Death in utero: causes, risk factors, prevention

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Philippe Gloaguen
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In Of The Country one pregnancy in about every 300 it does not end as everyone expects it to end - that is, well, with a new happy family - but with the death of the baby in the mother's womb: fetal intrauterine death, or stillbirth, is the technical term used to describe this tragic event. We have tried to clarify the causes, risk factors and prevention strategies, with the help of scientific documents and the gynecologist Laura Avagliano, contract professor at the University of our city and expert in fetal death.



In this article

  • Meaning of stillbirth
  • The frequency
  • The causes
  • The risk factors
  • What happens if the fetus dies
  • Prevention strategies

Stillbirth, a definition

By stillbirth we mean a fetal loss that generally occurs at an already advanced stage of pregnancy, beyond the first trimester for which the risk of spontaneous abortion is well known.



"However, it is more difficult to give a precise definition, which is lacking even at the international level", says Avagliano. Thus, for example, the World Health Organization speaks of "stillbirth" after 22 weeks of pregnancy, while some countries use 20 or 24 weeks as a discrimination. "In Del Paese the reference often used is that of Istat, set at 180 days, that is, at 25 weeks and 5 days".

This is no small matter, because having certain definitions allows us to work better, from the point of view of research and health policies. Outside the world of research and healthcare, however, for the individual families affected by this dramatic event, the week of pregnancy in which it occurred does not change things much.

“Whether it's what we call a miscarriage at 10 weeks, or a stillbirth at 26, that mom and dad have lost their baby,” Avagliano acknowledges.

The data: the frequency of the phenomenon

In Of The Country stillbirth is estimated to affect 3-5 families for every 1000 expectant families, with some regional differences. "In a somewhat crude way, we can say that the rates are slightly higher in the South" explains Avagliano.



According to the estimates published by the prestigious medical journal Lancet, which in 2022 dedicated a special series of articles to this topic, in 2022 alone all over the world two million and 600 thousand children died in the third trimester of pregnancy or in childbirth. More than 7100 per day. Globally, low-income countries are the most affected by the phenomenon (98% of total stillbirths are poor countries).

The causes: what causes stillbirth

From a purely theoretical point of view, Avagliano distinguishes three main causes of stillbirth:



  • maternal causes: "These are diseases or conditions of the mother, which can complicate the pregnancy and lead to fetal loss. For example maternal hypertension that can give rise to preeclampsia";
  • fetal causes, such as fetal growth retardation or the presence of infections (for example toxoplasmosis, rubella, cytomegalovirus, herpes simplex or parvovirus);
  • cause placentari, such as a placental abruption.

"However, it is clear that this is a somewhat artificial subdivision, because in pregnancy the mother, fetus and placenta are one and the same. If there is a maternal problem, this could affect the placenta, causing consequences for the fetus and vice versa. And in the same way, a placental problem hardly arises 'out of nowhere': more often it is the indicator of a maternal disease that had not yet been identified ". And again, if we think about infections it is obvious that in the first place these affect the mother and only if they pass to the fetus can they prove dangerous.

Read also: Pressure in pregnancy

In the vast majority of cases, to clarify what led to the death of a child in the mother's womb, it is necessary to work in three directions: accurate analysis of the clinical situation of the mother in general and especially during pregnancy; histological analysis of the placenta; fetal autopsy. "Where these procedures are followed scrupulously and carefully, the cause of fetal mortality is usually identified," says Avagliano.

However, this does not always happen. "Even if several years ago a group of experts had drawn up valid operational indications distributed by the Ministry of Health in all the birth centers, official Del Paesene guidelines on the subject have never been formulated. Thus, much depends on the center in which you give birth "explains the gynecologist. "Some centers follow American guidelines, others English ones or their own internal protocol and still others do not follow any particular path, so it becomes really difficult to understand what happened."

Cord knots and cord loops around the baby's neck: can they cause stillbirth?

A common belief about stillbirth is that in many cases it is caused by a choking on the part of the umbilical cord if it is knotted or tightened around the baby's neck (the famous "turns of the cord").

"In reality the situation is more complex than that" explains Avagliano, using a suggestive metaphor. "Let's think about men with ties: in the vast majority of cases, having that noose around their neck does nothing wrong. But if the tie gets caught somewhere and the man cannot free himself, then he can be suffocated. ".

In other words: knots or bead turns can represent a risk factor, but generally they act in conjunction with other factors and in any case it should never be taken for granted that they are, alone, responsible for an event of stillbirth. "This can only be said after carrying out accurate analyzes and verifying that the knotting actually caused slowdowns or interruptions in blood flow. From the data available to us, referring to 286 deaths in utero in the last 20 years, For example, it emerges that in the face of 15 cases of knots or turns of the cord, only 8 had led to an actual interruption of the flow. In the other cases, the causes of death were other ".

What happens, however, is that often the knots or turns of the cord are taken as an 'alibi' for stillbirth, avoiding carrying out subsequent investigations that could clarify the real cause of the child's death: a very important information for the couple, if they want to face a new pregnancy.

The risk factors


Are there any conditions that increase a baby's risk of stillbirth? Yes I'm here. Of course, it doesn't mean that the mom with those conditions will definitely lose her baby, just that there is a greater chance of this happening than someone who doesn't. Conversely, stillbirth can strike even in the absence of risk factors.

Some of the risk factors for fetal loss have to do with any pre-existing illnesses of the mother, others with particular aspects of the lifestyle. Let's see them:

  • presence of particular maternal diseases, such as hypertension, diabetes, autoimmune diseases such as systemic lupus erythematosus and antiphospholipid antibody syndrome. "In these cases the health conditions of the woman can worsen during pregnancy and this can lead to complications of the pregnancy itself, including death in the uterus" explains Avagliano.
    "For this reason it is important that in the presence of a chronic disease the search for a pregnancy is planned as much as possible, so that it occurs at a time when the disease is well compensated and in a silent state". Among other things, the programming allows to intervene also on the pharmacological front, to propose to the woman i less problematic drugs with respect to a possible pregnancy;
Read also: Aspirinetta in pregnancy: what it is for, when to take it, when to stop
  • cigarette smoke: “It is now well known that it is associated, among other things, with alterations in the mother's pressure that can interfere with the growth of the baby and with the correct functioning of the placenta”;
  • obesity: “In general this condition is a risk factor for metabolic diseases such as diabetes and hypertension, which in pregnancy represent risk factors for the fetus. This is combined with a generalized inflammatory state and a worse level of oxygenation ";
  • maternal age. But beware: it does not mean that mothers over 35 or over 40 have to experience their pregnancy in terror. Simply, knowing that this risk factor also exists must be an incentive for those following pregnancy to propose some more controls and to insist more on the quality of the lifestyle.
Read also: Mom at 40? Here's everything you NEED to know

What happens if the fetus dies

"I'm sorry ma'am, there is no heartbeat." For many mothers, for many couples, this is the phrase that announces that their baby is gone and marks the beginning of a painful path in mourning. But what happens from a medical point of view? How is that child to be born?

Childbirth

"If there is also a danger to the mother's life, a caesarean section is immediately intervened to safeguard her survival and health" explains Avagliano, underlining that however this happens in a minority of cases. Often, this danger is not there. "Then the mother can also go home for a few hours, if she prefers, and then go back to the hospital for the birth. If the clinical conditions allow it, the best thing to do would be to give birth vaginally (after induction), because compared to a caesarean this protects more the future reproductive health of women".

"Of course, it may seem absurdly nastiness to ask a woman who has lost her baby to also undergo the pain and fatigue of childbirth, but it must be explained to her that, if there are no other reasons for having a caesarean, this is the way. safer and more protective for her health Obviously, if the mother asks for it, everything will have to be done for relieve the physical pain of labor as much as possible, even with the epidural ".

And after the birth?

"According to international indications on the subject, the family that, after birth, has the possibility of be with the baby he is able to better realize what happened and to better elaborate the mourning. But be careful: it does not mean that this must be imposed on the family, on the mother, who may be afraid of the idea of ​​seeing her child dead at the start. But it is true that when you explain exactly what to expect (that the baby is still beautiful, warm, that you can decide to touch it or not, that you are not obliged to do anything anyway) many mothers and fathers decide to say hello and declare themselves then grateful to have been able to do it ".

Read also: How long to wait for a new pregnancy after stillbirth?

Prevention strategies


"Obviously - underlines Avagliano - those who have already known risk factors such as the presence of a chronic disease or the fact of having suffered a stillbirth in a previous pregnancy, will be addressed to specific assistance paths in specialized centers, which include more checks and, when possible, targeted therapies. Maybe to start before a pregnancy ".

But the prevention of pregnancy complications is something that should concern all women, and that should involve all of society (although this is not always the case).

There are not many fundamental indications to start a pregnancy in the best possible way:

  1. Try to program it as much as possible, so as not to be found "unprepared" for situations that could prove to be critical;
  2. Request a preconception visit, in which they will be prescribed blood tests specific, all to focus on the presence of any risk factors, such as the state of immunity with respect to particular infectious diseases such as toxoplasmosis or rubella. "If you are not immune to rubella - advises Avagliano - the indication is to get the vaccine before starting the search for pregnancy. And if you are not immune to toxo it can be implemented immediately, from when you start look for it, those preventive measures that reduce the risk of contracting it (wash the vegetables well, do not consume raw meat, wear gloves for gardening ...) ".
    Many women require a preconception visit to their private trusted gynecologist, but with the referral of the general practitioner it can be safely requested in the hospital, where it will be paid by the National Health Service. The same goes for preconception examinations.
  3. Try to take folic acid for a few months before conception;
  4. Stop smoking;
  5. Take care of the power supply.

E when there is pregnancy, there are two other small measures that can be put in place to reduce the risk of stillbirth:

  1. Sleeping on your side: the left is generally recommended, but the right is fine too. The important is avoid the supine position, which by making the mother's body weigh on her blood vessels could reduce the flow of blood to the fetus. Again, this does not mean that sleeping on your back alone is enough to cause stillbirth, but it can be a risk factor if the fetus is already fragile for some other reason.
  2. Pay attention to fetal movements. "Each child has his own rhythm and his mother soon learns to know him" explains Avagliano. "If you notice that this rhythm changes - that for example a child who was very lively, an 'earthquake', becomes slower or remains motionless for longer periods than usual - it is worth getting checked. Even at risk. to be taken for anxious mothers ". In many cases, fortunately, it will be discovered that there is nothing wrong, but sometimes critical aspects may emerge on which to intervene to avoid the worst.

Other sources for this article: Lancet series on stillbirth (2022); English guidelines on stillbirth; article Making stillbirths visible: a systematic review of globally reported causes of stillbirth, published in BJOG (Nov. 2022).

To learn more

  • How to deal with perinatal death
  • Death in utero, the testimony
  • How long to wait for a new pregnancy after stillbirth?
  • Perinatal death and stillbirth: that's why women need to talk

TAG:
  • stillbirth
  • termination of pregnancy
  • perinatal bereavement
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