10/11) Labour & Delivery - IUFD and Stillbirth

Question 1

Incidence of stillbirth

Answer 1

1 in 200

Question 2

What proportion of stillbirths are SGA babies?

Answer 2

Over 1/3

Question 3

What proportion of stillbirths are unexplained?

Answer 3

50%

Question 4

What percentage of stillbirths are associated with suboptimal care?

Answer 4

> 50%

Question 5

How to diagnose IUFD?

Answer 5

Real-time ultrasound (with second opinion where practical) demonstrating absence of FH.

Question 6

Sensitivity of USS for detecting abruption

Answer 6

15%

Question 7

Risk of DIC within 4 weeks of IUFD and risk after that

Answer 7

10% within 4 weeks and 30% after 4 weeks

Question 8

What investigations to do if mother opting for expectant management beyond 48 hours?

Answer 8

Twice weekly clinical assessment and bloods to detect DIC.

Question 9

What investigations should be done in a Rh NEG woman after an IUFD?

Answer 9

• Anti-D given
• Urgent Kleihauer and repeat 48 hours if large FMH
• Establish baby blood group

Question 10

What maternal blood tests to do after IUFD/SB?

Answer 10

FBC
UE/LFT
CRP
Clotting
Kleihauer
Random blood glucose & HbA1c
Thyroid

Question 11

Which microbiology investigations to do after IUFD/SB?

Answer 11

Parvo, rubella, CMV, HSV, toxoplasma and syphilis serology.

Feral blood (cord or cardiac), fetal swabs, placental swabs.

If maternal fever, flu-like symptoms, abnormal liquor or PROM: Blood cultures, MSU, HVS, Cervical swabs.

Question 12

When to do maternal thrombophilia screen?

Answer 12

If evidence IUGR or placental disease.

Question 13

When to do maternal antibodies?

Answer 13

Anti-red cell if feral hydrops.
Anti-Ro/La if hydrops, endomyocardial fibro-elastosis or AV node calcification.
Antiplatelet antibodies if fetal intracranial haemorrhage.

Question 14

What tissue to take for karyotype?

Answer 14

Deep fetal skin, fetal cartilage and placenta.

Question 15

Percentage of SB/IUFD with chromosomal abnormality

Answer 15

6%

Question 16

What percentage of postmortems will give a classification of death?

Answer 16

46%

Question 17

What percentage of postmortems will provide information on recurrence and management of future pregnancies?

Answer 17

40-50%

Question 18

When to do parental bloods for karyotype?

Answer 18

Fetal unbalanced translocation.
Fetal aneuploidy.
Fetal genetic testing fails and history suggestive of aneuploidy.

Question 19

When do women labour spontaneously after IUFD?

Answer 19

> 85% labour within 3 weeks

Question 20

When to induce labour after IUFD?

Answer 20

If maternal health well and membranes intact - risk of delaying labour 48 hours is low.
If sepsis, PET, abruption or SROM then advise immediate steps toward delivery.

Question 21

Consequences of prolonged expectant management

Answer 21

Need for twice weekly bloods for DIC.
Value of PM may reduce.
Appearance of baby may reduce.

Question 22

After induction how long will it take for vaginal birth?

Answer 22

90% of IUFD can achieve vaginal birth within 24 hours.

Question 23

Protocol for induction in women with unscarred uterus.

Answer 23

200mg mifepristone and then misoprostol.

<26+6: 100 micrograms misoprostol 6h
>27: 25-50 micrograms misoprostol 4h

Question 24

Induction of labour for women with scarred uterus

Answer 24

Can use mifepristone alone to increase chance of labour significantly within 72 hours.
Miso can be used at doses 25-50 micro grams.

Question 25

What percentage of women using simple measures to manage lactation report extreme pain?

Answer 25

1/3

Question 26

Dose of carbergoline

Answer 26

1mg STAT

Question 27

Success rate of carbergoline in suppressing lactation

Answer 27

90%

Question 28

Risk of parental relationships dissolving after SB compared to live birth

Answer 28

40% increased risk

Question 29

Who is responsible for registering birth?

Answer 29

Parents but can delegate to healthcare professional (42 days)

Question 30

Care of pregnancy following a SB

Answer 30

CLC GTT Serial growth scans Consider scheduled delivery

Question 31

Risks in future pregnancies

Answer 31

``` Future SB PET Placental abruption Placental disease Fetal distress Chorioamnionitis Extreme PTB Early neonatal mortality GDM ```

Question 32

What proportion of SB occur in low/middle income countries?

Answer 32

99%

Question 33

In high income countries, what percentage of SB occur intrapartum?

Answer 33

<10%

Question 34

What percentage of SB variation do maternal risk factors account for?

Answer 34

19%

Question 35

What is the only antenatal intervention shown to reduce SB rate?

Answer 35

Aspirin in women at risk of PET

Question 36

What would be the reduction in perinatal death from routine IOL at term?

Answer 36

50%