Max Brinsmead MB BS PhD May 2015 Stillbirth Max Brinsmead MB BS PhD May 2015

This presentation will consider... Definition and incidence Diagnosis of intrauterine fetal death Immediate management after diagnosis Investigations required after stillbirth Best practice intrapartum care Psychological care Puerperal care and follow up The next pregnancy

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 In the UK from 24w >350g in some states of US Overall incidence 1:200 total births Rate of SIDS is 1:10,000 livebirths Rate varies from 5 per 1000 resource rich countries to 32 per 1000 in South Asia & Sub-Saharan Africa

Trends in Incidence Steady decline through last half of last century Part of the overall reduction in perinatal mortality due to many advances For example the prevention of Rh disease Rates have levelled from 2000 Perhaps because any improvement in medical care has been cancelled by… Increasing maternal age and… Obesity

Types of Stillbirth Macerated stillbirth Fresh 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

Diagnosis of Stillbirth Absence of fetal movements is the usual symptom Diagnosis requires real-time ultrasound Diagnosis based on absence of fetal heart sounds will be wrong up to 20% of the time Both false positives and false negatives can occur Scalp clip ECG is a dramatic example May require colour Doppler in some cases Severe oligohydramnios Gross obesity

Immediate Management Send for a support person Breaking bad news Give the mother time to assimilate Offer early follow up and support contact Provide written material Be aware that mother may feel passive fetal movements after fetal death So be prepared to repeat the ultrasound A second opinion or look is a good idea Parents reactions can vary quite a lot

Investigations of a stillbirth Most parents want answers But there will be no answer ≈ 50% of the time Warn that some positive findings may not be relevant For example +ve ANA or thrombophilia heterozygote Autopsy requires encouragement and a careful consent process In about 10% of cases autopsy will reveal findings of relevance for the next pregnancy Investigation needs to be tailored by The clinical circumstances The resources available

Basic Investigations Begin with fetal weight Calculate weight centile for gestation Always send the placenta and membranes for pathology Preferably to a perinatal pathologist Maternal FBC, UEC, LFT’s & Random GLUC Serology for syphilis and HIV Maternal COAG screen Maternal Kleihauer ASAP after fetal death Fetomaternal haemorrhage a rare cause of IUFD Large doses of Anti-D sometimes required Fetal chromosomes desirable – 6% are abnormal Requires parental consent

Targeted or Advanced Investigations For all patients (if resources permit) Bile salts for cholestasis Thyroid function tests HBA1c but will be normal in most women with gestational diabetes TORCH serology (using booking bloods as a baseline & looking for seroconversion or rise in titre). Other here = Parvovirus, Malaria, Leptospirosis, Listeriosis, Typhus, Lyme etc. Blood group antibodies ± HB EPP when there is fetal hydrops Maternal thrombophophilia screen with IUGR or after identified placental pathology

Targeted Investigations cont.’d Maternal anti-Ro and anti-La antibodies If there is fetal hydrops Fetal endomyocardial fibro-elastosis or calcified AV node Maternal antiplatelet antibodies If there is fetal intracranial haemorrhage Parental chromosomes If there is unbalanced fetal chromosomal abnormality including 45XO Recurrent pregnancy loss Clinical or laboratory evidence of chorio-amnionitis requires suitable samples from mother and fetus/placenta Limitations recognised Autopsy

Management of Intrauterine Death Careful counselling required Encourage mother to vaginal birth after 24-48h Earlier if pre eclamptic etc. Twice weekly DIC screen for mothers who delay Prostaglandins (+ Mefipristone) are the agents of choice A few patients require abdominal delivery Failure of induction + some other problem High risk of uterine rupture Generous pain relief Use SC morphine or Omnopon or epidural after COAG screen

Management of Stillbirth cont.’d Early delivery enhances fetal testing Antibiotics required only for chorioamnionitis GBS Prophylaxis not required Limit VE’s and delay amniotomy Avoid Foley catheter Oxytocin in high concentration may be required But be careful when there is a uterine scar Be very careful about assigning sex FISH if required Consider thromboprophylaxis Offer puerperal lactation suppression Non pharmacological measures control 2/3rds of discomfort only Single dose Carbegoline is the drug of choice

Psychological Management of Stillbirth Be aware of individual & cultural variations Consider the best environment for care Balance safety with privacy Cancel all appointments etc. that assume an ongoing pregnancy Incl. the GP Remember partner & family Incl. children & grandparents Manage as a potential for post traumatic stress disorder Offer counselling & support Use support groups e.g. SANDS Provide a leaflet or similar

Psychological Management cont.’d Encourage contact but do not persuade or enforce I use the bit by bit uncovering approach Encourage but do not press artefacts of remembrance Photos, palm & footprints, locks of hair Store them in case patients ask later Encourage naming And use that name Liaise with elders of religion or similar Funerals are optional Commence a book of remembrance

Stillbirth Follow up Remember contraception Ovulation can occur quickly when lactation is suppressed Discuss the best time and place for follow up Have all the results ready Provide general & specific advice for the next pregnancy Delay conception until the grief work is done But delay often heightens partner anxiety Consider physical aspects such as Hb restoration and uterine scar healing Absolute risk of early conception is small Follow up with a written summary

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

A Baby after Previous Stillbirth Bonding issues can occur Recurrence of grief may be triggered There is an increased risk of postnatal depression Long term impact on the child needs to be acknowledged And never forget the impact of stillbirth on carers and staff in maternity units

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