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KEY QUESTIONS
What are the common causes of stillbirth?
What is the recommended workup for stillbirth?
How should the patient’s next pregnancy be managed?
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CASE 35-1
A 35 y.o. Gravida 2 Para 1001 presents at 36 weeks gestation with complaints of decreased fetal movements. Her pregnancy is complicated by advanced maternal age and prior cesarean delivery at term. Intrauterine fetal demise was confirmed.
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Fetal death is defined as spontaneous intrauterine death at any gestational age. There is no complete uniformity concerning when fetal deaths are reported. The US National Center for Health Statistics uses the gestational cutoff of ≥20 weeks or 350 grams, excluding terminations for lethal fetal anomalies and inductions for previable rupture of membranes. Meanwhile, the World Health Organization (WHO) defines death as a fetus with no signs of life at ≥28 weeks gestation prior to complete expulsion from the mother, regardless of the duration of pregnancy for international comparison purposes.1
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In 2013, the fetal death rate was reported to be 5.96 per 1000 live births, or 1 in 160 deliveries in the United States. Of these, 50% occur between the gestational ages of 20 to 27 weeks gestation, 30% between 28 weeks and term, and 20% at or near term. The overall US fetal mortality rate has remained relatively unchanged since 2006. An appreciable 3% decline in fetal death rate between the gestational ages of 20 to 27 weeks gestation was noted between 2012 and 2013.2
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The highest rates of stillbirth are at the earliest and latest gestational ages, with the lowest incidence between 29 and 33 weeks gestation and remaining low at 37 weeks, with a slow increase up to 42 weeks. The early fetal mortality rate is related to congenital anomalies, infections, growth restrictions, and underlying maternal conditions. In pregnancies >40 weeks gestation, the fetal mortality rate is generally related to problems surrounding the time of delivery; that is, placenta previa and abruption, cord prolapse and complications related to the labor and delivery (L&D) process.2,3
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The mortality rates vary considerably with race and ethnicity. The cause for this disparity remains largely unexplained. In the United States, non-Hispanic black women have the highest rate: 10.53 per 1000 live births.2,4 The Stillbirth Collaborative Research Network conducted a multicenter, population-based, case control study of stillbirths and live births involving 59 tertiary-care and community hospitals. The study suggested that much of the excess rate of stillbirth among non-Hispanic black women resulted from obstetric complications, infections, or both, with stillbirth occurring intrapartum at <24 weeks gestation.4 Others have attributed this difference to a higher risk of preterm delivery, and in part to differences in maternal preconception health, infection, income, education, and ...