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association was found between passive smoking and stillbirth unless FGR was also present (RR, 10.0). The risk of stillbirth was increased for all pregnancies with FGR, but was highest when the mother did not smoke (RR, 7.8). The highest population-attributable risks were associated with FGR, primiparity, and antepartum hemorrhage. Although several risk factors for stillbirth can be ascertained early in pregnancy, the main factor is FGR, which is not usually predicted or recognized

Ovid: Maternal and Fetal Risk Factors for Stillbirth: Population Based Study.

antenatally. The findings indicate the importance of improving current strategies and protocols for improved surveillance of fetal growth antenatally. Early detection of fetal growth problems can reduce the risk of stillbirth and must become a key indicator of safety and effectiveness in antenatal care.

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EDITORIAL COMMENT
(Although the largest contribution to perinatal morbidity and mortality is related to preterm birth, among term pregnancies without congenital anomalies, intrauterine fetal demise or stillbirth accounts for approximately half of the perinatal mortality. Strategies to prevent stillbirth focus on the identification of those women at highest risk and institution of care that incorporates antenatal testing and induction of labor. In addition, in those women at increased risk, fetal growth is commonly assessed, usually by ultrasound. Although there are a range of practices, antenatal testing and assessment of fetal growth only represent ways to identify women whose fetuses are at higher risk of stillbirth. At the core of any of these strategies is earlier delivery to prevent stillbirth. Historically, the rate of stillbirth was reported as number of stillbirths in the entire population using the denominator of live births. Unfortunately, when one does that by week of gestation, the numerator is stillbirths that occur during a particular week, but the denominator of live births that occurred at that week of gestation does not include all of the women who were at risk of having a stillbirth during that week. That would actually be everyone who was pregnant at a particular week of gestation. This latter denominator is known as ongoing pregnancy and includes all women who deliver at a particular week of gestation and those beyond as well. This matters because the traditional metric points toward a stillbirth nadir that occurs at 41 weeks gestation, whereas when the more appropriate metric of ongoing pregnancy is used, it appears that the risk of stillbirth increases throughout the term gestation. How do we use the stillbirth metric? When one is trying to reduce the risk of perinatal mortality, the goal is to deliver at a gestational age at which the risk of neonatal death is outweighed by the risk of stillbirth in an ongoing pregnancy. Recently, a study examined this threshold in the overall population and found that beyond 39 weeks of gestation, the risk of stillbirth outweighed the risk of neonatal death (Obstet Gynecol 2012;120:7682). However, it would be assumed that this threshold may be at lower gestational ages for higher-risk subgroups. In the current study abstracted above, Gardosi et al characterized a number of risk factors for stillbirth. These authors conducted a large population-based study and identified obesity, preexisting diabetes, smoking, and FGR as being associated with increased risk of stillbirth. Women with obesity are particularly interesting because, currently, routine recommendations for antenatal testing or early delivery do not exist. Similarly, many individuals do not specifically conduct antenatal testing in women with a history of smoking. Thus, there should be consideration and future research to determine whether these subgroups would benefit from antenatal testing or earlier delivery. The most interesting risk factor for stillbirth was FGR. In many of the other risk factors, they were only at increased risk for stillbirth if FGR was also present. Thus, screening for growth restriction is imperative when a woman has risk factors for stillbirth. However, FGR is challenging to screen for because our primary screening test, fundal height measurement, has incredibly poor sensitivity and specificity (J Matern Fetal Neonatal Med 2011;24:708712). Furthermore, once this screening test is abnormal, the diagnostic test is an obstetric ultrasound that also has a relatively poor positive predictive value. Finally, whether FGR of clinical significance occurs at less than the 10th, 5th, or 3rd percentiles is debatable as well. This confusion has led to a wide range of practices. For example, the American College of Obstetricians and Gynecologists/National Institute of Child Health and Human Development paper guiding timing of indicated late-preterm and early-term delivery left a range of 38 to 39 weeks for those women with otherwise uncomplicated FGR, but neglected to stratify based on growth restriction percentile (Obstet Gynecol 2011;118:323333) That being said, in the current study,

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