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Stillbirth

What's new

Added 2024 RCOG, 2020 ACOG, and 2018 SOGC guidelines for the evaluation and management of stillbirth.

Background

Overview

Definition
Stillbirth is defined as the death of a fetus in utero or the delivery of a fetus with no signs of life at ≥ 20 weeks of gestation.
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Pathophysiology
The pathophysiology of stillbirth often involves impaired placental function, which can lead to fetal growth restriction or preterm labor. Other factors include genetic abnormalities, infections, fetal-maternal hemorrhage, umbilical cord complications, and various maternal medical conditions.
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Epidemiology
The incidence of stillbirth in the US is estimated at 5.96 per 1,000 births, with 3.01 per 1,000 for early stillbirths (20-27 weeks of gestation) and 2.97 per 1,000 for late stillbirths (> 28 weeks of gestation).
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Risk factors
Several risk factors are associated with stillbirth, including advanced maternal age, obesity, pre-existing diabetes, chronic hypertension, smoking, alcohol use, nulliparity, multiple gestation, and non-Hispanic Black race.
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Disease course
The clinical course of stillbirth can vary, but it often involves a period of decreased fetal movement followed by the absence of fetal heart tones.
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Prognosis and risk of recurrence
The prognosis for future pregnancies after a stillbirth depends on the underlying cause and the presence of any modifiable risk factors.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of stillbirth are prepared by our editorial team based on guidelines from the Endocrine Society (ES 2024), the Royal College of Obstetricians and Gynaecologists (RCOG 2024,2016), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023,2020,2018,2014), and the American College of Obstetricians and Gynecologists (ACOG 2020,2012).
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Screening and diagnosis

Diagnosing intrauterine fetal demise: as per RCOG 2024 guidelines, obtain ultrasound for the accurate diagnosis of late intrauterine fetal demise.
B
seek a second opinion for the diagnosis.
E
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Diagnostic investigations

History and physical examination: as per RCOG 2024 guidelines, elicit a detailed history to guide subsequent investigations into the cause of stillbirth.
B
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  • Laboratory tests

  • Fetal examination

Diagnostic procedures

Placental and cord examination: as per RCOG 2024 guidelines, obtain a pathological examination of the cord, membranes, and placenta in all cases of stillbirth.
B
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  • Fetal autopsy and cytogenetic evaluation

  • Minimally invasive postmortem examination

Medical management

Antibiotic prophylaxis: as per RCOG 2024 guidelines, do not use routine antibiotic prophylaxis.
D
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  • Thromboprophylaxis

  • RhD immunoglobulin

Therapeutic procedures

Mode of delivery
As per RCOG 2024 guidelines:
Offer vaginal birth for most patients, but consider performing Cesarean delivery for some.
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Recognize that late intrauterine fetal demise is not a contraindication to pool birth in suitable circumstances.
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  • Induction of labor

Specific circumstances

Single fetal demise in multiple gestation: as per SOGC 2023 guidelines, obtain color Doppler ultrasound in case of death of one monochorionic twin early in pregnancy to exclude twin reversed arterial perfusion sequence by confirming the absence of blood flow in the suspected demised twin.
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  • Patients with antiphospholipid syndrome

Patient education

General counseling: as per ACOG 2020 guidelines, communicate the results of the autopsy, placental examination, laboratory tests, and cytogenetic studies to the family of the deceased infant in a timely manner.
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Preventative measures

Vitamin D supplementation: as per ES 2024 guidelines, consider offering empiric vitamin D supplementation during pregnancy to potentially lower the risk of intra-uterine mortality.
C
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Follow-up and surveillance

Suppression of lactation: as per RCOG 2024 guidelines, discuss lactation, milk donation, and milk suppression with patients.
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  • Antenatal surveillance

  • Management of subsequent pregnancy (monitoring)

  • Management of subsequent pregnancy (low-dose aspirin)

  • Management of subsequent pregnancy (thromboprophylaxis)

  • Management of subsequent pregnancy (timing of delivery)

  • Management of subsequent pregnancy (psychosocial support)