Care in Pregnancies Subsequent to Stillbirth or Perinatal Death

1. Care in pregnancies subsequent to
stillbirth or perinatal death
Presentor: Dr. Marcus
Supervisor: Dr. Voon H.Y

2. Pretest
1. What is the definition of stillbirth
a. Baby born with no signs of life in second trimester
b. Baby born with no signs of life after 22 weeks of gestation
c. Baby born with no signs of life after 24 weeks of gestation
d. Baby born with no signs of life as long as birth weight > 500g

3. 2. What is the most common cause of stillbirth?
1. SGA
2. FGR
3. Placenta related abnormalities
4. Unknown
5. Chromosomal abnormalities

4. 3. In the following placenta abnormalities, which type has the highest risk of
recurrence?
a. Maternal vascular malperfusion
b. Fetal vascular malperfusion
c. Chorioamnionitis
d. Villitis of unknown etiology
e. Chronic histiocytic intervillositis

5. 3. In the following placenta abnormalities, which type has the highest risk of
recurrence?
a. Maternal vascular malperfusion 25%
b. Fetal vascular malperfusion
c. Chorioamnionitis 25%
d. Villitis of unknown etiology 25-50%
e. Chronic histiocytic intervillositis 75-90%

6. What is stillbirth
• UK: baby delivered with no signs of life after 24 completed weeks of
pregnancy
• Rate of stillbirth reduction has remain beneath of infant or maternal
mortality rates
• How to reduce the stillbirth rates? To IDENTIFY pregnancies with risk
factors and increase SURVEILLANCE and directed INTERVENTION to
mitigate the additional risks

7. Outline
1. Risk factors
2. Complications
3. Causes and Investigation
4. Placenta histology
5. Care in subsequent pregnancy

8. Risk factors?
1. Fetal growth restriction OR 3.9
2. Advanced maternal age OR 2.9
3. Diabetes mellitus OR 2.9
4. Previous stillbirth OR 2.6
5. Essential hypertension OR 2.6
6. Pre-eclampsia OR 1.6
7. Post term pregnancy > 42 weeks OR 1.3
8. Smoking OR 1.4

9. Complications in subsequent pregnancy
• Preeclampsia OR 3.1
• Placenta adruptio OR 9.4
• LBW OR 2.8
• Intervention at delivery OR 3.2
** many of the association pathologies are associated with abnormal
placentation (39.6%)

10. Causes
Antepartum cause
Congenital malformation
Congenital fetal infection
Antepartum hemorrhage
Maternal disease : DM,
Hypertension
Intrapartum cause
Placenta abruption
Maternal or fetal
infection
Cord prolapse
Uterine rupture
Transplacenta infection
TORCHES
Listeriosis
Parvovirus B19

11. Investigation – to identify the cause

15. • In GTG unknown cause : 50% ,
• But after inclusion of placenta histology, it reduces the number of stillbirths
classified as unexplained
• In CoDAC reported :
34.6% unknown
31.8% placenta problems
9.2% congenital anomalies
1.8% intrapartum complications
IMPORTANCE OF PLACENTA HISTOLOGY!!

16. Most valuable investigations
• Placental examination – 95%
• Postmortem examination – 72%
• Cytogenetic analysis –29%
Most important is proper counselling

17. Some information placenta histopathological
abnormalities and poor perinatal outcomes
• When placenta examination is essential?
Stillbirth (antepartum or intrapartum)
Late miscarriage
Severe fetal distress requiring admission to neonatal unit
Prematurity < 30 weeks
FGR (<3rd centile)
Fetal hydrops
Maternal pyrexia > 38 degree

18. • When is optional?
Prematurity 30-36 weeks
Placenta abruption
Fetal congenital malformation
Rhesus isoimmunization
Morbidly adherent placenta
Abnormal placenta shape
Two vessels cord
Prolonged leaking > 3t6 hours
GDM
GBS
Pre-eclampsia
Maternal coagulopathy

19. Right way to store and send
• Store placenta at 4 degree celcius in tightly sealed container
• Placenta must not be frozen
• Send to laboratory in fresh state and whole placenta
• Formalin fixation is indicated if there is likely to be a delay in undertaking
examination or when refrigerated storage is not available

20. Basic physiology……
Placenta development & villous
formation

21. D1-8: blastocyst
formation
D8-13 Lacunar stage Chorionic plate

22. Day 13-28 post conception

23. 1st trimester
Mesenchymal villi

24. 2nd trimester
Intermediate villi & Stem villi

25. 3rd trimester
Mature intermediate villi and
terminal villi

26. At the end
20 - 25%
25%
45%
5%

27. Placenta lesions associated with stillbirth
What is normal?
-villi are well vascularized
with numerous
vasculosyncytial membranes
on the terminal villi

28. Types
1. Maternal vascular malperfusion
2. Fetal vascular malperfusion
3. Delay villous maturation
4. Immune inflammatory lesions
5. Ascending uterine infections

29. 1. Maternal vascular malperfusion
• Result of abnormal spiral artery blood flow associated with maternal
condition (eg: Pre-eclampsia)
• Distal villous hypoplasia (a.k.a terminal villus deficiency) associated with
post-placenta hypoxia and fetal growth restriction with absent or reverse
EDF

30. Agglutinated villi
Increased syncytial knots
Distal villous hypoplasia
infarcts

31. 2. Fetal vascular malperfusion
• a.k.a fetal thrombotic vasculopathy (FTV)
• Etilogy:
1. Hypercoagulable state caused by fetal polycythemia or maternal
thrombophilia
2. Endothelial cell injury caused by true knot, abnormal cord insertion
3. Blood flow stasis by cord entanglement or stricture
• Blood vessel atrophy caused by occlusive thrombus, the villi will be avascular

32. Thrombosed fetal vessels
Usually is focal and
clearly demarcated from
an adjacent normal villous
structure

33. 3. Delay villous maturation
• A.k.a villous dysmaturity
• Usually associated with maternal diabetes (80%)

34. Enlarged terminal villi
Increased number of capillaries
and macrophages

35. 4. Immune inflammatory lesions
• A.k.a villitis of unknow etiology (VUE)
• Chronic inflammation with destructive T cell infiltration into chorionic villi
• HPE: chronic villitis or intervillositis
• If chronic, 75-90% recurrence risk
• Associated with FGR , recurrent pregnancy loss

36. 5. Ascending uterine infection
• Chorioamnionitis
• Redline et al. classified into:
1. Grade 1 (mild to moderate) – individual or small clusters of maternal
neutrophils, diffusely infiltrating
2. Grade 2 (severe) - >3 chorionic micro-abscesses (confluence of neutrophils
measuring 10x20cells)
• associated with spontaneous preterm birth or adverse neonatal outcome

37. Category Placenta lesions Associated with Subsequent
pregancy
Clinical conditions
and its implications
Maternal vascular
malperfusion
• Placenta hypoplasia
• Distal villous
hypoplasia
• Accelerated villous
maturation
• FGR
• Preeclampsia
• Preterm birth
• Preterm stillbirth
• DM
• thrombophillia
• Assess maternal
CVS
• OGTT
• Thrombophilia
screening
• Recurrence risk 10-
25%
• Aspirin
• Uterine artery
doppler
• Early delivery at
39w
Fetal vascular
malperfusion
• Thrombosis
• Avascular villi
• Intramural fibrin
deposition
• FGR
• Preterm and term
stillbirth
• Thrombophilia
screen
• if thrombophilia
 LMWH since
pregnancy (
Delay villous
maturation
• Reduced
vasculosyncytial
membranes
• Term stillbirth
• DM
• OGTT • Advice monitor
FM
• Delivery prior 40w

38. Category Placenta lesions Associated with Subsequent
pregancy
Clinical
conditions and its
implications
Immune
inflammatory
lesions
• Chronic villitis
• Interbillositis
• Chronic
histiocytic
intervillositis
• FGR
• Miscarriage
• Preterm
stillbirth
• Autoimmune
testing
• Recurrence risk:
25-50%
• For CHI,
recurrence risk
75-90%
• Aspirin +/-
LMWH
Ascending uterine
infection
• Chorionitis
• Chorio-
amnionitis
• Vasculitis or
umbilical
phlebitis
• Perterm birth
• Adverse
neonatal
outcome
• Recurrence risk:
10-25%

39. Care in pregnancies after stillbirth
• Follow up the cause of the stillbirth, review all investigations
• Adequate emotional and psychological support
• Avoid risk factors (dietary, supplement advice, smoking cessation, weight loss etc)
• Consultant-led care with early screening (smoking and GDM)
** care should be individualized
**stop smoking before 16 weeks, risk is same as non smokers

40. Role of ultrasound surveillance
• GTG 2013
 Stillbirth is a major risk of SGA
 serial fetal biometry and umbilical artery doppler from 26-28 weeks
onwards

41. • TOG 2021
 measurement of blood flow through umbilical or uterine artery in second
trimester (abnormal blood flow in second trimester a/w increased risk of
developing FGR and pre-eclampsia which associated with abnormal
placentation and stillbirth
 In addition, to assess placenta structure – size, shape and echotexture (eg:
thickened placenta disc, echogenic cystic lesions in placenta)

42. Ultrasound show abnormal placenta

43. Thickened placenta disc

44. Pharmacological treatments
• Vitamin D
- 400 units (10mcg) daily – normal pregnant women
- 800 units daily – those who high risk of preeclampsia
- 1000 units daily – those increase skin pigmentation or obese women
• Aspirin 150mg once at night (before 16 weeks until 36 weeks)
• Low molecular weight heparin
- No high grade evidence to prevent fetal complication
- Used in women at high risk of VTE
- Women with APS or Chronic histiocytic intervillositis (CHI)

45. Timing of delivery
• 39 weeks of gestation (risk of stillbirth increases after this)
• No increase risk of caesarean section rates if planned IOL at 39 weeks
• Those who required additional emotional care may induced at 38 weeks

46. The algorithm

49. Cytogenetic form
Which lab???

51. Thank you