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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 3: Abnormalities of Pregnancy: Common Causes of Stillbirth). Overall, the most common cause is

• Abruptio placentae

Table 3
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
• Thrombotic screening (including factor V Leiden mutation; prothrombin G20210A mutation; protein C, S, and Z levels; activated protein C resistance; antithrombin activity; fasting homocysteine level; antiphospholipid antibody)
• TORCH test (toxoplasmosis [with IgG and IgM], other pathogens [eg, human parvovirus B19, varicella-zoster viruses], rubella, cytomegalovirus, herpes simplex)
• Rapid plasma reagin (RPR)
• Examination of the placenta

Often, cause cannot be determined.

Treatment

• Routine postdelivery care
• Emotional support

Postdelivery management is similar to that for live birth. If DIC occurs, labor is induced (eg, with IV oxytocinSome Trade Names
PITOCIN
SYNTOCINON
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infusion, sometimes preceded by a prostaglandin to make the cervix favorable—ie, open and effaced). Any coagulopathy that develops should be promptly and aggressively managed by replacing blood or blood products as needed while preparations for delivery are being made.

After the products of conception are expelled, curettage may be needed to remove placental fragments.

Alternatively, dilation and extraction (D&E) may be done. In all cases, preabortion osmotic dilator cervical ripening should be used with or without misoprostolSome Trade Names
CYTOTEC
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.

Parents typically feel significant grief and require emotional support and sometimes formal counseling. Risks with future pregnancy should be discussed with patients; risks are based on the stillbirth's cause.

Last full review/revision February 2010 by Antonette T. Dulay, MD

Content last modified February 2010