Stillbirth

Question 1

What

Answer 1

defined as the birth of a dead fetus after 24 weeks gestation. Stillbirth is the result of intrauterine fetal death (IUFD). It occurs in approximately 1 in 200 pregnancies.

Question 2

Causes

Answer 2

Many of the conditions that can affect pregnancy increase the risk of stillbirth. Unexplained stillbirth is common. The causes of stillbirth include:

Unexplained (around 50%)
Pre-eclampsia
Placental abruption
Vasa praevia
Cord prolapse or wrapped around the fetal neck
Obstetric cholestasis
Diabetes
Thyroid disease
Infections, such as rubella, parvovirus and listeria
Genetic abnormalities or congenital malformations

Factors that increase the risk of stillbirth include:

Fetal growth restriction
Smoking
Alcohol
Increased maternal age
Maternal obesity
Twins
Sleeping on the back (as opposed to either side)

Question 3

Present

Answer 3

A risk assessment for having a baby that is small for gestational age (SGA) or with fetal growth restriction (FGR) is performed on all pregnant women. Having risk factors for SGA increases the risk of stillbirth. Those at risk have the fetal growth closely monitored with serial growth scans. This helps identify women that need further investigations and management. They may need planned early delivery when the growth is static, or other concerns are identified.

Women at risk of pre-eclampsia are given aspirin. Any modifiable risk factors for stillbirth are treated, for example, stopping smoking, avoiding alcohol and effective control of diabetes. Sleeping on the side (not the back) is advised.

There are three key symptoms to always ask during pregnancy. Women would report these immediately if they occur:

Reduced fetal movements
Abdominal pain
Vaginal bleeding

Question 4

Manage

Answer 4

Ultrasound scan is the investigation of choice for diagnosing intrauterine fetal death (IUFD). It is used to visualise the fetal heartbeat to confirm the fetus is still alive.

Passive fetal movements are possible after IUFD, and a repeat scan is offered to confirm the situation.

Rhesus-D negative women require anti-D prophylaxis when IUFD is diagnosed. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

Vaginal birth is first-line for most women after IUFD, unless there are other reasons for caesarean section. Women are given a choice of induction of labour or expectant management (provided immediate delivery is not required, for example with sepsis, pre-eclampsia or haemorrhage). Expectant management involves awaiting natural labour and delivery. Women with expectant management need close monitoring. The condition of the fetus will deteriorate with time.

Induction of labour involves using a combination of oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue).

Dopamine agonists (e.g. cabergoline) can be used to suppress lactation after stillbirth.

With parental consent, testing is carried out after stillbirth to determine the cause:

Genetic testing of the fetus and placenta
Postmortem examination of the fetus (including xrays)
Testing for maternal and fetal infection
Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

Identifying the cause can help reduce the risk in future pregnancies. Pregnancies are closely monitored in women with previous stillbirth.

Sensitive breaking bad news and good emotional support is essential, provided in an appropriate place by appropriately trained and experienced staff. Counselling is offered to women, partners and family members. They are supported with their individual wishes, such as seeing the baby, naming the baby and keeping photographs (although not persuaded either way with what to do). They are also supported with wishes for funeral arrangements and services.