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Do Autopsies Improve Reports of Congenital Anomalies among Stillbirths ?

Do Autopsies Improve Reports of Congenital Anomalies among Stillbirths ?. Wes Duke, MD MPH ; Adolfo Correa, MD PhD Laura Williams, MPH.

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Do Autopsies Improve Reports of Congenital Anomalies among Stillbirths ?

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  1. Do Autopsies Improve Reports of Congenital Anomalies among Stillbirths? Wes Duke, MD MPH; Adolfo Correa, MD PhD Laura Williams, MPH “The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.”

  2. Stillbirth • One of the most common adverse pregnancy outcomes (~ 1% of all births) • Accounts for nearly one half of all perinatal mortality • Significant racial disparity in occurrence • Stillbirths (as an outcome) are largely understudied • Stillbirths (as an event) have inadequate evaluations

  3. Post-mortem Evaluations • Lack of standardization • Post-mortem evaluation protocols • Classifying cause of death • Known causes and risk factors are varied and often multifaceted ~1/4 with intrinsic fetal cause of death (Pauli, Reiser; Am J Med Gen 1994) ~1/3 with associated structural anomaly (Goldenberg, Kirby, Culhane; J Mat Fet Neo Med 2004)

  4. Post-mortem Evaluations • Autopsies: recommended core component • Corabian et al.; J. Obstet Gyn Can 2007; 29(7):560-7 • Value of the perinatal autopsy (Gordijn et al., Ped Dev Path 2002; Petersen et al., Ob Gyn 1999; Michalski et al., Am J Ob Gyn 2002; Hefler et al., Am J Med Gen 2001 ) • Confirmation of diagnosis • Change in or identification of additional information • Modest economic cost • Benefits for providers and families • Autopsy rates have declined worldwide • McPhee et al.; Arch Path Lab Med 1996; 120:743-8 • Brodlie; BMJ 2002; 324:761-3

  5. Objectives Use population-based birth defect surveillance data: • To determine the impact of having an autopsy on the reporting of congenital anomalies among stillbirths. • To characterize the major reported anomalies according to autopsy status and availability of autopsy results.

  6. Methods Data source: • MACDP: Metropolitan Atlanta Congenital Defects Program Definition: • All fetal deaths 20+ weeks or 350+ grams (if age unknown) with congenital anomalies (N=1051) Time period: • 1968 – 2003

  7. Methods MACDP: • Established 1967 • Population-based • Active case finding • Monitors births to 5-county residents • > 50,000 live births/yr

  8. Methods: Data Collection • Identifying information (infant, parents) • Demographic information • Diagnostic information • Pregnancy information • Outcome information • Maternal history information • Hospital and physician information

  9. Methods:Analysis • Defect classification: • Based on CDC modified BPA 6-digit code list • Total, majors (confirmed/possible), confirmed minors • MACDP minor code list • Rasmussen SA, et al. (2003). Guidelines for case classification for the National Birth Defects Prevention Study. BDRA 67:193-201. • For stillbirths: • Comparison by autopsy status and whether autopsy results were available at the time of abstraction • Median and mean number of defect diagnoses per case • Grouped major defects using CDC’s modified BPA codes for recording defects

  10. Cases with DefectsMACDP, 1968 - 2003 40,864 cases with defects 352 (<1%) Elective Terminations (ETP) 39,461 (96.6%) Live births 1051 (2.6%) Stillbirths 903 (2.3%) Post neonatal deaths 2000 (5.1%) Neonatal deaths

  11. Autopsy Status for Stillbirths by Hospital of Birth

  12. Autopsy Status for Stillbirths by Hospital of Birth

  13. Autopsy Status for Stillbirths by Hospital of Birth

  14. Autopsy Status by Outcome

  15. Availability of Autopsy Results by Outcome

  16. Median Number of Defect Diagnoses forStillbirths by Autopsy Status/Results IQR=interquartile range

  17. Mean Number of Defect Diagnoses forStillbirths by Autopsy Status/Results

  18. Mean Number of Defect Diagnoses forStillbirths by Autopsy Status/Results

  19. Confirmed Major Defects Among Stillbirths

  20. Confirmed Major Defects Among Stillbirths p<0.05 p<0.05

  21. Confirmed Major Defects Among Stillbirths p<0.05

  22. Confirmed Major Defects Among Stillbirths No Difference

  23. Confirmed Chromosomal Defects among Stillbirths p<0.05

  24. Summary • Stillbirths overall: • Similar autopsy rates to other outcomes • Autopsy rates vary according to hospital of delivery • Stillbirths undergoing autopsy with results available: • More total and confirmed major and minor defects identified • Fewer possible major defects recorded • Higher proportions of major internal anomalies identified

  25. Strengths/Limitations • Strengths: • Population-based • Long time period • MACDP methodology • Limitations: • No individual case review • Unable to assess the direct impact of autopsy in the identification and confirmation of defects • Standardization/uniformity of autopsy protocol unknown

  26. Public Health Implications • Autopsies improve the number of defects identified among stillbirths • Should be a core component of the post-mortem evaluation • Assist in optimizing the information available to clinicians and families for counseling purposes • Barriers to stillbirth evaluations (including autopsy) need to be studied further and addressed

  27. Thank You

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