So today we had a nice sit-down with Dr. M. I didn’t know what building his office was in, but considering he does maternal fetal medicine I figured it would be somewhere close to the maternity building. When we got there I asked where I might find the office and they directed me to the back… to the same waiting room as my midwives. I checked at the door and sure enough it also lists maternal fetal medicine. Shortly I was called back by the same nurse as I always do, and she took my blood pressure and weight. I almost asked, “Ummm, you know I’m here to have a consultation with Dr. M? Right?” but I didn’t. We were seated in the conference room… the same room I had sat in that day 8 weeks ago, waiting for Den to arrive. “I remember this room,” he said to me as he looked around. Oh yes, we remembered.
Dr. M. gave us copies of the reports, which I was very appreciative of… I like having copies of everything for my records – little quirk I aquired while going through infertility. I’ll write down the important parts (which may be quite technical), then I’ll write about what Dr. M. said and the future outlook.
2250 gram, 35 week, 4 day, gestational age, stillborn phenotypically male fetus
– crown-rump length: 26 cm (mean 30.0+/-3.9 cm)
– crown-heel length: 44 cm (mean 43.5+/-5.8 cm)
– foot length: 7.0 cm (mean 6.7+/-0.9 cm)
[Blah blah technical stuff] suggesting a period in the range of 4 days – 1 week death-to-delivery
Placenta:
– 248 gram ovid placenta ( mean weight for 35 weeks: 420 +/- 75 grams)
– P/F ratio 1:8.5 (mean P/F ratio 1:6.2)
– Dimensions: 15.0 x 11.0 x 2.0 cm.
Umbilical Cord:
– 62 cm 3 vessel umbilical cord (mean length: 52.5 +/- 11.2 cm)
– Dusky discoloration of umbilical cord
– Edema of Wharton’s jelly
– Amniotic band, constricting cord from 1.5 to 0.3 cm in diameter
Membranes:
The amnion is largely detached from the chorion and is fragmented into elongated strips. One of these strips is tightly wrapped around the cord.
Cytogenetics:
– Normal, 46 XY, male karyotype
Comment [from Pathologist]:
The fetus was the stillborn male weighing 2250 grams, born to a 30 year-old G1P0 mother (uhh wha? Wrong age there). At 35 4/7 weeks of gestation the mother was admitted to the hospital for induction of labor due to intrauterine fetal death. The pregnancy had been uneventful except for inadequate weight gain during pregnancy.
The most significant pathological findings were present in the placenta with minimal abnormal findings in the infant. Microscopic sections of fetal viscera exhibited autolytic changes with loss of nuclear basophilia of the liver, adrenal glands, gastrointestinal tract and kidneys sparing the primitive glomeruli suggesting a death-to-delivery period in the range of 1-2 weeks. Major anomalies were not identified, consistent with the normal 46,XY male karyotype.
The placenta was noted to be small for dates. Small placentas have been associated with increased risk for low birth weight. Maternal hypertension, poor maternal weight gain, fetal anomalies, and accelerated villous maturation have been cited as antecedents for decreased placental growth, either with or without fetal growth restriction. The P/F ratio indicates good fetal growth in utero with respect to placental size, although both are small for dates. Poor maternal weight gain is identified as a possible risk factor.
The umbilical cord length was of normal length with respect to the gestations! age, suggesting normal fetal movement prior to fetal demise. The umbilical cord was discolored with the presence on an amniotic band, constricting the cord from 1.5 to 0,3 cm in diameter. The gestational membranes were fragmented with presence of amniotic bands.
In summary, the small placenta is a concern and further clinical correlation is suggested in order to determine factors which may have compromised placental grown as this could be a risk for future pregnancies. However, the increased P/F ratio indicates good compensatory growth by the fetus. Although placental insufficiency may have been a problem had the pregnancy continued and the presence of nucleated red blood cells may reflect fetal ischemia, the diminished placental mass does not appear to have been the immediate cause of the poor outcome. The presence of amniotic bands surrounding the umbilical cord and extending from the gestational membranes most likely explains the fetal demise. Hypoxia secondary to cord compression by a constricting band surrounding the umbilical cord is the likely cause of death in this case.
Basically there are two major things to take from this all, and one minor thing of interest, if you could call it that.
The first, the major, is like I wrote before: what killed Devin was that the inner sac (amnion) was ruptured, creating amniotic bands, one of which wrapped very tightly around his umbilical cord. Dr. M. said that all the other test results and findings are pretty much incidental. There is no known cause for amnion rupture, other than cutting or piercing the amniotic sac (such as an amniocentisis, which we did not have). Sometimes it just happens. He said that there are roughly 10,000 births per year in the valley, around half of which are seen by this hospital. Almost all high-risk cases go through this hospital. So he pretty much sees everything. He sees amniotic bands maybe once a year. I asked him how often do the amniotic bands kill the baby – he said very very rarely. Usually it causes deformations or sometimes it doesn’t do anything. But once in a while you get what happened to Devin.
The second major thing is that the placenta was quite small. Now that doesn’t have anything to do with the amniotic bands and it didn’t lend a hand in his death; however, had he lived, that small placenta could have caused problems down the road. He said the baby’s size was normal, so despite the small placenta he was compensating and still growing appropriately. But as you get to term and overdue the small placenta might have started to cause more of an issue. So this, then, is something to be watchful of in my next pregnancy – it is something that they will monitor.
The third item was the blood results that came back. I don’t have a copy of them, but he went over them with us. Basically everything was negative, except for some common Herpes strain that has no effect on a baby (it just means that I’ve contracted it at some point in my life). The noteworthy part, to me, was that I do not have any immunity to CMV. What’s CMV you might ask? CMV is the virus that my best friend got during her pregnancy, which has caused major issues for her son (premature birth, 7 weeks in the NICU, and possible long-term mental disabilities that as of yet is completely unknown). Dr. M. said it’s something I’ll need to be aware of in future pregnancies, practice good hand-washing, but that I “can’t live in a bubble.” (I replied that it’s tempting to try to!)
Toxoplasmosis was negative, I’ll add, which is a relief because I do work with cats, and while I did take every precaution to avoid contracting toxo while pregnant (avoiding all literboxes at work and home) I still worried that somehow I had done something wrong. Negative for clotting disorders, there was no clotting problems in the placenta or baby. That’s good. My thyroid panel was normal.
We talked to him a little about IVF, Den explained how we used our insurance and the federal government loophole from the mandate, etc. He’s just appalled that we don’t have more coverage. He asked about our diagnosis, what treatments we tried, stuff like that. He’s also going to send a copy of the death report to the RE for us, so at least they’ll have that.
Then he talked with us for a while about what is required/recommended/offered during a subsequent pregnancy when we do get there. First of all, because of the placenta issue he recommends following the baby’s growth (and measuring the placenta or something) via ultrasound throughout the pregnancy (“serial growth ultrasounds”). Then, what they usually do in the case of pregnancy after a stillbirth is frequent U/S and NSTs around the time that the previous baby died, so for me it would be around 32-36 weeks. This is more for our sake than for a medical need to check on the baby, since in our case what happened was a total freak accident and really not very detectable during ultrasound anyways – I asked. He said sometimes these bands can be seen on ultrasound, but usually they are seen when no one is looking for them… and most of the time these bands go undetected until birth unless they cause some sort of major defect in the baby that can be seen by ultrasound. I mentioned renting a doppler, and he said we’re welcome to come in as often as we want to to listen to the baby’s heartbeat, even if it’s once a week or more frequently.
He also said that when a baby is known to be healthy and you’ve gotten past the point where you lost the previous child and the baby is full term the couple usually wants the baby out; that waiting around past due greatly increases anxiety level. He said in this case they would induce once the baby is term (around 39 weeks or further), if you want to be induced. He said it’s certainly not recommended, induction comes with risks of its own, but a lot of people opt to do that. That is something we’ll have to take as it comes. I am by far not a fan of induction for no medical reason. But bringing home a live baby… instead of waiting around for the worst to happen… well, I don’t know. We’ll see. I also mentioned my induction and how quickly it went, how easy it was – he said that my body was probably pretty primed and ready to go into labor on its own anyways. That’s what I was figuring, really… I felt that morning that something was starting, some cramping/contractions. Even though I wasn’t dialated when I was admitted, I’m willing to bet that my body was right on the edge and that’s why it responded so well to the induction. If I were induced before my body was ready the results might not be quite so favorable.
So there it all is. We have a pretty good plan in place for my next pregnancy, it seems I’ll be getting a lot of ultrasounds. Of course I am well aware that even highly monitored there’s still a chance something could go wrong. But I knew that before Devin died (well, not in quite the same way). But in the case of the unpredictable, it’s either going to go right or it’s not and there’s not much you can do about it. Chances are things will be fine, and I have to just function on that knowledge.
Now getting pregnant, on the other hand…. I’m afraid the chances are much more hazy in that direction. Sometimes I think I’m being completely foolish, hoping that something will happen naturally and spontaneously. So I guess we hope for the best while preparing to tackle IVF sometime in the future, somehow.