MEDICAL INSIGHTS INTO FETAL DEMISE: DIAGNOSIS AND TREATMENT

Fetal demise, often referred to as stillbirth, represents one of the most devastating outcomes of pregnancy for expectant parents and healthcare providers alike. It is defined as the intrauterine death of a fetus at or after 20 weeks of gestation or weighing 500 grams or more, varying slightly by regional definitions.

Explaining Fetal Demise

Fetal demise signifies the tragic loss of a pregnancy in its later stages, distinguishing it from a miscarriage which typically occurs before 20 weeks of gestation. When fetal demise occurs, the developing fetus ceases to exhibit signs of life, such as a heartbeat or movement, while still within the uterus. The emotional impact on parents is profound, often leading to intense grief, trauma, and psychological distress. While the exact cause remains unidentified in a significant proportion of cases, a thorough investigation is crucial to provide answers to the grieving family and inform future pregnancy planning. Understanding the multifaceted nature of fetal demise requires exploring its clinical presentation, underlying etiologies, and the comprehensive care pathways designed to support affected families.

Symptoms and Common Causes in Each Trimester

The symptoms of fetal demise can vary, but the most common presentations involve a sudden cessation of fetal movement, which is often the first and most alarming sign for parents. Other signs may include vaginal bleeding, abdominal pain, or a sudden decrease in the growth of the uterus. Upon medical examination, the absence of fetal heart tones confirms the diagnosis. The causes of fetal demise are diverse and can be categorized by the trimester in which they occur, alongside broader genetic, social, environmental, and nutritional factors.

(a) First Trimester (Conception to 13 Weeks 6 Days)

While fetal demise is primarily defined after 20 weeks, earlier losses can share similar etiologies.

• Symptoms: Often subtle, potentially mimicking a threatened miscarriage (light bleeding, mild cramping) or being asymptomatic until a routine ultrasound reveals no fetal heartbeat.
• Common Causes:
  • Genetic: Chromosomal abnormalities (e.g., aneuploidies like trisomy 13, 18, 21) are the most frequent cause, accounting for 50-70% of early losses.
  • Maternal Factors: Severe maternal infections (e.g., rubella, cytomegalovirus), endocrine disorders (e.g., uncontrolled diabetes, thyroid dysfunction), uterine anomalies (e.g., septate uterus), and thrombophilias.

(b) Second Trimester (14 Weeks to 27 Weeks 6 Days)

• Symptoms: Decreased or absent fetal movement, vaginal bleeding, abdominal pain, or premature rupture of membranes.
• Common Causes:
  • Genetic: Fetal structural anomalies or genetic syndromes that become more apparent.
  • Placental Factors: Placental abruption (premature separation of the placenta), placental insufficiency, or chorioamnionitis (infection of the amniotic fluid and membranes).
  • Maternal Factors: Preeclampsia, cervical insufficiency, severe maternal infections (e.g., Listeria, syphilis, parvovirus B19), uncontrolled chronic diseases.
  • Environmental/Social: Exposure to illicit drugs, alcohol, or toxins.

(c) Third Trimester (28 Weeks to Term)

• Symptoms: The primary symptom is a complete cessation of fetal movement or a significant reduction in movement. Other signs may include uterine tenderness (abruption) or vaginal bleeding.
• Common Causes:
  • Placental Factors: Placental abruption remains a leading cause, along with umbilical cord accidents (e.g., true knot, compression, prolapse), and severe placental insufficiency leading to fetal growth restriction.
  • Maternal Factors: Severe preeclampsia/eclampsia, uncontrolled gestational diabetes, cholestasis of pregnancy, autoimmune diseases, and chronic maternal conditions.
  • Fetal Factors: Major congenital anomalies, severe fetal growth restriction, and hydrops fetalis.
  • Unknown: A significant percentage (up to 30-50%) of third-trimester fetal deaths remain unexplained even after thorough investigation, highlighting the complexity of these events.

Broader Contributing Factors:

• Genetic Factors: Beyond specific chromosomal issues, inherited thrombophilias (e.g., Factor V Leiden) can increase the risk due to blood clot formation in the placenta.
• Social Factors: Low socioeconomic status, inadequate prenatal care, maternal stress, substance abuse (smoking, alcohol, illicit drugs), and domestic violence can significantly increase risk.
• Environmental Factors: Exposure to environmental toxins (e.g., pesticides, heavy metals, air pollution) and certain medications or illicit drugs during pregnancy.
• Nutritional Factors: Severe maternal malnutrition, anemia, and specific micronutrient deficiencies (e.g., folate, iron) can impair fetal development and placental function.

Diagnosis and Management of Fetal Demise

Diagnosis: The diagnosis of fetal demise typically begins with a patient’s report of absent or significantly decreased fetal movement. Clinical suspicion is then confirmed through:

1. Auscultation: Absence of fetal heart tones using a Doppler.
2. Ultrasound: The definitive diagnostic tool, demonstrating the absence of fetal cardiac activity. This also helps assess fetal anatomy for anomalies, measure fetal biometry, and evaluate placental function and amniotic fluid volume. Following confirmation, a comprehensive investigation is initiated to determine the cause, which may include maternal blood tests (e.g., complete blood count, coagulation profile, TORCH screen, genetic thrombophilia workup, Kleihauer-Betke test for fetomaternal hemorrhage), placental pathology, and fetal autopsy/karyotyping (with parental consent).

Management: Management focuses on facilitating the delivery of the fetus, providing immediate and ongoing emotional support, and investigating the cause.

• Delivery Options: Options are discussed with parents, including expectant management (waiting for spontaneous labor, though often not recommended due to maternal psychological distress and risk of coagulopathy), or induction of labor medically (using prostaglandins like misoprostol, often combined with mifepristone for earlier gestations). Depending on gestational age and provider expertise, dilation and evacuation (D&E) may be an option for earlier second-trimester losses. The choice is a shared decision, respecting parental wishes while prioritizing maternal safety.
• Value-Based Care: In the context of fetal demise, value-based care emphasizes delivering high-quality, patient-centered care that optimizes outcomes while being mindful of resource utilization. This means:
  • Patient-Centered Approach: Prioritizing shared decision-making regarding delivery options, respecting cultural and personal beliefs, and providing individualized emotional and psychological support.
  • Evidence-Based Practice: Utilizing validated diagnostic tools and management protocols to ensure efficacy and safety.
  • Holistic Support: Recognizing that psychological healing is as critical as physical recovery. This includes immediate grief counseling, peer support group referrals, and follow-up psychological care, which, while not directly “medical,” significantly impacts long-term patient well-being and reduces future healthcare utilization related to unresolved trauma.
  • Safety: Ensuring a safe delivery process, minimizing risks of hemorrhage, infection, and psychological trauma. Careful monitoring of the mother during induction of labor is paramount.

Multidisciplinary Team Approach

The management of fetal demise requires a compassionate and coordinated multidisciplinary team to address the complex medical, emotional, and social needs of the parents.

• Obstetricians/Maternal-Fetal Medicine (MFM) Specialists: Lead medical management, diagnose fetal demise, counsel on delivery options, and oversee the delivery process. MFM specialists are crucial for complex cases or recurrent losses.
• Nurses: Provide direct patient care, administer medications, monitor maternal well-being, offer immediate emotional support, facilitate memory-making, and ensure a respectful environment.
• Social Workers/Counselors: Offer critical psychosocial support, grief counseling, crisis intervention, facilitate communication with family, assist with funeral arrangements, and connect families with community resources and support groups.
• Pathologists: Conduct fetal autopsy and placental pathology, which are vital for determining the cause of death.
• Genetic Counselors: Provide information on genetic testing options (e.g., karyotyping, microarray), interpret results, and counsel on recurrence risks for future pregnancies.
• Chaplains/Spiritual Care Providers: Offer spiritual support, guidance, and facilitate religious or cultural rituals as desired by the family.
• Lactation Consultants: Provide support for mothers whose milk comes in, offering guidance on lactation suppression or milk donation if desired.
• Child Life Specialists: If there are older siblings, these specialists can help parents navigate conversations with their children about the loss.

Steps to Disclose a Diagnosis of Fetal Demise

Delivering the diagnosis of fetal demise is one of the most challenging tasks for a healthcare provider. A structured, empathetic approach is crucial:

1. Preparation: Confirm the diagnosis unequivocally via ultrasound. Gather all available information. Choose a private, quiet room where the parents can sit comfortably and have uninterrupted time. Ensure a support person (e.g., social worker, nurse) is present.
2. Introduction: Introduce everyone present and state the purpose of the meeting gently. “We need to talk about the results of your ultrasound.”
3. Delivering the News: Use clear, direct, and compassionate language. Avoid euphemisms. “I am so sorry to tell you that we could not find your baby’s heartbeat. Your baby has died.” Allow for silence and immediate reactions. Validate their pain: “I know this is incredibly difficult news, and I am so very sorry.”
4. Pause and Listen: Allow parents time to process. Be prepared for a variety of reactions (shock, denial, anger, sadness). Answer initial questions simply and honestly.
5. Provide Information (Next Steps): Once they are ready, offer a brief overview of immediate next steps. Explain options for delivery, investigation into the cause, and available support. Avoid overwhelming them with too much information initially. “We will need to decide on a way to deliver your baby. We can talk through your options when you’re ready.”
6. Offer Support: Immediately connect them with resources, such as a social worker or grief counselor. Provide written information about support groups, memory-making options, and follow-up care.
7. Memory Making: Gently offer opportunities for memory-making, such as handprints, footprints, photographs, or a lock of hair. Explain that these are forever keepsakes, and they don’t have to decide everything right away.
8. Follow-Up: Schedule follow-up appointments to discuss investigation results, physical recovery, and future pregnancy planning.

Factors Unique to Low-Resource Settings

In low-resource settings, the challenges associated with preventing, diagnosing, and managing fetal demise are significantly exacerbated by a complex interplay of social, cultural, and environmental factors.

• Social Factors:
  • Limited Education and Awareness: Lack of education about prenatal care, danger signs in pregnancy, and the importance of seeking timely medical attention.
  • Poverty and Malnutrition: High prevalence of maternal malnutrition, anemia, and micronutrient deficiencies directly contribute to poor fetal health and increased risk of demise.
  • Inadequate Prenatal Care: Limited access to routine antenatal visits, blood tests, and ultrasound scans means that risk factors and complications often go undetected until it is too late.
  • Gender Inequality: Women may have limited autonomy to make health decisions or access healthcare without male permission, leading to delayed care.
• Cultural Factors:
  • Traditional Beliefs: Cultural beliefs or taboos surrounding stillbirth can lead to stigma, blame, and a lack of open discussion, hindering emotional healing and support.
  • Traditional Birth Attendants (TBAs): Reliance on untrained TBAs for delivery, who may not recognize or manage complications effectively, leading to preventable deaths.
  • Fear of Hospitals: Mistrust or fear of modern medical facilities can deter women from seeking professional care.
• Environmental Factors:
  • Geographical Barriers: Long distances to healthcare facilities, lack of reliable transportation, and poor infrastructure can delay access to emergency obstetric care.
  • Poor Sanitation and Hygiene: Increased risk of maternal infections (e.g., malaria, syphilis, HIV, bacterial vaginosis) that can lead to fetal demise.
  • Exposure to Environmental Toxins: Living in areas with high levels of indoor air pollution (from biomass fuels), unsafe water, or agricultural pesticides can negatively impact pregnancy outcomes.
  • Climate Change Impacts: Extreme weather events, droughts, and floods can disrupt food security, increase disease vectors, and damage health infrastructure.
• Healthcare System Deficiencies (Implicit): Shortage of skilled healthcare professionals (doctors, nurses, midwives), lack of essential equipment (e.g., ultrasound machines, fetal monitors), limited access to medications (e.g., oxytocin, blood products), and inadequate emergency services contribute significantly to poor outcomes.

Addressing fetal demise in these settings requires a holistic approach that tackles these underlying determinants, including improving access to quality antenatal care, strengthening health systems, promoting health education, and addressing socioeconomic disparities.

Conclusion

Fetal demise represents a profound loss that impacts families deeply. A comprehensive and compassionate approach, grounded in medical expertise and psychosocial support, is essential for optimal patient outcomes. From accurate diagnosis and sensitive disclosure to multidisciplinary management and long-term grief support, every step must be guided by the principles of value-based care and patient safety. Recognizing and addressing the unique challenges in low-resource settings is also paramount to reducing the global burden of stillbirth and ensuring that all families receive the care and compassion they deserve during such a devastating time.

References

1. World Health Organization. (2020). Stillbirths: Accelerating progress in low- and middle-income countries. WHO. https://www.who.int/news-room/fact-sheets/detail/stillbirths (Accessed 2023-10-27)
2. American College of Obstetricians and Gynecologists (ACOG). (2020). Practice Bulletin No. 222: Stillbirth. Obstetrics & Gynecology, 136(2), e1-e17.
3. Goldenberg, R. L., Flenady, V., Froen, J. F., & McClure, E. M. (2016). Stillbirth: the global picture and future directions. Lancet, 387(10018), 587-596.
4. Lawn, J. E., Blencowe, H., Waiswa, P., Amouzou, A., Mathers, C., Hogan, M., … & Group, T. L. S. T. (2016). Stillbirths: rates, risk factors, and acceleration towards 2030. The Lancet, 387(10018), 587-603.
5. National Institute of Child Health and Human Development (NICHD). (n.d.). Stillbirth: Causes, Risk Factors, and Care. https://www.nichd.nih.gov/health/topics/stillbirth (Accessed 2023-10-27)