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A Systematic Approach to Stillbirth Examination in a Tertiary Hospital

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A Systematic Approach to Stillbirth Examination in a Tertiary Hospital ORIGINAL ARTICLE A Systematic Approach to Stillbirth Examination in a Tertiary Hospital Arby Jane R. Igualada,1 Efren J. Domingo2 and Jose Maria C. Avila3 1Department of Obstetrics and Gynecology, Philippine General Hospital, University of the Philippines Manila 2Department of Obstetrics and Gynecology, College of Medicine and Philippine General Hospital, University of the Philippines Manila 3Department of Pathology, College of Medicine, University of the Philippines Manila ABSTRACT Background. Stillbirth has a complex pathophysiology, hence the difficulty in arriving at a specific cause. Objectives. The study aimed to identify the probable causes of stillbirth in a tertiary hospital based on gross examination of the placenta and the fetus, as well as, to identify the demographic profile of the stillbirths. Methods. A cross-sectional descriptive study was conducted among 29 stillbirths delivered in a tertiary hospital from March 2016 to September 2016. The probable causes of stillbirth were categorized as obstetrics complications, placental abnormalities, umbilical cord abnormalities, fetal malformations, infections, hypertensive disorders, medical complications, and undetermined causes. Results. 86% of stillbirths in this study had a probable cause of death. Umbilical and placental abnormalities were the most probable causes (62% and 41%, respectively). The two most common identified cord abnormalities were short cord length (34%) and marginal insertion (23%), while small placenta (27%) was the most common for placental abnormalities. Conclusion. To be able to come up with the probable cause of stillbirth, the delivering physician or health personnel should always account the gross findings of the fetus and placenta after delivery. Key Words: fetal death in utero, placenta, stillbirth evaluation INTRODUCTION Obstetricians and other delivering clinicians should contribute to providing significant findings during fetal and placental examination of stillbirths. In a hospital setting where most of the patients are indigent, they would rather not do the extensive work-up for stillbirth examination. However, knowing the probable causes of stillbirth will help healthcare providers improve their counselling services and management of the next pregnancies. In 2015, there were 2.6 million stillbirths globally, with more than 7178 deaths a day. Ninety-eight percent (98%) occurred in low- and middle-income countries.1 This number could be an underestimation due to underreporting and different definitions of stillbirths.. Even with an extensive examination, as much as 14- Corresponding author: Arby Jane R. Igualada, MD 47% of stillbirths have unexplained causes.2 There have been Department of Obstetrics and Gynecology numerous attempts to catalog causes of fetal death, using Philippine General Hospital University of the Philippines Manila classification system but none have been universally accepted. Taft Avenue, Ermita, Manila 1000 Philippines Roberts (2013) suggested an alternative way in determining Telephone: +63 922 7119649 the cause of perinatal death for limited-resource settings. It Email: [email protected] includes taking clinical history (of the mother and the course VOL. 52 NO. 1 2018 ACTA MEDICA PHILIPPINA 81 Systematic Approach In Stillbirth Examination of labor), followed by fetal and placental examination. He Materials emphasizes that simple visual inspection and description, The following materials were provided and used by maybe all that is needed to establish a probable cause of the the investigator: gloves, plastic bags, scalpel, forceps, tray, 3 fetal death. cloth (to cover the tray and be used as the background for Based from a 3-year review of records in the Philippine photography purposes), saline water, weighing scale, tape General Hospital, there were a total number of 14,047 measure, camera, and refrigerator. deliveries, 293 of which were stillbirths (2.1%).4 This is a pilot study to evaluate the causes of fetal Patients death in a way that can be used in limited-resource settings. The investigator collected the following information: Identification of the probable causes of stillbirth were based age, marital status, obstetric score, medical conditions, pre- from those identified by the Stillbirth Collaborative Research natal check-ups, congenital anomalies, and other related Network Study 2011 namely: (1) obstetric complications, factors in the history taking as shown in the Mother’s (2) placental abnormalities, (3) fetal malformations, (4) Profile (Appendix). infections, (5) umbilical cord abnormalities, (6) hypertensive Upon delivery (either vaginally or through cesarean disorders, (7) medical complications, and (8) undetermined section), the placenta and the fetus were placed on a separate 5 causes. Evaluation included clinical history taking, fetal table for examination. examination, and placental examination. Placenta Maternal profile The placenta was examined within 24 hours from delivery. Factors that have been associated with an increased Upon receiving, the placenta was placed in a container and risk of antepartum stillbirth include advanced maternal age, rinsed briefly for about 10 seconds using tap water and African-American race, smoking, illicit drug use, obesity, and 4 was examined by the investigator. Systematic examination maternal medical diseases. of the placenta was based from Manual of Benirschke and Placental examination Kaufmann’s Pathology of the Human Placenta by Baergen 2005) and consisted of the following: A detailed placental pathologic examination is one 1. Checked the odor (foul-smelling or non foul-smelling). critical component of stillbirth evaluation given the placenta’s 6 2. Checked the umbilicus. essential role in maintaining a healthy pregnancy. More a. Checked the appearance (color). often than not, the placenta will provide answer to the cause b. Length was measured. Using a standard measuring of death or will certainly provide insight into the cause(s). tape the length was measured from the fetal Fetal examination umbilicus up to the cord insertion in the placenta. In cases where the cord was cut, the length of the The diagnosis of some congenital anomalies does not fetal cord was added to the placental cord. require histology, but it does require training and the careful c. Coiling pattern was observed. If more than 3 in examination of the fetus. By gross examination, one may tell the 5cm, it was labelled as hypercoiled, and if less than extent of skin peeling, maceration, and physical malformations 3 cm, it was labelled as hypocoiled or no twisting. that may have led to a probable cause of fetal death. d. The investigator identified whether the placental Objectives of the study insertion was central, marginal, or velamentous. e. Knots were identified. It was also indicated if how The main objective of the study was to identify the many knots, if loose or if tight. (Figure 2.6) probable causes of stillbirth in a tertiary hospital based on 3. Cord was cut from the placenta at the insertion site and gross examination of the placenta and the fetus. The study placed in the container. also aimed to identify the demographic profile of the 4. Placental membrane was inspected (including color, stillbirths. The probable causes of stillbirths were categorized completeness, and membrane insertion). to: (1) obstetric complications, (2) placental abnormalities, 5. Placental parenchyma was inspected. (3) fetal malformations, (4) infections, (5) umbilical cord a. Placenta was weighed in grams using a standard abnormalities, (6) hypertensive disorders, (7) medical weighing scale. complications, and (8) undetermined causes. b. Placenta was measured in three dimensions: width, METHODS length, and thickness. c. Maternal surface was inspected for the completeness of cotyledons/ lobules. Color was The study was conducted in a tertiary hospital and checked. Presence of infarcts and hematoma was included all women admitted for singleton stillbirths, with noted. more than 20 weeks age of gestation and fetus weighing at d. Fetal surface was inspected. Color was checked. least 500g, and who consented to be part of the study. 82 ACTA MEDICA PHILIPPINA VOL. 52 NO. 1 2018 Systematic Approach In Stillbirth Examination Fetus Table 1. Clinical characteristics of women who delivered with stillbirths 1. After drying, the fetus was weighed using the weighing Characteristic Summary measure scale in the Neonatal Section. Age in years 26 ± 7.77 (16 to 40 years) 2. Crown rump-heel length was measured using a Gravidity 2 ± 1.76 (1 to 7) measuring tape. Primipara 11 (42%) 3. Examination of the fetus per body parts was done and Parity 1 ± 1.96 (0 to 7) findings were written as indicated in the data collection History of abortion 3 (10.34%) tool – fetus section (Appendix). Civil status 4. After examination, photographs of the specimen were Single 20 (68.97%) Married 9 (31.03%) taken and saved. Presence of co-morbidities Gestational diabetes 1 (3.45%) Study analysis Gestational hypertension 1 (3.45%) The demographic and clinical variables were presented Pre-eclampsia 1 (3.45%) using the frequencies and percentages for categorical Hyperthyroidism 1 (3.45%) variables such as the presence of co-morbidities, cord and Pulmonary tuberculosis 1 (3.45%) Number of prenatal consults 4 ± 2.23 (0 to 8 visits) fetal characteristics (eg, coiling, insertion, color); or the mean, None 3 (10.3%) standard deviation, or range for continuous variables such as Local health center 16 (55.17%) age and other anthropometric measurements
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