Recurrent Pregnancy Loss/ Stillbirth

Question 1

Antibody tests for APS?

Answer 1

Anti-B2 glycoprotein 1
Anticardiolipin Antibody
Lupus Anticoagulant

Question 2

Indications for APS testing?

Answer 2

• Personal Hx of VTE
• Unexplained (morphologically normal) fetal deaths >/= 10 wk
• Delivery = 34 due to Pre E
• 3 or more, consecutive, unexplained, spontaneous losses

Question 3

Which of the following is MOST useful in the evaluation of a stillbirth?

Answer 3

Gross and microscopic examination of the placenta, umbilical cord, and fetal membranes by a pathologist is the most useful component of the evaluation of a stillbirth

Question 4

Single most informative study that can be performed after delivery?

Answer 4

Gross and histologic evaluation of the placenta

Question 5

Additional clinical investigation for IUFD?

Answer 5

1. Inspect fetus and placenta at delivery
2. Placenta to pathology!!!!!!!!!
3. Fetal autopsy OR postmortem MRI
4. Obtain specimens for cytogenetics
5. Review PMHx, FmHx, Pregnancy Hx
6. Work up for maternal chronic disease

Question 6

After IUFD, what to do next pregnancy?

Answer 6

1. Recurrence counseling, complete work up, social support, reassurance
2. Optimize risk factors (obesity, smoking, etc)
3. Kick counts starting at 28 weeks
4. Option of antenatal surveillance/growth US
   - Recommend starting 4 weeks prior to time of IUFD in prior pregnancy
5. Planned ELECTIVE delivery at 39 weeks

Question 7

Risk factors for IUFD?

Answer 7

AMA
Obesity
Diabetes
Non-hispanic black race
Tobacco/Alcohol/Drug use
Previous IUFD

Question 8

Potential Causes of IUFD?

Answer 8

Congenital anomalies/Genetic abnormalities
Placental insufficiency - FGR
Placental abruption
Umbilical cord accident

Question 9

Work up for IUFD?

Answer 9

Maternal History
PLACENTAL EXAM + FETAL AUTOPSY
Karyotype/Microarray
KB
Treponema
APL Testing (Lupus anticoagulant, B2 glycoprotein, anticardiolipin)

Question 10

Management of subsequent pregnancies after IUFD?

Answer 10

Optimize maternal risk factors
Genetic screening
Serial growth US to assess for FGR
Antenatal testing at 32 w (or 1-2 prior to previous IUFD)
Delivery 39w0d (or earlier if indicated)

Question 11

Why is microarray better for genetic testing on IUFD compared to karyotype?

Answer 11

Increases yield (can be done on non-viable tissue)

Detects chromosomal deletions/duplications too small to be detected by karyotyping

Question 12

Management of IUFD > 20 wks?

Answer 12

• Consider amnio if delivery isn’t imminent
• Discuss induction vs expectant management
• Can induce with prostaglandins in all situations (hx of c/s, hx of classical) up until 28 weeks. Then recommend foley balloon/pitocin

Grief management

Question 13

Causes of polyhydraminos?

Answer 13

1. Idiopathic
2. Maternal Diabetes
3. Congenital anomalies (GI obstruction, diaphragmatic hernia, esophageal atresia, cranio/facial abnormalities, GU dysfunction, high out put cardiac failure)

Question 14

Define normal AFI and levels of polyhydramnios

Answer 14

< 25 cm normal
25-30 cm mild
30-35 cm moderate
> 35 SEVERE

Question 15

Risks associated w/ polyhydramnios?

Answer 15

PPROM
PTL
Macrosommia
Malpresentation
Cord prolapse
Aburption
Stillbirth
Uterine Atony/ PPH

Question 16

Evaluation/management of polyhydramnios?

Answer 16

Consult MFM
Level II US to assess for anomalies/hydrops
Genetic evaluation
Consider diabetes screening, antibody screening, RPR, parovirus/CMV testing

Antenatal testing 32 wks
Serial US to monitor growth and AFI
Consider steroids given risk of PTB

Question 17

How do you address symptoms of SOB/ preterm contractions in a patient with severe polyhydramnios?

Answer 17

Consider amnioreduction

Question 18

Delivery planning for IUFD?

Answer 18

14-24 weeks D&E preferred
24-28 vaginal misoprostol
> 28 wks Oxytocin induction