Stillbirth and Miscarriage

Question 1

What are the general classifications of perinatal death?

Answer 1

• congenital abnormality
• infection
• HTN in pregnancy
• maternal conditions
• changing obstetric profile
• hypoxic peripartum death
• preterm birth
• FGR
• specific conditions

Question 2

What investigations do you do for congenital abnormalities as a cause for stillbirth?

Answer 2

• assess:
  
  • growth
  • obvious structural
  • Hx of teratogens
  • FHx
• Photo
• autopsy
• imaging
• genetic testing (future genetic planning)

Question 3

What about the profile of the obstetric population are associated with stillbirth?

Answer 3

• older
  
  • risk of HTN, DM, FGR, stillbirth
  • stepwise increase from 36 years old
• BMI
  
  • stepwise increase of stillbirth with BMI
  • FGR, HTN, diabetes
• reproductive assistance
  
  • doubling of stillbirth rate
  • even independent of high rates of multiple pregnancies

Question 4

What are the causes of Foetal death in utero?

Answer 4

Maternal:

• HTN - including PIH (pregnancy induced HTN) + PET (pre-eclampsia toxcemia)
• SLE
• CTD
• thrombophilia

Foetal

• malformation
• infection
• metabolic disease
• immune hemolytic disease
• non-immune foetal hydrops

Placental

• abruption
• twin-twin
• foeto-maternal transfusion
• insufficiency (IUGR)

Cord:

• cord accident

Question 5

Why does the day of birth have such a risk?

Answer 5

• hypoxic peripartum death - hypoxic challenge
• Treatment:
  
  • identify FGR prior to labour
    
    • 4x increased risk of stillbirth (small for gestational age)
    • 1/2 rate if you monitor and deliver properly
  • monitor pregnancy
    
    • code pink = emergency fetal distress,
    • code green = surgery
  • expedite the time of delivery

Question 6

What is the definition of foteal death in utero? What are some questions/investigations you can ask?

Answer 6

• after 20 weeks gestation before the onset of labour
• <1% - 50% unknown aetiology
• underlying condition? - abruption, pre-eclampsia toxemia, sepsis
• reduced foetal movement?
• Ix
  
  • foetal US or autopsy - most useful
    
    • Spalding’s sign - postmortem features (overriding/overlapping of fetal cranial bones)
    • in families who don’t allow autopsy
  • Bloods - RBG, HbA1c (diabetes), Rh Ab, Kleihaur (foetal RBCs in maternal - haemorrhage), CTD, TORCH, finbrinogen/platelet count (antiphospholipid syndrome)

Question 7

How to break bad news?

Answer 7

• quiet room and everyone has a seat. water and tissues. give phone/page to someone else.
• Warning shot, fire
• support person who is it?
  
  • who is driving you home
  • ring airline
  • ring employer
  • make terrible time a little bit better
• bare bones - offer to meet again and someone to be with them
• some point stop talking
• ALWAYS CALL GP

Question 8

How do you deliver a still birth?

Answer 8

• induce usually with prostaglandin
  
  • misoprostol = more potent - earlier
  • less potent for closer term
• appropriate anaesthetic
• try and keep them away from screaming mothers + babies

Question 9

What are the types of abortion? What are some questions you can ask to differentiate?

Answer 9

1. Threatened abortion - any bleeding/pain <20weeks
   
   • vaginal bleeding (spotting)
   • pain (some)
   • with cervical os closed
   • pregnancy loss does not always follow
2. Missed abortion - painless (normal)
   
   • internal os is closed
   • USS - uterus small for dates
   • contents are not viable
3. Inevitable
   
   • vaginal bleeding with crampy pain
   • cervical os open
4. Incomplete abortion
   
   • cervical bleeding +/- pelvic pain
   • some tissue passed
   • contents are retained in uterus
5. Complete abortion
   
   • products are completely removed
   • pain and bleeding finished (hx shows it though)
   • cervical os is closed
6. Septic abortion
   
   • spontaneous abortion accompanied by an intrauterine infection (incomplete with ascending infection)
   • more common following induced abortion

Questions to ask:

• has there been vaginal bleeding? Pain?
• is the internal os open/closed?
• are the uterus contents viable?
• is there a fever?

Question 10

What are some DDx for miscarriage?

Answer 10

• Not pregnant
• Intrauterine pregnancy
  
  • GTD - gestational trophoblastic disease
• ectopic pregnancy
• lower genital tract
  
  • cervical polyp/ca/ectropion
  • vaginal trauma

Question 11

What examination would you include for miscarriage?

Answer 11

• vitals/obs
• heart
• abdominal exam (gentle)
  
  • tenderness - lower abdominal, localised? (ectopic)
  • masses
  • palpate uterus from 12 weeks onwards (dates wrong or something else)
• speculum
  
  • internal os open/closed
• bimanual
  
  • adexal tenderness
  • feeling uterine size.

Question 12

What is the treatment for a miscarriage?

Answer 12

• expectant
  
  • inevitable/incomplete
  • associated with more days of bleeding
  • can take up to 4weeks
• Medical - not offered everywhere
  
  • misoprostol (SL, PV, oral)
  • POC in uterus
  • 80% success
  • significant bleeding
  • SE:
    
    • n/v/d
    • flushing
    • abdo cramps
• Anti-D
  
  • not required if <10weeks
  • <72hrs exposure to foetal blood if mother RH -
• D&C
  
  • 1% perforation rate/repeat procedure
  • under US due to increased risk of uterine rupture
  • IV antibiotics prior for septic miscarriage
• emotional support

Question 13

Acronym for perinatal death classification?

Answer 13

• Growth reduction
• Pre-term
• Congenital abnormality
• HTN
• Infection
• Maternal issues
• Perinatal issues (TTTS, ammonia)
• APH
• Hypoxia