Ruth C Fretts MD, MPHRuth C Fretts MD, MPHAssistant ProfessorAssistant ProfessorHarvard Medical SchoolHarvard Medical [email protected]@vmed.org
Stillbirth: Prevention Lets talk!Risk assessmentDecreased fetal movement
Objectives
Put stillbirth on your radarLearn the risk factors for late stillbirthWhat are possible strategies for
prevention, focus on decreased fetal movement and the risk assessment strategies
“HOW COME NO ONE EVEN MENTIONED THE POSSIBILITY OF A STILLBIRTH UNTIL WE HAD ONE!
Infant deaths by week of deathWest Midlands 1997 to 2003
0
500
1000
1500
2000
2500
Week 1 Week 4 Week 52
Early neonatal (N=1729, 58%)
Late neonatal (N=404, 14%)
Post neonatal (N=824, 28%)
Number of deaths
Gardosi et al
Stillbirths and infant deaths by week of deathWest Midlands 1997 to 2003
0
500
1000
1500
2000
2500
Week 1 Week 4 Week 52
Stillbirth (N=2256, 43%)
Early neonatal (N=1729, 33%)
Late neonatal (N=404, 8%)
Post neonatal (N=824, 16%)
Number of deaths
Gardosi et al
Born “Still Forever”-
Lifelong impact on familyStillbirth is common >1/200 in USFrame this risk against other life changing
eventsFocus on Risk AssessmentManagement of decreased fetal movement
Case 1
33 yr old G2 P0 (sab11 weeks)Japanese women history of infertility but
conceived spontaneouslyReceived BCG as a child, neg Chest XR
Case 1
Noted at 29w size < dates (SFH 27), “watch for growth”
31 2/7 no complaints (SFH 29) 35 3/7 no complaints (SFH 32), plan US following
week, discussed FM NST done because of low baseline, reactive
36 2/7 (SFH 31) US fetal weight 10-25% BPP 8/8 37 5/7 reported decreases FM for 4 days (SFH
33) plan bi weekly NST
Case 1
38 1/7 (SFH 33) NST reactive, reviewed kick counting 38 4/7 (SFH 34) NST reactive 39 2/7 Reactive NST (SFH 36) US 9% nl fluid normal
doppler 39 4/7 Fetal distress on labor APGAR 0, 0, 3 baby (5 lb
12 oz) 3% for growth, c-section under general Baby had severe hypoxic encephalopathy, seizures (MRI
showed severe hypoxic encephalopathy)
Case 1
Poor outcome, worsening placental dysfunction not recognized in spite of normal testing (falling off the growth curve)
Growth restriction and decreased fetal movement at term- beware that antepartum testing is falsely reassuring
Case
43 yr old IVF pregnancy presents at 40 4/7 weeks with decreased FM for 2 days. Advised that the baby had less room to drink a cold drink and if still concerned to make her way to the hospital
NST was performed which was reactiveSeen at 40 6/7 weeks still reported DFMReturned later that evening no FH.
DFM at TERM
Out-come based on if the person on call believes that DFM maters
No standard protocol Typical NST>Home Missed opportunity to
review other potential risks
We know multiple consultations is associated with increased risk*
LETS TALK…
Alex Heazell in press
Elliot’ Dad
Worried about Down’s, normal nuchal scan, so relieved
Comments to Nicki “You don’t look 43!” Noted DFM 40 +3, and 40 +4, NST normal, seen
by the midwife, OB gave the “all clear” on the phone, trying to get away Friday evening.
40 6/7 seen Still DFM thought they were being paranoid because the NST was normal, went for a walk around the pond, told to eat something and then return. Returned IUFD, unexplained.
Faster Trial your first obstetric visit
1. Triple screen
2. Quad screen
3. NT PAPP-A, free Bets-hCG
4. Integrated NT PAPP-A, free Bets-hCG, plus Quad screen
5. Serum Integrated PAPP-A plus Quad
6. Step wise Sequential
7. Contingent sequential combined first.
Faster Trial
38,033 women Cost per Down’s syndrome detected was
between $690,427 and $719,675
Ball et al Obstet Gynecol 2007
Maternal Age at Delivery
Risk of Trisomy 21
Risk of Any Chromosomal abnormality
20 1/1667 1/526
30 1/952 1/385
35-39 1/378 1/192
40+ 1/106 1/66
Hook EB. JAMA 1983:249 and Hook EB. Obstet Gynecol 1981, and adapted from Reddy et al 2006 Am J Obstet Gynecol*data only given for those less than 35.
Management and Perception of Risk
Maternal Age at Delivery
Risk of Trisomy 21
Risk of Any Chromosomal abnormality
Risk of Stillbirth after 37 weeks Multipara
Risk of Stillbirth after 37 weeksPrimipara
20 1/1667 1/526 1/775* 1/269*
30 1/952 1/385 1/775* 1/269*
35-39 1/378 1/192 1/502 1/156
40+ 1/106 1/66 1/304 1/116Hook EB. JAMA 1983:249 and Hook EB. Obstet Gynecol 1981, and adapted from Reddy et al 2006 Am J Obstet Gynecol*data only given for those less than 35.
Management and Perception of Risk
US Data 2005 CDCAIDS Deaths (all) 12,543
Deaths from Hepatitis 5,529
SIDS 2,230
Infant Deaths due to congenital anomalies
5,552
Cases of Salmonella related
illness to peanut butter
600
Number of fatal listeria cases (7 were in elderly)
9
Stillbirths (20+ weeks) 25,655
Lets TalkThe First Step to Prevention
Risk Assessment for Stillbirth
Overweight / obesity OR 2 - 3Hytertension OR 1.5-4Diabetes OR 1.5-3AMA (35 -39) OR 1.5-2.2 AMA 40+ OR 2.4-5.0Smoking OR 2 - 4Low education/ socioecon. status OR 2 - 7Primiparity and multiparity OR 2 – 3IUGR OR 3 – 7Macrosomia OR 2 - 3Reduced fetal movements OR 4 - 12
Stillbirth Risks: Preterm Term
OR PAR OR PAR<3rd 7.2 51.9 6.4 19.73-10th 2.0 9.8 2.4 11.1Non-white Ns Ns 2.3 12.8AMA Ns Ns 1.5 6.3>BMI 1.4 4.4 2.0 9.1RupturedUterus
Ns Ns 8.1 0.4
Froen Gardosi Acta Scan 2004
StillbirthsNon SGA [cust] & Non-SGA [pop]: => OR 1
6.1
5.0-7.5
5.1
4.3-5.9
1.2
0.8-1.9OR
95% C.I.
SGA [cust]
8887 = 29%
SGA [pop]
8884 = 29%
SGA [both]
21931
0
1
2
3
4
5
6
7
8
26 27 28 29 30 31 32 33 34 35 36 37 38 39
Weekly Rate of Weekly Rate of of Fetal Deathof Fetal Deathper 1000per 1000
Weeks of GestationWeeks of Gestation
Rouse et al 1995
Diabetic PregnanciesDiabetic Pregnancies
Gestational Age and Risk of Unexplained Stillbirth
00.20.40.60.8
11.21.41.61.8
2
29 31 33 35 37 39 41
otherUnexplained
Rate/1000Rate/1000undeliveredundelivered
Yudkin et al Lancet 1987Yudkin et al Lancet 1987
Timing of Stillbirth relatedTo pre-pregnancy obesity
Danish National CohortAagaard Nohr Obstet Gynecol2005
Obesity
Reddy et al AJOG 2006
National Collaborative Perinatal Project:The Risk of Stillbirth by Race
02468
101214161820
28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
WhiteBlack
Gestational Age
Per 1000 Ongoing Pregnancy
C-Section Rates by Parity and Induction Status BWH and
BIDMC
0
10
20
30
40
36 37 38 39 40 41 42
Gestational Age
Per
cent
Prim, induPrim, sponMultip, indumultip, spon
Heffner et al 2004Heffner et al 2004
cs rateCS rate
Tear
NICU
Low 5min
Induction of Labor Compared to Expectant Management in Nulliparous
IND EXP OR Spont
38 15.6% 17.6% 1.9 (1.3to2.9)9.0%
39 18.6% 19.9% 1.5 (1.1 to 2.1) 11.6%
40 22.5% 24.3% 1.6 (1.2 to 2.2) 15.2%
41 29.3% 33.1% 1.3 (1.0 to 1.8) 19.3%.M. Nicholson, L.C. Kellar and G.M. Kellar, The impact of the interaction between increasing gestational age and obstetrical risk on birth outcomes: evidence of a varying optimal time of delivery, J Perinatol 26 (2006), pp. 392–402
Optimal Timing of Delivery
Low risk- 37 1/7 - 41 0/7HT 39 2/7- 40 1/7AMA 38 5/7- 39 6/7model did not work for DM because most of
babies were admitted to the NICU to observe glucose levels
Hmmmm-
Until with have randomized controlled trials assessing the risk and benefit of expectant verses active management all we can do is discuss what we know– DFM– AMA– RACE– Obesity
Stillbirths
Births Stillbirths Rate OR
Total 13,133 62 4.6 Reference
DFM 476 8 16.9 4.1 (1.8-9.06)
(Femina)
Chart
DFM 15 29.4 8.0 (4.2-15.3)
GA Wt % DFM Evaluation COD1* 39 5/7 2673 3% 4+ days NST 2d prior Placental*2 41 3/7 4533 97% 12 hrs BPP 2d prior Unexp/infection3 36 6/7 2470 4% 2 days No IUGR 4 37 4/7 2693 19% 1 day No Unexplained5 36.5/7 3167 90% 12 hrs No Cord6 34.0 1424 <1% 2 days No IUGR/Cord7 32 2/7 1830 32% 9 hours No Cord8 30 4/7 1021 <1% 17 days No IUGR9 28 2/7* 1221 19% 15 days NST 2d prior Unexplained
Femina Cases
Case 1 APGAR 0, 0, 3 permanent severe disability
DFM by Medical Chart Review
GA Wt % DFM Eval COD10 38 6/7 3500 77% 18 hours No Unexp11 39 4000 98% 1day No Cord12 28 510 <1% 1day No IUGR13 30 710 <1% 14 days No IUGR14 39 4/7 3284 43% 2 days BPP 2 wks Cord15 30 2/7 850 <1% 3 days NoneIUGR/PET16 37 6/7 3080 58% 12 hr NoneAbruption
Gestational Age and Percentile Growth for Stillbirths with a History of DFM
0
20
40
60
80
100
120
25 27 29 31 33 35 37 39 41 43
Gestational Age
Per
cent
ile
Gro
wth
What are the useful tools Norway?... the peers’ experience of 2,930 cases of DFM ...
Tools needed to detect pathology:Test Usage Proved When Only When
useful path. finding path.
NST 97.5% 3.2% 23.4% 1.2% 9.9%Ultrasound 94.0% 11.6% 86.2% 8.7% 71.3%Doppler 47.3% 1.9% 14.1% 0.2% 1.7%
Growth Restriction
44% of the stillbirths were growth restricted (<4%)
Normal pregnancy Froen et al
Pregnancy in non-smoking mother, younger than 35 years, with BMI < 25, leading to a vaginal delivery at term of a healthy baby between the 10th and 90th birth weight centile.
Mean time to count to ten is 00:09:14.
N=305
Pregnancy while smoking Froen et al
Pregnancy in smoking women.
Mean time to count to ten is 00:12:44.
N=33
Fewer FM towards term
The 2 h ”alarm” occurs in 9.1% of these pregnancies
Pregnancy in obesity Froen et al
Pregnancy in obese women (BMI > 30).
Mean time to count to ten is 00:15:28.
N=111
Fewer FM throughout pregnancy
Fewer FM towards term
The 2 h ”alarm” occurs in 9.0% of these pregnancies
Pregnancy ending in emergency Cesarean section
Pregnancy leading to delivery by an emergency Cesarean section.
Mean time to count to ten is 00:13:37.
N=81
Fewer FM towards term
Fewer FM throughout pregnancy
The 2 h ”alarm” occurs in 9.9% of these pregnancies
Pregnancy ending in preterm delivery
Pregnancy leading to a preterm delivery.
Mean time to count to ten is 00:12:32.
N=37
Fewer FM towards time of delivery
The 2 h ”alarm” occurs in 13.5% of these pregnancies Specificity 97.6%
Undetected IUGR in stillbirths
Only between 11- 20 % of pregnancies that end in a stillbirth in a severely growth restricted baby are detected prior to the stillbirth
Prevention
Early prenatal care Black women and
immigrants Screen for congenital
anomalies Optimize health,
smoking, weight gain Reduce multiples
Improve awareness and management of decreased fetal movement
Individualize risk assessment late in pregnancy, include race, age, obesity, parity on treating a women when she is “post-dates”
Photogram published on AP takenBy Erin Fogarty, her husband and Claire after she was stillborn at term.
