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Ruth C Fretts MD, MPH Assistant Professor Harvard Medical School HVMA RFetts@vmed

Ruth C Fretts MD, MPH Assistant Professor Harvard Medical School HVMA RFetts@vmed.org. Stillbirth: Prevention Lets talk! Risk assessment Decreased fetal movement. Objectives. Put stillbirth on your radar Learn the risk factors for late stillbirth

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Ruth C Fretts MD, MPH Assistant Professor Harvard Medical School HVMA RFetts@vmed

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  1. Ruth C Fretts MD, MPHAssistant ProfessorHarvard Medical SchoolHVMARFetts@vmed.org Stillbirth: Prevention Lets talk! Risk assessment Decreased fetal movement

  2. 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

  3. “HOW COME NO ONE EVEN MENTIONED THE POSSIBILITY OF A STILLBIRTH UNTIL WE HAD ONE!

  4. Gardosi et al

  5. Gardosi et al

  6. 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

  7. 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

  8. 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

  9. 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)

  10. 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

  11. 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.

  12. 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… DFM at TERM Alex Heazell in press

  13. 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.

  14. Faster Trial your first obstetric visit • 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.

  15. Faster Trial • 38,033 women • Cost per Down’s syndrome detected was between $690,427 and $719,675 Ball et al Obstet Gynecol 2007

  16. Management and Perception of Risk 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.

  17. Management and Perception of Risk 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.

  18. US Data 2005 CDC

  19. Lets TalkThe First Step to Prevention

  20. Risk Assessment for Stillbirth Overweight / obesity OR 2 - 3Hytertension OR 1.5-4 Diabetes OR 1.5-3 AMA (35 -39) OR 1.5-2.2 AMA 40+ OR 2.4-5.0Smoking OR 2 - 4Low education/ socioecon. status OR 2 - 7Primiparity and multiparity OR 2 – 3IUGR OR 3 – 7Macrosomia OR 2 - 3Reduced fetal movements OR 4 - 12

  21. Stillbirth Risks: Preterm Term Froen Gardosi Acta Scan 2004

  22. Stillbirths Non SGA [cust] & Non-SGA [pop]: => OR 1 1.2 0.8-1.9 5.1 4.3-5.9 6.1 5.0-7.5 OR 95% C.I. SGA [pop] 8884 = 29% SGA [cust] 8887 = 29% SGA [both] 21931

  23. Diabetic Pregnancies Weekly Rate of of Fetal Death per 1000 Rouse et al 1995 Weeks of Gestation

  24. Gestational Age and Risk of Unexplained Stillbirth Yudkin et al Lancet 1987 Rate/1000 undelivered

  25. Obesity Timing of Stillbirth related To pre-pregnancy obesity Danish National Cohort Aagaard Nohr Obstet Gynecol 2005

  26. Reddy et al AJOG 2006

  27. National Collaborative Perinatal Project:The Risk of Stillbirth by Race Per 1000 Ongoing Pregnancy Gestational Age

  28. Heffner et al 2004

  29. NICU cs rate CS rate Tear Low 5min

  30. Induction of Labor Compared to Expectant Management in Nulliparous IND EXP OR Spont 15.6% 17.6% 1.9 (1.3to2.9) 9.0% 18.6% 19.9% 1.5 (1.1 to 2.1) 11.6% 22.5% 24.3% 1.6 (1.2 to 2.2) 15.2% 29.3% 33.1% 1.3 (1.0 to 1.8) 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 Perinatol26 (2006), pp. 392–402

  31. Optimal Timing of Delivery • Low risk- 37 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

  32. 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

  33. Stillbirths BirthsStillbirths Rate OR Total 13,133 62 4.6 Reference DFM 476 8 16.9 4.1 (1.8-9.06) (Femina) Chart DFM 15 29.4 8.0 (4.2-15.3)

  34. Femina Cases GA Wt % DFM Evaluation COD 1* 39 5/7 2673 3%4+ days NST 2d prior Placental* 2 41 3/7 4533 97% 12 hrs BPP 2d prior Unexp/infection 3 36 6/7 2470 4% 2 days No IUGR 4 37 4/7 2693 19% 1 day No Unexplained 5 36.5/7 3167 90% 12 hrs No Cord 6 34.0 1424 <1%2 days No IUGR/Cord 7 32 2/7 1830 32% 9 hours No Cord 8 30 4/7 1021 <1% 17 days No IUGR 9 28 2/7* 1221 19% 15 days NST 2d prior Unexplained Case 1 APGAR 0, 0, 3 permanent severe disability

  35. GA Wt % DFM Eval COD 10 38 6/7 3500 77% 18 hours No Unexp 11 39 4000 98% 1day No Cord 12 28 510 <1% 1day No IUGR 13 30 710 <1% 14 days No IUGR 14 39 4/7 3284 43% 2 days BPP 2 wks Cord 15 30 2/7 850 <1% 3 days None IUGR/PET 16 37 6/7 3080 58% 12 hr None Abruption DFM by Medical Chart Review

  36. Gestational Age and Percentile Growth for Stillbirths with a History of DFM

  37. What are the useful tools Norway?... the peers’ experience of 2,930 cases of DFM ... Tools needed to detect pathology: Test Usage Proved When Only When useful path. finding path. NST 97.5% 3.2% 23.4% 1.2% 9.9% Ultrasound 94.0% 11.6% 86.2% 8.7% 71.3% Doppler 47.3% 1.9% 14.1% 0.2% 1.7%

  38. Growth Restriction • 44% of the stillbirths were growth restricted (<4%)

  39. Normal pregnancy Froen et al 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. N=305

  40. The 2 h ”alarm” occurs in 9.1% of these pregnancies Pregnancy while smoking Froen et al Fewer FM towards term N=33 Pregnancy in smoking women. Mean time to count to ten is 00:12:44.

  41. The 2 h ”alarm” occurs in 9.0% of these pregnancies Pregnancy in obesity Froen et al Fewer FM towards term Fewer FM throughoutpregnancy N=111 Pregnancy in obese women (BMI > 30). Mean time to count to ten is 00:15:28.

  42. The 2 h ”alarm” occurs in 9.9% of these pregnancies Pregnancy ending in emergency Cesarean section 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.

  43. The 2 h ”alarm” occurs in 13.5% of these pregnancies Specificity 97.6% Pregnancy ending in preterm delivery Fewer FM towards time of delivery N=37 Pregnancy leading to a preterm delivery. Mean time to count to ten is 00:12:32.

  44. 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

  45. 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” Prevention

  46. Photogram published on AP taken By Erin Fogarty, her husband and Claire after she was stillborn at term.

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