TEALE FENNING

Nick Raine-Fenning · Posted: Wed Jul 19, 2006 6:46 pm Post subject: Stillbirth management

Let me start you off guys.

What about the following question ...

bronwyn · Posted: Sat Jul 22, 2006 10:06 am Post subject:

Nice question (I think?!)
Here goes Confused

Intro
Intrauterine fetal death defines as : stillbirth after 24 weeks
UK rate: 5.5/1000
Shocking/ difficult diagnosis for paretns and staff involved
Increased risk: High maternal age, obesity, postmaturity, social deprivation
Causes: Maternal (infection, haemorrhage, PET, Rh disease, anaemias, obstetric cholestasis, diabetic ketoacidosis, antiphosholipid, thrombophilias). Fetal (infection, cord accidents, chromosomal, IUGR). Placental (placcental insufficiency, smoking/drugs)
Management aimed at supporting parents, finding a cause and planning future pregnancies

Counselling
Experienced, informed, invite questions, breaking bad news, info sheets, support, partner, privacy, respect, time, second appointment

History
?Gestation (affects management)
?parity
Previous obs history (define risk: eg previous LSCS: risk of scar rupture with Misoprostol)
Previous medical history (diabetes, hypertension, renal problems)
Drugs, alcohol, smoking
recent travel (infections)
Recent symptoms (itching, PET symptoms, reduced fetal movements, bleeding, abdo pain)

Examination
Vitals (BP, pulse, temp) (infection, haemorhage, PET)
General (pallor, jaundice, oedema, lymphadenopathy)
Abdo (presentation, fundal height, tender rigid uterus)
VE: favourability

Investigations
Urinalysis: glucose, leucocytes, drugs
Bloods: FBC, kleihauer, group and save, clotting, renal function, liver function, bile salts
Vaginal swabs if infection suspected
Infection screen: TORCH, parvo, CMV
Check booking hepatitis, HIV, rubella, syphillis
Antiphospholipid and thrombophilia screen
HbA1C
Postmortum: full or limited (appropriate counselling: what designed to do, tissues kept, limited options)
Baby photos, foot/ hand prints
Placents (histology, genetics, microbiology swabs)
Examine fetus after birth for dysmorphic features & sex

Treatment
Mothers informed choice important
Unit protocol
Mifepristone and misoprostol regime (shorter induction to delivery interval)
Prostoglandin gel or tabs if in third trimester
ensure adequate analgesia (morphine and epidural discussed) & antiemetics
LSCS contraindicated (unless high grd placenta praevia, planned for obstetric indications, parents insist despite adequate counselling)
1:1 midwifery care
Monitor for PPH (high risk if PET, abruption, RPOC)
Suppress lactation (support bra, NSAIDS, Dopamine agonist)
Anti D if RH negative
Death certificate and register stillbirth

Follow-up
Allow parents time with baby if they wish
discharge home once safe
watch for PN depression
advise contraception, folate, rubella
bereavement team
funeral arrangements
see consultant 6 weeks (result PM and debrief)
see early subsequent pregnancy with clear plan

Gaps
Multidisciplinary (counsellor, midwife, consultant)
Documentation
Counselling

Took 10 minutes to bubble Embarassed

Need to speed up!
[/u]
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Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Sat Jul 22, 2006 10:24 am Post subject:

That's an excellent answer

10 minutes is fine - you will speed up and this is one of the most difficult as you have so many options / differentials. Whenever you have such a wide choice I recommened you stay fairly superficial in your explanation as you have done. You can address each cause and do history / exam / investigation within that cause i.e. take cholestastis and write a brief paragraph on this then move onto diabetes etc. I think this is easier.

I was just bubbling your Pregnanct after Endometrial Resection question.

I'll have a more detailed think about this later but you seem to have all the major points and most importantly have not forgotten about the support needed and the management of her delivery.

In the introduction I would keep the differential to a minimum i.e. obstetric and non-obstetric. You can't really mention the most common or sinister causes as they all are but I would say the majority of cases (70%, I think) remain unexplained.

What is the actual make up / incidence of each cause of a stillbirth? Not sure I have seen a percentage attributed to this. May be in the CESDI reports.

Let me know if you find out.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Nick Raine-Fenning · Posted: Sat Jul 22, 2006 10:33 am Post subject:

Causes of stillbirth

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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Sat Jul 22, 2006 10:39 am Post subject:

CEMACH2004 says
* classified by Extended Wigglesworth classification
* severe/ lethal congenital anomalies (15%)
* APH (10%)
* death from intrapartum causes (7,3%)
* just over 50% unexplained
* three quarters delivered after 28 completed weeks
* multiple births stillbirth rate 3.2 that of singletons
_________________
Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Sat Jul 22, 2006 10:45 am Post subject:

I was just looking at that as well!

Keep posting whatever ifno you find and I'll assimilate it into a defintive list when all of the votes have been cast!

In fact this has encouraged me to set up a new Forum in this group wehre we can post lists and useful refernce material such as staging. Silly not to have thought of that before.
_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Nick Raine-Fenning · Posted: Sat Jul 22, 2006 10:52 am Post subject:

Just found this in the BMJ which is quite useful if only for your thought processes when considering the differential

Classification system according to relevant condition at death (ReCoDe)

Group A: Fetus

1. Lethal congenital anomaly
2. Infection
2.1 Chronic
2.2 Acute
3. Non-immune hydrops
4. Isoimmunisation
5. Fetomaternal haemorrhage
6. Twin-twin transfusion
7. Fetal growth restriction (<10th customised weight for gestational age centile)

Group B: Umbilical cord

1. Prolapse
2. Constricting loop or knot (if severe enough to be considered relevant)
3. Velamentous insertion
4. Other

Group C: Placenta

1. Abruption
2. Praevia
3. Vasa praevia
4. Other "placental insufficiency” (histological diagnosis)
5. Other

Group D: Amniotic fluid

1. Chorioamnionitis
2. Oligohydramnios
3. Polyhydramnios
4. Other

Group E: Uterus

1. Rupture
2. Uterine anomalies
3. Other

Group F: Mother

1. Diabetes
2. Thyroid diseases
3. Essential hypertension
4. Hypertensive diseases in pregnancy
5. Lupus or antiphospholipid syndrome
6. Cholestasis
7. Drug misuse
8. Other

Group G: Intrapartum

1. Asphyxia
2. Birth trauma

Group H: Trauma

1. External
2. Iatrogenic

Group I: Unclassified

1. No relevant condition identified
2. No information available

You do not need to list or discuss / consider all of these of course but it is a good list all the same. I like the classification according to type and it certainly helps me think through the causes.

In your essay you just go for th big players and the preventable / recurrent ones.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Sat Jul 22, 2006 10:56 am Post subject:

Excellent! Idea

Need to get more people registered.....This web site is fab Very Happy

Do you have a list of e-mails of people who've attended recent courses...maybe you could mail them and tell them the new-and-much-improved site is up and running?
B
_________________
Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Sat Jul 22, 2006 10:58 am Post subject:

Wigglesworth's original classification of 2625 stillbirths was as follows:

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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Nick Raine-Fenning · Posted: Sat Jul 22, 2006 11:00 am Post subject:

Nick Raine-Fenning · Posted: Sat Jul 22, 2006 11:02 am Post subject:

One other thought about this question ... do not forget to mention

http://www.uk-sands.org/

I'd even put their web address in Wink

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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Sat Jul 22, 2006 11:20 am Post subject:

I never knew about them! Embarassed

Getting nervous about going on holiday to Antigua next week and missing out....might have to take the good old laptop on its first trip to the carribean!

Re question: how important is it to know percentages etc, isn't it enough just to know main causes
_________________
Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Sat Jul 22, 2006 11:34 am Post subject:

Antigua hey - wonderful. Leave your laptop at home and bubble lots of different essays in the sand Wink

You can do lots of revision in your head believe it or not.

You must go to a restaurant called Chez Pascal's - it is quite hard to find and you feel as you are driving into the middle of nowehere but keep going and you will be rewarded. We ate there twice and it was one of the best meals I have ever had. He had a few Michelin stars I believe when he cooked back in Paris. Also check out Half Moon Bay but take some rations as it is barren following the destruction of the 5 star hotel by a hurricane. There is a nice restaurant near there as well in some plantation up a hill. Get a decent car, a 4x4, and insurance as the roads are pretty awful off the beaten track.

Percentages - good question. No you do not need to know them for the essay and as far as I can remember I have not seen a mark ever awarded for quoting a figure or a study. You do ned to know the key ones for the MCQ however although they do not feature heavily in the pat Paper book as you know.

You see - you even get holiday advice!!
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Sat Jul 22, 2006 11:45 am Post subject:

Wow thanks...willl def do the day trips, hubbie a bit of a foodie Razz

Staying at the Blue Waters in Soldiers Bay........looks divine!
Can't wait

Off to do an exam now
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Bronwyn Bell
SpR
Portsmouth