Shared Placental and Asphyxial Pathways in Preterm Stillbirths and Neonatal Deaths: The Prospective Observational PURPOSe Study

Objective: To evaluate similarities in pathways leading to preterm stillbirth and preterm neonatal death. Design: Prospective observational study. Setting: Study hospitals in India and Pakistan. Population: Preterm stillbirths and neonatal deaths ≥ 1000 g delivered in a study facility and evaluated by an expert panel for cause of death. Methods: An observational study of stillbirths and preterm neonatal deaths. Main Outcome Measures: Asphyxia, placental maternal vascular malperfusion (MVM), maternal hypertension, fetal growth restriction (FGR). Results: There were 398 preterm stillbirths and 582 preterm neonatal deaths in our study population. Of these, the panel determined asphyxia as a cause of death for 80.2% of the preterm stillbirths and 57.4% of the preterm neonatal deaths. Of the 319 preterm stillbirths with asphyxia, 62.4% also had placental MVM, while only 38.0% of the preterm stillbirths without birth asphyxia had MVM. Maternal hypertension was present among 44.5% of the stillbirths and FGR in 35.2%. Among the stillbirths with hypertension, 64.4% had asphyxia and MVM compared to 38.5% among those without hypertension. Similar patterns were seen among neonatal deaths. Conclusions: Both MVM and birth asphyxia were commonly present among stillbirths and neonatal deaths, especially those associated with hypertension and FGR compared to stillbirths and neonatal deaths without those conditions. These findings suggest that MVM and fetal asphyxia are part of a common pathway for stillbirth and preterm neonatal deaths.