Espresso: Shoulder Dystocia

What is shoulder dystocia?

• After the delivery of the fetal head, the fetal anterior shoulder gets caught on the maternal pubic symphysis.

• Less common: posterior shoulder is impacted by the maternal sacral promontory 

• Reported incidence: ranges from 0.2-3% of vaginal deliveries

• Most often recognized when after delivery of the head, there is not easy delivery of the shoulders with gentle traction on the head. Can often see a “turtle” sign, when there is retraction of the fetal head from the maternal perineum 

• Risk factors 

  • Fetal macrosomia - and anything else that can cause it

    • Think maternal diabetes - Type I, Type II, or GDM, especially if poorly controlled 

  • History of shoulder dystocia (recurrence rate is 10%) 

  • Unfortunately, nothing has been reliably found to predict shoulder dystocia, including history, presence of diabetes, or even EFW or abdominal circumference to BPD ratio 

Why do we care about shoulder dystocia? 

• Risks to mom

  • Increased risk of postpartum hemorrhage (11%) 

  • Increased risk of 4th degree laceration (3.8%) 

  • Also performance of certain “heroic measures,” ie. Zavanelli and symphysiotomy (ouch) have significant risk for mom (ureteral injury, uterine rupture, cervical laceration, bladder injury)  

    • Thankfully they are rare !

    • I have never seen it in real life, but there is an … interesting episode with eclampsia, forceps, and shoulder dystocia all in one with Zavanelli’s maneuver on an episode of ER (Love’s Labor Lost, Season 1 Episode 19) from 1995.

• Risks to baby 

  • Most shoulder dystocias resolve without injury to the baby, but there is a higher overall neonatal injury rate, about 5.2% from a recent multicenter study in 2018 

  • Increased risk of brachial plexus injury from hyperextension of neck one way or the other → Erb palsy, Klumpke palsy 

  • Increased risk of clavicular or humeral fracture 

  • More rare is hypoxic-ischemic encephalopathy (HIE) 

  • Interestingly, the length of shoulder dystocia itself is not an accurate predictor of neonatal asphyxia or death 

How do we manage shoulder dystocia? 

• Prevention of shoulder dystocia 

  • Again, we cannot accurately predict shoulder dystocia, so unfortunately… it’s not easy to figure out what to do to prevent.

  • There have not been big trials looking at this time, but according to some studies looking at the cost analysis, there is some suggestion that offering primary cesarean for fetuses >5000g in non-diabetic mothers and >4500g in diabetic mothers may be “worth it.”

  • Similarly, you can consider for patients with history of shoulder dystocia where recurrence risk is ~10%.

  • What about induction of labor? 

    • Basically, there have been a lot of studies, but currently, evidence is unclear if there is benefit for earlier induction of labor vs. expectant management alone for shoulder dystocia prevention.

Maneuvers for shoulder dystocia/how to manage a shoulder dystocia

• Every hospital is going to be different, but this is how we were trained!

  1. Recognize a shoulder: turtling, shoulder not delivery easily despite gentle downward traction on the head 

  2. Communication: let the room know that there is a shoulder dystocia, ie. “We have a shoulder dystocia” - usually this will kick off a series of events 

     • The nurse may call for help, at our current hospital, there is an “emergency lever” that is pulled and help will come  

     • Talk to mom and ask her to stop pushing: “Ms. X, baby’s shoulder is stuck behind the pubic bone. I’m going to ask you to stop pushing while we help baby get out.”   

     • Once you call a shoulder dystocia, usually institutional implementation of someone to be recorder - call time, document maneuvers tried 

  3. Positioning: have nursing/other providers move mom down on the bed so that the perineum is right at the edge of the bed. Then place mom in McRobert’s maneuver, where the hips are flexed back, opening the pelvis.

  4. Maneuvers: there are no randomized controlled trials for what is better, but there are some logical steps to take that are easy to employ (McRobert’s, suprapubic pressure, and posterior arm will relieve 95% of shoulder dystocias in 4 minutes or less) 

     • Suprapubic pressure: another provider places pressure suprapubically to push the impacted shoulder under the pubic symphysis. This needs to be done in the correct direction. Often, we take a moment to figure out which shoulder is impacted and which direction it should go. Then direct the other provider by indicated with your hand or finger (“I want suprapubic pressure in this direction”) instead of verbally, because that can get confusing (ie. which right?) 

     • Posterior arm: some recent studies have shown that delivery of the posterior shoulder leads to a high success rate. This involves placing a hand into the vagina, finding the posterior arm and delivering it first. Sometimes, this may be more difficult, as it involves identifying the arm and hand, flexing it at the elbow, and gently pulling the arm around the head. If there is little room, may also require an episiotomy. 

       • Posterior shoulder sling - thread a catheter under the posterior armpit and deliver posterior shoulder this way 

     • Rubin and Woodscrew Maneuvers: Rubin’s involves placing a hand into the vagina and rotating the posterior shoulder anterior toward the fetal head. Woodscrew involves placing the hand on the anterior surface of the posterior fetal clavicle to turn the posterior shoulder until the anterior shoulder emerges.

     • Gaskin Maneuver: have the woman get on all fours and place pressure on the posterior pressure downward or upward traction on anterior shoulder.

***If these don’t work, try again. A study of 231 cases showed no association between maneuvers and neonatal injury. Try what works !

More aggressive maneuvers

• Zavanelli’s - when everything else has been tried, if the only other option is abdominal rescue for catastrophic cases, place pressure on the head to go back up through the vaginal canal for cesarean delivery 

• Symphysiotomy - cutting the symphysis. Not really a modern option in the era of readily available cesarean delivery, but has been performed in lower resourced settings.

• Breaking fetal clavicle - may decrease AP diameter, but may be difficult to perform. Always break in a manner that is away from the fetal chest (ie. pull clavicle away from body) to avoid damaging underlying structures.

Simulation is key to success in managing shoulder dystocia as a team! - if you don’t have this already, please ask about SIMing a shoulder dystocia at your institution.

• Not only to make providers more comfortable, but studies have also shown that team training protocols and sim have been associated with reduction in transient brachial plexus injury.

• Increased evidence-based management of shoulder dystocia.

HCG with Dr. Vivienne Meljen

Today we welcome Dr. Vivienne Meljen, senior resident at Duke OB/GYN, to talk to us about one of her favorite topics — bHCG, the “pregnancy hormone.” There’s a lot to unpack — so these notes are broken down as our Q&A conversation!

What is hCG?  

• Human chorionic gonadotropin or hCG is part of a family of glycoprotein hormones including TSH, FSH, and LH.  

• These are hormones produced by the pituitary gland. hCG included!

• They are each heterodimers and have an alpha and a beta subunit.  The alpha subunits are identical and beta subunits are all a bit different 

  • In fact, luteinizing hormone (LH) and hCG are super similar and come from shared genes, so when LH is being made in large amounts, hCG is also made and may be elevated.  

• HCG is metabolized by the liver and kidneys.  

Where does hCG come from?  

• Traditionally we think of hCG as being produced by “a pregnancy”. The part of a pregnancy that makes hCG is the trophoblast - what will eventually become the placenta.  

• It also comes from the pituitary gland as we mentioned earlier. And some cancers can make hCG 

What does hCG do?  

• To understand what hCG does, we need to back track a bit and remember how a pregnancy starts.  

• To get to hCG production, there must be fertilization and then implantation of the pregnancy. This process of reaching implantation takes about 7 – 10 days as the embryo floats through the tube to its final implantation site.  

• Once it has implanted, the trophoblast makes hCG which then stimulates the corpus luteum to keep making progesterone, which helps continue to support gestation. At about 10-12 weeks, hCG levels usually peak and thereafter, the placenta takes over hCG production. 

  • This is apparent in patients’ thyroid testing. In normal pregnancy with an asymptomatic patient, TFTs could be slightly abnormal at this point due to the cross-reactivity and homology between TSH and hCG.  

So someone can be pregnant, but not necessarily have hCG? Is that right?  

• Yes, while that blastocyst is making its way to implantation, the corpus luteum is making its own progesterone and there is no hCG yet so a pregnancy test will be negative. In order to minimize variation in ability to detect a pregnancy, we should time pregnancy testing to be done at 15 days after LH surge, instead of testing at the time of expected menses.

  • This is why in contraception management if we cannot reasonably exclude pregnancy, we recheck in ~ 2 weeks because we would “capture” most pregnancies at that point. 

I know there is hCG, but I always hear about “betas” or “checking a beta”. What’s that about?  

• Like I mentioned, hCG is a heterodimer with an alpha and a beta subunit. Most people say “check a beta” meaning “check a quant”. The reference to betas is actually due to a misunderstanding back when the hCG immunoassays were first being created, and a bottle of antibodies was labeled as “beta subunit” and it was interpreted as the test only testing for beta subunits. In fact, most hCG tests are detecting all different types of hCG when you get a quant.   

What can we use hCG testing for?  

• Detecting pregnancy  

• Tumor marker monitoring in molar pregnancy and GTN  

• Screening for trisomies in pregnancy with quad screen for example  

What can we use hCG itself for?  

• One of the evidence-based and legitimate ways to use it is in the REI world for ovarian hyperstimulation for ART. HCG is the “trigger shot” to help mature eggs because it simulates an LH surge due to its homology.  

• Note- by the time you’d want to test for pregnancy in a woman undergoing ART, this should have cleared so it shouldn’t affect testing.  

What’s the normal rate of rise for hCG in a normal pregnancy?  

• We use serial hCG concentration measurements as a tool to help us differentiate normal from abnormal pregnancies 

• Back in the day, the rule of thumb was that hCG would rise ~51% every 48 hours.  

• Now we know that hCG rate of rise depends on the initial value with the % rise being greater at lower values. For an initial hCG level of < 1,500 the expected rate of rise is > 49% versus starting over 3,000 the expected rate of rise is in the ~33% range. Most normal pregnancies will rise faster than this.  

What about hCG levels going down?  

• While we have some clear guidelines about a 15+% decrease in hcg levels between days 4 and 7 following mtx administration for suspected ectopic pregnancy, it is less clear in other situations. 

• There is no specific rule, but per ACOG, following an SAB hCG levels should normalize within 2-6 weeks. This likely depends on the initial value.  

What can cause a positive pregnancy test?  

• Pregnancy (normal, abnormal, ectopic) 

• HCG doping (people use it for weight loss and for sports) 

• A slew of possible causes of false positives we will get into later  

What’s the deal with urine and serum testing for hCG?  

• Urine tests are QUALITATIVE – positive or negative  

• Most Serum tests are QUANTITATIVE – give you a number amount usually in IU/L 

• Urine tests will typically turn positive at the same point at which a serum test is > 20-25. However, you can have a false negative urine study if the urine is very dilute and a woman’s hCG level is low.  

• Most of these test employs antibodies that sandwich hCG when present and then are converted into a test result.  

• Because they use antibodies though, some other things can cause antibodies to link and create a false positive or negative result that you need to be aware of.  

• On a typical urine test or a “UPT” seeing 1 line is a sign that the control and test works, 2 lines means hCG is present.  

  • You can get a false negative test with a rare situation called the “hook effect” when you have SUCH a high level of hCG (think GTN levels) that the sandwich antibodies are saturated on both ends and can’t link together to give a signal.  

False positive tests seem to be fairly common and weird. Can you take us through those?

• Heterophile antibodies are often referred to as “phantom hCG”. These are nonspecific, low affinity antibodies that can crosslink the antibodies in the test and make it seem positive. 

• Where do these antibodies come from? - Some people at greater risk of these heterophile antibodies are people who have worked on a farm or in a veterinary facility, women with rheumatologic conditions, patients who have rec’d recombinant antibodies for medical treatment, some who have received plasma exchange from an unknowingly pregnant donor.  You can filter out for these by cross checking with urine that should be negative, trying a different assay, or having your lab perform serial dilutions or use a heterophile-blocking agent. 

• Pituitary hCG is often seen in perimenopause or post-chemotherapy. This makes sense because of the homology to LH. So when LH is high, hCG rises with it. You can suppress this by giving OCPs to see if it normalizes in a few weeks.  

• “Chemical pregnancy” is another potential “false” but not really false positive. This is an implanted conception that produces hCG but results in a SAB by the time of expected menses.  

• Familial hCG is a bizarre and rare cause where there is a hereditary cause of hCG production that can be present throughout ones entire life at low levels.  

• Kidney disease is one of the more common causes I’ve been called for and this is a tricky one. The exact mechanism for why patients with ESRD have false positive hCG is not known but we think its related to impaired renal clearance and increased gonadotropin levels. The tough part is that these patients often do NOT produce urine so they get serum testing which if positive, we can’t cross check with urine to see easily if it is a heterophile. Often, these patients are tested in the setting of prepping for transplant and sometimes, in the final stretch before going to the OR for a new kidney; so a positive test can really complicate things. To make matters worse, they often have complicated menstrual histories so it is very hard to cross check timing of a possible pregnancy. It’s estimated that approximately 1.5% of dialysis receiving reproductive-aged women conceive over ~2 years so it’s possible. Usually, using a good history one can work this out and often these patients have a series of low positive quants over the course of years to help support that it is a false positive test. Some authors suggest using a good old fashioned progesterone level to help clarify the situation, though it isn’t fool proof.  

Pediatric Vulvovaginitis

Infrequently in the general gynecologist’s office, you may be asked to evaluate a child for concern of vulvovaginitis. Today’s episode will review some common questions regarding approach in pediatric gynecology, and be specific to a pre-pubertal population.

Many times this is the first time that the young patient has seen a gynecologist! It’s going to be a scary and unfamiliar environment, as the only context for physicians for many children at this point are their pediatrician or family physician. You’ll likely have to lean in to the parent/close relative/guardian for history and more information regarding chronicity, anxieties, and specific complaints.

Common complaints can include:

• Itching or discharge.

• Pain or irritation.

• Issues with going to the bathroom (ie. some children may have issues of leaking urine, seemingly losing the developmental milestone of urinary continence).

The approach in pediatrics is somewhat different:

• Getting the trust of the patient - this may be harder for us as Ob/Gyns, since we are not always used to dealing with a pediatric population.

  1. Stickers, coloring books, asking about school and friends etc.

• If they are old enough to speak for themselves, always ask them what’s going on!

• Then ask/tell them that you are going to talk to their parent/guardian who is with them that you’d like to ask them as well what is going on — this is respectful of the child and keeps them involved.

• For adolescent patients, usually have the parents/guardian step out of the room for some time for sensitive questions 

  1. Assess risk: safety at school, home, people they don’t get along with or who may be hurting them 

  2. Drug/alcohol/tobacco use - kids may feel guilty about using. Ask if friends/family use, then can broach the subject with them.

  3. Sexual activity (usually approached with “Do you have anyone at school that you might like? Have you held hands or kissed them?).

Specific questions related to the complaint:

• Assessment of vulvar hygiene

  1. Showering/bathing habits - bubble baths? What types of soaps? 

  2. Toileting - how do they wipe? Have them demonstrate 

  3. Choice of clothing/clothing due to hobbies/activities - leotards, tights, swimsuits, etc - how long are they wearing them during the day? What kind of underwear? What about pajamas? 

• The exam

  1. Most children will not have had a pelvic exam, and most (read: almost all) do not require a speculum exam!

  2. Check for abnormal breast development (ie. early breast development) in younger children.

  3. Check for abdominal masses.

  4. Pelvic exam:

     1. Child can be laid back on the table in frog leg position, can also have parent sitting on exam table and holding child on lap in this position.

     2. Careful external examination, also can spread labia from lower legs/bottom and look at urethra/hymenal ring.

        1. Look for skin changes on the labia - red? White? Thin? 

        2. Also, see if there is labial adhesions.

        3. Purulent discharge/other types of discharge can be seen on underwear as well 

     3. Q-tip test to evaluate for vaginal potency.

     4. Foreign objects that cannot be easily removed should not be done in the office with smaller children, may require vaginoscopy  

Now let’s review some differential diagnoses that may present in young children.

Infectious 

1. Candida 

   1. Possible to have yeast infection in children who have had recent antibiotic treatment or if they wear diapers.

   2. Usually uncommon in normal prepubertal girls, unlike in women.

   3. If mostly on the outside, or diaper dermatitis, can use topical antifungal agents like nystatin, clotrimazole, miconazole, etc.

2. Gardnerella - also possible, but it is not common. Treat like BV. 

3. STI - suspect if purulent discharge with evidence of sexual abuse on interview/exam

   1.  Evidence includes anal or genital tears, evidence of ejaculation.

   2. Laceration to lower half of the hymenal ring, usually 3-9 o’clock is consistent with penetrating injury.

   3. Suspicion of child abuse is something that requires mandatory reporting to authorities.

   4. Things to test for include gonorrhea, chlamydia, trichomonas.

   5. Genital warts: can be diagnosed clinically and usually with biopsy.

Noninfectious 

• Foreign body

  1. Can cause acute and chronic vulvovaginitis with purulent discharge, foul smell, and even bleeding.

  2. Most common things are toilet paper, small toys, etc → can usually be removed with warm vaginal lavage (ie. obtaining thin catheter and attach to 60cc syringe). Place the tip of catheter into the vaginal canal, and can lavage several times 

  3. Can treat introitus with small amount of Xylocaine jelly if needed for pain / local anesthetic.

  4. If large object or not easily removed, may need sedation/anesthesia for extraction.

  5. If there is suspicion for battery within the vagina, this is a reason for anesthesia, vaginoscopy for possible burns 

• Trauma 

  1. Vulvar trauma can cause significant bleeding - area is highly vascular 

  2. Interview is important - was there recent straddle injuring/skating injury?

     1. History should correlate with physical finding - otherwise suspect abuse.

  3. Straddle injury: injury usually anterior area of the vulva, including mons, clitoral hood, and anterior aspect of the labial 

     1. Should not have injury to the posterior fourchette and hymenal areas - this would suggest sexual abuse.

     2. Assess ability to urinate and presence of hematoma; if unable to urinate,, need to drain bladder, ice, and give pain medication if large hematoma.

        1. If not obstructive, can ice and give pain medication. Most hematomas will resolve spontaneously 

     3. Surgery is rarely needed and can result in introduction of skin → infection 

Skin issues 

• Lichen sclerosus 

  1. We talked about lichen sclerosus in postmenopausal women previously!

  2. It can cause itching, discomfort, even discharge.

  3. Usually appears white, thin skin (onion skin, cigarette-paper), and usually around the vulva and perianal regions.

     1. Can usually diagnose with visual inspection, and biopsy is rarely needed, though in adults you should biopsy (can be associated with malignancies in adulthood).

  4. Treatment: superpotent topical steroids → first start with more frequent treatment, then maintenance therapy.

• Labial adhesions

  1. Most frequently in infants and young children, peak incidence up to 3% in second year of life in girls.

  2. Usually due to inflammation + low estrogen.

  3. Can lead to discomfort and possible issues with urination, recurrent urinary tract infection.

  4. If asymptomatic, no treatment is necessary especially if it only involves a small portion of the labia.

  5. If symptomatic - initial treatment with topical estrogen/estradiol cream twice a day with fingertip or Q-tip, sometimes with a little pressure, but do not try to manually separate the adhesion as this can cause tearing/pain/bleeding.

     1. Usually can see a thin, translucent raphe in the middle (location of placing estrogen) 

     2. Another option is topical betamethasone as alternative or adjunctive topical treatment  

  6. Surgical separation - rarely indicated. Usually only for those with severe obstruction to urinary flow or who have urinary retention. 

• Vulvar ulcers 

  1. Can be non-sexually transmitted ulcers and can present with systemic symptoms like fatigue, malaise, fever, etc.

  2. Etiology may not always be determined, but viruses can sometimes cause them (ie. flu A, EBV, mycoplasma, CMV).

     1. Take a careful sexual history to rule out other STDs, HSV - but perform these tests as well just in case.

  3. Can also test with CBC and monospot test.

  4. If continues to be painful, unable to urinate, some girls may need to be admitted for pain control and foley placement.

  5. Other things to rule out: Behcet’s syndrome (if chronic ulcers), Crohn’s disease.

Nonvaginal issues 

• Urethral prolapse

  1. Distal end of the urethra can prolapse either partially or in a complete circumferential fashion (“donut-like”).

  2. Tissue can be friable and can become infected.

  3. Usually will have pain with urination, bleeding, etc. 

  4. May need to differentiate from other things like sarcoma botryoides or prolapsed ureterocele (may need a urologist!).

  5. If symptomatic, can be treated with topical estrogen 2x/day for two weeks, and then reassess.

• Pinworm 

  1. Can cause vulvar symptoms as well, like itching, but usually is perianal itching.

  2. Caused by the worm enterobiasis.

  3. Can be diagnosed with visual inspection or “paddle test” where there is a plastic paddle sometimes with adhesion pressed to perianal area → then place on glass slide to see worms.

  4. Treatment is with albendazole or mebendazole, and should think about treating the entire household.

  5. Wash all bedding and clothes!

The Standardized Cesarean Section

Back in June 2019, we did an episode on The Evidence-Based Cesarean Section. Back then, we talked a bit about incision types, infection practices, and some in surgical technique. In the November 2020 Green Journal, two of our podcast guests - Dr. Josh Dalhke and Dr. Jeff Sperling, in addition to their coauthors - make the case for standardizing cesarean delivery technique.

The text is definitely worth a read, as it’s a succinct review of the most current literature. Some of the practices you may employ already; others you may be surprised by! We talk a bit more with these two authors about the recommendations, what was most surprising, and what things are to come.

This checklist comes from the article, and is definitely worth discussing at your institutions. We’ll let the podcast speak for itself otherwise.

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Dahlke et. al, O&G, Nov. 2020 — hyperlink above

Stillbirth

Stillbirth is defined as fetal loss at 20 weeks’ gestation OR, if gestational age is unknown, then loss of a 350-gram fetus (which is the 50%tile weight at 20 weeks). Of note, this definition varies internationally. Stillbirth is synonymous with intrauterine fetal demise; some parent groups prefer the term stillbirth and recent research has started using this term instead. Its incidence is 1 in 160 deliveries in the United States, amounting to ~23,600 stillbirths reported annually in this country. 

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Potential causes of stillbirth:

• Placental abruption: identified as the cause of stillbirth in 5-10% of cases 

• Genetic abnormalities: an abnormal karyotype can be found in ~6-13% of stillbirths

• Infection: associated in 10-20% of stillbirths 

• Umbilical cord events: account for ~10% of stillbirths 

The Stillbirth Collaborative Research Network published a study that evaluated 512 stillbirths and identified a probable cause in almost 61% of cases. A possible/probable cause was identified in 76.2% of cases. They discovered that the placental pathology had the highest diagnostic yield (aiding in almost 65% of the cases) followed by fetal autopsy (in 42% of the cases).

How to workup a cause of stillbirth:

Maternal Workup:

• Medical history: diabetes, cHTN; autoimmune disease; thrombophilias, VTE; epilepsy

• Exposure history: medications; infections; tobacco, alcohol or drugs

• Obstetric history: recurrent pregnancy loss (RPL); fetal growth restriction

• Family History:

  • Three-generation pedigree including stillborn infants and RPL

  • Liveborn infants w/ developmental delays or structural anomalies

  • Arrhythmias and sudden death (SIDS) 

Maternal laboratory evaluation:

• Syphilis testing

• KB testing once diagnosis is made – and ideally before delivery because KB testing can be falsely elevated after delivery

• Antiphospholipid antibody syndrome: One of the clinical criteria for diagnosis of APS is stillbirth: “One or more unexplained deaths of a morphologically normal fetus at or beyond the 10th week of gestation, with normal fetal morphology documented by ultrasound or by direct examination of the fetus.”

  • Check out our previous episode on this topic for more info.

•  Routine testing of inherited thrombophilias has NOT been shown to be helpful. 

  • Other testing that is not helpful includes a full infectious serology panel 

• HbA1c should be obtained for patients with diabetes or suspected diagnosis of thereof.  

Grief and Bereavement: 

• Patient support is two part: emotional support and clear communication of test results 

• Important to recognize their parenthood and acknowledge their grief, offer referrals to bereavement counselors and peer support groups, and communicate results of the workup in a timely manner. 

• A provider may feel at loss of words when approaching grief-stricken parents for consent on autopsy and further workup. At times, providers may not feel as though they’ve developed a strong enough rapport with the parent group so may not offer an autopsy to parents due to the concern that it may upset parents further. However, it is important to consider that the evaluation may provide answers and closure for these parents.

  • In fact, a study done by Rankin et al. estimated that parents who did not consent to a postmortem examination were approximately twice as likely to regret their decision compared tho those who chose to have this investigation performed. 

Autopsy:

There are two types of autopsies: a partial and a complete autopsy.

A partial autopsy involves gross inspection of the fetus and placenta, ideally by a trained perinatal pathologist, and imaging studies. Approximately 20% of stillborn fetuses have dysmorphic features or skeletal abnormalities; of these, about 36% will have chromosomal abnormalities (Monosomy X, Trisomies).

Gross inspection would include measuring the weight of the fetus and the placenta, the head circumference and the length of the fetus, as well as obtaining frontal and profile photographs of the whole body, face, extremities, palms and any abnormalities.  

Gross and microscopic evaluation of the placenta, as well as umbilical cord and membranes by a trained pathologist is the single most useful aspect of the stillbirth evaluation. Here the pathologist can evaluate for abruption, umbilical cord thrombosis, velamentous cord insertion, vasa previa, infection, and anemia  

Cytogenetics Evaluation:

• Usually done with karyotyping or microarray. Although new research studies are underway to evaluate if whole genome sequencing may yield better diagnostic utility, it is not currently part of the standard genetics workup in stillbirth evaluations. 

• The cytogenetic specimens are obtained with sterile techniques and instruments. Acceptable cytogenetics specimens include (place these specimens in a sterile tissue culture medium of lactated ringers solution and keep at room temperature. Do not place in formalin!):

  • Amniotic fluid obtained by amniocentesis at time of prenatal diagnosis. GOLD STANDARD

  • Internal fetal tissue specimen, such as costochondral junction or patella; skin is not recommended 

  • Placental block (1x1cm) taken from below the cord insertion site below the unfixed placenta

  • Umbilical cord segment (1.5cm) 

• Techniques for cytogenetics evaluation include karyotyping which is fast and relatively inexpensive but can underestimate the contribution of genetic abnormalities because in up to 50% of karyotype attempts, cell culture is unsuccessful.

• Chromosomal microarray can detect smaller deletions and duplications as well as aneuploidy. Compared to karyotype analysis, microarray analysis increases the diagnosis of a genetic cause to almost 42%. 

• Recently, there is new evidence to suggest that whole exome sequencing may further increase diagnostic yield in the evaluation of stillbirth.

In Future Pregnancies:

• Offer aneuploidy screening, sonographic screening for fetal growth restriction after 28 weeks and antenatal fetal surveillance as detailed below.

• Antenatal fetal surveillance:

  • For patients with a previous stillbirth at or after 32’0 weeks, once or twice weekly antenatal surveillance is recommended at 32’0 weeks or starting at 1—2 weeks before the gestational age of the prior stillbirth

  • For prior stillbirths that occurred earlier than 32 weeks gestation, individualized timing of antenatal surveillance should be considered. 

    • Of note, antenatal fetal surveillance could lead to iatrogenic preterm deliveries based on false-positive test results. One study estimated a 1.5% rate of iatrogenic prematurity for interventions based on false-positive results, so this must be weighed in when deciding on type/frequency of surveillance. 

• Delivery: planned delivery at 39 0/7 weeks of gestation or as dictated by other maternal or fetal comorbid conditions.