Stillbirth

Question 1

What are the top ten interventions to reduce global burden of stillbirth?

Answer 1

• Periconceptual folic acid supplementation.
• Prevention of malaria
• Detection and treatment of syphilis.
• Detection and management of hypertensive disorders of pregnancy.
• Detection and management of diabetes in pregnancy.
• Detection and management of fetal growth restriction.
• Routine induction to prevent post-term pregnancies (>= 41 weeks).
• Skilled birth attendant
• Availability of basic emergency obstetric care.
Availability of comprehensive emergency obstetric care.

Question 2

What are the main causes of stillbirth (PSANZ classification of perinatal death)?

Answer 2

• Congenital abnormality / genetic abnormalities
AND
• Preterm delivery

20-30% no cause found
30-50% contributing / preventable factors identified

…Also…
Maternal factors:
• Perinatal infection including:
○ Bacterial: GBS, E coli, listeria, syphilis.
○ Viral: parovirus, CMV, HSV, rubella.
○ Protozoal: toxoplasmosis, malaria
• HTN in pregnancy (PET>gest HTN)
• Maternal medical conditions other than HTN:
- diabetes (particularly T2DM, or any poorly controlled diabetic)
- SLE (if recent active disease <6mo, renal disease, APS or previous adverse pregnancy outcome)
- obstetric cholestasis,
- Graves hyperthyroidism (TRAb cross placenta - increase risk 7 fold)
- APS (heritable thrombophilias no strong association)
- Drugs / alcohol / smoking
- obesity

Fetal factors:
• Fetal growth restriction
• LGA
• Red cell or platelet alloimmunisation

Pregancy/Birth factors:
• Fetomaternal haemorrhage: especially placental abruption, greatest risk when > 25% fetal loss or 20ml/kg.
• Hypoxic peripartum death: intrapartum complications such as uterine rupture, cord prolapse, shoulder dystocia, non-reassuring fetal status.
• Abnormal placentation
• cord pathology (velamentous, true knot, cord entanglement in MCMA)

Question 3

What % of stillbirths are preventable?

Answer 3

86% worldwide

In NZ/Aus 30-50% have potentially preventable causative factors (PSANZ)

Question 4

How to diagnose stillbirth?

Answer 4

History and examination including SFH, auscultation +/- CTG (screening, not diagnostic)

Definitive Dx: ultrasound
– B-mode + ideally M-mode and colour doppler
– X 60 seconds
– Experienced ultrasonographer
– Good equipment

Findings:

• absent fetal heart beat or flow
• overlapping skull bones (Spalding sign)
• fetal skin oedema
• If placental abruption is suspected, failure to visualise retroplacental haemorrhage on ultrasound does not exclude this condition because only a large retroplacental clot may be visible on ultrasound.

Question 5

What is the incidence of intrapartum stillbirth?

Answer 5

1:1000

Death after onset labour when >/= 20 weeks or >/= 400g

• Most due to preterm labour: cervical insufficiency, PPROM, chorioamnionitis and abruption.
• Previable/ periviable

Question 6

Aetiology fetal death in utero- what % unknown cause?

Answer 6

50% unknown

Question 7

Aetiology fetal death in utero - fetal causes

Answer 7

FETAL
• malformation (structural/ chromosomal)
• infection (bacterial, viral, protozoal)
• immune haemolytic disease
• non immune fetal hydrops
• metabolic disease

Question 8

Aetiology fetal death in utero - maternal causes

Answer 8

MATERNAL
• diabetes
• hypertension including PIH, PET
• Graves disease
• SLE, connective tissue disorders, antiphospholipid
syndrome

Question 9

Aetiology fetal death in utero - placental and cord causes

Answer 9

PLACENTA
• abruption
• placental insufficiency
– IUGR
– post term pregnancy
• twin-twin Tx
• feto-maternal transfusion

CORD
• cord prolapse
• velamentous cord
• true knot
• cord entanglement

Question 10

Presentation of FDIU?

Answer 10

Mostly, present with reduced or absent FM
• Unable to locate FH

May have features of the underlying condition
– severe PET
– abruption
– sepsis

Question 11

Which women are more likely to develop a coagulopathy?

Answer 11

• 25% of women with IUFD>4 Weeks over 20/40
• IUFD due to abruption
• Should resolve 24-48 hours after delivery

Question 12

Investigations - maternal?

Answer 12

Core:

1) Detailed history for timing and risk factors of stillbirth
2) Clinical Examination for risk factors
3) Kleihauer or flow cytometry

Focussed:
HbA1C (if not screened antenatally or LGA or IUGR)
Bile salts, LFTs (if maternal pruritus)
Thyroid function +/- TRAb antibodies if deranged (if maternal signs or sx hyperthyroidism)
APS screen (lupus anticoagulant, anti-cardiolipin Abs, Anti- B2 glycoprotein-1 Abs) - (if maternal or Fhx clots, IUGR, placental infarction/abruption)
CMV, Toxoplasmosis, Parvovirus (if IUGR)
+/- Rubella, HSV and Syphilis (if IUGR and not immune or screened antenatally)
Blood group and antibodies (if baby pale/jaundiced/hydropic or not screened antenatally)
PET screen, Renal Function Tests including Uric Acid (if maternal hypertension)

Question 13

Investigations - fetal

Answer 13

1) Clinical examination and measurements
2) clinical photographs
3) Gold standard is Post mortem

– If full PM unacceptable, consider
• Clinical photography, external examination by dysmorphologist
• X-Ray “babygram”
• Postmortem MRI
• +/- selected tissue samples e.g. for fibroblast culture, muscle for mitochondria etc.

Question 14

Investigations - placenta

Answer 14

Placenta:
– Macroscopic examination of placenta and cord
– histopathology
– cytogenetics
– swabs

Question 15

Mx - informing parents

Answer 15

– Most senior clinician present
– preferably both parents +/- support persons together in private room
– ensure won’t be interrupted
– use sensitive communication strategy, eg. 10 steps to breaking bad news
– be clear that the baby has died
– explain cause if one is apparent
– explain investigations in general terms
– Allow time for grieving
– Encourage any questions or concerns to be aired
– discuss delivery
• in general, no rush
• methods of induction
• pain relief
• post partum care
– pastoral care, SW, GP involvement

Question 16

Mx- LABOUR AND DELIVERY

Answer 16

Allow time for woman and family to come to terms with diagnosis prior to starting delivery - woman can be allowed to go home and return at a later time for delivery
Approach depends on gestation
Advocate for vaginal birth, unless other indication of CS or need for emergent delivery (e.g. life threatening abruption)
Offer quiet/secluded room ideally away from other labouring women if possible
One-to-one midwifery cares
Good analgesia - PCA or epidural if no coagulopathy
No requirement for CTG
No requirement for frequent vaginal examinations, considering assessing if patient sx suggest fully dilation or prolonged induction process with limited progress

Process:
– Cervical ripening with mifepistone and induction with Misoprostol
– Prostin- PGE2; Misoprostol- misoprostol.org
– induction with ARM and oxytocin
- don’t ARM until delivery can be anticipated reasonably soon: risk of overwhelming ascending infection

– Be aware high risk for DIC particularly if suspicion for abruption - have low threshold for blood transfusion and early involvement of haematology/anaesthetics/ICU

Question 17

Bereavement issues

Answer 17

– seeing the baby
– saying goodbye
– momentos
– memorial services
– dealing with family and friends

Question 18

Mx: POST DELIVERY

Answer 18

– pastoral care support re burial, funeral etc
– suppression of lactation
– early discharge if well enough, but good post natal
support – review FREQUENTLY (eg 2,4,6W) post partum
– Notify clinicians involved in collecting PMMRC data for audit

– Full debrief arranged with experienced clinician once all results available
– discussion of next pregnancy
- increased risk of stillbirth
- if modifiable causes found - address prenatally
- Assessment if aspirin beneficial next time
- LDA and heparin if APS
- Tertiary detailed anatomy scan
- Serial growth scans from 28 weeks
- Early IOL at 38-39 weeks

Question 19

Areas to target for stillbirth prevention

Answer 19

INTRAPARTUM:
– Timely IOL/delivery for at risk populations
– Micromorts
– Place of birth
- FHR monitoring
FETAL GROWTH RESTRICTION
 - identification and monitoring
FETAL ANOMALY
– folic acid
SOCIO-DEMOGRAPHIC
– Older mothers
– Ethnic diversity
PUBLIC HEALTH
– Obesity
– Influenza
– drug addiction and smoking
– side sleeping
– maternal education regarding RFMs

Question 20

Strategies to decrease intrapartum still birth rates

Answer 20

Ensure maternity unit adequately staffed
Risk of SB higher in nulliparous women at home than hospital
FHR education and monitoring
Training/procedures for shoulder dystocia/vaginal breech

Question 21

Highest ranking modifiable risk factor for stillbirth?

Answer 21

Obesity

followed by:

• AMA
• Smoking

Question 22

Impact of flu vaccine?

Answer 22

reduces still birth, prematurity and SGA during flu season

Question 23

Incidence mid trimester loss?

Answer 23

0.5 to 2% of pregnancies

Question 24

Third stage management after second trimester loss/MTOP?

Answer 24

Lower rates of bleeding and retention of placenta with use of 10IU IM oxytocin vs miso/no medication

Question 25

What are is the initial approach to CORE investigations for stillbirth as per PSANZ?

Answer 25

PSANZ recommends a more focussed/individualised approach to investigations rather than blanket approach, to avoid unnecessary investigations. Mother: - Detailed history for timing and risk factors of stillbirth - Clinical Examination for risk factors - Kleihauer (or flow cytometry for quantitive assessment fetomaternal haemorrhage) Baby: - Clinical examination and measurements - clinical photographs - Full autopsy recommended by specialised neonatal pathologist Placenta: - Clinical examination placenta and cord +/- swabs - Histopathology - Cytogenetics

Question 26

What findings from the core maternal investigations would prompt further investigation? And what INDICATED/SELECTIVE investigations would you do? (PSANZ)

Answer 26

- Hx of personal of FHx clotting abnormalities or recurrent fetal loss - Hx of itching - No diabetic screen in pregnancy - Signs or sx of hyperthyroidism - Hx substance misuse - S&S hypertension/PET - Blood group and antibodies not screened antenatally Tests: - antiphospholipid Abs - LFTs and bile acids - HbA1c - TFTs +/- Abs if deranged - Drug screen - PET screen incl renal function - Blood group and antibodies

Question 27

What findings from the core fetal investigations would prompt further investigation? And what INDICATED/SELECTIVE investigations would you do? (PSANZ)

Answer 27

- LGA - Growth restriction - Declining full autopsy Tests: - HbA1c (if LGA or IUGR) - APS screen (if IUGR) - Infection screen (if IUGR) - CMV, parvovirus, toxoplasma - Maternal blood group and antibodies (if baby pale/jaundiced/hydropic and/or not checked antenatally) Alternatives to autopsy: - limited autopsy - External examination - Photos - X-ray - MRI next best option if autopsy declined - Selective tissue sampling and storage

Question 28

What findings from the core placental investigations would prompt further investigation? And what INDICATED/SELECTIVE investigations would you do? (PSANZ)

Answer 28

- Placental infarction - Abruption - Evidence infection Tests: - APS screen (lupus anticoagulant, anti-cardiolipin abs, anti-B2 glycoprotein-1 abs) - Further testing as guided my microbiologist

Question 29

What are the definitions of perinatal death in NZ and Aus?

Answer 29

NZ - death of fetus or neonate from 20 weeks or >/= 400g, till 7 days postpartum Aus - death of fetus or neonate from 20 weeks or >/= 400g, till 28 days postpartum

Question 30

What are the rates of perinatal death in NZ and Aus?

Answer 30

NZ - 10 / 1000 | Aus - 9 / 1000

Question 31

Timing of induction for stillbirth - what are the considerations?

Answer 31

Prompt delivery should be advised if there is suspicion of a clinical condition that puts the mother at risk, for example, abruption, chorioamnionitis/sepsis, pre-eclampsia, ruptured membranes. If there is no obvious maternal clinical problem and the IUFD appears unexplained, a short delay of 1–2 days is unlikely to pose a significant risk to the mother. More than 85% of women with IUFD labour spontaneously within 3 weeks of diagnosis. The RCOG recommends that mothers who contemplate prolonged expectant management should have testing for DIC twice-weekly and should be informed that the appearance of the baby may deteriorate and the value of a postmortem may be reduced. The chance of maternal DIC is 10% within 4 weeks from the date of fetal death and increases thereafter.