The gynecological examination after a stillbirth.

by Claudia Ravaldi

by Laura Avagliano

Surgeon Specialist in Obstetrics and Gynecology PhD in Prenatal Development Science, Diagnosis and Fetal Therapy. Research Fellow at the University of Milan, San Paolo Hospital.

The first gynecological examination after a fetal loss is a delicate moment which requires both a detailed medical history and a “physical” evaluation of the woman.
There are many international guidelines regarding the investigations to be carried out in the event of intrauterine death; however, there are no guidelines that suggest how to approach the first visit. However, the most advanced scientific researches and the various study groups agree on some basic points. So let’s see what is important to know and what should be done during the visit following the loss of a baby in the uterus.

The gynecological examination

The gynecological examination in the strict sense is done taking into account the time elapsed since the birth.
If the first visit is performed at the canonical control on the 40th day, the genital and mammary system will be evaluated. If the birth took place vaginally, the external genitalia will be checked, observing the area where the episiotomy was made, to assess its correct adhesion and the resorption of the sutures; the same will be done for areas of spontaneous laceration.
If, on the other hand, the birth took place by caesarean section, the laparotomic suture will be checked to see that it is in order, with the flaps tightly attached and without areas reddened by infection or hematomas.
We will then proceed to the “internal visit” to evaluate the characteristics of the uterine cervix (observing its reconstitution) and the characteristics of the uterine body (observing its correct involution); the ovaries will be appreciated and any painful points or areas will be looked for.
Transvaginal ultrasound will help evaluate endometrial rhyme and ovarian features. If there has already been the birth, ie the first menstruation after the birth, the pap test will also be performed.

The analysis of the documentation relating to the previous pregnancy provided by the couple.

First of all, an accurate medical history must be collected, also evaluating the health characteristics of family members. It is important to ask about the health of close relatives (grandparents, parents, brothers and sisters) of which diseases they suffer or have suffered (for example hypertension, diabetes, myocardial infarction, stroke, etc.) and what were their reproductive outcomes ( miscarriages, premature babies, underweight babies, stillbirths). It is very important that the couple ask their family members for this information.
As for the personal medical history, the couple must bring everything in their possession: all responses for blood tests, visits, ultrasound scans and any other tests (for example, any vaginal swabs, amniocentesis, etc.) Take your time and analyze yourself one by one.
Of fundamental importance will be the analysis of the autopsy response and the histological examination of the placenta. The autopsy report generally takes at least 90 days, so it will not yet be available at the time of the first gynecological visit, if this is performed 40 days after the birth, it will therefore be necessary to review each other later, to evaluate the outcome of the examination together. .
It is also necessary to read all the medical records and evaluate which tests have already been done during hospitalization.
(I would like to open a quick start about the medical record, remembering that a copy must always be requested: the discharge letter in fact cannot be considered sufficient and exhaustive because it represents only a summary of the days of hospitalization and the complete progress of some exams).
If there have been other previous pregnancies, it is good to bring all their documentation, in order to be able to compare the trend with respect to the pregnancy just ended.
Exams done outside of pregnancy can also be helpful, so any tests performed by both parents in the past should be brought.

If the documentation is conspicuous, it will not always be possible to reach conclusions at the very moment of the first visit, but the gynecologist will take a few days to carefully analyze everything that has been provided by the couple.

In the light of what emerges from the documents, other examinations may be prescribed.
In fact, remember that not all blood tests can be carried out during hospitalization, because some can be distorted by pregnancy hormones and must therefore be performed at least 6 weeks after delivery. The exams to be requested may also depend on the results of the exams previously performed and therefore each couple may have personal exams to be carried out, different from those required of other parents. To give a practical example, the outcome of the pathological examination of the placenta may suggest specific diseases for which the couple will be subjected to in-depth tests, or the autopsy will reveal syndromic malformations not previously visible on ultrasound, which they will eventually require the carrying out of genetic investigations and an interview with the specialist to calculate the risk of repetition.
The first gynecological examination after a fetal loss, therefore, is not a moment of arrival, but the beginning of a journey.
We must be aware that it will not be a “very short” path: some in-depth studies (such as the autopsy) have long timescales; certain blood tests must be repeated more than once to be diagnostic; finally, it may happen that it is necessary to request a rereading of the histological preparations by experts in perinatal medicine. Unfortunately, the cause of the child’s death is not always found, but it is always worth trying to find it, with patience and determination.

The first gynecological examination after a fetal loss will therefore mark the steps of a journey to be made together, a path that will lead us to investigate thoroughly to try to understand the causes of the child’s death, a path that will lead us to look for pathologies in the parents and, possibly , to cure them, finally, a path that will lead us to have indications to look with serenity to the future and to have concrete ideas on how to best follow subsequent pregnancies.

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