Chapters Transcript Stillbirth and Pregnancy After Loss Course: Improving Practice In Obstetrics & Gynecology 2024 Annual Symposium Thank you, everyone. Um, good morning. Thank you for this opportunity. Um, I will be talking about management of stillbirth and pregnancies after loss, and again, thank you to Doctor Kinsler, who was the first faculty member to sit down with me and go over, um, a preconception consult and counseling patients who have experienced loss, um, and was the first to teach me about the Stillbirth collaborative Research Network, which I'll be talking about in great detail. So, um, my hope is by the end of this session, we'll be able to review together the epidemiology and risk factors associated with stillbirth, analyze the potential causes of stillbirth and their clinical implications, evaluate the effectiveness of different diagnostic tests based on clinical scenarios, develop a plan for providing bereavement care to families and apply evidence-based strategies for managing subsequent pregnancies after loss. Um, and my hope is that I will be able to share with you what we as clinicians need to know medically, um, but also what patients wish we knew, um, about taking care of, um, both the current stillbirth and pregnancies after loss. So, the US National Center for Health Statistics defines fetal death as delivery of a fetus showing no signs of life. There's no uniformity among states with regard to birth weight and gestational age criteria, but generally accepted is greater than 20 weeks, or 350 g of gestational age is not known. Um, and the WHO defines stillbirths globally as those occurring at greater than 28 weeks, so there is a slight difference in definitions. Stillbirth is the generally preferred term by patients and their families, so I'll be referring to it as such for the remainder of the talk. In the US it occurs in approximately 1 in 165 deliveries. With the rate of 5.7 per 1000 live births, which is approximately 65 stillbirths per day, and to put that into context, that is equivalent of a school bus full of children every day. And until the last 10 to 15 years, this has been essentially a neglected topic in medicine. This figure shows the rate of stillbirth over time in the US from 1990 to 2020, and since 1990, there has been a decrease, although not very substantial, and it is smaller than the decrease seen in other similar countries and settings. Notably, there's been a lack of decline in stillbirth over the past decade, while concomitantly, there's been a decline in infant mortality, such that since 2013, stillbirth rates have exceeded infant mortality rates. There's considerable state to state variation in stillbirth rates, ranging from approximately 3.5 per 1000 in Montana, um, to 10 per 1000 in Mississippi, and globally, the US is ranked 23rd um out of Out of 49 similar high income countries using the WHO definition of stillbirth at 28 weeks. I want to highlight the significant racial disparities in stillbirth rates in the United States. Black patients are twice as likely to experience stillbirth in this country, as well as patients of native Hawaiian or other Pacific Islander descent. Again, at rates more than twice that of non-Hispanic white women. The reason for these disparities is unclear, but multifaceted. We know that race in and of itself is not a race factor, but inequities in health care, contribution of environmental stressors, and social determinants of health due to systemic racism play a role. Higher rates of stillbirth persist in these groups after controlling for adequate prenatal care and education level. Going into risk factors themselves, it can be difficult to distinguish between risk factors and causes of stillbirth, um, because many conditions can occur both in live births and can occur more frequently in stillbirths. But I want to highlight a few of them, um, social demographic factors such as non-Hispanic black race, implicit and explicit bias and racism. Multiple gestations. Um, a previous obstetric history, including a previous stillbirth or prior adverse outcomes, studies can indicate maybe a 5 to 10-fold increased risk in people with a prior stillbirth, although it's difficult to assess the effects of management in subsequent pregnancies, and the recurrence risk is highest for early stillbirths, intrapartum stillbirths, and non-Hispanic black mothers. And male fetal sex is also a risk factor. Excuse me. Um, extremes of age. So the lowest rates of stillbirth in the United States occur in 5 per 1000 and people that are 30 to 34 years of age. That is in contrast to rates that are more than double in people that are less than 15. Years old, so 13 per 1000, and greater than 45, which is 11 per 1000. Comorbid medical conditions including diabetes and hypertension. And I want you to consider differentiating between risk factors and causes here. A patient, for example, a patient with very well-controlled diabetes with an appropriately grown baby with reassuring fetal testing may not be as at risk for stillbirth than the patient who has poorly controlled diabetes had an episode of decay and pregnancy, has fetal macrosomia and non-reassuring testing. Um, as well as acquired thrombophilia, so specifically antiphospholipid antibody syndrome and of note inherited thrombophilas, which I sometimes see ordered, um, an evaluation of stillbirths typically have no association. Increasing BMIs and gestational weight gain demonstrate a dose dependent association with stillbirth and are potentially modifiable risk factors. Um, again with cigarettes, smoking again, is a modifiable risk factor, um, as well as with alcohol, other substances, um, have been associated with an increased risk of stillbirth, although quality data is not available. We also see an increased risk with assisted reproductive technologies, in part due to the risk of multiple gestation, um, and with late term and post-term pregnancies, but most importantly, the majority of stillbirths, more than 80%, really have no risk factors. In 2006, the NICHD funded the first multi-center perspective population-based study of adequate size of stillbirth in the United States, um, with the hope of addressing many of the scientific gaps in knowledge in stillbirth. So between 2006 and 2008, investigators um recruited and enrolled patients who had stillbirth residing in five geographic areas, including academic and community hospital centers in. Texas, Georgia, Massachusetts, and Rhode Island. Their specific aims were to obtain a geographic population-based determination of the incidence of stillbirth, to determine the causes of stillbirth using a standard postmortem protocol, which includes things like reviewing clinical history, um specific protocols for postmortem and pathological examinations and testing and survey data, um, to elucidate what the risk factors were for stillbirth. Um, they created um a review form called ECode, which stands for the initial causes of fetal death, which was devised as, um, a protocol to provide a structured system, so that definitions used to ascertain the most likely causes of death were uniform. And that reviewing potential causes could communicate so that um so that experts could communicate with each other using a common language. An important goal of this system was to use the best available evidence and rigorous definitions determined before case review, when assigning a cause of death. And so approximately 663 patients with stillbirth were enrolled, and a complete evaluation, so including the postmortem evaluation, placental pathology, medical records, and interviews, um, was available for 512 stillbirths. And so those were used um to evaluate for causes of death, using the definitions that were outlined in the Ecode system. They compared that to a contemporaneous control group of 1900 patients with live births. In the development of this system, investigators and subcommittees reviewed the literature and used individual and group expertise to identify conditions of interest. Conditions of interest are maternal, fetal or placental conditions that might be a potential cause of fetal death. Once they identified a condition of interest, they then evaluated to classify the condition as either a probable cause of stillbirth, a possible cause of stillbirth, or a present condition. So probable cause of stillbirth was identified with high likelihood, the cause of the stillbirth. For example, maternal diabetes would be probable in a case, you know, like I mentioned before, uncontrolled episode of DKA. A possible cause of stillbirth um was an identified condition that could not with high likelihood be considered a cause of stillbirth, but that there was reasonable certainty that it may have been involved in the pathophysiologic sequence that led to the stillbirth. Um, and then a present condition was one that could not be classified as either probable or possible, even based um on expert opinion. Um, so in this circumstance, it was just identified as present, um, and would be maybe a potential risk factor. And this is, um, you know, the Worksheet. Um, I, I use this worksheet when I'm doing my preconception consults for stillbirth. Um, it goes over various categories of causes, um, and the criteria for which something would be, um, identified as a probable cause, a possible cause, or a present condition. I'd be happy to share this after. So using in code, a probable cause of death was found in 61% of stillbirth cases, and a possible or probable cause was found in 76%. Causes were then grouped into the following categories. So, the first being obstetric conditions, which occurred in 29.3%, and that includes cervical insufficiency, um P prom preterm delivery. Placenttal in 23.6, fetal genetic or structural abnormalities in 13.7, infection in 12.9%, umbilical cord abnormalities in 10.4%, hypertensive disorders of pregnancy in 9.2%, and other medical complications in 7.8%. But again, notably, a large proportion of stillbirths, close to 30%, remains unexplained. Um, and the causes were also categorized by gestational age, as you can see here. So going into some of the specific causes, um, so fetal growth restriction comprised a large, um, a large proportion of stillbirths, so higher risk with smaller percentiles and advancing gestational ages as you get. Um, to term and, um, as you get closer to 40, 41 weeks, the risk does go up, um, placental abruption in 5 to 10% of times and umbilical cord pathologies. So I wanted to highlight that, um, nuuccal cord is often attributed as a cause of death in an otherwise unexplained stillbirth, but we know that nucle cords occur in a very high percentage of normal deliveries as Well, up to 30%. Um, so using the encode criteria, um, a nucle cord in combination with evidence of corticclusion, which you could see pathologically or histologically with signs of edema, congestion, or thrombosis, um, in the umbilical cord, that is what you would need to be able to, um, say that it's a probable cause of stillbirth. Um, genetic, chromosomal and structural abnormalities. Um, so most commonly aniploides, um, occurred in 6 to 13% of cases, confined placental mosaicism where genetic abnormalities in the placenta in a genetically normal fetus, um, can also cause stillbirth by leading to placental insufficiency. Again, even if the fetus is genetically normal, and structural abnormalities in the presence or absence of genetic, um. Genetic abnormalities, and those included specifically hydrops cystic hygromas, thoracic or craniofacial abnormalities, and multiple anomalies were all strongly associated with stillbirth. And infection, which is higher in low resource settings, um, and can contribute to stillbirth either through direct fetal infection, placental damage, severe maternal illness, or intrauterine infection, and predominantly uh bacterial causes are attributed to E. coli, GBS or enterococcus, um, viral most commonly is CMB, and then less commonly you would see things like Listeria, syphilis, arbovirus, Zika, and COVID-19. The medical conditions were associated with 9% um of stillbirths. Um, intrapartum stillbirths occurred less commonly um in high resource settings, higher and low resource settings, and um were likely due to preterm birth associated with labor, cervical insufficiency, P prom choo, or abruption. Um, and then other, so up to 4% were contributed to fetal maternal hemorrhage, um, alloimmunization, trauma, or mental health related. So, a thorough workup is crucial um to accurately diagnose the cause of stillbirth and to minimize the unexplained stillbirths. Um, identifying the cause is important for closure of families to plan care for future pregnancies, and to affect quality improvement at a systems level. Yeah, here in the United States, we typically see that stillbirth evaluations are often incomplete. This graph shows the usefulness of various tests. In the stillbirth workup based on their contribution to determining a cause, and this again comes from the Stillbirth Collaborative Research Network, um, where in their, um, their findings show that placental pathology was useful more than 60% of the time and provided the highest yield in determining a cause of death. Um, and fetal autopsy was positive 38% of the time. So these two components are what's called the postmortem. Um, examination, and the 3rd most common, um, or 3rd most useful, um, component of workup was genetic testing. So with the 3 combined placental pathology, autopsy, and genetic testing, at least 1 of the 3 were positive in over 60% of cases. Um, so really should be performed in all, um, in all instances of stillbirth. After that, um, after that, the next most useful were testing for antiphospholipid and fetal maternal hemorrhage, such as with a KB. And so therefore, you know, these 5 are suggested in pretty much every case. The remaining type of diagnostic testing, so things like glucose screening, um, screening for torch infections, um, were really only positive and useful, um, or positive, yielded a positive result in less than 2% of the time. So, in terms of, you know, initial evaluation of stillbirth, again should include a gross and microscopic evaluation of the placenta, evaluation of the fetus, um, including autopsy and imaging. There are barriers to autopsy. A lot of it involves, um, you know, patient perceptions of autopsy, um maybe availability depending on your setting. Um, you can, you know, if it's a Concern about um being able to have um like an open casket funeral for the baby. Um, it is still possible after an autopsy. Um, and if they don't want an autopsy, there are ways to do it non-invasively either through like radiologic um evaluations, um, gross evaluations, imaging, um, photographs, um, X-rays, or even MRIs have been described, um, as, as useful. The laboratory studies, so a karyotype, although a karyotype is associated with 50% failure, um, the, the best specimen to obtain would be, um, amniotic fluid, if not possible, a placental block or a segment of the umbilical cord, um, or internal fetal tissue. Um, microarray is actually considered, um, More valuable than a karyotype because it does not rely on um culturing cells, um, to be able to yield a result. So you're more likely to get a diagnosis with microarray, um, especially if the tissue is non-viable. Um, and whole exome or genome sequencing, if available, um, will also increase your yield of getting a result. In terms of maternal evaluation, so obtaining a medical and obstetric history and family history can be important. There actually is new research emerging um on long QT syndrome, which does run in families as potentially being a contributor, um, both to stillbirth and and potentially SIDS as well. So, um, asking about family history can get you um some clues to guide your, your workup. So, um, again, in all cases, an autopsy and a placental pathology, and then based on what the findings are at the time of stillbirth, um, you can, you know, offer additional testing. Um, but pretty much in most cases, um, it would include genetic testing, EPS testing, and fetal maternal hemorrhage testing. Um, the exception would be If it's a known fetal anomaly, um, your, um, yield of having a positive antiphospholipid antibody workup would be, um, less, less than. Um, and other, other testing can be based on clinical suspicion. So let's say you have, you know, a very macrosomic BD, you know, you might wanna, you know, check the hemoglobin A1C in that scenario. Usually there is no medical urgency for delivery after a diagnosis of stillbirth, and the timing and mode of delivery should be determined by gestational age, patient preferences, and clinical circumstances. Most patients do desire to deliver um relatively soon, um for um personal emotional reasons, but sometimes they may need some time um to process, um, grieve and arrange, you know, logistical issues prior to, um, presenting, um, to the hospital for a procedure. One available 2nd trimester D&E is the safest and most cost effective option um in the 2nd trimester. Um, it may limit some efficacy of the autopsy and precludes holding baby, but there are still ways to create, um, a nice memory box, um, which is something that patients do desire. Um, there can be some benefits to induction of labor, such as delivery of an intact fetus may maybe provide a more like informative perinatal autopsy, um, but there is an increased risk of morbidity, predominantly infectious, um, morbidity compared to DNA in the second trimester. So, um, in terms of induction methods, either oral or vaginal misoprostol at higher doses prior to 28 weeks is appropriate. After 28 weeks typically is, you know, your usual, um, usual induction, um, protocol, and mifepristone, um, at, you know, less than 20 weeks. Some studies say up to 28 weeks can reduce time of delivery compared with misoprostol alone. In terms of our prior hysterotomy, so both um labor and DNA are appropriate. However, there is a tenfold increased risk of a repeat cesarean in those cases, um, and again options prior to 28 weeks, um, the risks associated with misoprostol, um, are, you know, do support, you know, giving misoprostol even with the prior hysterotomy, and after 28 weeks typically would be with them. Uh, a balloon to help, um, induce. And then special circumstances really should be individualized. So things like a prior classical, multiple hysterotomies. Although, um, a meta-analysis done at our institution, um, looking at second trimester, um, induction had shown even with multiple hysterotomies, um, misoprostol and, and regular induction methods were, were appropriate. Um, elective cesarean, this might be, um, this again is individualized and shared patient decision making. In some circumstances that, you know, anxiety and trauma associated with delivery, you know, may, um, may mean that an elective cesarean is a better option for the patient, but really it's, it's individualized, um, and we should support vaginal delivery as much as possible. In terms of bereavement care, just want to highlight some um best practices. The first is to slow down. There really is no um there really is no rush or urgency, um, you know, for us as clinicians, it's, you know, and just another patient and we have another one waiting in another room, um, but for couples who have experienced stillbirth, this really is, um. Like the end of the world. Um, and they, they deserve, you know, our patience, um, going through everything. So, in terms of communication, um, really, do you refer to, um, the stillbirth as, you know, your baby, um, avoid terms like fetus, embryo, fetal demise, or products, you know, in front of the patient. Um, shared decision making, adequate time to consider all options. Please recognize um their parenthood and acknowledge partner grief and um family grief. There might be other family members in the room and everyone is grieving. Um, be aware of burial, cremation, and funeral information, and this is really important for us as physicians, um, and clinicians to just be aware of what the options are in our local area, um, and specifically, I do want to say here in Nassau County, in contrast to New York City, after 20 weeks, parents are responsible for burial. There is no public disposition option, um. And that comes up sometimes, um, as we are part of an enterprise that includes um New York City, sometimes the standardized forms may not um indicate that, so we just have to be um aware that the patients do not have, you know, the the option for public disposition. Um, the opportunity to see and holds the infants, um, and the opportunity to make keepsake items and memory boxes. One of the, um, greatest regrets that bereaved parents have is a reported lack of memories of their baby. Um, we have, um, there are available through Star Legacy Foundation, you know, different types of certificates, um, that you can print for patients. Um, we do, I think we do a great job with, you know, memory boxes, um, but. There are things that are available online too, um, that patients may want to use. Um, and I want to highlight a local program called Angel Baby. Um, I first met the, um, the owner of this company about 10 years ago. She preserves wedding flowers, um, but she does have a charitable offshoot of her company, um, which preserves at no cost, um, funeral flowers for, um, stillbirth or, you know, um, infant loss. Um, important to have healthcare professionals trained in bereavement care. Um, there are trauma informed provider training courses that are available through stillbirth advocacy groups. I took one of them last year. I would be happy to recommend and share that information. Um, and healthcare professionals should also be able to access self-care. This is, um, or can be, you know, traumatic for us as well. Um, our institution typically provides patient information from the Star Legacy Foundation. Um, there's pamphlets, um, and also, um, opportunities for virtual in-person support groups. Um, in terms of postpartum care, so, um, social work referral and behavioral health referrals, um, may be considered, um, during the initial, um, hospitalization. I know, um, we do, we always order social work for these patients. In terms of postpartum follow up, please do check in with these patients after 1 or 2 weeks. Um, don't have them wait the full 6 weeks, but please also educate your staff, um, anyone answering telephones, reception. Appointment bookers, MA's, nurses, things like that, um, to know that it's a loss chart, and if there's a way to, you know, flag that in Epic, um, or your EMR, um, that would be really helpful. The worst thing would be, um, to assume that it's a routine postpartum visit and just start making conversation and asking about the baby, um, that they did not take home, and that, you know, those are things that um have happened, can happen, and we should be, um, supporting our patients. Um, referral to local, national, international stillbirth advocacy and support groups, even if you're not doing it, your patients are finding them, um, they're finding them on social media, um, so, um, having those resources available to them would be helpful. Um, you may not know, um, that stillborn babies do not qualify for dependent tax benefits in New York, but there are some other states that provide. Um, a stillbirth tax credit, um, and you may also not know that in New York state, paid family leave gets revoked in the event of a stillbirth, um, for the birthing patient only, not the partner, um, because the partner has somebody to take care of, um, but the birthing individual does not, um, and that's something that, you know, our, um, stillbirth advocacy groups really have been pushing for, um, every year, um, to remove, um, this loophole. So, I'm gonna shift gears now and talk about the concept of stillbirth prevention, um, and the idea of a preventable stillbirth. Um, and again, the data comes from a stillbirth collaborative secondary analysis looking at non- anomalous fetuses at greater than 24 weeks and greater than 500 g. Um, investigators came up with the following categories of what they called potentially preventable stillbirth, um, and they found that up to 25%, 1 in 4 stillbirths in the US. are potentially preventable, and the categories included intrapartum stillbirth, medical conditions, hypertensive disorders, placental insufficiency, multiple gestations, and preterm birth, and they're considered preventable because of the availability of surveillance, um, availability of cesarean delivery and medical optimization. Um, not yet adopted in the US, but there are stillbirth bundles available, um, in other countries, specifically the UK and Australia, that have been successfully implemented. The UK has the Saving Babies Lives care bundle, um, which has the goal to decrease or half their stillbirth rate from 4.7 per 1000 to 2.3 per 1000 by 2030. Remember, our rate is 5.7 per 1000 so we already have a higher stillbirth rate than they do in the UK, um, and their focus is on um four key elements, which include reducing smoking in pregnancy, risk assessment and surveillance for fetal growth restriction, raising awareness of fetal, reduced fetal movement, and effective fetal monitoring in labor to reduce intrapartum hypoxia. And each domain has specific strategic components. Um, this is an infographic provided by the NHS, um, regarding fetal movement awareness counseling. Um, so, um, you know, awareness that, um, fetal movement should increase, um, up until around 32 weeks and then remain relatively stable through the end of pregnancy, um, dispelling some myth. Like it's not true that babies move less at the end of pregnancy and that you should be continuing to feel regular movements, um, and what to do if you are concerned or if, um, fetal movements are reduced. And importantly, not to use any sort of handheld devices or Dopplers, um, to check a heartbeat, because even if you check a heartbeat, it does not necessarily mean that the baby is well. Um, in terms of the data on fetal kick counting, um, and fetal moveness, fetal movement, um, studies have shown that stillbirths are often preceded by the maternal perception of alterations in fetal activity, um, and that could be either decreased fetal movement or what can be described as a sudden. of excessive fetal activity. So things like frantic, wild, crazy, powerful or strong. Um, and survey data, um, while prone to recall bias shows that patients whose pregnancies ended in stillbirth were less likely to, um, remember having kept track of fetal movement and less likely to recall being counseled on fetal movements. Um, the affirmed trial out of the UK, um, was, um, stood for promoting awareness of fetal movements and focusing interventions to reduce fetal mortality, was a stepwise cluster randomized trial of a reduced fetal movement care package, um, that aims to see whether a care bundle could reduce stillbirth by raising awareness of and acting on reduced fetal movement. So patients were counseled to report. fetal movement and there was a protocol for assessment that include monitoring, sonogram, and maybe adjusting time of delivery. Um, the study showed a small reduction in stillbirth, but it was not statistically significant, um, and therefore unable to determine whether the reduction was due to chance. Um, but what they did find was that there was an increase in intervention, so increase in cesareans, induction of labor, and prolonged NICU. The history of um the conventional wisdom of, you know, 10 kicks in an hour, 10 kicks in 2 hours comes from a prospective study in 1989, um, where patients were instructed to record the elapsed time required to appreciate 10 movements. The meantime to 10 kicks for most patients is about 21 minutes, and that was supported by multiple other more recent studies. 95%. Patients will feel 10 movements in 60 minutes, 99.5% in 90 minutes, and if it takes 2 hours, 120 minutes, this is 5 standard deviations below the mean. So it is a baby that is really not moving as much as um typical. Um, and so there's a lot of, you know, There's a lot of work on fetal movement and how like setting these alarm limits may not necessarily be beneficial. Um, Doctor Hazel is a um physician out of the UK who does a lot of work on, um, stillbirth and um established the Rainbow Clinic, um, and he says there's no evidence that any absolute definition of reduced fetal movement is of greater value than the maternal subject. The perception of reduced fetal movements and the detection of intrauterine fetal death or fetal compromise. So, best practices tend to agree on the following things. So we should be encouraging patients to be aware of fetal movement patterns, being attentive to the complaints of reduced fetal movements, um, addressing the complaint in a systematic way, and using shared decision making to, um, use intervention safely. Um, this is an example of an app and a campaign in Iowa just in the interest of time. I'm gonna skip through it. Um. And then we'll go through, um, in terms of medical therapies, obviously the best studied is aspirin, um, multiple studies, systematic reviews, um, global studies have demonstrated a small but very modest, um, decrease in stillbirth with aspirin use. Um, a lot of times in the context of placental insufficiency and preeclampsia, so therefore, ACOG doesn't recommend low dose aspirin specifically for an unexplained stillbirth in the absence of other risk factors. Um, sleep position you'll hear about a lot. Um, sleep on your side on baby's inside. This is from the Australia, um, Stillbirth bundle. Um, there is some biologic plausibility here, um, and the Sydney Stillbirth Study did demonstrate, um, that supine sleeping in the last month of pregnancy was associated with SGA, more likely associated with stillbirth. So every now and then, um, studies on, or not studies but like awareness of sleep position will pop. Up on social media and patients may ask about it. Um, a very large, um, prospective evaluation of, I think it was close to 14,000 patients that was done here, the new mom to be trial. This was prospective. They actually had monitors on the patients, um, and monitor their sleep positions. It was not associated with adverse outcomes. So again, you know, it's important here not to cause harm. Um, keep in mind this is a going to sleep position, not a waking up position. Um, data regarding sleep position and stillbirth are prone to recall bias. Um, you can't control how you sleep, um, you can control how you fall asleep, but really not, um, not how you wake up, and we really don't want to cause excess anxiety and harm to our patients. Um, I'm just briefly going to mention estimated placental volume because your patients may be asking, um, based on the work of Dr. Harvey Kleinman at Yale. Um, so he created a formula measuring, um, placental volume on sonogram, um, with a nomogram that's available through his app. Um, patients may ask for it, so, um, that's why I'm bringing it up. Um, and placental hypoplasia can sometimes see growth restriction and other adverse outcomes, so that's the rationale for that. Um, in terms of an optimal interpregnancy interval after a stillbirth, we know following a live birth, the WHO and ACOG recommend 18 to 24 months. We know that a short interpregnancy interval of less than 6 months after a live birth is associated with preterm birth SGA and stillbirth. However, um, data after stillbirth, um, is, is less clear, um, and just for the interest of time, um, basically. Looking at multiple studies, there is no association specifically with an interpregnancy interval or a short interpregnancy interval with more adverse outcomes in a pregnancy that follows um a stillbirth. So after a stillbirth, this is already a very high risk group, um, and the, the interval between pregnancies does not alter that risk. Um, in terms of subsequent pregnancies after stillbirth, um, there is an increased risk for recurrent stillbirth, as well as other adverse outcomes, including preeclampsia, prematurity, low birth weight, abruption, or induction of labor. Um, and this could be because of the persistence of medical conditions, the persistence of risk factors, recurrent conditions, so, um, there can be recurrent placental lesions, um, and genetic disorders. Looking at a cohort of patients with a prior stillbirth, um, about 1% of them had a recurrence rate of stillbirth and 26% had a subsequent adverse outcome. And it was seen more often in patients that had a preexisting medical condition, smoker, or again, placental histopathologic findings in the index pregnancy. Um, so you may know that a rainbow baby is a healthy baby born to a family that has previously experienced a pregnancy loss, and so there is the concept of the Rainbow Clinic, um, first established in Manchester by Doctor Alexander Hazel. Um, there are rainbow clinics that are being developed here, um, which include, um, which follow a model of, you know, just understanding that the parents' experience of a pregnancy after a stillbirth is profoundly altered. There is a coexistence of emotions, they Um, don't wanna get too excited. They're always, you know, potentially prepared for, you know, the worst. Um, they have helpful and unhelpful coping strategies, they seek reassurance. They can feel isolated from friends and family who may incorrectly assume that a subsequent pregnancy will help them get over um the death of a previous baby, but it doesn't. Um, and so, um, so additional support is needed, and that's kind of where this like specialized care comes in. Um, so it's multidisciplinary specialist led, um, service, um, which includes, you know, the following, um, the following items, sensitive communication with patients and staff and appropriate organization. In terms of things that we can do, um, and managing pregnancies after loss, so preconception, you know, making sure that you have your detailed medical and obstetric history, evaluation of the previous stillbirth, determination of recurrence risk, um, optimizing medical factors, um, screening for diabetes, APS testing, support and reassurance, um, and then just some general tips, and this is from stillbirth advocacy groups. This is what they wish you knew. Um, you know, read the chart, note. Important details. It's OK to ask the name of the baby or the gestational age of the baby that died, and just be aware of milestone dates that may be potentially triggering, um, to patients. So the previous baby's birth date or due date or anniversaries and things. Um, you know, some places have a designated area of the waiting room if that's possible, um, or, you know, not to have them near, you know, fetal monitoring where they could potentially hear the NSTs. Um, in the first trimester, you know, providing a dating ultrasound, genetic screening, and support and reassurance, um, second trimester, anatomic surveys, screening, support and reassurance. In the third trimester, you can start, um, serial growth ultrasounds, fetal movement awareness counseling. There's little data on, you know, when specifically to start surveillance. Typically it's around 32 weeks or 1 to 2 weeks earlier than the prior. Stillbirth, although that's individualized. Um, and again, just, you know, no milestone dates. Um, sometimes you have to make arrangements and accommodations. Patients may be averse to certain exam rooms based on their previous history, they might request the ultrasound prior to the visit or prior to vital signs. Sometimes I've been in the room with the patient for the ultrasound until we hear the heartbeat, and then I let the sonographer finish. So, um there may need to be individualization here. Um, in terms of delivery, the decision to proceed, um, with delivery again incorporates understanding of, you know, risks and benefits and shared decision making. This is a group that has a higher, um, incidence of elective inductions, um, as well as early term delivery. Um, so the counseling regarding this is that there is an increased risk of maternal and neonatal complications with early term, um, deliveries, but sometimes severe patient anxiety, um, you know, may, um, you know, outweigh, you know, those risks of those. Um, I'm just gonna end, we're almost done, right? Yeah, OK. Um, I'm just gonna end with, you know, some, some tips which, you know, I'll have you read these, um, on your own, these slides are available on, you know, things that are helpful and maybe not so helpful, um, and caring for patients after loss. Um, these are my key points, and then thank you, and this is dedicated to my nephew, um, he was born still on New Year's Eve 2020. Oh, thank you. Published November 15, 2024 Created by Related Presenters Sevan Vahanian, FACOG, MD View full profile
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