|Case Study 6 - Title: Pregnancy after Stillbirth and Home Fetal Heart Rate Monitoring via the Internet. Jason H Collins MD|
Abstract: Stillbirth affects 30,000 pregnancies each year in the United States. Umbilical Cord Accident (UCA) accounts for 20%-25% of all stillbirths or 2-4 deaths/1000 live births. Recent studies have shown pregnancy after stillbirth has a recurrent stillbirth risk of 5-10 fold. The specific risk of UCA recurrence is unknown. It is hypothesized that the use of Home Fetal Heart Rate Monitoring can identify at risk fetuses for UCA. Those fetuses with umbilical cord compression patterns can be evaluated and impending recurrent stillbirth prevented.
Aims: To prospectively follow 25 patients with a history of UCA stillbirth and their subsequent pregnancy by using home fetal heart rate monitoring daily via the internet. To determine the presence of umbilical cord compression patterns and evaluate the delivery record for recurrent UCA.
Results: 21 out of 25 patients had UCA recurrence at 28-30weeks. 14 patients delivered with a recurrent UCA. All patients delivered by 37 weeks. 2 patients had expedited C/Sections for FHR decelerations during labor. No recurrent stillbirths occurred.
Conclusion: UCA can repeat in a subsequent pregnancy after UCA related stillbirth. Home Fetal Heart Rate Monitoring can detect umbilical cord compression and possibly offer an effective method of identifying the fetus at risk of repeat UCA stillbirth.
Background: Stillbirth affects 30,000 pregnancies each year in the United States. Umbilical Cord Accident (UCA) accounts for as much as 20% of all stillbirths or 2-4 deaths/1000 live births.(1,2) There are 25 different types of UCA pathology. Each year 1 million of the 4 million deliveries in the United States have some type of umbilical cord pathology. The most commonly observed UCAs are: Long cord (>70cm), Short cord (<32 cm), true knot, torsion, constriction, nuchal cord and velamentous insertion.
(www.preginst.com see UCA 2004 literature review). The ability to prevent stillbirth from UCA depends on clinical methods to identify risk factors and manage those factors successfully. There are no established standard protocols currently for prenatal screening, management and prevention of UCA.(3,4) However, UCA can be identified with ultrasound and managed with fetal heart rate monitoring. Several studies and individual case reports demonstrate the effectiveness of ultrasound to visualize and evaluate the fetus at risk for UCA associated stillbirth. (5,6,7,8) Any pregnancy after a stillbirth is considered a significant high risk event. Recent studies suggest a 5 to 10 fold higher risk of recurrent stillbirth in a subsequent pregnancy.(9,10) What the risk of recurrence is for UCA is unpredictable. Specific causes of recurrent stillbirth have been reported which includes umbilical cord accidents and cardiac related death such as the “prolonged Q-T syndrome”. (11,12,13,14)
How UCA pathology can cause fetal death can be reproduced in animal model studies. Various frequencies of intermittent umbilical cord compression can cause death in the fetus in under one hour. Fetal heart rate recordings can identify the fetus with UCA that is compromised. Fetal heart rate variability changes occur due to umbilical cord compression and can be detected by fetal heart monitoring.(15,16)
To increase antenatal surveillance in this group of women at increase risk of UCA stillbirth will require home fetal heart rate monitoring. Studies recommend increased antenatal surveillance for patients with a history of stillbirth,(17) UCA can be identified prenatally and followed with HFHRM.(18) HFHRM is convienent for the mom, can be applied according to the moms schedule, and is cost effective when compared to similar processes in the hospital or office. Eventually HFHRM can be applied to a wider range of high risk patients and reduce stillbirth risk.(19,20,21)
Stillbirth studies do not discuss “time of death”. PI has case evidence that UCA associated stillbirth occurs at home.(22) There are few witnessed cases of prenatal stillbirth at clinics and hospitals during day hours, There are no case reports of stillbirth occurring during fetal heart rate testing (NSTs) or Biophysical Profiles. (23)
Cotzias has reported that the majority of stillbirths occur at around 36 weeks.(24) Also recent reports by Gould and Domenighetti show the risk of stillbirth and neonatal death is greater after 8pm.(25,26) These reports suggest that the key to understanding stillbirth is by observing the onset of labor at night starting at 36 weeks. To date no studies have evaluated prenatal HFHRM and outcomes especially testing initiated after 8pm. PI believes that HFHRM can prevent stillbirth. It is well known that FHR monitoring has reduced the risk of death during labor.(27,28) It is reasonable to consider that it will reduce fetal loss during prelabor.
We propose a study which will evaluate the efficacy of HFHRM for patients who have experienced a previous stillbirth associated with a UCA. Our preliminary data initially reports 25 cases of recurrent pregnancy after stillbirth and HFHRM. (29)
Methods: Patients with a stillbirth experience contact Pregnancy Institute through the internet (www.preginst.com). Patients are interviewed about their pregnancy loss and apparent cause. Patients who decide to repeat pregnancy were offered the opportunity to be evaluated at PI between 28-30-weeks.Patients were evaluated prospectively and were from around the United States. The 28-30 week visit consisted of a 30 minute Fetal Heart Rate Recording with a hospital grade GE Corometrics Monitor (model 150). This test was followed by an Ultrasound Exam with the specific purpose of defining the following parameters: Umbilical Cord appearance , Umbilical Cord insertion into the placenta , Umbilical Cord position relative to thefetus.
Patients are offered Home Fetal Heart Rate Monitoring for the subsequent pregnancy. The managing Obstetrician is informed of the patient’s decision and Pregnacy Institute is consulted by the OB. Patients monitor for 30 minutes every night till delivery. The fetal heart rate recordings are transmitted via the internet to PI and sent by e-mail to the managing Obstetrician till delivery. Delivery findings are noted and specific interest is made of the placenta and umbilical cord.
Results: Over 15 years 1991-2006 >1000 Parents were interviewed regarding UCA related stillbirth. Out of this cohort from across the United States, twenty five patients were prospectivelystudied for repeat pregnancy in that time period. 21 out of 25 patients had recurrent UCA at 28-30 wks. 14 patients out of 25 had recurrent UCA at delivery (Table 1). The average weeks gestation for delivery @37 (all inductions). Two patients (with UCA recurrence) had expedited C/Sectionsfor FHR decelerations. There were no recurrent stillbirths.
Conclusion: UCA represents @ 20% of all stillbirths (>20 wks) . Stillbirth has an associated risk of recurrence of between 5 to 10 fold. This observational study is the fist to look at the risk of repeat UCA in a subsequent pregnancy after UCA associated stillbirth. UCA can repeat in a subsequent pregnancy. Following these patients with Home Fetal Heart Rate Monitoring can detect umbilical cord compression. This approach in patients with a known risk factor “Stillbirth” may be an effective method ofidentifying the fetus at risk of repeat UCA stillbirth.Table 1: Stillbirth Associated Umbilical Cord Accident and Subsequent Pregnancy
25 self referred patients were followed to delivery. Each patient experienced a prior umbilical cord associated stillbirth. Prenatal ultrasound was done at 28wks to 30wks to determine the presence or absence of umbilical cord pathology.
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