Evaluation of Stillbirth PowerPoint Presentation

Evaluation of Stillbirth PowerPoint Presentation

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Katy . Kemnetz. , PGY2. objectives. Evaluation of stillbirth. Objectives. The participant will be able to:. Identify the conditions that have been best demonstrated to cause stillbirth. Evaluate a stillbirth using the most effective workup. ID: 585098

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Presentations text content in Evaluation of Stillbirth

Slide1

Evaluation of Stillbirth

Katy

Kemnetz

, PGY2

Slide2

objectives

Evaluation of stillbirth

Slide3

Objectives

The participant will be able to:

Identify the conditions that have been best demonstrated to cause stillbirth

Evaluate a stillbirth using the most effective workup

Accurately formulate an etiology for a stillbirth, when possible

Employ the recmomended hospital policies for management of stillbirth

Slide4

Outline

Definitions

Causes of stillbirth

Workup of stillbirth

Other

considerations

Conclusions

Slide5

Definitions

Evaluation of Stillbirth

Slide6

Definitions

Spontaneous abortion

Intrauterine fetal demise

Miscarriage<20 weeks gestation or <500g

“Stillbirth”

>20 weeks gestation or >350g—state dependent

350g is 50%ile for 20 weeks gestation

Illinois: >20 weeks gestation

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

Does not include terminations of pregnancy or IOL for

previable

PPROM

Slide7

Causes

Evaluation of stillbirth

Slide8

Causes of stillbirth

>30 classification systems existImportant to distinguish betweenUnderlying cause of deathMechanism of deathRisk factors

Slide9

Classification of stillbirth

The National Institute of Child Health and Human Development

Slide10

Classification of Stillbirth

Eunice Kennedy Shriver workshop 2007

National Institute of Child Health and Human Development

“An optimal classification system would identify the

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

Slide11

Criteria for “cause”

Epidemiologic data demonstrate an

excess of stillbirth

associated with that condition

Biologic plausibility

that the condition causes stillbirth

Either

rarely seen in association with live births

or, when seen in live births, results in a

significant increase in neonatal death

A

dose-response relationship

exists

The greater the “dose” of the condition, the greater the risk of fetal death

Associated with

evidence of fetal compromise

The stillbirth

likely would not have occurred

if that condition had not been present

Slide12

Causes of stillbirth

Reddy, UM et al. “Stillbirth Classification—Developing an International Consensus for Research.” Obstetrics and Gynecology,

Vol 114, No 4, October 2009.

Slide13

Infections

Causes of stillbirth—NICHHD workshop consensus

Slide14

Infection

Associated with

10-20%

of stillbirths in developed countries

Higher association with

preterm birth

Sometimes difficult to prove

causality

Slide15

Infection

Ascending infectionamniotic fluid or fetusfetal pneumonitisHematogenous spreadvillitis

Kumar: Robbins pathologic basis of disease, 8

th

edition. 2009

Slide16

Mechanism of fetal death

Severe maternal illnessPlacental infection that prevents oxygen/ nutrients from crossing to the fetusFetal infection that causes a lethal congenital deformity

Fetal infection that

damages a vital organ

Precipitation of

preterm labor

, with intrapartum fetal

death

Slide17

Infections must be proven

Signs of infection in the fetusEvidence on autopsy of extensive organ involvementPositive fetal culturesPositive maternal cultures plus chorioamnionitis/ funisitis

Kumar: Robbins pathologic basis of disease, 8

th

edition. 2009

Slide18

Causes of IUFD: Spirochetes

OrganismMaternal diseaseCommentTreponema palladiumSyphilisMajor cause of stillbirth when maternal prevalence is highBorrelia burgdorferiLyme diseaseTick borne; not a common cause of stillbirthBorrelia recurrentisRelapsing feverTick borne; common in the Western US; rare cause of stillbirthBorrelia duttoniiRelapsing feverTick borne; sub-Saharan Africa; important cause of stillbirthLeptospira interrogansLeptospirosisUncommon

Severe placental dysfunction

Slide19

Protozoa

OrganismMaternal diseaseCommentTrypanosoma bruceiTrypanasomiasisTsetse flyTrypanosoma cruziChagas diseaseKissing bugPlasmodium falciparumMalariaCommon in endemic areasPlasmodium vivaxMalariaMosquitoesToxoplosmosis gondiiToxoplasmosisRare

Severe placental dysfunction

Slide20

Viruses

OrganismMaternal diseaseCommentParvovirus B19Erythema infectiosumLikely the most common viral etiologic agentCoxsackie A and BVariousMay be importantEchovirusVariousImportance unknownEnterovirusVariousImportance unknownHepatits E virusFulminant hepatic failureEspecially in endemic areasPoliovirusPolioHistoric causeVaricella zosterChickenpoxRare causeRubellaGerman measlesRare in developed countriesMumpsParotitisRare in developed countriesRubeolaMeaslesRare in developed countriesCytomegalovirusAsymptomaticCase reportsHIVAIDSNot likely causativeInfluenzaRespiratory tract infectionSevere maternal illness

Causes lethal fetal anomalies

Slide21

Bacteria

OrganismMaternal diseaseCommentE. ColiAsymptomaticProbably the most common organism assoc with stillbirthGBSAsymptomaticCommon cause of stillbirthKlebsiellaAsymptomaticCommon cause of stillbirthEnterococcusAsymptomaticUreaplasma, mycoplasmaAsymptomaticListeria monocytogenesListeriosisTransmitted transplacentallyChlamydia trachomatisPelvic infectionSuggested cause—case reportsNeisseria gonorrhoeaePelvic infectionSuggested cause—case reportsCandida albicansThrush; vaginitisConfirmed in case reports

Goldenberg RL, Thompson C. The infectious origins of stillbirth. Am J Obstet Gynecol2003;189:861–73

Severe placental dysfunction

Damage to vital organs (brain, heart)

Slide22

Maternal medical conditions

Causes of stillbirth—NICHHD workshop consensus

Slide23

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

ConditionEstimated stillbirth rate per 1000 births in patients with the conditionAll pregnancies6-7Chronic hypertension5-25Superimposed preeclampsia52Gestational hypertension and mild preeclampsia9Severe preeclampsia21Eclampsia18-48HELLP syndrome51

Hypertensive disorders

Slide24

Hypertensive disorders

Mechanism of fetal demise:

To consider cause of death:

Placental insufficiencyIUGRAbruption

If it progresses to

eclampsia

If it is associated with placental abruption or fetal growth restriction

Slide25

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

ConditionEstimated stillbirth rate per 1000 births in patients with the conditionAll pregnancies6-7Gestational diabetes5-10Type 1 diabetes6-10Type 2 diabetes35

Diabetes

Slide26

Diabetes

Mechanism of fetal demise:

To consider cause of death:

Congenital abnormalityPlacental dysfunctionObstructed labor and intrapartum deathMacrosomiaFetal hyperglycemiafetal insulin productionexcessive fetal growthmetabolic acidosis

Signs of intrauterine or

intrapartum

asphyxia

LGA fetus

SGA fetus

Severe malformation

Placenta demonstrates characteristic

histologic

findings

Large edematous

villi

Increased prominence of

cytotrophoblasts

Slide27

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

ConditionEstimated stillbirth rate per 1000 births in patients with the conditionAll pregnancies6-7Stable treated hyperthyroidism0-36Uncontrolled thyrotoxicosis100-156Subclinical hypothyroidism0-15Overt hypothyrodism15-125SLE40-150Mild chronic renal disease15Moderate and severe chronic renal disease32-200Cholestasis of pregnancy12-30

Thyroid/renal disorders

Slide28

Thyroid/renal disorders

Thyroid disorders

Renal disorders

Graves disease, where thyroid-stimulating hormone receptor antibody causes fetal toxicosisUntreated thyroid disorders

Linear relationship between maternal creatinine and risk of fetal demise

Systemic Lupus Erythematosus

Stillbirth

rates are higher in the presence of HTN, nephritis, or APL

Circulating

auto-antibodies, anti-Ro, anti-La

Congenital heart block,

hydrops

Slide29

Maternal medical conditions

Risk is a continuum

Reddy, UM et al, 2009

Slide30

thrombophilias

Causes of stillbirth—NICHHD workshop consensus

Slide31

Thrombophilias

Antiphospholipid syndrome

Inherited thrombophilias

Inflammation, thrombosis, and infarction in the placentaClear histopathological or clinical evidence of placental insufficiency

Factor V Leiden mutation, antithrombin III deficincy, prothrombin gene mutation, protein C deficiency, protein S deficiencyPlacental infarction and thrombosis

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

Thrombophilias

are common in healthy women with normal outcomes

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

Evidence of placental insufficiency such as fetal growth restriction or infarction and

Recurrent fetal loss

Slide32

alloimmunization

Causes of stillbirth—NICHHD workshop consensus

Slide33

Alloimmunization

Red cell alloimmunization

Platelet alloimmunization

Anti-Rhesus D, anti-Rhesus C, anti-KellMust have a positive indirect Coombs testAntibody titers more than 1:16 (or 1:8 for anti-Kell)Evidence of fetal anemia with hydropsEvidence of fetal extramedullary hematopoeisis

HPA-1a, HPA-5a, HPA-4

Maternal antibodies against paternal and fetal platelet antigens

Parental platelet incompatibility for the pertinent antigen

Fetal thrombocytopenia

Massive intracranial hemorrhage

Slide34

Congenital malformationschromosomal abnormalities

Causes of stillbirth—NICHHD workshop consensus

Slide35

Criteria

Epidemiologic data demonstrating an

excess of intrauterine mortality

Seen

rarely in

liveborn

neonates

When seen in

liveborn

neonates, it

frequently results in neonatal death

Biologic plausibility that it

can result in death

Slide36

Cause of deathStillbirth cases, % (out of total 2211 assessed)Trisomy 211.53Jugulolymphatic obstruction1.45Turner syndrome1.09Twin-twin transfusion syndrome1.09Anencephaly1.0Trisomy 180.81Amnion disruption sequence0.59Lower mesodermal defects0.50Idiopathic nonimmune fetal hydrops0.50Trisomy 130.41

Congenital malformations

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

Slide37

Chromosomal abnormalities

Incidence

Cytogenetic abnormalities account for 6-13% of all stillbirthsThis may be higher because 40-50% attempted karyotypes fail to grow23% monosomy X, 23% trisomy 21, 21% trisomy 18, 8% trisomy 13

Kumar: Robbins pathologic basis of disease, 8

th

edition. 2009

Slide38

Chromosomal abnormalities

Autosomal recessive disorders

Autosomal dominant disorders

Alpha thalessemia, Smith Lemli OpitzPhenotype in lethal cases may differ from live cases

Skeletal dysplasiasMore often spontaneous mutations

Firestein: Kelley’s Textbook of Rheumatology, 9

th

ed. Saunders 2012

Slide39

Fetomaternal hemorrhage

Causes of stillbirth—NICHHD workshop consensus

Slide40

Fetomaternal hemorrhage

The cause

4% of all stillbirths

Risk factors:

Placental abruption

Abdominal trauma

Multiple gestation

Abnormal fetal testing

Slide41

Fetomaternal hemorrhage

Risk of stillbirth depends on

Amount of hemorrhage

Acute/chronic

Gestational age

A threshold of

20

mL

/kg of fetal bleeding

is associated with increased risk of stillbirth

Autopsy confirmation of

fetal anemia and hypoxia

Slide42

Placental causes

Causes of stillbirth—NICHHD workshop consensus

Slide43

Placental causes

Placenta previa, vasa previa, neoplasmsPlacental abruption has 8.9 relative risk of stillbirthMay be considered the cause of death if >30% of the placenta shows signs of abruption

Reddy, UM et al, 2009

Slide44

Placental causes

Any disease that causes an SGA placenta may result in stillbirth

<5% expected weight for gestational age

Preeclampsia, DM, HTN, renal, chronic infections

Any disease that causes an LGA placenta may result in stillbirth

>95% expected weight for gestational age

Hydrops

fetalis

, DM, syphilis

Slide45

Umbilical cord pathology

Stillbirth classification—NICHHD workshop consensus

Slide46

Umbilical cord pathology

Account for

3.4-15% of stillbirths

Velamentous

insertion

If it leads to a

vasa

previa

or bleeding

during labor

Umbilical cord

prolapse

Associated with prematurity,

malpresentation

,

mutiparity

, obstetric manipulation

Umbilical cord occlusion

Cord

prolapse

, entanglement (mono-mono twins)

Torsion

Rupture, strictures, hematomas

Slide47

Velamentous insertion

Slide48

Umbilical cord pathology

Nuchal cordOccurs in up to 30% of normal pregnanciesNot associated with an increased risk of stillbirth in study of 14,000 deliveriesTrue knotAlso common in live birthsGrooving of the cord, constriction of the umbilical vessels, edema, congestion, thrombosisrequired to claim it is the etiology

Isolated finding of a nuchal cord or a true knot at the time of delivery is insufficient evidence that cord accident is the cause of stillbirth

Exclude other relevant causes of stillbirth

Find evidence of

hypoxia and cord occlusion

on postmortem examination

Slide49

Multifetal gestation

Stillbirth classification—NICHHD workshop consensus

Slide50

Complications of multifetal gestation

Monochorionic placentationTwin-twin transfusion syndrome occurs in 9% of mono-di twinsMortality can be 90% in untreated cases

Slide51

Complications of multifetal gestation

Mono-mono twinsCord entanglement, preterm birth, growth impairment, malformations, genetic abnormalities, vascular anastomoses

Gabbe: Obstetrics: normal and problem pregnancies, 6

th

ed. Saunders 2012

Slide52

Uterine complications

Causes of stillbirth—NICHHD workshop consensus

Slide53

Uterine complications

Uterine rupture

Evidence of obstructed circulation

Uterine abnormalities

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

Possibly due to

poorly

vascularized

uterine tissue

or

space constraints

Increased risk of PPROM, cervical insufficiency, preterm labor

Septate

uterus

has highest risk of stillbirth and placental abruption

Slide54

Workup

Evaluation of stillbirth

Slide55

importance

Workup of stillbirth

Slide56

Importance of a stillbirth evaluation

Counseling for

risk of recurrence

Possible

intervention

to reduce recurrence risk

Facilitate

emotional closure and healing

Slide57

Most stillbirths remain unexplained

Incomplete evaluation

Lack of clinician awareness

Concerns of the family

Lack of single universally accepted

classification scheme

Difficult to assign a definitive cause

Unknown cause

Sometimes despite thorough evaluation

Slide58

overview

Workup of stillbirth

Slide59

Overview

Recommended studiesSometimes helpfulNot generally usefulAutopsyPlacental pathologyKaryotypeKliehauer-BetkeIndirect CoombsAcquired thrombophilia panelAnti B2-glycoprotein abToxicology screenSyphilis serologyInherited thrombophilia panelGlucose screeningTSHCMV, toxoplasmosis, other infectiousBile acidsSonohysterogramRoutine TORCH titersANA testingCultures of placental membranes

Silver et al, 2010

Slide60

How do we know what works?

Evaluation of 1025 fetal deaths: proposed diagnostic workup

.”

Korteweg

FJ,

Erwich

JJHM,

Timmer

A, et al. AJOG 2012.

Prospective cohort study in 50 Dutch hospitals

Singleton IUFDs at >=20wks gestation, excluding pregnancy terminations and

intrapartum

deaths

Cause of death determined by a

multidisciplinary panel

(2 obstetricians, an OB resident,

perinatal

pathologist, neonatologist, genetics, microbiologist)

Initial

demonstratable

pathophysiological

entity

initiating the chain of events that irreversibly led to death

Contribution of each diagnostic test for determination of cause of death was determined by the panel

Valuable for “

establishing cause of death

” or “

excluding cause of death

Slide61

Medical history

Workup of stillbirth

Slide62

Thorough medical/obstetrical history

Pregnancy complications

Maternal medical history

Genetic abnormalities

Substance use

Pregnancy history

Family history

Slide63

Examinationof the fetusand placenta

Workup of stillbirth

Slide64

Examination of the fetus

Workup of stillbirth

Slide65

Physician’s exam

Weight, head circumference, lengthPhotographsFrontal and profieWhole body, face, extremeties, palms, abnormalities

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

Slide66

FindingTime of demiseBrown or red discoloration of the cord stumpDesquamation >1cm>6 hours agoDesquamation of face, back, abdomen>12 hours agoDesquamation >5% of the body or >2 body zones>18 hours agoSkin color brown or tan>24 hours agoMummification(reduced soft tissue, leathery skin, dark brown)>2 weeks ago

Time of demise

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

Slide67

Autopsy

New information that influences counseling in

26-51%

of cases

Dutch study: valuable in

72% of cases

However, it is performed in

<50% of cases

Clinician hesitation to recommend autopsy

Patient reservations

Slide68

Autopsy

Ask about patient reservations

Emphasize potential benefits to family

Allow the family ample time to hold the baby and perform religious/cultural activities first

Slide69

Autopsy

Medical autopsies require consent of next-of-kinConsent should be explicit enough that parents can limit the autopsy procedure

Slide70

Illinois Masonic Policy

“An autopsy is an option for fetuses 20 weeks or greater, but if clinically indicated or requested by the family, an autopsy can be offered before 20 weeks.”

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

Slide71

Components of an autopsy

Review of the clinical history, laboratories, antenatal imaging

External examination:

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

Joint mobility, facial features, hands, feet, genitalia

Intraoral examination:

Pharynx, soft palate, uvula

Take into consideration changes from maceration

Photographs

Slide72

External examination

Lentz: Comprehensive Gynecology, 6

th ed

Kumar: Robbins pathologic basis of disease, 8

th

edition. 2009

Slide73

Components of an autopsy

Internal examination

Y or T shaped incision on anterior trunk

Organs examined in situ

Heart sometimes opened in situ, sometimes removed and fixed

Vascular connections, septal defects

Organs removed in bloc for detailed dissection

Spinal cord removed

Slide74

Components of an autopsy

Brain

Coronal scalp incision extending to behind the ears

Skull is opened along cranial sutures

Can extend into posterior neck for posterior

fossa

(Dandy-Walker,

Chiari

) by removing occipital bone and cervical vertebrae

Brain is placed in formalin for 10 days before examination

Slide75

Brain

Chiari

malformation—downward displacement of medulla

Fligner

2011

Slide76

Components of an autopsy

Samples of tissue for

Microscopic evaluation

Viral cultures

Bacterial cultures

Metabolic studies (Guthrie card)

Slide77

Histologic exam

Kumar: Robbins pathologic basis of disease, 8

th edition. 2009

Extramedullary

hematopoeisis

in fetal liver in fetus with non-immune

hydrops

Slide78

What autopsy can identify

Markers of IUGR

Head circumference percentile higher than weight percentile

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

Altered brain

weight:liver

weight

Kidneys

Polycystic kidney disease

Certain brain pathologies

Congenital anomalies

Slide79

Kidneys

A: 28 wks, suspicious for

autosomal

recessive polycystic kidney disease

B: confirmed on autopsy

C: 22 wks, suspicious for ARPKD

D: Autopsy showed diffuse renal cystic dysplasia

Slide80

Autopsy can provide evidence

InfectionAnemiaHypoxia

Kumar: Robbins pathologic basis of disease, 8

th

edition. 2009

Slide81

Alternatives to autopsy

Partial autopsy

Head-sparing autopsy (may miss CNS pathology)

External examination by a trained pathologist

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

Will likely miss fetal infections and internal anomalies

External examination with selected biopsies

More likely to identify fetal infections

Slide82

Alternatives to autopsy: MRI

Very good for CNS pathologySometimes better than autopsy, because fetal brain has high water content and liquefiesFluid collections and effusions in the body

May miss cardiac anomalies, bowel anomaliesCannot diagnose infections or metabolic disease

Advantages

Disadvantages

Slide83

MRI

24 wks, massive bilateral

intraventricular hemorrhage

Fligner

2011

Slide84

MRI

Image-guided percutaneous biopsies<50% success rate at obtaining tissue in one studySomewhat inferior to autopsy:12 cases where “minimally invasive autopsy” provided equivalent information to autopsy12 cases where “minimally invansive autopsy” provided inferior information than autopsy2 cases where MRI and biopsy provided superior informationHowever, 73% of minimally invasive autopsies provided Information of equivalent clinical significance to autopsy

Fligner

2011

Slide85

Alternatives to autopsy

X ray

Useful for skeletal

dysplasias

Ribs/vertebrae as part of diagnosis of VACTERL or diabetic

fetopathy

Slide86

X ray

Achondrogenesis

1b (absence of vertebral bodies)

Fligner

2011

Slide87

X ray

Hemivertebrae

(VACTERL)

Fligner

2011

Slide88

Examination of the placenta

Suggested workup of stillbirth

Slide89

Examination of the placenta

The most valuable diagnostic test in most studies

Dutch study showed it to be valuable in 95% of

cases

Provides additional information in 30% of cases

Slide90

Examination of the placenta

Weight

in relation to norms for gestational age

Evidence of abruption, infarction,

thrombophilias

Hemosiderin

deposits

chronic

abruption

Perivillious

and marginal fibrin deposition

Decidual

necrosis

Evidence of infarction

Slide91

Examination of the placenta

Multiples:

c

horionicity

, vascular

anastomoses

in

multifetal

gestations

Cord: thrombosis

,

velamentous

cord insertion,

vasa

previa

Evidence of infections

More common in preterm stillbirth

Viral

nuclic

acid

amplification

Bacterial cultures

Slide92

Examination of the placenta

Kumar: Robbins pathologic basis of disease, 8

th

edition. 2009

Slide93

genetics

Workup of stillbirth

Slide94

Karyotype

Abnormal fetal

karyotype

noted in

8-13% of all stillbirths

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

Dutch study:

11.9% prevalence of a chromosomal abnormality

in the 362

IUFDs

who underwent

karyotyping

37%

trisomy

21, 16%

monosomy

X, 4%

trisomy

13

Karyotype

was

valuable in 29%

of cases

Slide95

Cell culture

Successful in

only

~50

%

of

cases

Cells must be cultured

in

vitro—need metaphase chromosomes

Only

1% of cells

are dividing at any time

Slide96

Kumar: Robbins pathologic basis of disease, 8

th edition. 2009

Slide97

Cell culture

Acceptable

cytologic

specimens:

Amniotic fluid

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

1x1cm placental block

from below the cord insertion site on an unfixed placenta

1.5cm

segement

of

umbilical cord

Internal fetal tissue specimen

(

costochondral

junction, patella, lung, kidney, gonad,

not skin

)

Slide98

Cell culture

Collect

the specimen in a

sterile

manner

Prokaryotic cells outcompete and overgrow any human cells

Transport to the laboratory

as soon as possible

Blood, amniotic fluid, chorionic

villi

at

room temperature

Solid tissue transported on

wet ice

Lysosomal

enzyme activity

is inhibited at 4 C and viability is maintained

Slide99

Cell culture

Monolayer in situ

U

p

to

2 weeks

for solid tissue culture

Cells are swelled

hypotonically

, ruptured (blowing on the

coverslip

) and metaphase chromosomes are spread

Automatic robotic harvesters

Stained with

Giemsa

or Wright

Results in banding pattern unique to each chromosome

Slide100

Karyotype

Count the chromosomes in each cellTechnologist at a microscopeMust analyze 15-20 cells to get karyotypePhotograph of karyogram or computer-assisted imagingManipulate/move chromosomesPattern-recognition software to generate karyogramComputer must be double-checked by a technologist

Stein 2011

Slide101

If culture is unsuccessful

Flourescent

in-situ

hybridization (FISH)

Can test for the most common

aneuploidies

Can test for specific mutations

Slide102

FISH

Molecular

probe

Fluorescent

dye

V

isualized

using fluorescence microscopy

Molecular probes can be

Specific to certain mutations

A cocktail that coats the whole chromosome

FISH can be performed on metaphase or

interphase

chromosomes—

cell culture not required for FISH

Slide103

FISH

DNA is denatured and allowed to hybridize with the probe

Nonhybridized

DNA is then

counterstained

Slide104

FISH

X, X

Trisomy

21

Normal chromosome 21

Stein 2011

Slide105

FISH

Microdeletion

in chromosome 22 associated with DiGeorge syndrome

Stein 2011

Slide106

FISH

Probes must be known genes/mutationsLimited number of colors can be seen with fluorescent microscope

Does not require metaphase chromosomesCan obtain karyotype and information about mutations

Advantages

Disadvantages

Slide107

FISH with computer-assisted system

Trisomy

18 and XXY

Fluorochromes can be mixedToo subtle for human eye, but computer assisted systems allow detection of all 24 chromosomesKaryotype in interphase

Stein 2011

Slide108

If live cells are not available: Microarray

Screens the genome for

copy number variations (CNPs)

BAC arrays provide

overview of genome

SNP arrays provide

more detailed coverage

with probes on every 100-1000 base pairs

Detects

deletions, duplications,

aneuploidies

, unbalanced translocations

with a gain/loss of sequences

Good for

small deletions

or cryptic changes

Cytogenetics

resolution is only 5-10Mb

Slide109

Microarray

Stein 2011

Slide110

Limitations

Many copy number changes are of

uncertain clinical significance

More CNVs are being identified every day

It will not detect

balanced translocations or

inversions

Slide111

Microarray versus karyotyping

Reddy UM et al,

2012:

Prospective population-based study of

532 stillbirths

over

2 years

Patients with IUFD

underwent:

Interview

, chart abstraction, postpartum examination, placental pathology,

karyotype

analysis, and specimen collection

DNA analyzed with an

SNP microarray

with data aligned to Human Genome release 18

Slide112

Microarray versus karyotyping

Benign CNV

: full length listed in any of three databases of unaffected persons

Pathogenic CNV

:

E

vidence

of

pathogenicity

in literature

A

gene listed in the OMIM database that is known to cause developmental/lethal

disease

In

a pathogenic database

Probably benign CNV

: no evidence of

pathogenicity

in literature

Unknown CNV

Slide113

Microarray versus karyotyping

Microarray analysis yielded a result in

87.4%

stillbirths compared to

70.5%

for

karyotype

85.2% of these were

benign, too small, or probably benign

2.6% were pathogenic, 6.9% were

aneuploid

Microarray detected CNV consistent

with

DiGeorge

syndrome

not detected by

karyotype

in 3 cases

Slide114

Conclusions: microarray

Can detect mutations too small for FISHHigher chance of obtaining a result

More expensive

Advantages

Disadvantages

Genetic workup should be guided by family history and presence of congenital

anomalies

Consider microarray when

karyotype

fails to grow in culture

Slide115

Maternal workup

Workup of stillbirth

Slide116

Immediate maternal workup

Workup of

stillbirth

Slide117

Laboratories (Recommended)

CBC

Kliehauer-Betke

Human

parvovirus B-19

IgG

and

IgM

Lupus anticoagulant,

anticardiolipin

antibodies

Indirect

Coombs

If not already done

antepartum

Toxicology

screen

Slide118

Kliehauer Betke

Recommended

to do

before induction

of labor

However, given that only massive hemorrhage is likely to cause fetal death,

can also be done up

to

2-3 weeks after delivery

In

Dutch study, FMH was a

contributing factor in 10.6%

of the total cohort

Slide119

Kliehauer Betke

Reddy et al 2009

Slide120

Antiphospholipid antibodies

One fetal death satisfies criteria for testingConfirm with repeat testing in 6-12 weeksMore likely positive if stillbirth was accompanied by IUGR or severe preeclampsiaTwo dutch studies (750 fetal deaths in Korteweg et al 2010, 1025 fetal deaths in Korteweg et al 2012) showed that neither testing for acquired nor inherited thrombophilia is valuableUnless the patient has a family or personal history of thrombophilia

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

Slide121

Laboratories (Sometimes useful)

SyphilisTSHInherited thrombophilia workupFactor V Leiden, prothrombin gene mutation, antithrombin III, fasting homocysteineGlucose screeningSonohysterogramEspecially if loss associated with preterm labor, PPROM, cervical insufficiency, previable gestations, fetal malpresentation

Guided by maternal history and risk factors

Slide122

Inherited thrombophilia

Korteweg et al 2010. Multicenter, prospective study. 750 singleton fetal deaths >=20 wks, excluding terminationsTested for vWF, antithrombin, protein C, total and free protein S, prothrombin gene mutation, factor V LeidenCause of death classified by a panel“Except for vWF and paternal free protein S, acquired and thrombophilic defects were not more prevalent after fetal death.”However, many case-control studies show an association

Consider it

in cases of

severe placental pathology, IUGR, or a history of thrombosis

However, remember that most women with these conditions will have uncomplicated pregnancies

Slide123

Laboratories (unproven benefit)

Toxoplasmosis, rubella, CMV, HSV, other infections

Viruses for which vaccines are prevalent are uncommon in developed countries

However, if

autopsy, pathology, or history is suggestive

, take maternal/neonatal serology, special tissue

staines

, testing for nucleic acids

ANA

Slide124

Routine TORCH

Dutch study: of the women tested for TORCH, 17.0% had positive

IgM

for TORCH,

parvo

, syphilis, or hepatitis

B

However only

1.8% of the total cohort

had infection as the cause of death

Slide125

Postpartum maternal workup

Suggested workup of stillbirth

Slide126

In selected cases

Paternal karyotypeProtein S and C activityKliehauer-Betke

Slide127

Considerations

Evaluation of stillbirth

Slide128

AIMMC protocol

All

intact fetal remains are sent to the morgue within 4 hours of expiration,

UNLESS

a Surgical Pathology examination is

requested

If

a Surgical Pathology examination is

requested

Remains with a Surgical

Pathology requisition to the Histology

Laboratory

Central

Transport

and

Nursing

are

responsible for the initial transport of the body

to

the

morgue

and filling out the morgue census sheet

Slide129

AIMMC protocol

If autopsy is requested, the fetus is obtained from the morgueAn autopsy is an option for fetuses >=20 weeksBut if clinically indicated or requested by the family, an autopsy can be offered before 20 weeks

Slide130

AIMMC protocol

Autopsies are performed by AIMMC pathologists

Trained in fetal/neonatal autopsies

Consult specialists when needed

Preliminary result in 24 hours; final result in 30 days

Genetic and molecular testing at ACL

A fetus that undergoes an autopsy

can

still receive private burial

Slide131

Fetal death disposition notification

Within 24 hours after an abortion/miscarriage the mother must be informed of her right to determine the final disposition of the remainsPrivate burialCremationHospital disposition

Slide132

Fetal death disposition notification

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

Slide133

Fetal death disposition notification

If patient is unclear,

sign the form

without making a

selection

RN notes “

undecided at

discharge”

Fax a copy to

Mission and Spiritual Care

at 773-296-5010 and place a copy in the chart

Mission

and Spiritual Care or the

Perinatal

Loss Coordinator will follow up with the family

If the family can not be reached

within

2

weeks

, Pathology

will initiate the procedure for hospital disposition

Slide134

Private burial

Perinatal

loss coordinator has a list of funeral homes

Cremation or burial

Only a

licensed funeral director

can pick up the fetus

Parents provide the name to Health Information Management

Cost: some funeral home directors

reduce the rate

Medicaid pays for modest funeral and burial

For

very young fetuses

, parents advised that there might not be many remains after autopsy

Slide135

Hospital disposition

St Luke’s Cemetery5300 N. Pulaski Road, Chicago, IL 60630“Babyland,” exact location not identifiedNo charge

Slide136

Perinatal loss coordinator

Always notifiy Anna Zieba (pager 61-7656, phone 61-7127)Always notify Mission and Spiritual Care 61-5005Can provide religious services from most religions

Slide137

Considerations

Parents benefit from

seeing/holding

the infant

Warn them about how the baby will appear

Use the term “

baby

Encourage parents to

name

the infant

Knowing the

sex

is important

Fetal loss can be devastation at

any gestational age

Different

cultures

grieve in different ways

Slide138

Considerations

Keepsakes and memory boxes

Child

Life specialist

can aid with

siblings

For a loss in the ER, consider consulting

crisis

if parents show signs of depression

Bereavement care track

after discharge

Slide139

Conclusions

Evaluation of stillbirth

Slide140

Conclusions

The cause of a stillbirth is the

initial

pathophysiologic

entity

that irreversibly led to fetal death

Cause must be proven

with evidence of fetal harm

There are

many benefits

to finding a cause

Encourage

patients

to allow an evaluation within the boundaries of their personal and cultural values

Slide141

Conclusions

Recommended laboratories are

CBC

,

Kliehauer-Betke

,

parvovirus

B-19

IgG

and

IgM

,

lupus

anticoagulant

,

anticardiolipin

antibodies

, and

toxicology screen

Only perform other labs as indicated by

maternal history

Encourage patients to receive an

autopsy

Partial autopsy

and

MRI

are alternatives

Always send the

placenta

to pathology

Slide142

Conclusions

Encourage

karyotyping

Base evaluation for other chromosomal abnormalities on

family history

and results of

other studies

Consider

FISH or microarray

if low likelihood of getting a result from cell culture

Utilize

hospital resources

for

perinatal

loss

Slide143

Thank you

Slide144

Sources

Evaluation of stillbirth

Slide145

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

Fligner

CL,

Dighe

M. “Fetal and

Perinatal

Death Investigation: Redefining the Autopsy and the Role of Radiologic Imaging.” Ultrasound

Clin

6, 2011 (105-117

).

Illinois Masonic Medical Center

Perinatal

Loss Policy. Policy 20.118.044

Korteweg

FJ,

Erwich

JJHM,

Timmer

A, et al. “Evaluation of 1025 fetal deaths: proposed diagnostic workup.” Am J

Obstet

Gynecol

2012; 206:53.e1-12

.

Korteweg

FJ,

Erwich

JJHM, et al. “Prevalence of Parental

Thrombophilic

Defects after Fetal Death and Relation to Cause.”

Obstet

and Gynecol. August 2010,

Vol

116, No 2, part 1.

Kumar: Robbins and

Coltran

Pathologic Basis of Disease, Professional Edition, 8

th

ed

. 2009 Saunders, an imprint of Elsevier.

Reddy UM,

Goldenburg

R, et al. “Stillbirth Classification—Developing an International Consensus for Research.”

Obstet

and Gynecol

. Oct 2009,

Vol

114, No 4.

Reddy UM, Page GP,

Saade

GR. “

Karyotype

versus Microarray testing for Genetic Abnormalities after Stillbirth.” N

Engl

J med 367; 23, December 2012

Silver R,

Heuser

C. “Stillbirth Workup and Delivery Management.”

Clin

Obstet

and

Gynecol

2010; 53, 3.

Stein, CK. “Applications of

cytogenetics

in Modern Pathology.”

McPherson: Henry’s Clinical Diagnosis and Management by Laboratory Methods, 22

nd

ed

. 2011 Saunders, an imprint of Elsevier.


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