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

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. 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

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 1. Triple screen 2. Quad screen 3. NT PAPP-A, free Bets-hCG 4. Integrated NT PAPP-A, free Bets-hCG, plus Quad screen 5. Serum Integrated PAPP-A plus Quad 6. Step wise Sequential 7. 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. Maternal Age at Delivery Risk of Trisomy 21 Risk of Any Chromosoma l abnormality 201/16671/526 301/9521/385 35-391/3781/192 40+1/1061/66 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

17. 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 201/16671/526 1/775*1/269* 301/9521/385 1/775*1/269* 35-391/3781/192 1/5021/156 40+1/1061/66 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. Management and Perception of Risk

18. US Data 2005 CDC AIDS Deaths (all)12,543 Deaths from Hepatitis5,529 SIDS2,230 Infant Deaths due to congenital anomalies 5,552 Cases of Salmonella related illness to peanut butter 600 Number of fatal listeria cases (7 were in elderly) 9 Stillbirths (20+ weeks)25,655

19. Lets Talk The First Step to Prevention

20. Risk Assessment for Stillbirth Overweight / obesityOR 2 - 3 HytertensionOR 1.5-4 DiabetesOR 1.5-3 AMA (35 -39)OR 1.5-2.2 AMA 40+OR 2.4-5.0 SmokingOR 2 - 4 Low education/ socioecon. statusOR 2 - 7 Primiparity and multiparityOR 2 – 3 IUGROR 3 – 7 MacrosomiaOR 2 - 3 Reduced fetal movementsOR 4 - 12

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

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

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

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

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

26. Reddy et al AJOG 2006

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

28. Heffner et al 2004

29. cs rate CS rate Tear NICU Low 5min

30. Induction of Labor Compared to Expectant Management in Nulliparous INDEXPORSpont 38 15.6%17.6%1.9 (1.3to2.9)9.0% 39 18.6% 19.9%1.5 (1.1 to 2.1)11.6% 40 22.5% 24.3%1.6 (1.2 to 2.2)15.2% 41 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 Perinatol 26 (2006), pp. 392–402

31. Optimal Timing of Delivery Low risk- 37 1/7 - 41 0/7 HT39 2/7- 40 1/7 AMA38 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 RateOR Total13,133624.6Reference DFM 476816.94.1 (1.8-9.06) (Femina) Chart DFM 1529.48.0 (4.2-15.3)

34. GAWt%DFMEvaluationCOD 1*39 5/72673 3%4+ daysNST 2d priorPlacental* 2 41 3/7453397%12 hrsBPP 2d priorUnexp/infection 336 6/72470 4%2 daysNoIUGR 437 4/7269319%1 dayNoUnexplained 536.5/7316790%12 hrsNoCord 634.01424<1%2 daysNoIUGR/Cord 732 2/7183032%9 hoursNoCord 830 4/71021<1%17 daysNoIUGR 928 2/7*122119%15 daysNST 2d priorUnexplained Femina Cases Case 1 APGAR 0, 0, 3 permanent severe disability

35. DFM by Medical Chart Review GAWt%DFM EvalCOD 1038 6/7350077%18 hoursNoUnexp 1139400098%1dayNoCord 1228 510<1%1dayNoIUGR 1330 710<1%14 daysNoIUGR 1439 4/7328443%2 daysBPP 2 wksCord 1530 2/7 850<1%3 daysNoneIUGR/PET 1637 6/7308058%12 hrNoneAbruption

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: TestUsageProvedWhenOnlyWhen usefulpath. findingpath. NST 97.5%3.2%23.4% 1.2%9.9% Ultrasound94.0%11.6%86.2% 8.7%71.3% Doppler47.3%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. Pregnancy while smoking Froen et al Pregnancy in smoking women. Mean time to count to ten is 00:12:44. N=33 Fewer FM towards term The 2 h ”alarm” occurs in 9.1% of these pregnancies

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

42. Pregnancy ending in emergency Cesarean section Pregnancy leading to delivery by an emergency Cesarean section. Mean time to count to ten is 00:13:37. N=81 Fewer FM towards term Fewer FM throughout pregnancy The 2 h ”alarm” occurs in 9.9% of these pregnancies

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

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

46. 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”

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