Is maternal hypotension during pregnancy and/or posterior located placenta associated with increased risk of stillbirth? A case-control study

Abstract

Title: Is maternal hypotension during pregnancy and/or posterior located placenta associated with increased risk of stillbirth? Design: A retrospective case-controlled study comparing a group of stillbirths with a live born control group matched for maternal age, baby gender, gestational age and year of birth. The purpose of this study was to ascertain whether hypotensive women or women with a posterior located placenta are at increased risk of stillbirth. Two Australian tertiary referral obstetric hospitals were chosen as participating hospitals for this study. All cases with a discharge diagnosis of stillbirth over a five year period at these hospitals were identified and considered as cases for inclusion in the study. An attempt was made to match each case with two controls. After exclusions there were 124 cases and 243 controls. Blood pressure (BP) readings throughout pregnancy were extracted from the medical record of each subject, and summary 'exposure' measures were created. These included: diastolic and systolic readings as well as mean arterial pressure taken at the initial (booking BP), minimum, calculated average, and final reading prior to the birth. Placental position, as determined by midtrimester ultrasound, was also collected. Results: This study found that low Diastolic Blood Pressure (DBP) readings (between 60-70mmHg) throughout pregnancy were associated with a statistically significant increased risk of stillbirth. This trend was seen from the initial reading at booking (OR 1.83 95% CI 1.0-3.2, p=0.03) through to the last taken before the birth (OR 1.53 95% CI 0.9-2.5, p=0.09) including the calculated average over the course of the pregnancy (OR 1.61 95% CI 1.0-2.6, p=0.05) and minimum observed during the pregnancy (OR 2.94 95% CI 0.98-8.8, p=0.05). In addition, this study found a minimum diastolic reading of less than 60mmHg carries a significant risk of stillbirth with a crude odds ratio of 3.5 (95% CI 1.18-10.41, p=0.02). This study did not show a statistically ignificant association of systolic hypotension with stillbirth. However, after combining both systolic and diastolic blood pressures to calculate the mean arterial blood pressure (MAP) the analysis did suggest that women with a minimum MAP between 73-83mmHg were at increased risk of stillbirth (OR 1.69 CI 1.02-2.81, p=0.04). Furthermore, this study found that three MAP readings of less than 83.3 during the course of the pregnancy carries almost twice the risk of stillbirth (adjusted OR 1.99) even after adjusting for race, gravidity, parity, BMI and SGA (and matching for maternal age, gestational age, gender and year of birth.) Women who have a posterior located placenta were statistically more likely to suffer a stillbirth than women who had a placenta in any other position (crude OR 1.64) and this estimate was largely unaffected by adjustment for blood pressure and other putative risk factors (adjusted OR 1.67) Conclusion: In conclusion, this is the first study which specifically examined a stillborn population in order to explore whether maternal hypotension and posterior located placenta impact negatively on stillbirth incidence and the results of this study suggest that both maternal hypotension and posterior located placenta are probably independent contributory risk factors for stillbirth. This means that maternity care providers should closely manage and monitor progress of women who are hypotensive during pregnancy or those whose placenta is posterior; and that effective management strategies need to be developed to care for these women.