18 Week fetus - Courtesy Westside Pregnancy Resource Center FAQ Center for Injury Research and Control (CIRCL)

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Frequently Asked Questions

What is a fetal injury related death?
Why is traumatic fetal injury important?
What do we need to know about fetal injury related deaths?
What is known about the causes of fetal injury related deaths?
How are fetal deaths recorded?
About how many fetal injury deaths occur each year?
How can I protect my unborn child and myself while driving?
What are the purposes of this Web site?
Where can I get more information?

What is a fetal injury related death?
Definition: A fetus which is directly or indirectly affected as a result of an in utero injury insult to itself or the mother (excluding birth related trauma), that dies either prior to birth or up to and including 27 days after birth.

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Why is fetal injury related mortality important?
Current national and international policies do not include the International Classification of Diseases (ICD) External Cause of Injury Coding (E-Codes) in state and federal fetal death vital registries. The absence of such information has led to the neglect of the problem. Few, if any, publications describing the societal burden of injuries includes the impact of fetal injuries. Few, if any, injury prevention programs target these events. They are mostly an untracked phenomena that have been neglected by the injury control field. This neglect is unfortunate because fetal injuries can result in catastrophic personal loss, immense family emotional burdens, and costly medical care. Yet like all injuries, fetal injuries at the core remain a largely preventable public health issue.

More specifically, fetal injury related mortality is important for the following reasons:

The need to account for injuries in studies of fetal death - Many studies of fetal death systematically ignore the contribution of injuries by reporting not the underlying cause of death (injury) but rather the direct cause of death, for example, abruptio placentae. Many (most) of the largest and well known population-based reports of fetal death epidemiology lack mention much less detail (such as the mechanism) of fetal/maternal injury.
To redress the lack of including fetal injury deaths in reports of the impact of injuries on populations. - All national publications describing the burden of injury on society have ignored this facet of the injury problem.
The need to improve fetal injury related death reporting - Systematic deficiencies in fetal injury death registration, if they exist, such as poor documentation and coding of fetal injuries, are likely only to be rectified by describing the extent of the problem.
General under use of fetal death registries - In many, if not most states in the U.S., fetal death registries are often underutilized. Such under use makes little sense and contrasts with the public health importance placed on infant mortality and reducing childhood injury risks.
Lack of correlation between minor and serious maternal and fetal injury severity - The problem cannot be studied by only looking at maternal injury because of this lack of correlation.
Lack of correlation between infant injury epidemiology and fetal injury epidemiology - One must keep in mind that the fetus, because of its total dependence on the mother, takes on the mothers injury risks and not those risks of a young child. The epidemiology of fetal injuries is far different from that of infants.
The need to determine and implement appropriate prevention strategies - Only by highlighting and defining the problem of fetal injury-related mortality are preventive efforts likely to be focused appropriately on the problem.
Lack of decline in perinatal mortality (fetal deaths plus infant deaths <7 days old) - As better medical care and other factors have reduced neonatal (age < 28 days) mortality in developing countries "fetal deaths have become the determining proportion of perinatal mortality" [Lammer, 1989] Therefore, future decreases in perinatal mortality rates will depend in part on reduction in the fetal injury mortality rate.

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What do we need to know about fetal injury related deaths?

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?

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What is known about the epidemiology of fetal injury related deaths?

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.

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How are fetal deaths recorded?

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:

Examples of Fetal Mortality ICD Codes
Pennsylvania, 1993

ICD Cause Group

ICD Code or
Range

Number of Deaths
(1993)

Maternal conditions 760 58
Premature rupture of membranes 761.1 161
Complication of placenta, cord and membranes 762 488
Unspecified low birth weight 765 148
Other and ill defined conditions originating in perinatal period (includes termination of pregnancy) 766-767, 774, 777-779 1,414
Other and unknown causes 001-739, 780-999 5

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About how many fetal injury related deaths occur each year in the U.S.?

 

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What are the purposes of this web site?

  1. Provide a central repository for information and Web links related to the epidemiology of Fetal Injury Related Mortality and related subjects.
  2. Provide a means for interested persons to explore collaborative opportunities and to share information and perspectives on the issue(s).

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For questions or feedback regarding this web, contact [Harold (Hank) Weiss], Webmaster
Copyright2001 Harold B. Weiss, Center for Injury Research & Control (CIRCL)
Last updated: October 11, 2001 10:48 AM.