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Stillbirth

(Fetal Demise)

by Antonette T. Dulay, MD

Stillbirth is delivery of a dead fetus at > 20 wk gestation. Maternal and fetal testing is done to determine the cause. Management is as for routine care after live delivery.

Etiology

Fetal death during late pregnancy may have maternal, placental, or fetal anatomic or genetic causes (see Table: Common Causes of Stillbirth). Overall, the most common cause is

  • Abruptio placentae

Common Causes of Stillbirth

Type

Examples

Maternal

Diabetes mellitus if uncontrolled

Hereditary thrombotic disorders

Preeclampsia or eclampsia

Sepsis

Substance abuse

Trauma

Placental

Abruptio placentae

Chorioamnionitis

Fetomaternal hemorrhage

Twin-twin transfusion

Umbilical cord accidents (eg, prolapse, knots)

Uteroplacental vascular insufficiency

Vasa previa

Fetal

Alloimmune thrombocytopenia

Chromosomal abnormalities

Fetal alloimmune or inherited anemia

Infection

Major congenital malformations (eg, of the heart or brain)

Nonimmune hydrops fetalis

Single-gene disorders

Complications

If a fetus dies during late pregnancy or near term but remains in the uterus for weeks, disseminated intravascular coagulation (DIC) may occur.

Diagnosis

Tests to determine cause include the following:

  • Fetal karyotype and autopsy

  • Maternal CBC (for evidence of anemia or leukocytosis)

  • Kleihauer-Betke test

  • Directed screening for hereditary and acquired thrombotic disorders, including tests for prothrombin G20210A mutation, protein C and S levels, activated protein C resistance (if positive, factor V Leiden mutation testing), antithrombin activity, fasting homocysteine level, and antiphospholipid antibodies (lupus anticoagulant, anticardiolipin [IgG and IgM], anti-β 2 glycoprotein I[IgG and IgM])

  • TORCH test (toxoplasmosis [with IgG and IgM], other pathogens [eg, human parvovirus B19, varicella-zoster viruses], rubella, cytomegalovirus, herpes simplex)

  • Rapid plasma reagin (RPR)

  • TSH (and if abnormal, free T 4 )

  • Diabetes testing (HbA 1C )

  • Examination of the placenta

Often, cause cannot be determined.

Treatment

  • Uterine evacuation if required

  • Routine postdelivery care

  • Emotional support

Uterine evacuation may have spontaneously occurred. If not, evacuation should be done using drugs (eg, oxytocin) or a surgical procedure (eg, dilation and evacuation [D & E], preceded by preabortion osmotic dilators to prepare the cervix, with or without misoprostol). Postdelivery management is similar to that for live birth.

If DIC develops, coagulopathy should be promptly and aggressively managed by replacing blood or blood products as needed.

After the products of conception are expelled, curettage may be needed to remove any retained placental fragments. Fragments are more likely to remain when stillbirth occurs very early in the pregnancy.

Parents typically feel significant grief and require emotional support and sometimes require formal counseling. Risks with future pregnancies, which are related to the presumed cause, should be discussed with patients.

Key Points

  • Abruptio placentae is the most common cause of stillbirth, but there are many other causes (maternal, fetal, or placental).

  • DIC may develop secondarily.

  • Do tests to determine the cause; however, the cause often cannot be determined.

  • Evacuate the uterus using drugs or D & E, and provide emotional support to the parents.

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Drugs Mentioned In This Article

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  • PITOCIN
  • CYTOTEC

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