IN THE LIT

R. M. Pauli, MD, Ph.D.

Stillbirth is no longer managed as a nonevent: a nationwide study in Sweden. Rådestad I, Nordin C, Steineck G, Sjögren B. Birth 23:209-215, 1996.

This article reports the results of a questionnaire study meant to assess how women who had delivered a stillborn infant were treated, how they perceived their care, and what options they chose regarding interaction with their stillborn babies. It does demonstrate a rather enlightened approach in hospitals in Sweden: nearly all mothers saw their babies, most touched or held, most named, most were offered remembrances (primarily photographs). When asked what else might have been offered them, mothers most often wished that locks of hair or hand and foot prints were part of the care routine. Overall about 70% felt that they had been treated well and that the hospital had good programs for support of the grieving mother. The author’s conclusion is simple: "Treating stillbirth as a nonevent has been largely, if not entirely, abandoned in Sweden." I hope that the same can be said for birthing hospitals in Wisconsin. I suspect that, in large part, it could. Indeed, data from a follow-up survey we completed some years ago show numbers quite comparable to those reported here.

It is only too bad that the authors seem to perceive that stillborn babies have only one parent (see the next commentary).

The grief response in the partners of women who miscarry. Johnson MP, Puddifoot JE. Br J Med Psychol 69:313-327, 1996.

This is one of the most extensive and well designed studies of fathers’ reactions to pregnancy loss that has been published. It deals, not with grieving following stillbirth, but after intrauterine death between 6 and 24 weeks (miscarriage by British definition). The authors emphasize that the psychological effects of miscarriage on male partners has not been well studied, and, indeed, has often been ignored; rather, if considered at all, the male’s role has often been viewed as secondary and supportive.

This investigation involves analysis of responses of 126 fathers (53% response rate) on two scales to measure the effects of miscarriage — the Perinatal Grief Scale and the Impact of Events Scale. In brief, these assessments show: a. fathers’ grief at 8 weeks after miscarriage is virtually identical in severity to that of mothers; b. pattern of responses, however, suggests marked heterogeneity, with a large proportion of men experiencing severe sense of loss and a smaller number seeming to be little affected; c. even more than in women, it seems, there is a positive correlation between duration of pregnancy and the intensity of grieving in men; d. intensity is increased in those who have seen the fetus by ultrasonographic assessment prior to the time of death.

The authors also conducted ten open ended interviews with a convenience subset of the men who responded to this survey. They were struck by the prominent ambivalence regarding grieving in many of the men. They suggest that this is at least in part because of a belief that "suffering of the woman was accepted as wholly legitimate, whereas that of the man might not be." They also confirmed that male partners tend to receive no social or institutional support, more often express anger (while the mothers more often described guilt) about the death of their child, often see their role as comforter rather than griever, and often express frustration at not being able to act or intervene ("I had this nightmare that the baby was crying inside my wife, screaming and afraid, shouting daddy, daddy, help me, help me, I’m frightened. I must have had that dream five or six times now. You see it is awful to think that I was powerless to help my baby," said one father).

That their grieving is so similar in intensity creates a dilemma, according to the authors. "The dilemma for men is psychologically different in major respects from that of their wife or partner, for they are concerned for their partner as well as distressed about the aborted child, and they feel there is an expectation that they should offer support rather than receive it."

This article is well worth reading and thinking about by anyone involved in bereavement issues, counseling and caring for families who experience miscarriage or stillbirth. PLEASE, read it.

Causes of fetal death in women of advanced maternal age. Fretts RC, Usher RH. Obstet Gynecol 89:40-45, 1997.

Older women have a higher risk for stillbirth. Why? Have those risks changed over time? The McGill Obstetrical Neonatal Database has tracked more than 100,000 hospital deliveries since 1961 providing a reasonably unbiased sample to use to try to answer such questions.

They confirm that the fetal death rate in women over 35 years is now nearly twice that of the remaining population. They document an interesting shift in the classes of cause particularly within this age group: the number of stillborn babies with lethal anomalies has decreased precipitously in this group but not nearly so dramatically in the population at large, while concomitantly, the number of stillbirths from undetermined cause has become a more prominent part of the diagnostic mix. The decrease in fetal processes is probably directly and wholly attributable to prenatal screening/diagnosis and selective termination of pregnancy. Obviously it is a lot harder to figure out why women over 35 years of age have an increased risk of unexplained fetal death (by definition, if it is unexplained then risk factors are not easily going to be identified).

What is lacking in this and many other studies are rigorous diagnostic criteria and rational categories of etiology. Those problems weaken all of the conclusions that are drawn about classes of cause.

Perinatal outcome in monochorionic twin pregnancy complicated with one fetal death after 20 weeks. Jou H-J, Teng R-J, Shyu M-K, Shih J-C, Su C-H, Chen H-Y, Hsieh F-J. J Maternal-Fetal Invest 6:145-147, 1996; Hysterotomy and selective delivery of an intrauterine dead fetus to prevent intrauterine death or brain damage of the surviving fetus in monochorionic twin pregnancy. Ito T, Kadowaki K, Takahashi H, Nagata N, Makio A, Terakawa N. J Perinat Med 25:115-117, 1997; Conservative management of twin pregnancies with one dead fetus — is it safe. Zorlu CG, Yalcin HR, Caglar T, Gokmen O. Acta Obstet Gynecol Scand 76:128-130, 1997.

These three brief articles would be an amusing triptych were the topic less serious. They all concern what the risks are to a surviving co-twin whose twin has died in utero and how one should care for such a pregnancy.

The first of the three (Jou et al.) is probably the most carefully done. It assesses 12 prospectively ascertained and consecutive instances of pregnancy complicated by the death of one monochorionic (identical) twin. Of the 12 initially surviving twins, 5 died and, of the survivors, another had severe central nervous system sequelae directly attributable to events related to the death of the co-twin. The authors convincingly argue that most deaths and complications in the second twin are related to blood vessel communication. The most common mechanism resulting in the second death is probably: death of one twin -> sudden drop in vessel resistance in that twin -> sudden shift of flow through vascular communications in the shared placenta -> the second twin becomes a secondary blood donor -> sudden decreased intravascular volume in donor -> hypotensive crisis -> death or recovery with consequent anemia and ischemic damage. Because of the considerable risks, these authors recommend immediate hospitalization, close monitoring and prompt delivery regardless of fetal maturity if any evidence of distress is detected.

In contrast, the second (Ito et al.) of these three articles suggests that emergent, selective hysterotomic delivery of the dead fetus should be done to prevent sequelae in the surviving co-twin. And the third (Zorlu et al.) recommends watchful waiting!

Immediate delivery of the dead fetus? Aggressive monitoring and consideration of delivery of the live twin regardless of maturity? Watchful waiting? Sort of makes clinical decision making difficult.