Fetal Death Prepared by Ahmad AlMasri Supervised by

Fetal Death Prepared by Ahmad Al-Masri Supervised by Dr. Suliman Ghunaim

DEFINITION • Fetal death : • refers to babies with no signs of life after 24 w of gestation (beyond age of viability) or weighing > 500 g. • IUFD v. s. Stillbirth? ? • Stillbirth defined as a baby delivered with no signs of life known to have died after 24 completed weeks of pregnancy. • Intrauterine fetal death refers to babies with no signs of life in utero. • Neonatal Death : within 28 days of life mostly due to complications during birth, prematurity malformations; infections acquired either at home or in hospital • Miscarriage (spontaneous abortion) is defined as pregnancy loss before 24 weeks gestation.

Epidemiology • Who is most affected 1. women > 35 years old 2. women with body mass index ≥ 30 kg/m 2 • INCIDENCE 4 /1000 births Impacts 1. medicolegal risk 2. health care system. 3. emotion

Morbid Pathology • The dead fetus undergoes an aseptic degenerative process called maceration. The epidermis is the 1 st structure to undergoes the process, whereby blistering and peeling off of the skin occur. It appears btw 12 -24 h after death. The fetus become swollen and looks dusky red. Gradually, aseptic autolysis of the ligamentous structure and liquefaction of the brain matter and other viscera take place. The changes vary in degree and are responsible for the characteristic radiological signs.

CAUSES • the RCOG guideline no. 55 states that parents should be told that no specific cause is found in 50% cases Maternal , fetal , placental & idiopathic. (5 -10%) (25 -40%) (20 -35%)

MATERNAL CAUSES 1. Obesity (>30 kg/m 2): proven, modifiable, highest ranking 2. Maternal age (>35 yrs) and paternal age 3. Smoking/alcohol/drug abuse 4. Infections (malaria, hepatitis, influenza, syphilis, sepsis) 5. Hyperpyrexia (Temp. >39℃) 6. Medical diseases DM, HTN, THYROID DISEASES 7. Pre-existing diseases (severe anemia, heart disease) 8. Autoimmune disorders (APS, SLE) 9. Thrombophilias 10. Cholestasis of pregnancy 11. PPROM, multifetal gestation. 12. Abnormal labor (prolonged or obstructed labor , preterm, uterine rupture)

FETAL CAUSES 1. Chromosomal abnormalities (m. c Turner, Down & Edwards syndrome) 2. Major structural anomalies 3. Infections (viral, bacterial & Chorioamnionitis) 4. Rh incompatibility 5. Non-Immune hydrops 6. IUGR

PLACENTAL CAUSES 1. 2. 3. 4. Antepartum hemorrhage (Placenta previa & Abruption placenta) Cord accidents (prolapse, true knot, cord around neck) Placental insufficiency TTTS ECV?

How to approach fetal death ? • History : absence of fetal movements, loss of symptoms of pregnancy. • Physical exam : 1. Retrogression of the positive breast changes. 2. decreased fundal height. 3. fetal movements aren’t felt during palpation. 4. difficult palpation of fetal parts. 5. fetal heart sound not audible. 6. CTG flat trace. 7. Egg-shell crackling feel of the fetal head (late) • Investigations: 1. US for the uterus for pregnancy profile 2. Plain X-ray of abdomen (rarely done now) 3. laboratory tests

US for the uterus for pregnancy profile • Earliest diagnosis is possible with sonography. • Lack of all fetal motion (including cardiac) during a 10 -min period of carful observation. • Gross distortion of fetal anatomy. • Soft tissue edema. • Oligohydramnios and collapsed cranial bones are evident. A second opinion should be obtained whenever practically possible mothers should be prepared for the possibility of passive fetal movement. if the mother reports passive fetal movement after the scan to diagnose IUFD, a repeat scan should be offered.

Radiological findings: 1. Robert’s sign : appearance of gas shadow within the heart or the greater vessels (in 12 hours) 2. Spalding sign: collapse skull bones (usually appears 7 days after ) 3. Ball sign : hyperflexion of the spine 4. Crowding of the ribs shadow 5. Helix sign : gas in umbilical arteries Ball sign + Crowding of the ribs shadow

Robert’s sign Spalding sign

laboratory tests • Clinical assessment and laboratory tests should be recommended to assess maternal wellbeing (including coagulopathy) and to determine the cause of death, the chance of recurrence and possible means of avoiding further pregnancy complications. üCBC ü Maternal serology ü Maternal bacteriology üblood grouping ü Maternal HBA 1 C üFIBRINOGEN ü Maternal THYROID FUNCTION ü COAGULATION PROFILE ü Anticardiolipin antibodies üKLEIHAUER ü Lupus anticoagulant ü CRP

WHAT IS THE BEST PRACTICE FOR DISCUSSING THE DIAGNOSIS AND SUBSEQUENT CARE? • if the woman is unaccompanied, an immediate offer should be made to call her partner, relatives or friends. • discussions should aim to support maternal/parental choice. • parents should be offered written information to supplement discussions • empathetic techniques must be used.

Treatment • Recommendations about labor and birth should take into account the mother’s preferences as well as her medical condition and previous intrapartum history. 1) Expectant attitude (Non-interference): • In about 80% of cases, spontaneous expulsion occurs with 2 weeks of death. The woman with intact membranes , no evidence of DIC or sepsis may remain at home with the advice to come to the hospital for delivery. Fibrinogen estimation should be done twice weekly. 2)Early interference: • Psychological upset of the pt. (common) • Manifestation of uterine infection. • Tendency of prolongation beyond 2 weeks. • Falling Fibrinogen levels (rare)

Induction of labor • Misoprostol can be safely used for induction of labor in women with a single previous CS and an IUFD but with lower doses • Women with more than two CS deliveries or atypical scars should be advised that the safety of induction of labor is unknown • mechanical methods of induction might increase the risk of ascending infection in the presence of IUFD • women laboring with a scarred uterus women undergoing VBAC should be closely monitored for features of scar rupture. • oxytocin augmentation can be used for VBAC, but the decision should be made by a consultant obstetrician. • vaginal birth can be achieved within 24 hours of induction of labor for IUFD in about 90% of women

Management of IUFD • Place of CS in case with IUD is limited • Indications of CS: • 2 or more previous CS • Placenta previa • Transverse lie (rare) • Other CS indications. • Postpartum suppression of lactation: Cabergoline (dopamine agonist) single dose (1 mg). • It should not be given to women with preeclampsia or HTN

COMPLICATIONS 1. Psychological upset 2. Infection: as long as the membranes are intact, infection is unlikely but once the membranes rupture, infection, especially by gas forming organism like Clostridium perfringens may occur. The dead tissue favours their growth with disastrous consequences. 3. Blood coagulation disorders (rare) (DIC): it’s due to gradual absorption of thromboplastin, liberated from the dead placenta and decidua into the maternal circulation. 4. During labour: • Uterine inertia • Retained placenta • PPH

Postmortem examination • Parents should be offered full postmortem examination to help explain the cause of an IUFD. • Parents should be advised that postmortem examination provides more information than other (less invasive) tests. • Attempts to persuade parents to choose postmortem must be avoided; individual, cultural and religious beliefs must be respected. • Written consent must be obtained for any invasive procedure on the baby including tissues taken for genetic analysis. • Parents should be offered a description of what happens during the procedure. • Postmortem examination should include external examination with birth weight, histology of relevant tissues and skeletal x-rays. • Pathological examination of the cord, membranes and placenta should be recommended whether or not postmortem examination of the baby is requested. the examination should be undertaken by a specialist perinatal pathologist. • Parents who decline full postmortem might be offered a limited examination (sparing certain organs)

Discuss contact baby : 1 -Some parents order minimal contact 2 -Other wish take baby home 3 -Others create memory box

Prevention • Preconception counselling and care to prevent its occurrence in the high-risk group. • Prenatal diagnosis by Chorionic villus sampling or amniocentesis in selected cases. • To screen the “at risk mothers” during antenatal care.

• legal issues obstetricians and midwives should be aware of the law related to stillbirth. • The following practice guidance is derived from statute and code of practice. • Stillbirth must be medically certified by a fully registered doctor or midwife. • The doctor or midwife must have been present at the birth or examined the baby after birth. • police should be contacted if there is suspicion of deliberate action to cause stillbirth. • the baby can be registered as indeterminate sex awaiting further tests.

• Psychological and social aspects of care perinatal death is associated with increased rates of admission owing to postnatal depression • Counselling should be offered to all women and their partners • Parents should be advised about support groups. • follow up • The wishes of the woman and her partner should be considered when arranging follow-up • Women should be offered general prepregnancy advice • Women should be advised to avoid weight gain • Family planning , control medical condition.

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