intensive care are applied, it is estimated that between 23 and 35% of infants could survive without disability [ 18,331. In conclusion, PNM rate at KFHU, AlKhobar is relatively low in comparison to other reports from developing countries [8,22,24]. Prematurity is the major cause of PND in the normally formed infants. PNM rate should improve if the pregnant women comply with regular ANC. Efforts should be made in improving the health status of the population and in preventing the spontaneous premature labor. Better facilities for monitoring fetal conditions during pregnancy, labor and the neonatal period should help in lowering the perinatal mortality rate. Acknowledgments The authors wish to thank Professor T.K. Chatterjee for his useful comments during the preparation of this manuscript, and for Dr. J. Absood from the Community Department for the statistical analysis. References
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Abudu 0, Akinkugbe A: Clinical causes and classification of perinatal mortality in Lagos. Int J Gynaecol Obstet20: 443,1982. Bonnie E, Fleischer A, Schulman H, Jagani N: Fetal acidosis and the abnormal fetal heart rate tracing. The term breech fetus. Obstet Gynecol63: 233,1984. Brans YW, Escobedo MB, Hayashi RI-I, Huff RW. Kagan-Hallet KS, Ramamurthy RS: Perinatal mortality in a large perinatal centre. Five years review of 31,000 births. Am J Obstet GynecolZ48: 284,1984. Buckell EWC. Wood BSB: Wessex perinatal mortality survey 1982. Br J Obstet Gynaecol92: 550,1985. Chalmers I: Enquiry into perinatal death. Br J Obstet Gynaecol 92: 545, 1985. Creasy RK, Gummer BA, L&gins GC: System for predicting spontaneous preterrn birth. Obstet Gynecol 55: 692, 1980. Dawudo AH, Adewunmi OA. Marinho AO: Perinatal mortality surveys in an African teaching hospital, the past and the present statistics. E Afr Med J 62: 243,1985. Dubowitz LMS, Dubowitz V, Goldberg C: Clinical assessment of gestational age on the newborn infant. J Pediatr 77: 1, 1970. Egley C, Cefalo R: Abruptio placenta. In Progress in Obstetrics and Gynecology (ed J Studd), Vol. 5, p 108. Churchill Livingstone, Edinburgh, London, Melbourne and New York, 1985. El-Zibdeh MY: The birth weight percentile for gestational age of single births, King Fahd Hospital of the University, Al-Khobar for 198311984 (unpublished data). Enkin M, Chalmers I: Inquiries into perinatal deaths at Area Health Authority Level (A status report Winter 1979/80). Commun Med 2: 219,198O. Gimovsky ML, Paul RH Singleton breech presentation in labor. Experience in 1980. Am J Obstet Gynecol143: 733, 1982. Harrigan JT. Kangos JJ, Sikka A. Spisso KR, Natarajan N, Rosenfeld D, Leiman S, Korn D: Successful treatment of fetal congestive heart failure secondary to tachycardia. N Engl J Med 304: 1527.1981. Hein HA, Lathrop SS, Papke KR: Comparing perinatal mortality. Obstet Gynecol66: 346, 1985. Hovatta 0, Lipasti A, Rapola J. Karjalainen 0: Causes of stillbirth: a clinico-pathological study of 243 patients. Br J Obstet Gynaecol90: 691,1983. Hurd WW, Miodovnik M, Hertzberg V, Lavin JP: Selective management of abruptio placentae: A prospective study. Obstet Gynecol61: 467,1983. Hutchinson AA, Drew JH, Yu VYH, Williams ML, Fortune DW, Beischier NA: Nonimmunologic hydrops fetalis: a review of 61 cases. Obstet Gynecol59: 347,1982. Ingemarsson E: Routine electronic fetal monitoring during labor. Acta Obstet Gynecol Stand Suppl99: 1, 1981. John P. Study of perinatal and infant deaths in 1%7, in Dhahran. Saudi Arabia. J Trop Pediatr 16: 43,197O. Knab DR: Abruptio placentae. Obstet Gynecol 52: 625, 1978.
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Kohli KL, Alomaim M: Infant and child mortality in Kuwait. J Biosoc Sci 15: 339,1985. Kopelman JN, Duff P, Karl RT, Schipul AH, Read JA: Computed tomographic pelvimetry in the evaluation of breech presentation. Obstet Gynecol68: 455,1986. Lister UG, Rossiter CE, Chong H: Perinatal mortality. Br J Obstet Gynaecol Suppl5: 86.1985. Main DM, Gabbe SG, Richardson D, Strong S: Can preterm deliveries be prevented? Am J Obstet Gynecol 151: 892.1985. Manning FA. Morrison I, Lange IR. Harman C: Antepar-turn determination of fetal health: composite biophysical profile scorhrg. Chn Perinatol9: 285,1982. Manning FA, Morrison I, Lange IR. Harman C: Antepartum evaluation of fetal health. In Recent Advances in Perinatal Medicine (ed ML Chiswick) Vol. 3, p 41. Churchill Livingstone, Edinburgh, 1983. McIlwaine GM, Howat RCL, Dunn F, MacNaughton MC: The Scottish perinatal mortality survey. Br Med J 2: 1103,1979. Meier PR, Manchester DK, Robert SH. Clewell WH,
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Stewart M: Perinatal autopsy: its clinical value. Obstet Gynecol67: 349.1986. Mosleh R: Perhratal mortality at the Riyadh Armed Forces Hospital, Riyadh. Saudi Med J 6: 135,1985. Pugh CK. Ledward RA: Pregnancy induced hypertension in Saudi Arabia. Trop Doct 11: 74,198l. Rosen MG, Lawrence C: The effect of delivery route on outcome in breech presentation. Am J Obstet Gynecol 148: 909,1984. Watson J, Campbell S: Antenatal evaluation and management in Nonimmune Hydrops Fetalis. Obstet Gynecol 67: 589,1986. Whitfield CR, Smith NC, Cockbum F, Gibson AAM: Perinatally related wastage: a proposed classification of primary obstetric factors. Br J Obstet Gynaecol93: 694, 1986.
Address for reprints: M. Y. El-zibdeh, MD P.O. Box 910101 Jordan
Clinical and Clinical Research