Stillbirth-a devastating outcome of a pregnancy

Stillbirth- A Devastating Outcome of a Pregnancy

Pregnancy is a period of joy and expectation for any woman and her family.  It is a heart breaking situation for any Gynaecologist when the news has to be broken that the baby is no longer alive in the uterus or the mother has given birth to a dead child .

This is a complicated scientific topic. Gynaecologists who treat such cases require compilation of all their knowledge and experience to evaluate the woman, whether she is pregnant right now or if she comes with history of previous stillbirth and is planning to conceive in near future.

In this write up, first we will deal with the scientific definition of Stillbirth. It’s division into three categories- Early, Intermediate & late. Causes & risk factors of stillbirth. Evaluation of stillbirth and finally its management aspect

Terms used in this topic

Fetus means- the child developing inside uterus
Gestation age -refers to the duration of pregnancy in weeks
Fetal death/ fetal mortality -is the term used to describe unfavorable outcome of pregnancy irrespective of duration of pregnancy (gestation age)
Stillbirth- is the term generally used by laymen when death of fetus occurs late in pregnancy

Scientific Definition of fetal mortality- Sillbirth

 Fetal death means death, prior to complete expulsion or extraction from the 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 definitive movement of the voluntary muscles.

Fetal mortality is generally divided into three periods

-Early- less than 20 completed weeks of gestation (pregnancy)
-Intermediate- 20-27 weeks
-Late – 28 weeks or more

In due course of the discussion of this topic, many causes (Clinical Situations) of Stillbirth will be discussed. Some of them are responsible for fetal mortality in all three periods of gestation. At the same time, for any case of fetal death, many factors may be responsible.

Many clinical entities are a topic of discussions in themselves hence they will be presented in only simplified and concise manner

 Statistics of Stillbirth (Fetal Mortality)

83 % of stillbirths occur before the start of labor pains- Antepartum stillbirths

CAUSES OF STILLBIRTH (FETAL MORTALITY)

1)Placental Causes

-Placental abnormalities– mainly utero-placental insufficiency

Placenta is the structure which is attached to the uterus and supplies food and oxygen to the fetus through umbilical cord. It gets its supplies from the mother. Various factors lead to its insufficient working.

Calcified placenta1

-Placental abruption

In this clinical entity placenta gets detached from its attachment to uterus. This results in stoppage of blood supply to the fetus and fetal death occurs.

placental abruption

2)Umbilical cord causes

-Prolapse– During labor (Birthing Process ) when cervix (mouth of uterus) is dilating, at times the umbilical cord comes out of it before the fetal head is born . This leads to compression of cord between fetal head and maternal bones of pelvis. There is cessation of blood supply to the baby and fetal mortality occurs

cord prolapse

 

-Stricture – This is structural abnormality of umbilical cord in which shrinkage of cord occurs at some point & cessation of blood supply occurs.

cord stricture

-Thrombosis – Clotting of blood occurs in the blood vessels of umbilical cord & blood flow to baby is hampered

3) Fetal Causes

-Multifetal gestation

When lady is pregnant with more than one fetus. Commonly encountered situations are Twins- pregnancy with two fetus, Triplet-three fetus, Quadruplet-four fetus etc

multifetal gestation

Fetal Malformations 

There are certain genetic abnormalities which result in major structural abnormalities in the fetus. These abnormalities are incompatible (Non survivable) with life.

4)Maternal Causes

Hypertensive disorders –

-Pre Eclampsia – High BP which results as a complication of pregnancy
-Chronic Hypertension – When mother is suffering from high BP and she becomes pregnant

Diabetes in mother

-Diabetic Embryopathy– Fetus of a diabetic mother is more prone to have certain congenital structural malformations. Some of them are lethal
-Diabetic ketoacidosis– Diabetic mother can develop this metabolic dysfunction. Blood sugar levels are high and insulin levels are low. Maternal cells are unable to utilize this sugar. This is a life-threatening situation for both mother and baby.

5) Obstetrics complications

Preterm labor

If pregnant woman goes in labor and delivers prematurely before the fetus has reached term and is capable of surviving independently.

Preterm Prelabor Rupture Of Membranes-PPROM 

Amniotic membranes make up Amniotic sac which is a covering around growing fetus to keep it safe inside uterus. If these membranes get broken due to some reason, Amniotic fluid (Fluid around fetus) gets drained resulting into Umbilical cord getting compressed between walls of uterus and fetus. This results in cessation of Oxygen supply to the fetus and ultimately fetal demise.
rupture of membranes

Infections

There are certain infections involving fetus and placenta which will lead to fetal death.

RISK FACTORS FOR FETAL DEATH

Gynaecologists come to know about these risk factors either during examination or history taking. When one or more of these risk factors are present, vigilance on part of both patient and doctor is required.

Education
Maternal age– 35-39 years, more than 40 years
Smoking
Drug abuse
Obesity– BMI (Body Mass Index- weight of person vs height) 25-29.9, more than 30

ART- Artificial Reproductive Techniques- if pregnancy is the result of fertility treatment- example- IVF- In Vitro Fertilization, ICSI- Intra Cytoplasmic Sperm Injection etc

Previous history of adverse outcome

Preterm birth
Growth retarded baby
Stillbirth
Pre-Eclampsia
Placental abruption
Cholestasis (Jaundice) of pregnancy

EVALUATION OF STILLBIRTH

Why is it Necessary-Aims & Objectives

-It is beneficial for maternal psychological adaptation to a significant loss. She is grieving and may be thinking of herself as guilty.
-Risk of recurrence can be judged and appropriate counseling and therapy offered
-There are certain inherited ( genetic ) disorders and identification of these syndromes will provide useful information for other family members

How is it done

1)Evaluation of fetus
Appropriate consent of parents is required before carrying out many of these processes

History taking in detail of pregnancy events
Clinical examination at the time of birth-It is found that up to 35% of stillborns have major structural anomalies. Some have Dysmorphic features (Distorted facial structure). Some may have skeletal ( bone) abnormalities. Weight, head circumference and length of fetus is also measured.
Photograph taking from different angles
Fetogram-Full radiograph of fetus (X-Ray) of fetus

Examination of
Placenta along with its weight
Umbilical cord
Amniotic membranes

-Karyotyping
Karyotyping reveals chromosomal (genetic material) abnormalities in the fetus
Sample required-
-3 ml of fetal blood is drawn from Umbilical blood vessels or direct Cardiac (Heart ) puncture & is put in sterile heparinized container
If blood is not obtained, other fetal tissues that can be sent in either Ringer Lactate (RL) solution or special cytogenetic solution are-
-Placental block of dimension 1 X 1 cm to be taken from the site, below the cord insertion
-Umbilical cord segment – 1.5 cm long
-Internal fetal tissue sample- Costochondral junction (Soft tissue which binds rib with Sternum-Bone in the middle of the chest), Patella- Knee cap

Important:
-These samples are to be stored at room temperature
-A full fetal karyotype may not be possible in cases with prolonged fetal death (Maceration)
-Skin is no longer recommended as tissue sample
-Placement of sample within Formalin or alcohol will kill remaining viable cells and will prevent chromosomal testing

Stillborn’s autopsy-
 MRI– Magnetic Resonance Imaging
USG– Ultrasound

MANAGEMENT OF PSYCHOLOGICAL ASPECTS OF MOTHER

The event of stillbirth is traumatic for mother & her family. She is at increased risk of mental depression. Regular visit to the Gynecologist is advised.

MANAGEMENT OF SUBSEQUENT PREGNANCY AFTER STILLBIRTH

Preconceptional or initial prenatal visit

 Detailed medical and obstetrical history -There are certain risk factors which are modifiable like hypertension and diabetes. Pregnant woman may have it at the time of diagnosis of pregnancy or there may be a history that she had these conditions at the time of that pregnancy which resulted in stillbirth. Specific management protocols are in place for managing these conditions

-Evaluation and workup of previous stillbirth- Bad Obstetrics History (BOH)

-Determination of recurrence risk

Smoking cessation
Weight loss in obese women (preconceptional only)
Genetic counseling if family genetic condition exists
Thrombophilia (Increased tendency of blood to clot) work up – antiphospholipid antibodies, along with Lupus anticoagulant
-Support and reassurance

First Trimester- Weeks 1-12

Dating ultrasonography- to confirm live pregnancy and expected due date

First trimester screen (Double Marker )- Blood tests include-PAPP-A- Pregnancy Associated Plasma Protein -A &Beta HCG- Human Chorionic Gonadotrophin along with sonography  for specific fetal features. These are Nuchal Transluscency (NT) which is thickness of nape of neck in millimeters & Nasal Bone (NB) presence

Second Trimester-Weeks 13-28

Fetal ultrasonographic anatomic survey-2 D, 3 D, at 18-20 weeks of gestation

Maternal blood tests- Quadruple  or single marker alpha fetoprotein if first trimester screening is not done .These tests are risk estimation for genetic disorder

Third Trimester-Weeks 29-40

Ultrasonographic screening for fetal growth restriction after 28 weeks if there is history of previous low birth weight baby Fetal Kick counts monitoring-starting at 28 weeks

Delivery

-Delivery -at 39 weeks or earlier is recommended. It can be an induced labor or Caesarean delivery depending on the clinical assessment of mother and fetus at that time.