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IUFD Quick Facts
PB102
Stillbirth = delivery of
fetus with no signs of life, 20+ weeks if GA known / 350+ grams if
GA unknown, excludes terminations for lethal anomalies and IOL for
pre-viable PPROM, occurs in 6.2/1000 births (evenly split between
20-27 week and 28+ week groups)
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Risk
Factors: Non-Hispanic black race (11.25 vs 6/1000 even with adequate
PNC), nulliparity, AMA (11-14/1000 if 35-39, 11-21 if 40+) and
obesity (5.5/1000 for Class I, 8/1000 for Class II, 11/1000 for
Class III) are the most prevalent. Also congenital anomalies,
abnormal karyotypes, fetal growth restriction, placental
abnormalities, thrombophilia, hypertensive disorders, diabetes, SLE,
renal disease, thyroid disorders, cholestasis, infections including
B19/CMV/syphilis/strep/listeria, multiple gestation, smoking, drug
use.
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Risk of
stillbirth in pregnancy, after prior pregnancy with IUGR and
livebirth before 32 weeks, is 21.8/1000 (twice as high as risk of
recurrent stillbirth)
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Evaluation:
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Complete maternal history
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Physical exam of fetus with descriptions, photos if possible
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Laboratory
studies (placenta pathology, fetal autopsy, karyotyping = most
important)Fetal autopsy and placental pathology, with parental
consent
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Alternatives
to autopsy: X-rays, ultrasounds, MRIs, blood/tissue samples
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Dysmorphic
features/skeletal abnormalities are found in 20% of stillbirths,
major malformations in 15-20%.
Fetal specimen for
cytology/karyotype, at least one, with parental consent:
amniocentesis fluid is highest yield, placental block (1x1 cm taken
from below cord insertion), umbilical cord segment (1.5 cm closet to
placenta), internal tissue (costochondral jxn or patella)
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Abnormal
karyotype is present in 8-13% of stillbirths, but rate is likely
underestimated, as up to 50% of cell cultures don’t yield results.
Monosomy X (23%), T21 (23%), T18 (21%) and T13 (8%) most common.
Maternal serum for CBC, fetal bleed screen, APLS testing (lupus
anti-coagulant, anti-cardiolipin antibodies, beta-2 glycoprotein
antibodies), parvovirus B19 IgG and IgM, syphilis, TSH
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Inherited
thrombophilia work-up (FVL, prothrombin, ATIII, Protein C &S,
MTHFR/homocysteine) only if severe placental pathology, significant
fetal growth restriction or personal/ family history of thrombosis.
Protein C&S have to wait until post-partum.
Consider the
following: parental karyotyping (if abnormal pedigree, if fetal
chromosomes don’t grow), Indirect Coombs (if Rh status not already
known), A1c (if fetus is LGA), toxicology (if drug use suspected or
abruption)
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ANA, Toxo,
Rubella, CMV, HSV are of unproven benefit
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Management:
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<28 weeks:
Vaginal misoprostol preferred regardless of Bishop score even in
patients with h/o cesarean (200-400 mcg q4-12h)
High-dose Pitocin also
acceptableD&E is an option if an experienced provider, although this
can impede autopsy
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>28 weeks:
Manage as you normally would based on Bishop score. Use
intracervical balloon for unfavorable cervix, rather than
misoprostol.
Pregnancy After Stillbirth
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Recurrence
of stillbirth in low-risk women with negative work-up/unexplained
stillbirth is low at 7.9-10.5/1000 and most of these occur preterm
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Preconception: detailed history, completion of any IUFD work-up not
previously done, determine of recurrence risk, smoking cessation
and weight loss counseling if applicable,
genetic counseling if applicable, DM screening
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1st
trimester: dating/viability US and serum screening + NT
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2nd
trimester: anatomy US at 18-20 weeks and MSAFP
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3rd
trimester: US for IUGR after 28 weeks, kick counts at 28 weeks,
antepartum monitoring…
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Evidence is
limited re: antenatal monitoring, most initiate at 32-34 weeks or
1-2 weeks earlier than prior stillbirth,
risk of recurrent stillbirth must be weighed against risk of
iatrogenic PTB after delivery for false+ testing
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Delivery at 39 weeks gestation,
earlier only with +FLM by amnio
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