Management of Stillbirth and Abortion — Obstetrics & Gynaecology

PART 1: ABORTION (< 20 weeks)

Classification of Abortion

Threatened Abortion

• Diagnosis: bleeding < 20 weeks + fetal cardiac activity on US, closed cervix
• No proven effective therapy (bed rest and progesterone are not effective and carry their own risks)
• Associated with later complications: 3× risk of preterm birth 28–31 weeks, increased risk of IUGR, PPROM, abruption
• Reassure patient: majority do not result in pregnancy loss

Inevitable Abortion

• Cervix open + effaced, no tissue passed
• Blood type, Rh, CBC
• Rho(D) immune globulin (RhoGAM): give if Rh-negative
  • 50 µg up to 12 completed weeks (if available); otherwise standard 300 µg
• Offer medical or surgical management

Incomplete Abortion

• Partial POC expulsion; cervix dilated; may see tissue at os
• If tissue protrudes from os → remove with ring forceps to reduce bleeding (vasovagal response possible)
• CBC, blood type, Rh; RhoGAM if Rh-negative
• If febrile → broad-spectrum antibiotics
• Proceed to medical or surgical management

Management of Spontaneous Abortion (all non-viable types)

1. Expectant Management

• Acceptable for stable, counseled patient
• Success rates vary by type:
  • Incomplete: 91%
  • Missed: 76%
  • Anembryonic: 66%
• May take 4–8 weeks for complete passage
• Higher risk of unscheduled surgical evacuations, bleeding, transfusion (no difference in infection rates)

2. Medical Management (Misoprostol)

• Routes: vaginal, oral, sublingual, buccal; dose 400–800 µg

• Mifepristone + misoprostol: Adding mifepristone 200 mg PO 24 hours before misoprostol improves success significantly — 83% vs 67% at first follow-up (no difference in adverse events, bleeding, or pain)

3. Surgical Management — Suction Curettage

• Patient desires surgical management
• Excessive/haemodynamically significant bleeding
• Unstable vital signs
• Reliable follow-up is not possible

Recurrent Pregnancy Loss (RPL)

• Parental karyotyping (chromosomal analysis of couple)
• Uterine cavity assessment (HSG, sonohysterography, hysteroscopy)
• Antiphospholipid antibody syndrome screen: lupus anticoagulant, anticardiolipin antibodies (IgG/IgM), β2-glycoprotein I antibodies
• Thyroid function
• Glucose screen (maternal DM)
• In selected cases: thrombophilia panel

PART 2: STILLBIRTH (≥ 20 weeks)

Definition

Causes (SCRN Data)

Evaluation After Stillbirth

Management of Subsequent Pregnancy After Stillbirth

Preconception / Initial Prenatal Visit

• Detailed medical and obstetric history
• Evaluation/workup of previous stillbirth
• Determination of recurrence risk
• Counsel on smoking, alcohol, illicit substance cessation
• Weight loss in obese women (preconception only; target BMI 18.5–24.9)
• Diabetes screen
• APS testing: lupus anticoagulant, anticardiolipin, β2-glycoprotein IgG/IgM

First Trimester

• Dating ultrasound (crown-rump length)
• First trimester screen: PAPP-A, hCG, nuchal translucency or cell-free fetal DNA

Second Trimester

• Fetal anatomic survey at 18–20 weeks
• Genetic screening if not done (or AFP if 1st trimester screen already done)

Third Trimester

• Serial USS from 28 weeks → rule out FGR (every 2–4 weeks if FGR found + Doppler)
• Fetal kick counts starting at 28 weeks
• Antepartum fetal surveillance (NST + AFI or BPP) from 32 weeks (or 1–2 weeks earlier than the gestation of previous stillbirth)

Delivery

• Planned delivery at 39 0/7 weeks (or earlier if dictated by comorbidities)
• In severe patient anxiety, early term delivery (37–38⁶/⁷ weeks) may be considered after counselling on neonatal risks vs. benefit

Prevention of Stillbirth (Population Level)

• Low-dose aspirin: reduces risk of FGR and preeclampsia (conditions associated with stillbirth); insufficient evidence specifically for stillbirth prevention alone
• Antepartum surveillance: ACOG/SMFM recommend individualised surveillance for AMA and obesity
  • BMI 35–39.9 kg/m²: start at 37 0/7 weeks
  • BMI ≥40 kg/m²: start at 34 0/7 weeks
• Induction of labour at 39 weeks: meta-analysis shows reduction in stillbirth (RR 0.50; 95% CI 0.25–0.99) and no increase in caesarean rate vs expectant management
• Fetal kick counts: no RCT evidence for reducing stillbirth; not routinely mandated

Key Risk Factors for Stillbirth

• Maternal age <15 or ≥35 years
• Nulliparity
• Black race (US data)
• Obesity (BMI >30) / large interpregnancy weight gain
• Smoking
• Multiple gestation
• Assisted reproductive technologies
• Previous adverse outcomes (preterm birth, SGA, prior stillbirth)

Summary Algorithm

ABORTION WORKUP
Positive pregnancy test + bleeding/pain < 20 weeks
    ↓
TVS + β-hCG
    ↓
Viable IUP → Threatened abortion → Supportive care
Non-viable IUP / anembryonic →
    ↓
Stable patient → Expectant / Misoprostol 800 µg vaginally
                  (add Mifepristone 200 mg 24h prior for better outcome)
Unstable / excessive bleeding → Suction Curettage
Always → Blood group & Rh, CBC, RhoGAM if Rh-negative

STILLBIRTH (≥20 weeks)
    ↓
Confirm intrauterine fetal death (ultrasound)
    ↓
Counselling + emotional support
    ↓
Evaluation: autopsy, placental histology, genetics, APS screen, Kleihauer-Betke
    ↓
Delivery planning (induction of labour)
    ↓
Subsequent pregnancy: individualised surveillance, planned delivery at 39 weeks

• Berek & Novak's Gynecology, pp. 1749–1753 (Spontaneous Abortion Management)
• Creasy & Resnik's Maternal-Fetal Medicine, pp. 1012–1013; Box 42.3 (Stillbirth — Evaluation, Prevention, Subsequent Pregnancy Management)

Vital Statistics in Obstetrics: Birth Rate, Maternal Mortality Ratio, Perinatal & Neonatal Mortality

1. BIRTH RATES & FERTILITY

Crude Birth Rate (CBR)

• Definition: Number of live births per 1,000 total population per year
• Formula: (Live births / Mid-year total population) × 1,000
• General indicator of reproductive activity of a population; not age-adjusted

General Fertility Rate (GFR)

• Definition: Number of live births per 1,000 women aged 15–49 years per year
• More specific than CBR as it restricts the denominator to women of reproductive age

Total Fertility Rate (TFR)

• Definition: Average number of children a woman would have over her lifetime if current age-specific fertility rates remained constant
• A TFR of 2.1 = replacement-level fertility (to maintain population size)

Age-Specific Fertility Rate (ASFR)

• Live births per 1,000 women in a specific age group per year

2. MATERNAL MORTALITY

Key WHO Definitions

Maternal Mortality Ratio (MMR) vs. Maternal Mortality Rate

Why is MMR technically a ratio, not a rate? Because the denominator (live births) excludes women who died from ectopic pregnancies, miscarriages, terminations, and stillbirths. The true denominator — total number of pregnant women — is unknowable, so live births are used as an approximation. Hence the correct term is maternal mortality ratio. — Creasy & Resnik's, p. 1108

Global MMR Data

• Worldwide (2015): 216 per 100,000 live births (~303,000 deaths); 43.9% decrease from 385 in 1990
• High-income countries: ~12 per 100,000
• Sub-Saharan Africa: ~546 per 100,000
• US historical trend: ~900/100,000 in 1901 → ~9/100,000 in 1991 (attributed to hospital births, aseptic technique, prenatal care, blood transfusion, antibiotics, anaesthesia)

Direct vs. Indirect Causes of Maternal Death

In resource-rich countries, rising causes include cardiovascular disease, suicide/homicide, and drug overdose. Suicide and homicide account for more pregnancy-associated deaths than haemorrhage or preeclampsia in many US states. — Creasy & Resnik's, p. 1113

Risk Factors for Maternal Mortality

• Advanced maternal age (>35 years): 17% of births but 37% of pregnancy-related deaths (California data)
• Obesity (BMI >30): 27% of maternal deaths in UK were obese women
• Black/minority race (in US, Black women have substantially higher MMR)
• Underlying comorbidities: hypertension, diabetes, cardiac disease

3. PERINATAL MORTALITY

Definition (Two WHO/ACOG Definitions)

Perinatal Mortality Rate (PMR) = (Stillbirths + Early neonatal deaths) / (Live births + Stillbirths) × 1,000

Key Data Points

• Preterm birth is the leading cause of perinatal and infant mortality for all racial/ethnic groups
• In 2017 (US): 13,443 fetal deaths + 14,329 neonatal deaths
• 80.8% of neonatal deaths occur within the first 7 days of birth
• Gestational age is the strongest predelivery predictor of survival and morbidity
  • IMR at <32 weeks: 185.79 per 1,000 live births
  • IMR at 32–36 weeks: 21.95 per 1,000 live births

4. NEONATAL MORTALITY

Definitions

Causes of Neonatal Mortality

• Preterm birth / low birth weight
• Birth asphyxia / intrapartum complications
• Neonatal sepsis / infections
• Congenital anomalies
• Respiratory distress syndrome (hyaline membrane disease)

5. INFANT MORTALITY RATE (IMR)

• Definition: Number of deaths of liveborn infants before the first year of age per 1,000 live births
• Stillbirths are excluded from the denominator (only liveborn infants counted)
• IMR is considered a key index of a country's overall health and socioeconomic status
• US IMR: 5.72/1,000 (2007) → 4.92/1,000 (2013) — a 14% decrease
• Racial disparity (US 2018): Non-Hispanic Black IMR (10.75) = more than double that of non-Hispanic Whites (4.63)

6. FETAL DEATH / STILLBIRTH RATE

• Fetal Death Rate: Number of fetal deaths (≥20 wks) per 1,000 live births + fetal deaths
• Stillbirth Rate: Fetal deaths ≥20 weeks per 1,000 total births
• Fetal deaths account for >50% of all perinatal deaths

7. SUMMARY TABLE: All Key Vital Statistics Definitions

8. SIGNIFICANCE OF THESE METRICS

• MMR = a "summary indicator" of maternity care quality; combined with IMR, measures a country's maternal-child health system
• IMR = best single indicator of a nation's overall socioeconomic development and healthcare quality
• Perinatal mortality = reflects quality of combined prenatal + intrapartum + early neonatal care
• Reducing MMR/IMR requires: access to skilled birth attendants, emergency obstetric care, antenatal care, nutrition, infection control, and addressing social determinants

• Creasy & Resnik's Maternal-Fetal Medicine — Chapter 47 (Maternal Mortality, pp. 1107–1115) and Chapter 38 (Preterm Birth / Perinatal & Infant Mortality, pp. 875–876)

1. Birth Rates — Crude Birth Rate, General Fertility Rate, Total Fertility Rate, Age-Specific Fertility Rate (with formulas and denominators)
2. Maternal Mortality — WHO definitions of maternal death, late maternal death, pregnancy-related vs. pregnancy-associated death; difference between MMR (ratio) vs. maternal mortality rate; global MMR data; direct vs. indirect causes; risk factors
3. Perinatal Mortality — Two WHO/ACOG definitions (Definition I vs. II); what each reflects clinically; key data on fetal deaths vs. neonatal deaths
4. Neonatal Mortality — Early NMR (<7 days), Late NMR (7–27 days), overall NMR (<28 days), post-neonatal MR; causes
5. Infant Mortality Rate — Definition, significance, racial disparities
6. Fetal Death / Stillbirth Rate — Definitions and relationship to perinatal mortality
7. Summary comparison table of all indicators with numerators, denominators, and multipliers
8. Clinical significance of each metric as public health indicators