Unexplained stillbirths

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Unexplained stillbirths

• Lessons learned Preventable, or just a mystery?
• J.Frederik Frøen, MD, dr.med, dr.philos

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Todays questions

• What is an unexplained stillbirth?
• When does it occur?
• The mom
• Who are these moms?
• What about her history? Complications, CS
  miscarriages?
• Next pregnancy next generation risk of
  recurrence?
• The baby
• Is it intrauterine SIDS?
• Who is affected?
• Can it be prevented?

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Unexplained or unexplored?Percentage of
stillbirths remaining unexplained
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SIDS unexplained stillbirths

• The Triple Risk Hypothesis
• The predisposed child (intrauterine factors)
• Triggering event or challenge
• Vulnerable age in development

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When in pregnancy?The risk of unexplained
stillbirth in an ongoing pregnancy increases
radically from 36 weeks of gestation
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Who are these moms?Risk mothersOverweight /
obesity (gt25) OR 2.4 95 CI 1.1 - 5.4High age
(gt35) OR 5.1 95 CI 1.3 - 20 Smokers
(gt10) OR 3.1 95 CI 1.2 8.1Low edu./
socioecon. status OR 3.8 95 CI 1.5
9.5Primiparity?Multiparity?At good health?
Alessandri al. 1992 Better health. Frøen
al. 2002 overall effect, p1.00 Insufficient
hemodilution OR 11 95 CI 1.4 -
81Inflammatory response? UTI OR .30 95 CI
.12 - .74What about cesarean sections and
previous miscarriages?
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Is it intrauterine SIDS?
1995 Walsh Mortimer propose that SIDS and
unexplained antepartum stillbirths are
disorders (that) represent a continuum of a
single spectrum of disease.
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Risk factors for SIDS
Comparing SIDS SIUD J.F.Frøen al. Arch Dis
Child 2002
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Comparison of SIUD and SIDS
Comparing SIDS SIUD J.F.Frøen al. Arch Dis
Child 2002
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To study stillbirths, population-based birth
weight charts can not be used. Fetal growth
estimates should be customized for maternal race,
height, weight, age, parity and fetal gender.
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JF Frøen, A Thurmann, JO Gardosi, A Francis, B
Stray-Pedersen 2004
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unexplained stillbirths are not sudden as 50
are growth restricted1. 50 of affected mothers
waited more than 24 hours without any fetal
activity before they contacted health
professionals 1 in 3 waited more than 48
hours2. 50 perceived reduced activity gradually
over several days3. many seek help in vain4. 1)
J.F.Frøen al, Acta Obstet Gynecol Scand 2004,
2) J.F.Frøen al, Am J Obstet Gynecol 2001, 3)
L. Maleckiene al, Acta Obstet Gynecol Scand
2001, 4)D. Fossen I. E. Silberg, Tidsskr Nor
Laegefor 1999.
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studies to improve pregnancy outcomes in
collaboration with the Universities of Oslo (N),
Bergen (N), Queensland (AUS) and Auckland (NZ),
Harvard Medical School (USA), and Boston (USA),
Rush (USA) and The Australian National (AUS)
Universities.
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Percentage of consultations for reduced fetal
activity where the mother waited for more than 24
hours with absent fetal movements before
contacting health care.
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Waiting 24 hours OR 4.7 (95 CI 1.1 19.7)
for death.
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Percentage of consultations for reduced fetal
activity where the mother waited for more than 48
hours with the perception of reduced fetal
movements (but not absent) before contacting
health care.
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Time with reduced FM is associated with birth
weight centile (p0.009) Waiting 48 hours OR
1.8 (95 CI 1.0 3.2) for death, preterm or IUGR
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The story of kick counting research
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The first reports
Sadovsky Yaffe 1973
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Impact of case-control of FMC
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The Lancet - effect
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The Lancet studyThe material methods

• The counters (n32.000)
• 99 stillbirths (93 n.f. sing.)
• 90 received chart
• 80 completed
• 60 completed every day

• The controls (n36.000)
• 100 stillbirths (98 n.f. sing.)
• 10 received chart
• 7 completed
• 4.3 completed every day

Within hospital clusters 60 of controls informed
in writing
Alarm No FM in 16-32h or less than 10 FM per 10h
for 40-56h 50 of women acted on alarms Only
analyzed by Intention to treat
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Time to count to ten compliance?
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The Lancet studyResults (mainly from within
hospital clusters)

• Counters
• 70 Avoidable
• 57 Unexplained
• 10 predicted by chart policy
• 2 predicted by movements
• Total of 19 alive at adm.
• 64 of them identified by FM

• Controls
• 81 Avoidable
• 67 Unexplained
• None predicted by chart policy
• None predicted by movements
• Total of 10 alive at adm.
• 0 of them identified by FM

Stillbirth rate reduced from 4/1000 to 2.8/1000
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The Lancet-effect
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Formal fetal movement counting

• Good evidence,
• or a premature burial?

Are we looking at the wrong place?
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femina consists of a collection of studies to
improve our understanding of reduced fetal
activity learning their epidemiology and
outcome. improving the quality of care by health
care providers. improving maternal information
and vigilance. exploring the basic associations
between activity and outcome. improving pregnancy
outcomes!
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pregnancies with reduced fetal activity affect a
large proportion of our pregnancies 5 to
10. are known to be at increased risk of adverse
outcome. represent a common challenge in
obstetric care. consume significant time and
resources for management provided without
guidelines, of unknown quality, indication and
effect.
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Percentage of consultations for reduced fetal
activity where an ultrasound was performed.
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Percentage of consultations for reduced fetal
activity where Doppler was used in the evaluation.
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The science of current western medicine is the
best the world has ever seen, and continues to
grow rapidly, - while the performance of health
care delivery leaves much to be
desired. Chassin, JAMA 1998
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Percentage of consultations for reduced fetal
activity followed up by a repeated control after
the initial examination.
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Percentage of consultations for reduced fetal
activity followed up with admission for
observation after the initial examination.
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Every system is perfectly designed to achieve
the results that it achieves Berwick, BMJ 1996
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Percentage of consultations for reduced fetal
activity where where outcome was either
stillbirth, IUGR or preterm birth.
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Percentage of consultations for reduced fetal
activity where no pathology was found at
examination, but where outcome was either
stillbirth, IUGR or preterm birth.
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pregnancies with reduced fetal activity affect a
large proportion of our pregnancies 5 to
10. are known to be at increased risk of adverse
outcome. represent a common challenge in
obstetric care. consume significant time and
resources for management provided without
guidelines, of unknown quality, indication and
effect. but increased vigilance and
well-informed mothers can reduce morbidity and
mortality. J.F.Frøen, J Perinat Med
20043213-24
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