The main cause of antenatal fetal death is What is antenatal fetal death and how to prevent it

Please help me understand what happened and why. A month ago, at 32 weeks, our girl was born - antenatal fetal death, intrauterine hypoxia, placental insufficiency. The girl was born EP, 920 g, placenta - 206 g.

I am 35 years old, menstruation since the age of 13, cycle 28-29 days. Height - 1.62 m, weight - 68-70 kg.
Pregnancy:
1) in 2001 - EP at 38 weeks, boy, weight - 3.0 kg.
2) in March 2013 - ST for a period of 8 weeks, honey. abortion.
3) in November 2013 pregnancy, antenatal fetal death at 32 weeks.
I. Ultrasound at 12 weeks: ktr - 63, tvp-1; NK - visualization. Blood screening showed a risk of DM of 1:85. Rarr - 0.51 MOM, hcg - 1.92 MOM. We decide to do an amniocentesis at 17 weeks.
II. Ultrasound at 17 weeks: all parameters are normal, except for NK - it is shortened and the thickness of the placenta is increased to 25 mm. We are waiting for the result of the amniocentesis. The result is a normal 46XX karyotype.
III. Ultrasound at 21 weeks: shortening of the NK (4.8 mm) and an increase in the thickness of the placenta up to 28 mm. Fetal weight - 403 g (normal). Approx. water - 125 (norm). All other parameters and organs are normal, ultrasound from the best specialist in the city. Ultrasound at 32 weeks recommended.

Feeling good throughout pregnancy, no pressure, no edema. Total weight gain - + 10 kg. The glucose test is good, I don’t remember the numbers, something about 4. I had ARVI - 2 times without fever, and the third time the temperature was 37.1 - 37.4 for 2 days at 29 weeks. All 3 times my throat hurt, I have xp. tonsillitis.
Physically, she helped at the dacha at the weekend - she got a little tired.
The last 2 weeks seemed to have little movement, she told the doctor. She asked about a small stomach, do I need an ultrasound earlier. The answer is, don't think. At 30 weeks, the trainee in the office measured the height of the fundus of the uterus - 25 cm, the doctor jumped up and measured it herself - she says 30 cm, and said that the trainee did not study well. I didn’t worry either, I believed the doctor, and the first pregnancy, although it was 13 years ago, proceeded without any complications and pills.
IV. Ultrasound at 32 weeks: no heartbeat, fetus at 25 weeks according to biometrics, IUGR grade 3, anhydramnios.

She was examined for infection (PCR) before pregnancy and during it again - all negative. According to TORCH - only immunity. The coagulogram is normal, only hemoglobin at the 21st week was 138. I asked the doctor, she said that, on the contrary, it was good.
Now, having read about FPN, I realized that I had it. It is not clear why my doctor did not see her, it could have been different. I ask questions in order to exclude such grief in the next pregnancy, I hope it will happen to me.

Questions and search for the cause:

1) Could my water leak imperceptibly, and because of this, the death of the fetus happened? At the last ultrasound, they were completely absent, where did they go?

2) Work in the country?

4) Blood donated for gene thrombophilia, 4 mutations were detected: FBG gene (g / a), PAL-1 gene (5G / 4G), ITGA-alpha 2 gene (C / T), MTHFR 677 (C / T). Maybe I need to inject LMWH? What doctor prescribes this?

5) Pressure?
Before pregnancy, the pressure was not controlled, in rare visits to the hospital with ARVI - it was 120/80 or 110/70. During pregnancy, they measured in the LCD - always the norm. But suddenly carelessly measured. I bought a mechanical tonometer - I measure it for 2 weeks - the pressure is stable 120/90. Could high diastolic pressure affect the baby and the placenta in this way?

6) Age?
What to check first of all, which doctors, so that the situation does not happen again if there is a pregnancy?

7) How soon can you plan? Only dreams that I will get pregnant help to cope with grief ...

The conclusion of the pathologist is attached.

intrauterine fetal death

death of the fetus during pregnancy (antenatal death) or during childbirth (intranatal death).

Among the circumstances of antenatal fetal death, a large place is occupied by diseases of a pregnant infectious nature (influenza, pneumonia, pyelonephritis, etc.), heart defects. hypertension, diabetes mellitus. anemia and other extragenital diseases, and inflammatory processes in the genitals. The cause of fetal death is often severe late toxicosis of pregnant women. pathology of the placenta (previa, premature detachment, malformations) and umbilical cord (genuine node), multiple pregnancy. oligohydramnios, incompatibility of the blood of the mother and fetus according to the Rh factor. Factors contributing to fetal death include chronic intoxication of a pregnant woman (mercury, lead, arsenic, carbon monoxide, phosphorus, alcohol, nicotine, drugs, etc.), misuse (for example, overdose) of drugs, hypo- and beriberi. trauma, and negative socioeconomic conditions. The death of the fetus in the intranatal period, apart from the above circumstances, may be caused by birth trauma to the skull and spine of the fetus. A striking circumstance of fetal death is more often Intrauterine infection , acute and chronic hypoxia (see Fetal Hypoxia) , fetal deformities incompatible with life. From time to time V.'s circumstance with. p. remains unclear.

A dead fetus can linger in the uterine cavity from several days to several weeks, months, sometimes years. In utero, it undergoes maceration, mummification or petrification. Approximately in 90% of cases, maceration is noted - a putrefactive wet necrosis of tissues. Quite often, it is accompanied by autolysis of the internal organs of the fetus, sometimes by their resorption. In the first days after the death of the fetus, aseptic maceration, after which the infection joins. In many cases, infection can lead to the formation of Sepsis in a lady. The macerated fruit is flabby, soft, its skin is wrinkled, with exfoliated in the form of blisters and deflated epidermis. As a result of detachment of the epidermis and exposure of the dermis, the skin of the fetus has a reddish color, and becomes green when infected. The head of the fetus is flattened, soft, with severed skull bones. The chest and belly are flattened. The soft tissues of the fetus can be soaked with liquid. The epiphyses of the bones are separated from the diaphyses. Bones and cartilage are stained dirty red or brown. V.'s indicator with. the item is a congenital atelectasis of the lungs. Mummification - dry necrosis of the fetus, is noted with the death of one of the fetuses in a multiple pregnancy, entanglement of the umbilical cord around the neck of the fetus. The fetus shrinks (paper fruit), the amniotic fluid is resorbed. In rare cases, more often during an ectopic pregnancy, the mummified fetus undergoes petrification (deposition of calcium salts in the tissues) - the so-called lithopedion is formed. or a petrified fetus, which can be in the mother's body for many years asymptomatically.

Clinical indicators of antenatal death of the fetus are the cessation of growth of the uterus (its size corresponds to the gestational age 1-2 weeks less than the real one), a decrease in uterine tone and the absence of its contractions, the cessation of the heartbeat and fetal movements, the disappearance of breast engorgement, malaise, weakness, a feeling of heaviness in a stomach. An indicator of intrapartum fetal death is the cessation of his heartbeat.

If antenatal fetal death is suspected, the pregnant woman should be hospitalized immediately. Precisely, the diagnosis of fetal death is confirmed by FCG and ECG of the fetus (lack of cardiac complexes) and ultrasound examination (in the early stages after the end of fetal death, the absence of respiratory movements and fetal heartbeat, fuzzy contours of his body, and subsequently - destruction of body structures) are revealed. During amnioscopy (see Fetus) in the first days after the end of antenatal death of the fetus, greenish (meconium-stained) amniotic fluid is detected, in the future the intensity of the green color decreases significantly, from time to time an admixture of blood appears. The skin of the fetus, flakes of caseous lubricant are colored green. When pressing with an amnioscope on the presenting part of the fetus, a recess remains on it due to the lack of tissue turgor. X-ray study is rarely used. X-ray indicators of a dead fetus: discrepancy between the size of the fetus and the gestational age, flattening of the vault and blurring of the contours of the skull, the tiled position of its bones, drooping of the lower jaw. curvature of the spine according to the type of lordosis, atypical articulation (scattering of the lower extremities), decalcification of the skeleton.

When establishing the diagnosis of antenatal fetal death in the first trimester of pregnancy, the fetal egg is removed surgically ( Scraping) ; spontaneous miscarriage is likely (see Abortion) . In case of fetal death in the second trimester of pregnancy and in case of premature detachment of the placenta, urgent delivery was demonstrated (its method is determined by the degree of readiness of the birth canal). Spontaneous expulsion of a dead fetus in the second trimester of pregnancy is rare. If there are no indications for urgent delivery, a clinical examination of the pregnant woman is necessary with a mandatory study of the blood coagulation system. Labor induction begins with the creation of an estrogen-glucose-vitamin-calcium background within 3 days. This is followed by oxytocin. prostaglandins. The introduction of funds that reduce the uterus, it is possible to combine with electrical stimulation of the uterus. Amniotomy is recommended. In the III trimester of pregnancy with antenatal death, childbirth. in most cases, they begin on their own, in other cases they perform stimulation of labor. In the postpartum period, prevention of endometritis and uterine bleeding has been demonstrated. In case of intranatal death of the fetus, according to indications, they resort to fruit-destroying operations (Destructive operations) .

At the end of the birth or removal of the dead fetus and placenta from the uterine cavity, their pathoanatomical study is performed. Macroscopically assess the color, weight, size, consistency, the presence of pathological transformations of the fetus and placenta, implement a morphological and cytological study of the placenta. In connection with cadaveric autolysis, the study of the internal organs of the fetus is often unrealistic.

V.'s prevention with. This includes compliance with hygiene rules by pregnant women (including diet and work), early diagnosis, adequate treatment of pregnancy complications, extragenital and gynecological diseases, and proper delivery. In the event of antenatal fetal death, it is advisable to conduct a medical genetic counseling for a married couple.

Bibliography: Becker S.M. Pathology of pregnancy, L. 1975; Bodyazhina V.I. Zhmakin K.N. and Kiryushchenkov A.P. Obstetrics. With. 224, M. 1986; Grishenko V.I. and Yakovtsova A.F. Antenatal fetal death, M. 1978.

1. Small medical encyclopedia. - M. Medical encyclopedia. 1991-96 2. First aid. - M. Huge Russian Encyclopedia. 1994 3. Encyclopedic dictionary of medical terms. - M. Soviet encyclopedia. - 1982-1984

Prevention of stillbirths largely consists in protecting the health of the woman, especially during pregnancy (see Antenatal protection of the fetus) and in the careful management of normal and pathological childbirth.

Stillbirth - a birth after 28 weeks of intrauterine life of a fetus with a length of at least 35 cm and a weight of at least 1000 g, which has not taken a single breath at birth. Stillborn are also children who were born with a heartbeat, but did not take a single breath, despite the ongoing measures of revitalization (fetuses born in asphyxia and not revived).

Distinguish between antenatal and intranatal fetal death. Antenatally dead include fetuses whose intrauterine death occurred in the period from 28 weeks before the onset of childbirth. Intranatal is the death of the fetus that occurs during the act of childbirth.

The causes of stillbirth are varied and not yet fully understood. Stillbirth is caused by pathological processes occurring in the body of the mother, the fetus itself and in the fetal egg.

The pathology of the fetus and changes in the placenta largely depend on the diseases of the mother, complications of pregnancy and childbirth.

In the pathogenesis of ante- and intranatal death of the fetus, asphyxia plays the main role (see), which can occur with a wide variety of maternal diseases and complications of pregnancy and childbirth. Infections matter (acute - influenza, typhoid, pneumonia, etc.; chronic - malaria, syphilis), intoxication (acute poisoning, toxicosis of pregnancy), hyperthermia, etc. In the pathological course of childbirth, cerebrovascular accidents of the fetus and the so-called intracranial birth trauma.

The combination of asphyxia and birth trauma is especially dangerous.

Etiology. In the antenatal period, the fetus may die due to infectious (and viral) and severe systemic diseases of the mother (heart defects, hypertension, nephropathy, diabetes, etc.), toxicosis of the second half of pregnancy, immunological incompatibility between the mother and fetus, and also due to anomalies in the development of the fetus, placenta and umbilical cord, with placenta previa, prenatal discharge of water and other pathological processes (see intrauterine death).

Among the causes of intranatal death of the fetus, a significant role is played by complications of childbirth with a narrow pelvis, anomalies of labor forces, incorrect positions (transverse, oblique) and various deviations from the normal mechanism of childbirth (improper insertion of the head, complications of childbirth in breech presentation and some pathological processes). Fetal death during childbirth often occurs with placenta previa, uterine rupture, eclampsia, etc.

Pathological anatomical diagnostics. With antenatal death, maceration of the skin is noted in 90% of cases. Since maceration also occurs in live births (although very rarely and in limited areas), only pronounced maceration is a sign of stillbirth. The placenta, due to the cessation of fetal circulation and the preservation of maternal circulation, becomes anemic as a result of compression of the vessels of the villi.

The most common causes of fetal death are: intrauterine asphyxia caused by placental pathology (premature detachment, malformations, large heart attacks, blood clots, hemangiomas), umbilical cord (true knots, twisting, shortness); maternal diseases accompanied by anoxemia; less often - infectious diseases of the fetus (intrauterine pneumonia with early discharge of water, listeriosis); fetal malformations or hemolytic disease occurring without jaundice. Negative hydrostatic tests are of great diagnostic value (see Live birth). The lungs of the fetus are usually fleshy and pressed to the root, less often they are completely straightened, but do not contain air, but amniotic fluid.

In intranatal death, fetal maceration and placental ischemia are usually absent. Hydrostatic tests are negative, but may be positive during artificial respiration. The most common causes of death are: asphyxia, birth trauma of the skull (ruptures of the cerebellar plaque, falciform process, subdural hemorrhages, rarely fractures of the bones of the skull) with anomalies in the position and presentation of the fetus, early discharge of water, mismatch in the size of the fetal head and mother's pelvis; rapid childbirth. Less common is a birth injury of the spine (its stretching with epi-, intra- or subdural or subarachnoid hemorrhages, less often with hematomyelia or ruptures), more often with traction of the fetus by the pelvic end. Injury to a premature fetus is also possible with normal childbirth. Fetal asphyxia occurs as a result of placenta previa or abruption, entanglement, nodulation, stretching, pressing or prolapse of the umbilical cord, early discharge of water, prolonged labor.

The presence of hyaline membranes (see), as a rule, excludes stillbirth.

X-ray diagnostics of stillbirth is mainly of forensic medical interest in the autopsy of the corpse of a newborn. Previously, sectional recognition of stillbirth was based on the absence of signs of extrauterine respiration, i.e., on the absence of lung airflow. The initial hopes of researchers for the possibility of judging the stillbirth of the fetus only by the X-ray picture of its airless lungs did not materialize, since in forensic practice there are cases of complete airlessness of the lungs in undoubtedly live births who lived for several hours. However, X-ray examination of the corpse of a newborn with great accuracy confirms the data of the pulmonary hydrostatic (swimming) test and, in this respect, has the value of an objective control method. But X-ray diagnostics of the state of the respiratory tract alone could not always be sufficient to answer the question of whether a child was born alive or dead, when his lungs turned out to be completely airless. Therefore, X-ray diagnostics in the study of the corpses of stillborns and children who died from asphyxia should consist in examining the entire corpse; special attention should be paid to the cardiovascular system. In many stillborns, gas is found in the cavities of the heart and in large vessels. This sign allows you to confirm the stillbirth of the fetus with the greatest persuasiveness. When sectioning, these gas accumulations usually do not open. If the presence of a large gas bubble in the heart can be sectionally detected by opening the corpse of a newborn under water (which is usually not done, since there are no preliminary instructions for this), then it is impossible to establish gases in the vessels in this way; radiologically they are found without any difficulties (fig., 1-4).

X-ray diagnosis of stillbirth: 1 - bell-shaped chest of a stillborn fetus; 2 - gas in the cavities of the heart and blood vessels in a stillborn fetus in the presence of gas in the stomach (direct projection); 3 - the same case in the lateral projection; 4 - putrid decomposition of a stillborn corpse two weeks after birth: a large accumulation of putrefactive gases in the subcutaneous tissue and in the cardiovascular system, in the absence of them in the lungs; in the stomach - a relatively small gas bubble.

Prevention of stillbirth. A pregnant woman is prescribed a diet that corresponds to her condition and the duration of pregnancy. A thorough examination of the pregnant woman is carried out, including serological examination (Wassermann reaction, determination of the Rh factor, detection of toxoplasmosis). When a disease is detected, timely therapeutic measures are taken, early hospitalization of pregnant women with an incorrect position of the fetus, breech presentation, multiple pregnancies, polyhydramnios, with an Rh-negative blood factor.

Antenatal fetal death is a very sad phenomenon, which is nevertheless common in obstetric practice. Fetal death can occur at any time during pregnancy. That is why information about what are the causes of this phenomenon will be useful to many.

What is the antenatal period?

The antenatal period is the period of the fetus. Its beginning coincides with the moment of fusion of germ cells and the formation of a zygote. This period ends with childbirth. It is also divided into two stages: embryonic (these are the first twelve weeks of pregnancy, when organs are laid down) and fertile, when the whole organism develops further.

Antenatal fetal death: causes

In fact, intrauterine death can occur for completely different reasons. Here are just the most common ones:

• infectious diseases suffered by the mother during pregnancy, including influenza, pneumonia, etc.;
• some diseases of the cardiovascular system, including heart defects, anemia, hypertension;
• problems in the work of the endocrine system, including diabetes mellitus;
• inflammation of the genitourinary system;
• severe toxicosis in the second half of pregnancy;
• pathology of the placenta, including its detachment and presentation;
• sometimes antenal fetal death occurs due to pathologies of the umbilical cord, for example, during the formation of a true knot;
• Rhesus conflict between the mother and child;
• polyhydramnios or, conversely, oligohydramnios;
• injuries during pregnancy, in particular a fall on the stomach;
• education during fetal development of pathologies that are incompatible with the life of the fetus;
• antenatal fetal death can occur as a result of hypoxia, when the developing baby does not receive enough oxygen;
• carried by the fetus can also be attributed to risk factors;
• sometimes the cause may be intoxication of the mother's body with heavy metals and poisons;
• abuse of certain drugs can also lead to miscarriage;
• alcoholism, smoking and addiction to drugs during childbearing also negatively affects health.

Unfortunately, doctors are not always able to determine why the death of a child occurs. In any case, a woman in this position needs help.

Antenatal fetal death and its signs

The death of the fetus in the womb is accompanied by some symptoms that are worth paying attention to. The doctor may notice that the uterus has stopped growing in size and has lost its tone. In addition, patients complain of weakness, dizziness, heaviness, and sometimes pain in the abdomen. During a routine examination, the gynecologist may notice that there is no movement.

It is worth noting that intrauterine death is extremely dangerous for a woman, as it is fraught with the development of sepsis. Therefore, action must be taken. In the early stages of pregnancy, doctors perform surgical removal of the embryo. If death occurred in the second half of the antenatal period, then it is necessary to stimulate childbirth.

Any loss of a fetus before this time is classified as a miscarriage.

The Maternal and Child Health Confidential Inquiry System defines stillbirth, a stillbirth after 24 weeks of pregnancy, and late miscarriage, a stillbirth between 20 and 23 weeks and 6 days of pregnancy. According to this classification, in 2003 there were 642,899 live births, 2,764 late miscarriages and 3,730 stillbirths in the UK, with a stillbirth rate of 5.77 per 1,000 live births.

In 2003 in the United States, when revising the ICD-10 coding of causes of fetal death, the National Center for Health Statistics classified fetal death as follows:

• early -<20 нед беременности;
• intermediate - 20-27 weeks of pregnancy;
• late -> 27 weeks of pregnancy.

In the past, different US states have used different definitions of late miscarriages, making it difficult to interpret national data.

In the US, perinatal death (stillbirth and neonatal death) occurs in 1% of pregnant women. Before 28 weeks, 10-25% of pregnancies are completed. Pre-delivery fetal death is diagnosed by the cessation of sensations of fetal movement or the disappearance of pregnancy symptoms, the former being more common. The doctor or midwife does not detect fetal heart sounds when listening with a stethoscope or Doppler machine. However, ultrasound performed by an experienced doctor remains the “gold standard” for diagnosis, and there may be errors during auscultation.

A pregnant woman may not have other symptoms and is diagnosed at a routine prenatal visit. On the other hand, a woman notices a lack of fetal movement combined with abdominal pain, as in placental abruption, or she is admitted to the intensive care unit after a traffic accident or a gunshot wound. With such different manifestations, it is important to consider the clinical picture as a whole and, if necessary, seek the help of consultants.

If fetal death is suspected during childbirth, the diagnosis is confirmed by ultrasound scanning. A possible diagnostic error is the application of electrodes to the fetal head after the disappearance of heart sounds when listening through the anterior abdominal wall with a recording device. The electrical activity of the mother's heart can be conducted through the dead fetus. This leads to misdiagnosis and caesarean section.

Common risk factors for intrauterine fetal death:

• mother's age - adolescents and women over 35;
• single mother;
• multiple pregnancy;
• a large number of births;
• another presentation of the fetus, except for the head;
• prematurity.

Anamnesis

History does not always indicate the cause of fetal death. This is a very emotionally difficult time for a woman, and if she knows that the child is already dead, taking anamnesis is not easy. Specific questions related to the patient's condition and/or pregnancy are useful for diagnosis.

Issues related to pregnancy include:

• a history of pain;
• a history of bleeding;
• problems identified during previous ultrasounds;
• possible discharge of amniotic fluid;
• serial number of pregnancy on the account, that is, the sequence of pregnancies, and multiple pregnancy.

In multiple pregnancies, the risk of intrauterine fetal death is higher than in single pregnancy. In the UK, this risk is 3.5 times higher. Sometimes one twin dies while the other stays alive. The risk of death of living twins depends on the number of chorions, with monochorionic twins it is much higher.

Questions specific to the patient's condition:

• concomitant therapeutic diseases, including diabetes mellitus, hypertension, kidney disease, thromboembolic disease and thrombophilia;
• the presence of other symptoms, including itching, characteristic of cholestasis;
• any recent infectious diseases (malaria, toxoplasmosis and parvovirus);
• recent use of prescribed medications or recreational drugs;
• injury, including traffic accidents or domestic violence. Domestic violence is revealed only if a woman wants to talk about it.

Survey

General examination of a woman - determination of vital signs to exclude sepsis, shock due to bleeding and symptoms of preeclampsia. Urinalysis for proteinuria is important.

Examination of the abdomen may reveal nothing suspicious or identify symptoms of placental abruption or local signs of damage in the mother, indicating damage to the uterus. After the exclusion of the most important diagnosis - placenta previa - a vaginal examination reveals signs of bleeding or inflammatory discharge. In this case, it is necessary to take smears for bacteriological examination.

In the UK, after the diagnosis of intrauterine fetal death, a large proportion of women choose active treatment tactics to end the pregnancy. Among those choosing conservative tactics, spontaneous labor begins within 2 weeks of fetal death in 80% of women.

It is necessary to discuss the issue of post-mortem examination of the fetus and placenta to determine the cause of intrauterine death before delivery. Parental consent to a complete fetal autopsy varies by location and cultural background. Some opt for a limited external fetal x-ray combined with a placental examination.

Pregnancy is arbitrarily divided into trimesters, although this is a collection of closely related phenomena. Common causes of fetal loss in the 1st trimester are genetic abnormalities, in the 2nd trimester - infections and in the 3rd trimester - problems with the placenta and umbilical cord. However, this is not always the case. Fetal death in the second or third trimester can be caused by one or more causes, its onset can be acute, subacute and chronic.

Causes of fetal death

In many cases, it is not possible to diagnose the underlying cause. In 10% of cases, the cause of which could not be determined, fetal maternal bleeding is assumed as the cause of fetal death in an amount sufficient to cause fetal death.

Acute

• Placental abruption (see Bleeding in late pregnancy).
• Umbilical cord injury and pathology play a role in fetal deaths (approximately 10% in one study). There is an association between excessive tortuosity (more than one umbilical cord loop per 5 cm) and thinning of the umbilical cord, leading to narrowing and reduced fetal perfusion - thin umbilical cord syndrome. Careful examination of the umbilical cord in fetal death may reduce the proportion of unexplained causes of fetal death.
• Trauma, including car accidents, gunshot, blast, or shrapnel trauma, causes maternal shock or hypoperfusion of the uteroplacental structure. These causes appear with wide geographic variations.
• Burns. In developing countries, they are accompanied by significant morbidity and mortality. The risk of fetal death is related to the total body surface burn area. Extensive burns lead to violations of the uteroplacental blood flow caused by massive acute loss of fluid by the mother's body.

Subacute

• Isthmino-cervical insufficiency. Loss of pregnancy in the second trimester is largely associated with cervical insufficiency. Worldwide, in women who have lost a fetus in a previous pregnancy due to cervical insufficiency, the cervical cerclage has been widely used, the use of which has recently been questioned. According to a recent Cochrane review, there was no conclusive evidence for the benefits of cerclage for all women. It is believed to be effective in women who are at very high risk of second trimester miscarriage due to cervical factor. These patients are difficult to identify, so some women receive unnecessary treatment.
• Infections caused by Escherichia coli, Listeria monocytogenes, group B streptococci, Ureaplasma urealyticum.
• Parvovirus B19, cytomegalovirus, coxsackievirus and toxoplasmosis. Swedish researchers recommend examining placental and fetal tissues for parvovirus B19 DNA, cytomegalovirus DNA and enterovirus RNA
• polymerase chain reaction. This is important because many women with fetal death associated with a viral infection do not have clinical signs of infection during pregnancy.
• Malaria. In areas endemic for malaria, fetal death induced by the disease is very likely.
• maternal infections.

Chronic

• Congenital malformations are the main factor determining perinatal mortality.
• Premature rupture of membranes and infection. In the second trimester, the leading cause of intrauterine fetal death is amnion infection, accompanied by placental abruption and placental insufficiency.
• Intrauterine fetal growth retardation.
• Maternal diabetes.
• Chronic arterial hypertension in the mother.
• Preeclampsia.
• thrombophilia. Fetal death in the third trimester is clearly associated with thrombophilia, especially prothrombin mutation and protein S deficiency. All women who have experienced intrauterine fetal death in the third trimester are shown a complete examination for thrombophilia.

Loss of a pregnancy at any time is devastating to the mother and her partner and triggers all phases of the acute grief reaction. The couple's biggest concern is what they could have done to cause or prevent a miscarriage, and whether it could happen again in the next pregnancy. To best explain to the woman the causes of intrauterine fetal death and the possible consequences for future pregnancy, the clinician needs a detailed and adequate study protocol.

Research methods

Research in intrauterine fetal death will depend on the equipment of the clinic.

For fetoplacental causes

• Karyotype from amniotic fluid, fetal blood sample, or skin biopsy.
• External examination of the fetus.
• X-ray examination of the fetus.
• Magnetic resonance imaging of the fetus.
• Screening for infections by examining a fetal blood sample, fetal and placental smears, or maternal serological testing for syphilis, toxoplasma, parvovirus (IgM and IgG levels against B19), rubella, and cytomegalovirus. Some of these studies are performed in early pregnancy and do not need to be repeated. The question of the cost-effectiveness of some components of this serological screening (Herpes simplex virus) is debatable, and it can apparently be resolved with an appropriate history.
• Macroscopic and microscopic pathological examination of the fetus and placenta.

Mother's examination

Blood tests:

• complete blood count;
• blood smear staining according to Kleihauer-Betka to search for fetomaternal transfusion;
• determination of anti-Rh antibodies;
• a study of the blood coagulation system (see Blood clotting disorders during pregnancy);
• determination of lupus anticoagulant;
• determination of anticardiolipin antibodies;
• thrombophilia screening;
• biochemical analysis, including urea and electrolyte levels, liver function tests, glucose and HbAlc levels.

Despite a large list of necessary studies, the cause of intrauterine fetal death remains unclear in 1/3-1/4 cases. It is advisable to warn a woman about this before starting research, especially during post-mortem examination of the fetus. In the vast majority of cases, the risk of recurrence of such an event in the next pregnancy is small. The woman should be reassured that when she and her partner are psychologically ready, she can try to get pregnant again. The couple should always be warned that the time of the expected delivery is emotionally difficult for both.