Great Message! Parents have made a Difference!

Parent Researcher Collaboration Japan 2006 Round Table parents and researchers together

2015 San Francisco ACOG First time stillbirth has been on the program!

3 hour course Etiology, management And prevention of stillbirth Session OB’s Guide to Stillbirth Bereavement (Rana Berry) Learn and lunch Stillbirth Evaluation

Highest contributor to perinatal mortality Rarely mentioned “How come no one mentioned stillbirth until we had one?” (Chris Wildsmith stillbirth parent)

First message: healthy habits, resources Smoking cessation healthy habits in pregnancy Exercise is good! Be mindful of fetal movement If diagnosed with maternal or fetal risk factors don’t be afraid of asking questions!

Fetal Movement message remains a very important message!

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, sent home Seen at 40 6/7 weeks still reported DFM on a Friday, NST done, plan for induction Monday 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 (age, parity) We know multiple consultations is associated with increased risk LETS TALK…

Lancet 1989 Randomized 60,000 women During the study stillbirth rate 2.8 in both arms when the pre-study rates were 4.0/1000 Randomize knowledge and vigilance? Hawthorn effect- participate a study for stillbirth Study it and you will reduce it!

Problem – RFM is a symptom Another symptom - Chest Pain Chest Pain is not necessarily an MI In primary care aetiology of chest pain Musculoskeletal (36-49%), Cardiac (15-18%), GI (8-19%), Pulmonary (5-10%), Psychiatric (8-11%) In ED – 4% of attendances with chest pain had MI

Pragmatic Practical 1.Use an existing tool to study DFM 2.In the setting of quality improvement study your outcomes with DFM. “and meet new friends”

Provider Response 50% of patients were evaluated within 1 hour after they reported decreased fetal movement to their provider. 7% were either admitted for observation or induction delivery 6% of babies were admitted to the neonatal intensive care unit after delivery. The rate of US increased from 11% to 18%

Duration Of DFM First Study(479) 31% <24 hrs 19% 24 hrs 50% >24 hrs (2-17 days) Risk of Stillbirth after complaint of DFM OR 4.1 ( )

Reduction of late stillbirth with the introduction of fetal movement information and guidelines Holm Tveit et al BMC 2009 Before and after design Consensus on guidelines, information to patients, and management for providers. 19,407 before compared to 46,143 after.

Reduction of late stillbirth with the introduction of fetal movement information and guidelines 14 hospitals information given at 18 week US (general information, getting to know your baby and kick chart, alarm limits). Guidelines to evaluate complaint (ultrasound)

Reduction of late stillbirth with the introduction of fetal movement information and guidelines Singleton 28 weeks or more Before vs After 6.3% 6.6% DFM Waiting >48Hrs 54% 49%* Use of Ultrasound 86% 94%* Stillbirth rate (total) 3.0/ /1000* * statistically significant

What are the useful tools Norway?... the peers’ experience of 2,930 cases of DFM Tools needed to detect pathology: TestUsageProved useful NST 97.5%3.2% Ultrasound94.0%11.6% Froen Seminars in Perinatology

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

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

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

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

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%

Optimal management of DFM Teach pt the importance of FM Assess the complaint NST to exclude imminent jeopardy Review maternal and fetal risk factors, (S D?) recommend US within the next hours if not available at the initial evaluation Have RN call the next day to inquired about FM Opinion by Fretts/ Froen

Case of DFM and placental problems JB 37 yr old G1, IUI pregnancy 28 weeks initial FH , pt turned and FH increased to 130’s occasional variable decel US done 1278g 69% normal fluid. Special thanks to Dr Drucilla Roberts

29 weeks, pt anxious slight increase in BP 144/ /72, urine negative for protein, PIH eval negative 31 weeks called 8:30 reports DFM for 1 hr -but because of impending storm asked to come for NST Seen at 10 am pt reports no FM NST non-reactive minimal variability with no accels or decels sent directly to hospital

JB Seen in hospital BPP 2/10 (2 for fluid) Classical c/section at 12:46 under spinal Male born 3 lb 12 oz APGARS 1,5, baby intubated and transferred to level three nursery Maternal post-partum uncomplicated At 18 months of age the boy is doing well, no issues related to prematurity

Placenta 238g, ~10 th percentile for 31 weeks GA Fetal thrombotic vasculopathy Meconium pigment Acute villous edema Features suggestive of villous maturational arrest

Mural Thrombus in Umbilical Vein

Nice Save!!!

One family NOT Part of the stillbirth Club!

RESEARCH

Large prospective observational cohort 10,000 singleton pregnancies Multi-center (8 sites) Case Western Reserve University Columbia University Indiana University University of Pittsburgh Northwestern University University of California – Irvine University of Pennsylvania University of Utah RTI International – DCC nuMoM2b

Sleep Position: A Possible Intervention? Sydney Stillbirth Study – Population-based case-control study of 103 women with stillbirth and 192 controls – Suspected IUGR (AOR 5.5) and supine sleeping in the last month of pregnancy (AOR 6.26) were the most strongly associated with increased odds of stillbirth – Subanalysis of SGA and maternal BMI ≥ 25 found SGA < 10 th percentile was overrepresented in the supine sleepers, in addition to being associated with late-pregnancy stillbirth SGA < 10 th percentile may be an effect modifier on the relationship between maternal BMI and supine sleeping Gordon A, et al. Obstet Gynecol, 2015 Slide courtesy of Dr. Andrea Edlow

Sydney Stillbirth Study Gordon A, et al. Obstet Gynecol, 2015

Effect of maternal position Compression of the aorta by the gravid uterus in the supine position NST reactivity at rest and labor Fetal pulse oximetry AFI Potentially modifiable SB risk factor > 28 weeks 1/3 time is spent in sleep 75% of pregnant women sleep in the left tilt in the late third trimester Effect of the mother’s overnight sleep position pattern on the fetus is unknown

Maternal Sleep Quality and Fetal ECG Study Maternal supine sleep in the late preterm period is an independent risk factor for short term non-reactive fetal ECG Maternal supine sleep in the late preterm period is an independent risk factor for short term non-reactive fetal ECG Women with SDB are more likely to have non-reactive fetal ECG Women with SDB are more likely to have non-reactive fetal ECG

Sleep Sub-study Primary Aim: Sleep disordered breathing (SDB) is a risk factor for APO among nulliparas SDB leads to pathophysiology similar to APO Increased sympathetic tone Oxidative stress Systemic inflammation Insulin resistance Hyperlipidemia SDB may be a modifiable risk factor for adverse pregnancy outcomes

NICHD Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-be (nuMoM2b)

Adverse Pregnancy Outcomes Pregnancies often complicated Preterm birth Preeclampsia / gestational high BP Fetal growth restriction Stillbirth Interventions in subsequent pregnancies to reduce the risk of recurrent pregnancy complications

Sleep Sub-study Protocol Large prospective observational cohort 10,000 singleton pregnancies Questionnaires / Clinical data Sleep position questions 3,630 singleton pregnancies Subset of the nuMoM2b parent cohort Objective measures of sleep disordered breathing (SDB) with Embletta Gold device

Embletta Nasal pressure, thoracic /abdominal inductance plethysmography, finger pulse oxymetry, snoring sounds, bipolar ECG In-home 7 channel polysomnography

Late Breaking Abstract #2 (Facco F for the NICHD nuMoM2b Network) SDB in mid-pregnancy was associated with hypertensive disorders of pregnancy aOR 1.62; 95% CI 1.10, 2.39 SDB in early and mid-pregnancy was associated with GDM Early aOR 3.62; 95% CI 2.01, 6.53 Mid aOR 2.79, 95% CI 1.62, 4.81

Induction as an intervention? Increasing maternal and perinatal risks after 39 weeks

When is the best time for delivery? Delivery Expectant management ≥ 42 weeks < 39 weeks weeks Slide courtesy of Dr. Bill Grobman

Perinatal Complications Pregnancies that continue beyond 39 weeks are associated with increased risks of: Stillbirth Meconium aspiration syndrome Mechanical ventilation Birth trauma Neonatal seizures/ICH/ encephalopathy Neonatal sepsis UA pH ≤7/BE < -12

Maternal Complications Pregnancies that continue beyond 39 weeks are associated with increased risks of: Cesarean delivery Operative vaginal delivery 3 rd and 4 th degree lacerations Febrile morbidity Hemorrhage

MacDorman et al; NVSS 2009;57:1-20 Prospective fetal mortality rate by single weeks of gestation: United States, 2005

Induction and cesarean delivery: Common wisdom Retrospective cohort studies  Induction of labor prior to 41 weeks of gestation is associated with an approximately 2-fold higher risk of cesarean delivery in nulliparous women

IOL prior to 41 weeks: HYPITAT IOL vs. expectant management for mild hypertensive disease after 36 weeks (N = 756) % P =.09 Cesarean Delivery

EIOL vs. expectant mgmt at 39 weeks: Perinatal consequences % Cheng AJOG 2012; Stock BMJ 2012 Perinatal mortality and morbidity 70% decreased odds of mec aspiration and mortality, respectively, in EIOL group

National study 10 years (Denmark (829,165 births) Hedegaard et al 2014 BMJ, increase of induction rate late in pregnancy reduced the stillbirth rate from 0.70 to 0.41/1000 ongoing pregnancies. Over the study period the c/s rate was steady at 20.4% but then dropped to 19.8% (P<0.01) EIOL vs. expectant management