IN THE LIT

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

Predictors of fetal mortality in pregnant trauma patients. Ali J, Yeo A, Gana TJ, McLellan BA. J trauma injury crit care 42:782-785, 1997. Motor vehicle accident during the second or third trimester of pregnancy. Aitokallio-Tallberg A, Halmesmäki E. Acta obstet gynecol Scand 76:313-317, 1997. Seat belt placement resulting in uterine rupture. Astarita DC, Feldman B. J trauma injury crit care 42:738-740, 1997.

Trauma in pregnancy is certainly not the most common of causes of intrauterine death. Nonetheless, trauma, and particularly motor vehicle accidents, do arise with considerable frequency.

The first of these three articles retrospectively reviewed all pregnant trauma patients assessed at two Toronto hospitals over a 5 year period. A total of 68 patients were cared for, and 13 fetal deaths resulted among 20 women who experienced severe injuries (even though there was only a single maternal death in this group). All but one of these injuries arose from a motor vehicle accident. Most of the fetuses died because of abruption of the placenta or from direct and severe fetal injury. Similarly, among 35 pregnancies complicated by an auto accident, Aitokallio-Tallberg & Halmesmaäki describe 5 fetal deaths, all in women involved in high speed accidents and all resulting from placental abruption. The findings of these two articles are not surprising: fetal death can arise after severe motor vehicle accidents and, indeed, fetuses are particularly susceptible to these accidents; this is particularly so in those that result in additional abdominal trauma to the mother; deaths are usually secondary to placental abruption.

Some pregnant women worry about whether seat belts create special risk for their babies. That is, might seat belts cause rather than prevent fetal injury? All of the articles cited here suggest answers, and Astarita & Feldman summarize what data there are regarding both seat belts and air bags. Overall, it appears that seat belt use is far safer than not, so long as the belts are appropriately deployed: The shoulder strap should be wholly above the uterine fundus, while the lap belt should be as low as feasible, across the lower pelvis, and wholly below the bulge of the fundus. Limited experience also suggests that air bags pose no special risks of fetal death.

Nuchal cord type A and type B. Collins JH. Am j obstet gynecol 177:94, 1997.

Often a stillborn infant will have a nuchal cord around the neck. Certainly, however, cord wrappage can arise after death and so be of no consequence in understanding the cause of that death. Sometimes, however, wrappage can be so tight as to result in obstruction of flow through the cord, in which instances it can result in the death of the fetus. In the WiSSP series, 10 of the first 1206 evaluations (0.8%) found obstruction secondary to a nuchal cord as the probable cause of the fetal death. This letter points out a clinical feature of nuchal cords that may be important. Collins argues that how the cord is looped is of great relevance. He distinguishes Type A and Type B nuchal cords. In Type A the placental end of the cord crosses over the fetal end, while in Type B the placental end of the cord crosses under the fetal end. The latter pattern, according to Collins, locks and cannot undo itself. Thus, one would expect that nuchal cords if they are to become tight enough to cause obstruction of flow would be of the locking, Type B sort. The scant data that Collins presents support the apparent risk of Type B nuchal cords: 3 of 850 deliveries were complicated by Type B nuchal cords, one resulting in stillbirth and the other two associated with fetal distress requiring cesarean delivery. It may be that those with Type B nuchal cords are at very high risk while whose with Type A have little or no risk at all.

The grief of late pregnancy loss. Hunfeld JAM, Wladimiroff JW, Passchier J. Patient edu couns 31:57-64, 1997.

This is a prospective and longitudinal study of women in whom a prenatal diagnosis of a lethal anomaly was made at 24 weeks gestation or beyond. The authors assessed the prevalence of ‘severe psychological instability’ both a few weeks after the ultrasound diagnosis and months and years after fetal death and also attempted to identify factors that place women at particular risk of severe psychological distress. This is a rather well designed study, limited mostly by the relatively small number of observations and the refusal (by 9 women initially, and 14 subsequently) of some to be involved. Unfortunately, that means that only 29 of an original sample of 55 participated fully (23 refusals and 3 in whom, unexpectedly, the baby was liveborn). Two to 6 weeks after a diagnosis was made, 45% of women were judged to be experiencing severe psychological instability which persisted to at least 3 months after delivery in 22%. Furthermore, even four years later 11 of 29 showed what was judged to be clinically significant psychological distress related to their infant’s death. Quite interestingly (if not surprisingly), the authors observed that the need for medical information was bimodal — there was a need immediately following the ultrasound diagnosis and again years later. Presumably, the first interval related to the cause, character and meaning of the defects while the second involved recurrence risks etc. In contrast, the need for supportive counseling was maximal in the intervening period — particularly in the assessments that occurred 3 months after delivery. Based on their data the authors provide a list of sensible recommendations.

Gender differences in coping following loss of a child through miscarriage or stillbirth: A pilot study. McGreal D, Evans BJ, Burrows GD. Stress med 13:159-165, 1997.

While addressing an important issue, this is a flawed study, most particularly because the 52 individuals assessed were recruited from a parent support organization (not then representative of all parents), who had experienced heterogeneous losses (miscarriage and/or stillbirth) and whose losses occurred anywhere between less than one year to greater than 5 years prior to this study. The study results, then, are suspect. In general, they suggest that more fathers process grieving more quickly than mothers, that women are more likely to find ways to blame themselves for the loss, and that more men will have grief mixed with frustration and anger. The authors emphasize that unappreciated discordance in the rate and character of grieving can contribute to marital stress. Despite the flaws, the authors should be applauded for adding to the meager literature on gender differences in grieving after intrauterine death.

"Give sorrow words; the grief that does not speak
Whispers the o'er-fraught heart and bids it break."

William Shakespeare [Macbeth IV,3, 209-210]