evaluation of stillbirth katy kemnetz, pgy2. objectives evaluation of stillbirth

Evaluation of StillbirthKaty Kemnetz, PGY2

OBJECTIVESEvaluation of stillbirth

Objectives

The participant will be able to:Identify the conditions that have been best

demonstrated to cause stillbirthEvaluate a stillbirth using the most effective

workupAccurately formulate an etiology for a

stillbirth, when possibleEmploy the recmomended hospital policies

for management of stillbirth

OutlineDefinitionsCauses of stillbirthWorkup of stillbirthOther considerationsConclusions

DefinitionsEvaluation of Stillbirth

DefinitionsSpontaneous abortion Intrauterine fetal demiseMiscarriage<20 weeks gestation or <500g

“Stillbirth” >20 weeks gestation or >350g—state

dependent◦ 350g is 50%ile for 20 weeks gestation

◦ Illinois: >20 weeks gestation

“Delivery of a fetus showing no signs of life as indicated by the absence of breathing, heart beats, pulsation of the umbilical cord, or definite movements of voluntary muscles”

Does not include terminations of pregnancy or IOL for previable PPROM

CausesEvaluation of stillbirth

Causes of stillbirth>30 classification systems existImportant to distinguish between

◦Underlying cause of death◦Mechanism of death◦Risk factors

CLASSIFICATION OF STILLBIRTH

The National Institute of Child Health and Human Development

Classification of StillbirthEunice Kennedy Shriver workshop 2007National Institute of Child Health and Human

Development“An optimal classification system would

identify the pathophysiological entity initiating the chain of events that irreversibly lead to death”

Criteria for “cause”Epidemiologic data demonstrate an excess of stillbirth

associated with that conditionBiologic plausibility that the condition causes stillbirthEither rarely seen in association with live births or,

when seen in live births, results in a significant increase in neonatal death

A dose-response relationship exists◦ The greater the “dose” of the condition, the greater the risk of

fetal deathAssociated with evidence of fetal compromiseThe stillbirth likely would not have occurred if that

condition had not been present

Causes of stillbirth

Reddy, UM et al. “Stillbirth Classification—Developing an International Consensus for Research.” Obstetrics and Gynecology, Vol 114, No 4, October 2009.

INFECTIONSCauses of stillbirth—NICHHD workshop consensus

InfectionAssociated with 10-20% of stillbirths in

developed countriesHigher association with preterm birthSometimes difficult to prove causality

InfectionAscending infectionamniotic fluid or

fetusfetal pneumonitisHematogenous spreadvillitis

Kumar: Robbins pathologic basis of disease, 8th edition. 2009

Mechanism of fetal deathSevere maternal

illnessPlacental infection

that prevents oxygen/ nutrients from crossing to the fetus

Fetal infection that causes a lethal congenital deformity

Fetal infection that damages a vital organ

Precipitation of preterm labor, with intrapartum fetal death

Infections must be provenSigns of infection in the fetus

◦Evidence on autopsy of extensive organ involvement

Positive fetal culturesPositive maternal cultures plus

chorioamnionitis/ funisitis


Causes of IUFD: Spirochetes

Organism Maternal disease Comment

Treponema palladium Syphilis Major cause of stillbirth when maternal prevalence is high

Borrelia burgdorferi Lyme disease Tick borne; not a common cause of stillbirth

Borrelia recurrentis Relapsing fever Tick borne; common in the Western US; rare cause of stillbirth

Borrelia duttonii Relapsing fever Tick borne; sub-Saharan Africa; important cause of stillbirth

Leptospira interrogans Leptospirosis Uncommon

Severe placental

dysfunction

ProtozoaOrganism Maternal disease Comment

Trypanosoma brucei Trypanasomiasis Tsetse fly

Trypanosoma cruzi Chagas disease Kissing bug

Plasmodium falciparum Malaria Common in endemic areas

Plasmodium vivax Malaria Mosquitoes

Toxoplosmosis gondii Toxoplasmosis Rare

Severe placental

dysfunction

VirusesOrganism Maternal disease Comment

Parvovirus B19 Erythema infectiosum Likely the most common viral etiologic agent

Coxsackie A and B Various May be important

Echovirus Various Importance unknown

Enterovirus Various Importance unknown

Hepatits E virus Fulminant hepatic failure Especially in endemic areas

Poliovirus Polio Historic cause

Varicella zoster Chickenpox Rare cause

Rubella German measles Rare in developed countries

Mumps Parotitis Rare in developed countries

Rubeola Measles Rare in developed countries

Cytomegalovirus Asymptomatic Case reports

HIV AIDS Not likely causative

Influenza Respiratory tract infection Severe maternal illness

Causes lethal fetal

anomalies

BacteriaOrganism Maternal disease Comment

E. Coli Asymptomatic Probably the most common organism assoc with stillbirth

GBS Asymptomatic Common cause of stillbirth

Klebsiella Asymptomatic Common cause of stillbirth

Enterococcus Asymptomatic

Ureaplasma, mycoplasma Asymptomatic

Listeria monocytogenes Listeriosis Transmitted transplacentally

Chlamydia trachomatis Pelvic infection Suggested cause—case reports

Neisseria gonorrhoeae Pelvic infection Suggested cause—case reports

Candida albicans Thrush; vaginitis Confirmed in case reportsGoldenberg RL, Thompson C. The infectious origins of stillbirth. Am J Obstet Gynecol2003;189:861–73

Severe placental

dysfunction

Damage to vital organs

(brain, heart)

MATERNAL MEDICAL CONDITIONS

Causes of stillbirth—NICHHD workshop consensus

Simpson, LL. Maternal medical disease: Risk of Antepartum Fetal Death. Semin Perinatol, 2002, 26, 47.

Condition Estimated stillbirth rate per 1000 births in patients with the condition

All pregnancies 6-7

Chronic hypertension 5-25

Superimposed preeclampsia 52

Gestational hypertension and mild preeclampsia

9

Severe preeclampsia 21

Eclampsia 18-48

HELLP syndrome 51

Hypertensive disorders

Hypertensive disordersMechanism of fetal demise:

To consider cause of death:

Placental insufficiency◦ IUGR

◦ Abruption

If it progresses to eclampsia If it is associated with

placental abruption or fetal growth restriction



All pregnancies 6-7

Gestational diabetes 5-10

Type 1 diabetes 6-10

Type 2 diabetes 35

Diabetes

DiabetesMechanism of fetal demise:

To consider cause of death:

Congenital abnormalityPlacental dysfunctionObstructed labor and

intrapartum deathMacrosomia

◦ Fetal hyperglycemiafetal insulin productionexcessive fetal growthmetabolic acidosis

Signs of intrauterine or intrapartum asphyxia

LGA fetusSGA fetusSevere malformationPlacenta demonstrates

characteristic histologic findings◦ Large edematous villi

◦ Increased prominence of cytotrophoblasts



All pregnancies 6-7

Stable treated hyperthyroidism 0-36

Uncontrolled thyrotoxicosis 100-156

Subclinical hypothyroidism 0-15

Overt hypothyrodism 15-125

SLE 40-150

Mild chronic renal disease 15

Moderate and severe chronic renal disease 32-200

Cholestasis of pregnancy 12-30

Thyroid/renal disorders

Thyroid/renal disordersThyroid disorders Renal disordersGraves disease, where thyroid-

stimulating hormone receptor antibody causes fetal toxicosis

Untreated thyroid disorders

Linear relationship between maternal creatinine and risk of fetal demise

Systemic Lupus ErythematosusStillbirth rates are higher in the presence of HTN, nephritis, or APLCirculating auto-antibodies, anti-Ro, anti-La

Congenital heart block, hydrops

Maternal medical conditionsRisk is a continuum

Reddy, UM et al, 2009

THROMBOPHILIASCauses of stillbirth—NICHHD workshop consensus

ThrombophiliasAntiphospholipid syndrome Inherited thrombophilias Inflammation, thrombosis, and

infarction in the placentaClear histopathological or

clinical evidence of placental insufficiency

Factor V Leiden mutation, antithrombin III deficincy, prothrombin gene mutation, protein C deficiency, protein S deficiency

Placental infarction and thrombosis

Two large prospective cohort studies found no association between factor V Leiden mutation and pregnancy loss or placental insufficiency

Thrombophilias are common in healthy women with normal outcomes

Thrombophilias should only be considered as the cause of stillbirth with:• Evidence of placental

insufficiency such as fetal growth restriction or infarction and • Recurrent fetal loss

ALLOIMMUNIZATIONCauses of stillbirth—NICHHD workshop consensus

AlloimmunizationRed cell alloimmunization Platelet alloimmunization

Anti-Rhesus D, anti-Rhesus C, anti-Kell

Must have a positive indirect Coombs test

Antibody titers more than 1:16 (or 1:8 for anti-Kell)

Evidence of fetal anemia with hydrops

Evidence of fetal extramedullary hematopoeisis

HPA-1a, HPA-5a, HPA-4Maternal antibodies against

paternal and fetal platelet antigens

Parental platelet incompatibility for the pertinent antigen

Fetal thrombocytopeniaMassive intracranial

hemorrhage

CONGENITAL MALFORMATIONSCHROMOSOMAL ABNORMALITIES


CriteriaEpidemiologic data demonstrating an excess

of intrauterine mortalitySeen rarely in liveborn neonatesWhen seen in liveborn neonates, it

frequently results in neonatal deathBiologic plausibility that it can result in

death

Cause of death Stillbirth cases, % (out of total 2211 assessed)

Trisomy 21 1.53

Jugulolymphatic obstruction 1.45

Turner syndrome 1.09

Twin-twin transfusion syndrome 1.09

Anencephaly 1.0

Trisomy 18 0.81

Amnion disruption sequence 0.59

Lower mesodermal defects 0.50

Idiopathic nonimmune fetal hydrops 0.50

Trisomy 13 0.41

Congenital malformations

Reddy, UM et al. “Stillbirth Classification—Developing an International Consensus for Research.” Obstetrics and Gynecology, Vol 114, No 4, October 2009.

Chromosomal abnormalitiesIncidence

Cytogenetic abnormalities account for 6-13% of all stillbirths

This may be higher because 40-50% attempted karyotypes fail to grow

23% monosomy X, 23% trisomy 21, 21% trisomy 18, 8% trisomy 13


Chromosomal abnormalitiesAutosomal recessive disorders

Autosomal dominant disorders

Alpha thalessemia, Smith Lemli Opitz

Phenotype in lethal cases may differ from live cases

Skeletal dysplasiasMore often spontaneous

mutations

Firestein: Kelley’s Textbook of Rheumatology, 9th ed. Saunders 2012

FETOMATERNAL HEMORRHAGE


Fetomaternal hemorrhageThe cause 4% of all stillbirthsRisk factors:

◦Placental abruption◦Abdominal trauma◦Multiple gestation◦Abnormal fetal testing

Fetomaternal hemorrhageRisk of stillbirth depends on

◦Amount of hemorrhage◦Acute/chronic◦Gestational age

A threshold of 20 mL/kg of fetal bleeding is associated with increased risk of stillbirth

Autopsy confirmation of fetal anemia and hypoxia

PLACENTAL CAUSESCauses of stillbirth—NICHHD workshop consensus

Placental causesPlacenta previa, vasa

previa, neoplasmsPlacental abruption

has 8.9 relative risk of stillbirth◦May be considered the

cause of death if >30% of the placenta shows signs of abruption Reddy, UM et al, 2009

Placental causesAny disease that causes an SGA placenta

may result in stillbirth◦<5% expected weight for gestational age◦Preeclampsia, DM, HTN, renal, chronic infections

Any disease that causes an LGA placenta may result in stillbirth◦>95% expected weight for gestational age◦Hydrops fetalis, DM, syphilis

UMBILICAL CORD PATHOLOGY

Stillbirth classification—NICHHD workshop consensus

Umbilical cord pathologyAccount for 3.4-15% of stillbirthsVelamentous insertion

◦If it leads to a vasa previa or bleeding during laborUmbilical cord prolapse

◦Associated with prematurity, malpresentation, mutiparity, obstetric manipulation

Umbilical cord occlusion◦Cord prolapse, entanglement (mono-mono twins)◦Torsion◦Rupture, strictures, hematomas

Velamentous insertion

Umbilical cord pathologyNuchal cord

◦Occurs in up to 30% of normal pregnancies◦Not associated with an increased risk of stillbirth in

study of 14,000 deliveriesTrue knot

◦Also common in live births◦Grooving of the cord, constriction of the umbilical

vessels, edema, congestion, thrombosisrequired to claim it is the etiology

Isolated finding of a nuchal cord or a true knot at the time of

delivery is insufficient evidence that cord

accident is the cause of stillbirth

•Exclude other relevant causes of stillbirth•Find evidence of hypoxia and cord occlusion on postmortem examination

MULTIFETAL GESTATIONStillbirth classification—NICHHD workshop consensus

Complications of multifetal gestationMonochorionic

placentation◦Twin-twin

transfusion syndrome occurs in 9% of mono-di twins

◦Mortality can be 90% in untreated cases

Complications of multifetal gestationMono-mono twins

◦Cord entanglement, preterm birth, growth impairment, malformations, genetic abnormalities, vascular anastomoses

Gabbe: Obstetrics: normal and problem pregnancies, 6th ed. Saunders 2012

UTERINE COMPLICATIONSCauses of stillbirth—NICHHD workshop consensus

Uterine complicationsUterine rupture

◦Evidence of obstructed circulationUterine abnormalities

◦There is an increased risk of uterine abnormalities in women with recurrent pregnancy loss/stillbirth

◦Possibly due to poorly vascularized uterine tissue or space constraints

◦ Increased risk of PPROM, cervical insufficiency, preterm labor

◦Septate uterus has highest risk of stillbirth and placental abruption

WorkupEvaluation of stillbirth

IMPORTANCEWorkup of stillbirth

Importance of a stillbirth evaluationCounseling for risk of recurrencePossible intervention to reduce recurrence

riskFacilitate emotional closure and healing

Most stillbirths remain unexplainedIncomplete evaluation

◦Lack of clinician awareness◦Concerns of the family

Lack of single universally accepted classification scheme◦Difficult to assign a definitive cause

Unknown cause◦Sometimes despite thorough evaluation

OVERVIEWWorkup of stillbirth

OverviewRecommended studies Sometimes helpful Not generally useful

•Autopsy•Placental pathology•Karyotype•Kliehauer-Betke•Indirect Coombs•Acquired thrombophilia panel•Anti B2-glycoprotein ab•Toxicology screen

•Syphilis serology•Inherited thrombophilia panel•Glucose screening•TSH•CMV, toxoplasmosis, other infectious•Bile acids•Sonohysterogram

•Routine TORCH titers•ANA testing•Cultures of placental membranes

Silver et al, 2010

How do we know what works? “Evaluation of 1025 fetal deaths: proposed diagnostic

workup.” Korteweg FJ, Erwich JJHM, Timmer A, et al. AJOG 2012. Prospective cohort study in 50 Dutch hospitals Singleton IUFDs at >=20wks gestation, excluding pregnancy

terminations and intrapartum deaths Cause of death determined by a multidisciplinary panel (2

obstetricians, an OB resident, perinatal pathologist, neonatologist, genetics, microbiologist)◦ Initial demonstratable pathophysiological entity initiating the chain

of events that irreversibly led to death Contribution of each diagnostic test for determination of cause of

death was determined by the panel◦ Valuable for “establishing cause of death” or “excluding cause of

death”

MEDICAL HISTORYWorkup of stillbirth

Thorough medical/obstetrical history

Pregnancy complications

Maternal medical history

Genetic abnorm

alities

Substance usePregnancy history

FAM

ILY H

ISTO

RY

EXAMINATIONOF THE FETUSAND PLACENTA

Workup of stillbirth

EXAMINATION OF THE FETUSWorkup of stillbirth

Physician’s examWeight, head circumference, lengthPhotographs

◦Frontal and profie◦Whole body, face, extremeties, palms,

abnormalities


Finding Time of demise

Brown or red discoloration of the cord stumpDesquamation >1cm

>6 hours ago

Desquamation of face, back, abdomen >12 hours ago

Desquamation >5% of the body or >2 body zones

>18 hours ago

Skin color brown or tan >24 hours ago

Mummification(reduced soft tissue, leathery skin, dark brown)

>2 weeks ago

Time of demise

“Estimating the time of death in stillborn fetuses: III. External fetal examination; a study of 86 stillborns.” Genest DR, Singer DB. Obstet and Gynecol, 1992; 80(4), 593

AutopsyNew information that influences counseling in

26-51% of casesDutch study: valuable in 72% of casesHowever, it is performed in <50% of cases

◦Clinician hesitation to recommend autopsy◦Patient reservations

AutopsyAsk about patient reservationsEmphasize potential benefits to familyAllow the family ample time to hold the baby

and perform religious/cultural activities first

AutopsyMedical autopsies require consent of next-of-

kinConsent should be explicit enough that

parents can limit the autopsy procedure

Illinois Masonic Policy“An autopsy is an option for fetuses 20 weeks

or greater, but if clinically indicated or requested by the family, an autopsy can be offered before 20 weeks.”

If an autopsy is not requested, a Surgical Pathology examination can be performed

Components of an autopsyReview of the clinical history, laboratories,

antenatal imagingExternal examination:

◦Weight, crown-rump length, foot length, crown-heel length, occipital-frontal circumference

◦ Joint mobility, facial features, hands, feet, genitaliaIntraoral examination:

◦Pharynx, soft palate, uvulaTake into consideration changes from macerationPhotographs

External examination

Lentz: Comprehensive Gynecology, 6th ed


Components of an autopsyInternal examination

◦Y or T shaped incision on anterior trunk◦Organs examined in situ◦Heart sometimes opened in situ, sometimes

removed and fixed Vascular connections, septal defects

◦Organs removed in bloc for detailed dissection◦Spinal cord removed

Components of an autopsyBrain

◦Coronal scalp incision extending to behind the ears◦Skull is opened along cranial sutures◦Can extend into posterior neck for posterior fossa

(Dandy-Walker, Chiari) by removing occipital bone and cervical vertebrae

◦Brain is placed in formalin for 10 days before examination

BrainChiari malformation—downward displacement of medulla

Fligner 2011

Components of an autopsySamples of tissue for

◦Microscopic evaluation◦Viral cultures◦Bacterial cultures

Metabolic studies (Guthrie card)

Histologic exam


Extramedullary hematopoeisis in fetal liver in fetus with non-immune hydrops

What autopsy can identifyMarkers of IUGR

◦Head circumference percentile higher than weight percentile

◦Brain weight appropriate for gestation while other organs are appropriate for body weight

◦Altered brain weight:liver weightKidneys

◦Polycystic kidney diseaseCertain brain pathologiesCongenital anomalies

Kidneys

A: 28 wks, suspicious for autosomal recessive polycystic kidney diseaseB: confirmed on autopsyC: 22 wks, suspicious for ARPKDD: Autopsy showed diffuse renal cystic dysplasia

Autopsy can provide evidenceInfectionAnemiaHypoxia


Alternatives to autopsyPartial autopsy

◦Head-sparing autopsy (may miss CNS pathology)External examination by a trained pathologist

◦Can identify syndromes, congenital anomalies, timing of death, growth anomalies

◦Will likely miss fetal infections and internal anomalies

External examination with selected biopsies◦More likely to identify fetal infections

Alternatives to autopsy: MRI

◦Very good for CNS pathology Sometimes better than

autopsy, because fetal brain has high water content and liquefies

◦Fluid collections and effusions in the body

◦May miss cardiac anomalies, bowel anomalies

◦Cannot diagnose infections or metabolic disease

Advantages Disadvantages

MRI

24 wks, massive bilateral intraventricular hemorrhage

Fligner 2011

MRIImage-guided percutaneous biopsies

◦<50% success rate at obtaining tissue in one study◦Somewhat inferior to autopsy:

12 cases where “minimally invasive autopsy” provided equivalent information to autopsy

12 cases where “minimally invansive autopsy” provided inferior information than autopsy

2 cases where MRI and biopsy provided superior information

However, 73% of minimally invasive autopsies provided Information of equivalent clinical significance to autopsy

Fligner 2011

Alternatives to autopsyX ray

◦Useful for skeletal dysplasias◦Ribs/vertebrae as part of diagnosis of VACTERL or

diabetic fetopathy

X ray

Achondrogenesis 1b (absence of vertebral bodies)

Fligner 2011

X ray

Hemivertebrae (VACTERL)

Fligner 2011

EXAMINATION OF THE PLACENTA

Suggested workup of stillbirth

Examination of the placentaThe most valuable diagnostic test in most

studies◦Dutch study showed it to be valuable in 95% of

casesProvides additional information in 30% of

cases

Examination of the placentaWeight in relation to norms for gestational

ageEvidence of abruption, infarction,

thrombophiliasHemosiderin depositschronic abruption

◦Perivillious and marginal fibrin deposition◦Decidual necrosis◦Evidence of infarction

Examination of the placentaMultiples: chorionicity, vascular anastomoses

in multifetal gestationsCord: thrombosis, velamentous cord

insertion, vasa previaEvidence of infections

◦More common in preterm stillbirth◦Viral nuclic acid amplification◦Bacterial cultures

Examination of the placenta


GENETICSWorkup of stillbirth

KaryotypeAbnormal fetal karyotype noted in 8-13% of

all stillbirths and in >20% of those with morphologic abnormalities or IUGR

Dutch study: 11.9% prevalence of a chromosomal abnormality in the 362 IUFDs who underwent karyotyping◦37% trisomy 21, 16% monosomy X, 4% trisomy 13

Karyotype was valuable in 29% of cases

Cell cultureSuccessful in only ~50% of casesCells must be cultured in vitro—need

metaphase chromosomesOnly 1% of cells are dividing at any time

Cell cultureAcceptable cytologic specimens:

◦Amniotic fluid (yield is 84%) obtained by amniocentesis at the time of prenatal diagnosis of demise, 20-30mL

◦1x1cm placental block from below the cord insertion site on an unfixed placenta

◦1.5cm segement of umbilical cord◦Internal fetal tissue specimen (costochondral

junction, patella, lung, kidney, gonad, not skin)

Cell cultureCollect the specimen in a sterile manner

◦Prokaryotic cells outcompete and overgrow any human cells

Transport to the laboratory as soon as possible

Blood, amniotic fluid, chorionic villi at room temperature

Solid tissue transported on wet ice◦Lysosomal enzyme activity is inhibited at 4 C and

viability is maintained

Cell cultureMonolayer in situUp to 2 weeks for solid tissue cultureCells are swelled hypotonically, ruptured

(blowing on the coverslip) and metaphase chromosomes are spread

Automatic robotic harvestersStained with Giemsa or Wright

◦Results in banding pattern unique to each chromosome

KaryotypeCount the chromosomes in

each cell◦ Technologist at a microscope

Must analyze 15-20 cells to get karyotype

Photograph of karyogram or computer-assisted imaging◦ Manipulate/move

chromosomes◦ Pattern-recognition software to

generate karyogram◦ Computer must be double-

checked by a technologistStein 2011

If culture is unsuccessfulFlourescent in-situ hybridization (FISH)

◦Can test for the most common aneuploidies◦Can test for specific mutations

FISHMolecular probe

◦Fluorescent dye ◦Visualized using fluorescence microscopy

Molecular probes can be◦Specific to certain mutations◦A cocktail that coats the whole chromosome

FISH can be performed on metaphase or interphase chromosomes—cell culture not required for FISH

FISHDNA is denatured and allowed to hybridize

with the probeNonhybridized DNA is then counterstained

FISH

X, X

Trisomy 21

Normal chromosome 21

Stein 2011

FISH

Microdeletion in chromosome 22 associated with DiGeorge syndrome

Stein 2011

FISH

Probes must be known genes/mutations

Limited number of colors can be seen with fluorescent microscope

Does not require metaphase chromosomes

Can obtain karyotype and information about mutations

Advantages Disadvantages

FISH with computer-assisted system

Trisomy 18 and XXY

•Fluorochromes can be mixed•Too subtle for human eye, but computer assisted systems allow detection of all 24 chromosomes•Karyotype in interphase

Stein 2011

If live cells are not available: MicroarrayScreens the genome for copy number

variations (CNPs)◦BAC arrays provide overview of genome◦SNP arrays provide more detailed coverage with

probes on every 100-1000 base pairs◦Detects deletions, duplications, aneuploidies, unbalanced translocations with a gain/loss of sequences

Good for small deletions or cryptic changes◦Cytogenetics resolution is only 5-10Mb

Microarray

Stein 2011

LimitationsMany copy number changes are of uncertain

clinical significance◦More CNVs are being identified every day

It will not detect balanced translocations or inversions

Microarray versus karyotypingReddy UM et al, 2012: Prospective

population-based study of 532 stillbirths over 2 years

Patients with IUFD underwent:◦Interview, chart abstraction, postpartum

examination, placental pathology, karyotype analysis, and specimen collection

DNA analyzed with an SNP microarray with data aligned to Human Genome release 18

Microarray versus karyotypingBenign CNV: full length listed in any of three

databases of unaffected personsPathogenic CNV:

◦Evidence of pathogenicity in literature◦A gene listed in the OMIM database that is known to

cause developmental/lethal disease◦In a pathogenic database

Probably benign CNV: no evidence of pathogenicity in literature

Unknown CNV

Microarray versus karyotypingMicroarray analysis yielded a result in 87.4%

stillbirths compared to 70.5% for karyotype85.2% of these were benign, too small, or

probably benign2.6% were pathogenic, 6.9% were aneuploidMicroarray detected CNV consistent with

DiGeorge syndrome not detected by karyotype in 3 cases

Conclusions: microarray

Can detect mutations too small for FISH

Higher chance of obtaining a result

More expensiveAdvantages DisadvantagesGenetic workup should be guided by family history and presence of congenital anomalies

Consider microarray when karyotype fails to grow in culture

MATERNAL WORKUPWorkup of stillbirth

IMMEDIATE MATERNAL WORKUPWorkup of stillbirth

Laboratories (Recommended)CBCKliehauer-BetkeHuman parvovirus B-19 IgG and IgMLupus anticoagulant, anticardiolipin

antibodiesIndirect Coombs

◦If not already done antepartumToxicology screen

Kliehauer BetkeRecommended to do before induction of

laborHowever, given that only massive

hemorrhage is likely to cause fetal death, can also be done up to 2-3 weeks after delivery

In Dutch study, FMH was a contributing factor in 10.6% of the total cohort

Kliehauer Betke

Reddy et al 2009

Antiphospholipid antibodiesOne fetal death satisfies criteria for testingConfirm with repeat testing in 6-12 weeksMore likely positive if stillbirth was accompanied

by IUGR or severe preeclampsiaTwo dutch studies (750 fetal deaths in Korteweg et

al 2010, 1025 fetal deaths in Korteweg et al 2012) showed that neither testing for acquired nor inherited thrombophilia is valuable◦Unless the patient has a family or personal history of

thrombophilia

Given significant implications for future pregnancies and future health of the mother, testing is generally recommended

Laboratories (Sometimes useful)SyphilisTSHInherited thrombophilia workup

◦Factor V Leiden, prothrombin gene mutation, antithrombin III, fasting homocysteine

Glucose screeningSonohysterogram

◦Especially if loss associated with preterm labor, PPROM, cervical insufficiency, previable gestations, fetal malpresentation

Guided by maternal history and risk factors

Inherited thrombophiliaKorteweg et al 2010. Multicenter, prospective study.

750 singleton fetal deaths >=20 wks, excluding terminations

Tested for vWF, antithrombin, protein C, total and free protein S, prothrombin gene mutation, factor V Leiden

Cause of death classified by a panel“Except for vWF and paternal free protein S,

acquired and thrombophilic defects were not more prevalent after fetal death.”

However, many case-control studies show an association

Consider it in cases of severe placental pathology, IUGR, or a history of thrombosisHowever, remember that most women with these conditions will have uncomplicated pregnancies

Laboratories (unproven benefit)Toxoplasmosis, rubella, CMV, HSV, other

infections◦Viruses for which vaccines are prevalent are

uncommon in developed countries◦However, if autopsy, pathology, or history is suggestive, take maternal/neonatal serology, special tissue staines, testing for nucleic acids

ANA

Routine TORCHDutch study: of the women tested for TORCH,

17.0% had positive IgM for TORCH, parvo, syphilis, or hepatitis B

However only 1.8% of the total cohort had infection as the cause of death

POSTPARTUM MATERNAL WORKUP

Suggested workup of stillbirth

In selected casesPaternal karyotypeProtein S and C activityKliehauer-Betke

ConsiderationsEvaluation of stillbirth

AIMMC protocolAll intact fetal remains are sent to the

morgue within 4 hours of expiration, UNLESS a Surgical Pathology examination is requested

If a Surgical Pathology examination is requested◦Remains with a Surgical Pathology requisition to

the Histology Laboratory◦Central Transport and Nursing are responsible for

the initial transport of the body to the morgue and filling out the morgue census sheet

AIMMC protocolIf autopsy is requested, the fetus is obtained

from the morgueAn autopsy is an option for fetuses >=20

weeks◦But if clinically indicated or requested by the

family, an autopsy can be offered before 20 weeks

AIMMC protocolAutopsies are performed by AIMMC

pathologists◦Trained in fetal/neonatal autopsies◦Consult specialists when needed

Preliminary result in 24 hours; final result in 30 days

Genetic and molecular testing at ACLA fetus that undergoes an autopsy can still

receive private burial

Fetal death disposition notificationWithin 24 hours after an

abortion/miscarriage the mother must be informed of her right to determine the final disposition of the remains◦Private burial◦Cremation◦Hospital disposition

Fetal death disposition notification

http://www.idph.state.il.us/vitalrecords/pdf/Fetal%20Death%20Disposition%20Notification.pdf

Fetal death disposition notificationIf patient is unclear, sign the form without

making a selection◦RN notes “undecided at discharge”

Fax a copy to Mission and Spiritual Care at 773-296-5010 and place a copy in the chart

Mission and Spiritual Care or the Perinatal Loss Coordinator will follow up with the family

If the family can not be reached within 2 weeks, Pathology will initiate the procedure for hospital disposition

Private burialPerinatal loss coordinator has a list of funeral homesCremation or burialOnly a licensed funeral director can pick up the

fetus◦Parents provide the name to Health Information

ManagementCost: some funeral home directors reduce the rate

◦Medicaid pays for modest funeral and burialFor very young fetuses, parents advised that

there might not be many remains after autopsy

Hospital dispositionSt Luke’s Cemetery

◦5300 N. Pulaski Road, Chicago, IL 60630“Babyland,” exact location not identifiedNo charge

Perinatal loss coordinatorAlways notifiy Anna Zieba (pager 61-7656,

phone 61-7127)Always notify Mission and Spiritual Care 61-

5005◦Can provide religious services from most religions

ConsiderationsParents benefit from seeing/holding the

infant◦Warn them about how the baby will appear

Use the term “baby”Encourage parents to name the infant

◦Knowing the sex is importantFetal loss can be devastation at any

gestational ageDifferent cultures grieve in different ways

ConsiderationsKeepsakes and memory boxesChild Life specialist can aid with siblingsFor a loss in the ER, consider consulting

crisis if parents show signs of depressionBereavement care track after discharge

ConclusionsEvaluation of stillbirth

ConclusionsThe cause of a stillbirth is the initial

pathophysiologic entity that irreversibly led to fetal death

Cause must be proven with evidence of fetal harm

There are many benefits to finding a causeEncourage patients to allow an evaluation

within the boundaries of their personal and cultural values

ConclusionsRecommended laboratories are CBC,

Kliehauer-Betke, parvovirus B-19 IgG and IgM, lupus anticoagulant, anticardiolipin antibodies, and toxicology screen

Only perform other labs as indicated by maternal history

Encourage patients to receive an autopsy◦Partial autopsy and MRI are alternatives

Always send the placenta to pathology

ConclusionsEncourage karyotypingBase evaluation for other chromosomal

abnormalities on family history and results of other studies

Consider FISH or microarray if low likelihood of getting a result from cell culture

Utilize hospital resources for perinatal loss

THANK YOU

SourcesEvaluation of stillbirth

ACOG Practice Bulletin Number 102. “Management of Stillbirth.” American College of Obstetricians and Gynecologists. March 2009. acog.org

Fligner CL, Dighe M. “Fetal and Perinatal Death Investigation: Redefining the Autopsy and the Role of Radiologic Imaging.” Ultrasound Clin 6, 2011 (105-117).

Illinois Masonic Medical Center Perinatal Loss Policy. Policy 20.118.044 Korteweg FJ, Erwich JJHM, Timmer A, et al. “Evaluation of 1025 fetal deaths: proposed diagnostic

workup.” Am J Obstet Gynecol 2012; 206:53.e1-12.Korteweg FJ, Erwich JJHM, et al. “Prevalence of Parental Thrombophilic Defects after Fetal Death and Relation to Cause.” Obstet and Gynecol. August 2010, Vol 116, No 2, part 1.

Kumar: Robbins and Coltran Pathologic Basis of Disease, Professional Edition, 8th ed. 2009 Saunders, an imprint of Elsevier.

Reddy UM, Goldenburg R, et al. “Stillbirth Classification—Developing an International Consensus for Research.” Obstet and Gynecol. Oct 2009, Vol 114, No 4.

Reddy UM, Page GP, Saade GR. “Karyotype versus Microarray testing for Genetic Abnormalities after Stillbirth.” N Engl J med 367; 23, December 2012

Silver R, Heuser C. “Stillbirth Workup and Delivery Management.” Clin Obstet and Gynecol 2010; 53, 3.

Stein, CK. “Applications of cytogenetics in Modern Pathology.” McPherson: Henry’s Clinical Diagnosis and Management by Laboratory Methods, 22nd ed. 2011 Saunders, an imprint of Elsevier.

evaluation of stillbirth katy kemnetz, pgy2. objectives evaluation of stillbirth

Documents

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risk of fetal deathassociated

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maternal prevalence

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