When a Baby Dies in Utero Does It Decompose
Int J Gynaecol Obstet. Author manuscript; bachelor in PMC 2015 Jun ane.
Published in last edited form as:
PMCID: PMC4025909
NIHMSID: NIHMS572860
Assessment of "fresh" versus "macerated" as accurate markers of time since intrauterine fetal demise in depression-income countries
Katherine J. Aureate
a Department of Family Medicine, University of Michigan, Ann Arbor, USA
b Department of Obstetrics and Gynecology, Academy of Michigan, Ann Arbor, United states
Abdul-Razak Southward. Abdul-Mumin
c Section of Obstetrics and Gynaecology, College of Wellness Sciences, Kwame Nkrumah University of Science and Engineering, Komfo Anokye Teaching Infirmary, Kumasi, Ghana
Martha E. Boggs
a Section of Family Medicine, University of Michigan, Ann Arbor, United states
Henry S. Opare-Addo
c Section of Obstetrics and Gynaecology, College of Health Sciences, Kwame Nkrumah Academy of Science and Technology, Komfo Anokye Pedagogy Hospital, Kumasi, Republic of ghana
Richard W. Lieberman
b Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, USA
d Section of Pathology, University of Michigan, Ann Arbor, United states of america
Abstract
Objective
To compare provider cess of fetal maceration with death-to-commitment interval to evaluate the reliability of appearance as a proxy for time of death.
Methods
Accomplice chart abstraction was performed for all stillbirth deliveries at or above 28 weeks of gestation during a 1-twelvemonth period in a teaching hospital in Republic of ghana.
Results
Of 470 stillborn infants, 337 had adequate data for analysis. Of 47 fetuses alive on admission with death-to-delivery intervals estimated to be less than viii hours (expected to exist reported every bit fresh), 14 (thirty%) were actually reported as macerated. Of 94 cases in which the fetus was deceased on admission with death-to-delivery interval of more than than 8 hours (expected to exist diminished), 17 (18%) were described equally fresh.
Conclusion
Provider description of fetal advent may be an unreliable indicator for fourth dimension since fetal death. The findings have significant implications for stillbirth prevention and assessment.
Keywords: Fetal death, Fetal pathology, Ghana, Depression-income state, Maceration, Stillbirth, Sub-Saharan Africa
ane. Introduction
Stillbirth remains a severely understudied and grossly underreported problem in depression-income countries [1,two]. Efforts to reduce unacceptably loftier stillbirth rates in low-income nations typically distinguish between deaths occurring prepartum (before labor) and those occurring intrapartum (during labor) [3]. Advocates take long causeless that fresh stillbirths occur shortly before delivery and so might be preventable based on changes in care, resource, education, or medical access [four–seven]. These have often been considered the first priority for researchers because they may be "near misses," which—in theory—might be avoidable losses if access to adequate and appropriate care were bachelor to the female parent in time.
A reliable method to identify the estimate time of expiry and the death-to-delivery interval is challenging to obtain in low-resource settings. In community studies, verbal autopsies utilise interviews with families to register out-of-infirmary births and fetal deaths and recording the last time that the female parent perceived fetal movement every bit a proxy for time of death [8,9]. In facility-based deliveries, expiry-to-delivery interval is generally based on fetal appearance, equally assessed by the physician, nurse, or midwife at delivery. A "macerated" fetus shows pare and soft-tissue changes (skin discoloration or concealment, redness, peeling, and breakdown) suggesting expiry was well before delivery (prepartum) [one,10]. A "fresh" fetus lacks such peel changes and is presumed to accept died much more than recently (intrapartum). Recent instance series from low-income countries have described cohorts of stillbirths delivered in hospital settings and have relied on fetal appearance to classify the death equally prepartum versus intrapartum [xi–13]. Unfortunately, at that place has been no inquiry in depression-income countries to study whether this is, in fact, a valid method of assessment.
The aim of the present study was to evaluate third-trimester stillbirths at a teaching infirmary in Ghana over 1 year to compare provider assessment of fetal status at delivery (fresh or diminished) with the time between death and commitment co-ordinate to medical records.
2. Materials and methods
From June 8, 2011, to June 12, 2012, we identified all stillbirths delivered at Komfo Anokye Pedagogy Hospital (KATH), which is one of the largest teaching hospitals in Ghana and is located in the heart of the 2nd largest metropolis, Kumasi. We used WHO criteria to define stillbirth: fetal deaths delivered at 28 or more gestational weeks without signs of life at delivery [14]. The written report was function of a broader investigation of take a chance factors associated with stillbirth. We hypothesized that the labeling of a fetus as fresh would correlate well with less than 8 hours since expiry, and diminished would correlate with at least 8 hours between death and delivery. The study was canonical by the institutional review board at the Academy of Michigan and the Committee on Human being Research Publication and Ethics of the Kwame Nkrumah University of Scientific discipline and Applied science in Kumasi, which governs research at KATH. Written informed consent was not required and data were de-identified. Reporting was based on STROBE guidelines [17].
The main reviewer (A-R.S.A-Chiliad.) visited the wards several times weekly throughout the twelvemonth to collect data from paper charts and to discuss cases with the midwives on duty in lodge to backup missing data and assess issues with staffing and personnel availability during the time of the patient's stay. For each fetal expiry, the reviewer abstracted the mother's nautical chart to identify maternal demographics and past medical history; prior pregnancy outcomes; prenatal intendance and labs in the current pregnancy; referral source; admission information; commitment information; complications; and potential contributors to death. A second reviewer (K.J.M., Chiliad.Due east.B.) re-bathetic data from approximately thirty% of charts to ensure accurateness, to fill up-in missing information points, and to confirm outlying data. Information were initially recorded on a written datasheet and then entered into a reckoner database (Admission version xiv; Microsoft, Redmond, WA, United states of america) and triple-checked for data entry accuracy.
In virtually cases, we could identify whether the fetus was alive at access to the hospital (yes/no) and the status on admission (whether in labor and whether membranes intact). Time of last fetal movement and time of labor onset were not documented for most cases, so we could rarely identify whether pre-infirmary deaths were prepartum or intrapartum. Nosotros also coded whether the fetus was identified as fresh or macerated based on the delivering team's (physician or nurse–midwife) cess of the infant recorded in the paper chart.
For all deaths, we collected data (when available) documenting day and time of admission, concluding documented positive fetal eye rate (FHR—recorded at the study infirmary via ultrasound, Doppler, or fetoscope), fourth dimension when intrauterine fetal demise (IUFD) was diagnosed, and time of delivery. While nosotros had access and commitment dates for most infants, information on last FHR and time of fetal decease were express, and in about cases applied to infants who were alive on access.
In some cases, it was unclear from charts whether the fetus was alive on admission, and not all deliveries listed fetal condition at commitment; therefore, from the initial 470 fetal deaths, nosotros restricted our assay to cases for which these data were available. This left 337 stillborn fetuses in the cohort for analysis (72% of the original dataset).
When the fetus was dead on admission, nosotros assigned the time of decease equally the fourth dimension of admission unless we had additional information (eastward.thousand. ultrasound prior to admission) that confirmed the time of IUFD. If nosotros had an ultrasound documenting a alive baby prior to admission, we calculated both a minimum expiry-to-delivery interval (fourth dimension from IUFD diagnosis until delivery) and a maximum expiry-to-delivery interval (1 hour after the last positive FHR was recorded).
When the fetus was alive on admission and the FHR was not rechecked before delivery, we assigned the time of decease as 1 hr after the last documented FHR. If the infant was alive on admission so diagnosed every bit IUFD during labor, we calculated a minimum death-to-commitment interval equally time betwixt IUFD confirmation and delivery. We calculated the maximum death-to-commitment interval equally 1 hour subsequently the last positive FHR and delivery. Sample cases illustrating calculation of minimum and maximum death-to-delivery intervals are described in Figure i.
Calculation of minimum and maximum death-to-delivery intervals for sample cases. Abbreviations: IUFD, intrauterine fetal demise; FHR, fetal centre rate.
Nosotros used eight hours as our cutoff fourth dimension based on the nearly usually used maceration criteria described past Langley [15]; this is too the timing mentioned in the practice guidelines for perinatal autopsy for the Dissection Committee of the College of American Pathologists [16]. If both the minimum and the maximum decease-to-delivery intervals were less than 8 hours or both were more than 8 hours, the nomenclature was straightforward. In a small number of cases, the minimum death-to-delivery interval was less than viii hours and the maximum was more than eight hours; in such cases, we reviewed the clinical scenario and determined the most likely timing.
Analysis to evaluate summary statistics was performed using STATA/IC version xi.0 (StataCorp, College Station, TX, Us).
3. Results
In that location were 465 mothers who delivered a stillborn fetus at 28 weeks or later at KATH during the study menstruum (Table ane). Ii-thirds of pregnancies were dated by fetal ultrasound and the rest by last menstrual period. Of these mothers, 443 (95%) had a singleton pregnancy, 20 had twins, and 2 had triplets. In most cases with multiples, only 1 fetus died. In 5 cases (all twin deliveries), both fetuses died. This resulted in a total of 470 stillborn fetuses. As noted, the analysis was restricted to the 337 fetuses with adequate information for analysis. The maternal demographics of this subgroup were non essentially different from those of the total group of mothers in the dataset.
Table i
Demographics of women (n=465) who delivered stillborn fetuses a
| Characteristic | Value |
|---|---|
| Age, y | 29 ± 6 (xiv–46) |
| Marital status | |
| Married | 194 (41.vii) |
| Living together | 92 (19.8) |
| Never married | 95 (xx.4) |
| Widowed | ane (0.2) |
| Data missing | 83 (17.8) |
| Principal residence | |
| Urban | 317 (68.2) |
| Rural | 44 (9.v) |
| Data missing | 104 (22.4) |
| Education | |
| None | 65 (xiv.0) |
| Primary school | 165 (35.5) |
| Center or junior secondary school | 161 (34.6) |
| Senior secondary school or higher | 38 (eight.2) |
| Information missing | 36 (7.seven) |
For the 71 fetuses identified equally being alive on admission, the time between death and delivery ranged from 0 to 275 hours (Figure 2). In 47 cases, the death-to-delivery interval was less than 8 hours: 33 (seventy%) fetuses were fresh and fourteen (30%) were macerated. In twenty cases, the death-to-delivery interval was more than than 8 hours, one-half of which were fresh and half diminished. In four cases, the decease-to-delivery interval (more or less than 8 hours) could non be definitively determined, then these cases were not analyzed.
Distribution of fresh and diminished stillbirths according to death-to-delivery interval.
Of the 266 fetuses that were expressionless on admission, 172 had less than 8 hours from admission to delivery but we could not rule out the possibility that the fetus had died long earlier the mother presented to the hospital. Therefore, these cases were non analyzed. Of the 94 fetuses with a expiry-to-delivery interval of at least eight hours, 17 (18%) were reported as fresh, including many known to accept been dead 24 hours or more, and 77 (82%) were reported as diminished.
The Wigglesworth criteria for cause of expiry in cases of stillbirth exclude fetuses with visible congenital anomalies [18,19]. We chose non to exclude fetuses with anomalies (n=21) because these were a small subset of the overall full and their classifications were not significantly unlike from the overall ready of stillbirths.
iv. Discussion
The present study demonstrated that appearance may non be an accurate proxy for death-to-delivery interval or prepartum versus intrapartum demise. Especially among fetuses noted to exist live on admission to the infirmary, one-third of those that would exist anticipated to exist fresh stillbirths were reported as macerated, and half of those that would be expected to exist diminished were really described equally fresh.
When a fetus dies in utero, there are changes in the skin and tissues—termed fetal maceration. This process takes place entirely in the womb and stops once the fetus is delivered [x,16]. The phenomenon of maceration was starting time described in 1922 as loss of the vernix and and so pare peeling [20]. In 1971, Langley [fifteen] discussed levels of maceration and noted that peeling skin is associated with death of at least 8 hours; this is the most common classification system utilized. Practice guidelines for perinatal and pediatric autopsy past the Autopsy Committee of the Higher of American Pathologists also uses the viii-hour cutoff [16]. Genest and Singer [20] identified 60 fetuses for which exact times of death and delivery were known and photographs were available. The authors described detailed changes in skin colour, desquamation, and collapse of the skull based on decease-to-delivery interval. Early signs of maceration (desquamation of more than one cm and cherry/brown cord discoloration) began at 6 hours post-death. However, in their study (the only 1 in the literature to make this comparing), decease-to-delivery interval was miscalculated in nigh 1-third of 26 "test" photographs of stillborn fetuses. These aforementioned criteria were recently used in a major The states written report on stillbirth [21]. A key reference volume for fetal pathology as well mentions vi–viii hours as the earliest signal when signs of maceration are seen [22].
Almost studies of stillbirth that evaluate maceration do and then without detailing a specific definition. Lawn et al. [1] reported that a fresh stillbirth implies decease less than 12 hours earlier delivery, only this appears to be a clinical judgment. Maceration is a subjective diagnosis; while all providers are likely to describe a fetus with extensive skin desquamation and skull collapse as macerated, categorization may be less clear for a fetus with minor skin changes or skin slippage.
Maceration tin can too exist an imprecise predictor of timing of death for technical reasons. Loftier microbial load in the amniotic fluid, long duration of hypoxia prior to bodily death, and maternal fever might all contribute to more than maceration than would otherwise be expected for a certain death-to-commitment interval. Many studies describe the rate of postmortem man decomposition, but none describes detailed events betwixt IUFD and delivery. We can, nonetheless, extrapolate basic theories about factors that accelerate human decomposition to those impacting fetal demise. Most notably, autolytic changes may occur faster nether the increased temperature with maternal hyperthermia/sepsis associated with prolonged rupture of membranes. Similarly, if the fetal death is a result of fulminating bacterial infection (chorioamnionitis due to prolonged rupture of membranes), accelerated putrefaction (decomposition) can also be expected [23].
In customs-based studies, verbal dissection is used to estimate population-based rates of stillbirth past asking women when fetal motion stopped [9,24]. 1 study on the accuracy of exact autopsy in 311 cases of stillbirth suggested that verbal autopsy and hospital-identified time of stillbirth were in concordance in 94% of prepartum deaths and 85% of intrapartum deaths, although the report used only fetal appearance of fresh versus macerated for some of the cases [ix]. Ellis et al. [25] utilized exact dissection to compare maternal written report of when fetal move stopped with maternal description of the fetus every bit fresh or macerated. Of 201 fetuses moving when labor started, 24% were described as diminished. Of the 117 fetuses non moving when labor started, 34% were described as fresh.
The present report had several limitations. First, the quality of medical nautical chart data in low-resource settings is variable and key data points were often not recorded, so the cases were excluded. This is a widespread barrier to data collection in low-income countries and reflects the reality of the working conditions and the challenges to conducting research in countries with the highest need for data. Second, the assay was performed at a major hospital with 14 000 deliveries each twelvemonth. Like about hospitals in Sub-Saharan Africa with this volume of deliveries, there was no equipment for continuous monitoring of FHR, which would let precise estimation of time of death. Third, at that place were a express number of midwives and physicians at the written report hospital and throughout Ghana and then, even with intermittent monitoring, there can be long gaps between assessments of FHR. 4th, no stillborn fetus in the nowadays written report had a postmortem autopsy, which would have allowed more precise identifications of time of death and fetal advent.
Strengths of the written report included the capture of all stillbirths over a 1-year period at a large urban hospital, as well as collection of systematic data on maternal demographics and hazard factors, pregnancy care, delivery complications, and hospital variables. Few hospital-based studies collect such detailed information, despite it enabling richer understanding of these deaths.
The present large and comprehensive report to assess fetal advent as a predictor of death-to-delivery interval indicates that such practice may exist problematic. Although intrapartum fetal demise has been seen equally a prime number target for stillbirth prevention, nosotros would caution against assuming that fetal appearance accurately indicates intrapartum deaths. Health facilities in low-income countries have enormous resource challenges to providing clinical intendance, and data collection is often a low priority. Even so, as the present written report shows, medical records that place accurate timing of positive FHR and diagnosis of fetal demise could provide critical data to focus efforts toward measuring and improving stillbirth outcomes worldwide.
Acknowledgments
Funding for travel was provided by grants from the University of Michigan Global REACH function and the University of Michigan Institute for Research on Women and Gender. K.J.Yard. received salary support from the National Institutes of Health as role of a K-23 training grant. No funder had a role in assay of results or grooming/review of the manuscript.
Footnotes
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Disharmonize of involvement
The authors accept no conflicts of interest.
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