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Intrauterine Fetal Death (IUFD) / Stillbirth

Definition

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Epidemiology

• Global: ~2.6 million stillbirths (≥28 weeks) occur annually; 98% in low- and middle-income countries.
• United States: 1 in 165 pregnancies; ~21,500/year; rate of 5.7 per 1,000 births.
• The US stillbirth rate declined only minimally from 2006–2019 (6.05 → 5.7/1,000), compared to 6.8%/year decline in some European countries.
• Early stillbirths (20–27 weeks): 2.98/1,000; Late (≥28 weeks): 2.73/1,000.
• Racial disparity: Non-Hispanic Black women have a 2.2× higher rate (10.41 vs. 4.71/1,000) than non-Hispanic White women — partly explained by obstetric complications and infection, but multifactorial and not fully explained.

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Risk Factors

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Causes (Pathogenesis)

Key Causes in Detail

• Ascending (e.g., Group B Streptococcus, E. coli) → chorioamnionitis, funisitis
• Hematogenous (e.g., Listeria, CMV, parvovirus B19, syphilis, malaria)
• Mechanisms: direct fetal infection, placental dysfunction, severe maternal illness, preterm labor

• Abruption, infarction, velamentous cord insertion, vasa previa, massive fetomaternal hemorrhage, chronic villitis

• Chromosomal abnormalities found in 6–13% of tested stillbirths; >20% when structural anomalies or FGR present
• Microarray detects additional copy-number variants missed by standard karyotype

• Cord prolapse, true knot, nuchal cord with compression, cord thrombosis

• Placental insufficiency → fetal hypoxia

• Developed countries: ~1/1,000 births; developing countries: ~7.3/1,000 (up to 20–25/1,000 in parts of Africa/Asia)
• Causes: shoulder dystocia, malpresentation, cord prolapse, birth trauma, abruption, uterine rupture

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Classification Systems

• Over 80 classification systems have been proposed — no global consensus
• INCODE (Stillbirth Collaborative Research Network): assigns "probable," "possible," or "condition present" levels of certainty
• ICD-PM (WHO ICD-10 based): preferred in low-resource settings

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Diagnosis & Evaluation

Initial Steps (All Cases)

1. Thorough medical and obstetric history (Box 42.1)
2. Placental pathology (gross + histologic) — single most useful test; should be done in all cases
3. Fetal autopsy — recommended in all cases; provides cause of death in >30%

Yield of Additional Tests (SCRN Data)

Clinical Scenario-Based Approach

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Management / Delivery

Timing

• No medical urgency for immediate delivery
• 80–90% of women enter spontaneous labor within 2 weeks
• Consumptive coagulopathy (DIC) from tissue factor release: occurs in ~3–4% after 4–8 weeks; risk increases with abruption or uterine perforation
• Coagulation screen (fibrinogen, platelets, PT, aPTT) required before neuraxial anesthesia

Mode of Delivery — by Gestational Age

• Lower complication rate (4%) vs. induction of labor (29%) when performed by experienced providers
• Limitation: limits quality of perinatal autopsy
• Admit: CBC, type & screen; doxycycline 200 mg PO 1 hour pre-procedure; misoprostol 200 μg vaginally 4 hours prior OR laminaria; RhD immune globulin if Rh-negative

• Uterus <28 weeks: Misoprostol 200–400 μg vaginally or orally q4h
• Uterus ≥28 weeks: Misoprostol 25–50 μg vaginally/orally q4h OR oxytocin infusion
• Consider fibrinogen level if fetal death >4 weeks
• Allow spontaneous placental delivery (avoid cord traction) to reduce retained placenta
• Epidural, IV narcotics (PCA), or intermittent dosing for analgesia

• Prior low-transverse: use misoprostol for <28 weeks; oxytocin + cervical Foley for ≥28 weeks
• Prior classic incision: repeat cesarean delivery is appropriate

Bereavement

• Parents encouraged to see, hold, and spend time with baby
• Offer keepsake items (photos, hand/footprints)
• Consider postpartum care on a non-maternity ward
• Bereavement services referral
• Follow-up visit at 2–6 weeks

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Screening & Prediction

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Prevention

• Most stillbirths occur in pregnancies with no identifiable prior risk factors — population-wide screening is needed
• Modifiable risk factors: smoking cessation, weight reduction (BMI >30), treating diabetes/hypertension optimally, avoiding illicit substances
• Antepartum fetal surveillance for high-risk pregnancies
• Fetal movement counting — awareness of decreased movements prompts evaluation

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Management of Subsequent Pregnancy (Box 42.3)

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Intrauterine Fetal Death (IUFD)

Definition

• Death of a fetus at or after 20 weeks of gestation (some definitions: ≥28 weeks for international comparisons)
• Before 20 weeks → called abortion/miscarriage
• Also called stillbirth

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Etiology (Causes) — "ABCDE" Framework

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Diagnosis

Symptoms

• Absent fetal movements (most common presenting complaint)
• Disappearance of pregnancy symptoms (breast tenderness, nausea)
• No fetal heart sounds on auscultation

Investigations

Gold standard for confirmation: Ultrasound — absence of fetal cardiac activity

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Complications (Maternal)

1. DIC / Coagulopathy ⚠️ (Most feared)

• Dead fetus releases thromboplastin (tissue factor) → activates extrinsic coagulation cascade → consumptive coagulopathy
• Occurs after 4+ weeks of fetal retention
• Risk: ~3–4% at 4–8 weeks; increases with abruption
• Monitor: Fibrinogen (earliest to fall), PT, aPTT, platelets
• Fibrinogen <150 mg/dL = treat before delivery

2. Infection / Sepsis

• From ascending organisms; especially with PPROM

3. Psychological morbidity

• Grief, depression, post-traumatic stress

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Management

Step 1 — Confirm diagnosis

• USG: absent cardiac activity

Step 2 — Evaluate

• Thorough history + examination
• Placental pathology + fetal autopsy — most useful investigations
• Coagulation screen (fibrinogen, PT, aPTT, platelets) — especially if dead >4 weeks
• Kleihauer-Betke test (fetomaternal hemorrhage)
• Antiphospholipid antibodies
• Karyotype/chromosomal microarray
• Infection screen (TORCH, parvovirus, syphilis)
• Blood glucose, thyroid function

Step 3 — Deliver

There is no medical emergency for immediate delivery unless coagulopathy, sepsis, or maternal indication exists. 80–90% of women go into spontaneous labour within 2 weeks.

• Administer anti-D immunoglobulin to all Rh-negative mothers
• If fibrinogen <150 mg/dL → correct coagulopathy before induction

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X-ray Signs of IUFD (Classical Exam Points)

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Bereavement Care

• Allow parents to see and hold the baby
• Photographs, handprints, footprints
• Refer to bereavement/psychological support
• Follow-up at 2–6 weeks post-delivery

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Subsequent Pregnancy Counselling

• Evaluate and treat cause before next pregnancy
• Serial growth ultrasounds from 28 weeks
• Antepartum fetal surveillance from 32 weeks (or 1–2 weeks before previous stillbirth GA)
• Fetal movement counting from 28 weeks
• Planned delivery at 39 weeks (or earlier if indicated)
• Risk of recurrence depends on cause; overall ~7–10× higher background risk

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Key High-Yield Points for Exams