Classification of the causes of stillbirth_Flenady.pdf

Current Stillbirth Classifications 

Vicki Flenady, Frederik Froen, Adrian Charles, Halit Pinar

Purpose of this study 

To describe the characteristics of current 

classification systems for stillbirths to inform 

the development of an internationally 

acceptable stillbirth classification.

The aim of any classification must be to derive 

strategies to understand the reasons for, 

and ultimately prevent perinatal mortality. 

Keeling et al 1989 

Why classify?

Specific purposes of stillbirth 

classification 

� Counselling parents: alleviate anxiety – “what 

went wrong”, future pregnancies 

� Education: training and practice improvement 

� Epidemiology: identification of groups for closer 

investigation; and ongoing monitoring 

� Public health: policy development prevention, 

health service utilisation 

� Research: finding the answers to reduce the risk

Jonathan Wigglesworth on 

ascertaining the main cause of death 

“The basic problem in the classification 

of perinatal deaths is the complexity of 

the clinical situation within which the 

fetus (…) dies.”

What makes a good classification? 

Classification Criteria by De Galan-Roosen 

� Ease of use by clinicians and perinatal pathologists 

with uniform definitions; 

� Ease of expansion in terms of sub classification; 

� Good level of agreement (low inter-observer 

variability); 

� Based on clinical factors and autopsy findings 

including histology of the placenta; 

� Explain the underlying cause of death; 

� Suitable in stillbirth as well as neonatal death; 

� Result in a high percentage of classifiable cases and 

a low percentage of unexplained cases 

One more: ABILITY TO RETAIN ALL IDENTIFIED 

SIGNIFICANT INFORMATION ABOUT THE DEATH

Methods 

Systematic literature search 

Sources: 

Electronic databases and expert informants. 

English language. 

Inclusion criteria: Unique classifications 

systems to determine causes of stillbirth (+/neonatal) 

Published cohorts occurring 1996 onwards 

Exclusions: “informal” groupings of deaths, 

minor modifications of existing classifications

Results 

Potentially eligible for inclusion: 11 

Excluded: 7 

•Revisions of included systems - 2 

•Cohorts

Current classifications 

Classification Country Population Factors 

Amended Aberdeen 

(1969) 

Extended 

Wigglesworth 

(1986) 

PSANZ-PDC 

(2004) 

ReCode 

(2005) 

Tulip 

(2006) 

UK SB, NND Maternal, fetal 

UK SB, NND Maternal, fetal 

Australia SB (20wks), 

NND 

Maternal, fetal, 

limited 

placental 

pathology 

UK SB Maternal, fetal, 

some placental 

pathology 

Netherlands SB (16wks), 

NND, PNND* 

Maternal, fetal, 

some placental 

pathology

Aberdeen To identify the factor that probably initiated the 

train of events leading to the death for the 

purpose of prevention. 

Wigglesworth To identify the cause of perinatal death to 

improve understanding for the purposes of 

prevention. 

PSANZ To identify the factor that initiated the sequence 

of events leading to the death – for the purposes 

of prevention. 

ReCode To identify the relevant condition at the time of 

death. “What went wrong , ….not necessarily 

why”. For teaching, counselling, public health 

policy. 

Tulip To identify the underlying cause and 

mechanism of death for the purpose of 

counselling and prevention.

User friendliness and validity…. 

Categories 

Major -Total 

Hierarchy Definitions 

Guides 

Agreement 

Aberdeen 8 - 22 Yes No/Minimal Good 

Wigglesw. 9-3 Yes No/Minimal Fair 

PSANZ 11-118 Mostly Yes Excellent 

ReCode 37-39 Yes Minimal ? 

Tulip 6-42 “Not 

strictly” 

Yes Excellent

Includes categories for ….. 

FGR Unexplained 

AP death 

Aberdeen No Partially 

includes, IP 

deaths, NND 

Unclassifiable 

Wigglesw. No Yes Yes 

(“last resort”) 

Assoc. 

Cond. 

IP 

death 

Yes No No 

No Yes 

PSANZ Yes Yes Partially Yes Yes 

ReCode Yes Yes Yes Yes Yes 

Tulip No Partially 

includes 

NND 

Yes No No

Risk per 1000 ongoing pregnancies 

1.8 

1.6 

1.4 

1.2 

1.0 

0.8 

0.6 

0.4 

0.2 

0.0 

23 

29 

Risk for unexplained stillbirth 

31 

34 

Frøen 

Huang 

Singer 

Yudkin 

36 

38 

Gestational age 

40 

42 

Risk factors for 

unexplained stillbirth 

Late gestation 

Overweight / obesity (OR 2.5) 

Maternal Age 35+ (OR 3-5) 

Smokers 

Low edu./ socioecon. status 

Multiparity 

(OR 3-5) 

Intrauterine growth restriction 

(OR 3) 

Reduced fetal movements 

Potentially Preventable

Unexplained: proportion of stillbirths 

Ireland 93 (Walsh 1995) 

Wales (Tuthill 1999) 

UK (Cesdi 2001) 

Sweden (Winbo 2001) 

UK (Gardosi 1998) 

Australia (Alessandri 1992) 

New Z (Westgate 1985) 

UK (Wagaarachchi 2002) 

UK (Shankar 2002) 

UK (Yudkin 1987) 

USA (Ananth 1995) 

USA (Lammer 1989) 

France (Goffinet 1996) 

France (Coujard 1975) 

Norway (Rasmussen 2003) 

USA (Brans 1984) 

USA (Incerpi 1998) 

Saudi Arabia (Meshle 2001) 

Australia & NZ (Flenady 2003) 

Australia (Robson 2001) 

Canada (Huang 2000) 

Norway (Frøen 2001) 

Queensland (Flenady 2003) 

Denmark (Kesmodel 2002) 

India (Naidu 2001) 

Sweden (Ahlenius 1995) 

Ireland 70ies (Walsh 1995) 

Sweden (Petersson 2002) 

0 10 20 30 40 50 60 70

Main categories of stillbirths 

Aberdeen 

(CESDI) 

Wiggles. 

(CESDI) 

Unexplained 

SB 

% 

CA 

% 

Spont. 

Preterm 

% 

APH 

% 

FGR 

% 

Total 

major 

50 12 12 74 

70 13 80 

PSANZ 28 20 10 8 64 

ReCode 15 15 43 73 

Tulip na na na na

Sub optimal care: EuroNatal study

See you at the round table!

Thank you


Classification (1969) 

Whitfield et al 


PSANZ-PDC 


Fetal deformity Fetal abnormality Congenital abnormality 

Infection of the fetus or 

neonate 

Infection Perinatal infection 

Toxaemia Hypertension Hypertension 

Antepartum haemorrhage 

(APH) 

APH APH 

Maternal disease Maternal disease Maternal conditions 

Mechanical causes Birth trauma Specific perinatal 

conditions 

(includes Birth trauma, 

Serological incompatibility Hemolytic disease Alloimmune disease, Twin-twin 

transfusion) 

Intrapartum asphyxia Hypoxic peripartum death 

Deaths of unknown origin IUGR (Intrauterine 

Growth Retardation) 

Fetal growth restriction 

Premature (5½lb/2500g or less) Spontaneous preterm Spontaneous preterm 

Mature (more than 5½lb/2500g) Unexplained 

Unexplained antepartum 

intrauterine death death 

Miscellaneous 

Other causes No obstetric antecedent 

Unclassified 

(includes Unknown, SIDS 

and postnatally acquired 

infection)

Extended Wigglesworth 

Revised Aberdeen 

Fetal and Neonatal Classification

1954 Aberdeen Maternity 

Hospital Classification 

1. Cause unknown: Premature (5½lb or less) 

(20%), Mature (14%); 

2. Trauma – mechanical stress during labour 

(19%); 

3. Fetal deformity (15%) 

4. Antepartum haemorrhage (11%); 

5. Toxaemia (10%); 

6. Maternal disease (6%); 

7. Other causes (5%).

UK obstetric antecedent classifications 

Amended Aberdeen Classification (1969) 

Fetal deformity 

Infection of the fetus or neonate 

Toxaemia 


Maternal disease 

Mechanical causes 

Serological incompatibility 

Deaths of unknown origin 

Premature (5½lb/2500g or less) 

Mature (more than 5½lb/2500g) 

Miscellaneous 

Unclassified

PSANZ 

Guidelines and training cases

Thank you

CESDI 8 TH Report

Causes of Late Fetal Death (>28wks) 

Unexplained 

antepartum death 

44% 

PSANZ-PDC 

PSANZ PDC 

MMH 1994-2004 

1994 2004 

No obstetric 

antecedent 

0% 

Spontaneous preterm 

4% 

Fetal growth 

restriction 

8% 

Congenital 

abnormality 

14% 

Perinatal infection 

0% 

Hypertension 

3% 

Antepartum 

haemorrhage 

9% 

Maternal conditions 

5% 

Specific perinatal 

conditions 

11% 

Hypoxic peripartum 

death 

2%

Purpose of the Classifications 

� PSANZ- Perinatal death classification 

To identify the single most important factor which led to 

the chain of events which resulted in the death. 

� PSANZ-Neonatal death classification 

Used in addition to the PDC to identify the single most 

important factor in the neonatal period which led to the 

chain of events which resulted in the death. 

To consider potentially preventable factors in perinatal 

mortality

Perinatal Society of Australia and New Zealand (of 

Perinatal Death Classification (PSANZ-PDC) 

(PSANZ PDC) 

1. CONGENITAL ABNORMALITY 

2. PERINATAL INFECTION 

3. HYPERTENSION 

4. ANTEPARTUM HAEMORRHAGE 

5. MATERNAL CONDITIONS 

6. SPECIFIC PERINATAL CONDITIONS 

7. HYPOXIC PERIPARTUM DEATH 

8. FETAL GROWTH RESTRICTION 

9. SPONTANEOUS PRETERM 

10. UNEXPLAINED ANTEPARTUM DEATH 

11. NO OBSTETRIC ANTECEDENT

Used across ANZ and reported in 

Australia's Mothers and Babies

Clinical Practice Guidelines for Perinatal Mortality Audit 

Incorporating 

Psychosocial and Social Aspects of Perinatal Bereavement 

Perinatal Society of Australia and New Zealand 

Perinatal Mortality Group

PSANZ 

Training cases - answers

PSANZ Perinatal Mortality Group Website 

www.psanzpnmsig.org

Cause of Perinatal Death by PSANZ-PDC: 

PSANZ PDC: 

QLD, SA, VIC 2000 

Unexplained antepartum 

death 

20% 

Congenital abnormality 

25% 

No obstetric antecedent 

1% 

Hypoxic peripartum death 

3% 

n=1303 


3% 


18% 


conditions 

9% 


6% 


6% 


6% 

Hypertension 

3%

PSANZ-PDC 

PSANZ PDC 

3. HYPERTENSION 

3.1 Chronic hypertension: essential 

3.2 Chronic hypertension: secondary, eg renal disease 

3.3 Chronic hypertension: unspecified 

3.4 Gestational hypertension 

3.5 Pre-eclampsia 

3.6 Pre-eclampsia superimposed on chronic hypertension 

3.8 Unspecified hypertension 

Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, Peek MJ, Rowan JA, 

Walters BNJ. Consensus Statement. The detection, investigation and management of 

hypertension in pregnancy: executive summary. Aust NZ J Obstet Gynaecol 

2000;40:133-138

PSANZ PDC/NDC Agreement 

Classification Major Category Agreement 

Perinatal Fetal 

deaths 

n = 70 

n (%) 

Neonatal 

n (%) 

58(83) 

- 

Neonatal 

deaths 

n= 30 

26 (87) 

Neonatal 

deaths 

n=28 

24 (86) 

Total 

deaths 

n=100 

84 (84) 

- 

Kappa 

0.83 to 0.95 

(p

How does PSANZ-PDC PSANZ PDC shape up? 

Ease of use by clinicians and perinatal pathologists with 

uniform definitions; 

Good level of agreement (low inter-observer variability); 

Ease of expansion in terms of sub classification; 

Based on clinical factors and autopsy findings including 

histology of the placenta; 

Explain the underlying cause of death; 

Suitable in stillbirth as well as neonatal death; 

Result in a high percentage of classifiable cases and a low 

percentage of unexplained cases

PSANZ-PDC 

PSANZ PDC 

2. PERINATAL INFECTION 

2.1 Bacterial 

2.11 Group B Streptococcus 

2.12 E coli 

2.13 Listeria monocytogenes 

2.18 Other bacterial 

2.19 Unspecified bacterial 

2.2 Viral 

2.21 Cytomegalovirus 

2.22 Parvovirus 

2.23 Herpes simplex virus 

2.24 Rubella virus 

2.28 Other viral 

2.29 Unspecified viral 

2.3 Protozoal eg Toxoplasma 

2.4 Spirochaetal eg Syphilis 

2.5 Fungal 

2.8 Other 

2.9 Unspecified organism






Based on clinical factors and autopsy findings 



Result in a high percentage of classifiable cases and a 

low percentage of unexplained cases 

Suitable in stillbirth as well as neonatal death;

PSANZ-PDC 

PSANZ PDC 

10 UNEXPLAINED ANTEPARTUM DEATH 

10.1With evidence of uteroplacental insufficiency, eg 

significant infarction, acute atherosis, maternal and/or 

fetal vascular thrombosis or maternal floor infarction 

10.2 With chronic villitis 

10.3 Without the above placental pathology 

10.4 No examination of placenta 

10.9 Unspecified unexplained antepartum death or not 

known whether placenta examined

Unexplained Antepartum 

Fetal Death 

“ Death of a normally formed fetus prior to the onset of 

labour where no predisposing factors are considered 

likely to have caused the death eg FGR or any other 

primary complication such as spontaneous preterm 

ROM” 

Unexplained (Unexplored?) Antepartum Fetal Death

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Congenital 

abnormality 

Perinatal Autopsy Rates by State 

QLD, VIC , SA 2000 

PSANZ – Classification 

Unexplained 


Spontaneous 

preterm 


conditions 

Antepartum 

haemorrhage 

Maternal conditions Overall 

State 1 

State 2 

State 3

PSANZ-PDC 

PSANZ PDC 

8. FETAL GROWTH RESTRICTION (FGR) 

8.1 With evidence of uteroplacental 

insufficiency eg significant infarction, acute 

atherosis, maternal and/or fetal vascular 

thrombosis or maternal floor infarction 

8.2 with chronic villitis 

8.3 Without the above placental pathology 

8.4 No examination of placenta 

8.8 Unspecified FGR or not known whether 

placenta examined

Australian birthweight percentiles for singleton girls 

Weight (grams) Percentile 

5000 

4000 

3000 

2000 

1000 

0 

22 24 26 28 30 32 34 36 38 40 42 44 

Gestational age (weeks) 

From: Roberts CL & Lancaster PAL. Australian national birthweight percentiles by gestational age. 

20 

APPENDIX 1B 

97 

90 

75 

50 

25 

10 

3

Courtesy of Jason Gardosi

Causes of Fetal Death 

QLD,WA, VIC 2000-2003 

n=3530 


Unexplained antepartum death 




Specific perinatal conditions 



Hypertension 


Congenital anomaly 

0.04 

0.14 

0.23 

0.18 

0.45 

0.58 

0.51 

0.82 

0.84 

1.38 

1.90 

0.00 0.50 1.00 1.50 2.00

Causes of Fetal Death, multiple and singletons 

QLD,WA, VIC 2000-2003 

n=3530 









Hypertension 



0 1 2 3 4 5 6 7 8

% of fetal death rate 

70 

60 

50 

40 

30 

20 

10 

0 

Unexplained Fetal Death (n=948) 

QLD,WA, VIC 2000-2003 

Unexplained fetal death contribution to fetal death rate by gestation 

singleton (n=3180) versus multiple (n=350) pregnancies 

20-21 22-23 24-27 28-31 32-34 35-36 37-41 42+ Overall 

Gestation at birth 

Singleton 

Multiple






Based on clinical factors and autopsy findings including 



Result in a high percentage of classifiable cases and a low 

percentage of unexplained cases 

Suitable in stillbirth as well as neonatal death;

per 1000 Births 

Cause of Perinatal Death by ANZACPM: 

QLD, SA, VIC 2000 

2.5 

2.0 

1.5 

1.0 

0.5 

0.0 


Births n=129752, Perinatal deaths n=1303 







PSANZ-PDC 

Hypertension 


Neonatal death 

Fetal death 


No obstetric antecedent


Neonatal Death Classification(PSANZ-NDC) 

Classification(PSANZ NDC) 

1. CONGENITAL ABNORMALITY 

2. EXTREME PREMATURITY 

3. CARDIO-RESPIRATORY DISORDERS 

4. INFECTION 

5. NEUROLOGICAL 

6. GASTROINTESTINAL 

7. OTHER

International systems

Recently developed International 

systems 

ReCode: 

� Stillbirth only 

� Identifies the relevant condition at the time of death in 

utero. 

� Hierarchical. 

� Starting with fetal condition 

� Secondary factors identified 

� Focus on growth restriction 

� 47% FGR – 50% with no apparent cause 

� 15% unexplained (ie 38% unexplained) 

� Difficult to identify clinically relevant conditions those 

which triggered the chian of events ( eg no spontaneous 

preterm category)

Recently developed International 

systems 

Tulip: 

� Late fetal loss, Stillbirth, Neonatal deaths 

and deaths before discharge 

� Not Hierarchical, 3 layers of coding 

� Identifies the Cause, Mechanisms and 

Pathway of the death 

� Focus on placental pathology - difficult to 

identify clinically relevant conditions (eg 

no category for pre-eclampsia)

International Stillbirth Alliance 

Conference Japan June1-4 June1 4 2006 

http://www.isaconference2006.com/

Would PSANZ consider an international 

classification system for stillbirths?


� Ease of use by clinicians and perinatal pathologists 


� Good level of agreement (low inter-observer 

variability); 

� Ease of expansion in terms of sub classification; 

� Based on clinical factors and autopsy findings including 


� Explain the underlying cause of death; 

� Suitable in stillbirth as well as neonatal death; 

� Result in a high percentage of classifiable cases and a 

low percentage of unexplained cases

Clinical Practice Guidelines for Perinatal 

Mortality Audit 

Incorporating 

Psychosocial and Social Aspects of Perinatal Bereavement 


Perinatal Mortality Group 

http://www.psanzpnmsig.org/

PSANZ Perinatal Mortality Audit 

Guidelines 

The guideline is presented in 7 sections as follows: 

Section 1: Overview & summary of recommendations; 

Section 2: Institutional perinatal mortality audit; 

Section 3: Psychological and social aspects of perinatal 

bereavement; 

Section 4: Perinatal post-mortem examination; 

Section 5: Investigation of stillbirths; 

Section 6: Investigation of neonatal deaths; 

Section 7: Perinatal mortality classifications

Objectives 

oBackground Background classification systems 

oDevelopment Development of the PSANZ Classification 

oExample Example cases 

oCauses Causes of perinatal death

Fetal, Neonatal and Perinatal Mortality 

QLD, SA, VIC 2000 and Australia 1999 

State Births Livebirths FD NND PND 

n rate 1 n rate 2 n rate 1 

SA 17872 17766 106 5.9 57 3.2 163 9.1 

QLD 49318 48960 358 7.3 184 3.8 542 11.0 

VIC 62562 62146 416 6.6 182 2.9 598 9.6 

Total 129752 128872 880 6.8 423 3.3 1303 10.0 

Australia 257394 255605 1789 7.0 822 3.2 2611 10.1 

1 per 1 000 births, 2 per 1 000 livebirths

% of Neonatal Deaths 

40 

35 

30 

25 

20 

15 

10 


5 

0 

Neonatal Deaths by NDC 

QLD, SA, VIC 2000, 

n=423 

34.8 

Extreme prematurity 

25.5 

Cardio-respiratory disorders 

14.9 

Neurological 

9.5 

PSANZ-NDC 

Infection 

6.9 

Other 

5.2 

Gastrointestinal 

3.3

Cause of Perinatal Death by Indigenous 

Status: PSANZ-PDC 

PSANZ PDC 

Hypoxic Peripartum Deaths 

No Obstetrical Antecedent 

Fetal Growth Restriction 

Perinatal Infection 

Antepartum Hemorrhage 

Maternal Conditions 

Hypertension 

Specific Perinatal Conditions 

Congenital Abnormality 

Unexplained Antepartum Death 

Spontaneous Preterm 

Indigenous n=81, Not Indigenous n=1220 

4.7 

2.7 

2.2 

9.8 

0.00 1.00 2.00 3.00 4.00 5.00 6.00 

4.1 

3.4 

3.4 

Indigenous 

Not Indigenous

Cause of fetal death by plurality 

QLD, WA, VIC 2000-2003 

2000 2003 

n=3530 

Multiple fetal death Singleton fetal death 

PSANZ Perinatal Death n % rate 

Classification 

1 n % rate 1 Relative Risk 

(95%CI) 

Congenital abnormality 38 10.9 2.3 650 20.4 1.4 1.71 (1.23, 2.37) 

Perinatal infection 2 0.6 0.1 90 2.8 0.2 0.65 (0.16, 2.63) 

Hypertension 13 3.7 0.8 104 3.3 0.2 3.65 (2.05, 6.49) 

Antepartum 

15 4.3 0.9 239 7.5 0.5 

haemorrhage 

1.83 (1.94, 2.15) 



10 2.9 0.6 408 12.8 0.9 0.72 (0.38, 1.34) 

conditions 

124 35.4 7.5 165 5.2 0.3 21.95 (19.39, 27.68) 

Hypoxic peripartum 1 0.3 0.1 68 2.1 0.1 

death 

0.43 (0.60, 3.09) 

Fetal growth restriction 9 2.6 0.5 217 6.8 0. 5 1.21 (0.62, 2.36) 

Spontaneous preterm 83 23.7 5.0 324 10.2 0. 7 7.48 (5.88, 9.52) 

Unexplained 

51 14.6 3.1 897 28.2 1.9 

antepartum 

1.66 (1.25, 2.20) 

No obstetric antecedent 4 1.1 0.2 18 0.6 0.04 6.49 (2.20, 19.17) 

Total 350 100 21.2 3180 100 6.6 3.21 2.99, 3.59

Future for PSANZ PDC&NDC 

� National collaboration: Annual reporting 

Australia’s Mother’s and Babies 

� Review and updating PSANZ SIG 

� International collaboration – meaningful 

comparisons across countries

PSANZ Classifications 

� Developed by perinatal clinicians, 

over a 15 year period 

� Hierarchical- ie, categories mutually 

exclusive and unambiguous 

� Categories clinically relevant 

� Easy to apply 

� Reproducible

Why not ICD? 

� 553 perinatal deaths in Queensland for 

the year 1997 

� Classified by three clinicians (VF, JK, 

DT) according to the Perinatal 

classification system. 

� The same cases were also assigned 

ICD9 (CM) codes by professional coders 

in Queensland Health.

Jason Gardosi – CESDI 8 Th report

PSANZ classification development 

•Clinical classifications of perinatal deaths since 

1986 - 1996 call for consensus 

•1999 Consensus reached - increasingly used 

•March 2003 endorsed by the Perinatal Society of 

Australia and New Zealand 

•Adopted across all Sates and Territories in Australia - 

increasing use in NZ. 

•Accepted by the Australian National Perinatal Statistics 

Unit for national reporting


Examples: 

Classify here: Intrauterine Fetal Death (IUFD) at 27 

weeks, with membranes intact, before onset of labour, 

no explanation. No autopsy or examination of placenta. 

Classify as Unexplained Antepartum Death, Category 

10.4. 

Do not classify here: Spontaneous ROM at 27 weeks, no 

significant maternal conditions present, subsequent 

IUFD prior to onset of labour. No chorioamnionitis. 

Classify as Spontaneous Preterm (Category 9.32).

PSANZ- PSANZ NDC classification development 

Wigglesworth 

Classification 

(1980)† 

Fetal and Neonatal 

Factors Classification 

(1986) 

(Hey, Lloyd, 

Wigglesworth) 

PSANZ-NDC 

(2000) 

Normally formed stillbirths 

Congenital malformations Congenital abnormalities Congenital abnormality 

Immaturity Severe pulmonary immaturity Extreme prematurity 

Hyaline membrane disease Cardio-respiratory disorders 

Asphyxia Asphyxia before birth 

(antepartum or intrapartum) 

Birth trauma 

Intracranial haemorrhage 

Neurological 

Other (Specific conditions) Infection Infection 

Gastrointestinal (eg Necrotising 

enterocolitis) 

Miscellaneous Other (eg SIDS, Accidents) 

Isoimmunisation 

Unclassified/Unknown


Classify here: Term prelabour rupture 

of the membranes, delivery following 

> 24hours of membrane rupture, 

neonatal pneumonia identified within 

48 hours of birth, subsequent 

neonatal death, Group B 

Streptococcus identified on vaginal 

culture and in gastric aspirate. 

Classify as Category 2.11 – GBS. 

Classify here: Antepartum fetal death 

at 27weeks gestation following 

maternal pyrexia. Autopsy confirmed 

overwhelming fetal sepsis with E coli 

isolated from blood cultures, 

placental swab, liver swab and lung 

swab. Acute villitis and 

chorioamnionitis were also present.. 

Death type Criteria of Infection 

Fetal 1. Histological confirmation of infection in cord (funisitis) 

or fetus (pneumonitis or pneumonia) with or without 

microbiological evidence of infection. 

OR 

2a. Convincing clinical evidence of primary maternal 

infection 

AND 

2b. Positive culture of a pathogen from mother or placenta 

Neonatal Congenital infection 

Early onset infection (within 48 hours of birth), defined as: 

1.Clinical signs in neonate consistent with sepsis 

AND 

2.Haematological changes consistent with sepsis 

AND ONE OR MORE OF 3a – 3d 

3a. Positive culture of a pathogen (bacterial or viral) from 

the neonate 

OR 

3b. Pathological evidence at autopsy 

OR 

3c. Positive serology 

OR 

3d. Positive culture of a pathogen from the mother or the 

placenta. 

NB: Some congenital viral infections may have onset later 

than 48 hours after birth. For neonatal deaths occurring 

within a few hours of birth, especially those for which 

resuscitation was not attempted, where infection is 

presumed to be the cause of death, the infection criteria for 

fetal death may be used.

PDC and ICD 9 Rankings 

Classification % ICD 9 % 

Major fetal abnormality 19 Diseases relating to short 

gestation and lowbirthweight 

20 

Unexplained 

19 Other ill defined conditions 19 


in the perinatal period 

Spontaneous preterm 13 Congenital abnormality 19 

Multiple pregnancy 13 Foetus or newborn affected 

by comps of placenta,cord 

and members 

10 

Antepartum 

12 Intrauterine hypoxia and 8 

haemorrhage 

birth asphyxia 

No obstetric antecedent 8 Infections specific to the 

perinatal period 

4 

Specific obstetric 7 Sudden death, cause 

3 

conditions 

unknown 

Hypertension 3 Other respiratory conditions 

of the fetus and newborn 

3 

Perinatal infection 2 Birth trauma 2 

Hypoxic peripartum 2 Foetal and neonatal 

2 

death 

haemorrhage 

Intrauterine growth 2 Conditions involving the 2 

restriction 

integument and temperature 

regulation

PSANZ-PDC 

PSANZ PDC 

4. Antepartum Haemorrhage 

4.1 Placental abruption 

4.2 Placenta praevia 

4.3 Vasa praevia 

4.4 Other APH 

4.8 APH of undetermined origin

PSANZ-PDC 

PSANZ PDC 

1. CONGENITAL ABNORMALITY (including terminations 

for congenital abnormalities) 

1.1 Central nervous system 

1.2 Cardiovascular system 

1.3 Urinary tract 

1.4 Gastrointestinal tract 

1.5 Chromosomal 

1.6 Metabolic 

1.7 Multiple 

1.8 Other congenital abnormality 

1.81 Musculoskeletal 

1.82 Respiratory 

1.83 Diaphragmatic hernia 

1.88 Other specified congenital abnormality 

1.9 Unspecified congenital abnormality

UK obstetric antecedent classifications 



Whitfield et al 


Fetal deformity Fetal abnormality 

Infection of the fetus or neonate Infection 

Toxaemia Hypertension 

Antepartum haemorrhage APH 

(APH) 

Maternal disease Maternal disease 

Mechanical causes Birth trauma 

Serological incompatibility Hemolytic disease 

Intrapartum asphyxia 

Deaths of unknown origin IUGR (Intrauterine Growth 

Retardation) 

Premature (5½lb/2500g or Spontaneous preterm 

less) 

Mature (more than 

Unexplained intrauterine death 

5½lb/2500g) 

Miscellaneous Other causes 

Unclassified

Rate per 1000 

Causes of Fetal Death, multiple and singletons 

QLD,WA, VIC 2000-2003 

n=3530 

8 

7 

6 

5 

4 

3 

2 

1 

0 



Hypertension 





PSANZ-PDC 


SINGELTON rate MULTIPLE rate 



No obstetric antecedent

Classification Criteria 

++Ease of use by clinicians and perinatal pathologists 


++ Good level of agreement (low inter-observer 

variability); 

++ Ease of expansion in terms of sub classification; 

+ Based on clinical factors and autopsy findings 


+ Explain the underlying cause of death; 

+ Result in a high percentage of classifiable cases and 

a low percentage of unexplained cases 

+ Suitable in stillbirth as well as neonatal death;

Stillbirth Still Happening……. Still

Care Improvement 

Potentially Contributing Factors 

The determination of potentially contributing 

factor in the death does not mean that death was 

certainly preventable, but that if a preferable 

course of action had been followed, the risk of 

death would be likely to have been reduced. 

Classification: 

o maternal/social 

o infrastructure/service organisation 

o professional care delivery

NZ 

ABS 

NPSU 

WHO 

International 

comparisons 

WHO National 

reporting 

National 

Health Data 

Dictionary 

PSANZ 

Guideline 

Definitions of stillbirth in ANZ 

GA 

20 

20 

20 

28 

22 

20 

20 

And/or 

And/or 

or 

or 

or 

or 

or 

or 

Weigh 

t 

400 

400 

400 

1000 

500 

400 

400 

Other 

Residents and 

non residents 

Only if 

birthweight is 

unavailable 

If birthweight 

unavailable 

Based on year of 

registration 

Only if 


unavailable 

Only if 


unavailable 

7.4 

5.3 

5.1 

and 

7.1 

Rate per 1000 

0.5 

2.8 

3.1 

10.4 

8 

8

So how many stillbirths in 

Australia? 

ABS: 5/1000= 1300 

State and Territories: 7/1000 = 1750 

450??

Causes of Fetal Death 

QLD,WA, VIC 2000-2003 

n=3530 









Hypertension 



0.04 

0.14 

0.23 

0.18 

0.45 

0.58 

0.51 

0.82 

0.84 

1.38 

1.90 

0.00 0.50 1.00 1.50 2.00

Cause of Perinatal Death by Indigenous Status, 

SA, QLD PSANZ-PDC 

n=2000 

Hypoxic Peripartum Deaths 

No Obstetrical Antecedent 

Fetal Growth Restriction 


Antepartum Hemorrhage 

Maternal Conditions 

Hypertension 

Specific Perinatal Conditions 

Congenital Abnormality 

Unexplained Antepartum Death 

Spontaneous Preterm 

2.2 

0.00 1.00 2.00 3.00 4.00 5.00 6.00 

3.4 

Indigenous 

Not Indigenous

CESDI 8 TH Report

CESDI 8 TH Report

Classification of the causes of stillbirth_Flenady.pdf

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