Late Pregnancy Loss

Aka: Late Pregnancy Loss, Second Trimester Pregnancy Loss, Stillborn, Intrauterine Fetal Demise, IUFD, Stillbirth

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II. Epidemiology: Incidence

  1. Overall Incidence of Intrauterine Fetal Demise in U.S.: 6.2 of every 1000 pregnancies
  2. Pregnancy loss at 13 to 19 weeks gestation: 1-5%
  3. Pregnancy loss after 20 weeks gestation: 0.3%

III. Definitions

  1. Miscarriage
    1. Fetal loss before 20 weeks Gestational age
  2. Early Stillbirth
    1. Fetal loss between 20-27 weeks Gestational age (or fetal weight 350 grams or less)
  3. Late Stillbirth
    1. Fetal loss between 28-36 weeks Gestational age
  4. Term Stillbirth
    1. Fetal loss between 37-40 weeks Gestational age

IV. Causes: Late Pregnancy Loss

  1. Fetal chromosomal and congenital anomalies (12-24% of cases)
    1. Trisomy 13, 18, 21
    2. Neural Tube Defects
    3. Monosomy X
  2. Uterine anomalies
    1. Incompetent Cervix
    2. Uterine Fibroids (related to growth restriction)
    3. Amniotic band syndrome
    4. Uteroplacental insufficiency
  3. Severe acute or chronic condition in the mother
    1. Diabetes Mellitus
    2. Pregnancy Induced Hypertension
    3. Chronic Hypertension
    4. Renal Disease
    5. Thyroid Disease
  4. Hypercoagulable state
    1. Antiphospholipid Antibody Syndrome
      1. Lupus Anticoagulant
      2. Anticardiolipin Antibody
    2. Systemic Lupus Erythematosus
    3. Factor V Leiden
    4. Protein S Deficiency
    5. Prothrombin G20210A
  5. Preterm Premature Rupture of Membranes
  6. Toxin exposure
    1. Teratogen Exposure
    2. Drug Abuse
    3. Tobacco Abuse (10 or more Cigarettes per day)

V. Imaging: Fetal Ultrasound

  1. Two examiners should independently confirm IUFD

VI. Labs: Modify based on Events leading up to Pregnancy Loss

  1. Maternal
    1. Endocrine testing
      1. Serum Glucose or Hemoglobin A1C
      2. Thyroid Function Tests (e.g. TSH)
      3. Liver Function Tests
    2. Hypercoagulable state evaluation
      1. Antinuclear Antibody (ANA)
      2. Partial Thromboplastin Time (PTT)
      3. Anticardiolipin Antibody and Lupus Anticoagulant
      4. Factor V Leiden
      5. Activated Protein C resistance and Protein S Deficiency
      6. Prothrombin G20210A Mutation
    3. Other labs to consider
      1. Maternal Urine Tox Screen
      2. Kleihauer-Betke
      3. Syphilis Serology (RPR, VDRL)
  2. Fetus
    1. Fetal Foot Measurement
      1. Most accurate method for dating Gestational age
    2. Autopsy of Stillborn baby
      1. Evaluate for fetal dysmorphology
      2. Alternatives to autopsy
        1. Fetal physical exam
        2. Ultrasound
        3. Whole body MRI
    3. Photograph Stillborn in profile and from front
    4. Placental pathology
    5. Fetal Chromosomal analysis (karyotype analysis)
    6. Obtain cord blood or cardiac puncture
      1. Use Green top tube (Heparinized)
    7. Obtain skin biopsy
      1. Store in Normal Saline
  3. References
    1. Incerpi (1998) Am J Obstet Gynecol 178: 1121-5 [PubMed]
    2. (2009) Obstet Gynecol 113(3): 748-61 [PubMed]

VII. Management: Delivery

  1. Induction for delivery of fetus
  2. Continue to attend to maternal health

VIII. Management: Initial approach to expressing an adverse birth outcome

  1. See Grief in Pregnancy Loss
  2. Meet with both parents together as soon as possible following Stillbirth
    1. Provide a private setting without disruption
    2. Sit down at eye level with family
  3. Explain in plain language without medical jargon
    1. Call infant by name
    2. Allow parents to ask question and express their feelings
    3. Review facts as known in the context of limited data
    4. Avoid attributing blame
    5. Avoid premature diagnoses (prior to autopsy and other definitive results)
  4. Discuss grief
    1. See Grief in Pregnancy Loss
    2. Self-blame is common but assure that they did not cause pregnancy loss
  5. Encourage parents to hold their child
    1. Encourage momentos (pictures, hair, footprints)
    2. Point out normal exam findings
  6. Disposition
    1. Schedule follow-up times (both before discharge and after) to continue discussion and answer questions
    2. Involve available resources (grief counseling, Pastoral Care, financial assistance, funeral arrangements)
  7. References
    1. Milstein (2007) Am J Hosp Palliat Care 24(5): 343-9 [PubMed]

IX. Resources

  1. Healing Hearts
    1. http://www.babylosskit.com/resource.html
  2. Miscarriage Association
    1. http://www.miscarriageassociation.org.uk/ma2006/index.htm

X. References

  1. Michels (2007) Am Fam Physician 76:1341-8 [PubMed]
  2. Goldenberg (2004) J Matern Fetal Neonatal Med 16: 79-94 [PubMed]
  3. McClure (2006) Intl J Gynaecol Obstet 94(2): 82-90 [PubMed]
  4. Van Dinter (2012) Am Fam Physician 85(9): 900-4 [PubMed]

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