You are in: eMedicine Specialties > Obstetrics and Gynecology > Obstetrical Complications Evaluation of Fetal DeathArticle Last Updated: Feb 27, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: James L Lindsey, MD, Staff Physician, Santa Clara Valley Medical Center, Affiliated Clinical Associate Professor, Stanford School of Medicine, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center James L Lindsey is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, and California Medical Association Coauthor(s): Sarah Azad, MD, Staff Physician, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center Editors: Andrea Witlin, DO, PhD, Former Assistant Professor, Department of Obstetrics and Gynecology, University of Texas Medical Branch; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Carl Vernon Smith, MD, Professor, Chairman, Department of Obstetrics and Gynecology, University of Nebraska College of Medicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Feinberg School of Medicine, Department of Obstetrics and Gynecology, Northwestern University; Chief, Division of Reproductive Genetics, Prentice Women's Hospital, Northwestern Memorial Hospital Author and Editor Disclosure Synonyms and related keywords: evaluation of fetal death, stillbirth, fetal demise, perinatal death, pregnancy loss after 20 weeks' gestation, fetal heart tones, fetal movement, fetal surveillance, induction, oxytocin, preinduction cervical ripening, antiphospholipid syndrome, cord occlusion, abruptio placentae, pregnancy loss, fetal death, fetal death evaluation, fetal demise evaluation, evaluation of fetal demise DEFINITION OF FETAL DEATHSection 2 of 11
  The loss of a fetus at any stage is a fetal demise. According to the 2003 revision of the Procedures for Coding Cause of Fetal Death Under ICD-10, the National Center for Health Statistics defines fetal death as "death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy. The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps." It is further classified as early (<20 weeks' gestation), intermediate (20-27 weeks' gestation), or late (>28 weeks' gestation). In an attempt to separate early pregnancy loss (spontaneous abortion) from later pregnancy loss, both the World Health Organization and the American College of Obstetricians and Gynecologists have recommended that statistics for fetal death include only deaths occurring in utero in which the fetus or neonate weighs 500 g or more. The American College of Obstetricians and Gynecologists also recommends including deaths occurring at 22 weeks of gestation or greater (other groups use 20 wk of gestation). Although this definition of fetal death is the most frequently used in medical literature, it is by no means the only definition in use. Even within the United States, the differences in the definitions used are substantial. The US National Center for Health Statistics, a division of the Centers for Disease Control and Prevention, periodically updates the Model State Vital Statistics Act and the regulations to assist states in developing vital statistics laws. They recommend reporting fetal deaths occurring in fetuses weighing 350 g or more or those of 20 weeks of gestation or greater (see National Center for Health Statistics). This policy is, however, only a guideline and reporting practices vary among states (see The 1997 fetal death reporting requirements). In addition, not all states interpret the weeks of gestation in the same manner. In California, 20 weeks' gestation is worded "twenty utero gestational weeks" and has therefore been interpreted to be 23 weeks from the last menstrual period. (Implantation in the uterus does not occur until 1 wk after fertilization.) Physicians must check the reporting requirements for the state(s) in which they practice. The 1997 fetal death reporting requirements from the National Center for Health Statistics
FREQUENCYSection 3 of 11
In 2003, data from the National Center for Health Statistics show a US national average fetal mortality rate of 6.9 deaths per 1000 births. Worldwide, this rate varies considerably, depending on the quality of medical care available in the country in question and the definitions used for classifying fetal deaths. Underreporting in developing nations is common, making comparisons even more difficult. DIAGNOSISSection 4 of 11
History and physical examination are of limited value in the diagnosis of fetal death. In most patients, the only symptom is decreased fetal movement. An inability to obtain fetal heart tones upon examination suggests fetal demise; however, this is not diagnostic and death must be confirmed by ultrasonographic examination. Fetal demise is diagnosed by visualization of the fetal heart and notation of the absence of cardiac activity. MANAGEMENTSection 5 of 11
Once the diagnosis of fetal demise has been confirmed, the patient should be informed of her condition. Often, allowing the mother to see the lack of cardiac activity helps to solidify the diagnosis. Care must be taken to be understanding of the patient's feelings and to give the patient time to adjust before proceeding with a discussion of further management. Usually, patients only require 5 or 10 minutes, or a phone call to a close friend or family member, before they are ready to discuss management options. Labor should be induced as soon as possible after diagnosis. Patient responses vary in regard to this recommendation; some wish to begin induction immediately, while others wish to delay induction for a period of hours or days until they are emotionally prepared. In one study, postponing delivery for more than 24 hours after diagnosis has been associated with increased anxiety years after the event when compared with women whose labor is induced within 6 hours. When a dead fetus has been in utero for 3-4 weeks, fibrinogen levels may drop, leading to a coagulopathy. This is rarely a problem with singleton pregnancies because of earlier recognition and induction, another reason for patients to be encouraged to begin induction soon after the diagnosis. In some cases of twin pregnancies, depending on the type of placentation, induction after the death of a twin may be delayed to allow the viable twin to mature. In these cases, some perinatologists recommend checking a set of baseline coagulation labs at the time of fetal demise and only rechecking them if the clinical situation warrants. Other perinatologists do not recommend checking coagulation labs at all. Overall, the risk of developing disseminated intravascular coagulopathy is rare. Induction may be accomplished with preinduction cervical ripening followed by intravenous oxytocin (see Cervical Ripening). Patients with a history of a prior cesarean delivery should be treated cautiously because of the risk of uterine rupture, just as in any birth following cesarean delivery (see Vaginal Birth After Cesarean Delivery). Early fetal demise may be managed with laminaria insertion followed by dilatation and extraction. In women with fetal death before 28 weeks' gestation, induction may be accomplished using prostaglandin E2 vaginal suppositories (10-20 mg every 4-6 h), misoprostol (ie, prostaglandin E1) vaginally or orally (400 mcg every 4-6 h), and/or oxytocin (preferred in women with prior uterine surgery). In women with fetal death after 28 weeks' gestation, lower doses should be used. The American College of obstetricians and gynecologists guidelines for induction of labor states that prostaglandin E2 and misoprostol should not be used in women with a history of a prior uterine incision because of the risk of uterine rupture. In 2003, Dickinson and Evans reported on the efficacy of oral, vaginal, and combined administration of misoprostol for second-trimester induction and found that the superior regimen was misoprostol at 400 mcg vaginally every 6 hours. Pretreatment with antidiarrheal and antiemetic agents may reduce adverse effects. These effects are generally less common with misoprostol than with prostaglandin E2. Pain management in patients undergoing induction of labor for fetal demise is usually easier to manage than in patients with live fetuses. Higher doses of narcotics are available to the patient and often a morphine or Dilaudid PCA is sufficient for successful pain control. Should a patient desire superior pain control to intravenous narcotics, epidural anesthesia should be offered. See Image 1 for an example of a checklist that can be used in the management of fetal demise. CAUSESSection 6 of 11
Unexplained causes account for 25-60% of all fetal demise; the incidence increases with increasing gestational age. In cases where a cause is clearly identified, the cause of fetal death can be attributable to fetal, maternal, or placental pathology. Maternal
Fetal
Placental
Risk factors
EVALUATIONSSection 7 of 11
The time following a fetal death is extremely difficult for both the family and the health care providers. In this stressful time, use of a checklist is helpful to prevent oversights in the evaluation of the mother, fetus, and placenta as well as to ensure that the emotional needs of the family are met. Image 1 is an example of such a checklist, which is used at Santa Clara Valley Medical Center. Most institutions have a standardized checklist that nursing and medical staff refer to jointly to assure a thorough workup. Another useful resource is a grief packet that can be given to the parents following the demise. This usually includes referrals for counseling, support groups, and other resources. A container or folder can be included so that the family can preserve keepsakes such as photos, footprints, or a lock of hair. Spiritual care is an important resource during such difficult times and should always be offered to patients and their families. Up to 60% of stillbirths have no identifiable etiology. Attempting to determine the cause of fetal death remains important because it may influence estimates of recurrence and future preconceptional counseling, pregnancy management, prenatal diagnostic procedures, and neonatal management. Incerpi et al, using a cost-effective stillbirth assessment protocol, were able to identify causes for fetal demises in 72% of patients. Many institutions use a selective workup based on clinical findings. For example, when clinical findings strongly suggest a cause for the fetal demise at Santa Clara Valley Medical Center, either no further testing or limited testing is performed. Causes deemed fairly obvious include cord accident (eg, prolapse, entanglement, true knot, tight nuchal cord), anencephaly, or previously known lethal karyotype. In such cases, no further workup is necessary. Another obvious cause is abruption (see Abruptio Placentae). If severe clinical abruption is present, testing can be limited to toxicology screening and a thrombophilia workup. The most important part of the workup of a fetal demise is the autopsy of the fetus. The decision to proceed with an autopsy must be made by the parents and informed consent is necessary. With parents who are resistant to the idea of a complete autopsy, a limited fetal evaluation should be discussed with the family. Although uncommon, postmortem MRIs can provide valuable information in the evaluation of a fetus when an autopsy cannot be performed. The placenta and the membranes should be carefully examined, including cultures. Again, an algorithm or checklist is helpful to avoid omissions (see Image 1). This inspection is even more important if the family declines an autopsy. Chromosomal analysis of a sample of amniotic fluid, fetal blood, or fetal tissue (skin or fascia lata) should be considered if the fetus is dysmorphic, has growth retardation, is hydropic, or has anomalies or other signs of chromosomal abnormality. Chromosomal analysis should also be considered in patients with multiple pregnancy losses, especially with a history of second- and third-trimester losses or when a parent has a balanced translocation or mosaic chromosomal pattern. This step is part of the comprehensive assessment of all stillborns in Icerpi's program. A summary of the protocol for the fetus and placenta is as follows:
MATERNAL STUDIESSection 8 of 11
Maternal studies that should also be considered during the workup of a fetal demise include the following:
The above tests have traditionally been a part of an evaluation for the etiology of fetal demise. If diabetes screening has been performed during the prenatal period, repeat testing for diabetes is probably not necessary. Similarly, if the patient has no signs or symptoms of thyroid disease, thyroid dysfunction is unlikely to be the cause of the demise. However, these tests are inexpensive and normal results may be reassuring to the patient. Additional tests that should be considered are as follows:
MANAGEMENT OF FUTURE PREGNANCYSection 9 of 11
If a particular medical problem is identified in the mother, it should be addressed prior to conception. For example, tight control of blood glucose prior to conception can substantially reduce the risk of congenital anomalies in the fetus. Preconceptional counseling is helpful if congenital anomalies or genetic abnormalities are found. Genetic screening and detailed ultrasound can evaluate future pregnancies. In some cases, such as cord occlusion, the patient can be assured that recurrence is very unlikely. Fetal death of unknown cause is a special problem. Although recurrent fetal loss is uncommon, patients are naturally anxious. Most patients find increased fetal surveillance with the next pregnancy reassuring, even though such testing is not clearly beneficial. Weekly biophysical profile or fetal heart rate testing can be combined with maternal kick counts in the third trimester. For patients who have experienced earlier loss, frequent ultrasound is reassuring. Optimal management of chronic medical conditions is very important prior to the next pregnancy. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Evaluation of Fetal Death excerpt Article Last Updated: Feb 27, 2006 | ||||||||||||
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