Stillbirth Flashcards Preview

General obstetrics > Stillbirth > Flashcards

Flashcards in Stillbirth Deck (31)
Loading flashcards...

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

• 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.


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

• Congenital abnormality / genetic abnormalities
• Preterm delivery

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

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
• 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)


What % of stillbirths are preventable?

86% worldwide

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


How to diagnose stillbirth?

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

- 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.


What is the incidence of intrapartum stillbirth?


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

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


Aetiology fetal death in utero- what % unknown cause?

50% unknown


Aetiology fetal death in utero - fetal causes

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


Aetiology fetal death in utero - maternal causes

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


Aetiology fetal death in utero - placental and cord causes

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

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


Presentation of FDIU?

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

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


Which women are more likely to develop a coagulopathy?

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


Investigations - maternal?

Kleihauer or flow cytometry

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)


Investigations - fetal

– 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.


Investigations - placenta

– Macroscopic examination of placenta and cord
– histology
– cytogenetics
– swabs


Mx - informing parents

– 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



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

– Cervical ripening with mifepistone and induction with Misoprostol
– Prostin- PGE2; Misoprostol-
– 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


Bereavement issues

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



– 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


Areas to target for stillbirth prevention

– Timely IOL/delivery for at risk populations
– Micromorts
– Place of birth
- FHR monitoring
- identification and monitoring
– folic acid
– Older mothers
– Ethnic diversity
– Obesity
– Influenza
– drug addiction and smoking
– side sleeping
– maternal education regarding RFMs


Strategies to decrease intrapartum still birth rates

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


Highest ranking modifiable risk factor for stillbirth?


followed by:
- Smoking


Impact of flu vaccine?

reduces still birth, prematurity and SGA during flu season


Incidence mid trimester loss?

0.5 to 2% of pregnancies


Third stage management after second trimester loss/MTOP?

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


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

PSANZ recommends a more focussed/individualised approach to investigations rather than blanket approach, to avoid unnecessary investigations.

- Detailed history for timing and risk factors of stillbirth
- Clinical Examination for risk factors
- Kleihauer (or flow cytometry for quantitive assessment fetomaternal haemorrhage)

- Clinical examination and measurements
- clinical photographs
- Full autopsy recommended by specialised neonatal pathologist

- Clinical examination placenta and cord +/- swabs
- Histopathology
- Cytogenetics


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

- 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

- antiphospholipid Abs
- LFTs and bile acids
- HbA1c
- TFTs +/- Abs if deranged
- Drug screen
- PET screen incl renal function
- Blood group and antibodies


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

- Growth restriction
- Declining full autopsy

- 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


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

- Placental infarction
- Abruption
- Evidence infection

- APS screen (lupus anticoagulant, anti-cardiolipin abs, anti-B2 glycoprotein-1 abs)
- Further testing as guided my microbiologist


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

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


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

NZ - 10 / 1000
Aus - 9 / 1000