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 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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