Fetal Death

FETAL DEATHFETAL DEATH

Definition of Fetal mortalityDefinition of Fetal mortalityAlmost 80% of stillbirths occur before term, and Almost 80% of stillbirths occur before term, and more than half occur before 28 wkmore than half occur before 28 wkThe stillbirths rate has decline over the past 5 The stillbirths rate has decline over the past 5 decadesdecades Deaths of infant with anomalies were Deaths of infant with anomalies were preventedprevented by by

early pregnancy terminationearly pregnancy terminationCommonly recognized causes of fetal death as Commonly recognized causes of fetal death as infection, malformations, fetal growth restriction infection, malformations, fetal growth restriction and and abruptioabruptio placentaeplacentaeMore than More than of fetal death were still unexplained of fetal death were still unexplained

Cause of fetal deathCause of fetal death

Generally be categorized as fetal, Generally be categorized as fetal, placental or maternalplacental or maternalAn autopsy performed by pathologist, An autopsy performed by pathologist, assisted by maternalassisted by maternal--fetal medicine, fetal medicine, genetic and pediatric specialistgenetic and pediatric specialist for for determines the cause of deathdetermines the cause of death

Categorizes and Causes of Fetal DeathCategorizes and Causes of Fetal Death

UnexplainedUnexplained(25(25--35%)35%)

AntiphospholipidAntiphospholipid antibodies, DM, HTantibodies, DM, HTTrauma, abnormal labor, sepsis, acidosis, hypoxiaTrauma, abnormal labor, sepsis, acidosis, hypoxiaUterine rupture, Uterine rupture, posttermpostterm pregnancy, drugs pregnancy, drugs

MaternalMaternal(5(5--10%)10%)

Abruption, Abruption, previaprevia, placental insufficiency, placental insufficiencyFetalFetal--maternal hemorrhage, twinmaternal hemorrhage, twin--toto--twin transfusiontwin transfusionCord accident, Cord accident, intrapartumintrapartum asphyxia, asphyxia, chorioamnionitischorioamnionitis

PlacentalPlacental(25(25--35%)35%)

Chromosomal anomaliesChromosomal anomaliesNon chromosomal birth defectNon chromosomal birth defectNon immune Non immune hydrophydropInfection (virus, bacteria, protozoa)Infection (virus, bacteria, protozoa)

FetalFetal(25(25--40%)40%)

Fetal causesFetal causesThe incidence of major The incidence of major congenital congenital malformationmalformation in stillborn is highly variablein stillborn is highly variable1/3 of fetal death were causes by structural 1/3 of fetal death were causes by structural anomalies of anomalies of NeuralNeural--tube defectstube defects HydropsHydrops Isolated hydrocephalus Isolated hydrocephalus Complex congenital heart disease Complex congenital heart disease

were the most commonwere the most common

The incidence of stillbirths cause by The incidence of stillbirths cause by fetal fetal infectioninfection appear to be remarkably consistentappear to be remarkably consistentMost were diagnosed as Most were diagnosed as chorioamnionitischorioamnionitis and and fetal or intrauterine sepsisfetal or intrauterine sepsisCongenital syphilisCongenital syphilis can be a common cause of can be a common cause of fetal death fetal death Other potential infection : CMV, parvovirus B19, Other potential infection : CMV, parvovirus B19, rubella, rubella, varicellavaricella and and listeriosislisteriosis

Fetal causesFetal causes

Placental abruptionPlacental abruption The most common single identifiable cause of The most common single identifiable cause of

fetal deathfetal death Associated with gestational hypertension in a Associated with gestational hypertension in a

half of half of casesscasessPlacental and membrane infectionPlacental and membrane infection Rarely occur in the absence of fetal infectionRarely occur in the absence of fetal infection Exceptions include tuberculosis and malariaExceptions include tuberculosis and malaria

Placental causesPlacental causes

Placental infarctsPlacental infarcts Areas of Areas of fibrinoidfibrinoid trophoblastictrophoblastic degeneration, degeneration,

calcification and ischemic infarction from calcification and ischemic infarction from spiral artery occlusionspiral artery occlusion

Causes from severe hypertension or Causes from severe hypertension or preeclampsiapreeclampsia

FetalFetal--maternal hemorrhagematernal hemorrhage Common with severe maternal traumaCommon with severe maternal trauma TwinTwin--toto--twin transfusion in twin transfusion in monochorionicmonochorionic

Placental causesPlacental causes

Maternal causesMaternal causesHypertensive disorder and diabetesHypertensive disorder and diabetes are the two are the two most commonly cited maternal diseasemost commonly cited maternal disease

Lupus anticoagulant and Lupus anticoagulant and anticardiolipinanticardiolipinantibodiesantibodies are associated with are associated with decidualdecidualvasculopathyvasculopathy, placental infarction, fetal growth , placental infarction, fetal growth restriction, recurrent abortion and fetal deathrestriction, recurrent abortion and fetal death

Some Some hereditary hereditary thrombophiliasthrombophilias linked with linked with placental abruption and fetal growth restrictionplacental abruption and fetal growth restriction

Evaluation of stillborn infantEvaluation of stillborn infant

Determining the cause of fetal deathDetermining the cause of fetal death Make counseling more accurateMake counseling more accurate May prompt therapy or intervention to May prompt therapy or intervention to

prevent a similar outcome in the next prevent a similar outcome in the next pregnancypregnancy

Identification of inherited syndromes also Identification of inherited syndromes also provides useful information for other family provides useful information for other family membersmembers

Clinical examinationClinical examination The examination of fetus, placenta and The examination of fetus, placenta and

membranes should be performed at deliver membranes should be performed at deliver and recordedand recorded

Photograph should be taken for recordedPhotograph should be taken for recorded A full radiograph of fetus A full radiograph of fetus fetogramfetogram These providing anatomical information when These providing anatomical information when

parent decline a full autopsyparent decline a full autopsy

Evaluation of stillborn infantEvaluation of stillborn infant

Laboratory evaluationLaboratory evaluation Autopsy Autopsy Chromosome studiesChromosome studies Fetal Fetal karyotypekaryotype, Parental , Parental karyotypeskaryotypes CytogeneticCytogenetic studystudy

Fluid obtained postmortem : a total 3 ml of fetal Fluid obtained postmortem : a total 3 ml of fetal blood, obtained from the blood, obtained from the umbilical cordumbilical cord or by or by cardiac puncturecardiac puncture is placed into a sterile is placed into a sterile heparinizedheparinizedtube for tube for cytologeneticcytologenetic studystudyIf blood cannot obtained , a piece of fetal or placental If blood cannot obtained , a piece of fetal or placental tissue can be substitutedtissue can be substituted

Evaluation of stillborn infantEvaluation of stillborn infant

Laboratory evaluationLaboratory evaluation Maternal blood should be obtained for testingMaternal blood should be obtained for testing

AntiphospholipidAntiphospholipid antibodies and lupus antibodies and lupus anticoagulant if indicatedanticoagulant if indicatedSerum glucose to exclude diabetesSerum glucose to exclude diabetes

Evaluation of stillborn infantEvaluation of stillborn infant

Autopsy Autopsy

A gross external examination, along with A gross external examination, along with photography, radiography, MRI, bacterial photography, radiography, MRI, bacterial culture, and selective use of chromosomal culture, and selective use of chromosomal and histopathology studies can often and histopathology studies can often determine the cause of deathdetermine the cause of deathParents should be contact and offered Parents should be contact and offered counseling regarding cause of death, to counseling regarding cause of death, to avoid recurrent in future pregnancyavoid recurrent in future pregnancy

Psychological aspectPsychological aspect

Fetal death is psychologically traumatic for Fetal death is psychologically traumatic for the woman and her familythe woman and her familyStress result from an interval of more than Stress result from an interval of more than 24 hr between the diagnosis of fetal death 24 hr between the diagnosis of fetal death and the induction of laborand the induction of laborThe woman is at increase risk for The woman is at increase risk for postpartum depression and should be postpartum depression and should be closely monitoredclosely monitored

Fetal death and delayed deliveryFetal death and delayed delivery

Most woman with fetal death, spontaneous labor Most woman with fetal death, spontaneous labor eventually within eventually within 2 wks2 wksCoagulation changeCoagulation change Disruption of maternal coagulation mechanism rarely Disruption of maternal coagulation mechanism rarely

developed before less than developed before less than 1 mo1 mo after fetal deathafter fetal death If fetus retain longer, about 25% of woman developed If fetus retain longer, about 25% of woman developed

coagulopathycoagulopathy Fibrin degradation products are elevated in serum, Fibrin degradation products are elevated in serum,

these change mediated by these change mediated by thromboplastinthromboplastin from the from the dead product of dead product of conceptusconceptus

The platelet tent to be decrease in these instance The platelet tent to be decrease in these instance

Pregnancy after previous stillbirthPregnancy after previous stillbirth

There are very few condition associated with There are very few condition associated with recurrent stillbirthrecurrent stillbirthOther than Other than hereditary disordershereditary disorders, only , only maternal such as maternal such as diabetes, chronic diabetes, chronic hypertension, or hereditary hypertension, or hereditary thrombophiliathrombophiliaincrease risk of recurrenceincrease risk of recurrenceSeveral study have cited rate of recurrent Several study have cited rate of recurrent stillbirth that range from 0stillbirth that range from 0--8%, depending on 8%, depending on specific population studied specific population studied

Losses that occur early in pregnancy are Losses that occur early in pregnancy are associated with a higher risk of associated with a higher risk of subsequent adverse outcomes than those subsequent adverse outcomes than those that occur late in gestation that occur late in gestation

Pregnancy after previous stillbirthPregnancy after previous stillbirth

Prenatal evaluationPrenatal evaluation In many cases allow a management plan to In many cases allow a management plan to

be made be made For example, For example, aneuploidyaneuploidy or familial or familial DiGeorgeDiGeorgesyndrome could be detected by syndrome could be detected by chorionicchorionic villous villous sampling or amniocentesissampling or amniocentesis

Maternal medical disorder are often easily Maternal medical disorder are often easily identifyidentify

For example, placental abruption associated with For example, placental abruption associated with chronic hypertension chronic hypertension this could be reduced with this could be reduced with more stringent BP control or early deliverymore stringent BP control or early delivery

Pregnancy after previous stillbirthPregnancy after previous stillbirth

Prenatal evaluationPrenatal evaluation In diabetic pregnanciesIn diabetic pregnancies

Intensive Intensive glycemicglycemic control in control in periconceptionalpericonceptionalperiod reduces the incidence of malformation and period reduces the incidence of malformation and generally improve outcomegenerally improve outcome

Lack of planning can lead to unexplained Lack of planning can lead to unexplained pregnancy loss pregnancy loss

Pregnancy after previous stillbirthPregnancy after previous stillbirth

Management Management Evaluated fetal heart rate testingEvaluated fetal heart rate testing

Woman with history of stillbirth were more likely to Woman with history of stillbirth were more likely to have have positive contraction stress testpositive contraction stress test than than woman tested for other indicationwoman tested for other indication

The investigator suggested they The investigator suggested they early deliveryearly deliveryhad been performed empirically in woman with had been performed empirically in woman with previous lossprevious loss

AntepartumAntepartum surveillance should begin at surveillance should begin at 32 wk32 wkor lateror later in the otherwise healthy woman with a in the otherwise healthy woman with a history of stillbirth (recommendations of ACOG)history of stillbirth (recommendations of ACOG)

Pregnancy after previous stillbirthPregnancy after previous stillbirth