Stillbirth
Max Brinsmead MB BS PhD
May 2015
This presentation will consider...
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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
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Heartbeat or breathing
 Definition varies from place to place
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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
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Rate of SIDS is 1:10,000 livebirths
 Rate varies from 5 per 1000 resource rich
countries to 32 per 1000 in South Asia & SubSaharan Africa
Trends in Incidence
 Steady decline through last half of last
century
 Part of the overall reduction in perinatal
mortality due to many advances
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For example the prevention of Rh disease
 Rates have levelled from 2000
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Perhaps because any improvement in medical
care has been cancelled by…
Increasing maternal age and…
Obesity
Types of Stillbirth
 Macerated stillbirth
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Skin peeling implies that intrauterine fetal death
has occurred >24 hours prior to delivery
 Fresh stillbirth
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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
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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
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Severe oligohydramnios
Gross obesity
Immediate Management
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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
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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
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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
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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
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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
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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
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If there is fetal hydrops
Fetal endomyocardial fibro-elastosis or calcified AV node
 Maternal antiplatelet antibodies
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If there is fetal intracranial haemorrhage
 Parental chromosomes
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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
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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
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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
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GBS Prophylaxis not required
 Limit VE’s and delay amniotomy
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Avoid Foley catheter
 Oxytocin in high concentration may be required
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But be careful when there is a uterine scar
 Be very careful about assigning sex
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FISH if required
 Consider thromboprophylaxis
 Offer puerperal lactation suppression
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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
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Incl. the GP
 Remember partner & family
 Incl. children & grandparents
 Manage as a potential for post traumatic stress
disorder
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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
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Photos, palm & footprints, locks of hair
Store them in case patients ask later
 Encourage naming
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And use that name
 Liaise with elders of religion or similar
 Funerals are optional
 Commence a book of remembrance
Stillbirth Follow up
 Remember contraception
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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
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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
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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
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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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