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Read terms. Fretts, MD; Uma M. Turrentine, MD. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable such as smokingmany are not.

Assessment of “fresh” versus “macerated” as accurate markers of time since intrauterine fetal demise in low-income countries

The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to as a definite cause to a stillbirth. A ificant proportion of stillbirths remains unexplained even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history eg, hysterotomyand maternal preference.

Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and Dating intrauterine fetal demise.

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in deliveries in the United States. Approximately 23, stillbirths at 20 weeks or greater of gestation are reported annually 1. The purpose of this document is to review the current information on stillbirth, including definitions and management, the evaluation of a stillbirth, and strategies for prevention. The U. National Center for Health Statistics defines fetal death as the delivery of a fetus showing no s of life as indicated by the absence of breathing, heartbeats, pulsation of the umbilical cord, or definite movements of voluntary muscles 1.

There is not complete uniformity among states with regard to birth weight and gestational age criteria for reporting fetal deaths. However, the suggested requirement is to report fetal deaths at 20 weeks or greater of gestation if the gestational age is knownor a weight greater than or equal to grams if the gestational age is not known 2.

The cutoff of grams is the 50th percentile for weight at 20 weeks of gestation.

To promote the comparability of national data by year and state, U. Terminations of pregnancy for life-limiting fetal anomalies and inductions of labor for previable premature rupture of membranes are specifically excluded from the stillbirth statistics and are classified as terminations of pregnancy 1. The term stillbirth is preferred among parent groups, and more recent research efforts have begun using this term in place of fetal death. Therefore, in this document, the term stillbirth is used. Inthe stillbirth rate in the United States was 5.

Between andthe rate of early stillbirth 20—27 weeks remained essentially unchanged, but between andthe rate decreased from 3. The rate of late stillbirth 28 weeks or greater has been relatively stable since and did not change ificantly between and at 2. There is ongoing discussion regarding the most useful calculation for analysis of stillbirth occurrences. Currently, fetal mortality rates are widely calculated using a birth-based approach: the of stillbirths per 1, live births and stillbirths 1. There may be some utility in changing the denominator to better capture the population at risk, that is, all women who are still pregnant at a given gestational age.

Dating intrauterine fetal demise a denominator of women who are still pregnant at a given gestational age allows for calculation of a prospective fetal mortality rate defined as the of stillbirths at a given gestational age in single weeks per 1, live births and stillbirths at that gestational age or greater 3.

Management of stillbirth

This approach produces the prospective risk of stillbirth, which can be clinically valuable to make predictions for individual pregnancies and to help health care providers balance the risks of expectant management with those of intervention 1 Figure 1. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history 4 5.

Non-Hispanic black women have a stillbirth rate that is more than twice the rate of other racial groups In the United States, the stillbirth rates for other groups were 4. The reason for this health care disparity in stillbirth rates is multifactorial and the subject of ongoing research 6. Higher rates of stillbirth persist among non-Hispanic black women with adequate prenatal care; this has been attributed to higher rates of diabetes mellitus, hypertension, placental abruption, and premature rupture of membranes 7 8.

The educational level for Hispanic and non-Hispanic black women does not appear to be protective as compared with white women, with the widest disparities observed between white and non-Hispanic black stillbirths at 20—27 weeks of gestation, regardless of educational attainment 9. Implicit and explicit bias and racism are implicated in many health disparities including perinatal morbidity and mortality It remains to be better characterized how biologic Dating intrauterine fetal demise modifiable risk factors, including care disparities and environmental stressors, biases, and racism further contribute to the risk for non-Hispanic black women The stillbirth rate among twin pregnancies is approximately 2.

The risk of stillbirth increases in all twins with advancing gestational age, and it is ificantly greater in monochorionic as compared with dichorionic twins The stillbirth rate for triplet pregnancies and higher order multiples is reported as Higher rates are due to complications specific to multiple gestation such as twin—twin transfusion syndromeas well as to increased risks of common complications such as aneuploidy, congenital anomalies, and growth restriction 1 Women with a stillbirth are at increased risk of recurrence.

Compared with women with no history of stillbirth, women who had a stillbirth in an index pregnancy had an increased risk in subsequent pregnancies pooled odds ratio, 4.

Women with adverse pregnancy outcomes, such as preterm delivery, growth restriction, or preeclampsia, are at increased risk of stillbirth in subsequent pregnancies The relationship between adverse pregnancy outcomes and stillbirth is strongest in the case of explained stillbirth. However, there remains a persistent 1.

In a study that examined preterm and small for gestational age SGA births and the risk of stillbirth in a subsequent pregnancy, the risk of stillbirth was increased in the setting of a prior SGA infant; the highest risk was for a prior SGA infant born at less than 32 weeks OR, 8. The relationship between cesarean delivery and subsequent stillbirth remains controversial.

In two large studies from the United Kingdom, cesarean delivery was associated with an increased rate of explained 17 and unexplained stillbirth 15 with an adjusted hazard ratio ranging from 2.

A Danish analysis showed a slight increase in the rate of stillbirth after cesarean in explained and unexplained stillbirths, but neither reached statistical ificance In addition, three large observational studies from the United States 19 20 21 and one from Canada 22 found no association between history of cesarean and stillbirth. In the largest of these studies, the unexplained stillbirth rates at term for women with and without a cesarean delivery were 0.

The extremes of parity have also been associated with stillbirth.

Higher rates of stillbirth are observed in nulliparous women as well as multiparas women with greater than three pregnancies when compared to women with one or two births Male sex of the fetus has been observed as a risk factor for stillbirth. In a recent review of data from more than 30 million births, in a wide range of high-income and low-income countries, the crude mean rate stillbirths per 1, total births was 6. The pooled RR was 1. Although this meta-analysis identifies fetal sex as an important risk factor for stillbirth, the reason why males are at higher risk is unknown.

Maternal age at either end of the reproductive age spectrum less than 15 years and greater than 35 years is an independent risk factor for stillbirth. Maternal age greater than or equal to 35 years of age is associated with an increased risk of stillbirth in nulliparous and multiparous women 25 A ificant proportion of perinatal deaths seen in older women are related to lethal congenital and chromosomal anomalies. The introduction of population-based screening for chromosomal abnormalities has contributed to lower rates of explained stillbirth or neonatal death resulting from chromosomal abnormalities Large observational studies demonstrate that advanced maternal age is an independent risk factor for stillbirth even after controlling for risk factors such as hypertension, diabetes, placenta previa, and multiple gestation 26 28 In addition, there appears to be an interaction between first birth and increasing maternal age that places nulliparous older women at higher risk Based on one study, the estimated risk of stillbirth is 1 in in a year-old nulliparous woman after 37 weeks of gestation, compared with 1 in in a multiparous woman of the same age The stillbirth rate for teenagers Dating intrauterine fetal demise than 15 years of age is This is nearly three times the rate of the lowest risk group, aged 25—29 years, with a rate of 5.

The rate for teenagers aged 15—17 years was 7. Many maternal medical conditions are associated with an increased risk of stillbirth Table 1. Hypertension and diabetes are two of the most common comorbid pregnancy conditions 4 Population-based studies demonstrated almost a twofold to fivefold increase in the risk of stillbirth among women with pregestational diabetes and gestational diabetes 4 32 33 Dating intrauterine fetal demise appears to be a t effect of pregestational diabetes and obesity that is stronger than the individual effects of each risk factor The perinatal mortality rate reported with maternal chronic hypertension is 2—4 times higher than that of the general population 38and the increased risk of stillbirth or neonatal death appears to be independent of other possible contributors such as superimposed preeclampsia or fetal growth restriction.

The precise blood pressure level at which antihypertensive therapy is indicated during pregnancy in women with chronic hypertension continues to be debated; similarly, it is unknown if strict blood pressure control reduces the risk of stillbirth There also appears to be interaction between chronic hypertension and pregestational diabetes on having a stillbirth and in women with both comorbidities, an even higher risk has been reported Numerous other medical conditions including systemic lupus erythematosus, renal disease, uncontrolled thyroid disease, and cholestasis of pregnancy have been associated with stillbirth Table 1.

Antiphospholipid syndrome APS is an acquired thrombophilia that has been associated with stillbirth. The diagnosis of APS depends on women meeting laboratory and clinical criteria for the disorder. One of the clinical criteria for APS is history of stillbirth. In contrast, inherited thrombophilias have not been associated with stillbirth, and testing for them as part of a stillbirth evaluation is not recommended 40 Table 2.

Evaluation of fetal death

Obesity is defined as a prepregnancy BMI defined as weight in kilograms divided by height in meters squared of 30 or greater and is the fastest growing health problem in the United States Obesity in pregnancy is associated with an increased risk of early fetal loss and stillbirth A comprehensive study of five high-income countries found that maternal overweight and obesity BMI greater than 25 was the most common modifiable risk factor for stillbirth A meta-analysis of 38 studies that included 16, stillbirths found that even small increases in maternal BMI were Dating intrauterine fetal demise with an increased risk of stillbirth.

For BMI levels of 20, 25, and 30, absolute risks per 1, pregnancies were 4. Further, excessive weight gain was associated with higher risk of stillbirth among obese and morbidly obese women There is some evidence that the obesity-related stillbirth risk increases with gestational age. In one study, the hazard ratio for stillbirth increased from 2. The reason for this association is likely multifactorial, but obesity is associated with a fivefold increased risk of stillbirth resulting from placental dysfunction.

Obesity remains an independent risk factor for stillbirth even after controlling for smoking, gestational diabetes, and preeclampsia 47 48 49 ; however, the optimal BMI to minimize stillbirth risk remains unknown

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According to the revision of the Procedures for Coding Cause of Fetal Death Under ICD, the National Center for Health Statistics defines fetal death as "death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy.


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