ConfidentialBrain Injury in Stillbirths• Becher et al 471 SB

– 35% had brain injury• Suggests Stillbirth often has previous

acute events• More common in IUGR in preterms• Associated with smaller placenta

» BJOG 2006 113;310-7

Confidential

Intrapartum Stillbirth - brain stem showing older changes

ConfidentialPlacental changes• Ischaemic

– Small, abnormal shape (? Due to localised uterine effects)

– Infarcts and ischaemic changes– Unreconstructed blood vessels/Atherosis– Thrombotic

• Villitis– Some Viral most probably immune

• Chromosomal mosaicism

ConfidentialIschaemic

Normal

ConfidentialMaternal Vascular Invasion

Confidential

Preeclampsia

Confidential

Confidential

Term 2 kg. Placenta 359 g Fetal distress

Confidential

Confidential

ConfidentialUmbilical cord and membranes

• Often thin in IUGR• Abnormal insertion• Circumvallate/circummarginate

membranes

ConfidentialVelamentous Cord insertion

Confidential

CircumvallateAssociated with bleeding

and also mild IUGR

ConfidentialIUGR vs non IUGR

• Often similar placental changes i.e. ischaemic seen in non-IUGR (including “unexplained Stillbirth”)

• Continuum of disease

ConfidentialModel(s)• The majority of stillbirths have some clues.• Many have evidence of chronic condition -

IUGR, abnormal brain liver ratio, stressed adrenals, costochondral junction, placental changes

• Many have evidence of previous brain changes

• Terminal episode appears to occur suddenly

• Therefore Stillbirth appears to have an acute and often a chronic cause

ConfidentialUnexplained

PIH/PE

IUGR

CongenitalAnomaly

Infection

The pigeon holes are not clearThe autopsy helps define the groups

ConfidentialPlacental Supply

Time

Relative demand

Sleeping/active, maternal pyrexia

Uterine contractions, IVC?

Term

Fetal demand

Absolute demand

ConfidentialThe tip of the DoHAD (Barker) Iceberg

• Stillbirths probably reflect the tip of fetal disease– Share features with

• Neonatal encephalopathy, Cerebral palsy, SIDS

– Abnormal fetal nutrition and metabolic syndrome

ConfidentialThe IUGR stillbirth and DOHAD

• The stillbirth and particularly the IUGR gives an insight into how the adult diseases may be developing in utero.

• Reduced number of glomeruli in kidney• Changes in IGF in rat liver with fetal IUGR

model• Pancreas ? No change in ß cells, ? Insulin

resistance

ConfidentialCESDI 8th Report -Adverse Findings

Failure to recognise high risk woman at booking 30Growth

Inadequate monitoring 33Failure to recognise or act on IUGR 35

Fetal MovementFailure to act on reduced fetal movements 21Mother reporting after delivery or not explained

48Management of pregnancy e.g high risk/diabetes

177Communications documentation 95Lifestyle, smoking poor antenal attendance

39Post delivery

Post mortem quality issues 66Screening 11

No. Comments

720 comment on 420 women

ConfidentialConclusion

• The autopsy (& particlularly the placenta) remains pivotal to obtaining information about each loss

• Helps identify and then classify IUGR• It provides important research possibilities• Quality of autopsy issues• It forms only part of the multidisciplinary

review of each case.

Confidential

ConfidentialAcknowledgements

• Jan Dickinson and Belinda Jennings & the PNLS team.

• Mary-Anne Measey & Catherine Harrison• Vicky Flenady & PSANZ Team• Cathy Buccilli-Douglas, Vivien Gee• The many parents who have allowed us to

examine their babies and given us the privilege to help them.

Confidential

ConfidentialCord anomalies• Cord Length

» >80 cm in 3.7%, 100 cm in 0.5%

• Knots (?10x) 1% of normal births• Nuchal loops (15% of normal deliveries)• Twists ?? <1 per 9cm• Velamentous and marginal cord SB 3-4 x more

common• Thin cord (often IUGR more prone to knots,

compression)• Meconium effects• Histological changes often not seen but?…….

» http://sidsalliance.org/conf2005/library/Cord%20Accident%20Ha