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Slide 1




              INVESTIGATION AND
          ASSESSEMENT OF STILLBIRTHS



                Dr: Salah Roshdy
          Professor & Senior Consultant
           Of Obstetrics & Gynecology
          Qassim College of Medicine,KSA
              Sohag University,Egypt
Slide 2

          Definition

           The World Health Organization (WHO)
            classification of stillbirth is defined as fetal
            loss in pregnancies beyond 20 weeks of
            gestation,
          or, if the gestational age is not
          known, a birth weight of 500 g or more,
            which corresponds to 22 weeks of
            gestation in a normally developing fetus.
Slide 3

          Definition

            The World Health Organization definition
             of perinatal death is death of the
             offspring ‘‘occurring during late pregnancy
             (at 22 completed weeks gestation and
             over), during childbirth and up to seven
             completed days of life.
          ’’ Stillbirths are subclassified as antepartum
             (ie, the fetus died before the onset of
             labor) or intrapartum (ie, the fetus died
             after the onset of labor but before birth).
Slide 4

          Definition

           Neonatal death is subdivided into
            early (in the first week of life) and
            late    (death in the second to fourth week
            of life).
          Although perinatal death strictly excludes
            late neonatal deaths, most of these deaths
            are related to obstetric events,
Slide 5


          Prevalence
          Stillbirth is a relatively common, but often
             completely random occurrence. Based on
             statistical data, it has been found that
          the mean stillbirth rate in the United States is
             approximately 1 in 115 births,
              which is roughly 26,000 stillbirths each year,
             or one every 20 minutes.
          In developing countries where medical care can
             be substandard or completely unavailable,
             this rate is much higher.
Slide 6


          Prevalence

                1 out of 5 African women loses a baby
                  during her lifetime, compared with 1 in
                  125 in rich countries.
                  Each year nearly 3.3 million babies are
                  stillborn, and more than 4 million others
                  die within 28 days of being born.
                  Newborn deaths now contribute to about
                  40% of all deaths in children under five
                  years of age globally, and more than half
                  of infant mortality.
Slide 7


          Prevalence

                It is estimated that each year over a
                   million children who survive birth
                   asphyxia develop problems such
                   as cerebral palsy, learning
                   difficulties and other disabilities.
                    Nearly three quarters of all
                   neonatal deaths could be
                   prevented if women were
                   adequately nourished and
                   received appropriate care during
                   pregnancy, childbirth and the
                   postnatal period.
Slide 8   Stillbirth rates
                                                1998        1999         2000          2001      2002         2003
                     W Mids                      5.6         6.3          5.8           5.6       6.3          6.1
                     E&W                         5.3         5.3          5.2           5.3       5.6          5.7   P<0.01
                                                                                                                     P<0.01

                                               Stillbirth rates in the West Midlands and England & Wales
                             Rate/000                                    1998-2003

                              7




                              6




                              5




                              4




                              3




                              2

                                                                                                           W Mids

                              1                                                                            E& W




                              0
                                        1998         1999         2000          2001          2002         2003
Slide 9




          Total No.of deliveries 8391

             Stillbirth 80 (9.53 /1000)
              Actual rate (4.78/1000)


            booked           Booked outside


            40                     40
Slide 10

   ReCoDe (Relevant Condition at Death)
  A. Fetal                      congenital, n-i hydrops, iso-immunisn,
                                feto-mat. hem, infection, TTTS,
                                fetal growth restriction
  B. Umbilical Cord    prolapse, constriction, velament. insertion
  C. Placenta          abruptio, previa, infarction, plac. disease
  D. Amniotic Fluid    chorioamnionitis, severe oligo, polyhydr.
  E. Uterus                     rupture, anomalies
  F. Maternal          DM, Th, EHT, PIH. lupus, cholest, drugs
  G. Intrapartum       asphyxia; birth trauma
  H. Trauma                     external; iatrogenic
  I. Unclassified      no relevant condn; no info available
Slide 11



                Stillbirths - ReCoDe
                                         Unclassified/
                                                           Congenital
                                        unknow n 16%
                                                         anomalies 15%




           Miscellaneous 5%
                                                                             Infection 3%



                Intrapartum
               Asphyxia 3%

               Mother 3%




               Placenta 9%



                                                                    Fetal grow th
                    Umbilical cord 3%
                                                                   restriction 43%
Slide 12




           Stillborn
           infant with
           Trisomy 21
Slide 13
Slide 14
Slide 15
Slide 16


           Unexplained or unexplored?
           Percentage of stillbirths remaining unexplained:

                      Ireland 93 (Walsh 1995)
                      Wales (Tuthill 1999)
                      UK (Cesdi 2001)
                      Sweden (Winbo 2001)
                      UK (Gardosi 1998)
                      Australia (Alessandri 1992)
                      New Z (Westgate 1985)
                      UK (Wagaarachchi 2002)
                      UK (Shankar 2002)
                      UK (Yudkin 1987)
                      USA (Ananth 1995)
                      USA (Lammer 1989)
                      France (Goffinet 1996)
                      France (Coujard 1975)
                      Norway (Rasmussen 2003)
                      USA (Brans 1984)
                      USA (Incerpi 1998)
                      Saudi Arabia (Meshle 2001)
                      Australia & NZ (Flenady 2003)
                      Australia (Robson 2001)
                      Canada (Huang 2000)
                      Norway (Frøen 2001)
                      Queensland (Flenady 2003)
                      Denmark (Kesmodel 2002)
                      India (Naidu 2001)
                      Sweden (Ahlenius 1995)
                      Ireland 70ies (Walsh 1995)
                      Sweden (Petersson 2002)


                                                      0   10   20   30   40   50   60   70
Slide 17
           Common Risk Factors For
                 Stillbirth
           1)  Race and Socio-ecomonic factors
           2)  Advanced materanal age 
               multiple pregnancy, hypertension,
               DM, abruptio placenta.
           3)  Obesity             Macrosomia
                                   GDM
                                   PET
                                   Hyperlipidemia
           4)  Thrombophilias
           5)  SLE
           6)  Medical risk factor
           7)  Hypertension
           8)  Infection
           9)  Multiple pregnancy
           10) Infertility
Slide 18

           Maternal disease & Risk of Stillbirth


            All pregnancies 6-7
            Hypertensive disorders
             Chronic hypertension 5-25
             Superimposed preeclampsia 52
              PIH/mild preeclampsia 9
              Severe preeclampsia21
              Eclampsia18-48
              HELLP syndrome51
Slide 19




           Diabetes mellitus
             Gestational diabetes5-10
             Type 1 diabetes6-10
              Type 2 diabetes35
           Obesity15-20
           Systemic lupus erythematosus40-150
           Chronic renal disease
              Mild renal insufficiency15
               Moderate and severe renal
             insufficiency32-200
Slide 20




           Thyroid disorders
             Stable treated hyperthyroidism0-
            36
              Uncontrolled thyrotoxicosis100-
            156
              Subclinical hypothyroidism0-15
               Overt hypothyroidism15-125
           Cholestasis of pregnancy 12-30
Slide 21
      ALGORITHM FOR ETIOLOGIC INVESTIGATION OF STILL BORN INFANTS

                                     STILL BIRTH


            Step 1                          Step 3                       Step 4
      Maternal & Family
                                                                        Cord Exam
           History                 Stillbirth Examination

                              a.   Physical Exam                         Step 5
                              b.   Clinical photographs            Placental Exam &
            Step 2            c.   Radiologic studies                Investigations
    Maternal Investigations   d.   Autopsy (full or partial)
                              e.   Consult                                Step 6
                                                                        Cytogenic
                                                                      Investigations


                              Information used in Counseling


               No Abnormalities found:                   Abnormalities found:
                Empriric Counseling                      Specific Counseling
Slide 22

             SIX STEPS IN THE ETIOLOGIC
           INVESTIGATION OF A STILLBIRTH

                     To be done at the time of
                   diagnosis of a stillbirth

            I.    MATERNAL AND FAMILY HISTORY
            A- Review past obstetric history
               1)   Emphasize details of previous
                   embryonic/fetal losses.
Slide 23



           B-Review history present pregnancy
              specifically with regard to:

             1) Gestational age
             2) Fetal growth
             3) History of bleeding
             4) Elevated blood pressure
             5) Recent illness or possible viral
                exposure
             6) Medications during pregnancy
             7) Maternal perception of fetal
                movements in recent past
Slide 24




           C-Review of antenatal
              investigations:
             1) Ultrasounds, including amniotic fluid
                assessments
             2) Laboratory investigations 9including
                all routine antenatal blood work)
             3) Prenatal diagnoses (triple screen,
                amniocentesis, or CVS)
             4) Fetal assessment (NT, biophysical
                profiles, Doppler ultrasound)

           D-Review Family History
Slide 25

           11-MATERNAL INVESTIGATIONS
           A.   Ultrasound, if possible, to
                evaluate for unknown
                congential anomalies
           B.   CBC, platelet count
           C.   Kleihauer or equivalent
           D.   Blood group and antibody screen
           E.   HBA1C
           F.   Infectious and Microbiological
                Investigations to be considered
                when:
                   Infection is suspected as an
                   etiologic factor
                   Cause of stillbirth is not
                   obvious
Slide 26




           1) Maternal serology (IgG and IgM)
              for
             a) Parvovirus
             b) Toxoplasmosis
             c) Cytomegalovirus
           2) Review chart for HIV, syphilis and
              rubella serology – send IgG and
              IgM if not previously done as part
              fo routine antenatal blood work.
           3) Maternal blood culture for Listeria
           4) Cervical/Vaginal cultures (aerobic)
Slide 27

           To be done at the time of diagnosis of a
           stillbirth

           III.   STILLBIRTH INVESTIGATIONS
             A.  Physical Exam
                 Perform a detailed physical examination of
                 the fetus and placenta.
             B.Autopsy
                 A full autopsy should be encouraged on all
                 stillbirths. An autopsy is recommended even
                 if cause of death appear obvious. If the
                 parents will not consent to a full autopsy, a
                 limited autopsy should be encourage.
Slide 28
Slide 29
Slide 30
Slide 31
Slide 32
Slide 33

           IV. CORD EXAMINATION
           A.    Length in cms
           B.    Number of vessels
           C.    Appearance – thin, thick, meconium,
                 stained, abnormalities
           D.    True knots – loose or tight
           E.    Cord Blood to be drawn- Possible only if a
                 FRESHS stillbirth (*)
                1) CBC, Blood group, Direct Antibody
                    Test
                2) Cytogenetics if there is evidence of
                       Congenital malformation on
                        ultrasound or seen on
                        examination of the stillbirth
Slide 34

               Hydrops
               Severe IUGR (5th%ile on ultrasound,
                  <3rd %ile birth weight)
               Amniotic fluid abnormality – severe
                  oligohydramnios or polyhydramnios.
               Ambiguous genitalia
               Parental history of
                 a) Repeated miscarriages
                 b) Past unexplained stillbirth
                 c) Past unexplained neonatal demise
                 d) Previous child with congenital
                     anomalies
           3)  Culture of GBS, Listeria and coliforms if
               infection is suspected as an etiologic
               factor or the cause of the stillbirth is not
               obvious
Slide 35

           V.        PLACENTA
                A.  Subamniotic swabs for aerobic and
                    anaerobic culture if infection
                    suspected as an etiologic factor or the
                    cause of the stillbirth is not obvious.
                   1. Swab between the amnion and the
                      chorion
                B. Placenta and cord to pathology. Check
                    with Pathology lab to determine if
                    placenta should be sent:
                   1) Fresh
                   2) In saline
                   3) In formalin (tissue sample for
                      cytogenetics must be taken before
                      the placenta is fixed in formalin)
Slide 36
           Test which can be done after the
           autopsy/placental pathology, if cause
           still unknown

           A.    Maternal Antiphospholipid
                 Antibody testing.
           B.    Investigations for thrombophilias,
                 for example:
                1) Factor v lEIDEN
                2) Protein S deficiency
                3) Protein C deficiency
                4) Antethrombin deficiency
                5) Hyperhomocysteinemia
           C.    If suspicious – TB skintest of
                 mother
                1) Further TB workup if positive
Slide 37
           VI.      CYTOGENETIC STUDIES
           A.     Cord blood and placental chorion and
                  amnion samples should be taken
                  immediately after delivery on all stillbirths
                  and sent for cytogenetic studies if:
                 1) The pathologist or clinician feels
                      cytogenetic studies should be
                      completed
                 2) As cord exam.
           B.     If there is a specific concern about
                  inheritable metabolic disease, portions of
                  the placental villi should be submitted in
                  cytogenetic culture media in order to
                  establish cell cultures for possible furhter
                  studies.
Slide 38
             Checklist tool for the investigation of
                          a Stillbirth

           A-When a stillbirth is diagnosed the following
               information should be collected if
               possible
              1-Is the BC Antenatal record completed
                   and available for review?
                  a) Gestational age confirmed by early
                      ultrasound (<20 weeks)
                  b) Past obstetrical history completed
                  c) Medication use in pregnancy
                      documented

                 d) Blood pressures recorded
Slide 39

           2-Has the woman has been
              asked the following
              questions;
               a) When was the last time
                  she fetl fetal
                  movement?
               b) Has there been any
                  recent vaginal
                  bleeding?
               c) Has there been any
                  vaginal fluid loss?
               d) Any history of possible
                  viral infection in the
                  pregnancy.
Slide 40




           3-Are the following investigations on
              the chart with results?
                a) Previous ultrasound reports?
                b)Routine antenatal blood work?
                c) Any prenatal diagnostic tests
                   (Triple screen, amniocentesis,
                   CVS, etc.)?
                d)Any recent antenatal fetal
                   monitoring.
Slide 41

           4-Have the following
              investigations been
              organzied following the
              diagnosis of the stillbirth?
               a) Ultrasound tolook for
                  potential cause?
               b) CBC, PLATELET COUNTS?
               c) Kleihauer or equivalent?
               d) Maternal blood group and
                  antibody screen?
               e) HbA1C or result of 50g
                  glucose screen or GTT?
Slide 42




           F) Infectious and microbiological
             investigations if indicated
             A. Maternal serology for:
                Parvovirus
                Toxoplasmosis
                Cytomegalovirus
             B. Maternal serology available for:
                HIV
                Syphilis
                Rubella
             C. Maternal blood culture for Listeria
             D. Cervical/vaginal culture
Slide 43
           B-After the stillbirth has been
              delivered the following
              information should be collected if
              possible:
             1. Gross physical examination of
                 the stillbirth?
             2. Autopsy
                 Full autopsy consented to?
                 (encourage for all stillbirths if
                 possible)
                 Limited autopsy consented to?
                a) External examination by
                    Pathologist?
                    Gross examination for
                    evidence of meconium?
Slide 44




           b) Clinical photographs?
           c) Radiographic studies?
           d) Limited tissue biopsies?
              Skin/tendon for cytogenetics
              Liver for infection or storage
              disorders?
              Sampling of all organs, including
              the CNS?
              Sampling of organs outside the
              CNS?
Slide 45




           3-Clinical examination of the umbilical cord
           4- Examination of the placenta.
           C-Information that can be collected if the cause
               of the stillbirth remains unknown after the
               above investigations are completed.
              1. Maternal Antiphospholipid Antibody
                  screening?
              2. Investigations for other thrombophilias if
                  indicated?
              3. TB skin test of mother if suspicious
                  (further work-up if positive?
Slide 46
Slide 47
           Clinical external stillbirth examination
                    at the time of delivery
           1-General - Global evaluation of the following
                 parameters:
              A.    State of preservation: fresh or
                    macerated (degree of maceration);
                    intact delivery or interventions required
                    to effect delivery.
              B.    Weight; gestational age; size for
                    gestational age
              C.    Measurements: circumference of head,
                    chest and abdomen; lengths of crown-
                    heel (with leg fully extended), crown-
                    rump and foot.
              D.    Colour: vernix white or meconium
                    stained; any lesions of skin such as
                    vesicles, bruising.
Slide 48
           11-Craniofacial
               A.    General impression of normality or
                     abnormality
               B.    Quantitative relationships:
                        As craniofacial height is roughly equal to
                        the cranial vault height, abnormalities in
                        the ratio indicate microcephaly or
                        hydrocephaly
                        As the intercanthic distance is roughly
                        equal to the orbit width, an abnormal ratio
                        suggests hypo/hypertelorism.
                        Abnormal ear location - normally external
                        meatus lies above level of nostrils and
                        long axis of the ear is nearly vertical.
               C.    Specific structural defects
                        Anterior - flat nasal bridge; short flat
                        nose; small eyes; epicanthal folds; cleft
                        lip (uni/bilateral or median); cleft palate;
                        small mouth; down turning angles of
                        mouth; glossoptosis and
                        retro/prognathism
                        Posterior - anencephaly, iniencephaly and
                        encephalocele (usually occipital)
Slide 49
           III.        Neck
                  A.     Abnormally short
                  B.     Thickened nuchal fold and cystic hygroma
                  C.     Cervical rachischisis and meningomyelocele
           IV.         Trunck
                  A.     Overview - presence of edema; abdominal
                         distention and muscular development
                  B.     Specific defects -
                                Ventral - omphalocele; umbilical
                                hernia; gastroschisis; diastasis recti
                                and rune belly
                                Dorsall - rachischisis; meningocele
                                and meningmyelocele
                                Cord insertion - normal location;
                                number of vessels and juxtrafetal
                                cord coarctationw ith abnormally
                                thin umbilical ring.
                                External genitalia - absent;
                                ambiguous and small or enlarged
                                structures (penis, scrotum, clitoris,
                                labia, vagina)
                                Anus - patency; imperforate;
                                stenotic and displaced interiorly
Slide 50

           1V-Extremities
              A.    General - normal/abnormal lenth;
                    shortenignof particular segment and
                    muscle development.
              B.    Specific Defects –

                         Upper - distortions;
                         amputations; finger
                         lengths; shape and size;
                         poly/syndactyly and
                         abnormal palmar creases
                         Lower - positional
                         abnormalities of feet, toe
                         lengths, shape and size;
                         increased sandal space;
                         poly/syndactyly and
                         rockers-bottom deformity.
Slide 51




              The Autopsy
              Clinical Photographs of Stillbirths
              Cytogenetic studies in stillbirth
               investigations
Slide 52

           Screening Options for Growth
           Restriction
           Ultrasound
            Accurate dating (LMP,
             OCCP, Lactating)
            Early dating scan

               DO NOT CHANGE
             the EDD

           Serial scans
           Growth Charts, and
             curves
           Doppler
           AFI / BPP
Slide 53

           Planning intervention

              Identify high risk groups
              Increased level of surveillance (fetal and
               placental Doppler ultrasound)
              Elective delivery if surveillance indicates
               fetal compromise or pregnancy reaches
               given threshold of gestation
               – Previous SB at 38 weeks
               – IDDM at 39 weeks
               – Post-dates pregnancy at term + 10 days
Slide 54

           Predicting risk

              High risk groups already identified
               – IDDM
               – Previous SB
               – Connective tissue disease
              Problem: most stillbirths occur to “low risk”
               women
              Solution: identify factors associated with
               an increased risk of stillbirth
Slide 55

           Where to start?

              Majority of stillbirths have a placental
               cause
               – Abruption
               – Pre-eclampsia
               – IUGR
              In the absence of overt risk factors, may
               be able to identify high risk women within
               a low risk population by screening tests of
               placental function
Slide 56

                      Labor and delivery
               When the diagnosis of growth restriction is made
                                    AFI
                          Normal              Oligohydramnios
             At > 36-37 weeks                  At> 34- 36 weeks

                                                       OR
           Assess Bishop’s score                 If Documented FLM

               Adequate

                                   Deliver
Slide 57




              Protocol for Placental and Cord Evaluation
           
              GROSS ASSESSMENT Weight (trimmed) ________g.
              Placental weight:Fetal weight ratio ________ContourSize ________cm x ________cmPresence of Accessory Lobes Y
               NInsertion of Cord CentralEccentric
               Marginal
               VelamentousMembranesMembranes ruptured ________cm from the margin.Membrane insertion NormalMarginal
               Circum-marginate
               CircumvallateMembrane character NormalAbnormal
               Meconium stained
               Blood stained
               Other ______________________Placental discColor Red
               Brown
               Green
               Pale
               Other___________________________Odor Normal
               FoulFeaturesBlood clot of maternal surface _________________________
               Thrombi of fetal surface ______________________________
               Fibrin(oid) deposition ________________________________
               estimated percentage of surface involved ____%
               Infarction _________________________________________
               estimated percentage of volume involved _____%
               Other_____________________________________________CordLength _______cm Diameter_______cm
               Number of vessels _______FeaturesTrue knot(s) ________________________________________
               False knot(s) ________________________________________
               Torsion/twisting _____________________________________
               Engorgement ________________________________________
               Narrowing/constriction ________________________________
               location ______________________________________
               Abnormal Wharton's jelly ______________________________
               _____________________________________________If Twins:Membrane ConfigurationMonochorionic-Monoamniotic
               Monochorionic-Diamniotic
               Dichorionic-DiamnioticPlacental VesselsAnastomotic vessels evident by gross inspection
               Anastomotic vessels demonstrated by injection/perfusionHISTOLOGIC ASSESSMENTSections should be obtained as
               follows:1. Cross section of umbilical cord
               1b. Cross section just proximal to and just distal to any apparent cord constriction or cord stricture
               2. Amniochorionic membrane roll
               3. Fetal side placenta
               4. Basal placenta
               5. Sampling of any apparent abnormalities.Reporting should include general description of each section and description
               (including severity and extent) ofInflammationChorioamnionitis
               ______________________________________________Cord Vasculitis
               _______________________________________________Funisitis
               ____________________________________________________Villitis
               ______________________________________________________Infarction
               __________________________________________________________Calcification(s)
               ______________________________________________________Fibrin Deposition
               ____________________________________________________Other
               ________________________________________________________________________________________________
               _________________________Placental and Cord Examination
               WiSSP home page
Slide 58




              CLINICAL EXAMINATION OF STILLBORN INFANT [Clinical
               description is often critical in the etiologic evaluation of stillborns.
               Yet it is often given less attention than it deserves in most formal
               postmortem evaluations. This is a suggested, simple and
               relatively non-jargon filled outline for such a clinical evaluation; it
               also includes space to provide brief notation of relevant prenatal,
               perinatal and family history.]
              I. General InformationDate ____ ____ ____ Baby's
               Name____________________Mother's
               Name____________________ Father's
               Name____________________Hospital____________________P
               arents' Address____________________Attending
               Physician___________________ Person performing this
               evaluation ________________________
              II. Brief History
              Prior Pregnancy History --
               Pregnancies____Deliveries____Liveborn____ Spont. Ab.
               ____Ind. Ab.____Prior Stillborns____Relevant maternal history
               and health [e.g. diabetes, hypertension, thyroid disease, etc.]
              ____________________________________________________
               ____________
              Significant problems in this pregnancy
               ________________________
              ____________________________________________________
               ____________
              Relevant family history [if not supplied in other records]
               ________________________
Slide 59




              III. General Data on Baby
              Gestational age:____weeks; How determined -- dates ultrasound clinical exam other
              Degree of Maceration:
              ____Fresh; no skin peeling
               ____Slight; focal minimal skin slippage
               ____Mild; some skin sloughing, moderate skin slippage
               ____Moderate; much skin sloughing but no secondary compressive changes or decomposition
               ___Marked, advanced
              IV. Measurements
              Crown-heel [stretched] ______ Weight ______
               Head Circumference ______
              V. Head and Face
              Head is --
              collapsed_____
               Anencephalic____
               Apparently hydrocephalic_____
               abnormally shaped_____; describe ____________________
               relatively normal_____
              check for and describe any:
              scalp defects_____ ;________________________________________
               cranial masses_____ ;________________________________________
              Eyes --
              normal_____; sunken_____; prominent_____;
              abnormally far apart_____; abnormally close together____;
              straight____;upslanting [V]____; or downslanting [/]___
              on opening the lids the following is found --
              eyelids are fused____
               globes appear normal_____
               globes are apparently absent____
               eyes seem extremely small____
               eyes seem extremely large____
               opacities are present____
              of the corneas____
               of the lenses____
               other________________________________________
              Nose
Slide 60




              Nose --
              normal____; abnormally small____; abnormally large____;
              asymmetric____
              nostrils are: apparently patent____; obstructed____;
           
               Single nostril only____
              other ________________________________________
              Mouth --
              size: normal____; large____; small____
              upper lip: intact____; cleft____; if cleft give location of cleft--
              Left__, Right__, Bilateral__, Midline__
              palate: intact____; cleft____
              mandible: normal___; very small____; asymmetric____
              other ________________________________________
              Ears --
              normal____; abnormal in form____; if abnormal describe or draw --
              lowset____; posteriorly rotated____;
              preauricular tags___; preauricular pits____
              other ________________________________________
              VI. Neck
              normal____; short____; excess or redundant skin____;
              cystic mass [hygroma]____
              other ________________________________________
Slide 61                        VII. Chest
 normal____; asymmetric____; small and constricted____; barrelled____
          other ________________________________________
                              VIII. Abdomen
                normal____; flattened____; distended____;
   wall defects____ [omphalocele____; gastroschisis____; hernia____]
 umbilical cord -- number of vessels____ clinical abnormality [describe]
          other ________________________________________
                                  IX. Back
   normal____; spina bifida____ [level of defect_____]; scoliosis____;
                               kyphosis____
          other ________________________________________
                                 X. Limbs
                 length: normal____; short____; long____
                   if short, what segment(s) seem short
       form: normal____; asymmetric____; have missing parts____
                 describe any asymmetry or missing parts
  position: normal____; clubfoot____; other positional abnormality____
  describe if abnormal ________________________________________
Slide 62




              Xa. Hands
              normal appearing____; abnormal____ if abnormal, describe
              fingers -- numbers present ___+___ [if not 5+5, describe ]
              unusual form of fingers ____; describe
              unusual position of fingers____; describe
              abnormal webbing or syndactyly____; describe
              Xb. Feet
              normal appearing____; abnormal____ if abnormal, describe
              toes -- numbers present___+___ [if not 5+5, describe ]
              abnormal spacing of toes____; describe
              XI. Genitalia
              Anus -- normal____; imperforate____; other
              Male --
              penis -- normal___; hypospadias___[level of opening_________];
              very small____; chordee____
              other ________________________________________
              scrotum -- normal____; abnormal____[describe ]
              testes -- descended____; undescended____
              other ________________________________________
              Female --
              urethral opening -- present____; absent/unidentifiable____
              vaginal introitus -- present____; absent____
              clitoris -- normal____; enlarged____; unidentifiable____
              other ________________________________________
              Ambiguous____; Describe
Slide 63

                Classification of perinatal
                          death
           1.   non-preventable:
                All the following criteria have to apply for a
                death to be classified as non-preventable:
           a)   prenatal care and fetal surveillance were
                adequate and appropriate.
           b)   Intervention was available, accessible,
                appropriate and timely.
           c)   Circumstances surrounding a death were
                not preventable.
Slide 64




           2.   Possibly preventable
             unrecognized but detectable
             fetal or newborn
             compromised:
            Not detected or not
             appreciate.
            Inappropriate, inadequate or
             untimely intervention.
           3.   Ideally preventable
                A sudden, compromising
                event for the fetus or
                newborn where intervention
                was not possible on this
Slide 65
Slide 66

           Facts and figures from The
           World Health Report 2005
               • “Children are the future of society and
                 their mothers are guardians of that
                 future.
               • Yet this year, almost 11 million children
                 under five years of age will die from
                 causes that are largely preventable.
               • Among them are 4 million babies who
                 will not survive the first month of life.
               • On top of that 3.3 million babies will be
                 stillborn.
               • At the same time, about half a million
                 women will die in pregnancy, childbirth
                 or soon after.”
               The World Health Report 2005
Slide 67

           Etiology OF Stillbirth

                         Booked   Unbooked
           D.M           9        6
           H.Disorder    5        7
           IUGR          3        11
           P.T           2        2
           Thyroid       1        0
           Cong.anomal   6        2
           Placental     3        3
           True knots    3        0
           Unexplained   8        9
Slide 68
Slide 69

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Etiology & prevention of stillbirth prof.salah

  • 1. Slide 1 INVESTIGATION AND ASSESSEMENT OF STILLBIRTHS Dr: Salah Roshdy Professor & Senior Consultant Of Obstetrics & Gynecology Qassim College of Medicine,KSA Sohag University,Egypt
  • 2. Slide 2 Definition  The World Health Organization (WHO) classification of stillbirth is defined as fetal loss in pregnancies beyond 20 weeks of gestation, or, if the gestational age is not known, a birth weight of 500 g or more, which corresponds to 22 weeks of gestation in a normally developing fetus.
  • 3. Slide 3 Definition  The World Health Organization definition of perinatal death is death of the offspring ‘‘occurring during late pregnancy (at 22 completed weeks gestation and over), during childbirth and up to seven completed days of life. ’’ Stillbirths are subclassified as antepartum (ie, the fetus died before the onset of labor) or intrapartum (ie, the fetus died after the onset of labor but before birth).
  • 4. Slide 4 Definition  Neonatal death is subdivided into early (in the first week of life) and late (death in the second to fourth week of life). Although perinatal death strictly excludes late neonatal deaths, most of these deaths are related to obstetric events,
  • 5. Slide 5 Prevalence Stillbirth is a relatively common, but often completely random occurrence. Based on statistical data, it has been found that the mean stillbirth rate in the United States is approximately 1 in 115 births, which is roughly 26,000 stillbirths each year, or one every 20 minutes. In developing countries where medical care can be substandard or completely unavailable, this rate is much higher.
  • 6. Slide 6 Prevalence 1 out of 5 African women loses a baby during her lifetime, compared with 1 in 125 in rich countries. Each year nearly 3.3 million babies are stillborn, and more than 4 million others die within 28 days of being born. Newborn deaths now contribute to about 40% of all deaths in children under five years of age globally, and more than half of infant mortality.
  • 7. Slide 7 Prevalence It is estimated that each year over a million children who survive birth asphyxia develop problems such as cerebral palsy, learning difficulties and other disabilities. Nearly three quarters of all neonatal deaths could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and the postnatal period.
  • 8. Slide 8 Stillbirth rates 1998 1999 2000 2001 2002 2003 W Mids 5.6 6.3 5.8 5.6 6.3 6.1 E&W 5.3 5.3 5.2 5.3 5.6 5.7 P<0.01 P<0.01 Stillbirth rates in the West Midlands and England & Wales Rate/000 1998-2003 7 6 5 4 3 2 W Mids 1 E& W 0 1998 1999 2000 2001 2002 2003
  • 9. Slide 9 Total No.of deliveries 8391 Stillbirth 80 (9.53 /1000) Actual rate (4.78/1000) booked Booked outside 40 40
  • 10. Slide 10 ReCoDe (Relevant Condition at Death) A. Fetal congenital, n-i hydrops, iso-immunisn, feto-mat. hem, infection, TTTS, fetal growth restriction B. Umbilical Cord prolapse, constriction, velament. insertion C. Placenta abruptio, previa, infarction, plac. disease D. Amniotic Fluid chorioamnionitis, severe oligo, polyhydr. E. Uterus rupture, anomalies F. Maternal DM, Th, EHT, PIH. lupus, cholest, drugs G. Intrapartum asphyxia; birth trauma H. Trauma external; iatrogenic I. Unclassified no relevant condn; no info available
  • 11. Slide 11 Stillbirths - ReCoDe Unclassified/ Congenital unknow n 16% anomalies 15% Miscellaneous 5% Infection 3% Intrapartum Asphyxia 3% Mother 3% Placenta 9% Fetal grow th Umbilical cord 3% restriction 43%
  • 12. Slide 12 Stillborn infant with Trisomy 21
  • 16. Slide 16 Unexplained or unexplored? Percentage of stillbirths remaining unexplained: Ireland 93 (Walsh 1995) Wales (Tuthill 1999) UK (Cesdi 2001) Sweden (Winbo 2001) UK (Gardosi 1998) Australia (Alessandri 1992) New Z (Westgate 1985) UK (Wagaarachchi 2002) UK (Shankar 2002) UK (Yudkin 1987) USA (Ananth 1995) USA (Lammer 1989) France (Goffinet 1996) France (Coujard 1975) Norway (Rasmussen 2003) USA (Brans 1984) USA (Incerpi 1998) Saudi Arabia (Meshle 2001) Australia & NZ (Flenady 2003) Australia (Robson 2001) Canada (Huang 2000) Norway (Frøen 2001) Queensland (Flenady 2003) Denmark (Kesmodel 2002) India (Naidu 2001) Sweden (Ahlenius 1995) Ireland 70ies (Walsh 1995) Sweden (Petersson 2002) 0 10 20 30 40 50 60 70
  • 17. Slide 17 Common Risk Factors For Stillbirth 1) Race and Socio-ecomonic factors 2) Advanced materanal age  multiple pregnancy, hypertension, DM, abruptio placenta. 3) Obesity Macrosomia GDM PET Hyperlipidemia 4) Thrombophilias 5) SLE 6) Medical risk factor 7) Hypertension 8) Infection 9) Multiple pregnancy 10) Infertility
  • 18. Slide 18 Maternal disease & Risk of Stillbirth All pregnancies 6-7 Hypertensive disorders Chronic hypertension 5-25 Superimposed preeclampsia 52 PIH/mild preeclampsia 9 Severe preeclampsia21 Eclampsia18-48 HELLP syndrome51
  • 19. Slide 19 Diabetes mellitus Gestational diabetes5-10 Type 1 diabetes6-10 Type 2 diabetes35 Obesity15-20 Systemic lupus erythematosus40-150 Chronic renal disease Mild renal insufficiency15 Moderate and severe renal insufficiency32-200
  • 20. Slide 20 Thyroid disorders Stable treated hyperthyroidism0- 36 Uncontrolled thyrotoxicosis100- 156 Subclinical hypothyroidism0-15 Overt hypothyroidism15-125 Cholestasis of pregnancy 12-30
  • 21. Slide 21 ALGORITHM FOR ETIOLOGIC INVESTIGATION OF STILL BORN INFANTS STILL BIRTH Step 1 Step 3 Step 4 Maternal & Family Cord Exam History Stillbirth Examination a. Physical Exam Step 5 b. Clinical photographs Placental Exam & Step 2 c. Radiologic studies Investigations Maternal Investigations d. Autopsy (full or partial) e. Consult Step 6 Cytogenic Investigations Information used in Counseling No Abnormalities found: Abnormalities found: Empriric Counseling Specific Counseling
  • 22. Slide 22 SIX STEPS IN THE ETIOLOGIC INVESTIGATION OF A STILLBIRTH To be done at the time of diagnosis of a stillbirth I. MATERNAL AND FAMILY HISTORY A- Review past obstetric history 1) Emphasize details of previous embryonic/fetal losses.
  • 23. Slide 23 B-Review history present pregnancy specifically with regard to: 1) Gestational age 2) Fetal growth 3) History of bleeding 4) Elevated blood pressure 5) Recent illness or possible viral exposure 6) Medications during pregnancy 7) Maternal perception of fetal movements in recent past
  • 24. Slide 24 C-Review of antenatal investigations: 1) Ultrasounds, including amniotic fluid assessments 2) Laboratory investigations 9including all routine antenatal blood work) 3) Prenatal diagnoses (triple screen, amniocentesis, or CVS) 4) Fetal assessment (NT, biophysical profiles, Doppler ultrasound) D-Review Family History
  • 25. Slide 25 11-MATERNAL INVESTIGATIONS A. Ultrasound, if possible, to evaluate for unknown congential anomalies B. CBC, platelet count C. Kleihauer or equivalent D. Blood group and antibody screen E. HBA1C F. Infectious and Microbiological Investigations to be considered when: Infection is suspected as an etiologic factor Cause of stillbirth is not obvious
  • 26. Slide 26 1) Maternal serology (IgG and IgM) for a) Parvovirus b) Toxoplasmosis c) Cytomegalovirus 2) Review chart for HIV, syphilis and rubella serology – send IgG and IgM if not previously done as part fo routine antenatal blood work. 3) Maternal blood culture for Listeria 4) Cervical/Vaginal cultures (aerobic)
  • 27. Slide 27 To be done at the time of diagnosis of a stillbirth III. STILLBIRTH INVESTIGATIONS A. Physical Exam Perform a detailed physical examination of the fetus and placenta. B.Autopsy A full autopsy should be encouraged on all stillbirths. An autopsy is recommended even if cause of death appear obvious. If the parents will not consent to a full autopsy, a limited autopsy should be encourage.
  • 33. Slide 33 IV. CORD EXAMINATION A. Length in cms B. Number of vessels C. Appearance – thin, thick, meconium, stained, abnormalities D. True knots – loose or tight E. Cord Blood to be drawn- Possible only if a FRESHS stillbirth (*) 1) CBC, Blood group, Direct Antibody Test 2) Cytogenetics if there is evidence of  Congenital malformation on ultrasound or seen on examination of the stillbirth
  • 34. Slide 34  Hydrops  Severe IUGR (5th%ile on ultrasound, <3rd %ile birth weight)  Amniotic fluid abnormality – severe oligohydramnios or polyhydramnios.  Ambiguous genitalia  Parental history of a) Repeated miscarriages b) Past unexplained stillbirth c) Past unexplained neonatal demise d) Previous child with congenital anomalies 3) Culture of GBS, Listeria and coliforms if infection is suspected as an etiologic factor or the cause of the stillbirth is not obvious
  • 35. Slide 35 V. PLACENTA A. Subamniotic swabs for aerobic and anaerobic culture if infection suspected as an etiologic factor or the cause of the stillbirth is not obvious. 1. Swab between the amnion and the chorion B. Placenta and cord to pathology. Check with Pathology lab to determine if placenta should be sent: 1) Fresh 2) In saline 3) In formalin (tissue sample for cytogenetics must be taken before the placenta is fixed in formalin)
  • 36. Slide 36 Test which can be done after the autopsy/placental pathology, if cause still unknown A. Maternal Antiphospholipid Antibody testing. B. Investigations for thrombophilias, for example: 1) Factor v lEIDEN 2) Protein S deficiency 3) Protein C deficiency 4) Antethrombin deficiency 5) Hyperhomocysteinemia C. If suspicious – TB skintest of mother 1) Further TB workup if positive
  • 37. Slide 37 VI. CYTOGENETIC STUDIES A. Cord blood and placental chorion and amnion samples should be taken immediately after delivery on all stillbirths and sent for cytogenetic studies if: 1) The pathologist or clinician feels cytogenetic studies should be completed 2) As cord exam. B. If there is a specific concern about inheritable metabolic disease, portions of the placental villi should be submitted in cytogenetic culture media in order to establish cell cultures for possible furhter studies.
  • 38. Slide 38 Checklist tool for the investigation of a Stillbirth A-When a stillbirth is diagnosed the following information should be collected if possible 1-Is the BC Antenatal record completed and available for review? a) Gestational age confirmed by early ultrasound (<20 weeks) b) Past obstetrical history completed c) Medication use in pregnancy documented d) Blood pressures recorded
  • 39. Slide 39 2-Has the woman has been asked the following questions; a) When was the last time she fetl fetal movement? b) Has there been any recent vaginal bleeding? c) Has there been any vaginal fluid loss? d) Any history of possible viral infection in the pregnancy.
  • 40. Slide 40 3-Are the following investigations on the chart with results? a) Previous ultrasound reports? b)Routine antenatal blood work? c) Any prenatal diagnostic tests (Triple screen, amniocentesis, CVS, etc.)? d)Any recent antenatal fetal monitoring.
  • 41. Slide 41 4-Have the following investigations been organzied following the diagnosis of the stillbirth? a) Ultrasound tolook for potential cause? b) CBC, PLATELET COUNTS? c) Kleihauer or equivalent? d) Maternal blood group and antibody screen? e) HbA1C or result of 50g glucose screen or GTT?
  • 42. Slide 42 F) Infectious and microbiological investigations if indicated A. Maternal serology for: Parvovirus Toxoplasmosis Cytomegalovirus B. Maternal serology available for: HIV Syphilis Rubella C. Maternal blood culture for Listeria D. Cervical/vaginal culture
  • 43. Slide 43 B-After the stillbirth has been delivered the following information should be collected if possible: 1. Gross physical examination of the stillbirth? 2. Autopsy Full autopsy consented to? (encourage for all stillbirths if possible) Limited autopsy consented to? a) External examination by Pathologist? Gross examination for evidence of meconium?
  • 44. Slide 44 b) Clinical photographs? c) Radiographic studies? d) Limited tissue biopsies? Skin/tendon for cytogenetics Liver for infection or storage disorders? Sampling of all organs, including the CNS? Sampling of organs outside the CNS?
  • 45. Slide 45 3-Clinical examination of the umbilical cord 4- Examination of the placenta. C-Information that can be collected if the cause of the stillbirth remains unknown after the above investigations are completed. 1. Maternal Antiphospholipid Antibody screening? 2. Investigations for other thrombophilias if indicated? 3. TB skin test of mother if suspicious (further work-up if positive?
  • 47. Slide 47 Clinical external stillbirth examination at the time of delivery 1-General - Global evaluation of the following parameters: A. State of preservation: fresh or macerated (degree of maceration); intact delivery or interventions required to effect delivery. B. Weight; gestational age; size for gestational age C. Measurements: circumference of head, chest and abdomen; lengths of crown- heel (with leg fully extended), crown- rump and foot. D. Colour: vernix white or meconium stained; any lesions of skin such as vesicles, bruising.
  • 48. Slide 48 11-Craniofacial A. General impression of normality or abnormality B. Quantitative relationships: As craniofacial height is roughly equal to the cranial vault height, abnormalities in the ratio indicate microcephaly or hydrocephaly As the intercanthic distance is roughly equal to the orbit width, an abnormal ratio suggests hypo/hypertelorism. Abnormal ear location - normally external meatus lies above level of nostrils and long axis of the ear is nearly vertical. C. Specific structural defects Anterior - flat nasal bridge; short flat nose; small eyes; epicanthal folds; cleft lip (uni/bilateral or median); cleft palate; small mouth; down turning angles of mouth; glossoptosis and retro/prognathism Posterior - anencephaly, iniencephaly and encephalocele (usually occipital)
  • 49. Slide 49 III. Neck A. Abnormally short B. Thickened nuchal fold and cystic hygroma C. Cervical rachischisis and meningomyelocele IV. Trunck A. Overview - presence of edema; abdominal distention and muscular development B. Specific defects - Ventral - omphalocele; umbilical hernia; gastroschisis; diastasis recti and rune belly Dorsall - rachischisis; meningocele and meningmyelocele Cord insertion - normal location; number of vessels and juxtrafetal cord coarctationw ith abnormally thin umbilical ring. External genitalia - absent; ambiguous and small or enlarged structures (penis, scrotum, clitoris, labia, vagina) Anus - patency; imperforate; stenotic and displaced interiorly
  • 50. Slide 50 1V-Extremities A. General - normal/abnormal lenth; shortenignof particular segment and muscle development. B. Specific Defects – Upper - distortions; amputations; finger lengths; shape and size; poly/syndactyly and abnormal palmar creases Lower - positional abnormalities of feet, toe lengths, shape and size; increased sandal space; poly/syndactyly and rockers-bottom deformity.
  • 51. Slide 51  The Autopsy  Clinical Photographs of Stillbirths  Cytogenetic studies in stillbirth investigations
  • 52. Slide 52 Screening Options for Growth Restriction Ultrasound  Accurate dating (LMP, OCCP, Lactating)  Early dating scan DO NOT CHANGE the EDD Serial scans Growth Charts, and curves Doppler AFI / BPP
  • 53. Slide 53 Planning intervention  Identify high risk groups  Increased level of surveillance (fetal and placental Doppler ultrasound)  Elective delivery if surveillance indicates fetal compromise or pregnancy reaches given threshold of gestation – Previous SB at 38 weeks – IDDM at 39 weeks – Post-dates pregnancy at term + 10 days
  • 54. Slide 54 Predicting risk  High risk groups already identified – IDDM – Previous SB – Connective tissue disease  Problem: most stillbirths occur to “low risk” women  Solution: identify factors associated with an increased risk of stillbirth
  • 55. Slide 55 Where to start?  Majority of stillbirths have a placental cause – Abruption – Pre-eclampsia – IUGR  In the absence of overt risk factors, may be able to identify high risk women within a low risk population by screening tests of placental function
  • 56. Slide 56 Labor and delivery When the diagnosis of growth restriction is made AFI Normal Oligohydramnios At > 36-37 weeks At> 34- 36 weeks OR Assess Bishop’s score If Documented FLM Adequate Deliver
  • 57. Slide 57  Protocol for Placental and Cord Evaluation   GROSS ASSESSMENT Weight (trimmed) ________g.  Placental weight:Fetal weight ratio ________ContourSize ________cm x ________cmPresence of Accessory Lobes Y NInsertion of Cord CentralEccentric Marginal VelamentousMembranesMembranes ruptured ________cm from the margin.Membrane insertion NormalMarginal Circum-marginate CircumvallateMembrane character NormalAbnormal Meconium stained Blood stained Other ______________________Placental discColor Red Brown Green Pale Other___________________________Odor Normal FoulFeaturesBlood clot of maternal surface _________________________ Thrombi of fetal surface ______________________________ Fibrin(oid) deposition ________________________________ estimated percentage of surface involved ____% Infarction _________________________________________ estimated percentage of volume involved _____% Other_____________________________________________CordLength _______cm Diameter_______cm Number of vessels _______FeaturesTrue knot(s) ________________________________________ False knot(s) ________________________________________ Torsion/twisting _____________________________________ Engorgement ________________________________________ Narrowing/constriction ________________________________ location ______________________________________ Abnormal Wharton's jelly ______________________________ _____________________________________________If Twins:Membrane ConfigurationMonochorionic-Monoamniotic Monochorionic-Diamniotic Dichorionic-DiamnioticPlacental VesselsAnastomotic vessels evident by gross inspection Anastomotic vessels demonstrated by injection/perfusionHISTOLOGIC ASSESSMENTSections should be obtained as follows:1. Cross section of umbilical cord 1b. Cross section just proximal to and just distal to any apparent cord constriction or cord stricture 2. Amniochorionic membrane roll 3. Fetal side placenta 4. Basal placenta 5. Sampling of any apparent abnormalities.Reporting should include general description of each section and description (including severity and extent) ofInflammationChorioamnionitis ______________________________________________Cord Vasculitis _______________________________________________Funisitis ____________________________________________________Villitis ______________________________________________________Infarction __________________________________________________________Calcification(s) ______________________________________________________Fibrin Deposition ____________________________________________________Other ________________________________________________________________________________________________ _________________________Placental and Cord Examination WiSSP home page
  • 58. Slide 58  CLINICAL EXAMINATION OF STILLBORN INFANT [Clinical description is often critical in the etiologic evaluation of stillborns. Yet it is often given less attention than it deserves in most formal postmortem evaluations. This is a suggested, simple and relatively non-jargon filled outline for such a clinical evaluation; it also includes space to provide brief notation of relevant prenatal, perinatal and family history.]  I. General InformationDate ____ ____ ____ Baby's Name____________________Mother's Name____________________ Father's Name____________________Hospital____________________P arents' Address____________________Attending Physician___________________ Person performing this evaluation ________________________  II. Brief History  Prior Pregnancy History -- Pregnancies____Deliveries____Liveborn____ Spont. Ab. ____Ind. Ab.____Prior Stillborns____Relevant maternal history and health [e.g. diabetes, hypertension, thyroid disease, etc.]  ____________________________________________________ ____________  Significant problems in this pregnancy ________________________  ____________________________________________________ ____________  Relevant family history [if not supplied in other records] ________________________
  • 59. Slide 59  III. General Data on Baby  Gestational age:____weeks; How determined -- dates ultrasound clinical exam other  Degree of Maceration:  ____Fresh; no skin peeling ____Slight; focal minimal skin slippage ____Mild; some skin sloughing, moderate skin slippage ____Moderate; much skin sloughing but no secondary compressive changes or decomposition ___Marked, advanced  IV. Measurements  Crown-heel [stretched] ______ Weight ______ Head Circumference ______  V. Head and Face  Head is --  collapsed_____ Anencephalic____ Apparently hydrocephalic_____ abnormally shaped_____; describe ____________________ relatively normal_____  check for and describe any:  scalp defects_____ ;________________________________________ cranial masses_____ ;________________________________________  Eyes --  normal_____; sunken_____; prominent_____;  abnormally far apart_____; abnormally close together____;  straight____;upslanting [V]____; or downslanting [/]___  on opening the lids the following is found --  eyelids are fused____ globes appear normal_____ globes are apparently absent____ eyes seem extremely small____ eyes seem extremely large____ opacities are present____  of the corneas____ of the lenses____ other________________________________________  Nose
  • 60. Slide 60  Nose --  normal____; abnormally small____; abnormally large____;  asymmetric____  nostrils are: apparently patent____; obstructed____;  Single nostril only____  other ________________________________________  Mouth --  size: normal____; large____; small____  upper lip: intact____; cleft____; if cleft give location of cleft--  Left__, Right__, Bilateral__, Midline__  palate: intact____; cleft____  mandible: normal___; very small____; asymmetric____  other ________________________________________  Ears --  normal____; abnormal in form____; if abnormal describe or draw --  lowset____; posteriorly rotated____;  preauricular tags___; preauricular pits____  other ________________________________________  VI. Neck  normal____; short____; excess or redundant skin____;  cystic mass [hygroma]____  other ________________________________________
  • 61. Slide 61 VII. Chest normal____; asymmetric____; small and constricted____; barrelled____ other ________________________________________ VIII. Abdomen normal____; flattened____; distended____; wall defects____ [omphalocele____; gastroschisis____; hernia____] umbilical cord -- number of vessels____ clinical abnormality [describe] other ________________________________________ IX. Back normal____; spina bifida____ [level of defect_____]; scoliosis____; kyphosis____ other ________________________________________ X. Limbs length: normal____; short____; long____ if short, what segment(s) seem short form: normal____; asymmetric____; have missing parts____ describe any asymmetry or missing parts position: normal____; clubfoot____; other positional abnormality____ describe if abnormal ________________________________________
  • 62. Slide 62  Xa. Hands  normal appearing____; abnormal____ if abnormal, describe  fingers -- numbers present ___+___ [if not 5+5, describe ]  unusual form of fingers ____; describe  unusual position of fingers____; describe  abnormal webbing or syndactyly____; describe  Xb. Feet  normal appearing____; abnormal____ if abnormal, describe  toes -- numbers present___+___ [if not 5+5, describe ]  abnormal spacing of toes____; describe  XI. Genitalia  Anus -- normal____; imperforate____; other  Male --  penis -- normal___; hypospadias___[level of opening_________];  very small____; chordee____  other ________________________________________  scrotum -- normal____; abnormal____[describe ]  testes -- descended____; undescended____  other ________________________________________  Female --  urethral opening -- present____; absent/unidentifiable____  vaginal introitus -- present____; absent____  clitoris -- normal____; enlarged____; unidentifiable____  other ________________________________________  Ambiguous____; Describe
  • 63. Slide 63 Classification of perinatal death 1. non-preventable: All the following criteria have to apply for a death to be classified as non-preventable: a) prenatal care and fetal surveillance were adequate and appropriate. b) Intervention was available, accessible, appropriate and timely. c) Circumstances surrounding a death were not preventable.
  • 64. Slide 64 2. Possibly preventable unrecognized but detectable fetal or newborn compromised:  Not detected or not appreciate.  Inappropriate, inadequate or untimely intervention. 3. Ideally preventable A sudden, compromising event for the fetus or newborn where intervention was not possible on this
  • 66. Slide 66 Facts and figures from The World Health Report 2005 • “Children are the future of society and their mothers are guardians of that future. • Yet this year, almost 11 million children under five years of age will die from causes that are largely preventable. • Among them are 4 million babies who will not survive the first month of life. • On top of that 3.3 million babies will be stillborn. • At the same time, about half a million women will die in pregnancy, childbirth or soon after.” The World Health Report 2005
  • 67. Slide 67 Etiology OF Stillbirth Booked Unbooked D.M 9 6 H.Disorder 5 7 IUGR 3 11 P.T 2 2 Thyroid 1 0 Cong.anomal 6 2 Placental 3 3 True knots 3 0 Unexplained 8 9