Management of fetal death after 20 weeks of gestation complicated by placenta previa.

Fetal death after 20 weeks of gestation in combination with complete placenta previa is rarely seen. A search in PubMed and EMBASE (1966–2006; search terms: ‘placenta previa’ and ‘fetal death’) revealed only one case report [1]. There is limited experience with these cases and management is controversial. An inquiry among the eight University Hospitals in the Netherlands revealed only three cases in the period of 1990 through 2005. These cases, in which three different policies were followed, are presented below. The first woman was a 33-year-old gravida 7 para 4, with a well-controlled diabetes mellitus. She had had four uncomplicated deliveries and two miscarriages. The pregnancy in question, in 1990, was complicated by complete placenta previa. Fetal death occurred unexpectedly at 33 weeks. There was no bleeding. Five days later labor induction was initiated using prostaglandins (intravenous sulprostone, intramuscular carboprost and intracervical dinoprostone, respectively). After eight days and a total administration of 17 000 mg prostaglandins, attempts to induce labor were discontinued because of minimal cervical response. Expectant management was now agreed upon. Nineteen days after the diagnosis of stillbirth, the woman was readmitted because of fever and ruptured membranes. Coagulation tests and hemoglobin were normal and bleeding was still minimal. Antibiotics and oxytocin were started intravenously. Fourteen hours after admission the patient gave birth to a stillborn son with a birth weight of 1070 g (55 percentile). The placenta had to be extracted manually and weighed 130 g (510 percentile). A central placental rupture was present, suggesting that the fetus was born through the placenta. Total blood loss was 50 mL and the postpartum period was uneventful. The second case was a 33-year-old woman, who was gravida 5 para 2. Her two previous children were born by cesarean section because of cephalopelvic disproportion. In 1998 at 26þ5 weeks she complained of painless vaginal bleeding. Ultrasound examination showed complete placenta previa with partial placental abruption and fetal death in transverse lie. Blood loss was moderate and coagulation tests and hemoglobin were normal. Contractions started and ultrasound examination showed cervical dilation of 1 cm. After ample consideration it was decided to perform a repeat cesarean section, because of the risk of uterine rupture and the explicit request of the mother who wished to try for another child in the future. A stillborn boy of 680 g (10–50 percentile) was delivered. The placenta weighed 165 g (510 percentile). The cesarean section was complicated by a hemorrhage of 1500 mL for which two units of packed cells, two units of fresh frozen plasma and sulprostone were administered intravenously. The postoperative period was uneventful with normal coagulation tests. The third woman was a 37-year-old gravida 4 para 2. Her obstetric history revealed two uncomplicated pregnancies and one spontaneous abortion. In 2000 at 20 weeks of gestation, she was referred because of moderate painless vaginal bleeding. Ultrasound The Journal of Maternal-Fetal and Neonatal Medicine, March 2007; 20(3): 267–269