HEARTBREAK IN PREGNANCY
| STILLBIRTH: A NEGLECTED OBSTETRICAL TRAGEGY —Catherine Y. Spong, MD, Chief, Pregnancy and Perinatology
Branch, National Institutes of Health, National Institute of Child Health & Human Development, Bethesda, Maryland
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| Incidence rates and reporting: ≈6.2 million pregnancies annually in the United States; ≈20% result in fetal loss; 15% to 16%
result in stillbirth; rate of stillbirth estimated 5 to 12 in 1000 live births (equal to mortality due to prematurity and sudden infant
death syndrome [SIDS] combined); general lack of information about stillbirth; ≥50% of stillbirths have undetermined
cause of death; currently, no significant research into etiology or pathogenesis of stillbirth; stillbirth 3 to 6 times more common
than SIDS; SIDS rate ≈0.6 per 1000 live births; stillbirth ≈1.8 per 1000 total births in general population and 4.0 per
1000 in women >35 yr of age; no uniform reporting requirements—information provided voluntarily; underreporting estimated
≈15% (rate believed higher); variability in quality and completion of fetal death report; no standard postmortem examination
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| Definitions: stillbirth—no signs of life present at or after birth; stillbirth rate—number of stillborn infants per 1000 born
(live and stillbirths); neonatal death—death of live-born infant at <29 days of life; perinatal death—death between 22
completed weeks gestation and 28 completed days after birth; classifications—antepartum or intrapartum; not early neonatal
death or spontaneous abortion; Oslo study—attempted to further classify and refine stillbirth; showed risk for sudden
intrauterine unexplained death increased with gestational age, high maternal age, high cigarette use, low education, and obesity;
unexplained antepartum fetal death should be baby that dies with no anomalies, no evidence of infection, no antepartum
bleeding or other placental problems; birth weight should be in >3rd percentile; there should be no maternal history of complications,
and death should occur before onset of labor; data showed unexplained stillbirth equal in number to those explained
at term
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| Causes of stillbirth: estimated ≤50% unexplained; ≈10% of stillbirths due to maternal medical conditions—
uncontrolled diabetes (especially type 1), systemic lupus erythematosus (SLE), hypertension, obesity, chronic renal disease,
thyroid disorders, and cholestasis of pregnancy; infection—10% to 15%; varies by gestational age; stillbirth at <28 wk
more commonly associated with infection than term stillbirth (estimated 2% of cases); infections likely to cause
stillbirth—parvovirus B19, cytomegalovirus (CMV), Treponema pallidum, Toxoplasma gondii, Listeria monocytogenes
, and chorioamnionitis; purported causes—Ureaplasma urealyticum, Mycoplasma hominis, Chlamydia trachomatis
, HIV, and others; evidence that parvovirus responsible for 8% of unexplained intrauterine fetal demise (IUFD);
parvovirus more common than traditional Toxoplasma gondii, rubella virus, CMV, and herpes simplex virus (TORCH)
agents as cause of stillbirth; testing for parvovirus should be included in TORCH screen when evaluating patient for stillbirth;
pregnancy-specific conditions—placental abruption, preeclampsia; intrapartum events; environmental factors—
prenatal alcohol exposure (especially in periconception period), cigarette smoking; genetic causes—mendelian disorders,
ie, autosomal recessive disorders, x-linked disorders, and confined placental mosaicism; many genetic causes unknown;
confined placental mosaicism more common in stillbirth; chromosomes 16, 3, 9, and 18 more commonly involved and associated
with stillbirth; thrombophilia—associated with fetal loss, especially if gestation >28 wk; odds of stillbirth increased
significantly with some or any combination of defects; antiphospholipid antibodies—indications for testing include history
of previous losses at >14 wk, fetal growth restriction (FGR), placental evidence of thrombosis, infarction, or vascular
damage; umbilical cord accidents—may account for 15% of stillbirths; possible mechanisms include cessation of blood
flow, intermittent disruption of blood flow, fetal blood loss, cord entanglement and abnormalities, and uterine ischemia
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| Evaluations: seeking cause of stillbirth and reviewing test results facilitates grieving process; counsel patient regarding risk
for recurrence and options for future pregnancies; recommended evaluations—thorough physical examination, notes,
photographs, clinical geneticist, autopsy, placental examination, x-rays (whole body anteroposterior view), karyotype (≈5%
abnormal, 25% with malformation), detailed obstetric and family history, serologic tests for TORCH agents, parvovirus
B19, bacterial infections, and fetal hemoglobin (Kleihauer-Betke); team approach, ie, obstetrician, neonatologist, pathologist,
and geneticist recommended; at diagnosis of stillbirth—review prenatal records and family history; obtain amniocentesis
for karyotype and assess for presence of FGR; at admission to hospital, obtain—blood glucose level (if 1-hr
glucose tolerance test not available), complete blood count (CBC) with platelet count, indirect Coombs test, VDRL test, and
urine toxicology screen; with evidence of FGR—lupus anticoagulant, anti-C peptide antibody, karyotype, and thrombophilia
work-up; if stillbirth unexplained—Kleihauer-Betke test, TORCH panel, and parvovirus B19; after delivery—
autopsy recommended; if no malformations observed, option to discard karyotype; with evidence of placental pathology,
order lupus anticoagulant and anticardiolipin antibody; American College of Obstetricians and Gynecologists
(ACOG)—examination of phenotype single most useful step in work-up of stillbirth; in ≈50% of cases, autopsy showed
cause of death differed from fetal death record; if indicated, obtain photographs and radiographs
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| Karyotyping: chromosome anomalies in ≈5% to 10% of stillbirths (tenfold increase over live births); obtain cells from amniotic
fluid, fascia lata, cord blood, or scrapings under diaphragm; indicated with history of recurrent losses, family history
of abnormal offspring, FGR, malformations, congenital anomalies, or hydrops fetalis; postnatal testing—failure
rate high (25% fail to grow); influenced by delivery-to-sampling interval, not gestational age or type of tissue sampled;
amniocentesis at time stillbirth diagnosed recommended; one study showed ≈35% had mendelian or chromosomal
causes; no normal fetuses had abnormal karyotype
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| Fetomaternal hemorrhage (FMH): one study showed FMH present in 14% of stillbirths (5% in another study); volume of
blood transfused 50% to 75% of total fetoplacental blood volume; all cases of FMH causing fetal death occurred in infants that
had unknown causes; do not test for FMH if cause of fetal death known
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| Antenatal management with previous stillbirth: antepartum testing at 32 wk or 1 wk before gestational age of previous
stillbirth recommended; data show recurrence rate of ≈1 in 300; of those, only 6% had abnormal antepartum test and it
was not related to gestational age of previous stillbirth
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| Relationship to SIDS: incidence ≈0.7 per 1000 live births; common associations between epidemiology of SIDS and stillbirth;
couple with baby who died of SIDS commonly had baby who was stillbirth; periconceptual alcohol use and smoking common
factors between stillbirth and SIDS; substantial decrease in number of babies dying of SIDS; more common in black women
than women of other races; infants dying of SIDS have diminished capacity to respond to autonomic challenge during vulnerable
development period; occurs only in first year of life; dysfunction or altered trajectory in development of autonomic nervous
system may be detected in utero and play role in stillbirth; fetus that does not have vulnerable period or insult in utero may be
susceptible in first year of life
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| TRAUMA DURING PREGNANCY —Carl V. Smith, MD, Professor and Chairman, Department of Obstetrics and Gynecology,
University of Nebraska School of Medicine, Omaha
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| Maternal mortality: trauma leading cause of nonobstetric maternal death worldwide; ≈1 million deaths annually; in
United States, trauma occurs in ≈10% of pregnant patients; motor vehicle accidents account for two thirds of trauma in
industrialized nations; domestic violence—epidemic; physician least likely to get positive response; improved response
if nurses question patient; accidental or intentional trauma (homicide or domestic violence) leading cause of maternal
mortality in women of reproductive age; prevalence 1% to 25%; goes unrecognized; patients reluctant to admit they are
victims; 60% of patients report 2 episodes during pregnancy
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| Fetal mortality: estimated 1300 to 4000 pregnancy losses annually in United States due to trauma; life-threatening maternal
trauma associated with ≥50% fetal mortality; incidence of placental abruption ≈50%; maternal mortality leading
cause of fetal mortality in trauma patients
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| Genitourinary: uterus and bladder intrapelvic organs, not intra-abdominal; by second and third trimester, intra-abdominal
cavity contains uterus and bladder; increased renal size probably due to increased blood flow to kidneys; hydronephrosis
possible as early as 10 wk (not necessarily pathologic); even in first trimester, dilatation of ureter common (more commonly
seen on right side than left); increase in renal blood flow leads to lowered normal values for serum creatinine and
serum urea nitrogen (BUN)
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| Gastrointestinal tract: increased progesterone elaborated by placenta reduces motility; prolonged gastric emptying; increased
risk for aspiration; uterine enlargement protects bowel from penetrating abdominal injury; enlarged and distended
abdomen may mask peritoneal signs; serum amylase level normal, but lipase level may be lower
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| Pulmonary system: hyperventilation occurs because of increased tidal volume, not increased respiratory rate; ≈50% increase
in minute ventilation; decreased functional residual capacity; reduced PCO 2 and reduced pH; net clinical effect is
partially compensated respiratory alkalosis; pregnant patient tolerates periods of apnea and hypoventilation poorly; supplemental
O2 always indicated to prevent desaturation
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| Cardiovascular system: cardiac output begins to increase in first trimester, eventually reaching 50% above prepregnancy
state; increase due to increase in stroke volume, not heart rate; blood volume increases by 50%; greater increase in
plasma volume than red blood cells
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| Hematologic changes: physiologic anemia protective against hemodynamic consequences of blood loss; once hemodynamic
instability evident, pregnant patient has lost large quantities of blood; mild leukocytosis common; increases in factors
VII, VIII, IX, and X aid in protecting patient against major blood loss, but may contribute to deep venous
thromboembolism and pulmonary embolism; fibrinogen increased; normal or low-normal level of fibrinogen indicates
significant consumption of clotting factors, and patient becoming increasingly ill; net result hypercoagulable state
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| General management: primary goal stabilization of mother; uterine displacement critical; prevention of aortocaval compression
essential (improves blood flow to fetus); put hip roll under spine board (not under hip) to prevent cervical spine
injury; uterus can be manually displaced off vena cava; computed tomography (CT) not contraindicated (fetus exposed to
≈3.5 rad); if feasible, shield abdomen with lead apron when taking cervical spine x-rays; if peritoneal lavage indicated,
perform under direct visualization
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| Blunt trauma: most common cause of trauma during pregnancy; outcome favorable in noncatastrophic trauma; assessment
of gestational age facilitates management decisions; uterus pelvic organ in first trimester; little increase in loss with noncatastrophic
trauma; before viability (<24 wk), focus should be on maternal condition, not fetal assessment; at >24 wk,
assessment of fetal status may provide information about adequacy of maternal resuscitation; Dahmus and Sibai
study—of 233 patients with blunt abdominal trauma, preterm delivery in only 2 (<1%); <2% of patients had fetal distress
after mild degrees of blunt abdominal trauma, and abruption occurred in only 2.6% of patients with blunt trauma;
study concluded coagulation studies and Kleihauer-Betke testing not helpful in patients who had noncatastrophic blunt
abdominal trauma; fetal injury and uterine rupture rare; placental abruption rare and seems to be independent of placental
location
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| Penetrating trauma: in second and third trimester, uterus intra-abdominal organ; incidence of fetal injury with stab or gunshot
wound disproportionately high; injury to maternal bowel much less (as is maternal mortality); penetration of uterus
strongly associated with fetal injury; decision to perform cesarean delivery complicated and controversial; should not be
performed at every laparotomy for trauma; study data show selective laparotomy may be appropriate in pregnant woman
with wounds confined to uterus
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| Pelvic fractures: commonly associated with concomitant injury to urinary tract; most patients do not require surgery; most
can deliver vaginally, unless fracture extensive (bony fragments in birth canal); seat belts—underutilized and often
worn improperly; encourage use and instruct on proper positioning; lap portion should be worn low across pelvis, below
uterus; data show increased compliance when seat belt use discussed at prenatal visit
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| Fetal assessment: <20- to 24-wk gestation—documentation of presence of fetal heart tones with ultrasonography or
Doppler probe sufficient; >20- to 24-wk gestation—continuous monitoring of fetal heart tones and uterine contractions
recommended; prolonged monitoring indicated with fetal heart rate decelerations, >4 uterine contractions per hour, ruptured
membranes, vaginal bleeding, uterine tenderness, or catastrophic maternal injury; placental abruption rare in trauma
patient if contractions less than every 10 min; more frequent uterine contractions associated with abruption in 20% of
cases; ACOG recommends minimum time for monitoring trauma patient 4 hr; FMH—300 mcg of anti-D immunoglobulin
protects against 30 mL of D-positive red blood cells or 15 mL of fetal cells; administer anti-D immunoglobulin to patient
with abdominopelvic trauma even if Kleihauer-Betke test negative
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| Postmortem cesarean delivery: fetal survival unlikely after 15 to 20 min of loss of maternal vital signs; best outcomes occur
within 4 min of cardiac arrest (based on isolated case reports); unknown whether cesarean delivery improves efficiency
of cardiopulmonary resuscitation (CPR)
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| Clinical protocol: stabilization of mother primary initial goal; identify major injuries; perform speculum examination to
exclude bleeding and ruptured membranes; if pregnancy not viable, document fetal heart tones; if pregnancy approaching
viability, hospitalize patient and initiate electronic fetal monitoring; if no evidence of excessive uterine activity, ruptured
membranes, vaginal bleeding, catastrophic maternal injury, or abnormal fetal heart rate, patient can undergo primary
treatment of injuries and be discharged from hospital
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Educational Objectives
| The goal of this program is to educate the listener about obstetric concerns relating to stillbirth and trauma. After hearing
and assimilating this program, the clinician will be better able to:
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 | 1. Define and identify the 2 classifications of stillbirth.
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| 2. State the conditions associated with stillbirth and its association with sudden infant death syndrome (SIDS).
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| 3. Discuss care for the patient with a stillbirth and research needs in the area of stillbirth.
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| 4. Identify the physiologic adaptations to pregnancy.
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| 5. Discuss care for the pregnant patient who is a trauma victim.
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Discussed on This Program
RhO (D) immune globulin (RhO [D] IGIM) [BayRho-D Full Dose, RhoGAM]
Suggested Reading
Collins JH: Umbilical cord accidents: human studies. Semin Perionatol 26(1):79, 2002; Connolly AM et al: Trauma and
pregnancy. Am J Perinatol 14(6):331, 1997; Froen JF et al: Risk factors for sudden intrauterine unexplained death: epidemiologic
characteristics of singleton cases in Oslo, Norway, 1986-1995. Am J Obstet Gynecol 184(4):694, 2001; Goldenberg
RL et al: Stillbirth: a review. J Matern Fetal Neonatal Med 16(2):79, 2004; Stephansson O et al: Maternal weight,
pregnancy weight gain, and the risk of antepartum stillbirth. Am J Obstet Gynecol 184(3): 463, 2001; Spong CY et al:
Stillbirth in obstetric practice: report of survey findings. J Matern Fetal Neonatal Med 14(1):39, 2003; Stone IK: Trauma
in the obstetric patient. Obstet Gynecol Clin North Am 26(3):459, 1999; Yost NP et al: A prospective observational study
of domestic violence during pregnancy. Obstet Gynecol 106(1):61, 2005
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty
reported nothing to disclose.
Dr. Spong was recorded at the 36th Annual OB/GYN Spring Symposium: Azaleas, Dogwoods, and Conditions Complicating
Pregnancy sponsored by the Medical University of South Carolina and held on April 4-6, 2005 in Charleston.
Dr. Smith was recorded at Clinical Approaches to Obstetrics and Gynecology, sponsored by the Medical College
of Georgia and held on July 11-14, 2005 at Kiawah Island, South Carolina. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
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