胎儿死亡定义为闭经14周后心脏活动的自发停止。在法国,22周后胎儿死亡的发生率为3.2至4.4/1000.关于在一般人群中预防胎儿死亡,不建议咨询休息,不要开维生素A,补充维生素D或微量营养素的唯一目的是降低胎儿死亡的风险(建议薄弱;证据质量低)。不建议开阿司匹林(弱推荐;证据质量很低)。建议在流行期间提供针对流感和针对SARS-CoV-2的疫苗接种(强烈推荐;证据质量低)。不建议在产前超声筛查过程中系统地寻找脐带周围(强烈建议;证据质量低),也不建议通过心脏造影进行系统的产前监测(弱建议;证据质量很低)。不建议要求女性进行积极的胎儿运动计数以降低胎儿死亡的风险(强烈推荐;高质量的证据)。关于胎儿死亡事件的评估,建议系统地提供外部胎儿检查(专家意见)。建议对胎盘进行胎儿病理学和解剖病理学检查,以参与病因鉴定(强建议。证据质量适中)。建议通过微阵列测试进行染色体分析,而不是常规的核型。为了能够更频繁地识别潜在的因果异常(强烈推荐,证据质量适中);为此,建议优选出于遗传目的对胎盘胎儿表面进行产后采样(专家意见)。建议测试抗磷脂抗体并系统地进行Kleihauer测试和不规则凝集素测试(专家意见)。建议提供总结咨询,为了评估父母的身体和心理状况,报告结果,讨论原因并提供后续妊娠监测信息(专家意见)。关于公告和支持,建议毫不含糊地宣布胎儿死亡,用简单的话,适应每一种情况,然后在照顾的各个阶段以同理心支持夫妻(专家意见)。关于管理,有人建议,在没有弥散性血管内凝血或母体活力风险的情况下,在确定胎儿死亡诊断与引产之间的时间时,应考虑患者的意愿。如果患者愿意,可以回家(专家意见)。在所有情况下,不包括危及产妇生命的紧急情况,首选的分娩方式是阴道分娩,不考虑剖宫产史(专家意见)。如果胎儿死亡,建议米非司酮200mg在诱导前至少24小时处方,减少诱导和分娩之间的延迟(低推荐。证据质量低)。文献中的数据不足以就米索前列醇的给药途径(阴道或口服)提出建议,既不是前列腺素的类型,以减少诱导分娩时间或产妇发病率。如果患者要求,建议在诱导开始时引入髓周镇痛,不管胎龄。建议产后立即开卡麦角林,以避免泌乳,不管胎龄是多少,在与患者讨论治疗的副作用后(专家意见)。在随后的怀孕中,不明原因的胎儿死亡后胎儿死亡复发的风险似乎没有增加,文献中的数据不足以就阿司匹林的处方提出建议.如果因血管问题而有胎儿死亡史,建议使用低剂量阿司匹林来降低围产期发病率,并且不应与肝素治疗联合使用(低推荐,证据质量很低)。建议不要仅仅因为胎儿死亡的历史而在开始再次怀孕之前建议最佳延迟。建议将心理支持的可能性告知妇女和共同父母。胎儿心率监测并不仅仅是因为有胎儿死亡史。建议不系统地诱导分娩。然而,可以根据上下文和父母的要求考虑归纳法。将讨论胎龄,考虑到利益和风险,尤其是在39周之前。如果确定了胎儿死亡的原因,管理将根据具体情况进行调整(专家意见)。如果双胎妊娠发生胎儿死亡,建议一旦诊断出胎儿死亡,就对存活的双胞胎进行评估。在绒毛膜下妊娠的情况下,建议每月提供超声监测。建议不要在双胞胎胎儿死亡后过早分娩。如果胎儿死亡发生在单绒毛膜双胎妊娠中,建议联系转诊能力中心,为了在存活的双胞胎中通过超声检查紧急寻找急性胎儿贫血的迹象,并在第一个月进行每周超声监测。建议不要立即催产。
Fetal death is defined as the spontaneous cessation of cardiac activity after fourteen weeks of amenorrhea. In France, the prevalence of fetal death after 22 weeks is between 3.2 and 4.4/1000 births. Regarding the prevention of fetal death in the general population, it is not recommended to counsel for rest and not to prescribe vitamin A, vitamin D nor micronutrient supplementation for the sole purpose of reducing the risk of fetal death (Weak recommendations; Low quality of evidence). It is not recommended to prescribe aspirin (Weak recommendation; Very low quality of evidence). It is recommended to offer vaccination against influenza in epidemic periods and against SARS-CoV-2 (Strong recommendations; Low quality of evidence). It is not recommended to systematically look for nuchal cord encirclements during prenatal screening ultrasounds (Strong Recommendation; Low Quality of Evidence) and not to perform systematic antepartum monitoring by cardiotocography (Weak Recommendation; Very Low Quality of Evidence). It is not recommended to ask women to perform an active fetal movement count to reduce the risk of fetal death (Strong Recommendation; High Quality of Evidence). Regarding evaluation in the event of fetal death, it is suggested that an external fetal examination be systematically offered (Expert opinion). It is recommended that a fetopathological and anatomopathological examination of the placenta be carried out to participate in cause identification (Strong Recommendation. Moderate quality of evidence). It is recommended that chromosomal analysis by microarray testing be performed rather than conventional karyotype, in order to be able to identify a potentially causal anomaly more frequently (Strong Recommendation, moderate quality of evidence); to this end, it is suggested that postnatal sampling of the placental fetal surface for genetic purposes be preferred (Expert Opinion). It is suggested to test for antiphospholipid antibodies and systematically perform a Kleihauer test and a test for irregular agglutinins (Expert opinion). It is suggested to offer a summary consultation, with the aim of assessing the physical and psychological status of the parents, reporting the results, discussing the cause and providing information on monitoring for a subsequent pregnancy (Expert opinion). Regarding announcement and support, it is suggested to announce fetal death without ambiguity, using simple words and adapting to each situation, and then to support couples with empathy in the various stages of their care (Expert opinion). Regarding management, it is suggested that, in the absence of a situation at risk of disseminated intravascular coagulation or maternal vitality, the patient\'s wishes should be taken into account when determining the time between the diagnosis of fetal death and induction of birth. Returning home is possible if it\'s the patient wish (Expert opinion). In all situations excluding maternal life-threatening emergencies, the preferred mode of delivery is vaginal delivery, regardless the history of cesarean section(s) history (Expert opinion). In the event of fetal death, it is recommended that mifepristone 200mg be prescribed at least 24hours before induction, to reduce the delay between induction and delivery (Low recommendation. Low quality of evidence). There are insufficient data in the literature to make a recommendation regarding the route of administration (vaginal or oral) of misoprostol, neither the type of prostaglandin to reduce induction-delivery time or maternal morbidity. It is suggested that perimedullary analgesia be introduced at the start of induction if the patient asks, regardless of gestational age. It is suggested to prescribe cabergoline immediately in the postpartum period in order to avoid lactation, whatever the gestational age, after discussing the side effects of the treatment with the patient (Expert opinion). The risk of recurrence of fetal death after unexplained fetal death does not appear to be increased in subsequent pregnancies, and data from the literature are insufficient to make a recommendation on the prescription of aspirin. In the event of a history of fetal death due to vascular issues, low-dose aspirin is recommended to reduce perinatal morbidity, and should not be combined with heparin therapy (Low recommendation, very low quality of evidence). It is suggested not to recommend an optimal delay before initiating another pregnancy just because of the history of fetal death. It is suggested that the woman and co-parent be informed of the possibility of psychological support. Fetal heart rate monitoring is not indicated solely because of a history of fetal death. It is suggested that delivery not be systematically induced. However, induction can be considered depending on the context and parental request. The gestational age will be discussed, taking into account the benefits and risks, especially before 39 weeks. If a cause of fetal death is identified, management will be adapted on a case-by-case basis (expert opinion). In the event of fetal death occurring in a twin pregnancy, it is suggested that the surviving twin be evaluated as soon as the diagnosis of fetal death is made. In the case of dichorionic pregnancy, it is suggested to offer ultrasound monitoring on a monthly basis. It is suggested not to deliver prematurely following fetal death of a twin. If fetal death occurs in a monochorionic twin pregnancy, it is suggested to contact the referral competence center, in order to urgently look for signs of acute fetal anemia on ultrasound in the surviving twin, and to carry out weekly ultrasound monitoring for the first month. It is suggested not to induce birth immediately.