Intrauterine Fetal Demise

What is Intrauterine Fetal Demise?

The United States Center for Health Statistics defines a fetal death as a situation where a baby is delivered showing no signs of life, such as breathing, heartbeat, movement of any voluntary muscles, or the pulsation of the umbilical cord. This can happen regardless of the length of the pregnancy. This is different from a stillbirth, which is when the baby dies in late pregnancy or at birth, often after 20 weeks of pregnancy or if the baby weighs 350 grams or more. Society is currently trying to make the understanding and use of the term “stillbirth” more widespread, even replacing “intrauterine fetal demise.”

Yet, comparing stillbirth rates across and within different countries can be challenging because the definition of stillbirth isn’t consistently used and not all instances of stillbirth are documented. According to global records, fewer than 5% of all stillbirths are actually recorded. Additionally, stillbirth is the 5th leading cause of death globally. In around 76% of cases, the reason for the stillbirth is unknown. Public health efforts are focusing on reducing stillbirth rates. Many developed countries have already achieved a goal of fewer than 15 stillbirths per 1000 births. Unfortunately, parts of Asia and Africa face higher stillbirth rates, mainly due to limited access to healthcare.

Almost all stillbirths occur in countries with low and middle incomes. There are several possible reasons for stillbirth, including complications during birth, high blood pressure, diabetes, infection, genetic abnormalities, problems with the placenta, and pregnancies that go beyond forty weeks. Understanding more about why stillbirths happen can help support those dealing with this tragic event, and importantly, aid in reducing the risk of stillbirth in future pregnancies. The entire healthcare team plays a crucial role in improving care for patients who have experienced a stillbirth.

What Causes Intrauterine Fetal Demise?

Understanding why a baby is stillborn can be a complex and challenging task. In many instances – about 76% of cases globally – the reasons remain unknown. Half of these tragic losses worldwide have been linked to problems during childbirth, and many could have been prevented with more access to skilled healthcare.

One study found that risk factors known at the beginning of pregnancy often account for only a small portion of the risk. Only having had a previous stillbirth, preterm birth, or a pregnancy where the baby didn’t grow as expected pose significant risks. Women who have previously had an unexplained stillbirth face a higher risk of it happening again, with one study suggesting the risk is 5 times higher, and another showing a 2 times greater risk.

Prior preterm birth, when a baby is born before 34 weeks of pregnancy, triples the risk of having a stillborn baby in a future pregnancy. Having had a baby whose growth was restricted also significantly raises the risk.

The reasons for stillbirth can vary greatly. For instance, issues with the placenta – the organ that provides nutrients and oxygen to the baby – and restricted growth of the baby are common findings in stillbirths. However, most pregnancies with these issues do not end in stillbirth. It can be challenging to detect these problems before the baby is born.

Other medical conditions, such as diabetes and obesity, can also increase the risk of stillbirth. Diabetes can raise the risk five-fold, although improving blood sugar control before getting pregnant can help lower it. Obesity is another significant risk factor, even after considering other problems like diabetes, smoking, and high blood pressure.

A mother’s age can also influence the risk. Older mothers, especially those over 35, have a higher risk of having a stillborn baby due to an increased risk of certain genetic abnormalities and other medical complications. Likewise, the risk of stillbirth goes up for women who smoke, use drugs, or misuse substances.

Other factors such as race, issues with the umbilical cord, or multiple pregnancies can also impact the risk of stillbirth. For instance, non-Hispanic black women in the U.S. have a higher rate of stillbirth compared to other racial groups. Twin pregnancies increase the risk four-fold compared to single pregnancies, and there is an even higher risk for pregnancies with more than two babies.

Infections can sometimes lead to stillbirth, especially if they cause preterm delivery or show significant findings in the placenta or baby’s organs. Conditions that affect pregnant women’s immune systems, such as the antiphospholipid syndrome, which causes problems with blood clotting, can also result in stillbirth.

In some cases, the amount of amniotic fluid surrounding the baby can influence the risk. Having too much (polyhydramnios) or too little (oligohydramnios) can lead to an increased risk.

It’s essential to start prenatal care early and see a healthcare provider regularly during pregnancy to monitor the baby’s growth and health. This can help identify and manage conditions that might increase the risk of stillbirth.

Risk Factors and Frequency for Intrauterine Fetal Demise

Every year, there are over 2.6 million cases of stillbirth in the third trimester around the world. This equates to 18.4 stillbirths per 1000 total births. Although there have been improvements to newborn and infant mortality rates over recent years, the decline in stillbirth rates has been slower. Specifically, in the USA, for every death that happens between 22 weeks gestation and 1 year of age:

• 25.2% are fetal deaths that occur from 22 to 27 weeks gestation,
• 24.5% are fetal deaths from 28 weeks gestation up until birth,
• 33.8% are newborn deaths in the first 28 days of life,
• and 16.1% happen from 28 days to 1 year of age.

In 2013, the number of stillbirths in the USA surpassed the infant mortality rate. Approximately 1 in every 168 pregnancies in the US results in stillbirth, totaling up to around 23,595 cases each year based on 2015 data. Despite these high numbers, the rate has not changed since 2006, remaining at nearly 6 stillbirths per 1000 total births. This rate is higher than other developed countries like Sweden and France which have rates of 3 and 3.87 per 1000 total births, respectively. The range in high-income countries spans from 1.3 to 8.8 stillbirths per 1000 total births. However, in countries like Pakistan and Nigeria, the stillbirth rate is remarkably high at 40 per 1000 total births.

Signs and Symptoms of Intrauterine Fetal Demise

For medical practitioners, it is vital to gather accurate and comprehensive pregnancy and medical history to find out the cause of a stillbirth. This information should include any abdominal pain, bleeding or discharge from the vagina, pelvic pressure felt, and the last noted fetal movement.

The history should also cover:

• Mother’s age, pregnancy history, past medical history
• Exposure to diseases (like Zika or malaria)
• Family history of genetic disorders and miscarriages
• Father’s age and potential for genetic disorders
• Current pregnancy specifics: bleeding, trauma, substance use, infection, blood pressure changes, diabetes, etc
• Past obstetric history: premature births, stillbirths, preeclampsia, diabetes, etc
• Vaccination record
• Social history: occupation, nutrition, substance use, domestic violence, etc
• Prenatal lab test results

Physical examination for patients is also crucial. It should include checking various vitals, checking the mother’s mental status, examining her skin, and looking for signs of injury or trauma. After birth, one should examine the umbilical cord and the placenta, test for any infections and photograph any abnormalities.

Examinations of the baby include measurement of weight, length, head circumference, analysis of facial features, neck and back examination, and much more. Pictures should be taken of the newborn and consent should be obtained for photography as certain cultures may not permit it.

The most crucial examination for stillbirth cases is of the placenta as it aids diagnosis in 53% of the cases. The procedure involves checking the completeness of the membranes, measuring distances, noting membrane insertion type, and assessing the umbilical cord’s physical properties. Cut the cord and weigh the placenta once it has been drained of blood. Document the placenta’s size, cut the placenta into 1cm wide sections, and take note of any abnormalities.

Testing for Intrauterine Fetal Demise

Your doctor may take small samples from different locations of the placenta for microscopic examination. These samples are essential for understanding the cause of a stillbirth, which is an unfortunate loss of a baby before birth.

An autopsy is a thorough examination of the body carried out after death. Autopsies help provide closure for families and can often determine the cause of stillbirth. They require careful documentation and must be handled respectfully. Although stillbirth autopsies may be difficult to discuss, they are critical for multiple reasons – they could determine the cause of the baby’s loss in almost half of the cases and may provide vital information for future prenatal care. Remember, autopsies require written consent from the families.

Your baby’s stillbirth examination might require an imaging procedure like an MRI, CT scan or ultrasound. These procedures can help find abnormal conditions inside the baby’s body. Sometimes a small sample of the affected tissue may be taken through these procedures as well for further examination. The discovery of problems through this process can help avoid complete autopsies and support future care.

Various other screenings can also help determine the cause of stillbirth. MRIs, CT scans, or Babygram (a full-body X-ray of the fetus) can highlight problems with the baby’s skeleton or internal organs. Other tests might include chromosomal studies that can detect abnormalities in the baby’s DNA, which may help explain the cause of stillbirth in some cases.

The process can also include lab tests, amniocentesis, or chorionic villus sampling to help identify any genetic abnormalities. Consent is usually required for these tests, while others like placental tissue sampling may not require consent but it’s respectful to ask for one anyway. DNA tests can be carried out on these samples to determine any genetics discrepancies.

Stillbirth process can also involve screening for infections and other conditions that may have caused the demise. Any conditions that are identified can then be effectively treated, reducing the risk in any future pregnancies.

Among these tests are also ones that check for coagulation disorders like Disseminated Intravascular Coagulation (DIC), which although rare, might occur in cases of undiagnosed stillbirth or stillbirths complicated by placental separation or infections. Their treatment includes managing blood loss and sepsis, providing blood products as necessary, monitoring, and engaging with relevant specialists. The diagnosis of DIC may involve a scoring system that involves checking the platelet count, the prothrombin (PT) level and the fibrinogen level, and combining the points for these tests.

All these procedures are aimed at helping families understand why the stillbirth happened, provide closure and help minimize similar occurrences in future pregnancies based on the findings.

Treatment Options for Intrauterine Fetal Demise

When a mother receives the devastating news of a stillbirth, it’s crucial that the healthcare provider communicates the diagnosis both quickly and kindly. Privacy, empathy, and support, are top priorities. While some mothers may need to leave immediately to process the news, others may need a hand to hold. It’s essential to respect and address these differing needs. Sometimes, mothers might find it helpful to understand the situation better by seeing the ultrasound images. The healthcare provider may try to answer questions, provide written information, and arrange any necessary follow-up meetings. Patients should be reassured that they are not to blame for the stillbirth.

The strong emotions experienced after the diagnosis of a stillbirth should be validated and met with sensitivity. Patients can feel a range of emotions, which are often tied to the five stages of grief: denial, anger, bargaining, depression, and acceptance. It’s important to give patients the time and privacy they need to express their emotions and to seek support. Providing emotional support is an imperative part of the care process.

Conveying bad news is a challenge, and different people might react differently. Some patients may prefer to leave immediately after receiving the news, while others may have a lot of questions. Either way, healthcare providers should try to answer questions to the best of their ability, provide written information for patients to take home, and be available when they are ready to talk.

When it comes to managing a stillbirth, it will depend on the specifics of the situation — factors such as gestational age, patient’s desires, and previous obstetrical/surgical history will all play a role. If a mother is medically unstable due to complications related to the stillbirth, she will need clear, concise information to make an informed decision on any urgent procedures.

In cases where a stillbirth diagnosis is given, options for delivery can vary widely. For those weeks into their pregnancy, certain delivery options are may be recommended based on the specifics of the case. A healthcare provider would share the various options, with an explanation of the benefits and risks of each.

Stillbirth is a traumatic event, and the way it’s handled by healthcare providers can significantly impact the emotional well-being of the parents. Clear communication of the management plan, considering and respecting the parents’ religious and cultural beliefs, and emotional sensitivity are all important factors.

There are also steps healthcare providers can take to honor the memory of the stillborn baby and support the grieving process. For instance, if the baby was named, using their name can be a powerful way to show respect. Parents might also appreciate keepsakes like photographs or a lock of hair. The healthcare provider should discuss the parents’ preference for autopsy, if any, and help them arrange for the disposition of the stillborn baby according to their cultural or religious beliefs. Even the decision on how and when to stop milk production can be approached in a way that supports the grieving process.

After a stillbirth, all efforts should be made to provide emotional support to the family over time. Regular checks-ups should take place to monitor for postpartum depression or other psychological effects. In some cases, providing resources for support groups can be extremely helpful. The decision for future family planning should be discussed at an appropriate time. Ultimately, the discussion on when to try for another baby will depend on when the parents are ready.

What else can Intrauterine Fetal Demise be?

To confirm stillbirth, or the death of a fetus before birth, it is crucial to use an ultrasound to ensure the fetus is not alive. Even with a viable pregnancy, fetal heart sounds may not always be heard.

The medical team should not confuse a stillbirth with a miscarriage. The best way to determine the duration of pregnancy is by comparing the estimated age of the fetus from the last menstrual period (LMP) and the early ultrasound scan. If the LMP is unknown and no previous ultrasounds are available, the fetus’s birth weight or foot length can estimate the age.

In cases of multiple pregnancies, like twins or triplets, a stillbirth in one could occur while the others remain alive. This needs to be ruled out too.

Around one in 17 stillbirths are linked to severe illness in the mother, such as acute appendicitis or systemic lupus. Also, conditions like placenta previa, severe bleeding, and high blood pressure are of high risk. Treatment is vital to prevent the illness from escalating to critical conditions such as acute respiratory distress syndrome, renal failure, or a blood clotting disorder (DIC). The chance of needing a blood transfusion is seven times higher after a stillbirth than after a live birth. In the US, over 15% of maternal deaths within 42 days of delivery are women who had a stillbirth.

Infections should be treated according to the Centers for Disease Control and Prevention (CDC) guidelines.

Any blunt trauma to the stomach can cause the fetus to die. Patients should be privately asked about any domestic violence or physical abuse experiences. If there are signs of physical trauma, patients should be questioned about these findings.

Certain rare causes of stillbirth should also be considered, such as:

• Poisoning due to consumption of drugs, food poisoning, or exposure to environmental toxins like carbon monoxide.
• An abdominal pregnancy, a rare condition often overlooked by ultrasound. Special measures should be taken to manage such cases due to the high risk for the mother. Emergency surgery may be required for the unstable mother. However, the placenta is typically left untouched due to risks of hemorrhage.
• A uterine rupture during medical induction for stillbirth in a patient without any previous uterus surgery history should be considered.
• Finally, a partial molar pregnancy or a fetus with 69 chromosomes should be examined. This condition can result in stillbirth and poses a higher risk for conditions like preeclampsia and postpartum hemorrhage.

Therefore, diagnosing stillbirth encompasses a range of assessments to rule out possible complications and other conditions.

What to expect with Intrauterine Fetal Demise

After a woman experiences a stillbirth, follow-up care includes guidance on the likelihood of it happening again. Women who’ve had a stillbirth are almost twice as likely to experience it again compared to women who’ve had a live birth. This increased risk is influenced by a range of factors, including the mother’s health, how far along the pregnancy was, and the reason(s) for the stillbirth.

For women whose stillbirth had no known cause, the chances of another stillbirth are between 7.8 to 10.5 in every 1000 births. Most of these occur before 37 weeks into pregnancy. The chances of experiencing another stillbirth at full term are 1.8 in every 1000 births. The next pregnancy may also have an increased risk of low birth weight, premature birth, and abruptio placentae, which is when the placenta separates from the uterus too early.

If a woman has had a stillbirth due to the baby being small for their gestational age at full term, the chances of another stillbirth in her next pregnancy are 4.7 in 1000 births. If instead the baby was born alive but small for their gestational age, the chances are 2.1 in every 1000 births.

If a reason for the stillbirth was found, for example, a congenital defect in the baby, the risk increases for the same defect occurring in the next pregnancy by 7.6 times, and the risk of a different defect is increased by 1.5 times compared to women whose previous child had normal structure.

Conditions related to restricted blood supply to the placenta, such as abruption, fetal growth restriction, preeclampsia, and stillbirth, all contribute to the risk of delivering a baby prematurely. Women who had a previous preterm, small-for-gestational-age live birth have a higher risk of stillbirth in the following pregnancy.

As for when a woman should have another baby after experiencing a stillbirth, there is no fixed guideline. However, most women typically wait between 6 to 12 months. This waiting period depends largely on how the baby was delivered and a variety of other life circumstances.

Possible Complications When Diagnosed with Intrauterine Fetal Demise

After a stillbirth, a woman may experience physical complications, like leftover tissues from the pregnancy which need medical attention or surgery, infection, hemorrhage, or a dangerous situation where her blood is not clotting properly. She might also have injuries to her uterus that need surgical repair, or in some cases, she might even need to have her uterus removed. Sadly, experiencing a stillbirth also increases the risk of it happening again in future pregnancies.

If certain health conditions like preeclampsia or diabetes were present at the time of the stillbirth, the woman has a higher chance of developing heart disease later in life. If she tested positive for anticardiolipin syndrome during her evaluation, this could lead to a higher risk of having a stroke or a condition known as deep vein thrombosis, which is when blood clots form in the lower legs or thighs.

Psychological impacts can also be significant and may include losing her job or income and worrying about the financial costs of the health care needed for this complication. She may also battle with feelings of depression, anxiety, and post-traumatic disorder due to unresolved grief or guilt.

These challenges can lead to difficulties in her relationships:

• She might feel stigmatized because she wasn’t able to deliver a healthy baby.
• She and her partner might cope with the loss differently, leading to disagreements.
• Her fear of another stillbirth could lead to her deciding not to have any more children.

The grief can also spread to other family members, including younger children living in the same household.

Preventing Intrauterine Fetal Demise

Finding and managing any health problems a pregnant woman may have early on is crucial to ensure a healthy pregnancy. Better care before and during delivery can help lower the chance of a stillbirth. Stillbirths – when a baby dies in the womb after 20 weeks of pregnancy – can sometimes be prevented by changing certain behaviors or conditions. For instance, a woman’s Body Mass Index (BMI – a measure that tells if a person has a healthy body weight) and blood sugar levels, especially if she has diabetes, are things that can be adjusted to lower the risk of losing the baby. Some stillbirths happen when the baby is full-term, so changing how we care for the pregnancy and planning to deliver the baby a little early could also help avoid this.

Keeping blood sugar levels balanced is a goal for all pregnant women, but it can be hard to predict which pregnancies might be at risk. This is because women who have had both a live baby and a stillbirth have a wide range of BMI and blood sugar levels.

Quitting smoking and stopping the use of recreational drugs are other changes a woman can make to lower her risk. We recommend screening all pregnant women for substance use so that those who need help can get the right treatment. The aim of treatment is to help women see that they can overcome their addictions and that they have the strength to try a different way of life. Mental health services, addiction experts, and coaches who have recovered from addiction themselves can help with this.

If a pregnant woman suffers from a condition called obstetric cholestasis (or OC – a liver disorder that can occur during pregnancy), having the baby at 37 or 38 weeks instead of full term should be based on each woman’s individual situation. This customized approach considers the risks of delivering a baby early and the lack of proof that OC directly increases stillbirth risk.

Performing an audit of newborn care, which is a critical review of how well we care for newborns, could also help reduce stillbirths. The usefulness of these audits depends on accurately recording and finding stillbirth information from hospital records of births or deliveries.