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Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis
Vicki Flenady MMedSc、Laura Koopmans BPsych、Philippa Middleton MPH、J Frederik Frøen MD、Prof Gordon C Smith MD、Kristen Gibbons BMaths、Michael Coory MD、Adrienne Gordon MD、Prof David Ellwood MD、Prof Harold David McIntyre MD、Ruth Fretts MD、Prof Majid Ezzati PhD
Summary
Background
Stillbirth rates in high-income countries have shown little or no improvement over the past two decades. Prevention strategies that target risk factors could be important in rate reduction. This systematic review and meta-analysis was done to identify priority areas for stillbirth prevention relevant to those countries.
Methods
Population-based studies addressing risk factors for stillbirth were identified through database searches. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. The numbers attributable to modifiable risk factors were calculated from data relating to the five high-income countries with the highest numbers of stillbirths and where all the data required for analysis were available. Odds ratios were calculated for selected risk factors, from which population-attributable risk (PAR) values were calculated.
Findings
Of 6963 studies initially identified, 96 population-based studies were included. Maternal overweight and obesity (body-mass index >25 kg/m2) was the highest ranking modifiable risk factor, with PARs of 8—18% across the five countries and contributing to around 8000 stillbirths (≥22 weeks' gestation) annually across all high-income countries. Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7—11% and 4—7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small size for gestational age and abruption are the highest PARs (23% and 15%, respectively), which highlights the notable role of placental pathology in stillbirth. Pre-existing diabetes and hypertension remain important contributors to stillbirth in such countries.
Interpretation
The raising of awareness and implementation of effective interventions for modifiable risk factors, such as overweight, obesity, maternal age, and smoking, are priorities for stillbirth prevention in high-income countries.
英語が苦手な方のために日本語で簡単に内容をまとめてみます。
高所得国5カ国における妊娠22週以降の死産の主要リスク因子を、集団ベースの研究96件のシステマティックレビューおよびメタアナリシスで調査した論文です。最上位の修正可能なリスク因子、言い換えると回避可能なリスク因子は母親の過体重・肥満(年間死産数約8000、人口寄与リスク8～18％)で、第2位は高齢出産(同4200超、7～11％)、第3位は喫煙(同2800超、4～7％)でした。
私のコメントです。
妊娠22週以降の死産の原因としては、染色体異常や先天奇形、臍帯・胎盤因子による子宮内胎児死亡などリスクを回避することが不可能あるいは極めて困難なものも多くあります。しかし、回避可能なリスク因子として肥満・高齢出産・喫煙があることが示されたことは有益です。
予想されたこととは言え肥満・高齢出産・喫煙は死産のリスクと大きく関わっています。そして、高齢出産については回避や予防が若干難しくなるかもしれませんが、肥満と喫煙に関しては生活習慣の改善など個人の努力で確実に回避可能です。
妊娠前・妊娠中の適切な体重管理・栄養管理が大切であること、妊娠中の禁煙が大切であることなど、我々産婦人科医がこれまで指導してきた内容が正しかったことの証でもあります。
日本人女性も原則的には高所得国の女性でありますので、これから妊娠・出産を目指す女性の方は肥満・高齢出産・喫煙によるリスクを回避すべく努力されるとよいかと思います。
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