What is a fetal injury related death?
is a fetal injury related death?
Why is fetal injury related mortality important?
More specifically, fetal injury related mortality is important for the following reasons:
1. Is there enough information on Fetal Death Certificates to accurately E-code external cause(s) of injury?
2. Can data linkage improve detection and documentation of fetal injury deaths?
3. What are the major causes of fetal injury mortality?
4. What are the impacts of these numbers extrapolated to national estimates of the injury burden?
5. What is the ratio of fetal to maternal deaths?
6. Do patterns of fetal injury causes vary by gestational age?
7. How do these causes vary by maternal education, maternal age, and amount of pre-natal care?
While there is an extensive literature dealing with clinical aspects and many case reports and institution based case series, population based studies are practically non-existent due to the problems discussed above.
Most studies of fetal and maternal trauma have focused on maternal trauma. This is inadequate because for many injuries, the fetus is reported to be more at risk of major injury or death than the mother. In general, life threatening injury risk to the mother usually puts the fetus at great risk, while the corollary is not usually the case (so long as access to modern medical facilities are available in a reasonable period of time).
For example, it has been reported that "visceral injuries" occur in only 19% of mothers but 60-70% of the fetuses involved in gunshot wounds. [Buchsbaum, 1979] More to the point for mortality, in penetrating abdominal injury, the risk of fetal death reportedly ranges from 8 to 14 times that of the mother. [Buchsbaum, 1979] Gunshot wounds to the pregnant abdomen have been reported in one review to result in a 71% fetal mortality rate compared to a maternal mortality rate of only 3.9%.[Sandy EA, Koerner M, 1979] Stab wounds mirror a similar story. In one case series of 19 cases, all mothers survived but the fetal mortality rate was 42%[Sakala EP, Kort DD, 1988] Traumatic rupture of the uterus, a relatively rare result of maternal injury [Pearlman MD, Tintinalli JE, and Lorenz RP, Blunt Trauma 1990] has been associated with essentially a 100% fetal mortality rate but a maternal mortality rate of less than 10%[Crosby, 1971][Rothenberger, 1978].
Minor trauma to the mother may not correlate with minor injury to the fetus. [Fries MH, 1989] A review by Pearlman and Tintinalli [Pearlman MD, Tintinalli JE, 1991] estimated the rate of fetal mortality at 41% among women with "life threatening" injury (defined as maternal shock, ruptured viscera, necessity of laparotomy, head injury with coma, or thoracic injury) and a rate of 1.6% among women with non-life threatening injuries. Yet, because the frequency of non-life threatening injuries is so much greater than life-threatening injuries the contribution of the former to overall fetal injury-related mortality must be substantial. Poole at al [Poole et al., 1996] documented fetal loss among victims of intentional injury and reported that 5 of the 8 women with fetal loss had maternal Injury Severity Scores of 0 (not severe). Other reports have documented many case reports of fetal mortality associated with minor maternal injury. [Stafford, 1988] Therefore, studies of maternal injury mortality cannot fully nor accurately describe the risks of fetal injury-related mortality and probably markedly underestimates the extent of fetal injury-related deaths.
Fetal death registration in most states includes fetuses from 16-20 weeks gestation are greater. A fetal death is defined as "the expulsion or extraction from its mother of a product of conception after 16 weeks gestation, which shows no evidence of life after such expulsion or extraction." (Pennsylvania Vital Statistics, 1993, Definition of Terms).
Although fetal/maternal injuries may be the underlying cause they may not be coded as such. Instead it appears to be the case that often the immediate causes may be listed (such as placental separation) without mention or coding of the underlying fetal or maternal injury. Many coded conditions could possibly include an injury as its underlying cause. This includes many ICD codes in the following ranges:
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