A stillbirth is the birth of a newborn after 28th completed week when the baby does not breathe or show any sign of life after delivery. Foetal death was defined by Apgar score of 0 at 1 and 5 minutes, and no signs of life by direct observation. This analysis was limited to stillbirths and live births at 24weeks or more days of gestation. Births less than 24weeks gestation were excluded to avoid confounding due to variable clinical management of live births at periviable gestational ages.¹Stillbirth, defined as foetal death after 20 weeks gestation ², accounts for an estimated 2.65 million deaths worldwide each year.³ Depending on the cause, the risk of stillbirths in future pregnancies is increased up to 10-fold.^4,5 Therefore, accurate assessment of the cause, based on placental examination and autopsy findings, is required for future stillbirth prevention.^6,7 Though a few studies have addressed the importance of these investigations⁸, 25–60% of stillbirths remain unexplained⁹. The high proportion of unexplained stillbirths hinders accurate understanding of their cause, which consequently affects targeted healthcare interventions to reduce its incidence.¹⁰Currently in 25-40% of stillbirths, the underlying cause cannot be determined and only approximately 20% of stillbirths are potentially predictable in early pregnancy. India accounts for the majority of global stillbirths due to high population, with 5921000 out of a total of 206 million of such births across the world. Between 2010 2013, India showed a decline in stillbirth rate from 33 per 1000 to 25 per 1000 live births and it continues to fall.Altered foetal growth and placental abnormalities are the strongest and most prevalent known risk factors for stillbirth.The placenta may be regarded as the ‘black box’ of pregnancy and detailed examination may afford insight into the foetal and maternal events leading to a tragic outcome. Altered foetal growth and placental abnormalities are the strongest and most prevalent known risk factors for stillbirth.A number of lesions have been recognised in association with stillbirth 24week gestation or more. Placental weight is thought to reflect function and the feto placental weight ratio as been suggested as a possible indicator of placental reserve capacity in IUGR. However the functional reserve of the placenta may also be indicated by assessing the size of the disc which should be measured in 3 dimensions. Amnion nodosum over the foetal surface which may reflect diminished liquor volume either secondary to premature rupture of membrane or to decreased placental reserve. Placental function may be compromised by ischaemia and or infarction. The form of placenta is also crucial. Circumvallation tends to be associated with bleeding in early pregnancy and may lead to discolouration of the membrane or to hemosiderin laden macrophages .catastrophic haemorrhage may lead to the death of an infant.Placental abnormalities are causal or contributory in >60% of stillbirths.¹¹ Recent perinatal death classification systems such as Tulip classification (The Netherlands) and Recode place great emphasis on placental findings and have recorded lower proportion of unexplained stillbirth.^11,12 Placenta plays a key role in maintaining healthy pregnancy, and there is evidence of placental pathology in clinical conditions associated with increased rate of stillbirth such as foetal growth restriction, pre-eclampsia and placental abruption.^13,14 However, a recent cohort study has reported that a range of placental lesions may also be present in clinically uncomplicated pregnancies, and the significance of such lesions in cases of stillbirth remains uncertain.¹⁵Examination of placental pathology to confirm its contribution to stillbirth has been limited by insufficient sample size, lack of appropriate controls and non-standardized placental examination protocols. Robust evidence is therefore required for appropriate interpretation of placental histopathological findings, which may be useful to accurately identify causes of stillbirth.The aim of this study is to compare the placental findings between stillbirth and live birth in our tertiary care hospital, Department of Gynaecology and Obstetrics, Eden Hospital, Medical college and hospital, Kolkata.

OBJECTIVES

Primary: To search placental findings for stillbirth cases and live birth controls in a tertiary care hospital admitted through Eden ER.

This observational cross-sectional study was conducted over a period of 1 year at labour room at department of obstetrics and gynaecology in Eden hospital ,Medical College and hospital,Kolkata after getting approval from Institutional Ethical Committee. We had selected all the stillborn cases occurring in our duty hours in eden, MCH.Then we had selected same number of live born cases in LRO. For every stillbirth cases we had selected a live birth baby delivering at the same time in labour room. Last year 80 stillbirths occur in labour room in my time. Considering this approximately my sample size was 160. (still birth+ live birth). (PURPOSIVE SAMPLING).

INCLUSION CRITERIA:

All the mother carring singleton pregnancy and having USG diagnosed IUFD admitted at eden hospital for delivery and comparable number of mother carring singleton live birth delivered at the same time.

EXCLUSION CRITERIA:

Following cases are excluded from study;Foetus having Congenital anomaly diagnosed antenatally or postnatally,APLA positive mother,PGDM,Mother with other vascular disorder (renovascular disorder),Mother with beta thalassemia major and intermediate.

The        parameters           which     were       studied are; Placental         size,Placental               weight,Placental membranes, Number of vessels in umbilical cord , site insertion of cord at the placenta – battledore, velamentous etc, Placental morphology- no of cotyledons, lobe- succenturiate lobe.

HISTOPATHOLOGICAL parameters include Calcification Ageing, Inflammation, Infarction, Atheroma

STATISTICAL ANALYSIS: All the relevant data were analyzed by appropriate statistical tests using Statistical Package for Social Sciences (SPSS) version 22.0. Results were expressed in terms of mean with standard deviations (SD), difference of means of two groups(live birth and Stillbirth )werel tested by student T test and Chi square test to find out the significant correlation. P-value of <0.05 were considered as significant.

In Live Birth group, 9 (11.3%) patients were ≤20 years old, 38 (47.5%) patients were 21-25 years old, 32 (40.0%) patient were 26-30 years old and 1 (1.3%) patients were 31-35 years old.

In Still Birth group , 8 (10.0%) patients were ≤20 years old, 37 (46.3%) patients were 21-25 years old and 35 (43.8%) patient were 26-30 years old.Association of Age between the two groups was not statistically significant (p=0.7514). In Live Birth, the mean Age (mean± s.d.) of patients was 24.8625± 3.3137.In Still Birth, the mean Age (mean± s.d.) of patients was 25.0625±  3.2152.Distribution of mean Age with Group was not statistically significant (p=0.6990

In Live Birth, 4 (5.0%) patients had P0+0 Parity, 13 (16.3%) patients had P0+1 Parity, 21 (26.3%) patient had P1+0Parity,19 (23.8%) patients had P1+1 Parity, 12 (15.0%) patients had P2+0 Parity, 3 (3.8%) patients had P2+1 Parity, 4 (5.0%) patients had P3+0 Parity and 4 (5.0%) patients had P3+1 Parity.In Still Birth, 10 (12.5%) patients had P0+0 Parity, 13 (16.3%) patients had P0+1 Parity, 12 (15.0%) patient had P0+2Parity,11 (13.8%) patients had P0+3 Parity, 12 (15.0%) patients had P1+0 Parity, 8 (10.0%) patients had P1+1 Parity, 5 (6.3%) patients had P2+0 Parity, 1 (1.3%) patient had P2+1 Parity, 4 (5.0%) patient had P3+0 Parity and 4 (5.0%) patient had P3+1 Parity.Association of Parity with Group was statistically significant (p<0.0001).

In Still Birth, 1 (1.3%) patient had single umbilical artery.Association of No of single umbilical artery with Group was not statistically significant (p=0.3157).

In Live Birth, 1 (1.3%) patient had Abnormal Site of umbilical cord insertion and 79 (98.8%) patients had Normal Site of umbilical cord insertion.In Still Birth, 6 (7.5%) patients had Abnormal Site of umbilical cord insertion and 74 (92.5%) patients had Normal Site of umbilical cord insertion.Association of Site of umbilical cord insertion with Group was not statistically significant (p=0.0532).

Table 1: Association of Calcification between two groups   GROUP

In Live Birth, 3 (3.8%) patients had Calcification.In Still Birth, 15 (18.8%) patients had Calcification.Association of Calcification with Group was statistically significant (p=0.0026).

Table 2: Association of Atheroma of umbilical vessels GROUP

In Live Birth, 2 (2.5%) patients had Atheroma of umbilical vessels.In Still Birth, 12 (15.0%) patients had Atheroma of umbilical vessels.Association of Atheroma of umbilical vessels with Group was statistically significant (p=0.0051).

Table 3: Association of Parenchymal infarction GROUP

In Live Birth, 7 (8.8%) patients had Parenchymal infarction.In Still Birth, 25 (31.3%) patients had Parenchymal infarction.Association of Parenchymal infarction with Group was statistically significant (p=0.0003).

Table 4: Association of Inflammation of membranes GROUP

In Live Birth, 5 (6.3%) patients had Inflammation of membrane.In Still Birth, 35 (43.8%) patients had Inflammation of membrane.Association of Inflammation of membrane with Group was statistically significant (p<0.0001).

Table 5: Association of Terminal villous immaturity and hypoplasia GROUP

In Live Birth, 3 (3.8%) patients had Terminal villous immaturity and hypoplasia.In Still Birth, 10 (12.5%) patients had Terminal villous immaturity and hypoplasia.Association of Terminal villous immaturity and hypoplasia with Group was statistically significant (p=0.0428).

Table 6: Association of Stained of meconium GROUP

In Live Birth, 9 (11.3%) patients had Stained of meconium.In Still Birth, 49 (61.3%) patients had Stained of meconium.Association of Stained of meconium with Group was statistically significant (p<0.0001).

Table 7: Association of Retroplacental hematoma GROUP

In Live Birth, 2 (2.5%) patients had Retroplacental hematoma.In Still Birth, 20 (25.0%) patients had Retroplacental hematoma.Association of Retroplacental hematoma with Group was statistically significant (p<0.0001).

In Live Birth, the mean Age (mean± s.d.) of patients was 24.8625± 3.3137.In Still Birth, the mean Age (mean± s.d.) of patients was 25.0625± 3.2152.Distribution of mean Age with Group was not statistically significant (p=0.6990).

In Live Birth, the mean GA (mean± s.d.) of patients was 38.7400± .6785.In Still Birth, the mean

GA (mean± s.d.) of patients was 38.7050± .7214.Distribution of mean GA with Group was not statistically significant (p=0.7524).

Table 8: Distribution of mean Placental Size diametre in cm

In Live Birth, the mean Placental Size diametre in cm (mean± s.d.) of patients was 20.8375±

3.5523.In Still Birth, the mean Placental Size diametre in cm (mean± s.d.) of patients was 13.6125± 3.5879.Distribution of mean Placental Size diametre in cm with Group was statistically significant (p<0.0001).

Table 9: Distribution of mean Placental Weight in gm

In Live Birth, the mean Placental Weight in gm (mean± s.d.) of patients was 448.6875± 26.2151.In Still Birth, the mean Placental Weight in gm (mean± s.d.) of patients was 286.4250± 72.1012.Distribution of mean Placental Weight in gm with Group was statistically significant (p<0.0001).

Table 10: Distribution of mean Number of lobes

In Live Birth, the mean Number of lobes (mean± s.d.) of patients was 20.1500± 1.2739.In Still Birth, the mean Number of lobes (mean± s.d.) of patients was 15.0875± 1.1713.Distribution of mean Number of lobes with Group was statistically significant (p<0.0001).

In Live Birth, the mean Length of umbilical cord (mean± s.d.) of patients was 56.4125± 6.0078.In Still Birth, the mean Length of umbilical cord (mean± s.d.) of patients was 61.8750± 25.1750.Distribution of mean Length of umbilical cord with Group was not statistically significant (p=0.0609).

Flenady V et al ¹⁶(2011) found that advanced maternal age (>35 years) and maternal smoking yielded PARs of 7–11% and 4–7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths.We found In Live Birth, 9 (11.3%) patients were ≤20 years old, 38 (47.5%) patients were 21-25 years old, 32 (40.0%) patient were 26-30 years old and 1 (1.3%) patients were 31-35 years old. In Still Birth, 8 (10.0%) patients were ≤20 years old, 37 (46.3%) patients were 21-25 years old and 35 (43.8%) patient were 26-30 years old. Association of Age in group with Group was not statistically significant (p=0.7514).

Darouich S et al ¹⁷(2020) found that the aim was to assess the contribution of placental examination in the etiologic investigation of stillbirth. A retrospective review of stillbirths that occurred after 14 weeks gestation was conducted for a one-year period. Twin pregnancies and fetuses without placentas were excluded. According to the fetoplacental examination, stillbirths were classified into etiologic groups. A total of 147 stillbirths were selected. They were associated with placental, materno-fetal, fetal and multiple causes in 89 cases (61%), 23 cases (16%), 14 cases (9%) and 13 cases (9%), respectively.

Our study showed that in Still Birth, 1 (1.3%) patient had single umbilical artery. Association of

No of single umbilical artery with Group was not statistically significant (p=0.3157).In Live Birth,  1 (1.3%) patient had Abnormal Site of umbilical cord insertion and 79 (98.8%) patients had Normal Site of umbilical cord insertion. In Still Birth, 6 (7.5%) patients had Abnormal Site of umbilical cord insertion and 74 (92.5%) patients had Normal Site of umbilical cord insertion. Association of Site of umbilical cord insertion with Group was not statistically significant (p=0.0532).

Pinar H et al ¹⁸(2014) found that to compare placental lesions for stillbirth cases and live birth controls in a population-based study. Vascular degenerative changes in chorionic plate was present in 55.7% of stillbirths and 0.5% of live births, retroplacental hematoma was present in 23.8% of stillbirths and 4.2% of live births, intraparenchymal thrombi was present in 19.7% of stillbirths and 13.3% of live births, parenchymal infarction was present in 10.9% of stillbirths and 4.4% of live births, fibrin deposition was present in 9.2% of stillbirths and 1.5% of live births, fetal vascular thrombi was present in 23% of stillbirths and 7% of live births, avascular villi was present in 7.6% of stillbirths and 2.0% of live births, and hydrops was present in 6.4% of stillbirths and 1.0% of live births.

We found in Live Birth, 3 (3.8%) patients had Calcification. In Still Birth, 15 (18.8%) patients had  Calcification. Association of Calcification with Group was statistically significant (p=0.0026).In Live Birth, 2 (2.5%) patients had Atheroma of umbilical vessels. In Still Birth, 12 (15.0%) patients had Atheroma of umbilical vessels. Association of Atheroma of umbilical vessels with Group was statistically significant (p=0.0051).In Live Birth, 7 (8.8%) patients had Parenchymal infarction. In Still Birth, 25 (31.3%) patients had Parenchymal infarction. Association of Parenchymal infarction with Group was statistically significant (p=0.0003).

Bukowski R et al ¹⁹(2017) found that worldwide, stillbirth is one of the leading causes of death. Fifteen findings were significantly associated with stillbirth. Ten of the 15 were also associated with fetal growth abnormalities (single umbilical artery; velamentous insertion; terminal villous immaturity; retroplacental hematoma; parenchymal infarction; intraparenchymal thrombus; avascular villi; placental edema; placental weight; ratio birth weight/placental weight) while 5 of the 15 associated with stillbirth were not associated with fetal growth abnormalities (acute chorioamnionitis of placental membranes; acute chorioamionitis of chorionic plate; chorionic plate vascular degenerative changes; perivillous, intervillous fibrin, fibrinoid deposition; fetal vascular thrombi in the chorionic plate).

Our study showed that in Live Birth, 5 (6.3%) patients had Inflammation of membrane. In Still Birth, 35 (43.8%) patients had Inflammation of membrane. Association of Inflammation of membrane with Group was statistically significant (p<0.0001).In Live Birth, 3 (3.8%) patients had Terminal villous immaturity and hypoplasia. In Still Birth, 10 (12.5%) patients had Terminal villous immaturity and hypoplasia. Association of Terminal villous immaturity and hypoplasia with Group was statistically significant (p=0.0428).In Live Birth, 9 (11.3%) patients had Stained of meconium. In Still Birth, 49 (61.3%) patients had Stained of meconium. Association of Stained of meconium with Group was statistically significant (p<0.0001).In Live Birth, 2 (2.5%) patients had Retroplacental hematoma. In Still Birth, 20 (25.0%) patients had Retroplacental hematoma. Association of Retroplacental hematoma with Group was statistically significant (p<0.0001).

Fadl S et al ²⁰(2017) found that the placenta plays a crucial role throughout pregnancy, and its importance may be overlooked during routine antenatal imaging evaluation. It also discusses various placental diseases and their potential clinical consequences. Placental pathologic conditions include abnormalities of placental size, cord insertion, placental and cord location, and placental adherence. Other conditions such as bleeding in and around the placenta, as well as trophoblastic and non-trophoblastic tumors of the placenta, are also discussed.

Also showed that in Live Birth, the mean Age (mean± s.d.) of patients was 24.8625± 3.3137.In Still Birth, the mean Age (mean± s.d.) of patients was 25.0625± 3.2152.Distribution of mean Age with Group was not statistically significant (p=0.6990).In Live Birth, the mean BMI (mean± s.d.) of patients was 22.9050± 1.9181.In Still Birth, the mean BMI (mean± s.d.) of patients was  22.9800± 1.8577.Distribution of mean BMI with Group was not statistically significant (p=0.8020).In Live Birth, the mean GA (mean± s.d.) of patients was 38.7400± .6785.In Still Birth, the mean GA (mean± s.d.) of patients was 38.7050± .7214.Distribution of mean GA with Group was not statistically significant (p=0.7524).In Live Birth, the mean Placental Size diameter in cm (mean± s.d.) of patients was 20.8375± 3.5523.In Still Birth, the mean Placental Size diameter in cm (mean± s.d.) of patients was 13.6125± 3.5879.Distribution of mean Placental Size diameter in cm with Group was statistically significant (p<0.0001).

Nikkels PG et al ²¹(2021) found that the incidence of umbilical cord or placental parenchyma abnormalities associated with mortality or morbidity of term infants is lacking. Placentas of 55 antepartum stillbirths (APD), 21 intrapartum stillbirths (IPD), 12 neonatal deaths (ND), and 80 admissions to a level 3 neonatal intensive care unit (NS) were studied and compared with 439 placentas from neonates from normal term pregnancies and normal outcome after vaginal delivery (NPVD) and with 105 placentas after an elective caesarian sections (NPEC).

Our study showed that in Live Birth, the mean Placental Weight in gm (mean± s.d.) of patients was 448.6875± 26.2151.In Still Birth, the mean Placental Weight in gm (mean± s.d.) of patients was 286.4250± 72.1012.Distribution of mean Placental Weight in gm with Group was statistically significant (p<0.0001).In Live Birth, the mean Number of lobes (mean± s.d.) of patients was 20.1500± 1.2739.In Still Birth, the mean Number of lobes (mean± s.d.) of patients was 15.0875±  1.1713.Distribution of mean Number of lobes with Group was statistically significant (p<0.0001).In Live Birth, the mean Length of umbilical cord (mean± s.d.) of patients was 56.4125± 6.0078.In Still Birth, the mean Length of umbilical cord (mean± s.d.) of patients was 61.8750±  25.1750.Distribution of mean Length of umbilical cord with Group was not statistically significant (p=0.0609).

We          noticed          that           uteroplacental   vascular pathology,    chronic        inflammation, chorioamnionitis, calcific changes, and retroplacental hematoma were the most significant placental lesions associated with stillbirth.Besides  antenatal imaging and adequate prenatal counseling regarding high risk factors,postnatal placental examination still remains valuable in  identifying cause of Stillbirth especially recurrent causes and assessment of clinical intervention.  For  identification of the precise causes of stillbirth,Further studies are required involving larger sample size of the  factors that influence stillbirth which  are postmortem evaluation, genetic and molecular testing, microbiology, and fetal blood or urine culture.

LIMITATIONS OF THE STUDY

In spite of every sincere effort my study has lacunae.The notable short comings of this study are:

1. The sample size was small. Only 160 cases are not sufficient for this kind of study.
2. The study has been done in a single centre.
3. The study was carried out in a tertiary care hospital, so hospital bias cannot be ruled out.
4. Ongoing COVID 19 pandemic and lockdown has further hampered the study.
5. Antepartum examination of placenta by USG with Doppler study are not included in my study (such as placental ageing and Doppler abnormality of placental vasculature).

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