Obstetrics Book


Late Pregnancy Loss

Aka: Late Pregnancy Loss, Second Trimester Pregnancy Loss, Stillborn, Intrauterine Fetal Demise, IUFD, Stillbirth
  1. See Also
    1. Miscarriage
    2. Grief in Pregnancy Loss
    3. Breaking Bad News
  2. 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%
  3. 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
  4. 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)
  5. Imaging: Fetal Ultrasound
    1. Two examiners should independently confirm IUFD
  6. 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]
  7. Management: Delivery
    1. Induction for delivery of fetus
    2. Continue to attend to maternal health
  8. 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]
  9. Resources
    1. Healing Hearts
      1. http://www.babylosskit.com/resource.html
    2. Miscarriage Association
      1. http://www.miscarriageassociation.org.uk/ma2006/index.htm
  10. 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]

Stillbirth (C0595939)

Definition (MEDLINEPLUS)

If a woman loses a pregnancy after she's past her 20th week, it's called a stillbirth. Stillbirths are due to natural causes. They can happen before delivery or during delivery. Causes include:

  • Problems with the placenta, the organ that transports oxygen and nutrients to the fetus
  • Genetic problems with the fetus
  • Fetal infections
  • Other physical problems in the fetus

In at least half of all cases, it is not possible to tell why the baby died.

If stillbirth happens before delivery, your health care provider may induce labor or perform a Cesarean section to deliver the fetus. In some cases, you can wait until you go into labor yourself. This usually happens within two weeks of stillbirth.

Counseling may help you cope with your grief. Later, if you do decide to try again, work closely with your health care provider to lower the risks. Many women who have a stillbirth go on to have healthy babies.

NIH: National Institute of Child Health and Human Development

Definition (NCI) A fetus of at least 20 weeks of gestation that is dead at the time of delivery, with Apgar scores of 0 at 1 and 5 minutes.(NICHD)
Definition (MSH) The event that a FETUS is born dead or stillborn.
Concepts Finding (T033)
MSH D050497, D011256
ICD10 P95
SnomedCT 157167009, 76358005, 268887007, 206581002, 237364002
LNC LA14271-3, LA14667-2
English Stillbirth, STILLBIRTH, stillbirth, stillborn infant, stillborn infant (physical finding), stillbirth (diagnosis), the infant was stillborn, Stillbirth NOS, Still birth, intra uterine death, intrauterine fetal demise, still birth, death fetal intrauterine, stillbirths, intrauterine death, stillborn, intrauterine fetal death, births still, death intrauterine, demises fetal intrauterine, stillborns, Deadborn fetus NOS, Stillbirth (disorder), Stillborn, SB - Stillbirth, Stillbirth (finding), deadborn fetus, Stillbirth, NOS, Stillbirth (finding) [Ambiguous], Stillbirths
Portuguese NATIMORTO, Morte fetal tardia NE, Natimorto durante o Parto, Nascido Morto, Perda Fetal Tardia, Natimorto Intraparto, Perdas Fetais Tardias, Óbito Fetal Tardio, Feto-Morto, Nascidos Mortos, Natimorto Pré-Parto, Natimortos, Natimorto durante o Trabalho de Parto, Nascimento sem Vida, Nado-morto, Natimorto
Spanish NACIDO MUERTO, Nacido muerto NEOM, nacido muerto, muerte intrauterina, muerte prenatal, feto muerto, Pérdida Fetal Tardía, Feto Mortinato, Nacido Muerto, Óbito Fetal Tardío, Feto Muerto, Nacidos Muertos, Pérdidas Fetales Tardías, Nacimiento sin Vida, mortinato (concepto no activo), mortinato (hallazgo), mortinato, Nacido muerto, Mortinato
Italian Mortinatalità, Mortinatalità NAS, Feto nato morto, Nascita di un feto morto
Dutch doodgeboorte NAO, doodgeboorte, Doodgeboorte
French Mort-né SAI, Naissance sans vie, Mort à la naissance, Mise au monde d'un enfant mort-né, Naissance d'un enfant mort-né, Mortinatalité, MORTINATALITE, Mortinaissance
German Totgeburt NNB, TOTGEBURT, Totgeburt, Totgeborenes
Japanese 死産, 死産NOS, シザンNOS, シザン
Czech narození mrtvého plodu, Porod mrtvého plodu, Porod mrtvého plodu NOS
Finnish Kuolleen lapsen synnytys
Swedish Dödfödsel
Polish Urodzenie martwe
Hungarian Halvaszületés, Halvaszületés k.m.n.
Derived from the NIH UMLS (Unified Medical Language System)

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