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
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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
• 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-β₂ 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 T₄)
• 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.

Last full review/revision May 2013 by Antonette T. Dulay, MD