in the lit

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

The coding of underlying cause of death from fetal death certificates: Issues and policy considerations. Kirby RS. Am J Public Health 83:1088-1091, 1993.

Improving cause-of-death statistics: The case of fetal deaths. Atkinson D. Am J Public Health 83:1084-1085, 1993.

Some of you may remember Russ Kirby, who authored the first of these two commentaries: he was formerly with the State of Wisconsin and was a vigorous advocate of birth defects monitoring and of ways to improve understanding of the causes of stillbirth.

This article, and the accompanying commentary by Atkinson, provide a good introduction to the problems of assessing causes of fetal death using current methods of fetal death reporting. By surveying fetal death reports of five states, Kirby demonstrated that in 29.5% to 42.8% (varying from state to state) of the reports cause of death reported was implausible (e.g. prematurity), extremely unlikely (e.g. respiratory distress syndrome) or unspecified.

These data, together with our previous demonstration of the inaccuracy even of those causes of death which are reported (Greb, Pauli & Kirby, Am J Public Health 77:1202-1206, 1987) suggest that major changes in fetal death reporting are needed. This seems particularly so since it has been proposed that a program for the national collection of fetal death information should commence. Without some of the changes recommended by Kirby such a national registry will well reflect the adage -- 'garbage in, garbage out'.

Hemostatic variables in patients with intrauterine fetal death. Duchinski T, Pisarek-Miedzinska D, Szczepanski M. Int J Gynecol Obstet 42:3-7, 1993.

One expressed fear of allowing a pregnancy to proceed naturally after diagnosis of intrauterine death is a concern that the retained baby will cause health or life threatening coagulopathy in the mother. The

thromboplastins which are released from the dead baby can activate the extrinsic coagulation pathway in the mother.

This study assessed 41 women with an intrauterine death in order to identify how often and how long after death such a coagulopathy may develop. Only one woman had clinically significant changes in blood coagulation tests and this was after more than four weeks post documentation of fetal death.

The authors conclude that such coagulopathy is rare and rarely of significance until long after most women carrying a stillborn are delivered. They also document that simple screening by determination of platelet count and fibrinogen concentration weekly (from the time of documentation of fetal death until delivery) is sufficient.

Fear of coagulopathy is not a justification for early induction (or Caesarean section). Other factors may justify induction at some point following the diagnosis of intrauterine death but concern about consumptive coagulopathy shouldn't be one of them.

Placental pathology for the nineties. Kaplan C. Pathol Annual 28:15-72, 1993.

This review article is a thorough and comprehensive summary of the value of placental and umbilical cord assessment. It properly provides insight into some of the nuances of such evaluation and illustrates the difficulty in reaching certain conclusions about the significance of abnormal placental and umbilical cord findings.

While not limited to a discussion of the placenta in intrauterine death, it does provide a good summary of placental processes associated with fetal death.