Stillbirth prof.salah roshdy

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Stillbirth prof.salah roshdy

  1. 1. Work-Up of StillbirthAn Evidence Review Salah Roshdy,MD Professor of Obstetrics & Gynecology Qassim College of Medicine,KSA Sohag University , Egypt
  2. 2. Definitions• Fetal death • Death prior to the complete expulsion of a product of human conception, irrespective of the duration of pregnancy .1• Delivery of a fetus showing no signs of life • Absence of breathing, heart beat, umbilical cord pulsations, definitive voluntary movements 1National Center for Health Statistics
  3. 3. Definition and Incidence• Birth of a baby who shows no evidence of life • Heartbeat or breathing• Definition varies from place to place • In Australia from 20w or 400g • WHO 500g- 22 w • In the UK from 24w • >350g in some states of US• Rate varies from 5 per 1000 resource rich countries to 32 per 1000 in South Asia & Sub-Saharan Africa
  4. 4. Incidence• > 3 million stillbirths each year worldwide• 2007 rate of 6-7/1000 total births in US• Rate of early stillbirth has remained stable• Rate of late fetal loss has decreased by 29% since 1990• African Americans have 2x stillbirth rate as Caucasians •DM, HTN, abruption, PPROM
  5. 5. Types of Stillbirth• Macerated stillbirth •Skin peeling implies that intrauterine fetal death has occurred >24 hours prior to delivery• Fresh stillbirth •Implies that fetal death occurred after the onset of labour and is perhaps a reflection of intrapartum care •Better referred to as intrapartum death
  6. 6. Diagnosis of Stillbirth• Absence of fetal movements is the usual symptom• Diagnosis requires real-time ultrasound • Which should be available at all times • Diagnosis based on absence of fetal heart motion will be wrong up to 20% of the time • Both false positives and false negatives can occur • Scalp clip ECG is a dramatic example• Some mothers feel passive fetal movements • So repeat ultrasound may be required• May require colour Doppler in some cases • Severe oligohydramnios • Gross obesity • Spalding’s sign & intrafetal gas sometimes
  7. 7. Work-Up of StillbirthAn Evidence Review
  8. 8. Etiology• Unknown in 25 – 60% of cases• Identifiable causes can be attributed to •Maternal conditions •Fetal conditions •Placental conditions
  9. 9. Maternal Conditions• Prolonged pregnancy • Eclampsia• Diabetes (poorly controlled) • Hemoglobinopathy• SLE • Rh disease• APAS • Uterine rupture• Infection • Maternal trauma or death• HTN • Inherited thrombophilia• Preeclampsia
  10. 10. Fetal conditions• Multiple gestation• IUGR• Congenital anomaly• Genetic abnormality• Infection• Hydrops
  11. 11. Placental Conditions• Cord accident• Abruption• PROM• Vasa previa• Fetomaternal hemorrhage• Placental insufficiency
  12. 12. Maternal Risk FactorsDeveloped Countries Developing Countries Obstructed prolonged labor andCongenital and karyotypic anomalies associated asphyxia, infection, injury Infection – syphilis and gram-negativeGrowth restriction/placental anomalies infectionMedical disease – diabetes, SLE, renal Hypertensive disease – complications ofdisease, thyroid, cholestasis preeclampsia and eclampsiaHypertensive disease, preeclampsia Congenital anomaliesInfection – Parvovirus B19, syphilis, Poor nutritional statusGBS, listeriaSmoking MalariaMultiple gestation Sickle cell disease
  13. 13. Risk Factors in Developed Countries• Non-Hispanic black race• Nulliparity• Advanced maternal age• Obesity ACOG Practice Bulletin #102 March 2009
  14. 14. Most Frequent Types of Stillbirth According to GA 24 - 27 weeks 28 - 37 weeks 37+ weeksInfection (19%) Unexplained (26%) Unexplained (40%)Abruptio placenta Fetal malnutrition Fetal malnutrition (14%) (19%) (14%)Anomalies (14%) Abruptio placenta Abruptio placenta (18%) (12%) Fretts and Usher. Contem Rev Ob Gyn 1997;9:173-9
  15. 15. Infection• Most common cause of stillbirth 24 – 27 weeks• Contribution to stillbirth rate is difficult to define• Some pathogens are clearly causally related • Parvo B-19 • CMV • Toxoplasmosis• Some are associated with stillbirth but absent evidence of causal relationship • Ureaplasma urealyticum • Mycoplasma hominis • GBS
  16. 16. Infection• Most stillbirths occur in premature fetuses • 19% of stillbirths < 28 weeks • 2% of stillbirths at term• No change despite widespread use of antibiotics• Viral pathogens are the most common source of hematogenous infection of the placenta • Fetal death resulting from maternal infection is rare • Diagnostic criteria are not well defined
  17. 17. Multiple Gestations• 19.6 / 1,000 stillbirth rate (4x singletons)• Complications specific to multiple gestations •TTTS• Increased risk of common complications• Placental abruption •Fetal anomalies •Growth restriction • PET Cord accident
  18. 18. Advanced Maternal Age• Lethal congenital and chromosomal anomalies• Medical complications associated with age •Multiple gestations •HTN •DM• Unexplained fetal demise is the only type that is statistically more common (late pregnancy)
  19. 19. Advanced Maternal Age Antepartum vs Intrapartum 12 10.5 10 9.3 8Rate per 1000 6.3 Stillbirth 6 5.3 Antepartum Intrapartum 4.4 4.4 4 3.6 3.6 3.7 3.2 2 1 1.2 0.8 0.6 0.6 0 20 - 24 25 - 29 30 - 34 35 - 39 > 40 Maternal age (yrs) Saliu et al. J Obstet Gynaecol 2008;34:843
  20. 20. Obesity (BMI ≥ 30)• Increased risk• Behavioral, socioeconomic and obstetric factors • Smoking, diabetes, preeclampsia• Risk remains even after controlling for above• Theories • Perception of fetal movements • Hyperlipidemia • Apnea – hypoxia events
  21. 21. Obesity BMI Stillbirth Rate per 1000 < 30 5.5 / 100030 – 39.9 8 / 1000 ≥ 40 11 / 1000
  22. 22. Chromosomal Abnormalities• Abnormal karyotype found in 8 – 13% stillbirths • > 20% with anatomic abnormalities or growth restriction • 4.6% with normally formed fetuses• Most common abnormalities • Monosomy X (23%) • Trisomy 21 (23%) • Trisomy 18 (21%) • Trisomy 13 (8%)• Karyotypic analysis underestimates risk
  23. 23. Chromosomal AbnormalitiesMethod Success RateAmniocentesis / CVS 85%Fetal tissue sampling 28% Korteweg et al 2008 Ob Gyn 111;865
  24. 24. Fetal Tissue• Umbilical cord – 32.1%• Fascia lata – 29.9%• Cartilage – 24.2%• Fetal blood – 22.2%• Pericardium – 0%• Other tissue – 19.2% •Placenta, skin, unknown
  25. 25. Chromosomal Abnormalities Korteweg et al 2008 Ob Gyn 111;865
  26. 26. Cord Accidents• 30% of normal pregnancies• Account for only 2.5% of stillbirths in autopsy case series• Attribution requires •Cord occlusion and hypoxic tissue on autopsy •Exclusion of other causes• Actual proportion remains uncertain
  27. 27. Thrombophilia• Relationship with late fetal death is more consistent than with early losses• Have been associated with late loss but lack of evidence of causal relationship• Inconsistent studies • OR range from 1.8 to 12• Thrombophilias are not uncommon • 15 – 25% of Caucasian populations
  28. 28. Thrombophilia• Some but not all studies show a relationship with adverse outcomes• Most are retrospective or case-controlled •Prospective longitudinal studies are needed• Inappropriate or no controls• No evaluation for other causes• At least one type of thrombophilia is seen in 30% of normal controls
  29. 29. ThrombophiliaGonen R et al. Absence of association of inherited thrombophiliawith unexplained third-trimester intrauterine fetal death. AJOG2005;192:742-6
  30. 30. Types• Wigglesworth classification• Aberdeen• ReCoDe• Fetal neonatal classification
  31. 31. ReCoDe• Relevant Condition at Death• Advantage-this system reduces the proportion of stillbirths currently categorised as unexplained.
  32. 32. ReCoDeCatergories Group A-Fetus Group B-Umbilical cord Group C-Placenta Group D-Amniotic fluid Group E-Uterus Group F-Mother Group G-Intrapartum Group H-Trauma Group I-unclassified
  33. 33. Group A-Fetus Group A-Fetus 2.infection1.lethal congenital abnormality 2.1 acute 2.2 chronic 3.non-immune hydrops 4.isoimmunisation 5.fetomaternal haemorrhage 6.GROWTH RESTRICTION 7.FETAL GROWTH RESTRICTION
  34. 34. Group B-UMBILICAL CORD B-UMBILICAL CORD 1-PROPLAPSE 2-CONSTRICTING LOOP OR KNOT 3-VELAMENTOUS INSERTION 4-OTHER
  35. 35. Group C-PLACENTAC-PLACENTA 1-ABRUTIO 2-PRAEVIA 3-VASA PRAEAVI 4-Other placental insuffiency 5-Other
  36. 36. Group D-amniotic fluidD-amniotic fluid 1-chorioamnionitis 2-oilgohydramnios 3-polyhrdramnios 4-other
  37. 37. Group E-UterusE-Uterus 1-rupture 2-uterine anomalies 3-other
  38. 38. Group F-motherMother 1-diabetes 2-thyroid disorders 3-essential hypertension 4-hypertensive diseases in pregnancy 5-lupus or antiphospolipid syndrome 6-cholestasis 7-drug misuse 8-other
  39. 39. Group G-IntrapartumG-Intrapartum 1-asphyxia 2-Birth trauma
  40. 40. Group H-traumaH-trauma 1-External 2-iatrogenic
  41. 41. Group I-unclassified I-unclassified 1-no relevant condition identified 2-no information available
  42. 42. Wigglesworth Classification• Pathophysiological approach• Category 1 Congenital defect/malformation (lethal or severe): • Only lethal or potentially lethal congenital malformation should be included here.• Category 2Unexplained antepartum fetal death:
  43. 43. EXTENDED WIGGLESWORTH CLASSIFICATION• Category 3’ Death from intrapartum ‘asphyxia’, ‘anoxia or ‘trauma’: •This category covers any baby who would have survived but for some catastrophe occurring during labour. •These babies will tend to be • normally formed, stillborn • or with poor Apgar scores, • possible meconium aspiration • or evidence of acidosis.
  44. 44. EXTENDED WIGGLESWORTH CLASSIFICATION• Category 4 Immaturity: •This applies to live births only, •who subsequently die from •structural pulmonary immaturity, •surfactant deficiency, • intra ventricular haemorrhage, • or their late consequences - including chronic lung damage.
  45. 45. EXTENDED WIGGLESWORTH CLASSIFICATION• Category 5 Infection: • This applies where there is clear microbiological evidence of infection that could have caused death e.g. maternal infection with G B S, rubella, parvovirus B19, syphilis etc
  46. 46. EXTENDED WIGGLESWORTH CLASSIFICATION• :Category 6 Other specific causes • Use this if there is a specific recognisable • fetal, • neonatal or • paediatric condition not covered under the earlier categories. • Examples include: (1) fetal conditions; twin-to-twin transfusion and hydrops fetalis; (2) neonatal conditions; • pulmonary haemorrhage, • pulmonary hypoplasia (3) paediatric conditions; malignancy acute abdominal catastrophe ( volvulus )
  47. 47. EXTENDED WIGGLESWORTH CLASSIFICATION• Category 7 :• Accident or non-intra partum trauma:• Category 8 :• Sudden infant death, cause unknown:• Category 9 :• Unclassifiable: To be used as a last resort. Details must be given if this option is ticked
  48. 48. Evaluation
  49. 49. Evaluation• Fetal autopsy • Single most useful test• Examination of placenta, cord and membranes• Karyotype evaluation • 8 – 13% of stillbirths • Comparative genomic hybridization • Useful when fetal cells cannot be cultured
  50. 50. Infection• Autopsy and histologic evaluation of placenta, membranes, and cord provide best evidence of infectious etiology• Value of routine cultures and serology is controversial• Parvovirus serology• Screening for syphilis• TORCH titers questionable utility• Placental culture problematic • Incidence in live birth is unknown • DNA test associated with false positives
  51. 51. Hematologic Etiology• Fetal – maternal hemorrhage •Kleihauer-Betke test •Typically underestimates fetal cell count with large FMH• Red cell alloimmunization •Indirect Coombs’ test •Autopsy and placenta assessment useful
  52. 52. Thrombophilia• Routine testing is controversial• Evidence to support limited testing •Evidence of placental insufficiency •IUGR •Placental infraction •Recurrent fetal loss •Personal or family history of thrombosis
  53. 53. Medical Complications• Exclude clinically overt diabetes and thyroid dysfunction •GDM has stillbirth rate similar to normal •Subclinical thyroid disease has not been proven as cause of still birth• Screening for subclinical disease is of unproven benefit
  54. 54. Ante partum Surveillance• Little evidence-based data to guide testing with previous unexplained stillbirth •32 – 34 weeks •2 – 4 weeks before gestational age of previous still birth• Most subsequent pregnancies have a favorable outcome• Increased risk of iatrogenic prematurity
  55. 55. Antepartum Testing Protocol Weeks et al.
  56. 56. Antepartum Testing Protocol• Protocol may not be appropriate for all previous stillbirths •Nonrecurring conditions •Perinatal infection •Fetal anomalies •Maternal trauma •Stillbirths following OB complications that can recur but cannot be predicted •Abruption •Prolapse •Uterine rupture
  57. 57. ACOG Practice Management of Stillbirth March 2009• Little evidence-based data to guide antepartum surveillance with prior unexplained stillbirth• Antepartum testing may be initiated at 32 – 34 weeks• Associated with potential morbidity and costs •16.3% delivery at or before 39 weeks •1% delivery before 36 weeks
  58. 58. ACOG Practice• Antenatal testing before 37 weeks gestation •1.5% rate of iatrogenic prematurity for intervention based on false-positive test• Excess risk of infant mortality due to late preterm birth •8.8 / 1000 at 32 – 33 weeks gestation •3 / 1000 at 34 – 36 weeks gestation
  59. 59. Silver et al. Work-up of stillbirth: a review of the evidence. AJOG 2007;196:433-444.
  60. 60. Pregnancy after Stillbirth• Early booking & careful dating• Obstetric consultation• Screen for gestational diabetes• Monitor fetal growth if previous loss was associated with IUGR• Large studies indicate an increased risk of stillbirth ≈12-fold independent of known recurrent causes• Timing of delivery needs to take into account • Risks to the baby • Potential mode of delivery • The time of the previous fetal loss • The wishes of the patient
  61. 61. Prevention• Early prenatal care • Improve awareness and management of• Screen for decreased fetal congenital movement anomalies • Individualize risk• Optimize health, assessment late in weight gain pregnancy, include• Reduce multiples race, age, obesity, parity on treating a women when she is “post-dates”
  62. 62. THANK YOU

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