A comparative review of the outcomes of two different perinatal mortality classification systems at an Obstetric unit in Cape Town, South Africa

Siebritz, Mark (2012-12)

Thesis (MMed)--Stellenbosch University, 2012.

Thesis

ENGLISH ABSTRACT: Background The annual burden of stillbirths is estimated to be more than 3 million deaths globally. Depending on the perinatal classification used, up to two thirds of deaths are reported as unknown.Gardosi, et al (2006) developed the ReCoDe system, which identified the relevant condition at the time of death in utero. The system aims to identify what went wrong in utero, without necessarily indentifying why fetal demise occurred. With comparison to the conventional Wigglesworth classification, the authors were able to reduce the number of unexplained stillbirths from 66.2% to 15.2%. The Perinatal Problem Identification Program (PPIP) is the nationally implemented perinatal classification system in South Africa. The PPIP database recorded approximately 660 000 births from the 1st January 2006 until 31st December 2007. This reflects approximately 40% of all births in health institutions in South Africa during this time period. There were 11742 stillbirths recorded in on the PPIP database for this two year period.Unexplained stillbirths formed 24% of the total perinatal deaths. The Saving Babies Report 2006-2007 has suggested that funding andresearch resources be directed to identifying the causes of deaths in this group. Objective: Our primary objective was to compare the outcomes of the PPIP to the ReCoDe classification system developed by Gardosi, with special attention as to reducing the number of unexplained stillbirths. Methods: We conducted a retrospective descriptive study on the perinatal deaths occurring at or presenting to the Department of Obstetrics and Gynaecology at Tygerberg Hospital, Cape Town, South Africa, for the time period extending from 01 January 2008 to 31 December 2008. A weekly Perinatal Mortality Audit meeting (PNM) is held at Tygerberg Hospital. In attendance at these meetings are General obstetricians, Fetal-maternal specialists, Neonatologists, Pathologists, a Geneticist, Obstetric and Paediatric Registrars. Relevant clinical details are summarised from clinical notes and Perinatal Losses data forms. These forms are specific to Tygerberg Hospital and completed by the attending doctor at first consultation. Placental histology and post-mortem examination would have been performed in certain cases as per the departmental protocol. All perinatal deaths, both stillborn and neonatal deaths weighing more than 499g, are discussed at this forum and consensus then reached on a primary and final cause of death. This information is then entered into the PPIP database, along with any identifiable avoidable factors.The investigators separately reviewed the information available from the Perinatal Losses and the PIPP V2.2 data capture forms and then reclassified each stillbirth according to the ReCoDe hierarchal system Results: We studied the data sheets of 406 stillbirths of babies of whom the deaths had been previously classified according to the PPIP classification. The median maternal age was 25.65 years (range 14 – 45) while the median birth weight was 1127 grams (range 500 – 4100).The vast majority of these stillbirths occurred in singleton pregnancies and are also classified as extremely low birth weight. The three major causes of stillbirth over the study period were antepartum haemorrhage (24.4%), hypertensive disorders (22.4%) and spontaneous preterm labour (11.1%). Within the ReCoDe classification, the leading categories were in the placental group (33.2%), fetal group (21.6%) and the maternal group (20%). The unexplained group (PPIP IUD group), from the index study constitutes 8.1% (33 of 406) of cases, while the number of unclassified stillbirths in the primary ReCoDe classification accounted for 15% (60 of 406) of the total. The main reasons for this difference is that ReCoDe does not incorporate preterm labour as a cause, and uses customised growth charts for identifying fetal growth restriction. Conclusion: PPIP remains the gold standard in Perinatal Audit in South Africa.We would recommend that ReCoDe be evaluated prospectively, alongside the established PPIP system, to better compare their performance outcomes. The development of customized fetal growth potential charts relevant to the local population should be explored. The Perinatal Losses data capture form should be revised to be more comprehensive and relevant.

AFRIKAANSE OPSOMMING: Agtergrond Die jaarlikse las van doodgeboortes word geskat op meer as 3 miljoen sterftes wêreldwyd. Afhangende van die perinataleklassifikasiesisteem wat gebruik word, tot twee derdes van sterftes is aangemeld as onbekend. Gardosi, et al (2006) het die ReCoDesisteemontwikkel, wat die betrokke toestand in die tyd van die dood in utero geïdentifiseer. Die sisteem het ten doel om te identifiseer wat verkeerd geloop het in utero, sonder om noodwendig te indentifiseer waarom fetaledood plaasgevind het. Invergelyking met die konvensionele Wigglesworth klassifikasie, was die skrywers in staat om die getal van die onverklaarbare dood geboortes van 66,2% tot 15,2% te verminder. Die Perinataleprobleemidentifikasie Program (PPIP) is die nasionaalgeïmplementeerperinataleklassifikasiesisteemin Suid-Afrika. Die PPIP databasis aangeteken ongeveer 660 000 geboortes van die 1ste Januarie 2006 tot 31 Desember 2007. Dit weerspieël ongeveer 40% van alle geboortes in die gesondheids-instellings in Suid-Afrika gedurende hierdie tydperk. Daar was 11.742 doodgeboortes aangeteken in op die PPIP databasis vir hierdie twee jaartydperk. Onverklaarbaredoodgeboortesvorm 24% van die totaleperinatalesterftes. Die Saving Babies Verslag 2006-2007 het voorgestel dat befondsing en navorsing gerig word aan die identifisering van die oorsake van sterftes in hierdie groep. Doelstelling: Ons primêre doel was om die uitkomste van die PPIP te vergelyk met die ReCoDeklassifikasiesisteem wat deur Gardosiontwikkelis , met spesiale aandag aan die vermindering van die aantal van onverklaarbaredoodgeboortes. Metodes: Ons het'n retrospektiewebeskrywendestudie uitgevoer op die perinatalesterftes wat aangemeld het by die noodeenheid van die Departement Obstetrie en Ginekologie aanTygerberg Hospitaal, Kaapstad, Suid-Afrika, vir die tydperk wat strek vanaf 01 Januarie 2008 tot 31 Desember 2008. 'n Weeklikse Perinatale Mortaliteit Ouditvergadering (PNM) word gehou by Tygerberg Hospitaal. In die bywoning van hierdie vergaderings is Algemene Verloskundiges, Fetale-moederskant Spesialiste, Neonatoloë, Patoloë, 'n Genetikus, Obstetriese en Pediatriese Klienieseassistente. Relevante kliniese inligting is uit die kliniese notas en perinataleverliesedatavorms opgesom. Hierdie vorms is spesifiek na die Tygerberg-hospitaal en deur die dokter by die eerstekonsultasie voltooi. Plasentale histologie en post-mortem ondersoek sou voltooi gewees het in sekere gevalle soos per die departementeleprotokol. Alle perinatalesterftes, beide doodgebore en neonatalesterftes wat meer as 499g, word bespreek op hierdie forum en konsensus bereik oor 'n primêre en finale oorsaak van die dood. Hierdie inligting word dan in die PPIP databasis, saam met 'n identifiseerbare voorkombare faktore. Die navorsers afsonderlik die inligting beskikbaar van die perinataleverliese en die PIPP v2.2 datavasleggingsvorms en dan herklassifiseer elke stilgeboorte volgens die ReCoDehiërargiesestelsel. Results: Ons bestudeer die data velle van 406 doodgeboortes van babas van wie die sterftes voorheen volgens die PPIP klassifikasie geklassifiseer is. Die mediaanmoeder se ouderdom was 25,65jaar (range 14? 45?) Terwyl die mediaangeboortegewig was 1127 gram (reeks 500? 4100). Die oorgrote meerderheid van hierdie doodgeboortes plaasgevind in Singleton swangerskappe en word ookgeklassifiseer as &'n baie lae geboortegewig. Die drie grootste oorsake van doodgeboorte oor die studietydperk was antepartum bloeding (24,4%), die hipertensiewesiektes (22,4%) en &'n voortydsekraam (11,1%). Binne die ReCoDeSistematiek, die voorstekategorieë in die plasentalegroep (33,2%), die fetalegroep (21,6%) en die moedergroep (20%). Die onverklaarbaregroep (PPIP IUD groep), van die indeksstudie behels 8,1% (33 van 406) van gevalle, terwyl die aantal van ongeklassifiseerde doodgeboortes in die primêre ReCoDeSistematiek verantwoordelik vir 15% (60 406) van die totaal. Die belangrikste redes vir die verskil is dat ReCoDenieneemvoortydsekraam as &'n oorsaak, en gebruike aangepasgroeikaarte vir die identifisering van fetalegroeibeperking. Gevolgtrekking: PPIP bly die gouestandaard in Perinataleoudit in Suid-Afrika. Ons sal aanbeveel dat ReCoDe vooruitwerkend geëvalueer word, saam met die gevestigde PPIP stelsel, om beter te vergelyk hulprestasieuitkomste. Die ontwikkeling van persoonlikefetalegroeipotensiaalkaarte met betrekking tot die plaaslike bevolking moet ondersoek word. Die perinataleverliese data capture vorm moet hersien word om meer omvattende en relevant te wees.

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