Still Birth and Miscarriage

Question 1

What is the difference between an abortion and a foetal death in utero?

Answer 1

• Abortion: pre 20 weeks
• FDIU: post 20 weeks

Question 2

List some reasons that a pregnancy may abort

Answer 2

• Foetal (genetic/morphological)
• Maternal (endocrine/cardiac/renal disease), autoimmunity

Question 3

When might you investigate recurrent abortion? What would you consider?

Answer 3

• Most are due to unknown causes, less to anatomical/chromosomal abnormality
• Occur in 50% of biochemical pregnancies, most in the first 12 weeks and mostly due to random aneuploidy
• Investigate if > 3 abortions, any second trimester loss, any complicated pregnancy outcome history
• Ix: chromosomal analysis of POC, anatomical studies (saline/MRI hysterogram), diabetes/thyroid/endocrine/autoimmunity screen

Question 4

If a woman’s recurrent abortion was due to a thrombophilia, how might you manage her next pregnancy?

Answer 4

Aspirin/heparin

Question 5

How often does stillbirth (FDIU) occur? What are the contributing/predisposing factors

Answer 5

• Less than 1:1000 pregnancies
• Maternal: diabetes, hypertension, SLE, connective tissue disorders, APS, thrombophilia
• Foetal: malformation, infection, haemolytic disease, metabolic disease
• Placenta: abruption, insufficiency (IUGR/post-term), TTTS, feto-maternal transfusion
• Cord: accident

Question 6

Clinically, how might you determine that a foetal death in utero has occurred?

Answer 6

• May have features of underlying condition
• Mostly - reduced or absent foetal movement
• Unable to locate foetal heart, no signs on CTG
• US - no signs of foetal movement (Spalding’s signs - overlapping of the skull bones)

Question 7

What is the most common maternal complication of a foetal death in utero?

Answer 7

• Coagulopathy (resolves after delivery)

Question 8

How might you investigate the cause of a foetal death in utero?

Answer 8

• Maternal
  
  • BGL, HbA1c
  • Rh antibodies
  • Kleihauer
  • ANA
  • Thrombophilia, anti-cardiolipin, lupus
  • TORCH screen
  • Fibrinogen and platelet count
• Foetal
  
  • US
  • Postmortem - most valuable examination
  • Or limited - swabs, small biopsy of skin, X-ray/MRI
• Placenta
  
  • Swabs, histology

Question 9

Describe the management of a foetal death in utero

Answer 9

• Tell the parents, be clear that the baby has died, second scan for confirmation
• Explain investigations in general terms
• Discuss delivery. In general, no rush
  
  • 80% labour spontaneously within 2-3 weeks, otherwise observe for coagulopathy
  • Induce with misoprostil, ARM as required
• Private room, analgesia
• Pastoral care, social work, GP involvement
• Bereavement care
  
  • Seeing the baby, saying goodbye, photos, footprints, memorials etc. as appropriate
  • Heartfelt - free service (photographers donate time to create mementos)
• Suppression of lactation
• Early discharge if possible with good post-natal support
• Frequent review, discussion of next pregnancy