Transcript Unexplained Fetal Death - Homepage
Stillbirth: Prevention Lets talk!
Risk assessment Decreased fetal movement
Ruth C Fretts MD, MPH Assistant Professor Harvard Medical School HVMA [email protected]
Objectives
Put stillbirth on your radar
Learn the risk factors for late stillbirth
What 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!
Number of deaths 2500 2000 1500 Early neonatal (N=1729, 58%)
Infant deaths by week of death West Midlands 1997 to 2003
1000 500 0 Late neonatal (N=404, 14%) Post neonatal (N=824, 28%) Week 1 Week 4 Gardosi et al Week 52
Number of deaths 2500 Stillbirth (N=2256, 43%) 2000
Stillbirths and infant deaths by week of death West Midlands 1997 to 2003
Early neonatal (N=1729, 33%) 1500 1000 500 0 Late neonatal (N=404, 8%) Post neonatal (N=824, 16%) Week 1 Week 4 Gardosi et al Week 52
Born “Still Forever”-
Lifelong impact on family
Stillbirth is common >1/200 in US
Frame this risk against other life changing events
Focus on Risk Assessment
Management of decreased fetal movement
Case 1
33 yr old G2 P0 (sab11 weeks)
Japanese women history of infertility but conceived spontaneously
Received 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 reactive
Seen at 40 6/7 weeks still reported DFM
Returned 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
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Triple screen Quad screen NT PAPP-A, free Bets-hCG Integrated NT PAPP-A, free Bets-hCG, plus Quad screen Serum Integrated PAPP-A plus Quad Step wise Sequential 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
Management and Perception of Risk
Maternal Age at Delivery 20 30 35-39 40+ Risk of Trisomy 21 1/1667 1/952 1/378 1/106 Risk of Any Chromosoma l abnormality 1/526 1/385 1/192 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 20 30 35-39 40+ Risk of Trisomy 21 1/1667 1/952 1/378 1/106 Risk of Any Chromosomal abnormality 1/526 1/385 1/192 1/66 Risk of Stillbirth after 37 weeks Multipara 1/775* 1/775* 1/502 1/304
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.
Risk of Stillbirth after 37 weeks Primipara 1/269* 1/269* 1/156
1/116
US Data 2005 CDC
AIDS Deaths (all) Deaths from Hepatitis SIDS Infant Deaths due to congenital anomalies Cases of Salmonella related illness to peanut butter Number of fatal listeria cases (7 were in elderly) Stillbirths (20+ weeks) 12,543 5,529 2,230 5,552 600 9 25,655
Lets Talk The First Step to Prevention
Risk Assessment for Stillbirth
Overweight / obesity Hytertension Diabetes AMA (35 -39) AMA 40+ Smoking Low education/ socioecon. status Primiparity and multiparity IUGR Macrosomia
Reduced fetal movements
OR 2 - 3 OR 1.5-4 OR 1.5-3 OR 1.5-2.2 OR 2.4-5.0
OR 2 - 4 OR 2 - 7 OR 2 – 3 OR 3 – OR 2 - 3 7
OR 4 - 12
Stillbirth Risks: Preterm Term
<3 rd 3-10 th Non-white AMA >BMI Ruptured Uterus OR 7.2
2.0
Ns Ns 1.4
Ns PAR 51.9
9.8
Ns Ns 4.4
Ns
Froen Gardosi Acta Scan 2004
OR 6.4
2.4
2.3
1.5
2.0
8.1
PAR 19.7
11.1
12.8
6.3
9.1
0.4
Stillbirths
Non SGA [cust] & Non-SGA [pop]: => OR 1
6.1
5.0-7.5
5.1
4.3-5.9
1.2
0.8-1.9
OR 95% C.I.
SGA [cust] 8887 = 29% SGA [both] 21931 SGA [pop] 8884 = 29%
Diabetic Pregnancies
8 7 6
Weekly Rate of
5
of Fetal Death
4
per 1000
3 2 1 0 26 27 28 29 30 31 32 33 34 35 36 37 38 39
Rouse et al 1995
Weeks of Gestation
Gestational Age and Risk of Unexplained Stillbirth
Yudkin et al Lancet 1987
Rate/1000 undelivered
0.8
0.6
0.4
0.2
0 2 1.8
1.6
1.4
1.2
1 29 31 33 35 37 39 41 other Unexplained
Obesity
Timing of Stillbirth related To pre-pregnancy obesity Danish National Cohort Aagaard Nohr Obstet Gynecol 2005
Reddy et al AJOG 2006
National Collaborative Perinatal Project: The Risk of Stillbirth by Race
Per 1000 Ongoing Pregnancy
20 18 16 14 12 10 8 6 4 2 0 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Gestational Age
White Black
C-Section Rates by Parity and Induction Status BWH and BIDMC
Heffner et al 2004
40 30 20 10 0 36 37 38 39 40 Gestational Age 41 42 Prim, indu Prim, spon Multip, indu multip, spon
NICU Low 5min Tear
Induction of Labor Compared to Expectant Management in Nulliparous IND EXP OR Spont
38 39 40 41 15.6% 18.6% 22.5% 29.3% 17.6% 19.9% 24.3% 33.1% 1.9 (1.3to2.9) 1.5 (1.1 to 2.1) 1.6 (1.2 to 2.2) 1.3 (1.0 to 1.8) 9.0% 11.6% 15.2% 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 HT 37 1/7 - 41 0/7 39 2/7- 40 1/7 AMA 38 5/7- 39 6/7 model 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
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DFM AMA RACE Obesity
Stillbirths
Births
Total 13,133 DFM (Femina) Chart DFM 476
Stillbirths Rate OR
62 4.6
Reference 8 16.9
4.1 (1.8-9.06) 15 29.4
8.0 (4.2-15.3)
Femina Cases
GA
1* 39 5/7 2 41 3/7 3 36 6/7 4 37 4/7 5 36.5/7 6 34.0
7 32 2/7 8 30 4/7 9 28 2/7*
Wt
2673
%
3% 4533 97% 2470 4% 2693 19% 3167 90%
DFM
4+ days 12 hrs 2 days 1 day 12 hrs 1424 <1% 2 days 1830 32% 9 hours 1021 <1% 17 days 1221 19% 15 days
Evaluation COD
NST 2d prior Placental* BPP 2d prior Unexp/infection No IUGR No No Unexplained Cord No No IUGR/Cord Cord No IUGR NST 2d prior Unexplained Case 1 APGAR 0, 0, 3 permanent severe disability
DFM by Medical Chart Review
GA 10 38 6/7 11 39 12 28 13 30 14 39 4/7 15 30 2/7 16 37 6/7 Wt % 3500 77% 4000 98% 510 <1% 710 <1% 3284 43% 850 <1% 3080 58% DFM 18 hours 1day 1day 14 days 2 days 3 days 12 hr Eval No No No No BPP 2 wks None None COD Unexp Cord IUGR IUGR Cord IUGR/PET Abruption
Gestational Age and Percentile Growth for Stillbirths with a History of DFM
120 100 80 60 40 20 0 25 27 29 31 33 35 Gestational Age 37 39 41 43
What are the useful tools Norway?
... the peers’ experience of 2,930 cases of DFM ...
Tools needed to detect pathology: Test Usage Proved When useful path. Only When finding path.
NST Ultrasound Doppler 97.5% 3.2% 23.4% 94.0% 11.6% 86.2% 47.3% 1.9% 14.1% 1.2% 8.7% 0.2% 9.9% 71.3% 1.7%
Growth Restriction
44% of the stillbirths were growth restricted (<4%)
Normal pregnancy Froen et al
N=305
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.
Pregnancy while smoking Froen et al
The 2 h ”alarm” occurs in 9.1% of these pregnancies Fewer FM towards term N=33
Pregnancy in smoking women. Mean time to count to ten is 00:12:44.
Pregnancy in obesity Froen et al
Fewer FM throughout pregnancy The 2 h ”alarm” occurs in 9.0% of these pregnancies Fewer FM towards term N=111
Pregnancy in obese women (BMI > 30). Mean time to count to ten is 00:15:28.
Pregnancy ending in emergency Cesarean section
The 2 h ”alarm” occurs in 9.9% of these pregnancies Fewer FM throughout pregnancy Fewer FM towards term
Pregnancy leading to delivery by an emergency Cesarean section. Mean time to count to ten is 00:13:37.
N=81
Pregnancy ending in preterm delivery
The 2 h ”alarm” occurs in 13.5% of these pregnancies Specificity 97.6% Fewer FM towards time of delivery N=37
Pregnancy leading to a preterm delivery. Mean time to count to ten is 00:12:32.
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 taken By Erin Fogarty, her husband and Claire after she was stillborn at term.