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Intrauterine Fetal
Death
Duy Nguyen
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Definition
Intrauterine fetal death
Intrauterine fetal demise
Stillbirth
Stillborn
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Definition
United States National Center for Health Statistics
The absence of breathing, heart beats,
pulsation of the umbilical cord, or definite
movement of voluntary muscles at 20 weeks
gestation or 350 grams
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Clinical vignette
A 26 year old G1 by IUP at 22 weeks presents to the ER
complaining that her baby isnt moving as much anymore since
two nights ago.
She denies vaginal bleeding, uterine contractions and loss of
fluid. She mentions that she has had persistent nausea since the
beginning of her pregnancy, but noticed it stopped yesterday
morning.
She admits to not feeling pregnant anymore. When asked if she
feels fetal movement since two nights ago, she says she is not
sure and starts to cry.
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First things first:
Sensitivity
Empathy
Sit down
Eye contact
Listen
Reflect:
I understand this is hard to talk about.
Im so sorry.
Validate:
What youre feeling is normal.
Support
Offer a touch on their shoulders
I will do everything I can to help you.

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Epidemiology
6.2 stillbirths out of 1000 total births in the U.S.
Black women have 2x the rate of stillbirths vs. Caucasians
Higher rates of diabetes mellitus, hypertension, placental abruption,
and PROM
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Etiology in the U.S.
Obstetric complications (e.g.,
abruption, multiple gestation, preterm
birth) 29.3%
Placental disease 23.6%
Fetal genetic/structural abnormalities 13.7%
Maternal or fetal infection 12.9%
Umbilical cord abnormalities 10.4%
Hypertensive disorders 9.2%
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Etiology in the U.S.
Early stillborn
(20-27 weeks gestation)
Late stillborn
(>27 weeks gestation)
Infection (19%)

Abruption (14%)

Fetal anomalies (14%)
Unexplained
(majority)

Risk factors: pre-gravid weight > 68
kg, parity of 3 or more, cord loops,
low SES, maternal age > 40 years,
intimate partner violence, smoking
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Diagnosis
Ultrasound documenting absence of fetal cardiac activity
Clinical signs:
Perceived decrease/loss in fetal movements
Decrease in pregnancy-related symptoms (e.g. nausea, breast
tenderness)
Uterine bleeding and contractions
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Delivery decision
Dont rush them to make a decision about inducing a delivery
There is an increased risk of anxiety years
after the loss if they were induced after 24
hours vs. those induced within 6 hours
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Antepartum evaluation
Fetal karyotyping
Amniocentesis
Chorionic villus sampling
Maternal laboratory evaluation
Fetomaternal hemorrhage (e.g. Kleihauer-Betke test, flow
cytometry)
Urine toxicology
CBC
Serologic testing for syphilis
Fasting blood glucose
Blood antibody screen to exclude alloimmunization
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Postpartum evaluation
Gross and histopathological information
Often leads to new information that may change your original list of
differentials and change recommendations for preconception and
prenatal care
Requires experienced pathologists to assist the autopsies
Estimating time of death
Brown or red discoloration of the umbilical cord = at least 6 hours
Desquamation of the face, back, abdomen = at least 12 hours
Brown or tan skin = at least 24 hours
Mummification = at least 2 weeks
Histological changes of the placenta

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Stillbirth consequences
Nearly of stillbirths occur in apparently uncomplicated
pregnancies
Despair & confusion
Severe emotional stress
Depression
PTSD
Deleterious effects on maternal-child attachment
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Counseling
Offer understanding & support
Allow them to talk about the death
Honest communication
Cultural sensitivity
Allow them to hold the baby
Refer to grief counseling
Obtain complete history with detailed timeline for risk of recurrence &
potential interventions
Schedule post-partum visits earlier than 6 weeks
Encourage regular communication & follow-up
Recurrence rate is 7.8 10.5 per 1000

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Can you screen?
No effective tests are available
Tests obtained as part of Down syndrome screening
Insufficient expansion of maternal plasma volume
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How do you prevent?
Folic acid
Malaria prevention
Syphilis detection and treatment
Hypertension detection and
management
Diabetes detection and
management
Fetal growth restriction
detection and management
Post-term pregnancy
identification and induction
Skilled birth attendant at birth
Availability of basic and
comprehensive emergency OB
care
Reduce smoking, recreational
drug use, alcohol intake
Healthy diet and weight
Regular prenatal visits with fetal
monitoring
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Questions?
Thank you!

Fretts, R.C. (2013). Diagnosis and Management of Stillbirth . In D.S. Basow
(Ed.), UpToDate. Retrieved from http://www.uptodate.com/
Fretts, R.C. (2013). Incidence, etiology, and prevention of stillbirth. In D.S.
Basow (Ed.), UpToDate. Retrieved from http://www.uptodate.com/