Slide 1

INVESTIGATION AND ASSESSEMENT OF STILLBIRTHS

Dr: Salah Roshdy Professor & Senior Consultant

Of Obstetrics & Gynecology Qassim College of Medicine,KSA

Sohag University,Egypt

Slide 2

Definition

The World Health Organization (WHO) classification of stillbirth is defined as fetal loss in pregnancies beyond 20 weeks of gestation,

or, if the gestational age is not

known, a birth weight of 500 g or more, which corresponds to 22 weeks of gestation in a normally developing fetus.

Slide 3

Definition

The World Health Organization definition of perinatal death is death of the offspring ‘‘occurring during late pregnancy (at 22 completed weeks gestation and over), during childbirth and up to seven completed days of life.

’’ Stillbirths are subclassified as antepartum (ie, the fetus died before the onset of labor) or intrapartum (ie, the fetus died after the onset of labor but before birth).

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Definition

Neonatal death is subdivided into

early (in the first week of life) and

late (death in the second to fourth week of life).

Although perinatal death strictly excludes late neonatal deaths, most of these deaths are related to obstetric events,

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Prevalence Stillbirth is a relatively common, but often

completely random occurrence. Based on statistical data, it has been found that

the mean stillbirth rate in the United States is approximately 1 in 115 births,

which is roughly 26,000 stillbirths each year, or one every 20 minutes.

In developing countries where medical care can be substandard or completely unavailable, this rate is much higher.

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Prevalence

1 out of 5 African women loses a baby

during her lifetime, compared with 1 in

125 in rich countries.

Each year nearly 3.3 million babies are

stillborn, and more than 4 million others

die within 28 days of being born.

Newborn deaths now contribute to about

40% of all deaths in children under five

years of age globally, and more than half

of infant mortality.

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Prevalence

It is estimated that each year over a

million children who survive birth

asphyxia develop problems such

as cerebral palsy, learning

difficulties and other disabilities.

Nearly three quarters of all

neonatal deaths could be

prevented if women were

adequately nourished and

received appropriate care during

pregnancy, childbirth and the

postnatal period.

Slide 8

Stillbirth rates in the West Midlands and England & Wales

1998-2003

0

1

2

3

4

5

6

7

1998 1999 2000 2001 2002 2003

Rate/000

W Mids

E & W

Stillbirth rates

1998 1999 2000 2001 2002 2003

W Mids 5.6 6.3 5.8 5.6 6.3 6.1

E & W 5.3 5.3 5.2 5.3 5.6 5.7P<0.01

P<0.01

Slide 9

40 40

Booked outside booked

Stillbirth 80 (9.53 /1000)

Actual rate (4.78/1000)

Total No.of deliveries 8391

Slide 10

ReCoDe (Relevant Condition at Death)

A. Fetal congenital, n-i hydrops, iso-immunisn,

feto-mat. hem, infection, TTTS,

fetal growth restriction

B. Umbilical Cord prolapse, constriction, velament. insertion

C. Placenta abruptio, previa, infarction, plac. disease

D. Amniotic Fluid chorioamnionitis, severe oligo, polyhydr.

E. Uterus rupture, anomalies

F. Maternal DM, Th, EHT, PIH. lupus, cholest, drugs

G. Intrapartum asphyxia; birth trauma

H. Trauma external; iatrogenic

I. Unclassified no relevant condn; no info available

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Miscellaneous 5%

Intrapartum

Asphyxia 3%

Mother 3%

Placenta 9%

Unclassif ied/

unknow n 16%Congenital

anomalies 15%

Infection 3%

Fetal grow th

restriction 43%Umbilical cord 3%

Stillbirths - ReCoDe

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Stillborn infant with Trisomy 21

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0 10 20 30 40 50 60 70

Ireland 93 (Walsh 1995)

Wales (Tuthill 1999)

UK (Cesdi 2001)

Sweden (Winbo 2001)

UK (Gardosi 1998)

Australia (Alessandri 1992)

New Z (Westgate 1985)

UK (Wagaarachchi 2002)

UK (Shankar 2002)

UK (Yudkin 1987)

USA (Ananth 1995)

USA (Lammer 1989)

France (Goffinet 1996)

France (Coujard 1975)

Norway (Rasmussen 2003)

USA (Brans 1984)

USA (Incerpi 1998)

Saudi Arabia (Meshle 2001)

Australia & NZ (Flenady 2003)

Australia (Robson 2001)

Canada (Huang 2000)

Norway (Frøen 2001)

Queensland (Flenady 2003)

Denmark (Kesmodel 2002)

India (Naidu 2001)

Sweden (Ahlenius 1995)

Ireland 70ies (Walsh 1995)

Sweden (Petersson 2002)

Unexplained or unexplored? Percentage of stillbirths remaining unexplained:

Slide 17

Common Risk Factors For Stillbirth

1) Race and Socio-ecomonic factors

2) Advanced materanal age multiple pregnancy, hypertension, DM, abruptio placenta.

3) Obesity Macrosomia

GDM

PET

Hyperlipidemia

4) Thrombophilias

5) SLE

6) Medical risk factor

7) Hypertension

8) Infection

9) Multiple pregnancy

10) Infertility

Slide 18

Maternal disease & Risk of Stillbirth

All pregnancies 6-7

Hypertensive disorders

Chronic hypertension 5-25

Superimposed preeclampsia 52

PIH/mild preeclampsia 9

Severe preeclampsia21

Eclampsia18-48

HELLP syndrome51

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Diabetes mellitus Gestational diabetes5-10 Type 1 diabetes6-10 Type 2 diabetes35 Obesity15-20 Systemic lupus erythematosus40-150 Chronic renal disease Mild renal insufficiency15 Moderate and severe renal

insufficiency32-200

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Thyroid disorders

Stable treated hyperthyroidism0- 36

Uncontrolled thyrotoxicosis100- 156

Subclinical hypothyroidism0-15

Overt hypothyroidism15-125

Cholestasis of pregnancy 12-30

Slide 21 ALGORITHM FOR ETIOLOGIC INVESTIGATION OF STILL BORN INFANTS

STILL BIRTH

Step 3

Stillbirth Examination

a. Physical Exam

b. Clinical photographs

c. Radiologic studies

d. Autopsy (full or partial)

e. Consult

Step 4

Cord Exam

Step 1

Maternal & Family

History

Step 2

Maternal Investigations

Information used in Counseling

Step 5

Placental Exam &

Investigations

Step 6

Cytogenic

Investigations

Abnormalities found:

Specific Counseling

No Abnormalities found:

Empriric Counseling

Slide 22

SIX STEPS IN THE ETIOLOGIC INVESTIGATION OF A STILLBIRTH

I. MATERNAL AND FAMILY HISTORY

A- Review past obstetric history 1) Emphasize details of previous

embryonic/fetal losses.

To be done at the time of diagnosis of a stillbirth

Slide 23

B-Review history present pregnancy specifically with regard to:

1) Gestational age 2) Fetal growth 3) History of bleeding 4) Elevated blood pressure 5) Recent illness or possible viral

exposure 6) Medications during pregnancy 7) Maternal perception of fetal

movements in recent past

Slide 24

C-Review of antenatal investigations:

1) Ultrasounds, including amniotic fluid assessments

2) Laboratory investigations 9including all routine antenatal blood work)

3) Prenatal diagnoses (triple screen, amniocentesis, or CVS)

4) Fetal assessment (NT, biophysical profiles, Doppler ultrasound)

D-Review Family History

Slide 25

11-MATERNAL INVESTIGATIONS

A. Ultrasound, if possible, to evaluate for unknown congential anomalies

B. CBC, platelet count C. Kleihauer or equivalent

D. Blood group and antibody screen

E. HBA1C

F. Infectious and Microbiological Investigations to be considered when:

Infection is suspected as an etiologic factor Cause of stillbirth is not obvious

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1) Maternal serology (IgG and IgM) for a) Parvovirus

b) Toxoplasmosis

c) Cytomegalovirus

2) Review chart for HIV, syphilis and rubella serology – send IgG and IgM if not previously done as part fo routine antenatal blood work.

3) Maternal blood culture for Listeria 4) Cervical/Vaginal cultures (aerobic)

Slide 27

To be done at the time of diagnosis of a stillbirth

A. Physical Exam

Perform a detailed physical examination of the fetus and placenta.

B.Autopsy

A full autopsy should be encouraged on all stillbirths. An autopsy is recommended even if cause of death appear obvious. If the parents will not consent to a full autopsy, a limited autopsy should be encourage.

III. STILLBIRTH INVESTIGATIONS

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A. Length in cms

B. Number of vessels

C. Appearance – thin, thick, meconium, stained, abnormalities

D. True knots – loose or tight

E. Cord Blood to be drawn- Possible only if a FRESHS stillbirth (*)

1) CBC, Blood group, Direct Antibody Test

2) Cytogenetics if there is evidence of

Congenital malformation on ultrasound or seen on examination of the stillbirth

IV. CORD EXAMINATION

Slide 34

Hydrops Severe IUGR (5th%ile on ultrasound,

<3rd %ile birth weight) Amniotic fluid abnormality – severe

oligohydramnios or polyhydramnios. Ambiguous genitalia Parental history of

a) Repeated miscarriages

b) Past unexplained stillbirth

c) Past unexplained neonatal demise

d) Previous child with congenital anomalies

3) Culture of GBS, Listeria and coliforms if infection is suspected as an etiologic factor or the cause of the stillbirth is not obvious

Slide 35

A. Subamniotic swabs for aerobic and anaerobic culture if infection suspected as an etiologic factor or the cause of the stillbirth is not obvious.

1. Swab between the amnion and the chorion

B. Placenta and cord to pathology. Check with Pathology lab to determine if placenta should be sent:

1) Fresh 2) In saline 3) In formalin (tissue sample for

cytogenetics must be taken before the placenta is fixed in formalin)

V. PLACENTA

Slide 36

Test which can be done after the autopsy/placental pathology, if cause still unknown

A. Maternal Antiphospholipid Antibody testing.

B. Investigations for thrombophilias, for example:

1) Factor v lEIDEN 2) Protein S deficiency 3) Protein C deficiency 4) Antethrombin deficiency 5) Hyperhomocysteinemia

C. If suspicious – TB skintest of mother

1) Further TB workup if positive

Slide 37

A. Cord blood and placental chorion and amnion samples should be taken immediately after delivery on all stillbirths and sent for cytogenetic studies if:

1) The pathologist or clinician feels cytogenetic studies should be completed

2) As cord exam.

B. If there is a specific concern about inheritable metabolic disease, portions of the placental villi should be submitted in cytogenetic culture media in order to establish cell cultures for possible furhter studies.

VI. CYTOGENETIC STUDIES

Slide 38

Checklist tool for the investigation of a Stillbirth

A-When a stillbirth is diagnosed the following information should be collected if possible

1-Is the BC Antenatal record completed and available for review?

a) Gestational age confirmed by early ultrasound (<20 weeks)

b) Past obstetrical history completed

c) Medication use in pregnancy documented

d) Blood pressures recorded

Slide 39

2-Has the woman has been asked the following questions;

a) When was the last time she fetl fetal movement?

b) Has there been any recent vaginal bleeding?

c) Has there been any vaginal fluid loss?

d) Any history of possible viral infection in the pregnancy.

Slide 40

3-Are the following investigations on the chart with results?

a) Previous ultrasound reports?

b)Routine antenatal blood work?

c) Any prenatal diagnostic tests (Triple screen, amniocentesis, CVS, etc.)?

d)Any recent antenatal fetal monitoring.

Slide 41

4-Have the following investigations been organzied following the diagnosis of the stillbirth?

a) Ultrasound tolook for potential cause?

b) CBC, PLATELET COUNTS?

c) Kleihauer or equivalent?

d) Maternal blood group and antibody screen?

e) HbA1C or result of 50g glucose screen or GTT?

Slide 42

F) Infectious and microbiological investigations if indicated

A. Maternal serology for:

Parvovirus

Toxoplasmosis

Cytomegalovirus

B. Maternal serology available for:

HIV

Syphilis

Rubella

C. Maternal blood culture for Listeria

D. Cervical/vaginal culture

Slide 43 B-After the stillbirth has been delivered the following information should be collected if possible:

1. Gross physical examination of the stillbirth?

2. Autopsy Full autopsy consented to?

(encourage for all stillbirths if possible)

Limited autopsy consented to? a) External examination by

Pathologist? Gross examination for

evidence of meconium?

Slide 44

b)Clinical photographs? c) Radiographic studies? d)Limited tissue biopsies? Skin/tendon for cytogenetics Liver for infection or storage

disorders? Sampling of all organs, including

the CNS? Sampling of organs outside the

CNS?

Slide 45

3-Clinical examination of the umbilical cord

4- Examination of the placenta.

C-Information that can be collected if the cause of the stillbirth remains unknown after the above investigations are completed. 1. Maternal Antiphospholipid Antibody

screening? 2. Investigations for other thrombophilias if

indicated? 3. TB skin test of mother if suspicious

(further work-up if positive?

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Slide 47

Clinical external stillbirth examination at the time of delivery

1-General - Global evaluation of the following parameters:

A. State of preservation: fresh or macerated (degree of maceration); intact delivery or interventions required to effect delivery.

B. Weight; gestational age; size for gestational age

C. Measurements: circumference of head, chest and abdomen; lengths of crown-heel (with leg fully extended), crown-rump and foot.

D. Colour: vernix white or meconium stained; any lesions of skin such as vesicles, bruising.

Slide 48

11-Craniofacial A. General impression of normality or

abnormality B. Quantitative relationships:

As craniofacial height is roughly equal to the cranial vault height, abnormalities in the ratio indicate microcephaly or hydrocephaly

As the intercanthic distance is roughly equal to the orbit width, an abnormal ratio suggests hypo/hypertelorism.

Abnormal ear location - normally external meatus lies above level of nostrils and long axis of the ear is nearly vertical.

C. Specific structural defects

Anterior - flat nasal bridge; short flat nose; small eyes; epicanthal folds; cleft lip (uni/bilateral or median); cleft palate; small mouth; down turning angles of mouth; glossoptosis and retro/prognathism

Posterior - anencephaly, iniencephaly and encephalocele (usually occipital)

Slide 49

III. Neck A. Abnormally short B. Thickened nuchal fold and cystic hygroma C. Cervical rachischisis and meningomyelocele

IV. Trunck A. Overview - presence of edema; abdominal

distention and muscular development B. Specific defects -

Ventral - omphalocele; umbilical hernia; gastroschisis; diastasis recti and rune belly

Dorsall - rachischisis; meningocele and meningmyelocele

Cord insertion - normal location; number of vessels and juxtrafetal cord coarctationw ith abnormally thin umbilical ring.

External genitalia - absent; ambiguous and small or enlarged structures (penis, scrotum, clitoris, labia, vagina)

Anus - patency; imperforate; stenotic and displaced interiorly

Slide 50

1V-Extremities A. General - normal/abnormal lenth;

shortenignof particular segment and muscle development.

B. Specific Defects –

Upper - distortions;

amputations; finger

lengths; shape and size;

poly/syndactyly and

abnormal palmar creases

Lower - positional

abnormalities of feet, toe

lengths, shape and size;

increased sandal space;

poly/syndactyly and

rockers-bottom deformity.

Slide 51

The Autopsy

Clinical Photographs of Stillbirths

Cytogenetic studies in stillbirth investigations

Slide 52

Screening Options for Growth Restriction

Ultrasound Accurate dating (LMP,

OCCP, Lactating) Early dating scan DO NOT CHANGE

the EDD Serial scans Growth Charts, and

curves Doppler AFI / BPP

Slide 53

Planning intervention

Identify high risk groups

Increased level of surveillance (fetal and placental Doppler ultrasound)

Elective delivery if surveillance indicates fetal compromise or pregnancy reaches given threshold of gestation – Previous SB at 38 weeks – IDDM at 39 weeks – Post-dates pregnancy at term + 10 days

Slide 54

Predicting risk

High risk groups already identified – IDDM – Previous SB – Connective tissue disease

Problem: most stillbirths occur to “low risk” women

Solution: identify factors associated with an increased risk of stillbirth

Slide 55

Where to start?

Majority of stillbirths have a placental cause – Abruption – Pre-eclampsia – IUGR

In the absence of overt risk factors, may be able to identify high risk women within a low risk population by screening tests of placental function

Slide 56

Labor and delivery

When the diagnosis of growth restriction is made

AFI

Normal

At > 36-37 weeks

Assess Bishop’s score

Adequate

Deliver

Oligohydramnios

At> 34- 36 weeks

If Documented FLM

OR

Slide 57

Protocol for Placental and Cord Evaluation GROSS ASSESSMENT Weight (trimmed) ________g. Placental weight:Fetal weight ratio ________ContourSize ________cm x ________cmPresence of Accessory Lobes Y

NInsertion of Cord CentralEccentric Marginal VelamentousMembranesMembranes ruptured ________cm from the margin.Membrane insertion NormalMarginal Circum-marginate CircumvallateMembrane character NormalAbnormal Meconium stained Blood stained Other ______________________Placental discColor Red Brown Green Pale Other___________________________Odor Normal FoulFeaturesBlood clot of maternal surface _________________________ Thrombi of fetal surface ______________________________ Fibrin(oid) deposition ________________________________ estimated percentage of surface involved ____% Infarction _________________________________________ estimated percentage of volume involved _____% Other_____________________________________________CordLength _______cm Diameter_______cm Number of vessels _______FeaturesTrue knot(s) ________________________________________ False knot(s) ________________________________________ Torsion/twisting _____________________________________ Engorgement ________________________________________ Narrowing/constriction ________________________________ location ______________________________________ Abnormal Wharton's jelly ______________________________ _____________________________________________If Twins:Membrane ConfigurationMonochorionic-Monoamniotic Monochorionic-Diamniotic Dichorionic-DiamnioticPlacental VesselsAnastomotic vessels evident by gross inspection Anastomotic vessels demonstrated by injection/perfusionHISTOLOGIC ASSESSMENTSections should be obtained as follows:1. Cross section of umbilical cord 1b. Cross section just proximal to and just distal to any apparent cord constriction or cord stricture 2. Amniochorionic membrane roll 3. Fetal side placenta 4. Basal placenta 5. Sampling of any apparent abnormalities.Reporting should include general description of each section and description (including severity and extent) ofInflammationChorioamnionitis ______________________________________________Cord Vasculitis _______________________________________________Funisitis ____________________________________________________Villitis ______________________________________________________Infarction __________________________________________________________Calcification(s) ______________________________________________________Fibrin Deposition ____________________________________________________Other _________________________________________________________________________________________________________________________Placental and Cord Examination WiSSP home page

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CLINICAL EXAMINATION OF STILLBORN INFANT [Clinical description is often critical in the etiologic evaluation of stillborns. Yet it is often given less attention than it deserves in most formal postmortem evaluations. This is a suggested, simple and relatively non-jargon filled outline for such a clinical evaluation; it also includes space to provide brief notation of relevant prenatal, perinatal and family history.]

I. General InformationDate ____ ____ ____ Baby's Name____________________Mother's Name____________________ Father's Name____________________Hospital____________________Parents' Address____________________Attending Physician___________________ Person performing this evaluation ________________________

II. Brief History Prior Pregnancy History --

Pregnancies____Deliveries____Liveborn____ Spont. Ab. ____Ind. Ab.____Prior Stillborns____Relevant maternal history and health [e.g. diabetes, hypertension, thyroid disease, etc.]

________________________________________________________________

Significant problems in this pregnancy ________________________

________________________________________________________________

Relevant family history [if not supplied in other records] ________________________ ________________________________________________________________

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III. General Data on Baby

Gestational age:____weeks; How determined -- dates ultrasound clinical exam other Degree of Maceration: ____Fresh; no skin peeling

____Slight; focal minimal skin slippage ____Mild; some skin sloughing, moderate skin slippage ____Moderate; much skin sloughing but no secondary compressive changes or decomposition ___Marked, advanced

IV. Measurements Crown-heel [stretched] ______ Weight ______

Head Circumference ______ V. Head and Face Head is -- collapsed_____

Anencephalic____ Apparently hydrocephalic_____ abnormally shaped_____; describe ____________________ relatively normal_____

check for and describe any: scalp defects_____ ;________________________________________

cranial masses_____ ;________________________________________ Eyes -- normal_____; sunken_____; prominent_____; abnormally far apart_____; abnormally close together____; straight____;upslanting [V]____; or downslanting [/\]___ on opening the lids the following is found -- eyelids are fused____

globes appear normal_____ globes are apparently absent____ eyes seem extremely small____ eyes seem extremely large____ opacities are present____

of the corneas____ of the lenses____ other________________________________________

Nose

Slide 60

Nose -- normal____; abnormally small____; abnormally large____; asymmetric____ nostrils are: apparently patent____; obstructed____;

Single nostril only____ other ________________________________________ Mouth -- size: normal____; large____; small____ upper lip: intact____; cleft____; if cleft give location of cleft-- Left__, Right__, Bilateral__, Midline__ palate: intact____; cleft____ mandible: normal___; very small____; asymmetric____ other ________________________________________ Ears -- normal____; abnormal in form____; if abnormal describe or draw -- lowset____; posteriorly rotated____; preauricular tags___; preauricular pits____ other ________________________________________ VI. Neck normal____; short____; excess or redundant skin____; cystic mass [hygroma]____ other ________________________________________

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VII. Chest

normal____; asymmetric____; small and constricted____; barrelled____

other ________________________________________

VIII. Abdomen

normal____; flattened____; distended____;

wall defects____ [omphalocele____; gastroschisis____; hernia____]

umbilical cord -- number of vessels____ clinical abnormality [describe]

other ________________________________________

IX. Back

normal____; spina bifida____ [level of defect_____]; scoliosis____;

kyphosis____

other ________________________________________

X. Limbs

length: normal____; short____; long____

if short, what segment(s) seem short

form: normal____; asymmetric____; have missing parts____

describe any asymmetry or missing parts

position: normal____; clubfoot____; other positional abnormality____

describe if abnormal ________________________________________

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Xa. Hands

normal appearing____; abnormal____ if abnormal, describe fingers -- numbers present ___+___ [if not 5+5, describe ] unusual form of fingers ____; describe unusual position of fingers____; describe abnormal webbing or syndactyly____; describe Xb. Feet normal appearing____; abnormal____ if abnormal, describe toes -- numbers present___+___ [if not 5+5, describe ] abnormal spacing of toes____; describe XI. Genitalia Anus -- normal____; imperforate____; other Male -- penis -- normal___; hypospadias___[level of opening_________]; very small____; chordee____ other ________________________________________ scrotum -- normal____; abnormal____[describe ] testes -- descended____; undescended____ other ________________________________________ Female -- urethral opening -- present____; absent/unidentifiable____ vaginal introitus -- present____; absent____ clitoris -- normal____; enlarged____; unidentifiable____ other ________________________________________ Ambiguous____; Describe

Slide 63

Classification of perinatal death

1. non-preventable:

All the following criteria have to apply for a death to be classified as non-preventable:

a) prenatal care and fetal surveillance were adequate and appropriate.

b) Intervention was available, accessible, appropriate and timely.

c) Circumstances surrounding a death were not preventable.

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2. Possibly preventable unrecognized but detectable

fetal or newborn compromised:

Not detected or not appreciate.

Inappropriate, inadequate or untimely intervention.

3. Ideally preventable A sudden, compromising

event for the fetus or newborn where intervention was not possible on this occasion.

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Facts and figures from The World Health Report 2005

• “Children are the future of society and their mothers are guardians of that future.

• Yet this year, almost 11 million children under five years of age will die from causes that are largely preventable.

• Among them are 4 million babies who will not survive the first month of life.

• On top of that 3.3 million babies will be stillborn.

• At the same time, about half a million women will die in pregnancy, childbirth or soon after.”

The World Health Report 2005

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Etiology OF Stillbirth

Booked Unbooked

D.M 9 6

H.Disorder 5 7

IUGR 3 11

P.T 2 2

Thyroid 1 0

Cong.anomal 6 2

Placental 3 3

True knots 3 0

Unexplained 8 9

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