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 50 th 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 A 1c – 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.