II. Epidemiology: Incidence

  1. Overall Incidence of Intrauterine Fetal Demise in U.S.: 6.2 of every 1000 pregnancies
  2. Pregnancy loss at 13 to 19 weeks gestation: 1-5%
  3. Pregnancy loss after 20 weeks gestation: 0.3%

III. Definitions

  1. Miscarriage
    1. Fetal loss before 20 weeks Gestational age
  2. Early Stillbirth
    1. Fetal loss between 20-27 weeks Gestational age (or fetal weight 350 grams or less)
  3. Late Stillbirth
    1. Fetal loss between 28-36 weeks Gestational age
  4. Term Stillbirth
    1. Fetal loss between 37-40 weeks Gestational age

IV. Causes: Late Pregnancy Loss

  1. Fetal chromosomal and congenital anomalies (12-24% of cases)
    1. Trisomy 13, 18, 21
    2. Neural Tube Defects
    3. Monosomy X
  2. Uterine anomalies
    1. Incompetent Cervix
    2. Uterine Fibroids (related to growth restriction)
    3. Amniotic band syndrome
    4. Uteroplacental insufficiency
  3. Severe acute or chronic condition in the mother
    1. Diabetes Mellitus
    2. Pregnancy Induced Hypertension
    3. Chronic Hypertension
    4. Renal Disease
    5. Thyroid Disease
  4. Hypercoagulable state
    1. Antiphospholipid Antibody Syndrome
      1. Lupus Anticoagulant
      2. Anticardiolipin Antibody
    2. Systemic Lupus Erythematosus
    3. Factor V Leiden
    4. Protein S Deficiency
    5. Prothrombin G20210A
  5. Preterm Premature Rupture of Membranes
  6. Toxin exposure
    1. Teratogen Exposure
    2. Drug Abuse
    3. Tobacco abuse (10 or more Cigarettes per day)

V. Imaging: Fetal Ultrasound

  1. Two examiners should independently confirm IUFD

VI. Labs: Modify based on Events leading up to Pregnancy Loss

  1. Maternal
    1. Endocrine testing
      1. Serum Glucose or Hemoglobin A1C
      2. Thyroid Function Tests (e.g. TSH)
      3. Liver Function Tests
    2. Hypercoagulable state evaluation
      1. Antinuclear Antibody (ANA)
      2. Partial Thromboplastin Time (PTT)
      3. Anticardiolipin Antibody and Lupus Anticoagulant
      4. Factor V Leiden
      5. Activated Protein C resistance and Protein S Deficiency
      6. Prothrombin G20210A Mutation
    3. Other labs to consider
      1. Maternal Urine Tox Screen
      2. Kleihauer-Betke
      3. Syphilis Serology (RPR, VDRL)
  2. Fetus
    1. Fetal Foot Measurement
      1. Most accurate method for dating Gestational age
    2. Autopsy of Stillborn baby
      1. Evaluate for fetal dysmorphology
      2. Alternatives to autopsy
        1. Fetal physical exam
        2. Ultrasound
        3. Whole body MRI
    3. Photograph Stillborn in profile and from front
    4. Placental pathology
    5. Fetal Chromosomal analysis (karyotype analysis)
    6. Obtain cord blood or cardiac puncture
      1. Use Green top tube (Heparinized)
    7. Obtain skin biopsy
      1. Store in Normal Saline
  3. References
    1. Incerpi (1998) Am J Obstet Gynecol 178: 1121-5
    2. (2009) Obstet Gynecol 113(3): 748-61

VII. Management: Delivery

  1. Induction for delivery of fetus
  2. Continue to attend to maternal health

VIII. Management: Initial approach to expressing an adverse birth outcome

  1. See Grief in Pregnancy Loss
  2. Meet with both parents together as soon as possible following Stillbirth
    1. Provide a private setting without disruption
    2. Sit down at eye level with family
  3. Explain in plain language without medical jargon
    1. Call infant by name
    2. Allow parents to ask question and express their feelings
    3. Review facts as known in the context of limited data
    4. Avoid attributing blame
    5. Avoid premature diagnoses (prior to autopsy and other definitive results)
  4. Discuss grief
    1. See Grief in Pregnancy Loss
    2. Self-blame is common but assure that they did not cause pregnancy loss
  5. Encourage parents to hold their child
    1. Encourage momentos (pictures, hair, footprints)
    2. Point out normal exam findings
  6. Disposition
    1. Schedule follow-up times (both before discharge and after) to continue discussion and answer questions
    2. Involve available resources (grief counseling, pastoral care, financial assistance, funeral arrangements)
  7. References
    1. Milstein (2007) Am J Hosp Palliat Care 24(5): 343-9

Images: Related links to external sites (from Google)

Ontology: Stillbirth (C0595939)

Definition (MEDLINEPLUS)

If a woman loses a pregnancy after she’s past her 20th week, it’s called a stillbirth. Stillbirths are due to natural causes. They can happen before delivery or during delivery. Causes include:

  • Problems with the placenta, the organ that transports oxygen and nutrients to the fetus
  • Genetic problems with the fetus
  • Fetal infections
  • Other physical problems in the fetus

In at least half of cases, it is not possible to tell why the baby died.

If stillbirth happens before delivery, your health care provider may induce labor or perform a Cesarean section to deliver the fetus. In some cases, you can wait until you go into labor yourself. This usually happens within two weeks of stillbirth.

Counseling may help you cope with your grief. Later, if you do decide to try again, work closely with your health care provider to lower the risks. Many women who have a stillbirth go on to have healthy babies.

NIH: National Institute of Child Health and Human Development

Definition (MSH) The event that a FETUS is born dead or stillborn.
Definition (NCI) A natural loss of the products of conception.
Concepts Pathologic Function (T046)
MSH D050497 , D011256
ICD10 P95
SnomedCT 76358005, 206581002, 237364002, 157167009, 268887007
English Stillbirth, STILLBIRTH, Stillbirth, NOS, stillbirth, still birth, stillbirth (diagnosis), Stillbirth (disorder), Stillbirth NOS, Still birth, intra uterine death, intrauterine fetal demise, death fetal intrauterine, stillbirths, intrauterine death, intrauterine fetal death, births still, death intrauterine, demises fetal intrauterine, SB - Stillbirth, Stillbirth (finding), Stillbirth (finding) [Ambiguous], Stillbirths
Portuguese NATIMORTO, Morte fetal tardia NE, Perda Fetal Tardia, Nato-Morto durante o Parto, Perdas Fetais Tardias, Natimorto Pré-Parto, Nato-Morto durante o Trabalho de Parto, Nato-Morto Intraparto, Natimorto durante o Trabalho de Parto, Natimorto durante o Parto, Óbito Fetal Tardio, Nascimento sem Vida, Natimorto Intraparto, Nado-Morto Pré-Parto, Nado-morto, Feto-Morto, Natimorto, Nascido Morto, Nascidos Mortos, Natimortos
Spanish NACIDO MUERTO, Nacido muerto NEOM, Feto Muerto, Feto Mortinato, Stillbirth, Obito Fetal Tardio, Nacimiento sin Vida, Óbito Fetal Tardío, Pérdidas Fetales Tardías, Perdida Fetal Tardia, Pérdida Fetal Tardía, Perdidas Fetales Tardias, feto muerto, mortinato (concepto no activo), mortinato (hallazgo), mortinato, muerte intrauterina, muerte prenatal, nacido muerto, Nacido muerto, Nacido Muerto, Mortinato, Nacidos Muertos
Italian Mortinatalità, Mortinatalità NAS, Feto nato morto, Nascita di un feto morto
Dutch doodgeboorte NAO, doodgeboorte, Doodgeboorte
French Mort-né SAI, Naissance sans vie, Mort à la naissance, Mise au monde d'un enfant mort-né, Naissance d'un enfant mort-né, Mortinatalité, MORTINATALITE, Mortinaissance
German Totgeburt NNB, TOTGEBURT, Totgeburt, Totgeborenes
Japanese 死産, 死産NOS, シザンNOS, シザン
Czech narození mrtvého plodu, Porod mrtvého plodu, Porod mrtvého plodu NOS
Finnish Kuolleen lapsen synnytys
Russian MLADENTSA ROZHDENIE BEZ PRIZNAKOV ZHIZNI, МЛАДЕНЦА РОЖДЕНИЕ БЕЗ ПРИЗНАКОВ ЖИЗНИ
Swedish Dödfödsel
Polish Urodzenie martwe
Hungarian Halvaszületés, Halvaszületés k.m.n.

Ontology: Stillborn (C0749019)

Concepts Pathologic Function (T046)
ICD10 P95
English Stillborn, STILLBORN, stillborn, stillborns, Deadborn fetus NOS, deadborn fetus