Fetal Demise Flashcards
fetal demise (stillbirth preferred by parent groups)
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
death occurring prior to 20 wks gestation usually classified as a
spontaneous abortion
suggested requirements for defining stillbirth
fetal loss after 20 wks gestational age OR
fetal wt >350 g
maternal causes that may increase the risk of fetal demise
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
maternal causes (disorders)
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
fetal causes of fetal demise
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
MC congenital abnormalities
monosomy X
trisomy 21, 18, 13
placental causes
cord accident abruption premature rupture of membranes vasa previa/velamentous insertion fetomaternal hemorrhage placental insufficiency (preeclampsia)
cord accident
dx w/ caution
found in 30% of nl births
evidence of obstruction or circulatory compromise
vasa previa
when vessel is in a vulnerable position
velamentous insertion
cord not attached nice in middle of placenta but along edge
fetomaternal hemorrhage
nl barriers between amnion & chorion is insufficient
commonly reported maternal RF & causes for stillbirth- all countries
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
commonly reported maternal RF & causes for stillbirth- developing countries
obstructed/prolonged labor (asphyxia, infxn, birth injury) infxns- syphilis & gram neg infxns HTN dz congenital anomalies poor nutrition malaria sickle cell dz
diagnosing fetal demise
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
management of fetal demise
inform pt
method & timing of delivery depends on gestational age, maternal hx, maternal preference- most desire prompt delivery
D&E
labor induction (>28 wks)
what is the most efficient method of induction before 28 wks?
vaginal misoprostol
induction accomplished w/ pre-induction cervical ripening followed by what?
IV pitocin
prostaglandin E2 & misoprostol (cytotec) should not be used in women w/ a hx of what?
prior uterine incision d/t risk of uterine rupture
eval of fetal demise
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
evaluation
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
support
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
mngt of future pregnancies
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
general mngt
detailed medical/ OB hx
consideration of maternal serum screening for aneuploidy may be beneficial
w/u of previous still birth
wt loss, smoking cessation
1st trimester mngt
dating ULS
1st trimester screen: preg. assoc. plasma protein A, HCG, nuchal translucency, support/reassurance
2nd trimester mgnt
ULS @ 18-20 wks
quadruple screen or AFP
support/reassurance
3rd trimester mgnt
ULS after 28 wks, kick counts from 28 wks, antenatal testing w/ weekly biophysical profile (BPP) starting at 32-36 wks, support/reassurance
delivery mgnt
elective induction at 39 wks or before w/ documented fetal lung maturity by amniocentesis
