Correspondence

Case 27-2007: Intrauterine Fetal Death

N Engl J Med 2007; 357:2310November 29, 2007

Article

To the Editor:

The Case Record in the August 30 issue1 describes a stillborn male infant who apparently died from group B streptococcal infection. However, the mother's history lacked an essential piece of information: whether she was or had been the victim of violence inflicted by an intimate partner. Intimate-partner violence is currently at epidemic proportions, and pregnant women are at particular risk. The American College of Obstetricians and Gynecologists estimates the prevalence of intimate-partner violence in women seeking prenatal care at 23%.2 The patient described in the Case Record was an immigrant, and immigrants constitute a group at high risk for intimate-partner violence.3 Assaults are often directed at the pregnant woman's abdomen.4 Intimate-partner violence increases the risk of placental abruption and fetal death.5,6 In his discussion of the case, Gibbs refers to “four broad categories” of intrauterine fetal death, one of which is “unexplained.” Despite the normal physical examination, the intrauterine fetal death in this case could well have been due to trauma and a subsequent abruption. Unless the patient is queried about intimate-partner violence, the cause of a stillbirth could be categorized as “unexplained” when it might better be categorized as “unasked.”

Linda R. Chambliss, M.D., M.P.H.
Saint Louis University School of Medicine, St. Louis, MO 63117
lrchambliss@yahoo.com

6 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 27-2007). N Engl J Med 2007;357:918-925
   Full Text | Web of Science | Medline

2. 2

   The American College of Obstetricians and Gynecologists department Web sites. (Accessed November 9, 2007, at http://www.acog.org/departments.)
   

3. 3

   The Family Violence Prevention Fund home page. (Accessed November 9, 2007, at http://endabuse.org.)
   

4. 4

   Campbell JC, Oliver C, Bullock L. AWHONN's clinical issues in women's health nursing. Philadelphia: Lippincott, 1994:350-62.
   

5. 5

   Coker AL, Sanderson M, Dong B. Partner violence during pregnancy and risk of adverse pregnancy outcomes. Paediatr Perinat Epidemiol 2004;18:260-269
   CrossRef | Web of Science | Medline

6. 6

   Shumway J, O'Campo P, Gielen A, Witter FR, Khouzami A, Blakemore KJ. Preterm labor, placental abuption, and premature rupture of membranes in relation to maternal violence or verbal abuse. J Matern Fetal Med 1999;8:76-80
   CrossRef | Medline

Author/Editor Response

Chambliss emphasizes the possibility of intimate-partner violence as a cause of stillbirth if the violence leads to abruption. Although I noted that many stillbirths are “unexplained,” abruption is recognized as a common cause.1 In the case presented, there was no evidence of physical abuse, nor was there evidence of abruption, either clinically or pathologically. Nevertheless, I agree that patients with stillbirth — indeed, all pregnant women — should be asked about abuse.

Ronald S. Gibbs, M.D.
University of Colorado School of Medicine, Denver, CO 80262

1 References

1. 1

   Fretts RC. Etiology and prevention of stillbirth. Am J Obstet Gynecol 2005;193:1923-1935
   CrossRef | Web of Science | Medline