II. Epidemiology: Incidence
- Overall Incidence of Intrauterine Fetal Demise in U.S.: 6.2 of every 1000 pregnancies
- Pregnancy loss at 13 to 19 weeks gestation: 1-5%
- Pregnancy loss after 20 weeks gestation: 0.3%
III. Definitions
-
Miscarriage
- Fetal loss before 20 weeks Gestational age
- Early Stillbirth
- Fetal loss between 20-27 weeks Gestational age (or fetal weight 350 grams or less)
- Late Stillbirth
- Fetal loss between 28-36 weeks Gestational age
- Term Stillbirth
- Fetal loss between 37-40 weeks Gestational age
IV. Causes: Late Pregnancy Loss
- Fetal chromosomal and congenital anomalies (12-24% of cases)
- Trisomy 13, 18, 21
- Neural Tube Defects
- Monosomy X
- Uterine anomalies
- Incompetent Cervix
- Uterine Fibroids (related to growth restriction)
- Amniotic band syndrome
- Uteroplacental insufficiency
- Severe acute or chronic condition in the mother
- Diabetes Mellitus
- Pregnancy Induced Hypertension
- Chronic Hypertension
- Renal Disease
- Thyroid Disease
- Hypercoagulable state
- Preterm Premature Rupture of Membranes
- Toxin exposure
- Teratogen Exposure
- Drug Abuse
- Tobacco Abuse (10 or more Cigarettes per day)
V. Imaging: Fetal Ultrasound
- Two examiners should independently confirm IUFD
VI. Labs: Modify based on Events leading up to Pregnancy Loss
- Maternal
- Endocrine testing
- Serum Glucose or Hemoglobin A1C
- Thyroid Function Tests (e.g. TSH)
- Liver Function Tests
- Hypercoagulable state evaluation
- Other labs to consider
- Maternal Urine Tox Screen
- Kleihauer-Betke
- Syphilis Serology (RPR, VDRL)
- Endocrine testing
- Fetus
- Fetal Foot Measurement
- Most accurate method for dating Gestational age
- Autopsy of Stillborn baby
- Evaluate for fetal dysmorphology
- Alternatives to autopsy
- Fetal physical exam
- Ultrasound
- Whole body MRI
- Photograph Stillborn in profile and from front
- Placental pathology
- Fetal Chromosomal analysis (karyotype analysis)
- Obtain cord blood or cardiac puncture
- Use Green top tube (Heparinized)
- Obtain skin biopsy
- Store in Normal Saline
- Fetal Foot Measurement
- References
VII. Management: Delivery
- Induction for delivery of fetus
- Continue to attend to maternal health
VIII. Management: Initial approach to expressing an adverse birth outcome
- See Grief in Pregnancy Loss
- Meet with both parents together as soon as possible following Stillbirth
- Provide a private setting without disruption
- Sit down at eye level with family
- Explain in plain language without medical jargon
- Call infant by name
- Allow parents to ask question and express their feelings
- Review facts as known in the context of limited data
- Avoid attributing blame
- Avoid premature diagnoses (prior to autopsy and other definitive results)
- Discuss grief
- See Grief in Pregnancy Loss
- Self-blame is common but assure that they did not cause pregnancy loss
- Encourage parents to hold their child
- Encourage momentos (pictures, hair, footprints)
- Point out normal exam findings
- Disposition
- Schedule follow-up times (both before discharge and after) to continue discussion and answer questions
- Involve available resources (grief counseling, Pastoral Care, financial assistance, funeral arrangements)
- References
IX. Resources
- Healing Hearts
- Miscarriage Association