Discuss perinatal loss
-Incidence globally
-Incidence in NZ and Australia
-Incidence in indigenous groups
- Global incidence 53:1000
- 1:165 overall
-Australia 7.0/1000
-NZ 8/1000
-Still birth incidence for indigenous groups is about double
Discuss risk factors for perinatal mortality rates
-Maternal related (6)
-Maternal medicine related (6)
-Fetal related (8)
-Placental related (4)
- Maternal related
-Ethnicity - Black or Asian ethnicity
-Maternal age <20 or >40
-High BMI
-Social depravation
-Drug use and smoking
-Grandmultip >3 - Maternal medicine related
-HTN disease
-Diabetes
-Obstetric cholestasis
-SLE
-Thrombophillia
-Maternal thyrotoxicosis - Fetal related
-IUGR or LBW <1500g
-Prematurity (leading cause)
-Congenital abnormalities / chromosomal abnormalities (Leading cause)
-Congenital infection
-Postmaturity
-Multiple pregnancy
-Intrapartum hypoxia, trauma
-Fetal haemolytic disease - Placental related
-Abruption
-Placenta praevia
-Cord prolpase
-Cord entanglement
Discuss perinatal loss
-Most common causes
-Number preventable
-Number secondary to SGA
-Number left unexplained
- Most common cause of PMR
-Congenital anomaly
-Spontaneous PTB - Number preventable - 20-30%
- Number due to SGA - 30%
- Number unexplained 30% overall 50% of those at term
Discuss diagnosis of perinatal mortality
-USS findings (4)
Diagnosis should be through USS to assess the fetal heart
USS findings
-Overlapping fetal skull bones
-Hydrops
-Maceration
-Intrafetal gas
Discuss the hospital process for perinatal mortality (6)
- Formal review process
- Comprehensive clinical summary including detailed interview with mother
- Perinatal mortality audit and meeting
- Follow-up for parents once results are available
- Notify GP
- Update medical certificate of perinatal death once outcome of PMM determined
Discuss management of perinatal mortality
-Communication (4)
-Cultural safety (1)
-Space and surroundings (4)
-Shared decision making (2)
-Communication between health professionals (2)
-Timing and mode of delivery (2)
-Decisions about investigations (3)
-Recognition of parenthood (5)
-Effective support (3)
- Communication
-Factual
-Clear, non-technical and slow
-Be responsive to provide the information they need
-Include both parents - Cultural safety
-Ask if the parents have religious or cultural needs - Space and surroundings
-Private place
-Away from mothers and babies
-Suitable for extended family
-Free of confronting material - Shared decision making
-Enquire about what is important to them
-Ask who they want involved in decision making - Communication between health professionals
-Use a universal bereavement symbol on door and notes
-Cancel all up coming appointments - Timing and Mode of delivery
-Develop birth plan
-Advise about benefit of vaginal birth - Decisions about investigations
-Offer autopsy and reassure about respect
-Discuss less invasive examinations
-Obtained verbal and written consent - Recognition of parenthood
-Provide information about the baby - weight, hair colour, length
-Support parenting activities - washing, dressing
-Provide photos, foot and hand prints
-Support commemorative rituals - naming, baptism - Effective support
-Give guidance around grief support
-Address physical postpartum needs - lactation suppression
-Follow-up appointment within 12 weeks
Discuss the indications for sending for placental histology
-Maternal factors (5)
-Fetal factors (8)
-Placental factors (5)
- Maternal factors
-Any systemic disorder
-Moderate/ Severe PET
-Suspected chorioamnioniitis
-APH in third trimester
-Maternal trauma - Fetal factors
-Severe IUGR
-Oligo or polyhydramnios
-Fetal hydrops
-PTB
-Failure to resus or admission to NICU
-Severe anaemia
-Congenital anomalies
-Still birth - Placental
-Placental abruption
-Abnormal placental size or weight or macroscopic appearance
-Suspected vasa praevia
-Umbilical cord lesion
-Abnormal umbilical cord length
What are the 5 elements of the safer baby bundle (5)
- Supporting women to stop smoking
- Improving detection and management of fetal growth restriction
- Raise awareness and improve care for reduced fetal movements
- Improve awareness of maternal safe going to sleep position in late pregnancy
- Improve decision making about timing of delivery for women with increased risk of stillbirth
Discuss improving detection and management of fetal growth restriction
-Methods of screening (3)
-Pros and cons of USS screening (3)
- Screening methods
-Screen for risk factors
-Measure SFH at each visit from 24 weeks
-One off 3rd trimester USS - Pros of one off third trimester USS
-Picks up 57% of SGA compared with 2% on routine care - Cons of one off USS screening
-Every case of correctly diagnosed SGA there are 2 which are incorrectly identified
-Does not show a growth trajectory
Discuss safe sleeping positions for women in pregnancy
1. General points (3)
2. Research findings (1)
- General points
-All women should sleep on their side from 28/40
-Sleeping supine is a risk factor for late still birth
-Sleeping on either side halves the risk of still birth - Research findings
-2.6 times the risk of late still birth if sleep on back cf side
Discuss the pathophysiology of still birth and sleeping supine (7 points)
Physiology of sleeping on back after 28/40
>80% reduction in blood flow in IVC
16% reduction in Cardiac output
32% reduction in blood flow through aortic bifurcation
Flow is reduced secondary to compression by gravid uterus
Fetal response is
-quiescent state, and reduced time awake
-Decelerations secondary to reduced O2 from reduced blood supply
Worse if IUGR as less compensation ability
Discuss timing of birth for women at risk of stillbirth
-Outline the five step approach
- Step one - assess for risk factors for still birth early in pregnancy. The majority of women have known risk factors
- Step two - undertake monitoring as indicated - USS
- Step three - Re-evaluate risks at 34-36 weeks
- Step four - Plan for increased surveillance where indicated (USS, CTG, clinical visits)
- Step five - Have discussion about timing of delivery with written information, most recent evidence and be culturally appropriate. Need to weigh up risks and benefits of earlier IOL to spontaneous labour.
Discuss maternal investigations for perinatal loss
-Core investigations (8)
-Selective investigations (11)
- Core investigations
-Comprehensive maternal hx
-Kliehauer-Betke
-Autopsy
-External examination of fetus
-Photos of fetus
-Examination of placenta and cord
-Placental histopathology
-Cytogenetics - Selective investigations
-CMV
-Parvovirus
-Rubella
-Toxoplasmosis
-Syphillis
-HbA1c
-Bile salts for OC
-Thrombophillias
-Thyroid function
-Blood group and Ab
-Drug screen
Discuss investigations for perinatal loss
-Outcome of investigations (2)
- Outcomes of investigation
-50% no cause is found
-Can change how future pregnancies are managed
Discuss fetal postmortem for perinatal loss
1. Why do it (2)
2. Who can OK it (2)
3. Who should do it (1)
4. What other options are there if full autopsy declined (3)
5. What should parents be counselled on (7)
- Why do it
-Gold standard as provides most information
-Can lead to changes in death certificate in 22-75% of cases - Who can OK it.
-Parents must consent - if declined often regret this (2 x more likely) - Who should do it
-Paediatric pathologist
-Coroner can mandate - Other options
-LIA - Less invasive autopsy - organ specific
-MIA - Minimally invasive autopsy - laparoscopic approach
-NIA - Non-invasive autopsy - No internal examination, detailed external examination, skin, biopsy, radiology. photographs - What should parents be counselled on?
-Written informed consent should be gained
-Value of autopsy
-Possibility that cause of death won’t be found
-Potential that some causes of death can be excluded
-Info might benefit others if not the family themselves
-May provide information for future pregnancies
-Care and respect will be given to the baby
Discuss selective testing of the fetus for perinatal loss
-Imaging (2)
-Metabolic testing (4)
-Other (1)
- Imaging
-X-rays - babygram - 20% of babies will have abnormalities detectable on X-ray
-MRI - good to look at CNS. Do soon after birth. Pick up rate much less cf autopsy - Metabolic autopsy
-If lethal genetic metabolic disorder is suspected
-If sudden unexpected fetal death
-Samples to collect include: blood, urine, knee cartilage or skin Bx, liver and muscle Bx
-Should be done in discussion with metabolic physician - Other
-Clinical photography
Discuss placental investigations for perinatal loss
-Types of investigations (4)
- Types of investigations
-Detailed macroscopic examination of placenta and cord
-Swabs for microscopy and culture
-Placental histopathology
-Cytogenetics - chromosomal microarray is preferred test
Discuss core investigations for neonatal loss as per PSANZ (9)
- Detailed maternal Hx - medical, social, antenatal
- Detailed external examination of baby with anthropomorphic parameters measured
- Kleihauer
- New born screening bloods
- Autopsy
- Clinical photos
- Cytogenetics - chromosomal microarray
- Detailed examination of placenta and cord
- Histopathology of placenta, membranes and cord
Discuss expectant management of late fetal demise
-Success rate (1)
-Contraindications (4)
-Risks (2)
-Monitoring (1)
-Advice (1)
- Success rate - 90% delivery within 3 weeks
- Contra-indications
-Bleeding
-DIC
-ROM
-PET - Risks
-DIC - 25% if retained for > 4weeks
-Infection - Monitoring
-If opting for expectant management for more than 48hrs then do 2 x weekly bloods to assess for DIC - Advice
-The longer the duration of expectant management the less value a post mortem is.
Discuss management of late term demise by induction of labour
-Success rates (1)
-Contraindications (3)
-Benefits (2)
-Disadvantages (1)
-Methods (3)
- Success rates - 90% deliver within 24hrs
- Contraindications
-Placenta praevia
-2 or more CS
-Non cephalic presentation - Benefits
-Quicker recovery and return home
-May be beneficial for grieving - Disadvantages
-Emotionally distressing - Methods
-Mifepristone 200mg PO - skip if scarred uterus
-Vaginal misoprostol - dose depends on gestation
-Later gestation = lower dose. >28/40 give 25mcg PV Q6H/
PO Q2H. (Vaginal better than PO - faster and less GIT SE)
-Antibiotics not routinely required
Discuss CS for management of late term fetal demise
-Success rate (1)
-Indications (4)
-Disadvantages (1)
- Success rate - 100%
- Indications
-Maternal refusal of IOL
-Non-cephalic presentation
-Placenta praevia
-Multiple CS (>2) - Disadvantages
-Surgical risks
Discuss management of late term fetal demise with scarred uterus
-Regimens (4)
-Options for 1 previous CS (2)
-Options for 2 previous CS (2)
-Options for 3 previous CS (2)
- Regimens
-Avoid mifeprostone
-Misoprostol but low dose
-Can consider mechanical cervical rippening
-Oxytocin augmentation possible - Option one previous CS
-Low dose misoprostol
-70% deliver within 72hrs - Option two previous CS
-Risk of uterine rupture 0.9% cf 0.7% with one previous
-OK for misoprostol - Option for 3 or more CS
-Risk of rupture unknown
-Consider CS
Discuss pain relief options for IOL in late fetal demise (3 points)
- All women should have the option to meet with an obstetric anaesthetist
- Offer regional anaesthesia - rule out DIC and sepsis first
- Offer morphine or PCA
Discuss management of future pregnancies post late term fetal demise
-Antenatal management (4)
-Location of delivery (2)
-Timing of delivery (4)
- Antenatal management
-Depends on cause of previous still birth
-Consider aspirin
-GDM screening
-Growth scans - Location of delivery
-Recommend delivery at specialist maternity unit if likely to recur
-Can decide if non-recurrent cause - Timing of delivery
-Depends on cause of previous still birth
-Increased risk of still birth
-Can offer IOL in 39th week
-Some centres offer IOL in week prior to previous still birth
