Previous fetal loss and future management considerations
The rate of fetal loss in the United Kingdom historically is approximately 1 in every 200 deliveries, which is a devastating experience for mothers and families (87). Fetal loss includes intrauterine fetal demise (IUFD), defined as the absence of life in utero, as well as stillbirth, defined as the death of a fetus after 24 weeks' gestation with absence of breath and signs of life (88, 89).
In 2013, the rate of stillbirth was 4.6 per 1000 births, which was slightly decreased from 5.7 per 1000 in 2003 (87). Although there are identifiable risk factors for stillbirth and IUFD, unfortunately near 50% of fetal loss in the United Kingdom remains unexplained (87).Counselling around fetal loss includes recognition of the psychosocial effects for the mother and family, and discussion about the risk of having another stillbirth or IUFD. There is controversial evidence regarding the relative risk of recurrence of stillbirth in low- risk women with previous unexplained fetal loss, with some studies showing no increased risk, and others finding a 3.5-6-fold increased risk relative to women who have previously had a live birth (90-92).
Identifiable causes of fetal loss can be broken down into categories of obstetrical complications, fetal complications, maternal complications, and unknown causes. Obstetrical causes include placental abruption, preterm premature rupture of membranes, cervical insufficiency, maternal-fetal haemorrhage, umbilical cord complications (including cord thrombosis, velamentous cord insertion, and cord accidents), amniotic band syndrome, and placental pathology (93-95). Many of these are either difficult to diagnose in early pregnancy, or non-modifiable, making counselling around these obstetrical complications difficult for future expectations. Although one study has suggested an increased risk of unexplained stillbirth at greater than 39 weeks' gestation, and highest at 41 weeks' gestation (96, 97), delivery should be guided by obstetrical indications, as there is no concrete recommendation for timing of delivery for previous unexplained fetal loss.
Fetal complications mainly include karyotype abnormalities, with the most common being trisomy 18 and 21 (98).
Counselling regarding these fetal complications is presented at the time of diagnosis, usually prior to 20 weeks, and includes discussion of therapeutic termination of pregnancy in cases where karyotype abnormalities may lead to IUFD or stillbirth. One of the fetal complications that poses a modifiable intervention to reduce the risk of congenital malformations leading to fetal loss includes ensuring adequate counselling regarding maternal folic acid fortification (99).Maternal causes include primarily pre-existing maternal disease, maternal trauma, and infection with syphilis, malaria, cytomegalovirus, and Coxsackie B virus as potential infections that contribute to fetal loss (93, 100). It is estimated that approximately 10-25% of stillbirths in high-income countries are the result of infection, which in some cases can be preventable (100). Counselling in this area should include discussion around vaccinations, including influenza vaccine, and to counsel women regarding foods to avoid including soft cheeses, and as well as some meats and seafood products (100). Maternal diabetes and hypertensive disorders are the two most common maternal complications that have identifiable and preventable risk factors (95). Counselling around these disorders begins with identification and subsequently preconceptional management to achieve maternal health prior to the woman's next pregnancy.