Stillbirth: Prevention
Lets talk!
Risk assessment
Decreased fetal movement
Ruth C Fretts MD, MPH
Assistant Professor
Harvard Medical School
HVMA
RFetts@vmed.org
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!
Infant deaths by week of death
West Midlands 1997 to 2003
Number of deaths
2500
2000
Early neonatal (N=1729, 58%)
1500
1000
500
Gardosi et al
Late neonatal (N=404, 14%)
Post neonatal (N=824, 28%)
0
Week 1 Week 4
Week 52
Stillbirths and infant deaths by week of death
West Midlands 1997 to 2003
Number of deaths
2500
Stillbirth (N=2256, 43%)
2000
Early neonatal (N=1729, 33%)
1500
1000
500
Late neonatal (N=404, 8%)
Post neonatal (N=824, 16%)
Gardosi et al
0
Week 1 Week 4
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
1.
2.
3.
4.
5.
6.
7.
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 Risk of
Delivery
Trisomy 21
20
30
35-39
1/1667
1/952
1/378
40+
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
Risk of
Trisomy 21
Risk of Any
Chromosomal
abnormality
Risk of
Stillbirth
after 37
weeks
Multipara
Risk of
Stillbirth after
37 weeks
Primipara
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
1/116
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.
US Data 2005 CDC
AIDS Deaths (all)
12,543
Deaths from Hepatitis
5,529
SIDS
2,230
Infant Deaths due to
congenital anomalies
Cases of Salmonella related
illness to peanut butter
Number of fatal listeria
cases (7 were in elderly)
5,552
Stillbirths (20+ weeks)
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 – 7
OR 2 - 3
OR 4 - 12
Stillbirth Risks:
Preterm
OR
<3rd
7.2
th
3-10
2.0
Non-white Ns
AMA
Ns
>BMI
1.4
Ruptured Ns
Uterus
PAR
51.9
9.8
Ns
Ns
4.4
Ns
Froen Gardosi Acta Scan 2004
Term
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
5.1
1.2
5.0-7.5
4.3-5.9
0.8-1.9
SGA [cust]
SGA [both]
SGA [pop]
8887 = 29%
21931
8884 = 29%
OR
95% C.I.
Diabetic Pregnancies
8
7
6
Weekly Rate of
of Fetal Death
per 1000
5
4
3
2
1
Rouse et al 1995
0
26 27 28 29 30 31 32 33 34 35 36 37 38 39
Weeks of Gestation
Gestational Age and Risk of Unexplained Stillbirth
Yudkin et al Lancet 1987
Rate/1000
undelivered
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
other
Unexplained
29
31
33
35
37
39
41
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
White
Black
28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Gestational Age
C-Section Rates by Parity and
Induction Status BWH and
BIDMC
Heffner et al 2004
Percent
40
Prim, indu
Prim, spon
Multip, indu
multip, spon
30
20
10
0
36
37
38
39
40
Gestational Age
41
42
NICU
cs rate
CS
rate
Tear
Low 5min
Induction of Labor Compared to
Expectant Management in Nulliparous
IND
38
39
40
41
15.6%
18.6%
22.5%
29.3%
EXP
OR
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)
Spont
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 risk37 1/7 - 41 0/7
 HT
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
–
–
–
–
DFM
AMA
RACE
Obesity
Stillbirths
Births
Stillbirths
Rate
OR
Total 13,133
62
4.6
Reference
DFM
476
(Femina)
Chart
DFM
8
16.9
4.1 (1.8-9.06)
15
29.4
8.0 (4.2-15.3)
Femina Cases
1*
2
3
4
5
6
7
8
9
GA
39 5/7
41 3/7
36 6/7
37 4/7
36.5/7
34.0
32 2/7
30 4/7
28 2/7*
Wt
2673
4533
2470
2693
3167
1424
1830
1021
1221
%
3%
97%
4%
19%
90%
<1%
32%
<1%
19%
DFM
4+ days
12 hrs
2 days
1 day
12 hrs
2 days
9 hours
17 days
15 days
Evaluation COD
NST 2d prior Placental*
BPP 2d prior Unexp/infection
No
IUGR
No
Unexplained
No
Cord
No
IUGR/Cord
No
Cord
No
IUGR
NST 2d prior Unexplained
Case 1 APGAR 0, 0, 3 permanent severe disability
DFM by Medical Chart Review
10
11
12
13
14
15
16
GA
38 6/7
39
28
30
39 4/7
30 2/7
37 6/7
Wt
3500
4000
510
710
3284
850
3080
%
77%
98%
<1%
<1%
43%
<1%
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
Percentile Growth
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.
NST
Ultrasound
Doppler
97.5% 3.2% 23.4%
94.0% 11.6% 86.2%
47.3% 1.9% 14.1%
Only
When
finding path.
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
The 2 h ”alarm”
occurs in 9.0% of
these pregnancies
Fewer FM
towards term
Fewer FM
throughout
pregnancy
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
N=81
Pregnancy leading to delivery by an emergency Cesarean section.
Mean time to count to ten is 00:13:37.
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.