Stillbirth is fetal death (fetal demise) at ≥ 20 weeks gestation (> 28 weeks in some definitions). Management is delivery and postpartum care. Maternal and fetal testing is done to determine the cause.
Stillbirth, by definition, involves death of the fetus. In the United States, stillbirth is defined as fetal death before or during birth at ≥ 20 weeks gestation. The World Health Organization defines stillbirth as fetal death after 28 weeks. There are almost 2 million stillbirths worldwide every year (1). Prior stillbirth increases the risk of death of the fetus in subsequent pregnancies.
General reference
1. World Health Organization: Stillbirth. Accessed March 2024.
Etiology of Stillbirth
Fetal death during late pregnancy may have maternal, placental, or fetal anatomic or genetic causes (see table Common Causes of Stillbirth).
Some Causes of and Risk Factors for Stillbirth
Type | Examples |
|---|---|
Maternal | Trauma Diabetes mellitus if uncontrolled Morbid obesity (body mass index [BMI] ≥ 40 kg/m2) Black race Age (adolescents or ≥ 35 years) |
Placental | Intraamniotic infection (chorioamnionitis) Fetomaternal hemorrhage Twin-twin transfusion Umbilical cord accidents (eg, prolapse, knots) Uteroplacental vascular insufficiency |
Fetal | Single-gene disorders Major congenital malformations (particularly of the heart or brain) Alloimmune thrombocytopenia Fetal alloimmune or inherited anemia Nonimmune hydrops fetalis Multiple gestation Infection |
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 of Stillbirth
History and physical examination
Tests to identify the cause
The diagnosis of stillbirth is clinical.
Tests to determine the cause of stillbirth may include the following:
General examination of the stillborn fetus (eg, physical appearance, weight, length, head circumference [1])
Fetal autopsy, karyotype, and microarray assessments
Examination of the placenta
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])
Thyroid-stimulating hormone (TSH) and, if abnormal, free T4 (thyroxine)
Diabetes testing (HbA1C)
TORCH test (toxoplasmosis [with IgG and IgM], other pathogens [eg, human parvovirus B19, varicella-zoster viruses], rubella, cytomegalovirus, herpes simplex)
Rapid plasma reagin (RPR)
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
1. American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine: Management of stillbirth. Obstetric Care Consensus No. 10, 2020. Reaffirmed 2021.
Treatment of Stillbirth
Uterine evacuation if required
Routine postdelivery care
Emotional support
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
Stillbirth is fetal death (fetal demise) at ≥ 20 weeks gestation (> 28 weeks in some definitions).
There are many causes of stillbirth (maternal, fetal, or placental).
Disseminated intravascular coagulation may develop secondarily if uterine evacuation is delayed.
Do tests to determine the cause; however, the cause often cannot be determined.
Evacuate the uterus with medication induction or surgical evacuation, and provide emotional support to the parents.
