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Case Study 6 - Title: Pregnancy after Stillbirth and Home Fetal Heart Rate Monitoring via the Internet.   Jason H Collins MD


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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.
Methods: Patients with a UCA stillbirth history contacted Pregnancy Institute through the internet web site (www.preginst.com). Patients were interviewed about their pregnancy loss and apparent cause. Patients who decide to repeat pregnancy were offered an evaluation at 28-30 weeks at PI. This visit consisted of a 30 min Fetal Heart Rate Recording and an Ultrasound for UCA recurrence. Patients were instructed on home use of a hospital grade fetal monitor (Analogic:Boston, MA). Patients monitored for 30 minutes every night. Recordings were sent via the internet to PI . Delivery findings were noted.

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. 
Patient Number Preg(1)-UCA Preg(2)U/S 28-30wks Preg(2)-GA Preg(2)-Delivery Preg(2)-UCA

1

SB-NCx2

NCx1

37wks

C/Sect

NCx1

2

SB-NCx2

NCx2/TN

36wks

C/Sect

NCx1-TNx1

3

SB-Velamentous

None

37wks

NSVD

None

4

SB-NCx1

NCx1

37wks

NSVD

NCx1

5

SB-NCx1

NCx1

36wks

NSVD

NCx1/DFM

6

SB-NCx1

NCx1

37wks

NSVD

NCx1

7

SB-NCx1

NCx1

37wks

NSVD

None/DFM

8

SB-Torsion

Torsion

36wks

C/Sect

Torsion

9

SB-TNx1

NCx1

36wks

NSVD

NCx1

10

SB-NCx2

NCx1

37wks

NSVD

None/DFM

11

SB-Torsion

NCx1

37wks

NSVD

None

12

SB-NCx3/TNx1

NCx2

36wks

NSVD

NCx1/DFM

13

SB-Velamentous

NCx1

36wks

NSVD

None

14

SB-NCx1

NCx1

37wks

NSVD

NCx1/DFM

15

SB-TNx1

NCx1

36wks

C/Sect

None

16

SB-Short Cord(SC)

None

36wks

C/Sect

SC

17

SB-NCx2

NCx2

38wks

NSVD

NCx1

18

SB-NCx1

Alx1

36wks

C/Sect

NCx1

19

SB-NCx2

NCx2

36wks

C/Sect

DFM

20

SB-NCx2

Velament

36wks

C/Sect

NCx1/Torsion/Long/Vela/FHR-decel

21

SB-NCx2

NCx1

36wks

NSVD

NC

22

SB-TNx1/NCx1

None

36wks

C/Sect

None

23

SB-NCx2

None

36wks

NSVD

None

24

SB-Torsion /AB

Torsion

37wks

C/Sect

Thin cord/FHRD *strip

25

SB AL<BL<LL

NCx3

37wks

NSVD

None

References:

(1) Goldenberg RL, Kirby R, Culhane JF. Stillbirth: a review, J Matern Fetal Med 2004;16:79-94.

(2)Bateman BT, Simpson LL. Higher rate of stillbirth at the extremes of reproductive age: a large nationwide sample of deliveries in the United States. Am J Obstet Gynecol 2006;194:840-5.

(3)Collins JH. Umbilical Cord Accidents : Human Studies . Semin Perinat 2002; 26: 79-82.

(4)Romero-Gutierrez G, Martinez-Ceja CA, Abrego-Olvira E, Ponce-Ponce de Leon AL. Multivariate analysis of risk factors for stillbirth in Leon, Mexico. Acta Obstet Gynecol Scand.2005;84:2-6.

(5) Simmons JN, Rufleth P, Lewis PE. Identification of nuchal cords during nonstress testing. J Reprod Med 1985; 30:97-100.

(6)Collins JH. Antenatal observation of umbilical cord torsion with subsequent premature labor and delivery of a 31-week infant with mild nonimmune hydrops. Am J Obstet Gynecol 1994;172:1048-1049.

(7)Sherer DM, et al. Recurrent antepartum compression of a single artery double nuchal cord necessitating emergency cesarean delivery. Am J Perinatol 2005 22:437-40.

(8)Oyelese Y, Smulian JC. Placenta Previa, Accreta, and Vasa Previa. Obstet Gynecol 2006;107:927-41.

(9)Blackwell S, et al. Adverse perinatal outcomes in subsequent pregnancies in women with prior stillbirth. Am J Obstet Gynecol Suppl 2005 ; 193:S106 Abstract 350

(10)Sharma PP, Salihu HM, Oyelese Y, Ananth CV, Kirby RS. Is Race a determinant of stillbirth recurrence? Obstet Gynecol 2006; 107: 391-7.

(11)Bakotic BW, et al. Recurrent Umbilical Cord Torsion Leading to Death in 3 Subsequent Pregnancies. Arch Pathol Lab Med. 2000;124:1352-55.

(12) French AE, et al. Umbilical Cord Stricture: A cause of Recurrrent Death. Obstet Gynecol 2005;105:1235-39.

(13)Baergen RN, et al. Morbidity, mortality, and placental pathology in excessively long umbilical cords. Pediatr Dev Pathol 2001;4:144-53.

(14) Miller TE, et al. Recurrent third-trimester fetal loss and maternal mosaicism for long-QT syndrome.Circulation 2004 ;109:3029-34.

(15)Westgate JA, Bennet L,Gunn AJ. Fetal Heart Rate variability changes during brief repeated umbilical cord occlusion in near term fetal sheep. Br J Obstet Gynaecol 1999;106:664-671.

(16)George S, et al. Fetal heart rate variability and brain stem injury after asphyxia in preterm fetal sheep. Am J Physiol Regul Integr Comp Physiol 2004;287:925-933.

(17)Freeman RK, Dorchester W, Anderson G, Garite TJ. The significance of a previous stillbirth. Am J Obstet Gynecol 1985;151:7-13.

(18)Pan J, et al. Value of long distance fetal heart rate monitoring on prepartum health care of the pregnant woman with umbilical cord loops. Zhonghua Fu Chan Ke ZA Zhi 2002 ; 37:451-4.

(19)Meystre S. The state of telemonitoring: a comment on the literature. Telemed J E Health 2005; 11: 63-9.

(20)Hod M, Kerner R. Telemedicine for antenatal surveillance of high-risk pregnancies with ambulatory and home fetal heart rate monitoring—an update. J Perinat Med 2003; 31:195-200.

(21)Kerner R, Yogev Y, Belkin A, Ben-Haroush A, Zeevi B, Hod M.Maternal self-administered fetal heart rate monitoring and transmission from home in high-risk pregnancies. Int J Gynaecol Obstet 2004;84:33-9.
 
(22)Collins JH, Collins CL. The Human Umbilical Cord. Kingdom J, Jauniaux E, O’Brien S, (eds): The Placenta, Basic Science and Clinical Practice. London, RCOG Press, 2000; 319-29.

(23)de la Vega A, Verdiales. Failure of intensive fetal monitoring and ultrasound in reducing the stillbirth rate. P R Health Sci J. 2002;21:123-5.

(24)Cotzias CS, Paterson-Brown S, Fisk NM. Prospective risk of unexplained stillbirth in singleton pregnancies at term: population based analysis. BMJ 1999;319:287-288.

(25)Gould JB,Qin C,Chavez G. Time of Birth and the Risk of Neonatal Death 2005;106:352-358.

(26)Domenighetti C, Paccaund F: The Night- A dangerous time to be born? Br J Obstet Gynaecol 1986; 93:1262-1267.

(27) Parer JT, King T. Fetal heart rate monitoring: Is it salvageable? Am J Obstet Gynecol 2000; 182:982-987.

(28)Collins JH. Umbilical Cord Vulnerability. Am J Obstet Gynecol 2001;184:776.

(29)Collins JH. Stillbirth Associated Umbilical Cord Accident and Subsequent Pregnancy. 1st Asia Pacific Congress of Maternal Fetal Medicine 2005:P-17:28.

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