Fetal Deaths

Review of "Late Term" Fetal Deaths, Utah, 1996 & 1997

The Perinatal Mortality Review Program (PMRP)(see "description of program"), of the Utah Department of Health (UDOH) reviewed all late term fetal deaths (35 weeks or greater) that did not have a lethal anomaly and occurred in Utah during the years 1996 and 1997. A total of 453 fetal deaths occurred during this period, 132 of these met the PMRP criteria for review. This represents approximately 29% of all fetal deaths during these years.

The definition of fetal death by the UDOH, Bureau of Vital Records is "a product of human conception: (a) of 20 weeks’ gestation or more, calculated from the date the last normal menstrual period began to the date of delivery; and (b) that was not born alive."¹ The average fetal death ratio (fetal deaths per 1000 live births) in Utah during 1996 & 1997 was 5.3/1000. The Healthy People 2000 Objectives include the recommendation to reduce the fetal death ratio to no more than 5 per 1000 live births.² The PMRP undertook the review of fetal deaths in order to identify public health strategies which may reduce the fetal death ratio.

The ages of Mothers experiencing fetal deaths reviewed ranged from 16 to 43 years with a mean of 28 years. Age specific fetal death ratios were highest among women 40-49 years of age (4.8/1000),(graph 1). Approximately 82% of Mothers experiencing fetal deaths reviewed began PNC during the first trimester of pregnancy, this is similar to the entire birth population in Utah during this time period. A very small percentage of Mothers included in the study group received late (3^rd trimester) or no prenatal care (3.2%).

Graph 1

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Fetal death ratios by Mother’s county of residence indicate that women living in rural Utah counties had a higher ratio of fetal deaths (1.9/1000) compared to those living in urban counties (1.4/1000). This increased risk may be due to lack of access to obstetricians in rural Utah. More than half of rural Utah counties (16 out of 29) are without any obstetrician.³

Fetal death ratios were found to be higher among women with 3 or more previous livebirths (graph 2). Additional statistical analysis is needed to determine if this variable is confounded by maternal age.

Graph 2

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Approximately 27% of fetal deaths reviewed occurred in Mothers whose body mass index (BMI) was rated as "high" or "obese"(Graph 3). This finding requires further research in light of the recently published findings of higher maternal weight before pregnancy increasing the risk of late fetal deaths.⁴

^{Graph 3}

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The Perinatal Mortality Review Committee (PMRC) deliberated following the review of each fetal death. Issues that may have contributed to the death were identified. The most frequently identified pregnancy related socio-demographic issue was a delay on the part of the Mother to seek care immediately when fetal movement was noted to be decreased or absent. This issue was identified in 52 of the 132 cases (39%). Other socio-demographic issues identified include: poverty (14.4%), being uninsured (8.3%), unintended pregnancy (8.3%) and being unmarried (12.3%), all of which are common risk factors for poor perinatal outcomes.

Pregnancy complications that may have contributed to the fetal deaths reviewed were also identified by the PMRC. Placental complications were identified in 36% of the cases reviewed, the most common of which were "abnormal placenta or cord"(n=23) and placental abruption (n=20). Other complications included: intra-uterine growth retardation (4.6%), gestational diabetes (5.3%), insufficient weight gain during pregnancy (6.9%), pregnancy-induced hypertension (6.1%) and oligohydramnios (4.6%). Again, all are well recognized risk factors for poor perinatal outcomes.

The PMRC identified medical care provider issues, that may have contributed to the fetal death, in many of the cases reviewed. These issues included delay/lack of diagnosis or treatment (9.2%), mismanagement (8.1%) and misdiagnosis (3.8%). In addition, only 20.5% of women who experienced a fetal death were referred to a specialist for care during their pregnancy. A list of PMRC recommendations was developed during the review process (Table 1).

During the development of the process for reviewing these fetal deaths, it became apparent that lack of information was a barrier. Many death certificates list "unknown" as the cause of death,
(Table 3) therefore, the committee decided to illustrate this critical issue by reporting on the lack of post-mortem assessment that occurs. Components of a complete fetal death workup include the following items: maternal history, family history, x-rays, photos, cultures, karyotype, placental exam, maternal blood work (including torch, APLA/LAC, KB, indirect coombs) and tox screen.⁵ Table 2 illustrates the number of cases in which post-mortem assessment was accomplished.

Review of fetal deaths is an ongoing responsibility of the PMRP. Development of public health interventions using PMRC recommendations is currently underway. It is hoped that these interventions will help to prevent these perinatal tragedies and promote healthy outcomes for pregnant women in Utah.

Table 1

Committee Recommendations	Frequency
Fetal Movement Count Issues:	27
Patient education regarding fetal movement counts and prompt seeking of care with decreased fetal movement	27
Antepartum Assessment Issues:	20
Follow up for Fifth’s disease needed with 3^rd trimester ultrasound	1
Provider recognition of mild hypertension and potential association with placental insufficiency	1
With probable evidence of acute fetal vascular catastrophe, antepartum testing should be done	1
Work-up for PIH should have been more extensive	1
Need adequate prenatal screening to determine gestational diabetes	2
Provider education regarding relationship between fetal tachycardia and oligohydramnios	1
Antepartum surveillance should begin at 32 weeks in healthy pregnancy women with a history of previous stillbirth	1
Adequate antepartum assessment for discordant twins	1
Assess amniotic fluid volume with ultra sound exam	1
Assess amniotic fluid volume with non stress test	2
Continuous fetal monitoring during labor when tracing is not reassuring	1
Assess blood glucose levels in women with gestational diabetes, particularly when receiving weekly steroid injections	1
Should have had karyotype to confirm diagnosis of Trisomy 21	1
Ultrasound assessment of presumed SGA infant is necessary	1
Unrecognized IUGR	1
Diagnosis should be followed with appropriate work-up	1
No documented record of NST	1
Follow up on foul smelling amniotic fluid	1
Documentation/Communication issues:	16
Medical records needed to note reason for admission, e.g. decreased fetal movement	1
Medical records should have indicated whether fetal heart tracing was reassuring or not	1
Provider needs to dictate record if handwriting is illegible	1
With positive urine culture, need documentation of treatment	1
Inadequate documentation of any attempt to diagnose	1
Limited ability to review death as hospital lost medical records	2
Cannot determine cause of death due to lack of information	1
FAX prenatal care records to tertiary care hospital when transporting patient	1
Document how long since fetal movement detected	1
Adequate documentation of procedures in medical records	1
Better communication between referring provider and the referral hospital	1
Better communication between providers when patient is receiving care in two locations	1
Better documentation by provider of history immediately prior to fetal death	1
Better documentation of history by provider who treated Mom	1
Records need to include results of lab work	1
Post-mortem assessment issues:	10
Follow-up with placental cultures for maternal infection	1
Autopsy authorized, but no report	1
Need to document fetal weight	3
Need for autopsy	2
Parents refused autopsy	2
MRI autopsy only	1
Consult/referral issues:	7
Referral for nutritional counseling	1
High risk patients should not be managed by midwives	1
General practitioner needed to seek consultation with obstetrician	1
Pregnant women with insulin dependent diabetes should not be managed by family practice physician, should be referred to obstetrician	1
Patients with high risk OB history need to be followed by MD	1
Referral to follow up for further assessment	1
Consult or refer to obstetrician	1
Prenatal Care issues:	5
Prenatal care providers need to follow-up with no show patients, especially those who are high risk	1
Patient should have sought prenatal care	1
Better follow-up with non compliant patients	1
Need to coordinate with medicaid for transportation for patients who have a need	1
Follow-up on missed prenatal care visits (no visits for two months)	1
Medical care issues:	5
Assume knee chest position for transport with prolapsed cord	1
Close follow-up of pre existing seizure disorder	1
Follow-up on positive RPR	1
Follow-up with appropriate cultures after diagnosis of chorioamnionitis	1
Educate provider on need for insulin in patients with elevated fasting blood/urine glucose levels	1
Substance use screening/referral issues:	4
Need tox screen in patients with history of substance abuse	1
Need tox screen in patients who present with placental abruption	2
Smoking cessation referral	1
Domestic Violence issues:	2
Screen for domestic violence when patient presents with bruising, and/or abruption	2

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Table 2

Post-mortem assessment component	Frequency of occurrence (n=132)
Maternal history	90(68.2%)
Family history	50(37.9%)
Autopsy	36(27.3%)
X-Rays	1 (.8%)
Photos	2 (1.5%)
Cultures	22(16.7%)
Karyotype	13 (9.8%)
Placental Exam	65(49.2%)
Maternal Blood Work
TORCH	9 (6.8%)
APLA/LAC	8 (6.1%)
KB	15(11.4%)
Indirect Coombs	5 (3.8%)
Tox Screen	6 (4.5%)

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Table 3

Cause of Death	Frequency
Infection	1
Asphyxia	3
Maternal Condition	34
Other	37
Unknown	54

REFERENCES:

1) Division of Community and Family Health Services. Report on Maternal and Infant Health in Utah. Salt Lake City, UT: Utah Department of Health, 1997; pg. 4.2.

2) Healthy People 2000 National Health Promotion and disease Prevention Objectives. DHEW publication no. PHS91-50212. Hyattsville, MD: US Department of Health and Human Services, 1991.

3)Division of Community and Family Health Services. Report on Maternal and Infant Health in Utah. Salt Lake City, UT: Utah Department of Health, 1997.

4) Cnattingius, S., Bergstrom, R., Lipworth, L. and Kramer, M. Prepregnancy Weight and the Risk of Adverse Pregnancy Outcomes. NEJM 1998;338,3:147-152.

5) Incerpi, M., Miller, D., Samadi, R., Settlage, R. & Goodwin, T. Stillbirth evaluation: What tests are needed? Am J Obstst Gynecol 1998;178,6:1121-1125.

Review of "Late Term" Fetal Deaths, Utah, 1996 & 1997

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