Stillbirth, by definition, involves death of the fetus; it increases the risk of death of the fetus in subsequent pregnancies (see High-Risk Pregnancy Overview of High-Risk Pregnancy In a high-risk (at-risk) pregnancy, the mother, fetus, or neonate is at increased risk of morbidity or mortality before, during, or after delivery. In 2017, overall maternal mortality rate in... read more ).
Etiology of Stillbirth
Fetal death during late pregnancy may have maternal, placental, or fetal anatomic or genetic causes (see table Common Causes of Stillbirth Common Causes of Stillbirth 
).
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 Disseminated Intravascular Coagulation (DIC) Disseminated intravascular coagulation (DIC) involves abnormal, excessive generation of thrombin and fibrin in the circulating blood. During the process, increased platelet aggregation and coagulation... read more (DIC) may occur.
Diagnosis of Stillbirth
Clinical evaluation
Tests to identify the cause
The diagnosis of stillbirth is clinical.
Tests to determine the cause of stillbirth include the following:
General examination of the stillborn fetus (eg, physical appearance, weight, length, head circumference [ 1 Diagnosis reference Stillbirth is delivery of a dead fetus at > 20 weeks gestation. Maternal and fetal testing is done to determine the cause. Management is as for routine care after live delivery. Stillbirth,... read more ])
Fetal karyotype
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])
TORCH test (toxoplasmosis [with IgG and IgM], other pathogens [eg, human parvovirus B19, varicella-zoster viruses], rubella, cytomegalovirus, herpes simplex)
Rapid plasma reagin (RPR)
Thyroid-stimulating hormone (TSH), and if abnormal, free T4 (thyroxine)
Diabetes testing (HbA1C)
Examination of the placenta
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 Thromboembolic Disorders in Pregnancy In the US, thromboembolic disorders— deep venous thrombosis (DVT) or pulmonary embolism (PE)—are a leading cause of maternal mortality. During pregnancy, risk is increased because Venous capacitance... read more ( 1 Diagnosis reference Stillbirth is delivery of a dead fetus at > 20 weeks gestation. Maternal and fetal testing is done to determine the cause. Management is as for routine care after live delivery. Stillbirth,... read more ).
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.
Treatment of Stillbirth
Uterine evacuation if required
Routine postdelivery care
Emotional support
Uterine evacuation may have spontaneously occurred. If not, evacuation should be done using drugs (eg, oxytocin) or a surgical procedure (eg, dilation and evacuation [D & E], preceded by preabortion osmotic dilators to prepare the cervix, with or without misoprostol), depending on the gestational age.
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
There are many causes of stillbirth (maternal, fetal, or placental).
Disseminated intravascular coagulation may develop secondarily.
Do tests to determine the cause; however, the cause often cannot be determined.
Evacuate the uterus using drugs or D & E, and provide emotional support to the parents.
