Correspondence to: R. A. Mesleh FRCOG, C124 Armed Forces Hospital, Riyadh, PO Box 7897, Riyadh 11159, Saudi Arabia. Tel: + 966 1 4777714 ext. 5461 ...
Journal of Obstetrics and Gynaecology (2 00 1 ) Vol. 2 1 , No. 1, 4 9 - 5 5
OBSTETRICS
Changing trends in perinatal deaths at the Armed Forces Hospital, Riyadh, Saudi Arabia R. A. MESLEH, A. M. KURDI, T. O. SABAGH and A. A. ALGWISER Department of Obstetrics and Gynecology, Armed Forces Hospital, Riyadh, Saudi Arabia
Summary A total of 104 522 babies were delivered at the Riyadh Armed Forces Hospital between 1979 and 1998, including 807 stillbirths and 658 neonatal deaths. The 20-year period was divided into four 5-yearly intervals for comparative purposes. The overall Perinatal Mortality Rate (PMR) for infants weighing 500 grams or more ranged between 20·2 per 1000 in 1979 and 13 per 1000 in 1998. The lowest PMR of 10·3 per 1000 was recorded in 1985. Thirty-one per cent of the perinatal deaths were unbooked. The corrected neonatal death rate (excluding congenital anomalies) dropped from 10·1 per 1000 in 1979 to 1·7 per 1000 live births in 1998 – The corrected stillbirth rate dropped from 12·1 per 1000 births in 1979 to six per 1000 in 1998. Of the 807 stillbirths, 24·1% had lethal congenital anomalies while 29·5% were unexplained, 4% had hydrops fetalis, 2% died as a consequence of toxaemia of pregnanc y, 7·5% were associated with antepartum haemorrhage, 7·9% were mechanical, related to cord accident and ruptured uterus, 9.8% died as a consequence of maternal disease, 5·4% of intrapartum asphyxia and 6·4% placental insufficiency. Of the 658 neonatal deaths, 47·5% had lethal congenital anomalies, 2% had hydrops fetalis, 7·6% died as a result of intrapartum asphyxia, 38% died as a result of prematurity with its complications of severe respiratory dysfunction and intraventriculor and pulmonary haemorrhage, 4·1% died in NICU of secondary infection and 0·7% were unclassified. The overall PMR for infants weighing 500 grams or more was 14·1 per thousand. Congenital anomalies and low birth weight/prematurity accounted for 85·5% of the neonatal deaths. Congenital anomalies and unexplained deaths accounted for 53% of total stillbirths while maternal disease was responsible for 9·8% of total stillbirths. Reducing congenital anomalies and preventing prematurity and provision of good antenatal care will help in reducing PMR still further.
Introduction The reproductive pattern in Saudi Arabia is characterised by pregnancies starting at an early age, by high fertility throughout the reproductive span, by low educational attainment of the mother and by poor coverage by antenatal services (Hashim and Anokute, 1994). Perinatal mortality is a good indicator of the quality of perinatal health care. Maternity services have shown a considerable improvement over the last 20 years. National statistics on perinatal mortality are limited (AI Faraidy et al., 1993). The most complete and officially reliable national statistical publication for Saudi Arabia comes from the Ministry of Health. The perinatal mortality rate for the Kingdom of Saudi Arabia declined from 25·6 per 1000 in 1981 to 16 per 1000 in 1989 (Hashim and Anokute, 1994). The aim of this study was to show the changing
trends in perinatal deaths at the RAFH over the last 20 years (1979–1998), define causes, outline measures of prevention and define areas of improvements. Material and methods The Armed Forces Hospital, Riyadh (RAFH) is a tertiary care hospital which was opened late in 1978. It cares for all employees of the armed forces, military and civilian and their families. Perinatal mortality meetings are held monthly and prenatal review meetings are held bi-monthly to discuss all cases of congenitally malformed babies discovered at routine ultrasound scanning. Malformations, which are considered incompatible with life, were marked not to carry out caesarean section for a fetal indication. This was a retrospective case record analysis of all reported stillbirths and neonatal deaths of babies delivered at Riyadh Armed Forces Hospital (RAFH) and weighing 500 grams or more. A stillbirth was defined as a baby delivered weighing 500 grams or more with no signs of life. Birth weight was taken into consideration as this is more accurate than gestational age, especially in a society where a considerable number of patients are unaware of their last menstrual period or conceived during a period of lactational amenorrhoea. Early neonatal death was defined as death of an infant during the first week of life, who was born alive, weighing 500 grams or over. The deaths were classified according to the cause of death as specified and agreed upon at the departmental perinatal mortality meeting. When more than one cause may have contributed to the death of that baby, the most likely primary cause was recorded. An attempt was made to correlate the cause of death to the predisposing antenatal, intrapartum or postpartum cause. The effect of antenatal care, method of delivery and birth weight were analysed. To make these data meaningful, we classified the period of study into 5-yearly intervals. Babies weighing less than 500 grams or delivered outside this hospital and who died in neonatal intensive care unit were excluded from the study. c 2 was used for statistical analysis and P value < 0·05 was considered statistically significant. Results The total annual deliveries have increased from 1377 in 1979 to 6988 in 1998. Table I shows a compara-
Correspondence to: R. A. Mesleh FRCOG, C124 Armed Forces Hospital, Riyadh, PO Box 7897, Riyadh 11159, Saudi Arabia. Tel: + 966 1 4777714 ext. 5461; Fax: + 966 1 4760853 . ISSN 0 1 4 4 - 3 6 1 5 print/ISSN 1 3 6 4 - 6 8 9 3 online/0 1 /0 1 0 0 4 9 - 0 7 ã DOI: 1 0 .1 0 8 0 /0 1 4 4 3 6 1 0 0 2 0 0 2 2 1 2 2
Taylor & Francis Limited, 2 0 0 1
1 5 1 1 ·6
Early neonatal death rate
9
12
Congenital anomalies 4
13
30
18
Neonatal deaths
8 ·7
7
28
5 ·8
9· 4
Corrected neonatal death rate excluding congenital anomalies 1 0 ·1
70
8
39
3· 9
9· 3
18
31
9· 2
6 ·2 11 · 6
10 · 9
1
1 2 ·9
3
Congenital anomalies 1
15
Corrected stillbirth rate excluding congenital anomalies 1 2 ·1
22
Stillbirth rate
43
25 · 7 1 7 ·8 20 · 8
52
2· 2
5· 6
12
20
8· 8
10 · 5
6
38
16
58
202 2 2416 336 1 361 5
1980 1981 1982 1983
18
Total stillbirths
Perinatal mortality rate 2 5 ·8
36
1396
Total infants delivered
Perinatal deaths
1979
Years
1 ·5
4 ·5
12
18
6
6 ·5
2
26
1 3 ·2
44
3 ·6
6 ·1
11
27
4 ·9
6 ·1
5
27
1 0 ·3
54
2 ·9
7
21
36
4 ·5
5 ·7
6
29
1 2 ·6
65
3 ·1
6 ·7
18
34
5 ·1
6 ·5
7
33
13
67
2 ·9
5
11
27
5 ·9
7 ·2
7
39
14
66
4· 3
7· 5
19
44
6· 1
7· 3
7
43
14 · 3
87
4· 4
5· 4
6
34
5· 3
7· 4
13
47
13 · 8
81
1· 7
5
15
23
3· 8
7· 6
10
35
12 · 1
58
4· 8
8· 4
25
58
4· 8
6· 5
12
45
14 · 9
103
2· 8
5· 4
18
38
5· 7
8· 8
22
62
15
100
3· 4
6· 1
19
43
4· 2
6· 1
13
43
12 · 5
86
4001 4440 5128 5074 5416 5861 6346 463 3 691 6 7015 708 2
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994
Table I. Comparative table for 20 years (Riyadh Armed Forces Hospital 1979- 1998) Total
3 ·3
7 ·4
30
54
5
7
14
51
1 4 ·2
105
1· 9
4· 1
17
32
5· 9
8· 1
17
63
12
95
1·7
5·2
27
40
6·4
8·3
15
64
13 ·4
104
1·7
3·3
11
23
6
9·7
26
68
13
91
3 ·3
6 ·3
313
658
5 ·8
7 ·7
195
807
1 4 ·1
1465
733 1 7801 7680 69881 04 522
1994 1996 1997 1998
50 R. A. Mesleh et al.
Changing trends in perinatal deaths, Saudi Arabia
51
Table II. Comparative table, Armed Forces Hospital, Riyadh, 1979- 1998 Years
1979- 1983 1984- 1988 1989- 1993 1994- 1998
Total infants delivered 12 8 10 Perinatal deaths 259 Perinatal mortality rate (PMR) 20 ·2 Corrected (PMR) excluding congenital anomalies 14 ·6 Total stillbirths 132 Congenital anomalies 19 Stillbirth rate 10 ·3 Corrected stillbirth rate excluding congenit al anomalies 8·8 Neonatal deaths 127 Congenital anomalies 53 Early neonatal death rate 10 ·0 Corrected neonatal death rate excluding congenit al anomalies 5·8
tive table. A total of 104 522 babies were delivered at this hospital during the last 20 years. During the same period, there were 1117 sets of twins, 42 sets of triplets, six sets of quadruplets and one conjoined twin. Eight hundred and seven babies were born dead and 658 died during the first week of life. The overall perinatal mortality rate (PMR) ranged between 25·8 and 10·3 per 1000 births (Figure 1). The corrected PMR dropped from 14·6 per 1000 in the first period to 7·9 per 1000 in the fourth period (Table II). Thirty-one per cent of the perinatal deaths were unbooked and received no antenatal care. Neonatal deaths Of the 103 715 live-born babies, 658 died during the first week of life. The early neonatal death rate was 6·3 per 1000. The corrected neonatal death rate dropped from 5·8 per 1000 in the first period to 2·4 per 1000 in the last period (Table II). Congenital anomalies. Of these 658 early neonatal deaths, 313 (47·5%) babies had lethal congenital anomalies (Table III). Of the 313 congenitally malformed babies, 47 (15%) had neural tube defect, 37 (11·8%) had congenital heart disease, 77 (24·6%) had multiple anomalies and 26 (8·3%) had Potter’s syndrome (Table IV). The trend of congenital anomalies as a cause of neonatal deaths remained constant ranging between 42 and 54% of total neonatal deaths. Birth asphyxia. Of the 50 (7.6%) babies who died as a result of birth asphyxia (Table II), the final method
Figure 1. Perinatal mortality rate, Riyadh Armed Forces Hospital (1979–1998).
Total
24 0 59 296 12 ·3 8·1 154 27 6·4
30 7 71 429 13 ·9 9·1 232 64 7·5
36 882 481 1 3 ·0 7 ·9 289 85 7 ·8
104 522 1465 1 4 ·1 9 ·1 807 195 7 ·7
5·3 142 73 5·9
5·4 197 83 6·4
5 ·5 192 104 5 ·2
5 ·8 658 313 6 ·3
2·9
3·7
2 ·4
3 ·3
of delivery was caesarean section (CS) in 24, forceps/ ventouse in four, assisted breech delivery in seven and normal delivery in 15. The indications for CS were: cord prolapse three, fetal distress 13, antepartum haemorrhage six and fetal distress in second twin two. Birth asphyxia as a cause of neonatal deaths showed a steady decline from 12·6% in first period to 2% in the fourth 5-year period. Prematurity. Two hundred and fifty (38%) babies died as a result of extreme prematurity with its associated morbidity. Of the 250 premature babies, 168 (67%) weighed below 1000 grams. All babies died as a result of known associated complications of extreme prematurity (hyaline membrane disease with severe respiratory dysfunction, intraventricular and pulmonary haemorrhage). Prematurity as a cause of neonatal deaths ranged between 27·4 and 42·5% of the total neonatal deaths. Congenital anomalies and prematurity together accounted for 85·5% of total neonatal deaths. Neonatal infection. Neonatal infection was responsible for 27 (4·1%) neonatal deaths. Stillbirths Of the 105 422 infants delivered, 807 were stillborn. This gave an overall stillbirth rate of 7·7 per thousand births. The corrected stillbirth rate dropped from 8·8 per 1000 in the first period to 5·5 per 1000 in the fourth one (Table II). Congenital anomalies. These accounted for 24·1% of the total stillbirths (Table V). Of the 195 stillbirths who had lethal congenital anomalies, 71 (8·8%) babies had multiple congenital anomalies, 53 (6·5%) had neural tube defect, 15 (1·8%) had congenital heart disease and 25 (3%) babies had severe hydrocephaly (Table VI). Congenital anomalies as a cause of stillbirth showed a steady rise from 14·4% in the first 5-year period to 29·4% in the fourth 5-year period (Table V). Hydrops fetalis. Thirty-three babies (4%) died as a result of hydrops fetalis. In eight cases it was secondary to rhesus incompatibility and 25 were secondary to non-immune hydrops fetalis. Apart from the first 5-year period which had only one stillbirth due to hydrops fetalis, the percentag e of hydropic babies ranged between 4 and 5.2% of total stillbirths.
52
R. A. Mesleh et al.
Table III. Causes of neonatal deaths Years
1979- 1983 198 4- 19 88 198 9- 19 93 1994- 1998
1. Congenital anomaly Neural tube defect Others
53 (41·7% ) 73 (51·4% ) 83 (42·0% )104 (54·0% ) 3 12 17 15 50 61 66 89
2. Hydrops fetalis Immune Non-immune 3. Asphyxi: intrapartum Mode of delivery 4. Prematurity
Grand total
31 3 (47·5% )< 0·001 47 266
0 (0·0% ) 0 0
3 (2·1% ) 2 1
6 (3·0% ) 3 3
4 (2·0% ) 1 3
13 (2·0 % ) 6 7
16 (1 2·6% )
14 (9·8% )
16 (8·1% )
4 (2·0% )
50 (7·6 % )< 0·0 01
Caesarean Forceps/Ventouse Breech Normal
6 3 2 5
8 0 1 5
8 0 4 4
2 1 0 1
54 (42·5% ) 39 (27·4% ) 86 (43·6% ) 71 (37·0% ) 22 23 63 60 25 13 19 10 7 3 4 1
Birth weight
1 00 0 ±g 1 0 0 0- 1 4 9 9 ±g 1 5 0 0- 1 9 9 9 ±g
Cause of death
HMD 49 HMD+ IVH 4 Pulmonary haemorrhage 1
NS
24 4 7 15 25 0 (38·0% )< 0·001 168 67 15
28 10 1
45 33 8
57 14 0
179 61 10
5. Infection Necrotising enterocolitis Septicaemia
3 (2·3% ) 3 0
9 (6·3% ) 0 9
6 (3·0% ) 0 6
9 (4·7% ) 0 9
27 (4·1 % ) 3 24
6. Unclassified Cot death Others
1 (0·8% ) 0 1
4 (2·8% ) 3 1
0 (0·0% ) 0 0
0 (0·0% ) 0 0
5 (0·7% ) 6 2
127
142
197
192
658
Total
P
NS
HMD: hyaline membrane disease; IVH: intraventricular haemorrhage; NS: not significant. Table IV. Site of anomaly in the early neonatal deaths Years
1979- 1983 1984- 1988 1989- 1993 1994- 1998
Grand total
Total congenital anomaly Neural tube defect Chromosome Inborn error of metabolism Congenital heart disease Renal abn. infantile polycystic Multiple anomalies Hydrocephalus Potter’s syndrome Down’s syndrome Diaphragmatic hernia Skeletal abnormalities Others
53 3 2 1 7 0 19 3 3 2 3 5 5
73 12 4 0 8 2 17 5 7 0 4 5 9
83 17 4 7 10 3 17 5 1 1 4 3 11
104 15 3 5 12 7 24 3 15 3 4 1 12
313 47 13 13 37 12 77 16 26 6 15 14 37
Total
53
73
83
104
313
Preeclampsia. This was the predisposing factor in the loss of 17 (2%) babies. The percentage of stillbirths related to pre-eclamptic toxaemia varied between 1 and 3% over the four 5-year periods. Antepartum haemorrhage. Abruptio placentae was the cause of death in 46 (75·4%) babies of the 61 who died as a result of severe antepartum haemorrhage. Mechanical. A total of 64 (7·9%) babies died as a result of mechanical problem. Fifty-five babies died
as a result of cord accidents (nine cord prolapse and 46 true knot/tight cord around the neck or body). In nine cases, ruptured uterus was to be blamed. The trend showed a steady decline from 11% of the cause for the second 5-year period to 5·9% in the fourth period. Maternal disease. This was the underlying cause in the loss of 79 babies. Over half the cases had diabetes mellitus. The trend over the four 5-year periods remained static.
Changing trends in perinatal deaths, Saudi Arabia
Figure 2. Perinatal mortality rate, Riyadh Armed Forces Hospital (1979–1998). ( u perinatal mortality rate; n stillbirth rate; s early neonatal death rate).
Unexplained. No cause was identified in over one-third of the stillbirths (236/807), half of whome weighed over 2·5 kg. Despite all the improvements in maternity services, the trend remained the same. Intrapartum asphyxia. This was the leading cause of death in 44 babies, which accounts for 5·4% of the total stillbirths. Caesarean section failed to save eight babies, 14 were delivered normally and 16 had an assisted breech delivery. The trend showed a steady decline from 11·3% in the first period to 2% in the fourth period. Placental insufficiency. Some element of growth restriction and placental insufficiency was evident in 52 (6·4%) stillbirths. Despite the extensive use and availability of modern methods of fetal monitoring and availability of good antenatal care, the trend of growth restriction pick-up as a risk factor remained the same over the years. The first 5 years of the study had the highest stillbirth rate of 10·3 per 1000, which then levelled off in the other periods (Figure 2). Discussion The wide institutional variation in classifying perinatal deaths makes international comparison difficult. All statistics on perinatal mortality in Saudi Arabia are hospital-based (Mesleh, 1985; Mesleh, 1986; Swailem et al., 1988; AI Najashi, 1991; AI Faraidy et al., 1993; Hashim and Anokute, 1994; Asindi et al., 1998). An average perinatal mortality of 14.1 per 1000 total births was similar to that reported from other tertiary hospitals in Saudi Arabia (Asindi et al., 1998) and much lower than 40 per 1000 deliveries reported from Libya (Taushanova, 1998). The perinatal mortality rate of teenage mothers who comprised 17% of total deliveries was 9·1 times the Swedish rate (Swailem et al., 1988). Only 1–2% of newborns have congenital abnormality, yet it is responsible for a much greater proportion of mortality and morbidity in infancy, childhood and during pregnancy (Stock and Jones, 1997). Lethal congenital anomalies (0·5% of newborns) accounted for (508/1465) 34·7% of total perinatal deaths compared to 24·1% from AI Khobar, Saudi Arabia (AI Najashi, 1991).
53
Nearly half of the neonatal deaths and one-quarter of the stillbirths are due to lethal congenital malformations. Congenital anomalies discovered early in pregnanc y, by ultrasound, could have been eliminated if termination of pregnancy had been carried out. This is not allowed on a religious basis and mothers have to continue their pregnancy until viability, when induction of labour can be carried out. Termination of pregnancy will only be authorised if continuation of pregnancy endangers the mother’s life. A list of lethal congenital anomalies, which are incompatible with life once diagnosis is confirmed, can be drawn and offered termination of pregnancy once permission is agreed by Religious Affairs. This list and permission will prevent the abuse of such procedures. The most significant factors influencing survival of the extremely low birth weight infants (< 1000 grams) to 28 days were gestation and birth weights. Survival increased from 33% at 24 weeks to 100% at 28 weeks’ gestation and from 29% at 500–599 grams to 87% at 900–999 grams birth weight (Finan et al., 1998). Two-thirds (67·2%) of our premature babies weighed below 1000 grams. Every effort should be made to prolong pregnancy to maturity. Tocolysis and antenatal corticosteroids must be given to reduce the number of infants admitted to NICU with prematurity and breathing difficulty. Antenatal assessment of cervical length and dilatation in high-risk groups will help in identifying cases which are prone to have premature labour, where cervical cerclage may be of benefit. This, in turn, may help in reducing the number of handicapped babies born with extremely low birth weight. Obstetricians have always been at the forefront of clinical audit. All maternity units should have regular monthly perinatal mortality and morbidity meetings to discuss all perinatal deaths, especially of normally formed infants, which should be audited and analysed annually. There is evidence that in some hospitals little importance is attached to audit meetings, attendance is poor, especially at consultant level. The safest method of delivery should always be adopted. Safe obstetrics has been the aim in most obstetric units. No obstetrician is willing to take the blame for a difficult forceps delivery, because this boy who was delivered by forceps did not become a university professor at the age of 20 years! Better understanding of the available methods of fetal monitoring, and less resort to difficult deliveries, helped to reduce intrapartum asphyxia as a cause of stillbirth from 11·3% of the total stillbirths in the first 5-year period to 2% in the fourth period. Early resort to emergency caesarean section may have prevented some of the 55 perinatal deaths related to intrapartum asphyxia. Factors operating before delivery accounted for 43% of the deaths of normally formed infants. The most common factors were short gestation, low birth weight, intra-uterine hypoxia and birth injury (Wood et al., 1984). Factors after delivery accounted for 33%, the most common being infection and sudden infant death. In the remaining 24%, it seemed that a combination of factors before and after birth had led to death. Factors before birth thus played a part in two-thirds of all neonatal deaths (Wood et al., 1984). Factors operating before delivery can be treated by preventive measures in the form of treating any maternal infec-
54
R. A. Mesleh et al.
Table V. Causes of stillbirths Years
1 9 7 9 - 1 9 8 3 198 4- 1 988 1 9 8 9 - 1 9 9 3 1 9 9 4 - 1 9 9 8
1. Congenital anomaly
Grand total
P
19 14·4 % 8 11
27 17·5 % 9 18
64 27 ·6% 11 53
85 29·4 % 25 60
195 24·1 % 53 142
1 0· 7% 0 1
6 3·9 % 0 6
11 4 ·7% 5 6
15 5·2 % 3 12
33 4·0 % 8 25
4 3·0 % 3 1
3 2·0 % 3 0
7 7 3 ·0% 7 0
3 1·0 % 3 0
17 2·0 % 16 1
14 10·6 % 6 8
12 7·8 % 9 3
15 6·4% 15 0
20 6·9 % 16 4
61 7·5 % 46 15
13 9·8 % 9 4
17 11·0 % 14 3
17 7·3% 15 2
17 5·9 % 17 0
64 7·9 % 55 9
11 8·3 % 0 0 1 1 8 1
14 9·0 % 2 2 0 2 5 3
23 10 ·0% 3 1 4 1 11 3
31 10·7 % 1 4 4 2 18 2
79 9·8 % 6 7 9 6 42 9
42 31·8 % 16 26
44 28·5 % 21 23
61 26 ·3% 27 34
91 31·5 % 59 32
238 29·5 % 123 115
15 11·3 % 3 3 3 1 5
13 8·4 % 2 5 0 1 5
10 4 ·3% 3 3 0 4
6 2·0 % 0 3 0 1 2
44 5·4 % < 0 ·00 1 8 14 3 3 16
9.· Placental insufficiency
9 6·8 %
15 9·7 %
14 6·0%
14 4·8 %
52 6·4 %
10. Unclassified
4 3·0 %
3 2·0 %
10 4·3%
7 2·4 %
24 3·0 %
Neural tube defect Others 2. Hydrops fetalis Immune (Rhesus) Non-immune 3. Toxaemia of pregnanc y Pre-eclampsia Eclampsia 4. Antepartum haemorrhage Abruptio Unknown 5. Mechanical Cord accident Ruptured uterus 6. Maternal disease Hypertension Renal Cardiac Maternal infection Diabetes mellitus Others 7. Unexplained < 2·5 kg ³ 2·5 kg 8. Asphyxia: intrapartum Method of Delivery
Total
Caesarean Normal Forceps Ventouse Breech
132
154
232
289
< 0 ·01
NS
NS
NS
NS
NS
< 0 ·05
NS
807
NS: not significant.
tion, tetanus immunisation, nutritional supplementation, correction and treatment of severe anaemia, folic acid supplementation, screening for gestational diabetes and combined antenatal diabetic clinics for diabetic patients. Factors operating after delivery can be dealt with by basic newborn resuscitation, which should be carried out by a skilled attendant. Risk of infection can be reduced by principles of cleanliness at birth, including a clean delivery surface, clean hands of the birth
attendants, sterile field and sterile gloves, clean instruments to cut the umbilical cord. The risk of hypothermia can be reduced by thermal protection and drying and covering of the baby. Early initiation and establishment of breast-feeding is as important. The biggest contribution to perinatal mortality statistics is from stillbirths. In our hospital, stillbirths accounted for 55% of the total perinatal deaths, and when congenital anomalies were excluded this contri-
Changing trends in perinatal deaths, Saudi Arabia
55
Table VI. Site of anomaly in stillbirths Years
1979- 1983 1984- 1988 1989- 1993 1994- 1998
Grand total
Total congenital anomaly Neural tube defect Infantile polycystic kidneys Potter’s syndrome Multiple abnormalities Conjoined twins Pena Shokeir syndrome Zellwegar syndrome Hydrocephalus Robert’s syndrome Thanatophoric dwarf A cardiac monster Dandy Walker Varter syndrome Congenital sialodosis Others
19 8 0 0 4 1 0 0 4 0 0 0 0 0 0 2
27 9 0 1 7 0 1 2 5 0 0 0 0 1 1 0
64 11 2 1 26 0 0 0 11 1 1 1 1 0 0 2
85 25 1 2 34 0 0 0 5 0 0 0 2 0 0 8
195 53 3 4 71 1 1 2 25 1 1 1 3 1 1 12
Total
19
27
64
85
195
bution increased to 64%. Thirty per cent of stillbirths received no antenatal care. Early booking and serial ultrasound scanning for growth may have saved some of these unbooked stillbirths. Nearly one-third of our stillbirths were unexplained. The clinical and diagnostic systems currently in use are unable to identify many fetuses at risk of death. A decrease in the rate of unexplained antepartum stillbirths awaits the discovery of new preventable causes, or of innovation in clinical or laboratory aspects of obstetric care (Allesandri et al., 1992). Many stillborn babies are small for gestational age. Many antepartum stillbirths, currently designated as unexplained, may be avoidable if slow fetal growth could be recognised as a warning sign (Gardosi et al., 1998). ‘You may take note for twenty years, from working tonight at the bedside of the sick, upon disease of the viscera, and all will be to you only a confusion of symptoms, a strain of incoherent phenomena. Open a few bodies and this obscurity will disappear’ (Rushton, 1998). Post mortem examinations may help to resolve and answer some of the causes of death of the ‘unexplained’ group. This is not allowed in Saudi Arabia on religious grounds. Conclusion Congenital anomalies and low birthweight/prematurity accounted for 563/658 (85·5%) of neonatal deaths. For the neonatal death rate to be reduced further, these two causes have to be dealt with. Congenital anomalies and unexplained intrauterine fetal deaths which accounted for 53·6% of total stillbirths. Proper antenatal care and good ultrasound scan facilities will help greatly in diagnosing congenital anomalies and selective termination of those incompatible with life would reduce the stillbirth rate further.
References
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