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New Born OB
 

IUFD Quick Facts              PB102

 

Stillbirth = delivery of fetus with no signs of life, 20+ weeks if GA known / 350+ grams if GA unknown, excludes terminations for lethal anomalies and IOL for pre-viable PPROM, occurs in 6.2/1000 births (evenly split between 20-27 week and 28+ week groups)

 

-        -  Risk Factors: Non-Hispanic black race (11.25 vs 6/1000 even with adequate PNC), nulliparity, AMA (11-14/1000 if 35-39, 11-21 if 40+) and obesity (5.5/1000 for Class I, 8/1000 for Class II, 11/1000 for Class III) are the most prevalent. Also congenital anomalies, abnormal karyotypes, fetal growth restriction, placental abnormalities, thrombophilia, hypertensive disorders, diabetes, SLE, renal disease, thyroid disorders, cholestasis, infections including B19/CMV/syphilis/strep/listeria, multiple gestation, smoking, drug use.

o   Risk of stillbirth in pregnancy, after prior pregnancy with IUGR and livebirth before 32 weeks, is 21.8/1000 (twice as high as risk of recurrent stillbirth)

 

          -          Evaluation:

 

o   Complete maternal history

o   Physical exam of fetus with descriptions, photos if possible

o   Laboratory studies (placenta pathology, fetal autopsy, karyotyping = most important)

  • Fetal autopsy and placental pathology, with parental consent

         Alternatives to autopsy: X-rays, ultrasounds, MRIs, blood/tissue samples

         Dysmorphic features/skeletal abnormalities are found in 20% of stillbirths, major malformations in 15-20%.

  • Fetal specimen for cytology/karyotype, at least one, with parental consent: amniocentesis fluid is highest yield, placental block (1x1 cm taken from below cord insertion), umbilical cord segment (1.5 cm closet to placenta), internal tissue (costochondral jxn or patella)

         Abnormal karyotype is present in 8-13% of stillbirths, but rate is likely underestimated, as up to 50% of cell cultures don’t yield results. Monosomy X (23%), T21 (23%), T18 (21%) and T13 (8%) most common.

  • Maternal serum for CBC, fetal bleed screen, APLS testing (lupus anti-coagulant, anti-cardiolipin antibodies, beta-2 glycoprotein antibodies), parvovirus B19 IgG and IgM, syphilis, TSH

         Inherited thrombophilia work-up (FVL, prothrombin, ATIII, Protein C &S, MTHFR/homocysteine) only if severe placental pathology, significant fetal growth restriction or personal/ family history of thrombosis. Protein C&S have to wait until post-partum.

  • Consider the following: parental karyotyping (if abnormal pedigree, if fetal chromosomes don’t grow), Indirect Coombs (if Rh status not already known), A1c (if fetus is LGA), toxicology (if drug use suspected or abruption)

         ANA, Toxo, Rubella, CMV, HSV are of unproven benefit

 

          -          Management:

 

o   <28 weeks: Vaginal misoprostol preferred regardless of Bishop score even in patients with h/o cesarean (200-400 mcg q4-12h)

  • High-dose Pitocin also acceptable

  • D&E is an option if an experienced provider, although this can impede autopsy

o   >28 weeks: Manage as you normally would based on Bishop score. Use intracervical balloon for unfavorable cervix, rather than misoprostol.

 

             Pregnancy After Stillbirth

 

         -          Recurrence of stillbirth in low-risk women with negative work-up/unexplained stillbirth is low at 7.9-10.5/1000 and most of these occur preterm

         -          Preconception: detailed history, completion of any IUFD work-up not previously done, determine of recurrence risk, smoking cessation and weight loss counseling if applicable,

                    genetic counseling if applicable, DM screening

 

         -          1st trimester: dating/viability US and serum screening + NT

         -          2nd trimester: anatomy US at 18-20 weeks and MSAFP

         -          3rd trimester: US for IUGR after 28 weeks, kick counts at 28 weeks, antepartum monitoring…

 

         -          Evidence is limited re: antenatal monitoring, most initiate at 32-34 weeks or 1-2 weeks earlier than prior stillbirth, risk of recurrent stillbirth must be weighed against risk of iatrogenic PTB after               delivery for false+ testing

         -         Delivery at 39 weeks gestation, earlier only with +FLM by amnio