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Intrauterine fetal death
Review
Intrauterine fetal death
Aetiology Chromosomal abnormalities These account for 30−60% of early fetal demise. The incidence increases with maternal age. Approximately 7% of fetuses with chromosomal abnormalities will survive to term. The commonest chromosomal abnormality is autosomal trisomy. Genetic anomalies affect the development of the fetus and the placenta. One recent study found an increase in apoptosis and a decrease in cell proliferation in chromosomally abnormal placentae compared to chromosomally normal placentae, implying that genetic abnormalities can lead to changes that affect trophoblast development and proliferation. Karyotype analysis often fails from the placenta, fetal blood (via an intracardiac sample) and fetal skin post delivery. Where there are specific concerns, the genetics laboratory may be able to help with specific diagnoses by utilizing other techniques such as fluorescent in-situ hybridization. Fetal chondrocytes have the most prolonged cell viability, and a small sample from the iliac crest can sometimes provide a diagnosis. Performing a fetal karyotype by transabdominal chorionic villus sampling before delivery avoids the problems associated with delay and infection of the placenta during delivery, although this is often not acceptable to the woman.
Farah Siddiqui Lucy Kean
Abstract Sadly, the death of a fetus may occur at any stage of a pregnancy, including during the labour process. A pregnancy loss will be devastating for the expectant parents. Obstetricians should be familiar with the management of intrauterine fetal death as prompt and appropriate counselling will aid the couple’s grief process. Understandably, couples wish to know the cause and chances of recurrence; thus, the full investigation of possible aetiological factors using a pragmatic approach will help in the postnatal counselling and management of future pregnancies. This review also explores the legal and ethical aspects of postmortem consent.
Keywords bereavement; intrauterine fetal death; stillbirth; postmortem; viral infections are often
Fetal structural anomalies These account for 35% of fetal deaths, and commonly include cardiac anomalies and renal abnormalities.
Introduction
Infection This is a significant risk for the fetus. The infection is often an ascending bacterial infection, such as Escherichia coli or Group B streptococcus, which triggers a cytokine cascade leading to fetal damage, preterm labour and intrauterine fetal death. Viral infections are often asymptomatic in adults but can be devastating to the fetus. For example, transplacental transmission of parvovirus B19 can result in fetal anaemia, hydrops and fetal death. Parasitic infections such as malaria and toxoplasmosis are also associated with fetal death. Typically infections are classed as a non recurring cause of fetal death.
Many definitions exist for intrauterine fetal death (IUFD); older definitions use a gestational age of 28 weeks, and the WHO classification includes a birthweight of greater than 500 g. The legal definition which is used by the Confidential Enquiry into Maternal and Child Death (CEMACH) is ‘a child that has issued forth from its mother after the 24th week of pregnancy and which did not at any time after being completely expelled from its mother breathe or show any other signs of life’ [Section 41 of the Births and Deaths Registration Act (1953), as amended by the Stillbirth Definition Act (1992)]. CEMACH reported the incidence of IUFD in England and Wales to be 5.3 per 1000 births in 2006. Mortality in singleton pregnancies has declined from 51.5 per 10 000 births in 1982–1990 to 42.0 in 1991–2000 (RR 0.82, 95% CI 0.76–0.87). During these periods there was a greater decline in mortalities from multiple pregnancies, from 197.9 to 128.0 per 10 000 (RR 0.65, 95% CI 0.51–0.83). In singletons, the largest reductions occurred in intrapartum-related deaths and deaths due to congenital anomalies, antepartum haemorrhage and preeclampsia. There was little change in the rate of unexplained antepartum death occurring at term (RR 0.97, 95% CI 0.84–1.11) or preterm (RR 0.94, 95% CI 0.82–1.07); these account for about half of all late fetal deaths.
Maternal diabetes Prior to the introduction of insulin, the life-expectancy of a diabetic was short; women who reached childbearing age were faced with infertility, recurrent miscarriages, congenital malformations and a stillbirth rate of almost 100%. The introduction of insulin has increased life-expectancy. However, despite insulin treatment and apparent good glycaemic control, a diabetic pregnancy is still associated with increased risks to the fetus and newborn compared to the non-diabetic pregnancy. Spontaneous miscarriages may be as high as 17%; congenital malformation rates are 4−10 times greater than in the non-diabetic population; stillbirth and perinatal mortality rates are five times greater; neonatal and infant mortality rates are 15 and 3 times greater, respectively. Gestational diabetes is associated with an increased risk of fetal death. However, maternal glucose metabolism returns to normal almost as soon as the fetus dies. Blood sugar estimation is generally unhelpful. Also, as the derangement is generally
Farah Siddiqui MB ChB DM MRCOG is a Sub Specialty specialist Registrar at the Fetal and Maternal Medicine, Nottingham NHS trust, City campus, Nottingham, UK. Lucy Kean BM BCh DM FRCOG is a Consultant at the Fetal and Maternal Medicine, Nottingham NHS trust, City campus, Nottingham, UK.
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Review
not known; however, risk factors include smoking, cocaine use, trauma, pre-eclampsia, hypertension, thrombophilia and prolonged rupture of membranes.
mild, HbA1c measurements are usually normal. Women with unexplained stillbirth have a four-fold increase in glucose abnormalities in subsequent pregnancies. Therefore, if this diagnosis is suspected, formal glucose testing should be undertaken in the next pregnancy.
Thrombophilias Thrombophilias associated with placental abruption include factor V Leiden mutations, prothrombin gene mutations, hyperhomocysteinaemia, activated protein C resistance, antithrombin III deficiency and anticardiolipin antibodies. These thrombophilias are also associated with intrauterine growth restriction and pre-eclampsia. Antiphospholipid syndrome can lead to IUFD. There is evidence that low-dose aspirin and low-molecular-weight heparin improve pregnancy outcome amongst those who present with recurrent miscarriage. Women with unexplained stillbirth are also more likely to be heterozygous for factor V Leiden mutation, and to be protein S or C deficient. Interestingly, these fetuses may not be growth restricted, although there may be placental features that point to an underlying thrombophilia.
Maternal age The effect of maternal age on perinatal deaths is described by a U-shaped curve with the highest death rates in very young and older mothers. Mothers younger than 20 and those older than 40 have the highest rates of stillbirth (5.6 and 8.1 per 1000 total births, respectively). The cumulative risk of IUFD at 38 weeks of gestation in an uncomplicated patient aged 40 or over is similar to the risk of IUFD at 41 weeks in an uncomplicated patient younger than age 35. These data raise the suggestion that routine antenatal testing beginning at maternal age 40 and at 38 weeks’ gestation should be considered. Maternal body mass index The CEMACH report of 2006 showed that among the women who had a stillbirth and a recorded body mass index (BMI), 26% (761/2924) were obese (BMI> 30). Other studies have demonstrated that nulliparous women with a BMI greater than 30 have a four-fold increase in the risk of IUFD compared with women with a BMI between 20 and 25. This may reflect a higher incidence of hypertensive disease and abnormal glycaemic control in these women.
Obstetric cholestasis The development of intense pruritis with no rash after 24 weeks’ gestation in association with abnormal liver function tests which improve after delivery suggests obstetric cholestasis. The condition is poorly understood although it is associated with a perinatal mortality rate (PMNR) which is improving with active management; from 13.4 in 1984 to 8.4 in 2002. The cause of the fetal death is thought to be anoxia, possibly related to the placental passage of bile salts. Fetal assessments with umbilical artery Doppler and cardiotocography (CTG) are not predictive of fetal death.
Cord complications A nuchal cord is found in 23% of all deliveries, both live and stillborn infants. Multiple nuchal loops are found in 3.7% of stillborns. A pathological examination is important to determine whether the finding is a postmortem event, as the demised fetus can become entangled in the cord during delivery. The incidence of true umbilical knots is 1% and is associated with a mortality rate of 2.7%. Again, the mere presence of knot does not predict fetal death; if the knot is loose, fetal circulation can be maintained. Decreased Wharton’s jelly in certain areas of the cord, most notably the fetal and placental insertions, can result in occlusion of fetal blood flow if the vessels are twisted sufficiently. It is vital not to attribute fetal death to a knot or nuchal cord without postmortem confirmation as this can deny parents knowledge of the real cause of death.
Diagnosis Women often present with a history of reduced fetal movements. The absence of a fetal heart beat on auscultation should always be confirmed by an ultrasound scan by experienced personnel, which can be challenging, especially if the woman presents in labour. On ultrasound examination, a four chamber view of the fetal heart should be obtained and watched for 1 minute for cardiac pulsations. Colour flow mapping can be useful in obese women. At the time of the ultrasound scan, the presence of skin oedema, hydrops, overlapping of the skull bones (Spalding sign) and the amount of liquor is useful in determining the timing of death; the femur length is useful for estimation of the gestation.
Placental complications If the umbilical cord inserts into the placenta abnormally, this can be associated with fetal death. Marginal insertions are present in 5–7% of pregnancies and can lead to fetal death if these vessels rupture or are compressed. Velamentous insertions, where the cord inserts into the external membranes of the placenta, are more common in monochorionic twins, but also occur in 1% of singleton pregnancies. The cord vessels in this case are not surrounded by Wharton’s jelly and thus are prone to torsion, rupture (vasa previa) and inflammation if they cross the cervix. Placental abruption, the premature separation of the placenta from the uterus, has an incidence of 1% and leads to fetal death in 0.12%. Symptoms may include bleeding, abdominal pain or reduced fetal movements. The cause of the abruption is often
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Management Prevention of Rhesus (D) isoimmunization Changes in the uteroplacental blood flow dynamics rapidly result in maternal transfusion of fetal blood; thus, Rhesus D-negative women should be administered anti-D; a Kleihauer test will confirm whether a further dosage is required. Providing choice and establishing safety of the mother Patient safety should be a prime concern: • Ensure the maternal blood pressure is not raised and there is no proteinuria, in order to exclude significant pre-eclampsia;
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can occur, and management must be safe. Common choices for induction are: • prostaglandin E2 preparations/oxytocin; • mifepristone and misoprostol. The standard prostaglandin E2 protocols have a good safety record in relation to uterine rupture. However, mifepristone and misoprostol have been used to good effect with low complication rates. The advantage of this second protocol is that the induction to delivery time is shorter (median: 8.5 h). In order for the process to work efficiently, mifepristone needs to be given 24–48 h before starting misoprostol. Although this time can be spent at home, many women do not wish to delay starting, and misoprostol alone or prostaglandin E2 may be used, accepting a longer induction to delivery interval in these women. Extra-amniotic saline has been shown to be reasonably effective as an alternative to the above methods. Other points to bear in mind during delivery are: • Hyperstimulation is particularly dangerous in women with a scar on the uterus; • Membranes should be left intact for as long as possible, as ascending infection can rapidly occur; • Postpartum haemorrhage is common, especially with preeclampsia, abruption, prolonged fetal death or infection; • Prolonged chorioamnionitis and repeated small abruptions predispose to retained placenta and occasionally placenta accrete; • There should be a low threshold for antibiotic prophylaxis.
• Exclude the possibility of an abruption which is usually possible from the history and examination; • When it is thought that the baby died some time prior to presentation (especially over a month), check a clotting screen to exclude the development of disseminating intravascular coagulopathy (DIC). Once the diagnosis has been confirmed, the woman should be informed clearly of the fetal death and condolences given. The woman should be encouraged to notify a friend or relative for support and given the time to digest the information. If her partner is present, allowing the couple time to console each other is important. Once ready, the options for delivery should be discussed. Overall, 80–90% of patients enter spontaneous labour within 2 weeks of fetal death. However, if labour is delayed the risk of developing DIC increases. How to deliver After 13 weeks’ gestation, the general advice is to aim for a vaginal delivery, although risk factors in the woman’s medical and obstetric history should be explored. A common request from bereaving mothers is for a surgical management either with a dilatation and evacuation or caesarean section. Both these methods are associated with significant maternal morbidity and increased risk of developing DIC. Recent studies suggest that vaginal delivery is associated with increased acceptance and a quicker recovery in grief reaction times. However, 10% of term vaginal deliveries are complicated by perineal, vaginal or cervical lacerations necessitating surgical repair. Third- and fourthdegree lacerations are commoner when the fetus weighs over 4 kg, but can be reduced by good management in labour, keeping the need for assisted delivery to a minimum. These pregnancies can also be complicated by severe shoulder dystocia. It is important to ensure a senior practitioner is present for delivery and, in a few exceptional circumstances where labour does not progress, abdominal delivery may be warranted. Circumstances where a caesarean section is appropriate include: • Where there is a high risk of uterine rupture, or suspected scar dehiscence or failed induction; • In cases of major placenta previa; • In women who cannot bear the concept of a vaginal delivery. Abdominal delivery is associated with a 50% risk of endomyometritis.
Investigations The investigations listed in Table 1 should be considered, but each woman must be individually assessed as not all investigations will be relevant to her. Postmortem The CEMACH reports a decline in the uptake of autopsies, with a postmortem being performed in only 38% of perinatal deaths in England and Wales, although there is marked regional variation. A recent report suggests that a lack of perinatal pathologists is the main reason that medical teams do not seek consent for postmortem. Although seeking consent for postmortem is perceived as difficult when the couple has just lost a child, valuable information may be obtained which would help in the planning of future pregnancies. A study of 400 stillborn fetuses and infants in Wales reported that, even when a likely prenatal diagnosis was reached, the autopsy significantly changed the cause of death in 12% and found new information in 26% of cases. The recent enquiry into perinatal pathology, including organ retention, has had an impact on public confidence. This has increased the need for practitioners to remain regularly updated on postmortem consent issues and for access to bereavement or pathology liaison midwives.
Delivery Most units have a dedicated area on the labour ward where these women are managed, with access to the labour ward if emergency treatment is required, adequate analgesia and a place where their partner and relatives can stay. The women should be offered the choice as to whether to delay treatment or to start it immediately. Analgesia should be discussed and encouraged; analgesics such as diamorphine and oromorphine are more effective than codeine and pethidine. If the clotting is normal, the woman may wish for an epidural. If an epidural is contraindicated, patientcontrolled analgesia should be considered.
Postmortem procedure It is important to explain to the couple that the postmortem will be performed by a dedicated perinatal pathologist, and that this may therefore require the baby being moved to another hospital. The baby will be returned once the postmortem is complete. The baby is treated with dignity and respect at all times. Incisions
Induction of labour When planning induction of labour, it is important to remember that complications such as uterine rupture and shoulder dystocia
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Where there is a suspected central nervous system (CNS) abnormality, the brain should be fixed before examination. This can take many days, especially in a large, term fetus. If this is an important aspect of the postmortem examination, parents have three options: • To forgo this extra information; • To delay funeral arrangements until this process is complete; or • To allow the pathologist to retain the fetal brain and to proeed with funeral arrangements without the brain being returned.
Investigations to consider in the event of fetal death Investigation
To detect
Kleihauer Full blood count with platelets
Fetal-maternal haemorrhage Need baseline in case of bleeding; abnormalities point to pre-eclampsia, disseminated intravascular coagulation screen Isoimmunization
Blood group, antibody screen and Coombs’ test Antinuclear antibody Anticardiolipin antibodies (IgG, IgM), lupus anticoagulant screen, factor V Leiden, antithrombin III, factor C, factor S HbA1C Creatinine Liver function tests, uric acid Bile acids VDRL, parvovirus antibody, CMV, IgM and IgG High vaginal swab
Postmortem examination of fetus and placenta including samples for cytogenetics. Prior written consent required
Human Tissues Act (2004) In the past fetuses of less than 28 weeks gestation were not recognizable in law and were often disposed of by burial or incineration, even after 28 week when the registration of the stillbirth was mandatory, without the involvement of the parents. Since the Human Tissues act 2004, the potential of the fetus for human life was recognized and any products of conceptus are treated with respect and the parent wishes for cremation or burial are respected. Stringent controls are now in place for the retention of fetal tissue. The Human Fertilization and Embryology Act (1990) reduced the age of viability to 24 weeks; however, it was not until 1992 that the definition was changed in the Stillbirth Act. Autopsies were still being performed with the retention of organs as part of the routine examination of the fetus, and it was only in the late 1990s that the Bristol and Liverpool enquiries highlighted the need for the mother’s informed consent for this practice. The Human Tissues Act (2004) recognized the fetus as the potential for human life. Stringent controls are now in place for the retention of fetal tissue.
Lupus, other autoimmune disorders Thrombophilia
Diabetes Renal disease Pre-eclampsia Obstetric cholestasis Transplacental transmission of viral or parasitic infection Transcervical ascending infection (especially Group B streptococcus) Structural or syndromic fetal abnormalities and detects inflammatory of infective causes
What can be offered to parents who do not wish to have a postmortem? In cases where a genetic syndrome is suspected and the parents decline a postmortem, they may accept fetal imaging with MRI or skeletal X-rays; in some cases, a geneticist may be able to examine the fetus externally for dysmorphic features. Couples usually consent to histological examinations of the placenta which often offers valuable information on inflammatory or infective causes. Placental abnormalities such as a circumvallate placenta or infarcts involving more than 20% of the placental surface may cause or be associated with fetal demise. Placental tissue can also be sent for karyotyping and cytogenetics.
Table 1
are needed to the scalp, abdomen and chest but not to the face and limbs; the organs are examined and then returned to the body and the incision closed. Closure may not be possible in very macerated fetuses; however, in these circumstances the baby is wrapped and once the baby is dressed, the appearance should be the same as before the postmortem. In cases of known fetal cardiac, renal or brain abnormality, the parents may wish to limit the postmortem to a specific organ; however, less information is obtained in this way as abnormalities in one organ may be linked to others (in the case of VACTERAL or VATER). The parents’ wishes must be respected and their consent should clearly document which organs or systems the pathologist should examine.
After delivery During the labour the couple should be asked whether they would like to see the baby. Studies have shown that seeing and holding the baby facilitates an adequate grief response, with earlier acceptance. It is well established that 90% of couples accept an offer to see and hold the child and that no mother regrets the decision; many often speak fondly of the experience. However, the couple’s wishes should be respected and if they choose not to see the baby, the option of taking photographs and keeping them in the medical records if the couple wishes to view them at a later date should be suggested. The maternity department often provides a memento box where hand and foot prints of the baby and a lock of the baby’s hair can be collected and presented.
What tissues are kept? All organs are returned to the body; although it may not be possible to return the organ to its original position. The organs are weighed, photographed and examined macroscopically; small samples are then taken to make up tissue slides for a microscopic examination. These tissue slides then make up part of the medical record so that they can be re-examined if the diagnosis is unclear. At early gestations small tissue samples may in fact comprise a whole organ. This must be clearly stated in the consent form. The parents may wish for the slides to be cremated or buried with the baby; once again this should be specified in the consent.
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The parents often wish to know the sex of the baby for identity and naming. Sexing the baby is difficult in earlier gestations and in the presence of dysmorphology. Wrong assignment of fetal sex can be very distressing. It is often better to await the results of the postmortem or karyotype. Most couples appreciate the option of having the baby blessed, anointed or baptized. The couple should be given information regarding the options for cremation or burial; most hospitals arrange a cremation, with the relatives being invited to a committal service. Some couples may wish to arrange the funeral themselves and the bereavement team can aid the couple in planning their own service. Bereavement teams are aware of differing cultural requirements and provide an important liaison between the pathologist and parents. Emotional support can be more easily accepted if it includes help with practical issues such as registration and funeral arrangements.
Suppression of lactation The physiological reaction to the postpartum period can be distressing, especially with lactation as the body is preparing to feed a baby, but there is no baby to care for. Often all that is required is a supportive bra and non-steroidal analgesia. Carbergoline (a long-acting dopamine agonist) is effective; however, this should not be used in women with pre-eclampsia or those with a strong personal or family history of thromboembolic disease. Contraception There is a possibility of the mother conceiving prior to the next period, which may delay the grieving process. Parents should be aware of this but a detailed discussion of options will need to wait until the appropriate time. Going home The couple will want early discharge, which is reasonable once the woman is medically fit. It is important to ensure that the bleeding is not heavy, the uterus is well contracted and the placenta and membranes are complete. The woman should be haemodynamically stable and not in need of intravenous antibiotics. It is less disruptive for the woman to stay in hospital an extra day rather than be readmitted with fulminating pre-eclampsia or sepsis. Both the midwife and GP should be alerted of the loss. Many midwives do not work from GP surgeries and it cannot be assumed that one will automatically inform the other. Often the GP or the community midwife arranges a home visit. All antenatal clinic and scan appointments should be cancelled. The woman should be informed of who to call if she is having problems. Contact numbers of support groups such as SANDS (Stillbirths and Neonatal Deaths) are a useful resource, offering contact or web-based forums with other parents who have faced similar experiences.
Legal issues The Royal College of Obstetricians and Gynaecologists and the Office for National Statistics highlighted the need for a statement on the interpretation and implementation of the registration law when it is known that one or more fetuses has died in utero, either naturally or through a medical intervention such as selective reduction. It can be said that the pregnancy of that fetus (or fetuses) has ended prior to 24 weeks gestation. It may be that there are other continuing pregnancies in the same womb but the pregnancy of the dead fetus (or fetuses) is no longer continuing. This means that in a number of situations where it is known that one or more fetuses has died prior to the 24th week of pregnancy (e.g. where there has been a delay between a diagnosed intrauterine death and delivery, vanishing twins or selective or multifetal pregnancy reduction in multiple pregnancies), those fetuses known to have died prior to the 24th week of pregnancy would not be registered as stillbirths. In all of these cases, there would have to be evidence that it was known that the fetus (or fetuses) had died prior to the 24th week of pregnancy and this evidence, usually based on ultrasound imaging, would need to be clearly detailed in the mother’s notes in case any queries arose at a later date. The law does not recognize fetal deaths before 24 weeks. The lack of legal recognition means that parents will not have a death certificate for these early fetal losses. It does not mean that they cannot arrange a funeral or cremation if they wish. It is necessary for parents to register the birth of any baby born after 24 weeks’ gestation. This is often a traumatic time for parents and the bereavement team can be helpful in assisting with this. It is extremely difficult to have death certificates changed, and parents can be deeply upset to find that a baby has a registered cause of death that is not accurate. When writing the stillbirth certificate: • Do not use abbreviations; • Do not guess the cause of death; • Sign and print your name clearly; • Write your GMC registered qualifications clearly; and • Write a contact or bleep number under your name. The coroner does not have any legal jurisdiction in cases of stillbirth (even intrapartum), and cases should not need to become the remit of the coroner.
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Bereavement care Loss of a child during pregnancy is generally accepted as a seriously distressing life event, leading to a grief reaction in the majority of mothers for 6–9 months, although this may be unrecognized for a lifetime. As traditional support systems diminish, parents may now look towards healthcare professionals for guidance and emotional support following the death of their baby. The grief process following a stillbirth involves prospective rather than retrospective grieving. It also involves the difficulty of recognizing a life and often simultaneously mourning a death. Parental grief is often secret and unrecognized by both relatives and healthcare professionals. Not all bereaved parents will need or accept professional counselling. However, bereaved parents should be given the choice whether or not to take up the offer of counselling.
Follow-up The following points should be noted: • The venue should be as neutral as possible and a home visit may be appropriate is some cases. • The baby’s name and sex should be ascertained before the consultation if possible.
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• There should be enough time for the parents to talk about the experience and their concerns, and for any questions to be answered honestly. • The results of the postmortem examination should be discussed and the couple offered a copy of the report. • When a cause is found on postmortem, the findings should be clearly discussed and a referral to clinical genetics considered. • If an investigation is positive, discuss management in future pregnancies and recurrence risks. • If no cause is found, a clear plan for the next pregnancy should be laid out. • Specific behaviours such as folic acid supplementation, stopping smoking and adequate blood glucose control in diabetics should be considered. • The patient’s grief response should be assessed to diagnose possible depression. • Clear documentation, including a letter to GP should be prepared. It may be helpful to write to the parents to summarize findings and management in future pregnancies, in case they chose to book elsewhere in future pregnancies. • The couple should be offered a further appointment to discuss certain aspects, or a preconceptual visit.
of investigation and labour ward teams require a clear understanding of its legal aspects. Sympathetic and supportive care of parents should respect parental wishes and allow choice wherever possible. However, maternal safety should also be a central aspect of care. ◆
Further reading Bahtiyar M, Funai E, Norwitz E, Buhimschi C, Rosenberg V. Advanced maternal age is an independent predictor of intrauterine fetal death at term. Am J Obstet Gynecol 2006; 195: 209. Bristol Royal Infirmary Inquiry. Bristol heart inquiry interim report. Available from: www.bristol-inquiry.org.uk/interim_report/index.htm, May, 2000. British Medical Association. Interim BMA guidelines on retention of human tissue at post mortem examination for the purposes of medical education and research. London: BMA, 2000. Carey JC, Rayburn WF. Nuchal cord encirclements and risk of stillbirths. Int J Gynaecol Obstet 2000; 69: 173–174. Cartlidge PH, Dawson A, Stewart J, Vujanic G. Value and quality of perinatal and infant post mortem examination: cohort analysis of 400 consecutive deaths. BMJ 1995; 310: 155–158. Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI). Post mortem protocol for sudden infant deaths, London: CESDI, 1993. Dorman J, McCarthy BJ, Norris JM, et al. Temporal trends in spontaneous abortion associated with type 1 diabetes. Obstet Gynaecol Surv 1999; 54: 616–618. Human Fertilisation and Embryology Authority. Code of practice. London: HFEA, 1991. Kohner N. A dignified ending: recommendations for good practice in the disposal of the bodies and remains of babies born before the legal age of viability. London: Stillbirth and Neonatal Death Society (SANDS), 1992. Royal College of Obstetricians and Gynecologists. Registration of stillbirths and certification for pregnancy loss before 24 weeks gestation. Good practice series no 4. London: RCOG, 2004. Smith NM. Broadsheet #56: mechanisms of fetal loss. Pathology 2000; 32: 107–115. Stillbirth and Neonatal Death Society. Pregnancy loss and the death of a baby: guidelines for professionals, London: SANDS, 1995. The Royal Liverpool Children’s Inquiry. The Royal Liverpool Children’s inquiry report. Available from: www.rlcinquiry.org.uk/download/index. htm, January, 2001.
Management of the next pregnancy It is very important for parents that future professionals adhere to the plans that were formulated after the loss of the baby. There may be minor differences of opinion in future management, but it is better to put these aside in the interests of maintaining the faith of the parents in their care when at all possible. When the plan needs to be changed (such as may occur when new information comes to light), it is important to explain clearly why the changes need to be made and how this will improve the prospects of a healthy pregnancy. After the birth of the next child, parents may require much reassurance that the baby is healthy. An examination by a senior paediatrician can help.
Conclusion Intrauterine fetal death is sadly a common occurrence and one which all labour ward personnel should be trained to manage. Recent advances have improved the likelihood of identifying a cause. The key to this is a logical and methodical approach to investigation. Postmortem examination remains a critical aspect
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Intrauterine fetal death
Aetiology Chromosomal abnormalities These account for 30−60% of early fetal demise. The incidence increases with maternal age. Approximately 7% of fetuses with chromosomal abnormalities will survive to term. The commonest chromosomal abnormality is autosomal trisomy. Genetic anomalies affect the development of the fetus and the placenta. One recent study found an increase in apoptosis and a decrease in cell proliferation in chromosomally abnormal placentae compared to chromosomally normal placentae, implying that genetic abnormalities can lead to changes that affect trophoblast development and proliferation. Karyotype analysis often fails from the placenta, fetal blood (via an intracardiac sample) and fetal skin post delivery. Where there are specific concerns, the genetics laboratory may be able to help with specific diagnoses by utilizing other techniques such as fluorescent in-situ hybridization. Fetal chondrocytes have the most prolonged cell viability, and a small sample from the iliac crest can sometimes provide a diagnosis. Performing a fetal karyotype by transabdominal chorionic villus sampling before delivery avoids the problems associated with delay and infection of the placenta during delivery, although this is often not acceptable to the woman.
Farah Siddiqui Lucy Kean
Abstract Sadly, the death of a fetus may occur at any stage of a pregnancy, including during the labour process. A pregnancy loss will be devastating for the expectant parents. Obstetricians should be familiar with the management of intrauterine fetal death as prompt and appropriate counselling will aid the couple’s grief process. Understandably, couples wish to know the cause and chances of recurrence; thus, the full investigation of possible aetiological factors using a pragmatic approach will help in the postnatal counselling and management of future pregnancies. This review also explores the legal and ethical aspects of postmortem consent.
Keywords bereavement; intrauterine fetal death; stillbirth; postmortem; viral infections are often
Fetal structural anomalies These account for 35% of fetal deaths, and commonly include cardiac anomalies and renal abnormalities.
Introduction
Infection This is a significant risk for the fetus. The infection is often an ascending bacterial infection, such as Escherichia coli or Group B streptococcus, which triggers a cytokine cascade leading to fetal damage, preterm labour and intrauterine fetal death. Viral infections are often asymptomatic in adults but can be devastating to the fetus. For example, transplacental transmission of parvovirus B19 can result in fetal anaemia, hydrops and fetal death. Parasitic infections such as malaria and toxoplasmosis are also associated with fetal death. Typically infections are classed as a non recurring cause of fetal death.
Many definitions exist for intrauterine fetal death (IUFD); older definitions use a gestational age of 28 weeks, and the WHO classification includes a birthweight of greater than 500 g. The legal definition which is used by the Confidential Enquiry into Maternal and Child Death (CEMACH) is ‘a child that has issued forth from its mother after the 24th week of pregnancy and which did not at any time after being completely expelled from its mother breathe or show any other signs of life’ [Section 41 of the Births and Deaths Registration Act (1953), as amended by the Stillbirth Definition Act (1992)]. CEMACH reported the incidence of IUFD in England and Wales to be 5.3 per 1000 births in 2006. Mortality in singleton pregnancies has declined from 51.5 per 10 000 births in 1982–1990 to 42.0 in 1991–2000 (RR 0.82, 95% CI 0.76–0.87). During these periods there was a greater decline in mortalities from multiple pregnancies, from 197.9 to 128.0 per 10 000 (RR 0.65, 95% CI 0.51–0.83). In singletons, the largest reductions occurred in intrapartum-related deaths and deaths due to congenital anomalies, antepartum haemorrhage and preeclampsia. There was little change in the rate of unexplained antepartum death occurring at term (RR 0.97, 95% CI 0.84–1.11) or preterm (RR 0.94, 95% CI 0.82–1.07); these account for about half of all late fetal deaths.
Maternal diabetes Prior to the introduction of insulin, the life-expectancy of a diabetic was short; women who reached childbearing age were faced with infertility, recurrent miscarriages, congenital malformations and a stillbirth rate of almost 100%. The introduction of insulin has increased life-expectancy. However, despite insulin treatment and apparent good glycaemic control, a diabetic pregnancy is still associated with increased risks to the fetus and newborn compared to the non-diabetic pregnancy. Spontaneous miscarriages may be as high as 17%; congenital malformation rates are 4−10 times greater than in the non-diabetic population; stillbirth and perinatal mortality rates are five times greater; neonatal and infant mortality rates are 15 and 3 times greater, respectively. Gestational diabetes is associated with an increased risk of fetal death. However, maternal glucose metabolism returns to normal almost as soon as the fetus dies. Blood sugar estimation is generally unhelpful. Also, as the derangement is generally
Farah Siddiqui MB ChB DM MRCOG is a Sub Specialty specialist Registrar at the Fetal and Maternal Medicine, Nottingham NHS trust, City campus, Nottingham, UK. Lucy Kean BM BCh DM FRCOG is a Consultant at the Fetal and Maternal Medicine, Nottingham NHS trust, City campus, Nottingham, UK.
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not known; however, risk factors include smoking, cocaine use, trauma, pre-eclampsia, hypertension, thrombophilia and prolonged rupture of membranes.
mild, HbA1c measurements are usually normal. Women with unexplained stillbirth have a four-fold increase in glucose abnormalities in subsequent pregnancies. Therefore, if this diagnosis is suspected, formal glucose testing should be undertaken in the next pregnancy.
Thrombophilias Thrombophilias associated with placental abruption include factor V Leiden mutations, prothrombin gene mutations, hyperhomocysteinaemia, activated protein C resistance, antithrombin III deficiency and anticardiolipin antibodies. These thrombophilias are also associated with intrauterine growth restriction and pre-eclampsia. Antiphospholipid syndrome can lead to IUFD. There is evidence that low-dose aspirin and low-molecular-weight heparin improve pregnancy outcome amongst those who present with recurrent miscarriage. Women with unexplained stillbirth are also more likely to be heterozygous for factor V Leiden mutation, and to be protein S or C deficient. Interestingly, these fetuses may not be growth restricted, although there may be placental features that point to an underlying thrombophilia.
Maternal age The effect of maternal age on perinatal deaths is described by a U-shaped curve with the highest death rates in very young and older mothers. Mothers younger than 20 and those older than 40 have the highest rates of stillbirth (5.6 and 8.1 per 1000 total births, respectively). The cumulative risk of IUFD at 38 weeks of gestation in an uncomplicated patient aged 40 or over is similar to the risk of IUFD at 41 weeks in an uncomplicated patient younger than age 35. These data raise the suggestion that routine antenatal testing beginning at maternal age 40 and at 38 weeks’ gestation should be considered. Maternal body mass index The CEMACH report of 2006 showed that among the women who had a stillbirth and a recorded body mass index (BMI), 26% (761/2924) were obese (BMI> 30). Other studies have demonstrated that nulliparous women with a BMI greater than 30 have a four-fold increase in the risk of IUFD compared with women with a BMI between 20 and 25. This may reflect a higher incidence of hypertensive disease and abnormal glycaemic control in these women.
Obstetric cholestasis The development of intense pruritis with no rash after 24 weeks’ gestation in association with abnormal liver function tests which improve after delivery suggests obstetric cholestasis. The condition is poorly understood although it is associated with a perinatal mortality rate (PMNR) which is improving with active management; from 13.4 in 1984 to 8.4 in 2002. The cause of the fetal death is thought to be anoxia, possibly related to the placental passage of bile salts. Fetal assessments with umbilical artery Doppler and cardiotocography (CTG) are not predictive of fetal death.
Cord complications A nuchal cord is found in 23% of all deliveries, both live and stillborn infants. Multiple nuchal loops are found in 3.7% of stillborns. A pathological examination is important to determine whether the finding is a postmortem event, as the demised fetus can become entangled in the cord during delivery. The incidence of true umbilical knots is 1% and is associated with a mortality rate of 2.7%. Again, the mere presence of knot does not predict fetal death; if the knot is loose, fetal circulation can be maintained. Decreased Wharton’s jelly in certain areas of the cord, most notably the fetal and placental insertions, can result in occlusion of fetal blood flow if the vessels are twisted sufficiently. It is vital not to attribute fetal death to a knot or nuchal cord without postmortem confirmation as this can deny parents knowledge of the real cause of death.
Diagnosis Women often present with a history of reduced fetal movements. The absence of a fetal heart beat on auscultation should always be confirmed by an ultrasound scan by experienced personnel, which can be challenging, especially if the woman presents in labour. On ultrasound examination, a four chamber view of the fetal heart should be obtained and watched for 1 minute for cardiac pulsations. Colour flow mapping can be useful in obese women. At the time of the ultrasound scan, the presence of skin oedema, hydrops, overlapping of the skull bones (Spalding sign) and the amount of liquor is useful in determining the timing of death; the femur length is useful for estimation of the gestation.
Placental complications If the umbilical cord inserts into the placenta abnormally, this can be associated with fetal death. Marginal insertions are present in 5–7% of pregnancies and can lead to fetal death if these vessels rupture or are compressed. Velamentous insertions, where the cord inserts into the external membranes of the placenta, are more common in monochorionic twins, but also occur in 1% of singleton pregnancies. The cord vessels in this case are not surrounded by Wharton’s jelly and thus are prone to torsion, rupture (vasa previa) and inflammation if they cross the cervix. Placental abruption, the premature separation of the placenta from the uterus, has an incidence of 1% and leads to fetal death in 0.12%. Symptoms may include bleeding, abdominal pain or reduced fetal movements. The cause of the abruption is often
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Management Prevention of Rhesus (D) isoimmunization Changes in the uteroplacental blood flow dynamics rapidly result in maternal transfusion of fetal blood; thus, Rhesus D-negative women should be administered anti-D; a Kleihauer test will confirm whether a further dosage is required. Providing choice and establishing safety of the mother Patient safety should be a prime concern: • Ensure the maternal blood pressure is not raised and there is no proteinuria, in order to exclude significant pre-eclampsia;
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can occur, and management must be safe. Common choices for induction are: • prostaglandin E2 preparations/oxytocin; • mifepristone and misoprostol. The standard prostaglandin E2 protocols have a good safety record in relation to uterine rupture. However, mifepristone and misoprostol have been used to good effect with low complication rates. The advantage of this second protocol is that the induction to delivery time is shorter (median: 8.5 h). In order for the process to work efficiently, mifepristone needs to be given 24–48 h before starting misoprostol. Although this time can be spent at home, many women do not wish to delay starting, and misoprostol alone or prostaglandin E2 may be used, accepting a longer induction to delivery interval in these women. Extra-amniotic saline has been shown to be reasonably effective as an alternative to the above methods. Other points to bear in mind during delivery are: • Hyperstimulation is particularly dangerous in women with a scar on the uterus; • Membranes should be left intact for as long as possible, as ascending infection can rapidly occur; • Postpartum haemorrhage is common, especially with preeclampsia, abruption, prolonged fetal death or infection; • Prolonged chorioamnionitis and repeated small abruptions predispose to retained placenta and occasionally placenta accrete; • There should be a low threshold for antibiotic prophylaxis.
• Exclude the possibility of an abruption which is usually possible from the history and examination; • When it is thought that the baby died some time prior to presentation (especially over a month), check a clotting screen to exclude the development of disseminating intravascular coagulopathy (DIC). Once the diagnosis has been confirmed, the woman should be informed clearly of the fetal death and condolences given. The woman should be encouraged to notify a friend or relative for support and given the time to digest the information. If her partner is present, allowing the couple time to console each other is important. Once ready, the options for delivery should be discussed. Overall, 80–90% of patients enter spontaneous labour within 2 weeks of fetal death. However, if labour is delayed the risk of developing DIC increases. How to deliver After 13 weeks’ gestation, the general advice is to aim for a vaginal delivery, although risk factors in the woman’s medical and obstetric history should be explored. A common request from bereaving mothers is for a surgical management either with a dilatation and evacuation or caesarean section. Both these methods are associated with significant maternal morbidity and increased risk of developing DIC. Recent studies suggest that vaginal delivery is associated with increased acceptance and a quicker recovery in grief reaction times. However, 10% of term vaginal deliveries are complicated by perineal, vaginal or cervical lacerations necessitating surgical repair. Third- and fourthdegree lacerations are commoner when the fetus weighs over 4 kg, but can be reduced by good management in labour, keeping the need for assisted delivery to a minimum. These pregnancies can also be complicated by severe shoulder dystocia. It is important to ensure a senior practitioner is present for delivery and, in a few exceptional circumstances where labour does not progress, abdominal delivery may be warranted. Circumstances where a caesarean section is appropriate include: • Where there is a high risk of uterine rupture, or suspected scar dehiscence or failed induction; • In cases of major placenta previa; • In women who cannot bear the concept of a vaginal delivery. Abdominal delivery is associated with a 50% risk of endomyometritis.
Investigations The investigations listed in Table 1 should be considered, but each woman must be individually assessed as not all investigations will be relevant to her. Postmortem The CEMACH reports a decline in the uptake of autopsies, with a postmortem being performed in only 38% of perinatal deaths in England and Wales, although there is marked regional variation. A recent report suggests that a lack of perinatal pathologists is the main reason that medical teams do not seek consent for postmortem. Although seeking consent for postmortem is perceived as difficult when the couple has just lost a child, valuable information may be obtained which would help in the planning of future pregnancies. A study of 400 stillborn fetuses and infants in Wales reported that, even when a likely prenatal diagnosis was reached, the autopsy significantly changed the cause of death in 12% and found new information in 26% of cases. The recent enquiry into perinatal pathology, including organ retention, has had an impact on public confidence. This has increased the need for practitioners to remain regularly updated on postmortem consent issues and for access to bereavement or pathology liaison midwives.
Delivery Most units have a dedicated area on the labour ward where these women are managed, with access to the labour ward if emergency treatment is required, adequate analgesia and a place where their partner and relatives can stay. The women should be offered the choice as to whether to delay treatment or to start it immediately. Analgesia should be discussed and encouraged; analgesics such as diamorphine and oromorphine are more effective than codeine and pethidine. If the clotting is normal, the woman may wish for an epidural. If an epidural is contraindicated, patientcontrolled analgesia should be considered.
Postmortem procedure It is important to explain to the couple that the postmortem will be performed by a dedicated perinatal pathologist, and that this may therefore require the baby being moved to another hospital. The baby will be returned once the postmortem is complete. The baby is treated with dignity and respect at all times. Incisions
Induction of labour When planning induction of labour, it is important to remember that complications such as uterine rupture and shoulder dystocia
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Where there is a suspected central nervous system (CNS) abnormality, the brain should be fixed before examination. This can take many days, especially in a large, term fetus. If this is an important aspect of the postmortem examination, parents have three options: • To forgo this extra information; • To delay funeral arrangements until this process is complete; or • To allow the pathologist to retain the fetal brain and to proeed with funeral arrangements without the brain being returned.
Investigations to consider in the event of fetal death Investigation
To detect
Kleihauer Full blood count with platelets
Fetal-maternal haemorrhage Need baseline in case of bleeding; abnormalities point to pre-eclampsia, disseminated intravascular coagulation screen Isoimmunization
Blood group, antibody screen and Coombs’ test Antinuclear antibody Anticardiolipin antibodies (IgG, IgM), lupus anticoagulant screen, factor V Leiden, antithrombin III, factor C, factor S HbA1C Creatinine Liver function tests, uric acid Bile acids VDRL, parvovirus antibody, CMV, IgM and IgG High vaginal swab
Postmortem examination of fetus and placenta including samples for cytogenetics. Prior written consent required
Human Tissues Act (2004) In the past fetuses of less than 28 weeks gestation were not recognizable in law and were often disposed of by burial or incineration, even after 28 week when the registration of the stillbirth was mandatory, without the involvement of the parents. Since the Human Tissues act 2004, the potential of the fetus for human life was recognized and any products of conceptus are treated with respect and the parent wishes for cremation or burial are respected. Stringent controls are now in place for the retention of fetal tissue. The Human Fertilization and Embryology Act (1990) reduced the age of viability to 24 weeks; however, it was not until 1992 that the definition was changed in the Stillbirth Act. Autopsies were still being performed with the retention of organs as part of the routine examination of the fetus, and it was only in the late 1990s that the Bristol and Liverpool enquiries highlighted the need for the mother’s informed consent for this practice. The Human Tissues Act (2004) recognized the fetus as the potential for human life. Stringent controls are now in place for the retention of fetal tissue.
Lupus, other autoimmune disorders Thrombophilia
Diabetes Renal disease Pre-eclampsia Obstetric cholestasis Transplacental transmission of viral or parasitic infection Transcervical ascending infection (especially Group B streptococcus) Structural or syndromic fetal abnormalities and detects inflammatory of infective causes
What can be offered to parents who do not wish to have a postmortem? In cases where a genetic syndrome is suspected and the parents decline a postmortem, they may accept fetal imaging with MRI or skeletal X-rays; in some cases, a geneticist may be able to examine the fetus externally for dysmorphic features. Couples usually consent to histological examinations of the placenta which often offers valuable information on inflammatory or infective causes. Placental abnormalities such as a circumvallate placenta or infarcts involving more than 20% of the placental surface may cause or be associated with fetal demise. Placental tissue can also be sent for karyotyping and cytogenetics.
Table 1
are needed to the scalp, abdomen and chest but not to the face and limbs; the organs are examined and then returned to the body and the incision closed. Closure may not be possible in very macerated fetuses; however, in these circumstances the baby is wrapped and once the baby is dressed, the appearance should be the same as before the postmortem. In cases of known fetal cardiac, renal or brain abnormality, the parents may wish to limit the postmortem to a specific organ; however, less information is obtained in this way as abnormalities in one organ may be linked to others (in the case of VACTERAL or VATER). The parents’ wishes must be respected and their consent should clearly document which organs or systems the pathologist should examine.
After delivery During the labour the couple should be asked whether they would like to see the baby. Studies have shown that seeing and holding the baby facilitates an adequate grief response, with earlier acceptance. It is well established that 90% of couples accept an offer to see and hold the child and that no mother regrets the decision; many often speak fondly of the experience. However, the couple’s wishes should be respected and if they choose not to see the baby, the option of taking photographs and keeping them in the medical records if the couple wishes to view them at a later date should be suggested. The maternity department often provides a memento box where hand and foot prints of the baby and a lock of the baby’s hair can be collected and presented.
What tissues are kept? All organs are returned to the body; although it may not be possible to return the organ to its original position. The organs are weighed, photographed and examined macroscopically; small samples are then taken to make up tissue slides for a microscopic examination. These tissue slides then make up part of the medical record so that they can be re-examined if the diagnosis is unclear. At early gestations small tissue samples may in fact comprise a whole organ. This must be clearly stated in the consent form. The parents may wish for the slides to be cremated or buried with the baby; once again this should be specified in the consent.
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The parents often wish to know the sex of the baby for identity and naming. Sexing the baby is difficult in earlier gestations and in the presence of dysmorphology. Wrong assignment of fetal sex can be very distressing. It is often better to await the results of the postmortem or karyotype. Most couples appreciate the option of having the baby blessed, anointed or baptized. The couple should be given information regarding the options for cremation or burial; most hospitals arrange a cremation, with the relatives being invited to a committal service. Some couples may wish to arrange the funeral themselves and the bereavement team can aid the couple in planning their own service. Bereavement teams are aware of differing cultural requirements and provide an important liaison between the pathologist and parents. Emotional support can be more easily accepted if it includes help with practical issues such as registration and funeral arrangements.
Suppression of lactation The physiological reaction to the postpartum period can be distressing, especially with lactation as the body is preparing to feed a baby, but there is no baby to care for. Often all that is required is a supportive bra and non-steroidal analgesia. Carbergoline (a long-acting dopamine agonist) is effective; however, this should not be used in women with pre-eclampsia or those with a strong personal or family history of thromboembolic disease. Contraception There is a possibility of the mother conceiving prior to the next period, which may delay the grieving process. Parents should be aware of this but a detailed discussion of options will need to wait until the appropriate time. Going home The couple will want early discharge, which is reasonable once the woman is medically fit. It is important to ensure that the bleeding is not heavy, the uterus is well contracted and the placenta and membranes are complete. The woman should be haemodynamically stable and not in need of intravenous antibiotics. It is less disruptive for the woman to stay in hospital an extra day rather than be readmitted with fulminating pre-eclampsia or sepsis. Both the midwife and GP should be alerted of the loss. Many midwives do not work from GP surgeries and it cannot be assumed that one will automatically inform the other. Often the GP or the community midwife arranges a home visit. All antenatal clinic and scan appointments should be cancelled. The woman should be informed of who to call if she is having problems. Contact numbers of support groups such as SANDS (Stillbirths and Neonatal Deaths) are a useful resource, offering contact or web-based forums with other parents who have faced similar experiences.
Legal issues The Royal College of Obstetricians and Gynaecologists and the Office for National Statistics highlighted the need for a statement on the interpretation and implementation of the registration law when it is known that one or more fetuses has died in utero, either naturally or through a medical intervention such as selective reduction. It can be said that the pregnancy of that fetus (or fetuses) has ended prior to 24 weeks gestation. It may be that there are other continuing pregnancies in the same womb but the pregnancy of the dead fetus (or fetuses) is no longer continuing. This means that in a number of situations where it is known that one or more fetuses has died prior to the 24th week of pregnancy (e.g. where there has been a delay between a diagnosed intrauterine death and delivery, vanishing twins or selective or multifetal pregnancy reduction in multiple pregnancies), those fetuses known to have died prior to the 24th week of pregnancy would not be registered as stillbirths. In all of these cases, there would have to be evidence that it was known that the fetus (or fetuses) had died prior to the 24th week of pregnancy and this evidence, usually based on ultrasound imaging, would need to be clearly detailed in the mother’s notes in case any queries arose at a later date. The law does not recognize fetal deaths before 24 weeks. The lack of legal recognition means that parents will not have a death certificate for these early fetal losses. It does not mean that they cannot arrange a funeral or cremation if they wish. It is necessary for parents to register the birth of any baby born after 24 weeks’ gestation. This is often a traumatic time for parents and the bereavement team can be helpful in assisting with this. It is extremely difficult to have death certificates changed, and parents can be deeply upset to find that a baby has a registered cause of death that is not accurate. When writing the stillbirth certificate: • Do not use abbreviations; • Do not guess the cause of death; • Sign and print your name clearly; • Write your GMC registered qualifications clearly; and • Write a contact or bleep number under your name. The coroner does not have any legal jurisdiction in cases of stillbirth (even intrapartum), and cases should not need to become the remit of the coroner.
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Bereavement care Loss of a child during pregnancy is generally accepted as a seriously distressing life event, leading to a grief reaction in the majority of mothers for 6–9 months, although this may be unrecognized for a lifetime. As traditional support systems diminish, parents may now look towards healthcare professionals for guidance and emotional support following the death of their baby. The grief process following a stillbirth involves prospective rather than retrospective grieving. It also involves the difficulty of recognizing a life and often simultaneously mourning a death. Parental grief is often secret and unrecognized by both relatives and healthcare professionals. Not all bereaved parents will need or accept professional counselling. However, bereaved parents should be given the choice whether or not to take up the offer of counselling.
Follow-up The following points should be noted: • The venue should be as neutral as possible and a home visit may be appropriate is some cases. • The baby’s name and sex should be ascertained before the consultation if possible.
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• There should be enough time for the parents to talk about the experience and their concerns, and for any questions to be answered honestly. • The results of the postmortem examination should be discussed and the couple offered a copy of the report. • When a cause is found on postmortem, the findings should be clearly discussed and a referral to clinical genetics considered. • If an investigation is positive, discuss management in future pregnancies and recurrence risks. • If no cause is found, a clear plan for the next pregnancy should be laid out. • Specific behaviours such as folic acid supplementation, stopping smoking and adequate blood glucose control in diabetics should be considered. • The patient’s grief response should be assessed to diagnose possible depression. • Clear documentation, including a letter to GP should be prepared. It may be helpful to write to the parents to summarize findings and management in future pregnancies, in case they chose to book elsewhere in future pregnancies. • The couple should be offered a further appointment to discuss certain aspects, or a preconceptual visit.
of investigation and labour ward teams require a clear understanding of its legal aspects. Sympathetic and supportive care of parents should respect parental wishes and allow choice wherever possible. However, maternal safety should also be a central aspect of care. ◆
Further reading Bahtiyar M, Funai E, Norwitz E, Buhimschi C, Rosenberg V. Advanced maternal age is an independent predictor of intrauterine fetal death at term. Am J Obstet Gynecol 2006; 195: 209. Bristol Royal Infirmary Inquiry. Bristol heart inquiry interim report. Available from: www.bristol-inquiry.org.uk/interim_report/index.htm, May, 2000. British Medical Association. Interim BMA guidelines on retention of human tissue at post mortem examination for the purposes of medical education and research. London: BMA, 2000. Carey JC, Rayburn WF. Nuchal cord encirclements and risk of stillbirths. Int J Gynaecol Obstet 2000; 69: 173–174. Cartlidge PH, Dawson A, Stewart J, Vujanic G. Value and quality of perinatal and infant post mortem examination: cohort analysis of 400 consecutive deaths. BMJ 1995; 310: 155–158. Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI). Post mortem protocol for sudden infant deaths, London: CESDI, 1993. Dorman J, McCarthy BJ, Norris JM, et al. Temporal trends in spontaneous abortion associated with type 1 diabetes. Obstet Gynaecol Surv 1999; 54: 616–618. Human Fertilisation and Embryology Authority. Code of practice. London: HFEA, 1991. Kohner N. A dignified ending: recommendations for good practice in the disposal of the bodies and remains of babies born before the legal age of viability. London: Stillbirth and Neonatal Death Society (SANDS), 1992. Royal College of Obstetricians and Gynecologists. Registration of stillbirths and certification for pregnancy loss before 24 weeks gestation. Good practice series no 4. London: RCOG, 2004. Smith NM. Broadsheet #56: mechanisms of fetal loss. Pathology 2000; 32: 107–115. Stillbirth and Neonatal Death Society. Pregnancy loss and the death of a baby: guidelines for professionals, London: SANDS, 1995. The Royal Liverpool Children’s Inquiry. The Royal Liverpool Children’s inquiry report. Available from: www.rlcinquiry.org.uk/download/index. htm, January, 2001.
Management of the next pregnancy It is very important for parents that future professionals adhere to the plans that were formulated after the loss of the baby. There may be minor differences of opinion in future management, but it is better to put these aside in the interests of maintaining the faith of the parents in their care when at all possible. When the plan needs to be changed (such as may occur when new information comes to light), it is important to explain clearly why the changes need to be made and how this will improve the prospects of a healthy pregnancy. After the birth of the next child, parents may require much reassurance that the baby is healthy. An examination by a senior paediatrician can help.
Conclusion Intrauterine fetal death is sadly a common occurrence and one which all labour ward personnel should be trained to manage. Recent advances have improved the likelihood of identifying a cause. The key to this is a logical and methodical approach to investigation. Postmortem examination remains a critical aspect
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