Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 44  |  Issue : 3  |  Page : 121-125

Impact of management protocols of intrauterine fetal death on perceived stress: A comparative study


1 Department of Gynecology and Obstetrics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
2 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India

Date of Web Publication14-Feb-2018

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_43_17

Rights and Permissions
  Abstract 

Background: Pregnancy loss is a distressing problem and retention of dead fetus in utero has its own ill effects on physical, psychological, and social aspects, and hence, it is better to recommend medical induction, provided this can be safely undertaken. Aims: The aim of this study is to compare the efficacy, tolerability, induction-delivery interval, and perceived stress scores between induction methods in late intrauterine fetal death (IUFD) with misoprostol alone and mifepristone with misoprostol combination in a rural population of Eastern India. Materials and Methods: This pilot study was conducted on 125 patients after taking institutional ethical clearance and informed consent of the patients in a time span of 1 year. Group 2 patients received 200 mg of mifepristone per orally and observed for 48 h, followed by 50 μg misoprostol administered in the posterior vaginal fornix, and repeated 6th hourly up to a maximum of four doses. Group 1 received 50 μg misoprostol per vaginally 6 hourly for four doses. Induction-delivery interval was calculated. Perceived stress level was calculated on admission and before discharge. Results: Significantly lower induction-delivery interval was observed in Group 2 as compared to Group 1 with P < 0.001. There was no significant difference of Cohen's perceived stress scores on admission, but the difference was significantly lower in Group 2 on discharge with the value of P = 0.03. Group 1 had significantly lower hospital stay in days as compared to Group 2 of patients with P < 0.001. Conclusions: Patients with IUFD administered misoprostol per vaginally only may require shorter hospital stay as compared to patients administered with oral mifepristone followed by misoprostol vaginally but the delivery induction time increases significantly and may increase perceived stress levels which may have short- and long-term negative psychological impact.

Keywords: Induction methods, intra uterine fetal death, perceived stress


How to cite this article:
Mandal M, Chaudhuri A, Banerjee D, Kanrar P, Hazra SK. Impact of management protocols of intrauterine fetal death on perceived stress: A comparative study. J Sci Soc 2017;44:121-5

How to cite this URL:
Mandal M, Chaudhuri A, Banerjee D, Kanrar P, Hazra SK. Impact of management protocols of intrauterine fetal death on perceived stress: A comparative study. J Sci Soc [serial online] 2017 [cited 2018 Sep 19];44:121-5. Available from: http://www.jscisociety.com/text.asp?2017/44/3/121/225508


  Introduction Top


Pregnancy loss is a distressing problem. The frequency of intrauterine fetal death (IUFD) with retained fetus occurs in approximately 1% of all pregnancies.[1],[2],[3] When fetus dies before birth, the option for care is either to wait for labor to start spontaneously or to induce labor. Most women (over 90%) go into labor within 3 weeks of IUFD.[4],[5] However, if labor does not begin there is a risk of developing complications such as coagulation disorders and intrauterine infections. Retention of dead fetus in utero has its own ill effects on physical, psychological, and social aspects. Hence, it is better to recommend medical induction, provided this can be safely undertaken.[5]

The loss of a wanted pregnancy is a major life event, which can affect mental health, and spontaneous abortions and stillbirths have been associated with grief, depression, anxiety, and social problems.[6],[7] Fetal loss may trigger mental health problems in some women, which could be related to stress,[8] difficulties in social functioning or changes in family dynamics related to the event.[9] A cohort study by Munk-Olsen et al. in 2014[10] using Danish population-based registers included participants from Denmark, a total of 1,112831 women born in Denmark from 1960 to 1995. In total, 87,687 cases of fetal death (International Classification of Disease-10 codes for spontaneous abortion or stillbirth) were recorded between 1996 and 2010. They concluded that fetal death was associated with a transient increased risk of experiencing a first-time episode of a psychiatric disorder, primarily adjustment disorders. The risk of psychiatric episodes tended to increase with increasing gestational age at the time of the loss.

In case of IUFD journey of labor pain is fruitless. This increases perceived stress among these mothers which may have both short- and long-term psychological complications.[11],[12] Hence, it is more important to search for methods which can reduce hours of pain in labor of IUFD cases.

Oral misoprostol administration for labor induction with IUFD was first used in 1987. Since that time use of misoprostol for obstetrical purposes has grown widely.[13],[14]

Mifepristone, also known as RU-486 is a synthetic, 19-nonsteroid, and anti-progesterone. In presence of progesterone, mifepristone acts as a competitive progesterone receptor antagonist. Mifepristone cause blockade of progesterone receptors directly causes endometrial decidual degeneration, cervical softening and dilatation, release of endogenous prostaglandins, and an increase in the sensitivity of the myometrium to contractile effects of prostaglandins. Mifepristone-induced decidual breakdown indirectly leads to trophoblast detachment.[13],[14]

The present study was conducted to compare the efficacy, tolerability, induction-delivery interval, and perceived stress scores between induction methods in late IUFD with misoprostol alone and mifepristone with misoprostol combination in a rural population of Eastern India, so that future strategies may be implemented for better management of patients taking to consideration both physical and psychological aspects.


  Materials and Methods Top


This pilot study was conducted in the Department of Gynecology and Obstetrics of Burdwan Medical College and Hospital after taking Institutional ethical clearance and informed consent of the participants in a time span of 1 year. From previous hospital records, it was observed that around 150–200 diagnosed IUFD cases are usually admitted over a period of 1 year in this tertiary care hospital of Eastern India catering rural population of nearly 5 districts. A total of 125 patients were taken for our study following the inclusion and exclusion criteria.

Inclusion criteria

  1. IUFD confirmed by ultrasonography (USG)
  2. Gestational age 24 completed weeks and above
  3. Patients not in labor (no regular contraction or unfavorable cervix)
  4. Singleton pregnancy.


Exclusion criteria

  1. History of more than 1 previous lower segment cesarean section
  2. Previous classical cesarean section or any other scar on the uterus
  3. Multiple pregnancies
  4. Abnormal coagulation profile
  5. History of allergy to prostaglandins
  6. Severe medical illness such as asthma, heart disease, and renal disease
  7. Those who need immediate surgical intervention such as Antepartum haemorrhage (APH), ruptured uterus.


Detailed history was taken from all the antenatal mothers, with less and no fetal movement after 24 weeks pregnancy, attending obstetrics emergency department. General examination was done; temperature, pulse, and blood pressure were noted. Gestational age was confirmed clinically and by USG of early weeks of gestation. Per abdominal examination regarding uterine activity, tone and tenderness, liquor volume, fundal height, and presentation was done. Per speculum examination was done to exclude any dribbling or bleeding per vagina. Digital pelvic examination was done with aseptic precautions.

Complete blood count, coagulation profile, liver function tests, renal function tests, fasting blood sugar, postprandial blood sugar, blood grouping and Rh typing, hepatitis B surface antigen, HIV screening, Urine routine, and microscopy were done. Perceived stress level assessment was done with Cohen's Perceived Stress Scale.[15] Coagulation profile of each patient was monitored from admission and repeated twice weekly.

Antenatal women with (USG diagnosed) IUFD after 24 completed weeks were selected for this study. They were allocated into two groups by randomization using an online randomizer (Group 1 and Group 2).

Group 2 received 200 mg of mifepristone per orally and observed for 48 h, followed by 50 μg misoprostol administered in the posterior vaginal fornix and repeated 6 hourly up to a maximum of four doses. If in the meantime patient did not go into labor, after a 24 h' interval the next dose of misoprostol was repeated.

Group 1 received 50 μg misoprostol per vaginally 6 hourly for four doses. Subsequent to misoprostol administration, uterine contractions, pulse, blood pressure, temperature, and systemic symptoms were monitored hourly.

Patients were observed in antenatal ward and examined at 4 hourly intervals to see the cervical changes, features of chorioamnionitis, dribbling per vagina, bleeding per vagina, or discharge of any show.

Operative intervention was considered if the patient did not go into labor even after 7 days of onset of induction or fibrinogen level decreased below100 mg/dl or sepsis was not controlled with the 3rd generation cephalosporin, metronidazole, or impending rupture in post cesarean section pregnancies.

Induction-delivery interval was calculated. Perceived stress level was calculated on admission and before discharge. Patients having hyperthermia >100° Fahrenheit was treated with paracetamol (acetaminophen). Analgesics were administered as per patient's requirement orally or parentally.

Statistical analysis

The computer software “Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.)” was used to analyze the data.


  Results Top


This study was carried out during the period from January 2015 to December 2015 (1 year). A total of 125 pregnant women with USG confirmed IUFD of more than 24 weeks were included for the study. Patients were divided into two groups containing 64 in Group 2 (mifepristone plus misoprostol receiving) and 61 in Group 1 (receiving misoprostol). There was no significant difference in parameters such as gravida, parity, and gestational age (P value of gravida 0.5, parity 0.66, periods of gestation 0.384) between the two groups. There was no significant difference between the two groups as per abdominal and USG findings [Table 1]. No significant difference in bleeding time (BT), clotting time (CT), fibrinogen level, platelet count, and international normalized ratio (INR) between two groups of patients on admission was observed [Table 2]. Significantly lower induction-delivery interval was observed in Group 2 as compared to Group 1 with P < 0.001** [Table 3]. Results showed that there was no significant difference of Cohen's perceived stress scores on admission, but the difference was significantly lower in Group 2 as compared to Group 1 before discharge with a P = 0.03 [Table 4]. Incident rate of retained placenta was 3.125% in Group 1 as compared to 0.8% in Group 2. More dosages of analgesics were required in Group 1 as compared to Group 2. Intrapartum, postpartum complications, and operative interventions were almost same in both groups [Table 5] and [Table 6]. There was no need for blood transfusion in any group. Group 1 had significantly lower hospital stay in days as compared to Group 2 of patients with P < 0.001 [Table 7]. The incidence of postpartum hemorrhage rate 4.91% in misoprostol group as compared to 0.8% in combination group. Incidence of retained placenta was 3.125% in misoprostol group as compared to 0.8% in combination group.
Table 1: Comparison between two groups on admission as per abdominal finding and ultrasonography finding

Click here to view
Table 2: Comparison of bleeding time, clotting time, fibrinogen level, platelet count and international normalized ratio between two groups on admission

Click here to view
Table 3: Comparison of induction-delivery interval between the two groups

Click here to view
Table 4: Comparison of Cohen's perceived stress on admission and before discharge

Click here to view
Table 5: Comparison of outcome (normal delivery and lower segment cesarean section) between two group of patients

Click here to view
Table 6: Comparison of safety and tolerance of both regimen

Click here to view
Table 7: Comparison of hospital stay between two groups of patients

Click here to view



  Discussion Top


Role of mifepristone and misoprostol in induction of labor in late IUFD has been extensively studied. In the present study, comparison between the efficacy and tolerability and psychological impact of misoprostol alone and mifepristone and misoprostol combination for induction of labor in late IUFD was attempted.[16],[17],[18] One hundred and twenty-five pregnant women with less fetal movement or no fetal movement after 24 weeks of gestation and fulfilling the inclusion criteria and USG confirmed IUFD were enrolled for the present study. Then, they were randomized into two groups using an online randomizer, one group (Group 1) containing 61 pregnant women and another group (Group 2) containing 64 pregnant women. Group 1 received misoprostol 50 μg in posterior fornix and Group 2 received 200 mg mifepristone orally then 50 μg misoprostol vaginally. Then, they are followed up till labor was started or induction failure criteria reached. Interval between induction to time of delivery were calculated in both the groups, along with it maternal complications were noted and stress level assessment done by Cohen's Perceived Stress Scale.

In this study, there was no statistically significant difference between gravida, parity, and blood investigations such as BT, CT, INR, and platelet count between the two groups. There were no significant differences in parameters such as gravida parity and gestational age (P value of gravida 0.5, parity 0.66, periods of gestation 0.384) between the two groups.

We found that there was a significant difference in induction-delivery interval between two groups. It was found that combination group had significantly lower induction-delivery interval than only misoprostol group with P < 0.0001**. There was no statistical significant difference of psychological stress by Cohen's Perceived Stress Scale on admission and the difference became significant before discharge with Group 2 having significantly lower scores though the hospital stay time was more in Group 2. Intrauterine fetal death (IUFD) is a serious incidence that has been shown to impact mothers' psychological well-being in the short-term and long-term. Cohen's perceived stress scores were significantly lower in Group 2 as compared to Group 1 and the cause may be decreased induction delivery time interval in Group 2.

IUFD is a serious incidence that has shown to impact mother's psychological well-being. Janssen et al.[19] compared women after miscarriage with women who gave birth to live-born babies. After 6 months, these two groups differed substantially according to depression scores, anxiety scores, and somatization. A study by Klier et al.[20] and Neugebauer et al.[21] found that miscarrying women had a 2.5-fold and 5-fold higher risk for an episode of major and minor depressive disorder, respectively, 6 months after miscarriage compared to control women. Previous studies have also found an increasing risk of psychiatric symptoms or disorders with increasing gestational age at spontaneous abortion.[19],[22]

In the present lifestyle, stress and anxiety have become part and parcel of life.[22],[23] Women in emerging economic and social markets are more stressed than those in developed countries. About 87% of Indian women feel stressed most of the times, with 82% having insufficient time to relax. Stress experiences often lead to various chronic health conditions such as hypertension and coronary heart disease.[23],[24],[25],[26]

The average lifespan of Indian women is 65 years while in developed countries it is 80 years, so women of our country deserve special attention.[27]

Psychological stress either at work or at home raises the risk of myocardial infarction across all ethnic groups in geographic regions in both genders.[28],[29],[30],[31] Plausible pathophysiological mechanisms involve direct neuroendocrine effect.[23],[27],[28] The autonomic imbalance is associated with stress. Vagal inhibitory influence decreases and sympathetic activity increases.[27],[28],[29],[30]

Patients with IUFD administered misoprostol per vaginally only may require shorter hospital stay as compared to patients administered with oral mifepristone followed by misoprostol vaginally but the delivery induction time increases significantly and may increase perceived stress levels which may have short- and long-term negative psychological impact.

Negative emotions are strongly related to the development of heart diseases. A reduction in positive mood and increase in worry can reduce blood supply to the heart just within 15 min, a condition known as silent transient myocardial ischemia. The Women's Ischemic Syndrome Evaluation study is changing the concept that women suffer less from heart diseases.[27],[28],[29],[30],[31]

The present study may help in future strategies to be implemented for better management of maternal health in a rural population of a developing country, taking into consideration both physical and psychological aspects.


  Conclusions Top


Patients with IUFD administered misoprostol per vaginally only may require shorter hospital stay as compared to patients administered with oral mifepristone followed by misoprostol vaginally but the delivery induction time increases significantly and may increase perceived stress levels which may have short- and long-term negative psychological impact.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
EL-Gharib MN, Elebyary MT. Vagiprost in management of second and third trimester IUFD. Acad J 2011;2:16-22.  Back to cited text no. 1
    
2.
Choudhury A, Gupta V. Epidemiology of IUFD a study in tertiary referral center in Uttarakhand. J Dent Med Sci 2014;13:3-6.  Back to cited text no. 2
    
3.
Gomez R. Misoprostol for intra uterine fetal death. Int J Gynaecol Obstet 2007;99:S190-3.  Back to cited text no. 3
    
4.
Panda S, Jha V, Singh S. Role of combination of mifepristone and misoprostol verses misoprostol alone in induction of labour in late intrauterin fetal death: A prospective study. J Family Reprod Health 2013;7:177-9.  Back to cited text no. 4
    
5.
Gandhi P, Shameem VP, Rao A, Rao B. Mifepristone plus misoprostol versus only misoprostol in induction of labour in IUFD. Int J Pharm Biochem Res 2013;4:108-10.  Back to cited text no. 5
    
6.
Lok IH, Neugebauer R. Psychological morbidity following miscarriage. Best Pract Res Clin Obstet Gynaecol 2007;21:229-47.  Back to cited text no. 6
    
7.
Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, et al. Stillbirths: The way forward in high-income countries. Lancet 2011;377:1703-17.  Back to cited text no. 7
    
8.
Li J, Laursen TM, Precht DH, Olsen J, Mortensen PB. Hospitalization for mental illness among parents after the death of a child. N Engl J Med 2005;352:1190-6.  Back to cited text no. 8
    
9.
Rogers CH, Floyd FJ, Seltzer MM, Greenberg J, Hong J. Long-term effects of the death of a child on parents' adjustment in midlife. J Fam Psychol 2008;22:203-11.  Back to cited text no. 9
    
10.
Munk-Olsen T, Bech BH, Vestergaard M, Li J, Olsen J, Laursen MT. Psychiatric disorders following foetal death: a population based cohort study. BMJ Open 2014;4:e005187.  Back to cited text no. 10
    
11.
Gravensteen IK, Helgadottir LB, Jacobsen EM, Sandset PM, Ekeberg Ø. Long-term impact of intrauterine fetal death on quality of life and depression: A case-control study. BMC Pregnancy Childbirth 2012;12:43.  Back to cited text no. 11
    
12.
Satyanarayana VA, Lukose A, Srinivasan K. Maternal mental health in pregnancy and child behavior. Indian J Psychiatry 2011;53:351-61.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Väyrynen W, Heikinheimo O, Nuutila M. Misoprostol-only versus mifepristone plus misoprostol in induction of labor following intrauterine fetal death. Acta Obstet Gynecol Scand 2007;86:701-5.  Back to cited text no. 13
    
14.
De Heus R, Graziosi GC, Christiaens GC, Bruinse HW, Mol BW. Medical management for termination of second and third trimester pregnancies: A comparison of strategies. Eur J Obstet Gynecol Reprod Biol 2004;116:16-21.  Back to cited text no. 14
    
15.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.  Back to cited text no. 15
    
16.
Cheng SY, Ming H, Lee JC. Titrated oral compared with vaginal misoprostol for labor induction: A randomized controlled trial. Obstet Gynecol 2008;111:119-25.  Back to cited text no. 16
    
17.
Kundodyiwa TW, Alfirevic Z, Weeks AD. Low-dose oral misoprostol for induction of labor: A systematic review. Obstet Gynecol 2009;113:374-83.  Back to cited text no. 17
    
18.
Crane JM, Butler B, Young DC, Hannah ME. Misoprostol compared with prostaglandin E2 for labour induction in women at term with intact membranes and unfavourable cervix: A systematic review. BJOG 2006;113:1366-76.  Back to cited text no. 18
    
19.
Janssen HJ, Cuisinier MC, Hoogduin KA, de Graauw KP. Controlled prospective study on the mental health of women following pregnancy loss. Am J Psychiatry 1996;153:226-30.  Back to cited text no. 19
    
20.
Klier CM, Geller PA, Neugebauer R. Minor depressive disorder in the context of miscarriage. J Affect Disord 2000;59:13-21.  Back to cited text no. 20
    
21.
Neugebauer R, Kline J, Shrout P, Skodol A, O'Connor P, Geller PA, et al. Major depressive disorder in the 6 months after miscarriage. JAMA 1997;277:383-8.  Back to cited text no. 21
    
22.
Cuisinier MC, Kuijpers JC, Hoogduin CA, de Graauw CP, Janssen HJ. Miscarriage and stillbirth: Time since the loss, grief intensity and satisfaction with care. Eur J Obstet Gynecol Reprod Biol 1993;52:163-8.  Back to cited text no. 22
    
23.
Khanna A, Paul M, Sandhu JS. A study to compare the effectiveness of GSR biofeedback training and progressive muscle relaxation training in reducing blood pressure and respiratory rate among highly stressed individuals. Indian J Physiol Pharmacol 2007;51:296-300.  Back to cited text no. 23
    
24.
Varvogli L, Darviri C. Stress management techniques: Evidence-based procedures that reduce stress and promote health. Health Sci J 2011;5:74-89.  Back to cited text no. 24
    
25.
Känel RV. Psychological distress and cardiovascular risk. J Am Coll Cardiol 2008;52:2163-5.  Back to cited text no. 25
    
26.
Kohli P, Gulati M. Exercise stress testing in women: Going back to the basics. Circulation 2010;122:2570-80.  Back to cited text no. 26
    
27.
Chaudhuri A, Borade NG. Menopause and autonomic control of heart. Med J DY Patil Univ 2012;5:4-9.  Back to cited text no. 27
  [Full text]  
28.
Chandola T, Brunner E, Marmot M. Chronic stress at work and the metabolic syndrome: Prospective study. BMJ 2006;332:521-5.  Back to cited text no. 28
    
29.
Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet 2007;370:1089-100.  Back to cited text no. 29
    
30.
Chaudhuri A, Borade NG. Menopause and autonomic control of heart. Med J DY Patil Univ 2012;5:4-9.  Back to cited text no. 30
  [Full text]  
31.
Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11,119 cases and 13,646 controls from 52 countries (the INTERHEART study): Case-control study. Lancet 2004;364:953-62.  Back to cited text no. 31
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusions
References
Article Tables

 Article Access Statistics
    Viewed769    
    Printed64    
    Emailed0    
    PDF Downloaded178    
    Comments [Add]    

Recommend this journal