How did my baby die and what is the probability that my next one will?

by deprimita_patro 3 min read19th Jan 201623 comments

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Summary: My son was stillborn and I don't know why. My wife and I would like to have another child, but would very much not like to try if the probability of this occurring again is above a certain threshold (of which we have already settled on one). All 3 doctors I have consulted were unable to give a definitive cause of death, nor were any willing to give a numerical estimate of the probability (whether for reasons of legal risk, or something else) that our next baby will be stillborn. I am likely too mind-killed to properly evaluate my situation and would very much appreciate an independent (from mine) probability estimate of what caused my son to die, and given that cause, what is the recurrence risk?

Background: V (L and my only biologically related living son) had no complications during birth, nor has he showed any signs of poor health whatsoever. L has a cousin who has had two miscarriages, and I have an aunt who had several stillbirths followed by 3 live births of healthy children. We know of no other family members that have had similar misfortunes.

J (my deceased son) was the product of a 31 week gestation. L (my wife and J's mother) is 28 years old, gravida 2, para 1. L presented to the physicians office for routine prenatal care and noted that she had not felt any fetal movement for the last five to six days. No fetal heart tones were identified. It was determined that there was an intrauterine fetal demise. L was admitted on 11/05/2015 for induction and was delivered of a nonviable, normal appearing, male fetus at approximately 1:30 on 11/06/2015.

Pro-Con Reasoning: According to a leading obstetrics textbook1, causes of stillbirth are commonly classified into 8 categories: obstetrical complications, placental abnormalities, fetal malformations, infection, umbilical cord abnormalities, hypertensive disorders, medical complications, and undetermined. Below, I'll list the percentage of stillbirths in each category (which may be used as prior probabilities) along with some reasons for or against.

Obstetrical complications (29%)

  • Against: No abruption detected. No multifetal gestation. No ruptured preterm membranes at 20-24 weeks.

Placental abnormalities (24%)

  • For: Excessive fibrin deposition (as concluded in the surgical pathology report). Early acute chorioamnionitis (as conclused in the surgical pathology report, but Dr. M claimed this was caused by the baby's death, not conversely). L has gene variants associated with deep vein thrombosis (AG on rs2227589 per 23andme raw data).
  • Against: No factor V Leiden mutation (GG on rs6025 per 23andme raw data and confirmed via independent lab test). No prothrombin gene mutation (GG on l3002432 per 23andme raw data and confirmed via independent lab test). L was negative for prothrombin G20210A mutation (as determined by lab test). Anti-thrombin III activity results were within normal reference ranges (as determined by lab test). Protein C activity results were withing normal reference ranges (as determined by lab test). Protein S activity results were within normal reference ranges (as determined by lab test). Protein S antigen (free and total) results were within normal references ranges (as determined by lab test).

Infection (13%)

  • For: L visited a nurse's home during the last week of August that works in a hospital we now know had frequent cases of CMV infection. CMV antibody IgH, CMV IgG, and Parvovirus B-19 Antibody IgG values were outside of normal reference ranges.
  • Against: Dr. M discounted the viral test results as the cause of death, since the levels suggested the infection had occurred years ago, and therefore could not have caused J's death. Dr. F confirmed Dr. M's assessment.

Fetal malformations (14%)

  • Against: No major structural abnormalities. No genetic abnormalities detected (CombiSNP Array for Pregnancy Loss results showed a normal male micro array profile).

Umbilical cord abnormalities (10%)

  • Against: No prolapse. No stricture. No thrombosis.

Hypertensive disorder (9%)

  • Against: No preeclampsia. No chronic hypertension.

Medical complications (8%)

  • For: L experienced 2 nights of very painful abdominal pains that could have been contractions on 10/28 and 10/29. L remembers waking up on her back a few nights between 10/20 and 11/05 (it is unclear if this belongs in this category or somewhere else).
  • Against: No antiphospholipid antibody syndrome detected (determined via Beta-2 Glycoprotein I Antibodies [IgG, IgA, IgM] test). No maternal diabetes detected (determined via glucose test on 10/20).

Undetermined (24%)

What is the most likely cause of death? How likely is that cause? Given that cause, if we choose to have another child, then how likely is it to survive its birth? Are there any other ways I could reduce uncertainty (additional tests, etc...) that I haven't listed here? Are there any other forums where these questions are more likely to get good answers? Why won't doctors give probabilities? Help with any of these questions would be greatly appreciated. Thank you.

If your advice to me is to consult another expert (in addition to the 2 obstetricians and 1 high-risk obstetrician I already have consulted), please also provide concrete tactics as to how to find such an expert and validate their expertise.

Contact Information: If you would like to contact me, but don't want to create an account here, you can do so at deprimita.patro@gmail.com.

[1] Cunningham, F. (2014). Williams obstetrics. New York: McGraw-Hill Medical.

EDIT 1: Updated to make clear that both V and J are mine and L's biological sons.

EDIT 2: Updated to add information on family history.

EDIT 3: On PipFoweraker's advice, I added contact info.

EDIT 4: I've cross-posted this on Health Stack Exchange.

EDIT 5: I've emailed the list of authors of the most recent meta-analysis concerning causes of stillbirth. Don't expect much.

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