Stillbirth

1. Stillbirth Max Brinsmead PhD FRANZCOG December 2010

2. 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

3. 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

4. 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

5. 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

6. Diagnosis of Stillbirth • Absence of fetal movements is the usual symptom • Diagnosis requires real-time ultrasound • Which should be available at all times • Diagnosis based on absence of fetal heart motion will be wrong up to 20% of the time • Both false positives and false negatives can occur • Scalp clip ECG is a dramatic example • Some mothers feel passive fetal movements • So repeat ultrasound may be required • May require colour Doppler in some cases • Severe oligohydramnios • Gross obesity • Spalding’s sign & intrafetal gas sometimes

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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