Fetal Demise Flashcards
What is the definition of fetal demise/stillbirth?
No signs of life:
- No breathing
- No Heart beat
- No cord pulsations
- No voluntary muscle mvt
What is the suggested birth weight & GA requirement?
Fetal weight >350g
After 20wks
How is spontaneous abortion classified?
Before 20wks gestation
What are maternal causes of Fetal Demise?
- Infxn
- Renal Dz
- Thyroid disorder
- Cholestasis of pregnancy
- Hemoglobinopathy
- Systemic Lupus erythemotasus
- Rh disease
- Uterine rupture
- Maternal trauma or death
- Inherited thrombophlebitis
- Antiphospholipid
Other maternal Causes of Fetal Demise
- Race
- Advanced maternal age (AMA)
- Multiple gestation
- Previous pregnancy complications
- Obesity
- Smoking, drugs, alcohol
- Low educational attainment
- Diabetes
- HTN-chronic, PIH, preeclampsia, eclampsia
Fetal Causes of fetal Demise
- Multiple gestation
- Intrauterine growth restrictions (IUGR)
- Congenital ABNL
- Infxn (CMV, Listeria, Syphyilis, Parvovirus)
- Hydrops fetalis
Suspected causes include above +
Maternal death & birth injury
Placental Causes of fetal demise
- Cord accident
- Placental abruption
- Premature rupture of MBs
- Placental abruption *
- Vasa previa/vela mentors insertion
- Fetomaternal hemorrhage
- Placental insufficiency
Maternal risk factors in all countries
- 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*
Maternal risk factors in Developing countries
- Obstructed/prolonged labor (asphyxia, infxn, birth injury)*
- Infxns*
- Syphilis(same)
- Gram negative infxns - Malaria*
- Sickle Cell*
- Poor nutrition*
- congenital anomalies (same)
- HTN (same)
What is the definition of Unexplained Stillbirth?
Fetal death can’t be explained by identifiable fetal, placental, maternal or obstetric etiology
25-60%
Independent risk factors of stillbirth
- maternal prepregnancy wt >68kg (150lbs)
- Parity of >3 and Primiparity
- Cord Loops
- low SES
- maternal age >40
- birth weight ratio (SGA & LGA)
Diagnosis of fetal demise
- decreased fetal mvt
- decreased preg sxs
- bleeding/contractions
- inability to obtain fetal heart tones (NOT DIAGNOSTIC)
What is required to dx Fetal Demise?
Visualization of fetal heart w/ no of cardiac activity
- Must be confirmed by Ultrasound!
- 2 examiners
How do you manage fetal demise in the 2nd trimester?
Dilation & evacuation
Cytotec (vaginal misoprostol)
Pitocin (IV)
How do you manage fetal demise in later gestation (3rd trimester)?
Labor induction if no dilation & evacuation (D&E) available
C-section fo UNUSUAL circumstances/Emergencies
How do you manage fetal demise before 28 wks (3rd tirmester)?
What is the potential danger
Cytotec (Misoprostol) & Pitcoin IV
Can’t use if she’s had a C-section. May cause Uterine rupture
Fetal Demise checklist (chart)
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
What’s included in the eval of fetal demise?
- 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
What eval may be useful?
Thrombophlilia eval:
- Lupus
- Antiphospholipid A (Anticardiolipin) Abs
- Factor V Leiden
- Prothrombin mutation
- Protein C, S & Antithrombin III deficiency
Uncertain utility
- Hgb A1c
- TORCH titers
- Placental cultures
- other thrombophilias
Grief cycle
Normal Functioning
- shock & denial
- avoidance
- confusion
- Fear
- Numbness
- blame - Anger
- frustration
- Anxiety
- Imitation
- embarrassment
- shame - Depression/Detachment
- overwhelmed
- blahs
- lack of energy
- helplessness - Dialogue & Bargaining
- reaching out to others
- desire to tell the story
- struggle to find meaning - Acceptance
- exploring options
- new plan
Returning to meaningful life
- empowerment
- security
- self-esteem
- meaning
When do most women recover psychologically from fetal demise?
About a year
- should wait to try again within 1-3yrs
- PTSD if conception soon after
What are the risks for subsequent pregnancies?
preterm birth, low birth weight, abruption
What’s the future mgt of 1st trimester?
1st trimester:
- early dating U/S
- First combined testing
