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FETAL DEATH

Definition of Fetal mortality


Almost 80% of stillbirths occur before term, and
more than half occur before 28 wk
The stillbirths rate has decline over the past 5
decades
Deaths of infant with anomalies were prevented by
early pregnancy termination

Commonly recognized causes of fetal death as


infection, malformations, fetal growth restriction
and abruptio placentae
More than of fetal death were still unexplained

Cause of fetal death


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

Categorizes and Causes of Fetal Death


Fetal
(25-40%)

Chromosomal anomalies
Non chromosomal birth defect
Non immune hydrop
Infection (virus, bacteria, protozoa)

Placental
(25-35%)

Abruption, previa, placental insufficiency


Fetal-maternal hemorrhage, twin-to-twin transfusion
Cord accident, intrapartum asphyxia, chorioamnionitis

Maternal
(5-10%)

Antiphospholipid antibodies, DM, HT


Trauma, abnormal labor, sepsis, acidosis, hypoxia
Uterine rupture, postterm pregnancy, drugs

Unexplained
(25-35%)

Fetal causes
The incidence of major congenital
malformation in stillborn is highly variable
1/3 of fetal death were causes by structural
anomalies of
Neural-tube defects
Hydrops
Isolated hydrocephalus
Complex congenital heart disease
were the most common

Fetal causes
The incidence of stillbirths cause by fetal
infection appear to be remarkably consistent
Most were diagnosed as chorioamnionitis and
fetal or intrauterine sepsis
Congenital syphilis can be a common cause of
fetal death
Other potential infection : CMV, parvovirus B19,
rubella, varicella and listeriosis

Placental causes
Placental abruption
The most common single identifiable cause of
fetal death
Associated with gestational hypertension in a
half of casess

Placental and membrane infection


Rarely occur in the absence of fetal infection
Exceptions include tuberculosis and malaria

Placental causes
Placental infarcts
Areas of fibrinoid trophoblastic degeneration,
calcification and ischemic infarction from
spiral artery occlusion
Causes from severe hypertension or
preeclampsia

Fetal-maternal hemorrhage
Common with severe maternal trauma
Twin-to-twin transfusion in monochorionic

Maternal causes
Hypertensive disorder and diabetes are the two
most commonly cited maternal disease
Lupus anticoagulant and anticardiolipin
antibodies are associated with decidual
vasculopathy, placental infarction, fetal growth
restriction, recurrent abortion and fetal death
Some hereditary thrombophilias linked with
placental abruption and fetal growth restriction

Evaluation of stillborn infant


Determining the cause of fetal death
Make counseling more accurate
May prompt therapy or intervention to
prevent a similar outcome in the next
pregnancy
Identification of inherited syndromes also
provides useful information for other family
members

Evaluation of stillborn infant


Clinical examination
The examination of fetus, placenta and
membranes should be performed at deliver
and recorded
Photograph should be taken for recorded
A full radiograph of fetus fetogram
These providing anatomical information when
parent decline a full autopsy

Evaluation of stillborn infant


Laboratory evaluation
Autopsy
Chromosome studies
Fetal karyotype, Parental karyotypes
Cytogenetic study
Fluid obtained postmortem : a total 3 ml of fetal
blood, obtained from the umbilical cord or by
cardiac puncture is placed into a sterile heparinized
tube for cytologenetic study
If blood cannot obtained , a piece of fetal or placental
tissue can be substituted

Evaluation of stillborn infant


Laboratory evaluation
Maternal blood should be obtained for testing
Antiphospholipid antibodies and lupus
anticoagulant if indicated
Serum glucose to exclude diabetes

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

Psychological aspect
Fetal death is psychologically traumatic for
the woman and her family
Stress result from an interval of more than
24 hr between the diagnosis of fetal death
and the induction of labor
The woman is at increase risk for
postpartum depression and should be
closely monitored

Fetal death and delayed delivery


Most woman with fetal death, spontaneous labor
eventually within 2 wks
Coagulation change
Disruption of maternal coagulation mechanism rarely
developed before less than 1 mo after fetal death
If fetus retain longer, about 25% of woman developed
coagulopathy
Fibrin degradation products are elevated in serum,
these change mediated by thromboplastin from the
dead product of conceptus
The platelet tent to be decrease in these instance

Pregnancy after previous stillbirth


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

Pregnancy after previous stillbirth


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

Pregnancy after previous stillbirth


Prenatal evaluation
In many cases allow a management plan to
be made
For example, aneuploidy or familial DiGeorge
syndrome could be detected by chorionic villous
sampling or amniocentesis

Maternal medical disorder are often easily


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

Pregnancy after previous stillbirth


Prenatal evaluation
In diabetic pregnancies
Intensive glycemic control in periconceptional
period reduces the incidence of malformation and
generally improve outcome

Lack of planning can lead to unexplained


pregnancy loss

Pregnancy after previous stillbirth


Management
Evaluated fetal heart rate testing
Woman with history of stillbirth were more likely to
have positive contraction stress test than
woman tested for other indication

The investigator suggested they early delivery


had been performed empirically in woman with
previous loss
Antepartum surveillance should begin at 32 wk
or later in the otherwise healthy woman with a
history of stillbirth (recommendations of ACOG)

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