PB 10: Management of Stillbirth

Question 1

Criteria for stillbirth

Answer 1

Fetal death at 20 weeks or greater of gestation

OR

Weight greater than or equal to 350 g (0.77 lbs) if GA is not known

[350 g = 50%ile for weight at 20 w]

Question 2

In 2013, the stillbirth rate in the US was:

Answer 2

5.96 per 1,000 live births

Question 3

Risk factors associated with stillbirth

Answer 3

• Black race
• Nulliparity
• AMA
• Obesity
• Preexisting diabetes
• Chronic HTN
• Smoking
• Alcohol use
• ART
• Male fetal sex
• Unmarried status
• Multiple gestation

Question 4

Stillbirth rate among twin pregnancies is approximately ___ times higher than for singletons

Answer 4

2.5 times higher (14.07 vs. 5.65 per 1,000 live births and stillbirths)

Question 5

Acquired and Inherited Thrombophilias and stillbirth

Answer 5

APLS is an acquired thrombophilia ASSOCIATED with stillbirth.

In contrast, inherited thrombophilias NOT ASSOCIATED with stillbirth.

Question 6

Benefit of microarray analysis in stillbirth workup

Answer 6

Not only detects aneuploidy but also detects copy number variants (smaller deletions and duplications) that are not detectable by karyotype.

As compared to karyotype analysis, microarray analysis increased the diagnosis of a genetic cause to 41.9% in all stillbirths.

Question 7

Algorithm for management of stillbirth

Answer 7

Question 8

What is antiphospholipid syndrome testing?

Answer 8

• Lupus anticoagulant
• Immunoglobulin G and immunoglobulin M for both anticardiolipin and beta2-glycoprotein antibodies
  
  • ​A moderate to high IgG phospholipid or IgM phospholipid titer (greater than 40, or greater than 99%ile) considered positive but must be confirmed with repeat testing 12 weeks later.
  • Elevated levels of anticardiolipin and anti-beta2-glycoprotein-I antibodies associated with 3x-5x increased odds of stillbirth, which supports testing for APLS
• Testing for inherited thrombophilias is not recommended

Question 9

Method of delivery

Answer 9

D&E vs. IOL

D&E = may limit efficacy of autopsy for the detection of macroscopic fetal abnormalities, and often precludes seeing or holding the fetus after removal.

However, D&E is superior - more effective and lower complication rates

IOL = high risk of requiring a D&C for removal of the placenta after delivery of the fetus. In addition, IOL for fetal demise between 14 and 24 w associated with increased risk of maternal morbidity (predominantly infection that requires IV abx) when compared with surgical uterine evacuation

Question 10

IOL medical management

Answer 10

Before 28 weeks, typical dosages for misoprostol are 400-600 mcg vaginally every 3-6 h

Question 11

Medical management prior to 20 weeks

Answer 11

Mifepristone then misoprostol

Question 12

Risk of recurrent stillbirth

Answer 12

2.5

Question 13

Antepartum fetal surveillance for previous stillbirth

Answer 13

Twice weekly testing starting at 32 w or starting at 1-2 w before the GA of the previous stillbirth

Question 14

Delivery plan for stillbirth

Answer 14

Planned delivery at 39 0/7 weeks or as dictated by other matneral comorbid conditions