Stillbirth
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Transcript of Stillbirth
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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