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Management of Stillbirth

Management of Stillbirth. Christopher R. Graber, MD Salina Women’s Clinic 27 Jan 2012. Overview. Context Definitions Risk Factors Management of Stillbirth Fetal, placental, & maternal evaluations Method of Delivery Recurrence Risk Surveillance. Context.

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Management of Stillbirth

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  1. Management of Stillbirth Christopher R. Graber, MD Salina Women’s Clinic 27 Jan 2012

  2. Overview • Context • Definitions • Risk Factors • Management of Stillbirth • Fetal, placental, & maternal evaluations • Method of Delivery • Recurrence Risk • Surveillance

  3. Context • Stillbirth – one of the most common adverse pregnancy outcomes • 1 in 160 deliveries in US • 25,000 per year (3 million worldwide) • Emotionally difficult for family and caregivers • Also called fetal death but the term stillbirth is preferred among parent groups

  4. Definitions • Fetal death – delivery of a fetus showing no signs of life • Absence of breathing, cord pulsation, movement • Greater than 20w (16-28w) gestation (if known) • Greater than 350-500g (if age not known) • 350g is 50th percentile at 20w • Miscarriage/abortion – pregnancy loss prior to 20 weeks gestation

  5. Definitions – Other • Criteria for stillbirth do not imply viability • Birth and death certificates not needed for miscarriage

  6. Frequency • 2004: rate of 6.2 per 1,000 births • Since 1990 • rate of early stillbirth (20-27w) stable at 3.2 per 1,000 births • Rate of late stillbirth (28w+) decreased from 4.3 to 3.1 per 1,000 births • US statistics – excluded fetal losses due to terminations of pregnancy for lethal anomalies or pre-viable premature rupture of membranes

  7. Risk Factors • Non-Hispanic black race • 11.25 per 1,000 in US • Nulliparity • Advanced maternal age • Obesity • Maternal comorbidities • Multiple gestations • Smoking

  8. Risk Factors – Potential Causes • Unexplained – 25-60% of all cases • Fetal growth restriction • Likely secondary to placental dysfunction • Placental abruption – 10-20% of all cases • Infection • Congenital anomalies

  9. Risk Factors – Potential Causes • Chromosomal and genetic abnormalities • Abnormal karyotype found in 8-13% of stillbirths • Monosomy X (23%), trisomy 21 (23%), trisomy 18 (21%), and trisomy 13 (8%) • Cord events • Nuchal cord, knots, vasa previa • Hydrops fetalis – immune or non-immune • Uterine condition – rupture

  10. Management of Stillbirth • Allow family plenty of time to grieve • Both after diagnosis and after delivery • Inform parents about the options and reasons for evaluation • May be useful in planning future pregnancies • Provide both counseling and support as needed in a team approach

  11. Management of Stillbirth – Fetal • General external exam • Weight, length, head circumference • Note any dysmorphic features • Photographs recommended • Whole-body x-ray • Karyotype • Amniotic fluid, cord, fetal tissue, or placenta • Offer autopsy to parents • Head sparing autopsy another option

  12. Management of Stillbirth –Placental • Gross and microscopic exams • Include membranes and cord • Consider bacterial cultures • Don’t forget photographs

  13. Management of Stillbirth –Maternal • Thorough history looking for risk factors • Family history • Offer extensive lab options • Kleihauer-Betke, parvovirus IgG and IgM, TSH • Anti-phospholipid syndrome • Lupus anticoagulant, anticardiolipin Ab • If history of thrombosis • Factor V, prothrombin, antithrombin III, protein C/S

  14. Management of Stillbirth –Maternal • Other labs • Urine toxicology • Fasting glucose or hgb A1c • Blood antibody screen/type • TORCH titers • Toxo, other (syphilis), rubella, CMV, HSV

  15. Method of Delivery • Method and timing of delivery depend on gestational age, previous uterine scar, and maternal preference • Coagulopathies are rare unless prolonged time • Dilation and evacuation vs. labor induction vs. cesarean (hysterotomy)

  16. Method of Delivery • D&E • Second trimester • Only for experienced personnel • Labor induction (including VBAC) • High dose pitocin (up to 500mu) • Prostaglandins (ex: misoprostol 400mcg PV q 6h) • Cesarean delivery (hysterotomy) • Caution: maternal risks without fetal benefit

  17. Recurrence Risk • When specific risks are known, recurrence risk may be quantifiable • Low-risk mom, history of unexplained stillbirth • 7.8 – 10.5 / 1000 (before 37 weeks) • 1.8 / 1000 (after 37 weeks) • History of stillbirth + fetal growth restriction • 21.8 / 1000 • Rates higher in moms with comorbidities

  18. Surveillance • Antepartum surveillance • Initiated at 32-34 weeks: NST or BPP • May increase prematurity rates • Fetal kick counts • Effectiveness unproven • Delivery timing • Consider maternal and fetal risks/benefits • Consider amnio for FLM

  19. Questions? • ACOG Practice Bulletin 102; Management of Stillbirth. March 2009 • UpToDate: Incidence, etiology, and prevention of fetal demise. Evaluation of stillbirth.

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