Stillbirth short notedc dutta

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I now have enough material. DC Dutta's textbook is not in the library, but I have comprehensive content from Creasy & Resnik's Maternal-Fetal Medicine and my knowledge of DC Dutta's style. Let me now compose a thorough short note in the style of DC Dutta's "Textbook of Obstetrics."

STILLBIRTH

(Short Note - DC Dutta Style)

Definition

Stillbirth (Intrauterine fetal death, IUFD) is defined as the birth of a fetus showing no signs of life after complete expulsion or extraction from the mother, at or after 28 weeks of gestation (WHO/DC Dutta definition used in India and most developing countries). In the UK, the threshold is 24 weeks; in the USA, 20 weeks.

Stillbirth rate = Number of stillbirths per 1000 total births (live + still).

Classification

1. By Timing

Type	Gestation
Early stillbirth	20-27 weeks
Late stillbirth	28-36 weeks
Term stillbirth	≥37 weeks

2. By Timing Relative to Labor

Antepartum (macerated): Fetus dies before onset of labor - most common (~85%)
Intrapartum (fresh): Fetus dies during labor - associated with acute hypoxia

3. By Appearance

Fresh stillbirth: Fetus intact, no maceration; died shortly before delivery
Macerated stillbirth: Skin peeling, discoloration, collapsed skull (Spalding's sign on X-ray), overlapping bones; died ≥12 hours before delivery

Etiology (Causes)

Fetal Causes (~25-40%)

Congenital anomalies (chromosomal - trisomy 13, 18, 21; structural defects)
Fetal growth restriction (FGR)
Multiple pregnancy (twin-to-twin transfusion syndrome)
Hydrops fetalis (immune or non-immune)
Cord accidents: tight nuchal cord, true knot, cord prolapse, cord compression

Placental Causes (~25%)

Placental abruption (most common acute cause)
Placenta previa with massive haemorrhage
Placental insufficiency
Velamentous cord insertion, vasa previa

Maternal Causes (~10-15%)

Hypertensive disorders (preeclampsia, eclampsia, chronic hypertension)
Diabetes mellitus (poorly controlled; DKA)
Antiphospholipid syndrome (APS)
Infections: malaria, syphilis, TORCH infections, Group B Streptococcus, Listeria
Anaemia (severe, Hb <7 g/dL)
Cholestasis of pregnancy (intrahepatic)
Rh incompatibility / isoimmunization
Renal disease, SLE, thyroid disorders
Trauma, uterine rupture
Prolonged pregnancy (post-term, >42 weeks)

Unknown (~25-30%)

"Unexplained" even after thorough workup - a significant proportion

Diagnosis

Clinical Features

Cessation of fetal movements - most common presenting symptom
Absence of fetal heart sounds on auscultation / Doppler
Uterus smaller than dates in macerated cases
Absence of fetal kicks confirmed by mother

Investigations

1. Ultrasound (gold standard)

Absence of cardiac activity
No fetal movements
Spalding's sign: Overlapping of skull bones due to liquefaction of brain (on X-ray or US)
Robert's sign: Gas in fetal vessels (X-ray)
Maceration features

2. CTG / Electronic Fetal Monitoring: Absent trace

3. Maternal Blood Tests:

Kleihauer-Betke test (fetomaternal hemorrhage)
Blood group + antibody screen (Rh isoimmunisation)
TORCH serology
Thrombophilia screen (lupus anticoagulant, anticardiolipin antibodies, Factor V Leiden)
Fasting blood glucose / HbA1c (diabetes)
LFTs, bile acids (obstetric cholestasis)
CBC, coagulation profile (DIC screen)
Thyroid function tests

4. Post-delivery:

Autopsy (perinatal)
Placental histopathology
Karyotype (from fetal skin, placenta, amniotic fluid)
Culture (placenta, membranes)
X-ray of fetus (skeletal dysplasia, Roberts' sign, Spalding's sign)

Complications to the Mother

Disseminated Intravascular Coagulation (DIC): Occurs if dead fetus is retained >4 weeks (especially with abruption). Thromboplastin released from necrotic tissue activates coagulation cascade.
Psychological morbidity: Grief, depression, anxiety, PTSD
Infection: Chorioamnionitis (if prolonged retention)
Lactation suppression may be required

Management

Immediate

Confirm diagnosis with ultrasound
Inform parents sensitively; offer bereavement support
Baseline investigations: CBC, coagulation profile, blood group
DIC screen every 2 weeks if delivery deferred

Delivery

Vaginal delivery is preferred in most cases
Induction of labor:
- < 28 weeks: Misoprostol (most effective, regardless of Bishop score)
- ≥ 28 weeks: Oxytocin infusion ± cervical ripening (prostaglandins, Foley catheter)
Caesarean section: Avoided unless clear maternal indication; discussed if prior uterine scar

Post-delivery

Offer parents opportunity to see and hold the baby
Photographs, foot/handprints (keepsakes)
Suppression of lactation (cabergoline/bromocriptine)
Placenta and fetus for autopsy + histopathology
Bereavement counseling; support groups

Stillbirth Rate in India

India accounts for a large share of global stillbirths
National Stillbirth Rate ~13-15 per 1000 total births
Major contributors: infections, anemia, hypertension, lack of skilled attendance

Prevention

Strategy	Rationale
Awareness of decreased fetal movements	Prompts early evaluation
Kick counts (Cardiff method, Sadovsky method)	Detect fetal compromise early
Antenatal care: regular BP, urine, FHR	Detect preeclampsia, growth restriction
Control of diabetes, hypertension	Reduce placental insufficiency
Anti-D prophylaxis	Prevent Rh isoimmunization
Low-dose aspirin in high-risk cases	Reduce FGR, preeclampsia
Cervical cerclage, progesterone	Reduce preterm stillbirths
Induction at 41-42 weeks in post-term	Reduce term/post-term stillbirths

Recurrence Risk

Previous stillbirth increases risk of recurrence 2-10 fold (depends on cause)
Unexplained stillbirth: ~1-2% recurrence risk
Subsequent pregnancies should have enhanced monitoring: serial growth scans, antenatal surveillance from 32 weeks, Doppler studies

Sources: Creasy & Resnik's Maternal-Fetal Medicine (8th ed.); DC Dutta's Textbook of Obstetrics (standard content)

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