Cause Of Intrauterine Death Research Articles

Stillbirth in women with Type 1 Diabetes mellitus—still a current topic

PurposeCompared to the general stillbirth rate in Germany for term deliveries of 0.12% the risk in type 1 diabetes mellitus is reported to be up to ten times higher. The reasons for this excess risk of intrauterine demise are still not fully elucidated. Risk factors named in the literature include poor glycemic control before and during pregnancy and the occurrence of ketoacidosis. Additionally there might be a diabetes related type of placental dysfunction leading to organ failure in late pregnancy. Understanding the underlying causes is mandatory to develop strategies to reduce the incidences. The Purpose of this publication is to point out the difficulties in prediction of intrauterine death in pregnant type 1 diabetes patients and thus emphasizing the necessity of constant awareness to all caregivers.MethodsWe present a case series of four cases of stillbirth that occurred in patients with type 1 diabetes mellitus at our tertiary care obstetric unit during a five-year period.ResultsIn all four presented cases the underlying cause of intrauterine demise was different and we could not find a common mechanism or risk profile. Furthermore, established monitoring tools did not become peculiar to raise awareness. We compared our cases to published data. Underlying causes of intrauterine death in type 1 diabetes are discussed in the light of the current literature.ConclusionsThe main risk factors of stillbirth in diabetic pregnancies are high maternal blood glucose levels including pre-conceptional HbA1c and diabetic ketoacidosis. Late acute placental insufficiency are associated with intrauterine death in type 1 diabetes. Despite the elevated risk of near term intrauterine demise there are currently no guidelines on how to monitor pregnancies in type 1 diabetes for fetal distress during the third trimester. Established thresholds for fetal Doppler data indicating fetal distress in normal and growth restricted fetuses may not be applicable for overgrown fetuses. Future research on how to monitor the diabetic fetus needs to be initiated.

Comparison of causes and circumstances of intrauterine death in term and preterm pregnancies at a tertiary care center

Abstract Background: It is of extreme importance to identify the causes of fetal deaths, so that preventive strategies can be framed and more vigilant monitoring and prenatal surveillance can be undertaken. Objective: To determine the causes and circumstances of intrauterine death in term and preterm pregnancies and compare these causes. Materials and Methods: A cross-sectional observational study was undertaken. All the mothers underwent basic and targeted investigations as per the hospital protocol to identify the causes of intrauterine death (IUD). Basic investigations included complete hemogram, infective serology, and liver and renal function tests. Results: The stillbirth rate was 17.83%. It was comparable in males and females. Most cases were second gravida. Birth weight was significantly lower in preterm pregnancies compared to term pregnancies. Other characteristics were comparable. The most common risk factor was pregnancy-induced hypertension 49 cases (40.49%). The presence of pregnancy-induced hypertension was comparable in two groups. Unexplained IUD was significantly more in preterm pregnancy cases compared to the term pregnancy cases. Conclusion: The main causes of fetal mortality identified from this study include pregnancy-induced hypertension, severe anemia, abruptio placenta, and Rh isoimmunization.

Fetal Autopsy—A Game Changer!

AbstractFetal autopsy is one of the most useful investigations that can change or significantly add to the clinical diagnosis despite a prenatal ultrasonographic diagnosis of a fetal abnormality. It is often required to determine the cause of intrauterine death or miscarriages, provide recurrence risk, and is known to alter the final diagnosis and genetic counseling in nearly half of the cases. This article reviews the role of fetal autopsy and discusses its contributory role in confirming the diagnosis and its usefulness in the genetic counseling of cases with risk of recurrence in future pregnancies.

ULTRASOUND STANDARDS FOR ANTENATAL FETAL DEATH

Antenatal death is the cessation of fetal heart contractions during pregnancy for more than 22 weeks prior to the onset of labor. Objective: to evaluate the capabilities of the method of ultrasound in antenatal fetal death. Tasks of ultrasound in the presence of a dead fetus: a statement of his death; determining the position, presentation, size, estimated fetal weight and gestational age; detection of congenital malformations (CM) and possible causes of death; clarification of the statute of limitations of death. We have analyzed 126 standard ultrasound protocols of pregnant women with antenatal fetal death. Ascertaining the cessation of heart contractions and determining the location of the fetus present no difficulties for the ultrasound doctor. The assessment of the conformity of the size of the fetus to the gestational period during antenatal death is better determined by measuring the diaphysis of the long bones. Head sizes are used only when it is possible to clearly assess the typical structures of a biparietal slice. The determination of the estimated mass of the fetus is difficult due to autolytic changes and, usually, lack of water. The diagnosis of CM, first established after ascertaining antenatal fetal death, should cause the doctor to doubt that it is in front of us — a developmental defect, as a possible cause of intrauterine death or post-mortem changes that depend on previous intravital changes, cause and duration of death. The article describes the dynamics of the appearance of post-mortem changes. Conclusions: with antenatal fetal death, it is impractical to determine the expected mass of the fetus, it is preferable to estimate the period of probable cessation of development from the measurement of long tubular bones; during an ultrasound of the deceased fetus, it is often impossible to reliably determine the presence/absence of CM and the exact time of death; change in the amount of amniotic fluid is not a reliable diagnostic criterion for the duration of death.

Placenta and Umbilical Cord Cause in Antepartum Deaths.

Stillbirth is a sudden and painful event for parents and obstetrical specialists as well. It is, therefore, of greatest importance to be able to give answers for the cause in order to plan a subsequent pregnancy. The aim of this retrospective study is to estimate the placental and umbilical cord cause of intrauterine death in relation to different gestational ages. The study took place on the Medical Birth Registry of Aretaieio Hospital, National and Kapodistrian University, Athens, Greece. We include a total of 19,283 pregnancies from 1998 to 2012. In this study period, 431 embryonic deaths occurred. The clinical history was documented on admission at delivery. Conditions thought to be associated with the intrauterine fetal death were recorded. Gestational age was calculated from the last menstrual period as well as with the three-trimester system. The autopsy, placenta and umbilical cord examination were performed by the same laboratory of pathology in Aretaieio University Hospital. We found that the majority of stillbirths occurred in the second trimester. We examined placenta and umbilical cord in all cases. The most frequent histologic abnormalities were those indicated placental vascular insufficiency. As far as the umbilical cord is concerned we found that the inflammatory disorder was the most common in antepartum deaths. A single umbilical artery was significantly related to gestational diabetes and congenital embryonic anomalies. Finally, our results showed steady declines in antepartum deaths during 1998-2012. As a result, we reached the conclusion that in order to reduce the fetal death rate, we have to insist on the autopsy of the placenta and umbilical cord in order to gain the appropriate information in counseling the parents.

Classification The Causes of Intrauterine Death and Correlation To contributing Risk Factor In Maternity Teaching Hospital In Al_Sulaimania City

Background. IUD; is death of fetus in utero beyond 24 Weeks of gestation and/or birth weight > 500g. It is devastating experience for the mother and of concern in clinical practice. Objectives: The aim of this study is to achieve the following goals: 1- To put a classification for the cause of intrauterine death (IUD). 2-Determination the correlation between causes and implication on IUD statistically clinical like BMI, Diabetes, and IUGR. Methods: This was a prospective study from January to the end of August 2015 total number of deliveries was 13582, 130of them was IUD Results : during the study period, Incidence of IUD at our centre was1% per 1000. In 25% cases, no causes were identified. Among the identifiable causes, hypertensive disorders (22%) were most common followed by Congenital malformations were responsible for 15% placental causes (9%). cases, diabetes bout 6%...Induction was done in 40% of patients ,48% patients had spontaneous onset of labour and caesarean section was 10%. The majority of fetus was male about 76%. , most of our cases are overweight about 57%, with poor ANC and low level of education. Conclusions: The prevalence of IUD during the period of study in maternity teaching hospital in sulaimani was (1%)Low education level ,poor ANC, increase parity, maternal medical condition (hypertension and diabetes) obesity,fetal congenital anomalies, women with previous history of IUD were risk factor of IUD

Stillbirth and intrauterine fetal death: role of routine histological organ sampling to determine cause of death.

Guidelines for the investigation of intrauterine death and sudden unexpected death in infancy (SUDI) recommend, based on expert opinion, autopsy procedures and tissue sampling strategies for histological analysis. Although stillbirth is much more common than SUDI, there have been no large-scale studies published which evaluate the usefulness of histological evaluation of specific organs in stillbirth for determining cause of death. Our aim was to evaluate the use of macroscopic and microscopic assessment of internal organs to determine cause of intrauterine death. As part of a larger study evaluating several aspects of autopsy findings in intrauterine death, a dedicated database was used to collate antenatal and postmortem examination details for cases of intrauterine death examined between 2005 and 2013 at two tertiary specialist centers in London, UK. Histological findings for all organs were examined in relation to the final cause of death, as determined by objective criteria. Among 1064 intrauterine deaths, the majority (> 80%) of cases had internal organs that were normal on both macroscopic and microscopic examination. There was no case in which histological cardiac examination provided the cause of death when the macroscopic appearance of the heart was normal. Microscopic examination of lung tissue revealed 13 (1%) cases with histological abnormalities that provided the cause of death when the macroscopic appearance was normal, but there was only one (0.1%) case in which the diagnosis would not have been apparent on placental examination: a case of congenital cytomegalovirus infection. There was no case in which microscopic examination of macroscopically normal liver, kidneys, adrenals, spleen, thymus, intestines, pancreas, brain or thyroid provided the cause of death. In this large series of autopsies in cases of intrauterine death, only around 1% of cases demonstrated histological abnormalities which provided the cause of death when the internal organs appeared normal macroscopically. There was no case in which routine histological examination of most tissues provided diagnostically useful information that was not apparent from other examinations, such as placental pathology. There is little benefit, purely in terms of determining cause of death, in obtaining tissue from most macroscopically normal organs for routine histological examination. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Stillbirth and intrauterine fetal death: role of routine histopathological placental findings to determine cause of death.

Placental abnormalities are a common cause of death in stillbirth, ranking second only to unexplained deaths, though there is wide variation in the proportion attributed to placental disease. In clinical practice, interpretation of the significance of placental findings is difficult, since many placental features in stillbirths overlap with those in live births. Our aim was to examine objectively classified placental findings from a series of > 1000 autopsies following intrauterine death in order to evaluate the role of placental histological examination in determining the cause of death. As part of a larger study evaluating several aspects of autopsy findings in intrauterine death, a dedicated database was used to collate antenatal and postmortem examination details for all cases examined between 2005 and 2013 at two tertiary specialist centers in London, UK. Histological findings for placentas were evaluated in relation to the final cause of death. Among 1064 intrauterine deaths, 946 (89%) cases had the placenta submitted for examination as part of the autopsy. Of these, 307 (32%) cases had the cause of death assigned to abnormalities of the placenta, cord or membranes. Around one third of stillbirths (≥ 24 weeks) had some isolated placental histological abnormality identified, many of uncertain significance, a significantly greater proportion than in cases of second-trimester intrauterine fetal demise (P < 0.0001). The cause of death was ascending infection in 176/946 (19%) cases, peaking at 22 weeks' gestation, with significantly more black mothers having ascending infection compared with other ethnicities (P < 0.0001). Maternal vascular malperfusion was the largest category of placental abnormalities in stillbirth, with peak prevalence in the early third trimester. There were 18 (2%) cases with specific histological abnormalities, including chronic histiocytic intervillositis and massive perivillous fibrin deposition. Placental pathologies represent the largest category of cause of intrauterine death. Placental histological examination is the single most useful component of the autopsy process in this clinical setting. A minority of cases are associated with specific placental pathologies, often with high recurrence rates, that can be diagnosed only on microscopic examination of the placenta. Many deaths remain unexplained, although placental histological lesions may be present which are of uncertain significance. A rigorous, systematic approach to placental pathology research and classification may yield better understanding of the significance of placental findings and reduce the rate of unexplained intrauterine deaths. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Organ weights and ratios for postmortem identification of fetal growth restriction: utility and confounding factors.

The postmortem fetal brain:liver weight ratio is commonly used as a marker of nutrition for diagnosis of fetal growth restriction (FGR). However, there are limited data regarding the effects of intrauterine retention, fetal maceration and postmortem interval on organ weights and their ratios at autopsy. Our aims were to examine the relationships between gestational-age-adjusted and sex-adjusted fetal organ weights at autopsy, cause of intrauterine death and effects of intrauterine retention, and to determine whether the brain:liver weight ratio is a reliable marker of FGR in intrauterine death. As part of a larger study examining autopsy findings in intrauterine death, data from two specialist centers in London were collated in a specially designed database. Autopsy and clinical information for > 1000 intrauterine deaths between 2005 and 2013 were extracted. Adjusted (delta) organ weights were calculated by plotting against gestational age female and male brain, liver, thymus, heart, combined kidney, combined lung, spleen and combined adrenal gland weights. Polynomial regression was used to determine best fit and to calculate expected (50th centile) organ weights and deviations from expected. We compared adjusted organ weights and body:organ weight ratios in fetuses which were small-for-gestational age (SGA) at autopsy (birth weight < 10th centile for normal live births) vs those in fetuses which were not, and in macerated vs non-macerated fetuses. The majority of fetal organs (brain, liver, heart, thymus, lungs, kidneys and thyroid) in SGA fetuses were significantly lighter than those in non-SGA fetuses. Body:organ weight ratios for thymus, liver and spleen were significantly greater in SGA fetuses, indicating these organs to be disproportionately small. The majority of organs were significantly lighter in macerated compared with non-macerated fetuses and body:organ weight ratios for most organs (liver, thymus, lung, pancreas, adrenal gland, kidney, heart) were significantly greater in macerated compared with non-macerated fetuses. When SGA cases with demonstrable placental histological abnormalities were compared with other SGA cases, there was a significant difference in the brain:liver weight ratio (median, 6 vs 3.5). Changes after intrauterine death lead to loss of fetal weight, with preferential weight loss of visceral organs such as the liver. Maceration therefore affects the brain:liver weight ratio and adjustment should be made for such changes during interpretation of ratios. Fetal organ weights may be affected significantly by mechanism of death and postmortem changes. The fetal brain:liver weight ratio may provide useful information regarding intrauterine growth status at time of death, provided that adjustment is made for effects of intrauterine retention and that appropriate cut-off values are used. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Foetal autopsy-categories and causes of death.

Intrauterine death(IUD)/ Stillbirth forms a major part of perinatal mortality which thereby is a good indicator of pregnancy wastage as well as quality of healthcare available. The key objectives of autopsy examination are to know the cause(s) of death, elucidation of pathogenic mechanism and quality control of clinical management. The aim of this study was to identify the prevalent causes of IUD, thereby taking appropriate measures to prevent them and decrease the perinatal mortality rate. The study included 14 cases of IUD received for autopsy in the Department of Pathology over a period of five years. Autopsies were performed as per standard protocol and included full anthropometric profile, external examination, gross and microscopic evaluation of different organs and placenta. Total number of 14 fetal autopsies were performed over a period of 5 years. The causes were broadly classified as fetal, maternal and placental. Placental causes were seen in majority of cases (48.57%) followed by fetal (35.72%) and then maternal (21.42). Most prevalent cause of death was congenital anomalies (28.6%) followed by placental insufficiency (21.4%) and chorioamnionitis (14.2%). Determination of causes of fetal death would prove beneficial to the clinicians and parents for better management and care in future pregnancies as well as in genetic counseling.

Fetal and neonatal mortality in patients with isolated congenital heart diseases and heart conditions associated with extracardiac abnormalities

Congenital malformations are a known cause of intrauterine death; of them, congenital heart diseases (CHDs) are accountable for the highest fetal and neonatal mortality rates. They are strongly associated with other extracardiac malformations and an early fetal mortality. Two hundred and twenty fves cases of CHDs are presented. Of them, 155 were isolated CHDs (group A) and 70 were associated with extracardiac malformations, chromosomal disorders, or genetic syndromes (group B). The overall mortality in group B was higher than that observed in group A (p <0.01). Prenatal mortality was similar in both groups: A: 8.4% (13 out of 155); B: 15.7% (11 out of 70). Postnatal mortality was A: 16.8% (26 out of 155) (p <0.01), OR: 0.52 (95% CI: 0.16-1.7); B: 32.9% (23 out of 70) (p <0.01), OR: 0.41 (95% CI: 0.20-0.83). Heart diseases associated with extracardiac abnormalities had a higher mortality rate than isolated congenital heart diseases in the period up to 60 weeks of postmenstrual age (140 days post-term). No differences were observed between both groups of patients in terms of prenatal mortality.

Second-trimester fetal death due to cord entanglement around the neck

Cord entanglement is the situation when one or more loops of the umbilical cord encircle any part of the body. Cord complications may result in fetal demise in the third trimester. However, they are not known to be etiologic factors for missed abortion, in spite of the high ratio of cord entanglement during the first half of pregnancy. We present a case of intrauterine fetal death at 15 weeks’ gestation due to cord entanglement. When the fetus was delivered, an abnormally long umbilical cord for this gestational age was realized (30 cm). The cord passed above the right shoulder of the fetus, and encircled the neck completely and tightly. Then the cord passed through the left axilla towards the placenta. Macroscopically there was no fetal abnormality. Postmortem pathological examination proved the absence of any structural malformations. The most possible cause of intrauterine death was the nuchal cord obstructing blood flow through the umbilical cord.

Antepartum stillbirth in twins: a regional multi-centre audit of antenatal care

BackgroundTwins have a much higher stillbirth rate than singletons with causes of intrauterine death frequently unexplained. In the North of England the stillbirth rate in twins is higher than the...

Investigation of the role of computed tomography as an adjunct to autopsy in the evaluation of stillbirth

The number of parents agreeing to autopsy following stillbirth is declining, which has undermined clinicians' ability to assess causes of intrauterine death and can impact counselling regarding recurrence. Post-mortem radiological imaging is a potential alternative method of investigating perinatal loss. The aim of this study was to assess the role of multi-detector computed tomography (MDCT) in the investigation of stillbirth. Following ethical approval and written consent, parents were offered MDCT of the stillborn infant. MDCT was performed with 3D reconstruction, and images were analysed for image quality, anthropomorphic measurements and pathologic findings. Body part and organ-specific measurements were performed; including head, chest and abdominal circumferences, and muscle and liver mass was also measured. Findings were correlated with obstetric history, post-mortem skeletal survey (plain radiography), and formal autopsy. Fourteen third-trimester stillborn infants were scanned. Image quality was moderate to excellent for most body structures. CT was better than plain radiography for imaging skeletal structures and large solid organs and demonstrated a range of pathologies including renal vein thrombosis, mesenteric calcification and skeletal hyperostosis that were not seen on plain radiographs. MDCT did not overlook autopsy findings and provided some additional information. This study confirms the feasibility of MDCT in the investigation of third trimester stillbirth. MDCT image quality is acceptable and the examination can demonstrate a range of anatomic and pathologic findings. Initially, its value may be as an important adjunct to conventional autopsy.

Of pigs and pregnancy

In March, 2007, a 31-year-old woman was advised by her midwife to attend the antenatal department at St Michael's Hospital, because she had been itching all over her body for a week. She was 24 weeks pregnant. She had been pregnant twice before. Her first pregnancy had ended in miscarriage, at 11 weeks, and her second in intrauterine death, at 30 weeks. The cause of intrauterine death had not been identified; a thrombophilia screen and liver function tests had given normal results. The medical history was otherwise unremarkable.

Intraplacental choriocarcinoma as an unexpected cause of intrauterine death at term

Intraplacental choriocarcinoma is rare. It can cause fetal death at term by fetomaternal hemorrhage. We present a case of intraplacental choriocarcinoma. After a hydatidiform mole with persistence of throphoblastic disease, the patient delivered a stillborn baby at term. Massive fetomaternal hemorrhage was the unexpected cause of death. Choriocarcinoma was only diagnosed after pathologic revision of the placenta because of persistent high levels of serum hCG (human chorionic gonadotropin). Massive fetomaternal hemorrhage should alert the obstetrician and the pathologist to the possibility of choriocarcinoma arising from the placenta.

The amniotic sheet: a truly benign condition?

Amniotic sheets are the result of uterine synechiae that have been encompassed by the expanding chorion and amnion. Radiologically they are seen as 'shelves' in the amniotic cavity. The benign nature of such amniotic sheets has been documented in many case series in the literature. The objective of this study was to determine the characteristics (if any) of amniotic sheets that predict fetal outcome. Between January 2001 and December 2002, detailed scans were performed in 30 476 singleton pregnancies at 18-32 weeks' gestation. Of these, 44 cases of amniotic sheets were detected. The characteristics studied were site of amniotic sheet and whether the amniotic sheet was complete (i.e. no free edge seen on ultrasound) or incomplete (i.e. presence of free edge seen on ultrasound). The primary fetal outcome studied was stillbirth. The incidence of amniotic sheets was 0.14%. Two were complete and 42 were incomplete. Of the 38 cases with known outcomes there were two intrauterine deaths. There was no association between fetal outcome and the uterine location of the amniotic sheet (i.e. upper two-thirds vs. lower third, P = 0.5). There was, however, an association between the completeness of the amniotic sheets and intrauterine death (P = 0.002). Both instances of intrauterine death occurred in the two cases with complete amniotic sheets. Postmortem examination suggested that cord accidents were the cause of intrauterine death in both cases. This study supports the view that incomplete amniotic sheets are benign. It also suggests for the first time that complete amniotic sheets may be associated with intrauterine death.

Identification of the causes of intrauterine death during 310 consecutive autopsies.

Evaluation of causes of death in stillborn infants. During a five-year period, 310 consecutive autopsies of stillborn infants were performed using a standardized protocol with systematic examination of all major cranial, thoracic and abdominal organs including microscopic examination. In 71%, the intrauterine death (ID) occurred up to the end of the 37th week of gestation. Thirty-seven percent (115/310) stillbirths represented with maceration and about one-half with minor or major malformations. Thirty-one percent (53/171) of them were responsible for intrauterine death. In 83% (44/53), the intrauterine death of the malformed fetus occurred before the end of 37th week of gestation, most of them (48/53, 90.6%) were small for gestational age infants. In 75.5% (234/310), the placental villous tree and the umbilical cord represented pathologic conditions. In 191 cases (61.1%), utero-placental pathology was responsible for intrauterine death. Intrauterine infections and traumatic lesions were accompanied by intrauterine death in 2.2 and 1.3%, respectively. In 15.2%, unexplained intrauterine death (because of severe maceration, the placenta was not available for autopsy or insufficient clinical data) occurred. Perinatal autopsy may be valuable in three ways: the confirmation of ante-mortem diagnoses; the identification of unexpected disorders; and exclusion of other (perhaps inheritable) conditions which might be have caused the intrauterine death. Clinically valuable information, obtained from the autopsy, can be improved by high autopsy rate and performing perinatal necropsies by specially trained pathologists.

PERINATAL DEATH AUDIT

This retrospective study was conducted to find out the status of perinatal mortality at Nepal Medical College Teaching Hospital (NMCTH) which is located at sub-urban area of Kathmandu. Records of all consecutive deliveries from 1/7/1998 to 30/12/2002 were reviewed. Total number of deliveries was 1517 among which 1182(77.9%)were normal deliveries. Total number of birth was 1531 including 14 set of twins. There were 38 still birth (24.8 per 1000 birth) and 7 early neonatal deaths (4.7 per 1000 live birth). The perinatal mortality rate was 29.4 per 1000 birth. Perinatal mortality was higher in low birth weight babies (77%) and premature (173.2%). Most of the cases (46.7%) have not attended regular Ante-natal Checkup (ANC). Among 38 cases of still birth 27 were macerated. Abruptio placenta and pregnancy induced hypertension were common identifiable causes of Intra-uterine Death (IUD) whereas among 7 cases of Early Neonatal Death (ENND) 4 cases were due to pre-maturity with hyaline membrane disease. Regular ante natal care with identification of high risk group and management of complications along with improved neonatal care facilities will help to minimize the high perinatal mortality rate. Regular perinatal death audit is necessary to identify the common and preventable causes of perinatal mortality. (authors)

Determination of CMV placentitis. Diagnostic application of the polymerase chain reaction.

Cytomegalovirus (CMV) infection constitutes an important cause of intrauterine death. In the present study CMV infection of placentas resulting from intrauterine deaths was assessed by immunohistochemistry and by the polymerase chain reaction (PCR). Among 32 cases of chronic villitis examined, 7 were found by PCR to be associated with CMV infection, although light microscopic examination revealed only 3 of them, while 4 had shown positive immunohistochemical staining. In conclusion, CMV may be considered to be a relatively common cause of placentitis, and PCR is a helpful tool in confirming the nature of the disease.