Stillbirth is associated with postpartum severe maternal morbidity compared with gestational age matched and term live births

Abstract

BACKGROUND

The rates of severe maternal morbidity in the United States continue to increase. The American College of Obstetricians and Gynecologists recommends close postpartum follow-up for patients at increased risk for severe maternal morbidity and mortality, such as those who suffer from preeclampsia or hypertension. Data on the association between stillbirth and severe maternal morbidity are limited.

OBJECTIVE

This study aimed to evaluate the association between stillbirth and severe maternal morbidity in comparison with gestational age–matched and term live births.

STUDY DESIGN

This was a multicenter, retrospective cohort study that was performed at 3 centers within a hospital system from 2017 to 2023. Severe maternal morbidity was defined with guidance from the indicators outlined by the Centers for Disease Control and Prevention. The inclusion criteria for the stillbirth group were delivery of a fetus that showed no signs of life at 20 weeks’ gestation or later. Cases with antepartum preeclampsia, multiple gestations, maternal age less than 18 years, duplicate records, and voluntary terminations of the pregnancy after 20 weeks’ gestation were excluded. We selected gestational age- and term-matched live births as the control groups. A logistic regression analysis was performed to evaluate the odds of the composite severe maternal morbidity in stillbirths vs gestational age–matched and term-matched live births, separately, with adjustment for potential confounders. The data were presented as the adjusted odds ratios with 95% confidence intervals, and statistical significance was set at a P value of <.05.

RESULTS

Of the 29,060 deliveries during the study period, there were 129 (0.44%) stillbirths. Stillbirth was associated with significantly higher odds of severe maternal morbidity than term (adjusted odds ratio, 4.35; 95% confidence interval, 1.75–10.84) and gestational age matched livebirths (adjusted odds ratio, 3.39; 95% confidence interval, 1.72–6.66). There was no significant difference in the rate of postpartum hemorrhage when stillbirths were compared with gestational age–matched live births (10.1% vs 7.3%; P=.42), however, there were significantly more transfusions needed in the stillbirth group (10.1% vs 1.6%; P=.017). When compared with the term live births, there were significantly more transfusions (10.1% vs 1.6%; P<.001), intensive care admissions (2.3% vs 0%; P=.007), postpartum preeclampsia (2.3% vs 0%; P=.007), and sepsis (2.3% vs 0%; P=.007).

CONCLUSION

Stillbirth is associated with an increased risk for severe maternal morbidity when compared with gestational age- and term-matched live births. Increased postpartum surveillance should be implemented into practice, and preventative interventions, such as tranexamic acid administration, should be evaluated further in prospective studies.