Case 2/17/09 HPI: 23 yo G3P1011 @ 32w1d by LMP 7/8/08 EDD 4/14/09 c/w 19w sono p/w decreased fetal movement and lower abdominal cramps from 3pm yesterday. No LOF/VB. No h/o trauma to abdomen. No HA/visual changes/epigastic pain. Denied tobacco or cocaine use. Admitted to marijuana use during current pregnancy. Pt was given betamethasone on 2/13 and 2/14 for IUGR. Per EU records on 2/14, NST was reactive and BP was 127/60. PNI: Intake BP 102/50 (102-132/ 50-90). Weight gain 158 189 (31 lbs). 1. IUGR dxed on 2/13/09 sono @ 31w. Fetus <3%tile. TORCH and thrombosis w/u negative. Amnio normal XY. PNL: wnl/ unremarkable Sonos: 10/29/08 @ 15w3d. AFI nl. 11/19/08 @ 19w1d no anatomical anomalies. Fetus 20%tile. 2/13/09 @ 31w1d: Fetus <3%tile. SD ratio 4.8. AFI 11.
Case POB: 2004 ectopic R lap salpingotomy. 2005 FT NSVD of 6lb female. No complications. PGyn: no cysts/ fibroids/ STIs/ abnl paps. 12/reg/5. PMH: spina bifida occulta, chronic lower back pain PSH: R lap salpingotomy Meds: PNV, Reglan, Zofran All: NKDA PE: BP 132/40 max 170/102 (Hydralazine 5mg IVP given) HR 74 T36.6 Abd: +fundal tenderness FHT: absent Toco: irritability SVE: 1/80/-2 BSUS: Absent fetal heart activity. Breech presentation. Minimal fluid.
A/P: Labs: 23 yo G3P1011 @ 32w1d with IUGR fetus, now with IUFD and elevated BPs. 1. IUGR, DIC- Unclear etiology, history and PE c/w abruption. Admit to L&D for IOL. 2. Preeclampsia/ HELLP syndrome INR 2.5Cr 1.2SGOT 46-57Hct 28Fibr <120 PT 22.8Uric acid 6.0SGPT 17-21WBC 30.2UA >300prot PTT 30LDH *hemPlt 52-40-17-14
Delivery 2/17/09 6:15am Pt c/o pain. Female infant found to be delivered with approx 1000cc blood clot on bed. No FH/FM. Cord clamped x 2 and cut. Placenta promptly delivered spontaneously- 3v, intact. Fundus firm. Pitocin 20U in D5LR bolused and 1000mg cytotec given. No lacerations. Pt declined seeing fetus. Upon examination of fetus, no gross abnormalities- appeared SGA with small placenta. BP 151/100 151/83. MgSO4 bolus given.
IUFD Stillbirth = fetal death ≥ 20 weeks Incidence in U.S. 0.4-0.9% Etiology: Unexplained 25-60%: depending on classification system IUGR: risk of IUFD in IUGR is 5-7x greater Abruption: occurs in 10-20% of stillbirths (vs. 1%) Infection Chromosomal and genetic abnormalities: single gene defects, confined placental mosaicism, microdeletions with normal amnio Congenital malformations: 15-20% Abd wall defects, NTDs, Potter syndrome, achondrogenesis, amniotic band syndrome Fetomaternal hemorrhage Umbilical cord complications: nuchal cord, knot Hydrops fetalis
IUFD Risk Factors Pregravid obesity Socioeconomic factors Race: black women 2x higher risk, even with adequate PNC AMA Multiple gestation Smoking Maternal medical disorders: DM, HTN, SLE, renal dz, thrombophilia, cardiac dz, thyroid dz, etc. Previous IUFD and SGA
Management Fetal karyotyping: Amniocentesis more likely to yield viable cells prior to delivery Fetal blood/ skin Placental pathology Laboratory work-up: KB, CBC, Chem, Utox, TFTs, thrombophilia, lupus anticoagulant, anticardiolipin Induction vs. spontaneous labor (80-90% w/i 2 wks) Vaginal misoprostol +/- oxytocin Coagulopathy Caused by gradual release of thromboplastin from placenta, usually after 4 weeks
Counseling Giving bad news: straightforward, empathetic, without blame Kubler-Ross stages of grief: denial, anger, bargaining, depression, acceptance Induction after 24 hours vs. within 6 hours associated with increased risk for anxiety? Contact with stillborn Autopsy option Fetal remains Postpartum care: before and after discharge
Counseling Increased risk for depression, anxiety, PTSD, decreased maternal-fetal attachment In one study of 65 mothers of stillbirths, less incidence of adverse outcomes in mothers who did not have contact with the stillborn. Recently bereaved women at higher risk for depression and anxiety in subsequent pregnancy. Increased risk for subsequent stillbirth and complications including preeclampsia, abruption, preterm delivery, low birth weight
References JAMA 2001 Jun 20;285(23):2978. Am J Obstet Gynecol 2005 Dec;193(6):1923. Hughes P, et al. Assessment of guidelines for good practice in psychosocial care of mothers after stillbirth: a cohort study. Lancet 2002 July;360:114-8. Stillbirth as risk factor for depression and anxiety in the subsequent pregnancy: cohort study. BMJ 1999 Jun 26;318(7200):1721. Stillbirth as risk factor for depression and anxiety in the subsequent pregnancy: cohort study. Hughes PM; Turton P; Evans. BMJ 1999 Jun 26;318(7200):1721-4. Dynamed: Fetal death, 2009 Feb