FETAL DEATH IN-UTERO

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FETAL DEATH IN-UTERO

CAUSES

Maternal

• Diabetes mellitus

• Hypertensive disorders

• Auto-immune disorders (SLE, anti-phospholipid antibody syndrome)

• Drug abuse

• Obstetric cholestasis

Fetal

Structural / chromosomal anomalies, infection, haemolytic disease, cord accidents, metabolic

disorders, hypoxia / acidosis (IUGR / Placental abruption)

Causes of stillbirths - England, Wales & N. Ireland (1999)

• Unexplained antepartum stillbirth - 71.3%

• Congenital malformation - 12.6%

• Intrapartum stillbirth - 7.3%

• Infection - 2.4%

• Accident - 0.1%

• Other specific causes - 5.7%

• Unclassifiable - 0.6%

Causes of neonatal deaths

• Immaturity - 47.2%

• Congenital malformation 24.4%

• Intra-partum events 9.1%

• Infection 8.2%

• Sudden infant death syndrome 2.5%

• Other causes 7.1%

• Unclassified 1.4%

ROUTINE INVESTIGATIONS

Protocols vary in different units

• Detailed fetal ultrasonography at time of diagnosis, identify structural anomalies / IUGR / hydrops

• Maternal FBC, LFT, Clotting, glucose (random / fasting / GTT depending on suspected aetiology),
Kleihauer test

• Thrombophilia screen - antiphospholipid antibody screen; relevance of V Leiden mutation uncertain

• Viral infection screen

• Fetal keryotype - amniotic fluid / placental tissue / fetal blood

• Placental / fetal swabs for culture, fetal blood for viral infection screen

• Post-mortem - counsel with regards to extent of procedure, tissues to be removed and storage of
tissue for further analysis / research

MANAGEMENT

• Deal with emotional upset / grief - berevement counselling

• Identification of underlying cause may help with grief / management of future pregnancy

• Sensitive counselling as no cause is found in majority of cases

• Treat underlying cause if necessary, for instance concealed abruption / severe pre-eclampsia

• Initiate delivery - method dependent on gestation age. Use prostaglandins + oxytocin or

mifepristone + prostaglandins + oxytocin according to unit protocol

• Risk of DIC minimal unless prolonged fetal death or associated with placental abruption or severe
pre-eclampsia

• Adequate intra-partum analgesia

• Keep membranes intact for as long as possible

• Avoid operative delivery / perineal lacerations if at all possible

• Encourage parents to hold baby if they wish

• Obtain photographs / hand and foot prints

• Discuss post-mortem and other investigations including fetal tissue removal

• Make arrangements for registration / funeral

• Provide bereavement counselling / local support groups

• Manage breast engorgement / lactation - simple analgesia + firm support usually sufficient.
Bromocriptine poorly tolerated, carbegolline is an alternative if medical treatment required

• Inform GP and cancel any pending appointments

• Discuss interim diagnosis, arrange post-natal follow-up to discuss post-mortem and results of other
investigations and device plan for subsequent pregnancy

• Discuss contraception

POST-MORTEMS - SUMMARY OF ROYAL COLLEGE OF PATHOLOGISTS RECOMMENDATIONS (From

CESDI 8th annual report)

• Medical schools and hospitals should provide training for medical and other appropriate personnel,
such as nurses or bereavement counselling officers, in the process of obtaining consent for
postmortem examination and advising parents about the examination including tissue and organ
retention. This educative process should also be part of induction programmes for all relevant staff.

• Those staff, medical or otherwise, obtaining consent for post-mortem should be aware of the need
for tissue retention in individual cases, and discuss this with the pathologist, if necessary, before
obtaining consent.

• Hospital authorities should provide an information leaflet for parents explaining the purpose of the
postmortem examination and their rights to grant or withold consent.

• A copy of the consent form signed by the parents should be available for them to keep, as well as
 any information received.

• The consent form should offer parents a range of options for which they can separately grant or
withold their agreement.

• Parents whose infant or child is subject to a Coroners postmortem, should be provided with
information, including a leaflet, explaining the legal requirements and the need, when appropriate,
for tissue and organ retention.

• Coroners postmortem reports should state clearly what, if any, tissues or organs have been retained
in the investigation of death.

• Hospitals should have written standard operating procedures for archiving and disposal of tissues
retained from post-mortem examinations. Methods should meet with public expectation, be
respectful, safe and lawful.

• If any tissue (or organ) is retained after the infant or baby has been buried or cremated, it should
be: respectfully disposed of; retained for medical education or research (with appropriateconsent);
released, with confirmation of identity, to funeral directors who are acting on behalf of parents and
who are able legitimately to dispose of tissue with appropriate regard to health and safety
regulations.

• Guidelines should be reviewed periodically and amended in the light of advances in medicine and
changes in public attitude or legislation.

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