Stillbirth: Who is at greater risk?

Alice Umuhoza, a mother of one and resident of Kimironko, says the loss of her baby during birth was too painful. Umuhoza says delays and prolonged labour led to the death of her baby. “Can you imagine carrying a child for nine months without any problem and then she suddenly dies during delivery due to avoidable circumstances? It was the worst experience of my life and I would not wish it on any woman,” she says. The loss of her baby plunged her into depression; and eventually had to deal with prolonged trauma as a result. What causes stillbirth? According to Emmanuel Ssemwanga, a gynaecologist/obstetrician at La Croix Du Sud Hospital in Kigali, Umuhoza’s case is among the many causes, if not well managed, brings about stillbirth. However, he points out that most times, he encounters cases where physical assault of pregnant woman leads to the death of the foetus in the womb. “I have experienced quite a number of incidents where a mother has to deliver a dead baby due to trauma. Most of the time, they were hit by their spouses in the stomach, creating trauma to the foetus and posing a risk for the woman to deliver a dead child,” he says. He explains that for one to have a stillbirth, there are other factors that contribute to that. Ssemwanga says these factors can be categorised in two; the first one is known as antepartum complications, where the baby dies during the period of pregnancy, while other factors are known as intrapartum complications, which happen during delivery time. “The baby can be fine during the entire pregnancy period, and during delivery due to complications, the baby dies,” he says. Antepartum complications One of the most common causes under antepartum complications, he says, is intrauterine death which is brought about by antiphospholipid syndrome. He explains that a death that occurs prior to 20 weeks’ gestation is usually classified as a spontaneous abortion; those occurring after 20 weeks constitute a foetal demise or stillbirth. Iba Mayale, a gynaecologist at Clinic Galien in Remera, says hypertensive disorder in pregnancy like preeclampsia which is hypertensive disorders, can also cause stillbirth. He notes that a woman can be normal with no hypertension, but from 20 weeks, she gets hypertension. He notes that if this hypertension is not well managed, the baby can die in the uterus after like seven or eight months. Additionally, Mayele says, women who have diabetes, or those with chronic diabetes that they got before or after conceiving (gestation diabetes), are also at risk. He explains that if all this is not followed and managed well, there are high possibilities of the unborn baby dying. Mayale notes that women who have severe anaemia should also be closely monitored and followed to ensure the safety of the baby and that of the mother. “Some women can have infections, for instance, HIV, among others, and if not managed well, they could lead to stillbirth,” Mayale says. He explains that another possible factor that leads to stillbirth is intrauterine growth restriction. This is where the babies appear to be smaller than expected, specifically, if an ultrasound indicates that their weight is below the 10th percentile for their gestational age. John Muganda, a Kigali based gynaecologist, adds that placental abruption also causes stillbirth. This is when the placenta detaches from the uterine wall. “For the baby to survive there must be a connection of blood from the mother. She gives blood to the placenta and the placenta takes the blood to the foetus through the umbilical cord. “When the placenta is dispatched from the uterine wall, it loses the blood supply which is supposed to go to the baby. This brings about the baby’s death,” he says. Muganda says this could lead to the baby’s death at seven, eight or even nine months depending on the complication. In rare cases, Muganda points out that sometimes, stillbirth can occur as a result of the umbilical cord tied around the baby’s neck, making it hard for the baby to breathe. Prevention Ssemwanga says if the woman is not monitored well during pregnancy, some women can develop foetus distress, leading to its death. Therefore, frequent monitoring during pregnancy and labour is important. “This is common in settings where there are no monitors to observe the whole process of labour. They only depend on hearing instruments that help with listening to the foetus,” he says. Ssemwanga says that it is imperative to consult with an obstetrician/gynaecologist, respect their appointments and go for antenatal care as required to avoid complications, because some of these mishaps can be prevented. “During antenatal visits, an obstetrician is in the position to reveal any risks that may pose a threat to the life of the mother and or the baby,” he says. For instance, if a woman is found to have had preeclampsia, a potentially dangerous pregnancy complication characterised by high blood pressure, a gynaecologist would provide medication capable of preventing it from happening again. “This can be done through checking the full blood status of the mother to find out how much haemoglobin she has. Depending on what is found, the right medicine is administered to prevent any complications that may arise,” he adds. Also, Mayale notes that in cases of diabetes, there are drugs given depending on the type one has. This, he says, prevents complications that could result in a stillbirth. Muganda says that in a setting with good equipment like monitors and enough nurses, an obstetrician who has been following up on the pregnancy of mothers should put a continuous monitor on them during the whole process of labour. “During delivery, doctors should not leave the patient with the nurse alone; they should be around to help her where necessary,” he says. In cases where the labour is complicated, Mayale says experts should intervene by considering a Caesarean section before the baby dies in the womb or complications pose a threat to the mother too. “Nurses, obstetricians and general practitioners should always be alert when dealing with women in labour to prevent cases of stillbirths due to complications,” he says. Likely complications The major complication a woman is likely to encounter if the infant dies in the womb for maybe two and more weeks, Ssemwanga says, is disseminated intravascular coagulopathy. This is when there is a bleeding condition and this is when the baby has been dead in the womb for like four weeks and so. When this happens, after delivery, there is severe bleeding known as Postpartum haemorrhage (PPH) which can result in death. Francis Kazungu, a general practitioner in Kigali, says that another complication comes about if the mother is not well counselled; they can develop psychosomatic disorder. They need to be counselled well before delivering the dead baby and after the delivery too. Depending on what has caused the stillbirth, Kazungu points out that the patients should be closely monitored during their next pregnancy and prevention measures should be taken throughout the next pregnancy. About when to conceive again, Kazungu says one can still plan for another pregnancy anytime but always remember to go for frequent check-ups. editorial@newtimes.co.rw

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Stillbirth: Who is at greater risk?