Slide 1 INVESTIGATION AND ASSESSEMENT OF STILLBIRTHS Dr: Salah Roshdy Professor & Senior Consultant Of Obstetrics & Gynecology Qassim College of Medicine,KSA Sohag University,Egypt
Slide 2 Definition The World Health Organization (WHO) classification of stillbirth is defined as fetal loss in pregnancies beyond 20 weeks of gestation, or, if the gestational age is not known, a birth weight of 500 g or more, which corresponds to 22 weeks of gestation in a normally developing fetus.
Slide 3 Definition The World Health Organization definition of perinatal death is death of the offspring ‘‘occurring during late pregnancy (at 22 completed weeks gestation and over), during childbirth and up to seven completed days of life. ’’ Stillbirths are subclassified as antepartum (ie, the fetus died before the onset of labor) or intrapartum (ie, the fetus died after the onset of labor but before birth).
Slide 4 Definition Neonatal death is subdivided into early (in the first week of life) and late (death in the second to fourth week of life). Although perinatal death strictly excludes late neonatal deaths, most of these deaths are related to obstetric events,
Slide 5 Prevalence Stillbirth is a relatively common, but often completely random occurrence. Based on statistical data, it has been found that the mean stillbirth rate in the United States is approximately 1 in 115 births, which is roughly 26,000 stillbirths each year, or one every 20 minutes. In developing countries where medical care can be substandard or completely unavailable, this rate is much higher.
Slide 6 Prevalence 1 out of 5 African women loses a baby during her lifetime, compared with 1 in 125 in rich countries. Each year nearly 3.3 million babies are stillborn, and more than 4 million others die within 28 days of being born. Newborn deaths now contribute to about 40% of all deaths in children under five years of age globally, and more than half of infant mortality.
Slide 7 Prevalence It is estimated that each year over a million children who survive birth asphyxia develop problems such as cerebral palsy, learning difficulties and other disabilities. Nearly three quarters of all neonatal deaths could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and the postnatal period.
Slide 8 Stillbirth rates 1998 1999 2000 2001 2002 2003 W Mids 5.6 6.3 5.8 5.6 6.3 6.1 E&W 5.3 5.3 5.2 5.3 5.6 5.7 P<0.01 P<0.01 Stillbirth rates in the West Midlands and England & Wales Rate/000 1998-2003 7 6 5 4 3 2 W Mids 1 E& W 0 1998 1999 2000 2001 2002 2003
Slide 9 Total No.of deliveries 8391 Stillbirth 80 (9.53 /1000) Actual rate (4.78/1000) booked Booked outside 40 40
Slide 10 ReCoDe (Relevant Condition at Death) A. Fetal congenital, n-i hydrops, iso-immunisn, feto-mat. hem, infection, TTTS, fetal growth restriction B. Umbilical Cord prolapse, constriction, velament. insertion C. Placenta abruptio, previa, infarction, plac. disease D. Amniotic Fluid chorioamnionitis, severe oligo, polyhydr. E. Uterus rupture, anomalies F. Maternal DM, Th, EHT, PIH. lupus, cholest, drugs G. Intrapartum asphyxia; birth trauma H. Trauma external; iatrogenic I. Unclassified no relevant condn; no info available
Slide 16 Unexplained or unexplored? Percentage of stillbirths remaining unexplained: Ireland 93 (Walsh 1995) Wales (Tuthill 1999) UK (Cesdi 2001) Sweden (Winbo 2001) UK (Gardosi 1998) Australia (Alessandri 1992) New Z (Westgate 1985) UK (Wagaarachchi 2002) UK (Shankar 2002) UK (Yudkin 1987) USA (Ananth 1995) USA (Lammer 1989) France (Goffinet 1996) France (Coujard 1975) Norway (Rasmussen 2003) USA (Brans 1984) USA (Incerpi 1998) Saudi Arabia (Meshle 2001) Australia & NZ (Flenady 2003) Australia (Robson 2001) Canada (Huang 2000) Norway (Frøen 2001) Queensland (Flenady 2003) Denmark (Kesmodel 2002) India (Naidu 2001) Sweden (Ahlenius 1995) Ireland 70ies (Walsh 1995) Sweden (Petersson 2002) 0 10 20 30 40 50 60 70
Slide 17 Common Risk Factors For Stillbirth 1) Race and Socio-ecomonic factors 2) Advanced materanal age multiple pregnancy, hypertension, DM, abruptio placenta. 3) Obesity Macrosomia GDM PET Hyperlipidemia 4) Thrombophilias 5) SLE 6) Medical risk factor 7) Hypertension 8) Infection 9) Multiple pregnancy 10) Infertility
Slide 18 Maternal disease & Risk of Stillbirth All pregnancies 6-7 Hypertensive disorders Chronic hypertension 5-25 Superimposed preeclampsia 52 PIH/mild preeclampsia 9 Severe preeclampsia21 Eclampsia18-48 HELLP syndrome51
Slide 19 Diabetes mellitus Gestational diabetes5-10 Type 1 diabetes6-10 Type 2 diabetes35 Obesity15-20 Systemic lupus erythematosus40-150 Chronic renal disease Mild renal insufficiency15 Moderate and severe renal insufficiency32-200
Slide 21 ALGORITHM FOR ETIOLOGIC INVESTIGATION OF STILL BORN INFANTS STILL BIRTH Step 1 Step 3 Step 4 Maternal & Family Cord Exam History Stillbirth Examination a. Physical Exam Step 5 b. Clinical photographs Placental Exam & Step 2 c. Radiologic studies Investigations Maternal Investigations d. Autopsy (full or partial) e. Consult Step 6 Cytogenic Investigations Information used in Counseling No Abnormalities found: Abnormalities found: Empriric Counseling Specific Counseling
Slide 22 SIX STEPS IN THE ETIOLOGIC INVESTIGATION OF A STILLBIRTH To be done at the time of diagnosis of a stillbirth I. MATERNAL AND FAMILY HISTORY A- Review past obstetric history 1) Emphasize details of previous embryonic/fetal losses.
Slide 23 B-Review history present pregnancy specifically with regard to: 1) Gestational age 2) Fetal growth 3) History of bleeding 4) Elevated blood pressure 5) Recent illness or possible viral exposure 6) Medications during pregnancy 7) Maternal perception of fetal movements in recent past
Slide 24 C-Review of antenatal investigations: 1) Ultrasounds, including amniotic fluid assessments 2) Laboratory investigations 9including all routine antenatal blood work) 3) Prenatal diagnoses (triple screen, amniocentesis, or CVS) 4) Fetal assessment (NT, biophysical profiles, Doppler ultrasound) D-Review Family History
Slide 25 11-MATERNAL INVESTIGATIONS A. Ultrasound, if possible, to evaluate for unknown congential anomalies B. CBC, platelet count C. Kleihauer or equivalent D. Blood group and antibody screen E. HBA1C F. Infectious and Microbiological Investigations to be considered when: Infection is suspected as an etiologic factor Cause of stillbirth is not obvious
Slide 26 1) Maternal serology (IgG and IgM) for a) Parvovirus b) Toxoplasmosis c) Cytomegalovirus 2) Review chart for HIV, syphilis and rubella serology – send IgG and IgM if not previously done as part fo routine antenatal blood work. 3) Maternal blood culture for Listeria 4) Cervical/Vaginal cultures (aerobic)
Slide 27 To be done at the time of diagnosis of a stillbirth III. STILLBIRTH INVESTIGATIONS A. Physical Exam Perform a detailed physical examination of the fetus and placenta. B.Autopsy A full autopsy should be encouraged on all stillbirths. An autopsy is recommended even if cause of death appear obvious. If the parents will not consent to a full autopsy, a limited autopsy should be encourage.
Slide 33 IV. CORD EXAMINATION A. Length in cms B. Number of vessels C. Appearance – thin, thick, meconium, stained, abnormalities D. True knots – loose or tight E. Cord Blood to be drawn- Possible only if a FRESHS stillbirth (*) 1) CBC, Blood group, Direct Antibody Test 2) Cytogenetics if there is evidence of Congenital malformation on ultrasound or seen on examination of the stillbirth
Slide 34 Hydrops Severe IUGR (5th%ile on ultrasound, <3rd %ile birth weight) Amniotic fluid abnormality – severe oligohydramnios or polyhydramnios. Ambiguous genitalia Parental history of a) Repeated miscarriages b) Past unexplained stillbirth c) Past unexplained neonatal demise d) Previous child with congenital anomalies 3) Culture of GBS, Listeria and coliforms if infection is suspected as an etiologic factor or the cause of the stillbirth is not obvious
Slide 35 V. PLACENTA A. Subamniotic swabs for aerobic and anaerobic culture if infection suspected as an etiologic factor or the cause of the stillbirth is not obvious. 1. Swab between the amnion and the chorion B. Placenta and cord to pathology. Check with Pathology lab to determine if placenta should be sent: 1) Fresh 2) In saline 3) In formalin (tissue sample for cytogenetics must be taken before the placenta is fixed in formalin)
Slide 36 Test which can be done after the autopsy/placental pathology, if cause still unknown A. Maternal Antiphospholipid Antibody testing. B. Investigations for thrombophilias, for example: 1) Factor v lEIDEN 2) Protein S deficiency 3) Protein C deficiency 4) Antethrombin deficiency 5) Hyperhomocysteinemia C. If suspicious – TB skintest of mother 1) Further TB workup if positive
Slide 37 VI. CYTOGENETIC STUDIES A. Cord blood and placental chorion and amnion samples should be taken immediately after delivery on all stillbirths and sent for cytogenetic studies if: 1) The pathologist or clinician feels cytogenetic studies should be completed 2) As cord exam. B. If there is a specific concern about inheritable metabolic disease, portions of the placental villi should be submitted in cytogenetic culture media in order to establish cell cultures for possible furhter studies.
Slide 38 Checklist tool for the investigation of a Stillbirth A-When a stillbirth is diagnosed the following information should be collected if possible 1-Is the BC Antenatal record completed and available for review? a) Gestational age confirmed by early ultrasound (<20 weeks) b) Past obstetrical history completed c) Medication use in pregnancy documented d) Blood pressures recorded
Slide 39 2-Has the woman has been asked the following questions; a) When was the last time she fetl fetal movement? b) Has there been any recent vaginal bleeding? c) Has there been any vaginal fluid loss? d) Any history of possible viral infection in the pregnancy.
Slide 40 3-Are the following investigations on the chart with results? a) Previous ultrasound reports? b)Routine antenatal blood work? c) Any prenatal diagnostic tests (Triple screen, amniocentesis, CVS, etc.)? d)Any recent antenatal fetal monitoring.
Slide 41 4-Have the following investigations been organzied following the diagnosis of the stillbirth? a) Ultrasound tolook for potential cause? b) CBC, PLATELET COUNTS? c) Kleihauer or equivalent? d) Maternal blood group and antibody screen? e) HbA1C or result of 50g glucose screen or GTT?
Slide 42 F) Infectious and microbiological investigations if indicated A. Maternal serology for: Parvovirus Toxoplasmosis Cytomegalovirus B. Maternal serology available for: HIV Syphilis Rubella C. Maternal blood culture for Listeria D. Cervical/vaginal culture
Slide 43 B-After the stillbirth has been delivered the following information should be collected if possible: 1. Gross physical examination of the stillbirth? 2. Autopsy Full autopsy consented to? (encourage for all stillbirths if possible) Limited autopsy consented to? a) External examination by Pathologist? Gross examination for evidence of meconium?
Slide 44 b) Clinical photographs? c) Radiographic studies? d) Limited tissue biopsies? Skin/tendon for cytogenetics Liver for infection or storage disorders? Sampling of all organs, including the CNS? Sampling of organs outside the CNS?
Slide 45 3-Clinical examination of the umbilical cord 4- Examination of the placenta. C-Information that can be collected if the cause of the stillbirth remains unknown after the above investigations are completed. 1. Maternal Antiphospholipid Antibody screening? 2. Investigations for other thrombophilias if indicated? 3. TB skin test of mother if suspicious (further work-up if positive?
Slide 47 Clinical external stillbirth examination at the time of delivery 1-General - Global evaluation of the following parameters: A. State of preservation: fresh or macerated (degree of maceration); intact delivery or interventions required to effect delivery. B. Weight; gestational age; size for gestational age C. Measurements: circumference of head, chest and abdomen; lengths of crown- heel (with leg fully extended), crown- rump and foot. D. Colour: vernix white or meconium stained; any lesions of skin such as vesicles, bruising.
Slide 48 11-Craniofacial A. General impression of normality or abnormality B. Quantitative relationships: As craniofacial height is roughly equal to the cranial vault height, abnormalities in the ratio indicate microcephaly or hydrocephaly As the intercanthic distance is roughly equal to the orbit width, an abnormal ratio suggests hypo/hypertelorism. Abnormal ear location - normally external meatus lies above level of nostrils and long axis of the ear is nearly vertical. C. Specific structural defects Anterior - flat nasal bridge; short flat nose; small eyes; epicanthal folds; cleft lip (uni/bilateral or median); cleft palate; small mouth; down turning angles of mouth; glossoptosis and retro/prognathism Posterior - anencephaly, iniencephaly and encephalocele (usually occipital)
Slide 49 III. Neck A. Abnormally short B. Thickened nuchal fold and cystic hygroma C. Cervical rachischisis and meningomyelocele IV. Trunck A. Overview - presence of edema; abdominal distention and muscular development B. Specific defects - Ventral - omphalocele; umbilical hernia; gastroschisis; diastasis recti and rune belly Dorsall - rachischisis; meningocele and meningmyelocele Cord insertion - normal location; number of vessels and juxtrafetal cord coarctationw ith abnormally thin umbilical ring. External genitalia - absent; ambiguous and small or enlarged structures (penis, scrotum, clitoris, labia, vagina) Anus - patency; imperforate; stenotic and displaced interiorly
Slide 50 1V-Extremities A. General - normal/abnormal lenth; shortenignof particular segment and muscle development. B. Specific Defects – Upper - distortions; amputations; finger lengths; shape and size; poly/syndactyly and abnormal palmar creases Lower - positional abnormalities of feet, toe lengths, shape and size; increased sandal space; poly/syndactyly and rockers-bottom deformity.
Slide 51 The Autopsy Clinical Photographs of Stillbirths Cytogenetic studies in stillbirth investigations
Slide 52 Screening Options for Growth Restriction Ultrasound Accurate dating (LMP, OCCP, Lactating) Early dating scan DO NOT CHANGE the EDD Serial scans Growth Charts, and curves Doppler AFI / BPP
Slide 53 Planning intervention Identify high risk groups Increased level of surveillance (fetal and placental Doppler ultrasound) Elective delivery if surveillance indicates fetal compromise or pregnancy reaches given threshold of gestation – Previous SB at 38 weeks – IDDM at 39 weeks – Post-dates pregnancy at term + 10 days
Slide 54 Predicting risk High risk groups already identified – IDDM – Previous SB – Connective tissue disease Problem: most stillbirths occur to “low risk” women Solution: identify factors associated with an increased risk of stillbirth
Slide 55 Where to start? Majority of stillbirths have a placental cause – Abruption – Pre-eclampsia – IUGR In the absence of overt risk factors, may be able to identify high risk women within a low risk population by screening tests of placental function
Slide 56 Labor and delivery When the diagnosis of growth restriction is made AFI Normal Oligohydramnios At > 36-37 weeks At> 34- 36 weeks OR Assess Bishop’s score If Documented FLM Adequate Deliver
Slide 57 Protocol for Placental and Cord Evaluation GROSS ASSESSMENT Weight (trimmed) ________g. Placental weight:Fetal weight ratio ________ContourSize ________cm x ________cmPresence of Accessory Lobes Y NInsertion of Cord CentralEccentric Marginal VelamentousMembranesMembranes ruptured ________cm from the margin.Membrane insertion NormalMarginal Circum-marginate CircumvallateMembrane character NormalAbnormal Meconium stained Blood stained Other ______________________Placental discColor Red Brown Green Pale Other___________________________Odor Normal FoulFeaturesBlood clot of maternal surface _________________________ Thrombi of fetal surface ______________________________ Fibrin(oid) deposition ________________________________ estimated percentage of surface involved ____% Infarction _________________________________________ estimated percentage of volume involved _____% Other_____________________________________________CordLength _______cm Diameter_______cm Number of vessels _______FeaturesTrue knot(s) ________________________________________ False knot(s) ________________________________________ Torsion/twisting _____________________________________ Engorgement ________________________________________ Narrowing/constriction ________________________________ location ______________________________________ Abnormal Whartons jelly ______________________________ _____________________________________________If Twins:Membrane ConfigurationMonochorionic-Monoamniotic Monochorionic-Diamniotic Dichorionic-DiamnioticPlacental VesselsAnastomotic vessels evident by gross inspection Anastomotic vessels demonstrated by injection/perfusionHISTOLOGIC ASSESSMENTSections should be obtained as follows:1. Cross section of umbilical cord 1b. Cross section just proximal to and just distal to any apparent cord constriction or cord stricture 2. Amniochorionic membrane roll 3. Fetal side placenta 4. Basal placenta 5. Sampling of any apparent abnormalities.Reporting should include general description of each section and description (including severity and extent) ofInflammationChorioamnionitis ______________________________________________Cord Vasculitis _______________________________________________Funisitis ____________________________________________________Villitis ______________________________________________________Infarction __________________________________________________________Calcification(s) ______________________________________________________Fibrin Deposition ____________________________________________________Other ________________________________________________________________________________________________ _________________________Placental and Cord Examination WiSSP home page
Slide 58 CLINICAL EXAMINATION OF STILLBORN INFANT [Clinical description is often critical in the etiologic evaluation of stillborns. Yet it is often given less attention than it deserves in most formal postmortem evaluations. This is a suggested, simple and relatively non-jargon filled outline for such a clinical evaluation; it also includes space to provide brief notation of relevant prenatal, perinatal and family history.] I. General InformationDate ____ ____ ____ Babys Name____________________Mothers Name____________________ Fathers Name____________________Hospital____________________P arents Address____________________Attending Physician___________________ Person performing this evaluation ________________________ II. Brief History Prior Pregnancy History -- Pregnancies____Deliveries____Liveborn____ Spont. Ab. ____Ind. Ab.____Prior Stillborns____Relevant maternal history and health [e.g. diabetes, hypertension, thyroid disease, etc.] ____________________________________________________ ____________ Significant problems in this pregnancy ________________________ ____________________________________________________ ____________ Relevant family history [if not supplied in other records] ________________________
Slide 59 III. General Data on Baby Gestational age:____weeks; How determined -- dates ultrasound clinical exam other Degree of Maceration: ____Fresh; no skin peeling ____Slight; focal minimal skin slippage ____Mild; some skin sloughing, moderate skin slippage ____Moderate; much skin sloughing but no secondary compressive changes or decomposition ___Marked, advanced IV. Measurements Crown-heel [stretched] ______ Weight ______ Head Circumference ______ V. Head and Face Head is -- collapsed_____ Anencephalic____ Apparently hydrocephalic_____ abnormally shaped_____; describe ____________________ relatively normal_____ check for and describe any: scalp defects_____ ;________________________________________ cranial masses_____ ;________________________________________ Eyes -- normal_____; sunken_____; prominent_____; abnormally far apart_____; abnormally close together____; straight____;upslanting [V]____; or downslanting [/]___ on opening the lids the following is found -- eyelids are fused____ globes appear normal_____ globes are apparently absent____ eyes seem extremely small____ eyes seem extremely large____ opacities are present____ of the corneas____ of the lenses____ other________________________________________ Nose
Slide 60 Nose -- normal____; abnormally small____; abnormally large____; asymmetric____ nostrils are: apparently patent____; obstructed____; Single nostril only____ other ________________________________________ Mouth -- size: normal____; large____; small____ upper lip: intact____; cleft____; if cleft give location of cleft-- Left__, Right__, Bilateral__, Midline__ palate: intact____; cleft____ mandible: normal___; very small____; asymmetric____ other ________________________________________ Ears -- normal____; abnormal in form____; if abnormal describe or draw -- lowset____; posteriorly rotated____; preauricular tags___; preauricular pits____ other ________________________________________ VI. Neck normal____; short____; excess or redundant skin____; cystic mass [hygroma]____ other ________________________________________
Slide 61 VII. Chest normal____; asymmetric____; small and constricted____; barrelled____ other ________________________________________ VIII. Abdomen normal____; flattened____; distended____; wall defects____ [omphalocele____; gastroschisis____; hernia____] umbilical cord -- number of vessels____ clinical abnormality [describe] other ________________________________________ IX. Back normal____; spina bifida____ [level of defect_____]; scoliosis____; kyphosis____ other ________________________________________ X. Limbs length: normal____; short____; long____ if short, what segment(s) seem short form: normal____; asymmetric____; have missing parts____ describe any asymmetry or missing parts position: normal____; clubfoot____; other positional abnormality____ describe if abnormal ________________________________________
Slide 62 Xa. Hands normal appearing____; abnormal____ if abnormal, describe fingers -- numbers present ___+___ [if not 5+5, describe ] unusual form of fingers ____; describe unusual position of fingers____; describe abnormal webbing or syndactyly____; describe Xb. Feet normal appearing____; abnormal____ if abnormal, describe toes -- numbers present___+___ [if not 5+5, describe ] abnormal spacing of toes____; describe XI. Genitalia Anus -- normal____; imperforate____; other Male -- penis -- normal___; hypospadias___[level of opening_________]; very small____; chordee____ other ________________________________________ scrotum -- normal____; abnormal____[describe ] testes -- descended____; undescended____ other ________________________________________ Female -- urethral opening -- present____; absent/unidentifiable____ vaginal introitus -- present____; absent____ clitoris -- normal____; enlarged____; unidentifiable____ other ________________________________________ Ambiguous____; Describe
Slide 63 Classification of perinatal death 1. non-preventable: All the following criteria have to apply for a death to be classified as non-preventable: a) prenatal care and fetal surveillance were adequate and appropriate. b) Intervention was available, accessible, appropriate and timely. c) Circumstances surrounding a death were not preventable.
Slide 64 2. Possibly preventable unrecognized but detectable fetal or newborn compromised: Not detected or not appreciate. Inappropriate, inadequate or untimely intervention. 3. Ideally preventable A sudden, compromising event for the fetus or newborn where intervention was not possible on this
Slide 66 Facts and figures from The World Health Report 2005 • “Children are the future of society and their mothers are guardians of that future. • Yet this year, almost 11 million children under five years of age will die from causes that are largely preventable. • Among them are 4 million babies who will not survive the first month of life. • On top of that 3.3 million babies will be stillborn. • At the same time, about half a million women will die in pregnancy, childbirth or soon after.” The World Health Report 2005