Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Stillbirth

13,606 views

Published on

stillbirth norman meyer uthsc memphis pregnancy ob gyn

Published in: Health & Medicine
  • DOWNLOAD THI5 BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... ACCESS WEBSITE for All Ebooks ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... Download Full EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ACCESS WEBSITE for All Ebooks ......................................................................................................................... Download Full PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... Download EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... Download doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... ,DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/yyxo9sk7 } ......................................................................................................................... ,DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/yyxo9sk7 } ......................................................................................................................... ,DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/yyxo9sk7 } ......................................................................................................................... ,DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/yyxo9sk7 } ......................................................................................................................... ,DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/yyxo9sk7 } ......................................................................................................................... ,DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/yyxo9sk7 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE Format, ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Stillbirth

  1. 1. Stillbirth N.L. Meyer University of Tennessee
  2. 2. Definitions <ul><li>Fetal death </li></ul><ul><ul><li>Death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy 1 </li></ul></ul><ul><li>Delivery of a fetus showing no signs of life </li></ul><ul><ul><li>Absence of breathing, heart beat, umbilical cord pulsations, definitive voluntary movements </li></ul></ul><ul><ul><li>Excludes </li></ul></ul><ul><ul><ul><li>Transient cardiac contractions </li></ul></ul></ul><ul><ul><ul><li>Fleeting respiratory efforts (gasps) </li></ul></ul></ul>1 National Center for Health Statistics
  3. 3. Definitions <ul><li>Not all fetal deaths are stillbirths </li></ul><ul><li>World Health Organization </li></ul><ul><ul><li>Fetal death late in pregnancy </li></ul></ul><ul><ul><li>Allows each country to define gestational age at which fetal death is considered stillbirth </li></ul></ul><ul><ul><ul><li>16 to 28 weeks </li></ul></ul></ul><ul><li>National Center for Health Statistics </li></ul><ul><ul><li>Most states use 20 weeks or a fetal weight of ≥ 350 g or ≥ 500 g </li></ul></ul><ul><ul><li>28 weeks (late stillbirth) </li></ul></ul><ul><li>Tennessee Code Annotated </li></ul><ul><ul><li>Fetal death ≥ 500 g or in the absence of weight, ≥ 22 completed weeks gestation </li></ul></ul>
  4. 4. Incidence <ul><li>> 3 million stillbirths each year worldwide </li></ul><ul><li>2005 rate of 6.2/1000 total births in US </li></ul><ul><li>Rate of early stillbirth has remained stable </li></ul><ul><li>Rate of late fetal loss has decreased by 29% since 1990 </li></ul><ul><li>African Americans have 2x stillbirth rate as Caucasians </li></ul><ul><ul><li>DM, HTN, abruption, PPROM </li></ul></ul>
  5. 5. Urban Child Institute <ul><li>July 2009 report </li></ul><ul><ul><li>Variation in 2006 Infant Mortality in Tennessee </li></ul></ul><ul><li>No universal method for calculating IMR </li></ul><ul><ul><li>Discrepancies in reports may be artificial </li></ul></ul><ul><ul><li>Wide variation in reporting practices among counties </li></ul></ul><ul><li>Suggest Tennessee Office of Vital Records implement criteria to differentiate fetal death vs live birth vs infant death </li></ul><ul><ul><li>American Academy of Pediatrics </li></ul></ul><ul><ul><ul><li>Threshold for live birth 400 gm or 23 weeks </li></ul></ul></ul>
  6. 6. Etiology <ul><li>Unknown in 25 – 60% of cases </li></ul><ul><li>Identifiable causes can be attributed to </li></ul><ul><ul><li>Maternal conditions </li></ul></ul><ul><ul><li>Fetal conditions </li></ul></ul><ul><ul><li>Placental conditions </li></ul></ul>
  7. 7. Maternal Conditions <ul><li>Prolonged pregnancy </li></ul><ul><li>Diabetes (poorly controlled) </li></ul><ul><li>SLE </li></ul><ul><li>APAS </li></ul><ul><li>Infection </li></ul><ul><li>HTN </li></ul><ul><li>Preeclampsia </li></ul><ul><li>Eclampsia </li></ul><ul><li>Hemoglobinopathy </li></ul><ul><li>AMA </li></ul><ul><li>Rh disease </li></ul><ul><li>Uterine rupture </li></ul><ul><li>Maternal trauma or death </li></ul><ul><li>Inherited thrombophilia </li></ul>
  8. 8. Fetal conditions <ul><li>Multiple gestation </li></ul><ul><li>IUGR </li></ul><ul><li>Congenital anomaly </li></ul><ul><li>Genetic abnormality </li></ul><ul><li>Infection </li></ul><ul><li>Hydrops </li></ul>
  9. 9. Placental Conditions <ul><li>Cord accident </li></ul><ul><li>Abruption </li></ul><ul><li>PROM </li></ul><ul><li>Vasa previa </li></ul><ul><li>Fetomaternal hemorrhage </li></ul><ul><li>Placental insufficiency </li></ul>
  10. 10. Maternal Risk Factors Sickle cell disease Multiple gestation Malaria Smoking Poor nutritional status Infection – Parvovirus B19, syphilis, streptococcal infection, listeria Congenital anomalies Hypertensive disease, preeclampsia Hypertensive disease – complications of preeclampsia and eclampsia Medical disease – diabetes, SLE, renal disease, thyroid, cholestasis Infection – syphilis and gram-negative infection Growth restriction/placental anomalies Obstructed prolonged labor and associated asphyxia, infection, injury Congenital and karyotypic anomalies Developing Countries Developed Countries
  11. 11. Risk Factors in Developed Countries <ul><li>Non-Hispanic black race </li></ul><ul><li>Nulliparity </li></ul><ul><li>Advanced maternal age </li></ul><ul><li>Obesity </li></ul>ACOG Practice Bulletin #102 March 2009
  12. 12. Most Frequent Types of Stillbirth According to GA Fretts et al. Ob Gyn 1992;79:35-9 Fretts and Usher. Contem Rev Ob Gyn 1997;9:173-9 Abruptio placenta (12%) Abruptio placenta (18%) Anomalies (14%) Fetal malnutrition (14%) Fetal malnutrition (19%) Abruptio placenta (14%) Unexplained (40%) Unexplained (26%) Infection (19%) 37+ weeks 28 - 37 weeks 24 - 27 weeks
  13. 13. Infection <ul><li>Most common cause of stillbirth 24 – 27 weeks </li></ul><ul><li>Contribution to stillbirth rate is difficult to define </li></ul><ul><li>Some pathogens are clearly causally related </li></ul><ul><ul><li>Parvo B-19 </li></ul></ul><ul><ul><li>CMV </li></ul></ul><ul><ul><li>Toxoplasmosis </li></ul></ul><ul><li>Some are associated with stillbirth but absent evidence of causal relationship </li></ul><ul><ul><li>Ureaplasma urealyticum </li></ul></ul><ul><ul><li>Mycoplasma hominis </li></ul></ul><ul><ul><li>GBS </li></ul></ul><ul><ul><li>Colonization common among healthy women </li></ul></ul>
  14. 14. Infection <ul><li>Most stillbirths occur in premature fetuses </li></ul><ul><ul><li>19% of stillbirths < 28 weeks </li></ul></ul><ul><ul><li>2% of stillbirths at term </li></ul></ul><ul><li>No change despite widespread use of antibiotics </li></ul><ul><li>Viral pathogens are the most common source of hematogenous infection of the placenta </li></ul><ul><ul><li>Fetal death resulting from maternal infection is rare </li></ul></ul><ul><ul><li>Diagnostic criteria are not well defined </li></ul></ul><ul><ul><li>High frequency of asymptomatic maternal colonization </li></ul></ul>
  15. 15. Multiple Gestations <ul><li>19.6 / 1,000 stillbirth rate (4x singletons) </li></ul><ul><li>Complications specific to multiple gestations </li></ul><ul><ul><li>TTTS </li></ul></ul><ul><li>Increased risk of common complications </li></ul><ul><ul><li>AMA </li></ul></ul><ul><ul><li>Fetal anomalies </li></ul></ul><ul><ul><li>Growth restriction </li></ul></ul>
  16. 16. Advanced Maternal Age <ul><li>Lethal congenital and chromosomal anomalies </li></ul><ul><li>Medical complications associated with age </li></ul><ul><ul><li>Multiple gestations </li></ul></ul><ul><ul><li>HTN </li></ul></ul><ul><ul><li>DM </li></ul></ul><ul><li>AMA is an independent risk factor </li></ul><ul><li>Unexplained fetal demise is the only type that is statistically more common (late pregnancy) </li></ul>
  17. 17. Advanced Maternal Age Antepartum vs Intrapartum Maternal age (yrs) Rate per 1000 Saliu et al. J Obstet Gynaecol 2008;34:843
  18. 18. Obesity (BMI ≥ 30) <ul><li>Increased risk </li></ul><ul><li>Behavioral, socioeconomic and obstetric factors </li></ul><ul><ul><li>Smoking, diabetes, preclampsia </li></ul></ul><ul><li>Risk remains even after controlling for above </li></ul><ul><li>Theories </li></ul><ul><ul><li>Perception of fetal movements </li></ul></ul><ul><ul><li>Hyperlipidemia </li></ul></ul><ul><ul><li>Apnea – hypoxia events </li></ul></ul>
  19. 19. Obesity 11 / 1000 ≥ 40 8 / 1000 30 – 39.9 5.5 / 1000 < 30 Stillbirth Rate per 1000 BMI
  20. 20. Chromosomal Abnormalities <ul><li>Abnormal karyotype found in 8 – 13% stillbirths </li></ul><ul><ul><li>> 20% with anatomic abnormalities or growth restriction </li></ul></ul><ul><ul><li>4.6% with normally formed fetuses </li></ul></ul><ul><li>Most common abnormalities </li></ul><ul><ul><li>Monosomy X (23%) </li></ul></ul><ul><ul><li>Trisomy 21 (23%) </li></ul></ul><ul><ul><li>Trisomy 18 (21%) </li></ul></ul><ul><ul><li>Trisomy 13 (8%) </li></ul></ul><ul><li>Karyotypic analysis underestimates risk </li></ul>
  21. 21. Chromosomal Abnormalities Korteweg et al 2008 Ob Gyn 111;865 28% Fetal tissue sampling 85% Amniocentesis / CVS Success Rate Method
  22. 22. Fetal Tissue <ul><li>Umbilical cord – 32.1% </li></ul><ul><li>Fascia lata – 29.9% </li></ul><ul><li>Cartilage – 24.2% </li></ul><ul><li>Fetal blood – 22.2% </li></ul><ul><li>Pericardium – 0% </li></ul><ul><li>Other tissue – 19.2% </li></ul><ul><ul><li>Placenta, skin, unknown </li></ul></ul>
  23. 23. Chromosomal Abnormalities Korteweg et al 2008 Ob Gyn 111;865
  24. 24. Cord Accidents <ul><li>30% of normal pregnancies </li></ul><ul><li>Account for only 2.5% of stillbirths in autopsy case series </li></ul><ul><li>Attribution requires </li></ul><ul><ul><li>Cord occlusion and hypoxic tissue on autopsy </li></ul></ul><ul><ul><li>Exclusion of other causes </li></ul></ul><ul><li>Actual proportion remains uncertain </li></ul>
  25. 25. Thrombophilia <ul><li>Relationship with late fetal death is more consistent than with early losses </li></ul><ul><li>Have been associated with late loss but lack of evidence of causal relationship </li></ul><ul><li>Inconsistent studies </li></ul><ul><ul><li>OR range from 1.8 to 12 </li></ul></ul><ul><li>Thrombophilias are not uncommon </li></ul><ul><ul><li>15 – 25% of Caucasian populations </li></ul></ul>
  26. 26. Thrombophilia <ul><li>Some but not all studies show a relationship with adverse outcomes </li></ul><ul><li>Most are retrospective or case-controlled </li></ul><ul><ul><li>Prospective longitudinal studies are needed </li></ul></ul><ul><li>Inappropriate or no controls </li></ul><ul><li>No evaluation for other causes </li></ul><ul><li>At least one type of thrombophilia is seen in 30% of normal controls </li></ul>
  27. 27. Thrombophilia Gonen R et al. Absence of association of inherited thrombophilia with unexplained third-trimester intrauterine fetal death. AJOG 2005;192:742-6
  28. 28. Evaluation <ul><li>Fetal autopsy </li></ul><ul><ul><li>Single most useful test </li></ul></ul><ul><li>Examination of placenta, cord and membranes </li></ul><ul><li>Karyotype evaluation </li></ul><ul><ul><li>8 – 13% of stillbirths </li></ul></ul><ul><ul><li>Comparative genomic hybridization </li></ul></ul><ul><ul><ul><li>Useful when fetal cells cannot be cultured </li></ul></ul></ul>
  29. 29. Infection <ul><li>Autopsy and histologic evaluation of placenta, membranes, and cord provide best evidence of infectious etiology </li></ul><ul><li>Value of routine cultures and serology is controversial </li></ul><ul><li>Parvovirus serology </li></ul><ul><li>Screening for syphilis </li></ul><ul><li>TORCH titers questionable utility </li></ul><ul><li>Placental culture problematic </li></ul><ul><ul><li>Incidence in live birth is unknown </li></ul></ul><ul><ul><li>DNA test associated with false positives </li></ul></ul>
  30. 30. Hematologic Etiology <ul><li>Fetal – maternal hemorrhage </li></ul><ul><ul><li>Kleihauer-Betke test </li></ul></ul><ul><ul><li>Typically underestimates fetal cell count with large FMH </li></ul></ul><ul><li>Red cell alloimmunization </li></ul><ul><ul><li>Indirect Coombs’ test </li></ul></ul><ul><ul><li>Autopsy and placenta assessment useful </li></ul></ul>
  31. 31. Thrombophilia <ul><li>Routine testing is controversial </li></ul><ul><li>Evidence to support limited testing </li></ul><ul><ul><li>Evidence of placental insufficiency </li></ul></ul><ul><ul><ul><li>IUGR </li></ul></ul></ul><ul><ul><ul><li>Placental infraction </li></ul></ul></ul><ul><ul><li>Recurrent fetal loss </li></ul></ul><ul><ul><li>Personal or family history of thrombosis </li></ul></ul>
  32. 32. Medical Complications <ul><li>Exclude clinically overt diabetes and thyroid dysfunction </li></ul><ul><ul><li>GDM has stillbirth rate similar to normal </li></ul></ul><ul><ul><li>Subclinical thyroid disease has not been proven as cause of still birth </li></ul></ul><ul><li>Screening for subclinical disease is of unproven benefit </li></ul>
  33. 33. Silver et al. Work-up of stillbirth: a review of the evidence. AJOG 2007;196:433-444.
  34. 34. Antepartum Surveillance <ul><li>Little evidence-based data to guide testing with previous unexplained stillbirth </li></ul><ul><ul><li>32 – 34 weeks </li></ul></ul><ul><ul><li>2 – 4 weeks before gestational age of previous still birth </li></ul></ul><ul><li>Most subsequent pregnancies have a favorable outcome </li></ul><ul><li>Increased risk of iatrogenic prematurity </li></ul>
  35. 35. Antepartum Surveillance <ul><li>300 women with previous stillbirth </li></ul><ul><ul><li>49% unexplained </li></ul></ul><ul><li>1 recurrent stillbirth despite reassuring testing </li></ul><ul><ul><li>Perinatal mortality 3.3/1000 </li></ul></ul><ul><li>Earliest delivery associated with a positive test result was 32 weeks </li></ul>Weeks et al. Antepartum surveillance for a history of stillbirth: When to begin. AJOG 1995;172:486-92.
  36. 36. Antepartum Testing Protocol Weeks et al.
  37. 37. <ul><li>Protocol may not be appropriate for all previous stillbirths </li></ul><ul><ul><li>Nonrecurring conditions </li></ul></ul><ul><ul><ul><li>Perinatal infection </li></ul></ul></ul><ul><ul><ul><li>Fetal anomalies </li></ul></ul></ul><ul><ul><ul><li>Maternal trauma </li></ul></ul></ul><ul><ul><li>Stillbirths following OB complications that can recur but cannot be predicted </li></ul></ul><ul><ul><ul><li>Abruption </li></ul></ul></ul><ul><ul><ul><li>Prolapse </li></ul></ul></ul><ul><ul><ul><li>Uterine rupture </li></ul></ul></ul>Antepartum Testing Protocol
  38. 38. ACOG Practice Bulletin #102 <ul><li>Little evidence-based data to guide antepartum surveillance with prior unexplained stillbirth </li></ul><ul><li>Antepartum testing may be initiated at 32 – 34 weeks </li></ul><ul><li>Associated with potential morbidity and costs </li></ul><ul><ul><li>16.3% delivery at or before 39 weeks </li></ul></ul><ul><ul><li>1% delivery before 36 weeks </li></ul></ul>Management of Stillbirth March 2009
  39. 39. ACOG Practice Bulletin #102 <ul><li>Antenatal testing before 37 weeks gestation </li></ul><ul><ul><li>1.5% rate of iatrogenic prematurity for intervention based on false-positive test </li></ul></ul><ul><li>Excess risk of infant mortality due to late preterm birth </li></ul><ul><ul><li>8.8 / 1000 at 32 – 33 weeks gestation </li></ul></ul><ul><ul><li>3 / 1000 at 34 – 36 weeks gestation </li></ul></ul>

×