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Causal analysis of fetal death in high-risk pregnancies

  • Mónica Aguinaga EMAIL logo , Yolotzin Valdespino , Daniela Medina , Salvador Espino y Sosa , Rosalba Sevilla , Osvaldo Miranda , Sandra Acevedo , Irma E. Monroy , Addy C. Helguera , Javier Pérez , Luisa F. Mariscal , Mauricio R. Murillo , Rosa M. Lara , Jessica C. Armijos , Gabriela Rogel and Jorge A. Cardona



To determine the causes of fetal death among the stillbirths using two classification systems from 22 weeks of gestation in a period of three years in high-risk pregnancies. This is a retrospective observational study.


The National Institute of Perinatal Health in Mexico City is a Level 3 care referral center attending high-risk pregnancies from throughout the country. The population consisted of patients with fetal death during a three-year period. Between January 2016 and December 2018, all stillbirths were examined in the Pathology Department by a pathologist and a medical geneticist. Stillbirth was defined as a fetal death occurring after 22 weeks of gestation.


Main outcome measures: Causal analysis of fetal death using the International Statistical Classification of Disease and Related Health Problems-Perinatal Mortality (ICD-PM) and initial causes of fetal death (INCODE) classification systems. A total of 297 stillborn neonates were studied. The distribution of gestational age in antepartum stillbirths (55.2%) showed a bimodal curve, 36% occurred between 24 and 27 weeks and 32% between 32 and 36 weeks. In comparison, the majority (86%) of intrapartum deaths (44.8%) were less than 28 weeks of gestation. Of the 273 women enrolled, 93 (34%) consented to a complete fetal autopsy. The INCODE system showed a present cause in 42%, a possible cause in 54% and a probable cause in 93% of patients.


The principal causes of antepartum death were fetal abnormalities and pathologic placental conditions and the principal causes of intrapartum death were complications of pregnancy which caused a premature labor and infections.

Corresponding author: Mónica Aguinaga, MD, MSc, Human Genetics and Genomics Department, Instituto Nacional de Perinatología, Montes Urales 800, Col. Lomas de Chapultepec IV Secc, C.P 11000, Mexico City, Mexico, Phone: +52 55209900 x316, E-mail:


We would like to express our gratitude to Regina Castro for the editorial assistance.

  1. Research funding: None declared.

  2. Author contributions: JAC, SE, MA initiated the concept. MA, YV, SE and JAC designed the study. DM, RS, OM, LM, MM, RML, CA, YV and MA evaluated the patients. MA, YV, SE, OM, SA and DM performed the analysis. IM, CH, JP and GR performed the genetic and infectious analysis. MA, YV and SE drafted the initial manuscript. MA, YV, DM, SE, RS, OM, SA, IM, CH, JP, LM, MM, RML, CA, GR and JAC reviewed and approved the submitted manuscript. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: The procedures of the study received ethics approval from the Institutional Review Board, Comité de Etica Hospitalaria del Instituto Nacional de Perinatología, Mexico City in January 2016.


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Supplementary Material

The online version of this article offers supplementary material (

Received: 2020-07-24
Accepted: 2021-02-11
Published Online: 2021-03-19
Published in Print: 2021-07-27

© 2021 Walter de Gruyter GmbH, Berlin/Boston

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