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Stillbirth

(Fetal Demise)

By

Antonette T. Dulay

, MD, Main Line Health System

Last full review/revision Oct 2020| Content last modified Oct 2020
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Stillbirth is delivery of a dead fetus at > 20 weeks gestation. Maternal and fetal testing is done to determine the cause. Management is as for routine care after live delivery.

Stillbirth, by definition, involves death of the fetus; it increases the risk of death of the fetus in subsequent pregnancies (see High-Risk Pregnancy).

Etiology

Fetal death during late pregnancy may have maternal, placental, or fetal anatomic or genetic causes (see table Common Causes of Stillbirth).

Table
icon

Common Causes of Stillbirth

Type

Examples

Maternal

Diabetes mellitus if uncontrolled

Morbid obesity (body mass index [BMI] ≥ 40 kg/m2)

Trauma

Placental

Intra-amniotic infection (chorioamnionitis)

Fetomaternal hemorrhage

Twin-twin transfusion

Umbilical cord accidents (eg, prolapse, knots)

Uteroplacental vascular insufficiency

Fetal

Alloimmune thrombocytopenia

Fetal alloimmune or inherited anemia

Infection

Major congenital malformations (particularly 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, consumptive coagulopathy or even disseminated intravascular coagulation (DIC) may occur.

Diagnosis

  • Clinical evaluation

  • Tests to identify the cause

The diagnosis of stillbirth is clinical.

Tests to determine the cause of stillbirth include the following:

  • General examination of the stillborn fetus (eg, physical appearance, weight, length, head circumference [1])

  • Fetal karyotype

  • Maternal complete blood count (CBC) for evidence of anemia or leukocytosis

  • Kleihauer-Betke test

  • Directed screening for acquired thrombotic disorders, including tests for antiphospholipid antibodies (lupus anticoagulant, anticardiolipin [IgG and IgM], anti-beta2 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)

  • Thyroid-stimulating hormone (TSH), and if abnormal, free T4 (thyroxine)

  • Diabetes testing (HbA1C)

  • Examination of the placenta

Testing for hereditary thrombophilia is controversial and is not routinely recommended. The association between stillbirth and hereditary thrombophilia is not clear but does not appear to be strong, except for possibly factor V Leiden mutation. Testing (eg, for factor V Leiden) can be considered when severe abnormalities are detected in the placenta, intrauterine growth restriction occurs, or the woman has a personal or family history of thromboembolic disorders (1).

Often, cause cannot be determined.

Diagnosis reference

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), depending on the gestational age.

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.

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

Postdelivery management is similar to that for live birth.

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

  • There are many causes of stillbirth (maternal, fetal, or placental).

  • Disseminated intravascular coagulation 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.

Drugs Mentioned In This Article

Drug Name Select Trade
CYTOTEC
PITOCIN
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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version

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