intrauterine fetal demise

8/12/2019 Intrauterine Fetal Demise

1/17

+

Intrauterine FetalDeathDuy Nguyen


2/17

+Definition

Intrauterine fetal death

Intrauterine fetal demise

Stillbirth

Stillborn


3/17

+Definition

United States National Center for Health Statistics

The absence of breathing, heart beats,

pulsation of the umbilical cord, or definitemovement of voluntary muscles at 20 weeks

gestation or 350 grams


4/17

+Clinical vignette

A 26 year old G1 by IUP at 22 weeks presents to the ER

complaining that her baby isnt moving as much anymore since

two nights ago.

She denies vaginal bleeding, uterine contractions and loss of

fluid. She mentions that she has had persistent nausea since the

beginning of her pregnancy, but noticed it stopped yesterday

morning.

She admits to not feeling pregnant anymore. When asked if shefeels fetal movement since two nights ago, she says she is not

sure and starts to cry.


5/17

+First things first:

Sensitivity Empathy

Sit down

Eye contact

Listen Reflect:

I understand this is hard to talk about.

Im so sorry.

Validate:

What youre feeling is normal.

Support

Offer a touch on their shoulders

I will do everything I can to help you.


6/17

+Epidemiology

6.2stillbirths out of 1000total births in the U.S.

Black women have 2xthe rate of stillbirths vs. Caucasians Higher rates of diabetes mellitus, hypertension, placental abruption,

and PROM


7/17

+Etiology in the U.S.

Obstetric complications (e.g.,abruption, multiple gestation, preterm

birth) 29.3%Placental disease 23.6%

Fetal genetic/structural abnormalities 13.7%

Maternal or fetal infection 12.9%

Umbilical cord abnormalities 10.4%

Hypertensive disorders 9.2%


8/17

+Etiology in the U.S.

Early stillborn(20-27 weeks gestation)

Late stillborn(>27 weeks gestation)

Infection (19%)

Abruption (14%)

Fetal anomalies (14%)

Unexplained

(majority)

Risk factors: pre-gravid weight > 68

kg, parity of 3 or more, cord loops,

low SES, maternal age > 40 years,

intimate partner violence, smoking


9/17

+Diagnosis

Ultrasounddocumenting absence of fetal cardiac activity

Clinical signs:

Perceived decrease/loss in fetal movements Decrease in pregnancy-related symptoms (e.g. nausea, breast

tenderness)

Uterine bleeding and contractions


10/17

+Delivery decision

Dont rush them to make a decision about inducing a delivery

There is an increased risk of anxiety years

after the loss if they were induced after 24hours vs. those induced within 6 hours


11/17

+Antepartum evaluation

Fetal karyotyping

Amniocentesis

Chorionic villus sampling

Maternal laboratory evaluation

Fetomaternal hemorrhage (e.g. Kleihauer-Betke test, flow

cytometry)

Urine toxicology

CBC Serologic testing for syphilis

Fasting blood glucose

Blood antibody screen to exclude alloimmunization


12/17

+Postpartum evaluation

Gross and histopathological information Often leads to new information that may change your original list of

differentials and change recommendations for preconception and

prenatal care Requires experienced pathologists to assist the autopsies

Estimating time of death

Brown or red discoloration of the umbilical cord = at least 6 hours

Desquamation of the face, back, abdomen = at least 12 hours Brown or tan skin = at least 24 hours

Mummification = at least 2 weeks

Histological changes of the placenta


13/17

+Stillbirth consequences

Nearly of stillbirths occur in apparently uncomplicatedpregnancies

Despair& confusion

Severe emotional stress

Depression

PTSD

Deleterious effects on maternal-child attachment


14/17

+Counseling

Offer understanding & support

Allow them to talk about the death

Honest communication

Cultural sensitivity

Allow them to hold the baby

Refer to grief counseling

Obtain complete history with detailed timeline for risk of recurrence &

potential interventions

Schedule post-partum visits earlier than 6 weeks

Encourage regular communication & follow-up

Recurrence rate is 7.810.5 per 1000


15/17

+Can you screen?

No effective tests are available

Tests obtained as part of Down syndrome screening

Insufficient expansion of maternal plasma volume


16/17

+How do you prevent?

Folic acid

Malaria prevention

Syphilis detection and treatment

Hypertension detection and

management

Diabetes detection and

management

Fetal growth restriction

detection and management

Post-term pregnancy

identification and induction

Skilled birth attendant at birth

Availability of basic and

comprehensive emergency OBcare

Reduce smoking, recreational

drug use, alcohol intake

Healthy diet and weight

Regular prenatal visits with fetal

monitoring


17/17

+Questions?

Thank you!

Fretts, R.C. (2013). Diagnosis and Management of Stillbirth . In D.S. Basow

(Ed.),UpToDate

. Retrieved from http://www.uptodate.com/

Fretts, R.C. (2013). Incidence, etiology, and prevention of stillbirth. In D.S.

Basow (Ed.), UpToDate. Retrieved from http://www.uptodate.com/
http://www.uptodate.com/home/index.htmlhttp://www.uptodate.com/home/index.htmlhttp://www.uptodate.com/home/index.htmlhttp://www.uptodate.com/home/index.htmlhttp://www.uptodate.com/home/index.htmlhttp://www.uptodate.com/home/index.htmlhttp://www.uptodate.com/home/index.htmlhttp://www.uptodate.com/home/index.html

intrauterine fetal demise

Documents