Stillbirth 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
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)
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
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.
What is the incidence of intrapartum stillbirth?
1:1000
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
FETAL • malformation (structural/ chromosomal) • infection (bacterial, viral, protozoal) • immune haemolytic disease • non immune fetal hydrops • metabolic disease
Aetiology fetal death in utero - maternal causes
MATERNAL • diabetes • hypertension including PIH, PET • Graves disease • SLE, connective tissue disorders, antiphospholipid syndrome
Aetiology fetal death in utero - placental and cord causes
PLACENTA • abruption • placental insufficiency – IUGR – post term pregnancy • twin-twin Tx • feto-maternal transfusion
CORD • 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?
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)
Investigations - fetal
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.
Investigations - placenta
Placenta: – Macroscopic examination of placenta and cord – histopathology – 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