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354 STILLBIRTH AND FETAL GROWTH RESTRICTION AT PRETERM ANDTERM GESTATIONS IN SINGLETON PREGNANCIES: A MULTIVARIATEANALYSIS JASON GARDOSI1, ANDRE FRANCIS1, SVEN CNATTINGIUS2,1West Midlands Perinatal Institute, Birmingham, West Midlands, UnitedKingdom 2Karolinska Institute, Stockholm, Sweden

OBJECTIVE: Intrauterine growth restriction is associated with stillbirth, butlittle is known about the interaction withmaternal characteristics, fetal maturity,and complications in pregnancy.

STUDY DESIGN: Stepwise logistic regression of 340,721 singleton births onthe Swedish Birth Register, including 442 preterm ( <37 weeks) and 450 termstillbirths. Variables included maternal physiological characteristics, smoking,pregnancy complications and fetal conditions including anomalies and fetalgrowth restriction (FGR). FGR was categorized as severe ( <3rd customizedpercentile, adjusted for constitutional variables) or mild (3rd-10th customizedpercentile). The etiological fraction (population attributable risk, PAR) wascalculated on the basis of prevalence and odds ratio (OR).

RESULTS: The Table lists the variables that had significant associations withstillbirth, together with their population attributable risk.

CONCLUSION: Fetal growth restriction has strong associations with fetaldeath in the preterm, as well as term, periods. Its early detection is essential forthe development of effective strategies for stillbirth prevention.

December 2003Am J Obstet Gynecol

S158 SMFM Abstracts

IS CLAVICULAR FRACTURE PROTECTIVE AGAINST BRACHIAL PLEXUSPALSY? ROBERT ALLEN1, MICHELE DONITHAN2, PATRICIA MOORE3,SHAWN STALLINGS4, SCOTT PETERSEN3, LEORA ALLEN5, EDITHGUREWITSCH3, 1Johns Hopkins University, Biomed Eng, Baltimore, MD2Johns Hopkins University, Epidemiology, Baltimore, MD 3Johns HopkinsUniversity, Gyn/Ob, Baltimore, MD 4Shands Hospital, Ob/Gyn, Gainesville,FL 5Johns Hopkins University, Nursing, Baltimore, MD

OBJECTIVE: To determine, among vaginal deliveries resulting in claviclefracture (Fx) and/or brachial plexus palsy (BPP), whether Fx is protectiveagainst BPP.

STUDY DESIGN: With IRB approval, vaginal deliveries associated with Fxand/or BPP were identified from 3 databases: (1) all shoulder dystocia (SD)cases resulting in BPP (1994-1997) from a single institution; (2) all vaginaldeliveries complicated by Fx and/or BPP (1993-2003) from a single institution;and (3) litigated cases of permanent BPP with or without SD frommultiple U.S.institutions. BPPs were considered severe if permanent and were complete (C5-C8/T1) or involved at least one nerve root avulsion. Mild BPPs were eithertemporary or permanent without being severe. Cases of isolated Fx and/or mildBPP were compared with severe BPP for associated Fx using chi-square, withsignificance set at P < 0.05. A stepwise linear regression analysis was performed tocontrol for potential confounding variables and generate odds ratios forpredicting BPP.

RESULTS: Of 350 vaginal deliveries complicated by Fx and/or BPP, therewere 70 isolated Fx, 21 concomitant Fx and BPP, 212 mild BPP, and 68 severeBPP (Table). After controlling for maternal obesity, birth weight, shoulderdystocia and operative vaginal delivery in the regression model, clavicle fracturewas negatively associated with BPP (OR 0.1, CI: 0.03-0.57).

CONCLUSION: Among vaginal deliveries associated with clavicularfracture and/or brachial plexus palsy, fracture is associated more often withno or mild BPP, whereas infants with severe BPP rarely sustain a concomitantfracture. This may reflect a protective effect of clavicle fracture against brachialplexus palsy.

Correlation of clavicular fracture with brachial plexus palsy

No Fracture (N = 259) Fracture (N = 91) P value

No or Mild BPP 193 (74.5%) 89 (97.8%) <0.0001Severe BPP 66 (25.5%) 2 (2.2%) <0.0001

‘‘UNEXPLAINED’’ STILLBIRTHS: AN INVESTIGATION OF THE CLINI-CALLY RELEVANT CONDITIONS AT THE TIME OF FETAL DEATH JASONGARDOSI1, SARAH BADGER1, ANN TONKS1, ANDRE FRANCIS1, 1WestMidlands Perinatal Institute, Birmingham, West Midlands, United Kingdom

OBJECTIVE: The majority of stillbirths are currently classified as ‘‘un-explained,’’ regardless of whether a postmortem has been carried out. This is oflimited usefulness when wanting to counsel the mother about her loss, whenplanning management of future pregnancies, or when seeking to focusattention and resources of the health service on the areas of greatest need.

STUDY DESIGN: The cohort consisted of all stillbirths notified in the WestMidlands in 2001. They were categorized using the usual Wigglesworthclassification, and a new method we developed to identify the RelevantCondition at Death (ReCoDe). Categories are hierarchical, starting fromconditions of (1) the fetus, (2) the umbilical cord, (3) placenta, (4) amnioticfluid, (5) uterus, (6) trauma, (7) maternal conditions, and (8) ‘‘unexplained.’’Condition of the fetus included anomalies, multiples, intrapartum asphyxia,and growth restriction. Fetal growth restriction was defined as a weight belowthe10th customized percentile adjusted for maternal characteristics andgestational age.

RESULTS: A total of 341 stillbirths were notified, of which 231 (68%) wereWigglesworth ‘‘unexplained.’’ These deaths occurred at later gestations(median 34 weeks) than those in other categories (28 weeks). Using ReCoDeleft only 13% of stillbirths unclassified; of the Wigglesworth ‘‘unexplained’’stillbirths, 57%had fetal growth restriction, 13% related to cord or placenta, and6% had a relevant maternal condition.

CONCLUSION: Current methods of classifying antepartum fetal deathshide important underlying factors. Most ‘‘unexplained’’ stillbirths are associatedwith fetal growth restriction in the third trimester and have to be regarded aspotentially avoidable.

355 NEONATAL DEATHS AND FETAL GROWTH RESTRICTION AT PRETERMAND TERM GESTATION IN SINGLETON PREGNANCIES: A MULTIVARI-ATE ANALYSIS JASON GARDOSI1, ANDRE FRANCIS1, SVEN CNATTIN-GIUS2, 1West Midlands Perinatal Institute, Birmingham, West Midlands,United Kingdom 2Karolinska Institute, Stockholm, Sweden

OBJECTIVE: We set out to investigate the association between fetal growthfailure and neonatal deaths.

STUDY DESIGN: Stepwise logistic regression of 340,721 singleton births onthe Swedish Birth Register, with two outcome categories: early neonatal deathafter (1) preterm birth ( < 37 weeks), n = 422; and (2) after term birth, n = 305.Variables included maternal characteristics, smoking, complications duringpregnancy, congenital anomalies, and fetal growth restriction (FGR). FGR wascategorized as severe ( < 3rd customized percentile) and mild (3rd-10thcustomized percentile). The etiological fraction (population attributable risk,PAR) was calculated on the basis of prevalence and odds ratio (OR).

RESULTS: Of the variables studied, the strongest factors associated withneonatal death were congenital anomaly and fetal growth restriction. The Tablelists the variables that had significant associations with neonatal deaths, togetherwith their population attributable risk.

CONCLUSION: The results highlight the need for early identification ofcongenital anomalies and fetal growth restriction, which are associated withneonatal deaths at term, as well as preterm gestations.