1. Slide 1
INVESTIGATION AND
ASSESSEMENT OF STILLBIRTHS
Dr: Salah Roshdy
Professor & Senior Consultant
Of Obstetrics & Gynecology
Qassim College of Medicine,KSA
Sohag University,Egypt
2. Slide 2
Definition
The World Health Organization (WHO)
classification of stillbirth is defined as fetal
loss in pregnancies beyond 20 weeks of
gestation,
or, if the gestational age is not
known, a birth weight of 500 g or more,
which corresponds to 22 weeks of
gestation in a normally developing fetus.
3. Slide 3
Definition
The World Health Organization definition
of perinatal death is death of the
offspring ‘‘occurring during late pregnancy
(at 22 completed weeks gestation and
over), during childbirth and up to seven
completed days of life.
’’ Stillbirths are subclassified as antepartum
(ie, the fetus died before the onset of
labor) or intrapartum (ie, the fetus died
after the onset of labor but before birth).
4. Slide 4
Definition
Neonatal death is subdivided into
early (in the first week of life) and
late (death in the second to fourth week
of life).
Although perinatal death strictly excludes
late neonatal deaths, most of these deaths
are related to obstetric events,
5. Slide 5
Prevalence
Stillbirth is a relatively common, but often
completely random occurrence. Based on
statistical data, it has been found that
the mean stillbirth rate in the United States is
approximately 1 in 115 births,
which is roughly 26,000 stillbirths each year,
or one every 20 minutes.
In developing countries where medical care can
be substandard or completely unavailable,
this rate is much higher.
6. Slide 6
Prevalence
1 out of 5 African women loses a baby
during her lifetime, compared with 1 in
125 in rich countries.
Each year nearly 3.3 million babies are
stillborn, and more than 4 million others
die within 28 days of being born.
Newborn deaths now contribute to about
40% of all deaths in children under five
years of age globally, and more than half
of infant mortality.
7. Slide 7
Prevalence
It is estimated that each year over a
million children who survive birth
asphyxia develop problems such
as cerebral palsy, learning
difficulties and other disabilities.
Nearly three quarters of all
neonatal deaths could be
prevented if women were
adequately nourished and
received appropriate care during
pregnancy, childbirth and the
postnatal period.
8. Slide 8 Stillbirth rates
1998 1999 2000 2001 2002 2003
W Mids 5.6 6.3 5.8 5.6 6.3 6.1
E&W 5.3 5.3 5.2 5.3 5.6 5.7 P<0.01
P<0.01
Stillbirth rates in the West Midlands and England & Wales
Rate/000 1998-2003
7
6
5
4
3
2
W Mids
1 E& W
0
1998 1999 2000 2001 2002 2003
9. Slide 9
Total No.of deliveries 8391
Stillbirth 80 (9.53 /1000)
Actual rate (4.78/1000)
booked Booked outside
40 40
10. Slide 10
ReCoDe (Relevant Condition at Death)
A. Fetal congenital, n-i hydrops, iso-immunisn,
feto-mat. hem, infection, TTTS,
fetal growth restriction
B. Umbilical Cord prolapse, constriction, velament. insertion
C. Placenta abruptio, previa, infarction, plac. disease
D. Amniotic Fluid chorioamnionitis, severe oligo, polyhydr.
E. Uterus rupture, anomalies
F. Maternal DM, Th, EHT, PIH. lupus, cholest, drugs
G. Intrapartum asphyxia; birth trauma
H. Trauma external; iatrogenic
I. Unclassified no relevant condn; no info available
16. Slide 16
Unexplained or unexplored?
Percentage of stillbirths remaining unexplained:
Ireland 93 (Walsh 1995)
Wales (Tuthill 1999)
UK (Cesdi 2001)
Sweden (Winbo 2001)
UK (Gardosi 1998)
Australia (Alessandri 1992)
New Z (Westgate 1985)
UK (Wagaarachchi 2002)
UK (Shankar 2002)
UK (Yudkin 1987)
USA (Ananth 1995)
USA (Lammer 1989)
France (Goffinet 1996)
France (Coujard 1975)
Norway (Rasmussen 2003)
USA (Brans 1984)
USA (Incerpi 1998)
Saudi Arabia (Meshle 2001)
Australia & NZ (Flenady 2003)
Australia (Robson 2001)
Canada (Huang 2000)
Norway (Frøen 2001)
Queensland (Flenady 2003)
Denmark (Kesmodel 2002)
India (Naidu 2001)
Sweden (Ahlenius 1995)
Ireland 70ies (Walsh 1995)
Sweden (Petersson 2002)
0 10 20 30 40 50 60 70
17. Slide 17
Common Risk Factors For
Stillbirth
1) Race and Socio-ecomonic factors
2) Advanced materanal age
multiple pregnancy, hypertension,
DM, abruptio placenta.
3) Obesity Macrosomia
GDM
PET
Hyperlipidemia
4) Thrombophilias
5) SLE
6) Medical risk factor
7) Hypertension
8) Infection
9) Multiple pregnancy
10) Infertility
18. Slide 18
Maternal disease & Risk of Stillbirth
All pregnancies 6-7
Hypertensive disorders
Chronic hypertension 5-25
Superimposed preeclampsia 52
PIH/mild preeclampsia 9
Severe preeclampsia21
Eclampsia18-48
HELLP syndrome51
19. Slide 19
Diabetes mellitus
Gestational diabetes5-10
Type 1 diabetes6-10
Type 2 diabetes35
Obesity15-20
Systemic lupus erythematosus40-150
Chronic renal disease
Mild renal insufficiency15
Moderate and severe renal
insufficiency32-200
21. Slide 21
ALGORITHM FOR ETIOLOGIC INVESTIGATION OF STILL BORN INFANTS
STILL BIRTH
Step 1 Step 3 Step 4
Maternal & Family
Cord Exam
History Stillbirth Examination
a. Physical Exam Step 5
b. Clinical photographs Placental Exam &
Step 2 c. Radiologic studies Investigations
Maternal Investigations d. Autopsy (full or partial)
e. Consult Step 6
Cytogenic
Investigations
Information used in Counseling
No Abnormalities found: Abnormalities found:
Empriric Counseling Specific Counseling
22. Slide 22
SIX STEPS IN THE ETIOLOGIC
INVESTIGATION OF A STILLBIRTH
To be done at the time of
diagnosis of a stillbirth
I. MATERNAL AND FAMILY HISTORY
A- Review past obstetric history
1) Emphasize details of previous
embryonic/fetal losses.
23. Slide 23
B-Review history present pregnancy
specifically with regard to:
1) Gestational age
2) Fetal growth
3) History of bleeding
4) Elevated blood pressure
5) Recent illness or possible viral
exposure
6) Medications during pregnancy
7) Maternal perception of fetal
movements in recent past
24. Slide 24
C-Review of antenatal
investigations:
1) Ultrasounds, including amniotic fluid
assessments
2) Laboratory investigations 9including
all routine antenatal blood work)
3) Prenatal diagnoses (triple screen,
amniocentesis, or CVS)
4) Fetal assessment (NT, biophysical
profiles, Doppler ultrasound)
D-Review Family History
25. Slide 25
11-MATERNAL INVESTIGATIONS
A. Ultrasound, if possible, to
evaluate for unknown
congential anomalies
B. CBC, platelet count
C. Kleihauer or equivalent
D. Blood group and antibody screen
E. HBA1C
F. Infectious and Microbiological
Investigations to be considered
when:
Infection is suspected as an
etiologic factor
Cause of stillbirth is not
obvious
26. Slide 26
1) Maternal serology (IgG and IgM)
for
a) Parvovirus
b) Toxoplasmosis
c) Cytomegalovirus
2) Review chart for HIV, syphilis and
rubella serology – send IgG and
IgM if not previously done as part
fo routine antenatal blood work.
3) Maternal blood culture for Listeria
4) Cervical/Vaginal cultures (aerobic)
27. Slide 27
To be done at the time of diagnosis of a
stillbirth
III. STILLBIRTH INVESTIGATIONS
A. Physical Exam
Perform a detailed physical examination of
the fetus and placenta.
B.Autopsy
A full autopsy should be encouraged on all
stillbirths. An autopsy is recommended even
if cause of death appear obvious. If the
parents will not consent to a full autopsy, a
limited autopsy should be encourage.
33. Slide 33
IV. CORD EXAMINATION
A. Length in cms
B. Number of vessels
C. Appearance – thin, thick, meconium,
stained, abnormalities
D. True knots – loose or tight
E. Cord Blood to be drawn- Possible only if a
FRESHS stillbirth (*)
1) CBC, Blood group, Direct Antibody
Test
2) Cytogenetics if there is evidence of
Congenital malformation on
ultrasound or seen on
examination of the stillbirth
34. Slide 34
Hydrops
Severe IUGR (5th%ile on ultrasound,
<3rd %ile birth weight)
Amniotic fluid abnormality – severe
oligohydramnios or polyhydramnios.
Ambiguous genitalia
Parental history of
a) Repeated miscarriages
b) Past unexplained stillbirth
c) Past unexplained neonatal demise
d) Previous child with congenital
anomalies
3) Culture of GBS, Listeria and coliforms if
infection is suspected as an etiologic
factor or the cause of the stillbirth is not
obvious
35. Slide 35
V. PLACENTA
A. Subamniotic swabs for aerobic and
anaerobic culture if infection
suspected as an etiologic factor or the
cause of the stillbirth is not obvious.
1. Swab between the amnion and the
chorion
B. Placenta and cord to pathology. Check
with Pathology lab to determine if
placenta should be sent:
1) Fresh
2) In saline
3) In formalin (tissue sample for
cytogenetics must be taken before
the placenta is fixed in formalin)
36. Slide 36
Test which can be done after the
autopsy/placental pathology, if cause
still unknown
A. Maternal Antiphospholipid
Antibody testing.
B. Investigations for thrombophilias,
for example:
1) Factor v lEIDEN
2) Protein S deficiency
3) Protein C deficiency
4) Antethrombin deficiency
5) Hyperhomocysteinemia
C. If suspicious – TB skintest of
mother
1) Further TB workup if positive
37. Slide 37
VI. CYTOGENETIC STUDIES
A. Cord blood and placental chorion and
amnion samples should be taken
immediately after delivery on all stillbirths
and sent for cytogenetic studies if:
1) The pathologist or clinician feels
cytogenetic studies should be
completed
2) As cord exam.
B. If there is a specific concern about
inheritable metabolic disease, portions of
the placental villi should be submitted in
cytogenetic culture media in order to
establish cell cultures for possible furhter
studies.
38. Slide 38
Checklist tool for the investigation of
a Stillbirth
A-When a stillbirth is diagnosed the following
information should be collected if
possible
1-Is the BC Antenatal record completed
and available for review?
a) Gestational age confirmed by early
ultrasound (<20 weeks)
b) Past obstetrical history completed
c) Medication use in pregnancy
documented
d) Blood pressures recorded
39. Slide 39
2-Has the woman has been
asked the following
questions;
a) When was the last time
she fetl fetal
movement?
b) Has there been any
recent vaginal
bleeding?
c) Has there been any
vaginal fluid loss?
d) Any history of possible
viral infection in the
pregnancy.
40. Slide 40
3-Are the following investigations on
the chart with results?
a) Previous ultrasound reports?
b)Routine antenatal blood work?
c) Any prenatal diagnostic tests
(Triple screen, amniocentesis,
CVS, etc.)?
d)Any recent antenatal fetal
monitoring.
41. Slide 41
4-Have the following
investigations been
organzied following the
diagnosis of the stillbirth?
a) Ultrasound tolook for
potential cause?
b) CBC, PLATELET COUNTS?
c) Kleihauer or equivalent?
d) Maternal blood group and
antibody screen?
e) HbA1C or result of 50g
glucose screen or GTT?
42. Slide 42
F) Infectious and microbiological
investigations if indicated
A. Maternal serology for:
Parvovirus
Toxoplasmosis
Cytomegalovirus
B. Maternal serology available for:
HIV
Syphilis
Rubella
C. Maternal blood culture for Listeria
D. Cervical/vaginal culture
43. Slide 43
B-After the stillbirth has been
delivered the following
information should be collected if
possible:
1. Gross physical examination of
the stillbirth?
2. Autopsy
Full autopsy consented to?
(encourage for all stillbirths if
possible)
Limited autopsy consented to?
a) External examination by
Pathologist?
Gross examination for
evidence of meconium?
44. Slide 44
b) Clinical photographs?
c) Radiographic studies?
d) Limited tissue biopsies?
Skin/tendon for cytogenetics
Liver for infection or storage
disorders?
Sampling of all organs, including
the CNS?
Sampling of organs outside the
CNS?
45. Slide 45
3-Clinical examination of the umbilical cord
4- Examination of the placenta.
C-Information that can be collected if the cause
of the stillbirth remains unknown after the
above investigations are completed.
1. Maternal Antiphospholipid Antibody
screening?
2. Investigations for other thrombophilias if
indicated?
3. TB skin test of mother if suspicious
(further work-up if positive?
47. Slide 47
Clinical external stillbirth examination
at the time of delivery
1-General - Global evaluation of the following
parameters:
A. State of preservation: fresh or
macerated (degree of maceration);
intact delivery or interventions required
to effect delivery.
B. Weight; gestational age; size for
gestational age
C. Measurements: circumference of head,
chest and abdomen; lengths of crown-
heel (with leg fully extended), crown-
rump and foot.
D. Colour: vernix white or meconium
stained; any lesions of skin such as
vesicles, bruising.
48. Slide 48
11-Craniofacial
A. General impression of normality or
abnormality
B. Quantitative relationships:
As craniofacial height is roughly equal to
the cranial vault height, abnormalities in
the ratio indicate microcephaly or
hydrocephaly
As the intercanthic distance is roughly
equal to the orbit width, an abnormal ratio
suggests hypo/hypertelorism.
Abnormal ear location - normally external
meatus lies above level of nostrils and
long axis of the ear is nearly vertical.
C. Specific structural defects
Anterior - flat nasal bridge; short flat
nose; small eyes; epicanthal folds; cleft
lip (uni/bilateral or median); cleft palate;
small mouth; down turning angles of
mouth; glossoptosis and
retro/prognathism
Posterior - anencephaly, iniencephaly and
encephalocele (usually occipital)
49. Slide 49
III. Neck
A. Abnormally short
B. Thickened nuchal fold and cystic hygroma
C. Cervical rachischisis and meningomyelocele
IV. Trunck
A. Overview - presence of edema; abdominal
distention and muscular development
B. Specific defects -
Ventral - omphalocele; umbilical
hernia; gastroschisis; diastasis recti
and rune belly
Dorsall - rachischisis; meningocele
and meningmyelocele
Cord insertion - normal location;
number of vessels and juxtrafetal
cord coarctationw ith abnormally
thin umbilical ring.
External genitalia - absent;
ambiguous and small or enlarged
structures (penis, scrotum, clitoris,
labia, vagina)
Anus - patency; imperforate;
stenotic and displaced interiorly
50. Slide 50
1V-Extremities
A. General - normal/abnormal lenth;
shortenignof particular segment and
muscle development.
B. Specific Defects –
Upper - distortions;
amputations; finger
lengths; shape and size;
poly/syndactyly and
abnormal palmar creases
Lower - positional
abnormalities of feet, toe
lengths, shape and size;
increased sandal space;
poly/syndactyly and
rockers-bottom deformity.
51. Slide 51
The Autopsy
Clinical Photographs of Stillbirths
Cytogenetic studies in stillbirth
investigations
52. Slide 52
Screening Options for Growth
Restriction
Ultrasound
Accurate dating (LMP,
OCCP, Lactating)
Early dating scan
DO NOT CHANGE
the EDD
Serial scans
Growth Charts, and
curves
Doppler
AFI / BPP
53. Slide 53
Planning intervention
Identify high risk groups
Increased level of surveillance (fetal and
placental Doppler ultrasound)
Elective delivery if surveillance indicates
fetal compromise or pregnancy reaches
given threshold of gestation
– Previous SB at 38 weeks
– IDDM at 39 weeks
– Post-dates pregnancy at term + 10 days
54. Slide 54
Predicting risk
High risk groups already identified
– IDDM
– Previous SB
– Connective tissue disease
Problem: most stillbirths occur to “low risk”
women
Solution: identify factors associated with
an increased risk of stillbirth
55. Slide 55
Where to start?
Majority of stillbirths have a placental
cause
– Abruption
– Pre-eclampsia
– IUGR
In the absence of overt risk factors, may
be able to identify high risk women within
a low risk population by screening tests of
placental function
56. Slide 56
Labor and delivery
When the diagnosis of growth restriction is made
AFI
Normal Oligohydramnios
At > 36-37 weeks At> 34- 36 weeks
OR
Assess Bishop’s score If Documented FLM
Adequate
Deliver
57. Slide 57
Protocol for Placental and Cord Evaluation
GROSS ASSESSMENT Weight (trimmed) ________g.
Placental weight:Fetal weight ratio ________ContourSize ________cm x ________cmPresence of Accessory Lobes Y
NInsertion of Cord CentralEccentric
Marginal
VelamentousMembranesMembranes ruptured ________cm from the margin.Membrane insertion NormalMarginal
Circum-marginate
CircumvallateMembrane character NormalAbnormal
Meconium stained
Blood stained
Other ______________________Placental discColor Red
Brown
Green
Pale
Other___________________________Odor Normal
FoulFeaturesBlood clot of maternal surface _________________________
Thrombi of fetal surface ______________________________
Fibrin(oid) deposition ________________________________
estimated percentage of surface involved ____%
Infarction _________________________________________
estimated percentage of volume involved _____%
Other_____________________________________________CordLength _______cm Diameter_______cm
Number of vessels _______FeaturesTrue knot(s) ________________________________________
False knot(s) ________________________________________
Torsion/twisting _____________________________________
Engorgement ________________________________________
Narrowing/constriction ________________________________
location ______________________________________
Abnormal Wharton's jelly ______________________________
_____________________________________________If Twins:Membrane ConfigurationMonochorionic-Monoamniotic
Monochorionic-Diamniotic
Dichorionic-DiamnioticPlacental VesselsAnastomotic vessels evident by gross inspection
Anastomotic vessels demonstrated by injection/perfusionHISTOLOGIC ASSESSMENTSections should be obtained as
follows:1. Cross section of umbilical cord
1b. Cross section just proximal to and just distal to any apparent cord constriction or cord stricture
2. Amniochorionic membrane roll
3. Fetal side placenta
4. Basal placenta
5. Sampling of any apparent abnormalities.Reporting should include general description of each section and description
(including severity and extent) ofInflammationChorioamnionitis
______________________________________________Cord Vasculitis
_______________________________________________Funisitis
____________________________________________________Villitis
______________________________________________________Infarction
__________________________________________________________Calcification(s)
______________________________________________________Fibrin Deposition
____________________________________________________Other
________________________________________________________________________________________________
_________________________Placental and Cord Examination
WiSSP home page
58. Slide 58
CLINICAL EXAMINATION OF STILLBORN INFANT [Clinical
description is often critical in the etiologic evaluation of stillborns.
Yet it is often given less attention than it deserves in most formal
postmortem evaluations. This is a suggested, simple and
relatively non-jargon filled outline for such a clinical evaluation; it
also includes space to provide brief notation of relevant prenatal,
perinatal and family history.]
I. General InformationDate ____ ____ ____ Baby's
Name____________________Mother's
Name____________________ Father's
Name____________________Hospital____________________P
arents' Address____________________Attending
Physician___________________ Person performing this
evaluation ________________________
II. Brief History
Prior Pregnancy History --
Pregnancies____Deliveries____Liveborn____ Spont. Ab.
____Ind. Ab.____Prior Stillborns____Relevant maternal history
and health [e.g. diabetes, hypertension, thyroid disease, etc.]
____________________________________________________
____________
Significant problems in this pregnancy
________________________
____________________________________________________
____________
Relevant family history [if not supplied in other records]
________________________
59. Slide 59
III. General Data on Baby
Gestational age:____weeks; How determined -- dates ultrasound clinical exam other
Degree of Maceration:
____Fresh; no skin peeling
____Slight; focal minimal skin slippage
____Mild; some skin sloughing, moderate skin slippage
____Moderate; much skin sloughing but no secondary compressive changes or decomposition
___Marked, advanced
IV. Measurements
Crown-heel [stretched] ______ Weight ______
Head Circumference ______
V. Head and Face
Head is --
collapsed_____
Anencephalic____
Apparently hydrocephalic_____
abnormally shaped_____; describe ____________________
relatively normal_____
check for and describe any:
scalp defects_____ ;________________________________________
cranial masses_____ ;________________________________________
Eyes --
normal_____; sunken_____; prominent_____;
abnormally far apart_____; abnormally close together____;
straight____;upslanting [V]____; or downslanting [/]___
on opening the lids the following is found --
eyelids are fused____
globes appear normal_____
globes are apparently absent____
eyes seem extremely small____
eyes seem extremely large____
opacities are present____
of the corneas____
of the lenses____
other________________________________________
Nose
60. Slide 60
Nose --
normal____; abnormally small____; abnormally large____;
asymmetric____
nostrils are: apparently patent____; obstructed____;
Single nostril only____
other ________________________________________
Mouth --
size: normal____; large____; small____
upper lip: intact____; cleft____; if cleft give location of cleft--
Left__, Right__, Bilateral__, Midline__
palate: intact____; cleft____
mandible: normal___; very small____; asymmetric____
other ________________________________________
Ears --
normal____; abnormal in form____; if abnormal describe or draw --
lowset____; posteriorly rotated____;
preauricular tags___; preauricular pits____
other ________________________________________
VI. Neck
normal____; short____; excess or redundant skin____;
cystic mass [hygroma]____
other ________________________________________
61. Slide 61 VII. Chest
normal____; asymmetric____; small and constricted____; barrelled____
other ________________________________________
VIII. Abdomen
normal____; flattened____; distended____;
wall defects____ [omphalocele____; gastroschisis____; hernia____]
umbilical cord -- number of vessels____ clinical abnormality [describe]
other ________________________________________
IX. Back
normal____; spina bifida____ [level of defect_____]; scoliosis____;
kyphosis____
other ________________________________________
X. Limbs
length: normal____; short____; long____
if short, what segment(s) seem short
form: normal____; asymmetric____; have missing parts____
describe any asymmetry or missing parts
position: normal____; clubfoot____; other positional abnormality____
describe if abnormal ________________________________________
62. Slide 62
Xa. Hands
normal appearing____; abnormal____ if abnormal, describe
fingers -- numbers present ___+___ [if not 5+5, describe ]
unusual form of fingers ____; describe
unusual position of fingers____; describe
abnormal webbing or syndactyly____; describe
Xb. Feet
normal appearing____; abnormal____ if abnormal, describe
toes -- numbers present___+___ [if not 5+5, describe ]
abnormal spacing of toes____; describe
XI. Genitalia
Anus -- normal____; imperforate____; other
Male --
penis -- normal___; hypospadias___[level of opening_________];
very small____; chordee____
other ________________________________________
scrotum -- normal____; abnormal____[describe ]
testes -- descended____; undescended____
other ________________________________________
Female --
urethral opening -- present____; absent/unidentifiable____
vaginal introitus -- present____; absent____
clitoris -- normal____; enlarged____; unidentifiable____
other ________________________________________
Ambiguous____; Describe
63. Slide 63
Classification of perinatal
death
1. non-preventable:
All the following criteria have to apply for a
death to be classified as non-preventable:
a) prenatal care and fetal surveillance were
adequate and appropriate.
b) Intervention was available, accessible,
appropriate and timely.
c) Circumstances surrounding a death were
not preventable.
64. Slide 64
2. Possibly preventable
unrecognized but detectable
fetal or newborn
compromised:
Not detected or not
appreciate.
Inappropriate, inadequate or
untimely intervention.
3. Ideally preventable
A sudden, compromising
event for the fetus or
newborn where intervention
was not possible on this
66. Slide 66
Facts and figures from The
World Health Report 2005
• “Children are the future of society and
their mothers are guardians of that
future.
• Yet this year, almost 11 million children
under five years of age will die from
causes that are largely preventable.
• Among them are 4 million babies who
will not survive the first month of life.
• On top of that 3.3 million babies will be
stillborn.
• At the same time, about half a million
women will die in pregnancy, childbirth
or soon after.”
The World Health Report 2005