Fetal Demise

Question 1

fetal demise (stillbirth preferred by parent groups)

Answer 1

the delivery of a fetus showing no signs of life as indicated by the absence of breathing, heartbeat, umbilical cord pulsation, or definite mvnts of voluntary muscles
-no uniformity in regard to birth wt & gestational age criteria

Question 2

death occurring prior to 20 wks gestation usually classified as a

Answer 2

spontaneous abortion

Question 3

suggested requirements for defining stillbirth

Answer 3

fetal loss after 20 wks gestational age OR

fetal wt >350 g

Question 4

maternal causes that may increase the risk of fetal demise

Answer 4

race (black at greater risk)
advanced maternal age (AMA)
multiple gestation (4x higher)
previous pregnancy complications
obesity
smoking, drugs, EtoH
low educational attainment
DM
HTN (chronic & PIH)
preeclampsia/eclampsia

Question 5

maternal causes (disorders)

Answer 5

infxn (TORCH, CMV, etc)
renal dz
thyroid d/o
cholestatsis in pregnancy
hemoglobinopahty (SCD, thalassemias)
SLE
Rh dz
uterine rupture
maternal trauma/death
inherited thrombophilias
antiphospholipid syndrome

Question 6

fetal causes of fetal demise

Answer 6

multiple gestations- twin twin transfusion
intrauterine growth restrictions (uterine abnormalities)
congenital abnormality
infxn (ex. parvovirus, CMV, syphillis)
hydrops fetalis (immune-Rh non-compatibility, or non-immune

Question 7

MC congenital abnormalities

Answer 7

monosomy X

trisomy 21, 18, 13

Question 8

placental causes

Answer 8

cord accident
abruption
premature rupture of membranes
vasa previa/velamentous insertion
fetomaternal hemorrhage
placental insufficiency (preeclampsia)

Question 9

cord accident

Answer 9

dx w/ caution
found in 30% of nl births
evidence of obstruction or circulatory compromise

Question 10

vasa previa

Answer 10

when vessel is in a vulnerable position

Question 11

velamentous insertion

Answer 11

cord not attached nice in middle of placenta but along edge

Question 12

fetomaternal hemorrhage

Answer 12

nl barriers between amnion & chorion is insufficient

Question 13

commonly reported maternal RF & causes for stillbirth- all countries

Answer 13

congenital/Karyotypic anomalies
growth restriction & placental abnormalities
dz- HTN/preeclampsia, DM, SLE, renal dz, thyroid dz, cholestasis
infxn- human parvovirus B19, Syphilis, streptococcal infxn, listeria
smoking
multiple gestations

Question 14

commonly reported maternal RF & causes for stillbirth- developing countries

Answer 14

obstructed/prolonged labor (asphyxia, infxn, birth injury)
infxns- syphilis & gram neg infxns
HTN dz
congenital anomalies
poor nutrition
malaria
sickle cell dz

Question 15

diagnosing fetal demise

Answer 15

hx & PE
reported decrease of fetal mvnt
unable to obtain fetal heart tones is NOT diagnostic
confirm by ULS & by 2 people
dx by visualization of fetal heart & absence of cardiac activity

Question 16

management of fetal demise

Answer 16

inform pt
method & timing of delivery depends on gestational age, maternal hx, maternal preference- most desire prompt delivery
D&E
labor induction (>28 wks)

Question 17

what is the most efficient method of induction before 28 wks?

Answer 17

vaginal misoprostol

Question 18

induction accomplished w/ pre-induction cervical ripening followed by what?

Answer 18

IV pitocin

Question 19

prostaglandin E2 & misoprostol (cytotec) should not be used in women w/ a hx of what?

Answer 19

prior uterine incision d/t risk of uterine rupture

Question 20

eval of fetal demise

Answer 20

thorough maternal, family, OB hx
fetal autopsy
placental eval
fetal karyotype
indirect coombs test
syphilis test (VDRL/RPR)
testing for fetal-maternal hemorrhage (Klienhauer-Betke or other)
urine tox xcreen
parvovirus serology
CBC w/ platelet count
thyroid function testing

Question 21

evaluation

Answer 21

sometimes useful
thrombophilia eval to include the following: lupus anticoagulant, antiphopholipid (Anticardiolipin) Ab, factor V leiden, prothrombin mutation, protein C, S & antithrombin III deficiency- uncertain utility, Hgb A1C, TORCH titers

Question 22

support

Answer 22

emotional support
clear communication of test results
referral to bereavement counselor, religious leader, peer support group or mental health professional, SANDS
feelings of guilt &/or anger common

Question 23

mngt of future pregnancies

Answer 23

evidence-based consensus for optimal mngt of future pregnancies following a fetal loss is lacking
emotional preparedness of couple- grief process
interpregnancy intervals of 12-36 months appear to be assoc. w/ lower risks of subsequent adverse pregnancy outcomes
in low risk women w/ unexplained stillbirth, risk of recurrence (after 20 wks) is 7.8-10.5/1000
optimal mngt of chronic conditions

Question 24

general mngt

Answer 24

detailed medical/ OB hx
consideration of maternal serum screening for aneuploidy may be beneficial
w/u of previous still birth
wt loss, smoking cessation

Question 25

1st trimester mngt

Answer 25

dating ULS

1st trimester screen: preg. assoc. plasma protein A, HCG, nuchal translucency, support/reassurance

Question 26

2nd trimester mgnt

Answer 26

ULS @ 18-20 wks
quadruple screen or AFP
support/reassurance

Question 27

3rd trimester mgnt

Answer 27

ULS after 28 wks, kick counts from 28 wks, antenatal testing w/ weekly biophysical profile (BPP) starting at 32-36 wks, support/reassurance

Question 28

delivery mgnt

Answer 28

elective induction at 39 wks or before w/ documented fetal lung maturity by amniocentesis