Lecture stillbirth

2021-03-21 12:00 AM

There are many causes of stillbirth and there are also many stillbirths that cannot be found. It is thought that between 20 and 50% of stillbirths have no cause.

Define

The definition of stillbirth is not consistent across countries. We think that stillbirths are all dead pregnancies that remain in the uterus for more than 48 hours. There are authors who consider stillbirths as fetal deaths after 20 weeks of gestation, weighing over 400g.

The basic feature of stillbirth is sterility. Although the fetus dies and stays in the uterus, it is sealed by the cervical mucus, preventing pathogens from entering at higher altitudes. On the contrary, once the amniotic fluid has ruptured, infection occurs very quickly and very seriously. In many cases stillbirth is difficult to find a cause. Stillbirth poses two major risks to the mother:

Disorders of blood clotting in the form of bleeding because blood clots are scattered in the lumen of the vessel.

Rapid and severe infections when the amniotic fluid ruptures for a long time.

In addition, there are also more or less influences on the mother's sentimentality, especially in rare cases of children. A dead fetus in the womb is always traumatic for the mother, requiring the support of those around her, especially medical staff.

The stillbirth rate at the Central Obstetrics and Gynecology Hospital is about 4.4% (1994-1995) compared to the total number of births at the hospital. The stillbirth rate is 0.76% in central Foch (France). Western Australia, this rate is 0.7% (only deaths after 20 weeks of total births)

Reason

There are many causes of stillbirth and there are also many stillbirths that cannot be found. It is thought that between 20 and 50% of stillbirths have no cause.

Causes are from the mother

Mother suffered from chronic diseases: nephritis, liver failure, anemia, tuberculosis, heart disease, high blood pressure ...

Mother with endocrine diseases: Basedow, hypothyroidism, diabetes, dysfunction or adrenal hyperplasia.

Mild to severe fetal toxicity can both cause stillbirth. The stillbirth rate is higher if the fetal toxicity is worse and not treated or treated incorrectly. The disease lasted for many days, making the fetus malnourished and died. The fetal death rate is very high when there are complications of pregnancy poisoning such as pre-eclampsia, eclampsia, premature peeling vegetables.

Mother suffers from parasitic infections such as malaria (in malignant malaria, almost 100% of fetal death), bacterial infection (such as syphilis), viral infection (hepatitis, mumps, flu, measles .. .)

In these cases the fetus can die from:

The direct impact of the cause of the disease on the fetus, on the vegetable cake.

The mother's fever, the fetus is very poor with the mother's fever. The fetal ability to lose heat is very poor. The fetal thermostatic system is not working yet. Every time the mother has a fever for any reason, it makes the fetus more susceptible to stillbirth.

Mother has acute or chronic poisoning. Mother uses some drugs that can cause the fetal death, especially some medicines for cancer in early pregnancy. Mother is irradiated for medical reasons or accidentally.

Uterus: A malformed uterus is also a cause of stillbirth, which can be seen in all types of uterine deformities. The fetus uterus, underdeveloped uterus makes the fetus poorly nourished, possibly still dead.

Some favorable factors for stillbirth are:

Mother's age: The stillbirth rate increases in mothers over 40 years old, the risk of stillbirth is 5 times higher than that of young women.

Poor nutrition, hard work, difficult life. In a history of stillbirth, the risk of stillbirth in the next pregnancy is 3 to 4 times higher.

Causes from the fetus

Chromosomal disorders: A major cause of death of a fetus less than 3 months old. A chromosomal disorder can be inherited from one parent; This may be due to mutations in ovulation, spermatogenesis, fertilization, and embryonic development. The incidence of chromosomal disorders increases markedly with maternal age, especially in mothers over 40 years of age.

Fetus malformation: hydrocephalus, intracranial, vegetable edema

Maternal and child immunological disagreement due to Rh factor, fetuses are very likely to remain stillborn in subsequent pregnancies.

Pregnancy in the month: vegetable cakes are aging, not ensuring the nourishment of the fetus, leading to stillbirth if not handled promptly.

Multiple pregnancies: The fetus can die in case of blood transfusion to the placenta, the fetus for blood donation is likely to die still. Furthermore, during development, a fetus can die as a baby, passing away without clinical manifestations. While the neighboring pregnancy continues to develop normally. Therefore, when the baby has an ultrasound to detect twins, until the fetus is older, only one fetus can be seen on ultrasound. Cases like these are not uncommon.

Gender factors: It seems that male fetuses have a higher risk of stillbirth than girls, probably related to a genetic problem with the sex chromosomes.

Causes from the fetus

Umbilical cord: Any abnormality in the umbilical cord can result in stillbirth. The umbilical cord is knotted, the umbilical cord is absolutely short, the umbilical cord is wrapped around the neck, around the body, around the extremities. The umbilical cord is pinched, especially in the case of the amniotic fluid, the umbilical cord is too twisted.

Vegetable cake: Fiber vegetable cake, peeling vegetable cake, glioma of the glaucoma of vegetable cake. The fetal blood flows to the mother

Amniotic fluid: Acute or chronic poly amniotic fluid, minimal amniotic fluid.

It has been found that between 20% and 50% of stillbirths have no cause found, despite modern means of exploration.

Pathology

Depending on the stage of death of the fetus, there are the following forms:

Pregnancy is dissipated

In the first weeks, at the full vegetable stage, if the fetus dies, it can be completely defecated, leaving only a pack of water.

Atrophy of the fetus

The fetus dies in the 3rd and 4th month will atrophy, dry again. Pregnant skin is yellow-gray as earth color, wrinkled and wrapped around bones. The amniotic fluid is less, thick and cloudy, eventually drying, leaving a white wax layer around the fetus.

Pregnant rot

After 5 months of fetal death will be spoiled. The epidermis will be peeled off, gradually peeling from the legs to the reincarnation. The hemoglobin-absorbent endoderm should be purple-red in color. The internal organs were crushed, making the head rickety, the skull bones overlap, the chest flattened, and the abdomen flattened. Vegetable cake yellow, shriveled, stiff. The vegetable film is yellow. The amniotic fluid is less and less viscous, in contrast, a pink-red color. The umbilical cord shrinks. You can rely on the skin peeling phenomenon to know the time of fetal death:

Day 3: peeling the skin of the feet.

Day 4: Peeling of lower extremities.

Day 8: body peeling.

 

The fetus is rotting

If the amniotic fluid breaks for a long time, the fetus that stays in the uterus becomes infected very quickly and very seriously. Bacterial infection spreads very quickly causing poisoning to the mother. Anaerobic bacteria that cause gangrene may develop slightly in the uterus. The fetus can plug the inner hole of the uterus, which slightly accumulates, causing the uterus to stretch, containing gas.

Symptom

Pregnancy less than 20 weeks died

Many cases of stillbirth are still silently, with no symptoms, making diagnosis difficult.

The patient has signs of pregnancy such as: delayed period, morning sickness, abdominal enlargement, hCG in positive urine, fetal ultrasound and cardiac activity.

Spontaneous vaginal bleeding, little, no abdominal pain, dark red or dark brown blood. This is a common sign of stillbirth under 20 weeks of pregnancy.

The uterus is younger than gestational age:

Patient feels that the baby's abdomen goes away or does not feel enlarged despite a long period of missed periods.

When a uterine volume is found to be smaller for gestational age, the density of the uterus is sometimes stronger than that of a live pregnant uterus.

Testing for HCG in the urine is negative only after the fetus has died for a while. The length of time for hCG to become negative depends largely on the level of the response to detect hCG (for the Galli – Mainini reaction is also negative only after weekly fetal death).

Ultrasound is valuable exploration for early and accurate diagnosis. On ultrasound, you can see clear pregnancy echoes without any activity of the fetal heart. Or only the amniotic sac is visible and no pregnancy echoes - also known as an empty amniotic sac. The image of an empty amniotic sac is more likely to be a stillbirth if it is large in size (over 35 mm in diameter), the edge of the bag is distorted and irregular. In doubtful cases, we should check with ultrasound after 1 week to see the progression of the amniotic sac to get an accurate conclusion.

Pregnant over 20 weeks died

The symptoms are often obvious, leading to immediate medical attention. As a result, it is also easy to determine the latent period, the time when the fetus has died.

The patient is showing signs of pregnancy, especially when the fetus is moving. The physician felt the fetal part, heard the fetal heartbeat with an obstetric stethoscope, and determined the height of the uterus.

The patient cannot see the fetus moving anymore. This is the main sign that compels the patient to pay attention, to seek medical attention. Thanks to that, we can easily determine the time of fetal death (latent time).

Natural colostrum secretion of breasts makes the patient pay attention to this phenomenon.

Vaginal bleeding is a rare sign of fetal death over 20 weeks of death.

The patient feels that the abdomen is not enlarged, even if the baby is dead for a long time.

If the patient has some comorbidities such as poisoning in pregnancy, heart disease ... then the disease will go away on its own, the patient feels more comfortable.

Examination found:

The uterus is smaller for gestational age, and is especially valuable if uterine height is reduced through two measurements at two different times, measured by the same person.

Difficult to touch see the fetus.

Do not hear the fetal heartbeat through an obstetric stethoscope.

Ultrasound for accurate results. There was no movement of the fetal heart. Head distorted, can see signs of two rings in the fetal skull due to scalp peeling off. Amniotic fluid may be less visible or even absent. Now this is mainly a probe, for a very sure and very early diagnosis.

The methods of X-ray exploration such as unprepared abdominal imaging, amniocentesis ... are rarely used today. These methods can harm the mother, especially the fetus if the fetus is still alive. Therefore, these methods are only applied when the diagnosis is still made, or when the fetus is nearly full term.

On an unprepared abdominal film can see:

The superimposed skull bones, sign of Spalding I, appear at 10 days of fetal death.

Folded fetal spine, sign of Spalding II.

Light ring around reincarnation, Devel sign.

May see balloon in heart chamber or large blood vessels, sign Roberts.

Quantification of fibrinogen in blood to evaluate the effect of stillbirth on blood clotting. If the dead fetus is still in the uterus, blood fibrinogen must be measured weekly. This is an important test that is indispensable for pregnancy intervention.

Differential diagnosis

For stillbirths over 20 weeks, a differential diagnosis is rarely made. For stillbirths under 20 weeks, may be confused with:

Out of womb pregnancy because there is black blood in the vagina, uterus is younger than gestational age. Stillbirth when going to miscarriage also causes colic.

Treatment, especially confused with regression. Sometimes it is impossible to distinguish if it is based on clinical and ultrasound. Only when curettage and pathological tests do curettage can provide definitive diagnosis. The clinical picture of stillbirth and regressive pregnancy is sometimes identical.

The uterus has fibroids, the uterus is larger than normal with abnormal vaginal bleeding.

Still alive, this is a matter of great caution because it can always be wrong, especially when in a hurry to diagnose. All physical or physical symptoms, including ultrasound screening to diagnose stillbirths, can be wrong or mistaken. The best way to avoid this unfortunate mistake is that we should not rush in diagnosis and management. Many times, it is necessary to examine and explore many times, by many people to get an accurate diagnosis.

Evolution

Affecting the mother's psychology and affection

Stillbirth in the uterus always causes psychological and emotional consequences for the mother because:   

Losing an expected baby. These psychological consequences are more severe in those who are rarely born or infertile.

Psychological fear of being pregnant has died.

Physicians need to explain carefully, reassuring, sympathy with the mother. All of these issues need to be done carefully before interventions to remove a pregnancy.

Blood clotting disorder

A coagulation disorder is a serious complication of stillbirth. Thromboplastin is abundant in amniotic fluid, in vegetable cakes and membranes fall into the mother's circulation, activating the process of coagulation, causing scattered blood clots in the lumen and fibrinolysis. Another factor that interferes with blood clotting disorders is that the factors that activate the diarrheal system are abundant in the organization of fetal death. Thromboplastin permeation into the mother's circulation (Jimenez and Pritchard, 1968; Lerner and Cs 1967) is especially common when the uterus contracts, when there is an intervention in the uterus. This intravascular scattered coagulation is characterized by a dominant secondary fibrinolytic process, leading to clinical manifestations of bleeding, low or absent fibrinogen in the blood. Risk of blood clotting disorders when blood fibrinogen drops below 1 g / l, usually appears about 9 weeks after fetal death. The concentration of fibrinolysis product (FDP) in the blood increases gradually. Platelet counts tend to decrease, but this is not always the case. Scattered coagulation in the lumen may take place slowly. It was found that the greater the potential duration of 4 weeks and the greater the fetus, the higher the risk of a bleeding disorder. Pritchard's retrospective study found that clotting disorders occur very rarely within 1 month of fetal death. In addition, the process of scattered coagulation in the lumen can be acute when conditional coagulation disruptors flow into the mother's circulation. That is when it interferes with the uterus or when the uterus contracts. Clinical manifestations are bleeding from the uterus, blood not clotting. Bleeding appeared several hours after the intervention.

Bacterial infection when the amniotic fluid ruptures for a long time

Not afraid of infection while the amniotic fluid remains. But when the water is broken, the infection can be very rapid and severe. In addition to the common bacteria such as staphylococci, bacillus, proteus ..., anaerobic bacteria such as Clostridium perfringens can be encountered. Severe, widespread infections can cause endotoxins to mothers, especially from Gram-negative bacteria.

Some features of labor of stillbirth

The pear-shaped amniotic sac, protruding through the cervix, and slouched into the vagina is the result of the amniotic membrane no longer being able to stretch. The pear amniotic fluid tip does not help the cervix open, making it easier to misdiagnose the opening of the cervix on examination, but never amniocentesis when the cervix is ​​not fully opened.

The amniotic fluid is pink red, sometimes mixed with a lot of pennies if the fetus is stillborn from chronic fetal failure.

Regardless of the star, the fetus can also lay the lower line. If the fetus is in a horizontal position, the spine will be folded to allow the fetus to fall and pass. Once you need help getting pregnant, apply abortion procedures such as brain puncture, skull clamping, abortion ...

After the vegetable book, it is necessary to carry out an active and systematic control of the uterus because vegetables are always missing.

Pay attention to patients using antibiotics to avoid infection.

Treatment

Correct blood clotting disorders, if any

If fibrinogen is low, we need to adjust it before intervening to remove the pregnancy. The drugs can be used:

Fibrinogen intravenously.

Whole fresh blood.

Antibacterial drugs such as EAC, Transamine ...

American authors have used heparin for treatment at doses ranging from 5000 to 10000 units per day. We have not used heparin for this treatment. This issue needs to be studied more to be applicable without causing complications.

Cervical angioplasty, abortion

Cervical angioplasty, curettage is used for stillbirths where the volume of the uterus is less than 3 months pregnant, or the uterus height is less than 8 cm. The curettage procedure is more difficult than live curettage because the fetal bone is large and solid, because fibrous vegetables are attached to the uterus. To relieve pain for the patient before curettage, using uterotonic drugs and antibiotics after the procedure. Attention should be paid to monitoring bleeding after curettage. Bleeding usually appears a few hours after the procedure. Treatment of bleeding (fibrinogen, blood, anti-fibrinolytic drugs ...) results in most cases, preserving the uterus.

Before the medical treatment, it is necessary to ensure that there are no vegetables left, no tears in the cervix or uterus. There was no recurrent bleeding after medical treatment.

Miscarriage, labor

Miscarriage, labor is applied to all cases of stillbirth, which cannot be aborted. There are many methods to get pregnant.

The method of placing a water bag. Not recommended because of the risk of bacterial infection and rupture of membranes.

The Stein method:

The stein classic includes giving the patient a warm bath, douching, and taking estrogen and quinine before an oxytocin infusion. Nowadays, the Stein method has been improved and simplified. Usually people proceed as follows:

Use estrogen, namely Benzogynestryl 10mg/day for 3 consecutive days.

On the fourth day intravenous oxytocin infusion causes uterine contractions. The maximum daily dose of oxytocin is 30 units, infused in batches for 3 consecutive days. The sessions are 7 days apart. Usually, the fetus is expelled in the first 1 to 2 days of infusion.

Pure intravenous oxytocin infusion:

The patient received immediate intravenous oxytocin without prior estrogen preparation. The same goes for oxytocin infusion as seen in the Stein method. The successful results of this approach are the same as those of the Stein method. The advantage of this method is that it does not use estrogen, which shortens the hospital stay. The result of oxytocin infusion is higher if the Bishop index is favorable ( ³ 6), the chicken, the gestational age is large. The method is effective, sure, to avoid unwanted effects of drugs of the prostaglandin group.

Use of prostaglandins is currently the preferred method. People prefer to use prostaglandins belonging to group E2 such as: Cytotec (misoprostol), Prostine, Nalador, Cervagème than drugs of group F2 a . The route of administration can be vaginal, intramuscular, or intravenous. The amniotic membrane must be kept until the cervix is ​​completely open. Simple and economical is to administer Cytotec vaginally, 100 m g each time and once every 12 hours. The average time to conceive is 12.6 hours, only 8% of the cases are born after 24 hours (but before 48 hours) (the study applies to stillbirths between the ages of 18 and 40). week). Unwanted effects of the drug are negligible.

With all these methods, the higher the success rate the larger the uterus, the greater gestational age, around the expected date of delivery. Facing difficult cases, the physician is not in a hurry to let the fetus out. Forcing the fetus to be pregnant at all costs will put the physician at risk of serious and dangerous complications and complications. We should not forget that there are cases of stillbirth with spontaneous labor, giving birth often ends without much difficulty. So if there is no risk of blood clotting disorders, the expectation to expect natural labor is also an acceptable treatment. In cases where labor is difficult to induce, we can wait a few weeks, hoping for a spontaneous labor to occur provided the coagulation tests are normal.

Preventing stillbirth is a very complex issue. In many cases, the cause cannot be found, making the patient and the physician confused in the next pregnancies. Stillbirth should be seen as a risk for the next pregnancy. Care should be taken in diagnosing and avoiding rush in the management of pregnancy.