FETAL DEATH

NUSWIL BERNOLIAN
FETOMATERNAL DIVISION
DEPARTMENT OF OBSTETRIC AND
GYNAECOLOGY
DR MOH. HOESIN GENERAL HOSPITAL
PALEMBANG

DEFINITION
WHO: a death before
complete expulsion or
extraction from the mother of
the product of conception,
irrespective of duration of
pregnancy.
Michael J. Paidas, Nazli Hossain.
Embryonic and fetal demise. Creasy and
Resniks maternal and fetal medicine.

Centers for Disease Control

and Prevention and the
Vital Statistics Reports
Only those dead fetus and
neonates born at after 19
weeks, or if gestational age is
not available, weighing 350 g
or more (MacDorman and
Kirmeyer, 2009)
The absence of signs of life at
or after birth

EPIDEMIOLOGY
USA : Rate of stillbirths higher
than neonatal mortality
1985 : 7.8.. 2003: 6.2 per 1000
live births
One half occurred less than 28
weeks, and 20% near term
2-3 x higher in black fetuses
RR 1,17 in interracial couples
ACOG: Increase 4x in multifetal

Simulian et al: In low risk

groups : 1.6 per 1000 births
In abruption : 61.4
SGA : 9.6
Gestational hypertensive
disorders : 3.5
Chronic hypertension : 7.6
Diabetes : 3.9

ETIOLOGY
FETAL : 25 40 PERCENT
PLACENTAL : 25 35
PERCENT
MATERNAL 5 10 PERCENT
UNEXPLAINED 15 35
PERCENT

FETAL 25 40%
CHROMOSOMAL
ABNORMALITIES
NONCHROMOSOMAL BIRTH
DEFECTS
NONIMMUNE HYDROPS
INFECTIONS : VIRUSES,
BACTERIA, PROTOZOA

PLACENTAL 25-35 %
PREMATURLEY RUPTURED MEMBRANES
ABRUPTION
FETOMATERNAL HAEMORRHAGE
CORD ACCIDENT
PLACENTAL INSUFFICIENCY
INTRAPARTUM ASPHYXIA
PREVIA
TWIN-TWIN TRNASFUSION
CHORIOAMNIONITIS

MATERNAL 5 10
%
SMOKING

DIABETES
HYPERTENSIVE
DISORDERS

ILLICIT DRUGS AND

ALCOHOL

OBESITY

INFECTIONS AND
SEPSIE

AGE > 35 YEARS

PRETERM LABOUR

THYROID DISEASE

ABNORMAL LABOUR

RENAL DISEASE

UTERINE RUPTURE

ANTIPHOSPOLIPID

POSTTERM
PREGNANCY

THROMBOPHILIAS

PROTOCOL FOR
EXAMINATIONS
INFANT
DESCRIPTION
MALFORMATIONS
SKIN STAINING
DEGREE OF
MACERATION
COLOR: PALE,
PLETHORIC

UMBILICAL CORD
PROLAPSE

ENTANGLEMENT:
NECK, ARMS, LEGS
HEMATOMAS OR
STRICTURES
NUMBER OF VESSELS
LENGTH
WHARTON JELLY:
NORMAL, ABSENT

AMNIOTIC FLUID

PLACENTA
WEIGHT

COLOR: MECONIUM,
BLOOD
CONSISTENCY
VOLUME

MEMBRANES

STAINED: MECONIUM,
CLOUDY

THICKENING

STAINING-MECONIUM
ADHERENT CLOTS
STRUCTURAL
ABNORMALITIES:
CIRCUMVALLATE OR
ACCESSORY LOBES,
VELAMENTOUS
INSERTION
EDEMA: HYDROPHIC
CHANGES

EVALUATION FOR
RECURRENT TM 1 LOSS
KARYOTYPE OF
MISCARRIED
TISSUE
PARENTAL
KARYOTYPE
LUTEAL-PHASE
ASSESSMENT
GTT
THYROID

UTERINE CAVITY
ASSESSMENT BY
SONOHYSTEROGRAPH
Y (PREFFERED), HSG,
OR HYSTEROSCOPY
APS ANTIBODY
SCREEN
INHERITED
THROMBOPHILIAS, IF
LOSSES BETWEEN 10
-13 WEEKS

RECOMMENDED
EVALUATION FOR TM
MATERNAL WORK
2-3 LOSS
FETAL WORK UP

UP

CBC, KLEIHAUER-BETKE
TEST

FETAL AUTOPSY

PARVOVIRUS B 19 IgM,
IgG

PLACENTHAL
PATHOLOGY

SYPHILLIS

RADIOGRAPH OF
FETAL SKELETON

ANTICARDIOLIPIN AB

LUPUS ANTICOAGULANT

F-THYROXINE, TSH
INHERITED
THROMBOPHILIAS

LABORATORY
EVALUATION

If autopsy and chromosomal studies

performed: 35% discovered have
major structural anomalies.
20% have dysmorphic features or
skeletal abnormalities, 8%
chromosomal abnormalities
ACOG 2009 recommends ideally
karyotyping all stillborns
If no morphologic anomalies found,
5% have chromosomal abnormalities.

Appropriate consent must be

obtained to take fetal tissue
samples, including fluid by
postmortem aspiration
3 mL of fetal blood obtained from
umbilical cord (preferably) or by
cardiac puncture, is placed into a
sterile, heparinized tube for
cytogenetic studies.
Maternal blood : APS, diabetes,
Lupus, Kleihauer-Betke staining
If blood cannot be obtained, ACOG
(2009) recommends one of the

1. A placental block about 1x1 cm taken

below the cord insertion site in the
unfixed specimen
2. Umbilical cord segment about 1.5 cm
long, or
Internal fetal tissue specimen, such as
costochondral junction or patella (skin
is no longer recommended)
Tissue is washed with sterile saline
prior to placement in lactated Ringer
solution or sterile cytogenetic medium.
Placement in formalin or alcohol kills
remaining viable cells and prevents
cytogenetic analysis.

MANAGEMENT
DELIVERY BY A CARING PHYSICIAN
COUNSELING : AUTOPSY
RISK OF DEPRESSION
COAGULOPATHY : 25 30%, CHECK
FIBRINOGEN AND PLATELET

RECURRENCE RISK
RECURRENCE RISK : 3% IF > 27 WEEKS,
GREATER IF < 27 WEEKS
SHARMA ET AL, 2006: STILLBIRTH RATE 22.7
PER 1000 IN WOMEN WITH PRIOR FETAL DEATH
SURKAN ET AL, 2004: TERM IUGR LIVE FETUS,
HAS 2X RISK OF STILLBIRTH. IF PRETERM: 5X
ACOG 2009: LOW RISK WOMAN UNEXPLAINED
STILLBORN: RISK 10 X.
RISK OF STILLBORN > 37 WEEKS : 1.8 PER
1000
GOLDENBERG ET AL 1993: 95 WOMEN WITH
PREGNANCY LOSS 13 -24 WEEKS: NEXT

SUBSEQUENT
PREGNANCY
COUNSELING FOR RISK FACTORS
ANTENATAL SURVEILLANCE, PRENATAL
DIAGNOSIS
RISK IS REDUCED BY 14% WITH ASPIRIN
HEPARIN FOR THROMBOPHILIA
IMMUNOGLOBULIN, PROGETERONE

FETAL KICK COUNTS : START AT 28

WEEKS
INTERVAL 2 WEEKS : USG, NST, BPP, AFI
ACOG RECOMMENDATIO, 2009 :
ANTEPARTUM SURVEILLANCE START AT
32 WEEKS
EARLIER IN IUGR OR CHRONIC DISEASE
ELECTIVE INDUCTION AT THE
COMPLETION OF 39 WEEKS GESTATION
OR 37 TO 38 AFTER LUNG MATURITY IS
DOCUMENTED BY AMNIOCENTESIS

CONCLUSION
CATASTROPHIC EVENTS IN A COUPLES
LIVES.
POSSIBILITIES OF ETIOLOGIES
INVESTIGATIONS : FETUS, PLACENTA,
UMBILICAL CORD, MEMBRANE
COUNSELING THE COUPLES
PLANNING THE SUBSEQUENT
PREGNANCIES

THANK YOU