Fetal Demise

Question 1

What is the definition of fetal demise/stillbirth?

Answer 1

No signs of life:

• No breathing
• No Heart beat
• No cord pulsations
• No voluntary muscle mvt

Question 2

What is the suggested birth weight & GA requirement?

Answer 2

Fetal weight >350g

After 20wks

Question 3

How is spontaneous abortion classified?

Answer 3

Before 20wks gestation

Question 4

What are maternal causes of Fetal Demise?

Answer 4

1. Infxn
2. Renal Dz
3. Thyroid disorder
4. Cholestasis of pregnancy
5. Hemoglobinopathy
6. Systemic Lupus erythemotasus
7. Rh disease
8. Uterine rupture
9. Maternal trauma or death
10. Inherited thrombophlebitis
11. Antiphospholipid

Question 5

Other maternal Causes of Fetal Demise

Answer 5

• Race
• Advanced maternal age (AMA)
• Multiple gestation
• Previous pregnancy complications
• Obesity
• Smoking, drugs, alcohol
• Low educational attainment
• Diabetes
• HTN-chronic, PIH, preeclampsia, eclampsia

Question 6

Fetal Causes of fetal Demise

Answer 6

1. Multiple gestation
2. Intrauterine growth restrictions (IUGR)
3. Congenital ABNL
4. Infxn (CMV, Listeria, Syphyilis, Parvovirus)
5. Hydrops fetalis

Suspected causes include above +
Maternal death & birth injury

Question 7

Placental Causes of fetal demise

Answer 7

1. Cord accident
2. Placental abruption
3. Premature rupture of MBs
4. Placental abruption *
5. Vasa previa/vela mentors insertion
6. Fetomaternal hemorrhage
7. Placental insufficiency

Question 8

Maternal risk factors in all countries

Answer 8

• congenital/karyotype anomalies (same)
• growth restriction & placental ABNLs*
• Diseases*
  - HTN(same)/preeclampsia , DM, SLE, Renal dz, thyroid disease, cholestasis
• Infxn*
  - Parvovirus B19, Syphilis, Strep, Listeria
• Smoking*
• Multiple gestation*

Question 9

Maternal risk factors in Developing countries

Answer 9

• Obstructed/prolonged labor (asphyxia, infxn, birth injury)*
• Infxns*
  - Syphilis(same)
  - Gram negative infxns
• Malaria*
• Sickle Cell*
• Poor nutrition*
• congenital anomalies (same)
• HTN (same)

Question 10

What is the definition of Unexplained Stillbirth?

Answer 10

Fetal death can’t be explained by identifiable fetal, placental, maternal or obstetric etiology

25-60%

Question 11

Independent risk factors of stillbirth

Answer 11

• maternal prepregnancy wt >68kg (150lbs)
• Parity of >3 and Primiparity
• Cord Loops
• low SES
• maternal age >40
• birth weight ratio (SGA & LGA)

Question 12

Diagnosis of fetal demise

Answer 12

• decreased fetal mvt
• decreased preg sxs
• bleeding/contractions
• inability to obtain fetal heart tones (NOT DIAGNOSTIC)

Question 13

What is required to dx Fetal Demise?

Answer 13

Visualization of fetal heart w/ no of cardiac activity

• Must be confirmed by Ultrasound!
• 2 examiners

Question 14

How do you manage fetal demise in the 2nd trimester?

Answer 14

Dilation & evacuation

Cytotec (vaginal misoprostol)

Pitocin (IV)

Question 15

How do you manage fetal demise in later gestation (3rd trimester)?

Answer 15

Labor induction if no dilation & evacuation (D&E) available

C-section fo UNUSUAL circumstances/Emergencies

Question 16

How do you manage fetal demise before 28 wks (3rd tirmester)?

What is the potential danger

Answer 16

Cytotec (Misoprostol) & Pitcoin IV

Can’t use if she’s had a C-section. May cause Uterine rupture

Question 17

Fetal Demise checklist (chart)

Answer 17

Admission & DX

• confirm dx
• H&P

Antepartum eval
           -  amniotic fluid 
           - maternal blood
           - cervical/vaginal exam
Delivery/Intrapartum          
- pain control
- choice of PP care (pics, holding baby)

Postpartum

• Fetal physical exam
• Placenta

Follow up

• 1-2wks, PPD screen
• 6wks
  - review autopsy
  - reinforce preconception visit
  - Protein S/genetics referral
  - screen PPD

Question 18

What’s included in the eval of fetal demise?

Answer 18

• maternal OB, FH history
• fetal autopsy/karyotype
• placental eval
• Indirect Coombs test (ABO compatibility)
• RPR, parvo testing, CBC/platelets, TSH
• maternal/fetal hemorrhage (Kleinhauer-Betke)
  - measures how mom & baby’s blood mix (trauma/Rh factor)
• urine tox screen

Question 19

What eval may be useful?

Answer 19

Thrombophlilia eval:

• Lupus
• Antiphospholipid A (Anticardiolipin) Abs
• Factor V Leiden
• Prothrombin mutation
• Protein C, S & Antithrombin III deficiency

Question 20

Uncertain utility

Answer 20

• Hgb A1c
• TORCH titers
• Placental cultures
• other thrombophilias

Question 21

Grief cycle

Answer 21

Normal Functioning

1. shock & denial
   - avoidance
   - confusion
   - Fear
   - Numbness
   - blame
2. Anger
   - frustration
   - Anxiety
   - Imitation
   - embarrassment
   - shame
3. Depression/Detachment
   - overwhelmed
   - blahs
   - lack of energy
   - helplessness
4. Dialogue & Bargaining
   - reaching out to others
   - desire to tell the story
   - struggle to find meaning
5. Acceptance
   - exploring options
   - new plan

Returning to meaningful life

• empowerment
• security
• self-esteem
• meaning

Question 22

When do most women recover psychologically from fetal demise?

Answer 22

About a year

• should wait to try again within 1-3yrs
• PTSD if conception soon after

Question 23

What are the risks for subsequent pregnancies?

Answer 23

preterm birth, low birth weight, abruption

Question 24

What’s the future mgt of 1st trimester?

Answer 24

1st trimester:

• early dating U/S
• First combined testing

Question 25

What’s the future mgt of 2nd trimester?

Answer 25

U/S @ 18-20wks

Doppler velocimetry

Quad screen or AFP

Question 26

What’s the future mgt of 3rd trimester (after 28wks)?

Answer 26

U/S

Kick counts

Dopppler w/ BPP every wk (32-36wks)

Question 27

What’s recommendation does ACOG have regarding future pregnancies after fetal demise?

Answer 27

Fetal testing 1-2wks before last stillbirth

Question 28

When should delivery happen?

Answer 28

Elective induction @ 39wks or before with documented fetal lung maturity by amniocentesis