Research Article
Stillborn Infants: Associated Malformations
Lewis B. Holmes *1,2,3, Hanah Nasri1,2, Rebecca Beroukhim4, Anne-Therese Hunt5,
Drucilla J. Roberts6,7, M. Hassan Toufaily 1,2, and Marie-Noel Westgate1,2
Background: Stillbirth, defined as death of a fetus in utero after 20 weeks of
gestation, occurs in 1 to 2% of pregnancies in the United States. Many of
these stillborn infants have associated malformations, including chromosome
abnormalities, neural tube defects, and malformation syndromes. Other
causes are abnormalities of the placenta and maternal conditions, such as
pre-eclampsia and obesity. A consecutive sample of malformed stillborn
infants can establish the relative frequency and severity of the associated mal-
formations. Methods: Stillbirths were identified in the Active Malformations
Surveillance Program at Brigham and Women’s Hospital (1972–2012). The
findings at autopsy, including the findings in the placenta and the results of
diagnostic studies, were compiled. Results: One hundred twenty-seven
stillborn infants with malformations were identified at autopsy among 289,365
pregnancies, including trisomies 21, 18, and 13; 45,X; triploidy; anencephaly;
lower urinary tract obstruction; holoprosencephaly and severe heart defects,
such as hypoplastic left heart syndrome and tetralogy of Fallot with pulmonary
Introduction
Stillbirth, defined as fetal death in the third trimester of
pregnancy, occurs in approximately 1 in 160 pregnancies
and accounts each year for approximately 26,000 deaths
in the United States (VanderWielen et al., 2011). The rate
of stillbirths has remained relatively constant (Cousens
et al., 2011). World-wide the vast majority of stillbirths
occur in low to middle income countries, such as South
Asia and sub-Saharan Africa. At least half of the stillbirths
occur during labor or birth (Walker, 2011).
In this study, the Active Malformations Surveillance Pro-
gram, the definition of stillbirth used was fetal death after
1
Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital,
Boston, Massachusetts
2
Medical Genetics Unit, MassGeneral Hospital for Children, Boston,
Massachusetts
3
Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
4
Division of Pediatric Congenital Cardiology, MassGeneral Hospital for
Children, Boston, Massachusetts
5
Hunt Consulting Associates, Chapel Hill, North Carolina
6
Department of Pathology, Massachusetts General Hospital, Boston,
Massachusetts
7
Department of Pathology, Harvard Medical School, Boston, Massachusetts
Supported by funds provided by the Birth Defects Registry of the Massachu-
setts Department of Public Health, which is part of the National Birth Defects
Prevention Study, a project of the Birth Defects and Developmental Disabilities
Center of the Centers for Disease Control, Atlanta.
*Correspondence to: Lewis B. Holmes, Medical Genetics Unit, MassGeneral
Hospital for Children, 5th Floor, 175 Cambridge Street, Boston, MA 02114.
E-mail: holmes.lewis@mgh.harvard.edu
Published online in Wiley Online Library (wileyonlinelibrary.com). Doi: 10.
1002/bdr2.1097
C 2018 Wiley Periodicals, Inc.
V
atresia. The severity of the abnormalities in stillborn infants was more severe
than the spectrum of abnormalities identified in live-born infants. Conclusion:
An autopsy of the stillborn fetus, including chromosome microarray and an
examination of the placenta, can identify the underlying causes of the
stillbirth. This review of stillborn fetuses with malformations showed that
several different lethal malformations and heart defects are more common
than among live-born infants. These postmortem examinations can improve
the counseling of the parents about risks in future pregnancies.
Birth Defects Research 110:114–121, 2018.
C 2018 Wiley Periodicals, Inc.
V
Key words: lethal; severe-handicapping malformations; stillbirth; heart defects;
trisomies; 45,X
20 weeks of gestation and before delivery. Others have used
the definition of fetal death at 28 weeks of gestation or a
birth weight of equal to or greater than 1000 (Cousens
et al., 2011).
The causes of stillbirth have been shown in several sys-
tematic studies to be either maternal factors or fetal factors or
a combination of those factors. Two systematic studies, the
Wisconsin Stillbirth Services Program from 1983 to 1988
(Pauli, 1994; Pauli and Reiser, 1994; VanderWielen et al.,
2011; Jorgensen et al., 2014) and the Stillborn Collaborative
Research Network from 2006 to 2008 (Dudley et al., 2010;
Reddy et al., 2012; Gibbs Pickens, 2015; Page et al., 2017),
have identified the many causes of stillbirth and have provided
recommendations for the evaluation of the stillborn fetus, the
placenta, and the potentially relevant maternal factors.
The maternal factors identified include obesity, ad-
vanced maternal age, smoking, diabetes mellitus, and hyper-
tension (Flenady et al., 2011). Autopsies of stillborn fetuses
and analyses of placentas have identified severe villous
fibrosis of the placenta, abruptio placenta, and umbilical
cord pathology as common causes (Bonetti et al., 2011). For
example, the evaluation of 310 consecutive autopsies of still-
born infants showed that utero-placental pathology was the
cause of death in 191 (61.6%) of the fetuses (Horn et al.,
2004). By comparison, malformations were considered to
be the cause of intrauterine death in 80 (25.8%) of the
fetuses. In another study of 124 stillbirths and early neona-
tal deaths, 35% of the fetuses had structural physical abnor-
malities (Mueller et al., 1983).
The spectrum of malformations identified in stillborn
infants has been described in several systematic studies
BIRTH DEFECTS RESEARCH 110:114–121 (2018)
(Mueller et al., 1983, Pauli, 1994; Pauli and Reiser, 1994;
Yamauchi et al., 1999; Botto et al., 2007; Pinar et al., 2009;
Jorgensen et al., 2014). Chromosome abnormalities, primar-
ily the trisomies, have been the most common diagnoses.
Several different lethal or severe handicapping malforma-
tions, such as anencephaly, severe heart defects, lower uri-
nary tract obstruction, and the complications of twin–twin
transfusion syndrome, have been prominent findings.
We present here the malformed stillborn infants identi-
fied in the surveillance of a consecutive, hospital-based
sample of 289,365 births.
Materials and Methods
The Active Malformations Surveillance Program was carried
out at a tertiary maternity center, the Boston Lying-In Hospi-
tal, which later became part of Brigham and Women’s Hos-
pital in Boston, from February 16, 1972, to October 1, 2012.
The definition used for a malformation was a structural
abnormality with surgical, medical, or cosmetic importance.
The malformations were divided into four groups by sever-
ity: lethal (anencephaly); severe, handicapping (lower uri-
nary tract obstruction); moderate, fixable (cleft lip and
palate [CLP]); and mild (polydactyly, postaxial, type B). The
details of the methodology and the demographic character-
istics of the population surveyed have been presented in
Holmes et al, 2018, in another article in this special issue of
the journal.
The findings in stillborn infants and the fetuses in preg-
nancies terminated because of anomalies identified in pre-
natal testing were determined from reading the medical
records of each postpartum woman; the autopsy reports of
the Department of Pathology; the responses of each postpar-
tum mother to questions about prenatal testing results and
family history; and the reports of imaging studies, chromo-
some analysis, and the findings in the placenta. This review
in 2013 to 2016 confirmed the diagnosis and established,
whenever possible, the apparent etiology of each infant’s
malformation(s). We present here the findings in the mal-
formed stillborn infants identified among the births to 7020
nontransferred mothers, that is, those who had always
planned to deliver at this hospital.
Z-tests were used to compare the proportion of total and
specific malformations in the stillborn infants with those of
the live-born infants and fetuses in elective termination, as
shown in Table 3. Significance was adjusted for multiple
comparisons using the Benjamini Hochberg false discovery
rate (Benjamini and Hochberg, 1995).
Results
A total of 127 of 1496 (8.5%) of stillborn infants had one or
more malformations, compared with 2.4% among all live
births and elective terminations among 289,365 births sur-
veyed in the Surveillance Program (1972–2012) (p <
0.0001). Several different types of malformations were
115
identified: chromosome abnormalities (the trisomies 21, 18,
13, and 45,X [Turner syndrome]); neural tube defects (pri-
marily anencephaly); heart defects, such as hypoplastic left
heart syndrome and tetralogy of Fallot with pulmonary atre-
sia; and malformation syndromes, such as lower urinary
tract obstruction/posterior urethral valves (Tables 1 and 2).
The most common malformations identified in the auto-
psies were much more common among stillborn infants, with
the range of the increase between 4.4X and 44.5X, than
occurred in the live-born infants and malformed fetuses in
elective terminations because of anomalies detected prena-
tally (Table 3).
Using the range of severity of malformations developed
in this study, the severity of the malformations in the 127
stillborn infants was: 34.6%, lethal; 48%, severe, handicap-
ping; 15.7%, moderate, fixable; 1.5%, mild. For comparison,
the distribution of the range of severity in 1355 malformed
infants identified in this study in the years 1999 to 2002
was: 10.3%, lethal; 38.9%, severe, handicapping; 43.8%,
moderate, fixable; 7.6%, mild (Thomas et al., 2016). Statisti-
cal comparison shows significantly greater percentages of
lethal malformations (p < 0.0001) and significantly less
moderate (p < 0.0001) in the stillborns than in the mal-
formed infants. There were no significant differences (p 5
.38) in the percentage of severe handicapping malforma-
tions between the two groups. Although, two specific mal-
formation syndromes, lower urinary tract obstruction and
holoprosencephaly, with severe handicapping severity, were
significantly more common among the stillborn infants.
Fifty-eight (45.7%) of the 127 malformed stillborn
infants had chromosome analysis. In many other fetuses,
attempts at cell culture for chromosome analysis were
unsuccessful. The most common chromosome abnormalities
identified were the most common trisomies (21, 18, and
13), triploidy, and 45,X (Table 1). None of the fetuses had
chromosome microarray studies.
The findings in the placenta were available on 31
(24.4%) of the 127 malformed stillborn, as the delivering
obstetrician had the option of requesting an evaluation of
the placenta or not. No abnormalities were identified in
three fetuses. Among the other 28, there was maternal vas-
cular malperfusion in 9 (8 had infarcts; one was “small”);
fetal vascular malperfusion, such as thrombi in fetal vessels,
in 4; acute abruption in 3; hydrops placentalis in 3; inflam-
matory pathology in 7; anatomic findings in 10, such as true
knot in cord (n 5 1), single umbilical artery (n 5 5) and
membranous insertion of the umbilical cord (n 5 2); other
changes, such as acute villous edema in 14. Some of these
changes, such as a true knot in the umbilical cord, could
have been the primary cause of the stillbirth.
Fetal growth restriction was defined as a birth weight
or crown-rump length less than the 10th percentile, using
the tables published by Archie et al. (2006). Among the 79
fetuses for which measurements were recorded, 38% were
growth restricted.
116 STILLBORN INFANTS: ASSOCIATED MALFORMATIONS

7. Teratoma locations: intrapericardial 2

TABLE 1. Recognized Phenotypes and Etiologies among Stillborn Infants
anterior cervical* and upper mediastinum*

1. Chromosome abnormalities 8. Mendelian disorders

Trisomy 21** 15 Saldino-Noonan syndrome** 1

Trisomy 18* 9 Osteogenesis imperfecta, type II* 1

Trisomy 13* 5 Noonan syndrome** 1

e
45,X** 5 Private syndrome * 1

Triploidy* 3 Private syndromef* 1

Other: 46,XX/47,XX,1mar**; 2 Infantile polycystic kidney disease* 1

tetrasomy 12p (48,XY,22/22)* Hypochondroplasia** 1

Total 39 Pyloric stenosis with epidemolysis bullosa* 1

2. Neural tube defects Total 8

Anencephaly * a,b
17 9. Multiple congenital anomalies ? etiology

Myelomeningocele** 2 Corbiloculare, mitral atresia, transposition 1

Lipomeningocele *** c
1 of great arteries, absent radius and thumb, clubfoot**

Total 20 CLP, membranous VSD*** 1

3. Heart defects Esophageal atresia, VSD, malrotation*** 1

Isolated/no other anomalies identified 14 Esophageal atresia and unilateral renal agenesis*** 1

(severity listed on Table 2) Hydrocephalus, hydronephrosis, syndactyly toes 3-4*** 1

4. Malformation syndromes Omphalocele and absent thumb*** 1

Lower urinary tract obstruction** 5 Sagittal synostosis, triphalangism, 1

Holoprosencephaly, polydactyly 3 short metatarsals, small nails**

and other anomalies** Tetralogy of Fallot with pulmonary 1

Arthrogryposis, cleft palate, club 3 atresia, preaxial polydactyly of foot,

foot and other anomalies** hypoplasia right ear** 8

VACTERL association** 2 Total 127

Renal agenesis (bilateral) and other anomalies* 2 Severity scale: * 5 lethal; ** 5 severe, handicapping; *** 5 mod-
erate, fixable; **** 5 mild.
Amniotic band syndrome – limb body wall deformity* 1 a
One infant of diabetic mother with anencephaly and myelomeningocele.
Heterotaxy** 1 b
One infant of a diabetic mother with anencephaly.
c
Total 17 Cord tight around neck.
d
5. Malformations – isolated True knot in umbilical cord in one fetus.
e
CL, cleft palate alone, CLP*** 3
One SB male in family with two affected males with brain malforma-
tion, growth retardation, and polyhydramnios (Holmes et al, 1997).
Talipes equinovarus*** 3 f
One SB male in family with two affected males with hypoplastic left
Postaxial polydactyly**** 2 heart syndrome, absence of corpus callosum, nephromegaly and
facial anomalies (Neish and Roberts, 1991).
Diaphragmatic herniad** 2
SB, stillborn fetus or infant; VSD, ventricular septal defect.
Multicystic dysplastic kidneys** 1

Hypospadias*** 1
There were slightly more malformed females than males:
Hydranencephaly* 1
60:54 5 1.1.
Hydrocephalus** 1 The racial/ethnic distribution, based on the mother’s
Total 14 designations, was: White 63.7%, Black 16.8%, Hispanic
6. Twin–twin transfusion with acardia* 3 14.2%, Asian 2.6%, and mixed ancestry 6.2%. This distri-
bution is similar to that in the total population surveyed
Co-twin with schizencephaly** 1
(Holmes et al, 2018), in another article in this series of
Co-twin with omphalocele*** 1
articles in this special issue of the journal.
Total 5 The age distribution of the mothers of the malformed
stillborn infants is as follows: 5.1% less than 20, 74.6%
BIRTH DEFECTS RESEARCH 110:114–121 (2018)
TABLE 2. Heart Defects among Stillborn Infants
Heart defects: isolated and with other phenotypes
HLHS**
Tetralogy of Fallot with pulmonary atresia**
Tetralogy of Fallot with VSD***
Ebstein anomaly**
Preductal aortic stenosis with dilated root***
Bicuspid aortic valve***
Double outlet right ventricle with
mitral valve stenosis and VSD**
VSD***
ASD***
Total
Other phenotypes with heart defects:
15. Saldino-Noonan syndrome with HLHS,
mitral valve stenosis, and aortic valve hypoplasia
16. Trisomy 13: holoprosencephaly with tetralogy
of Fallot with pulmonary atresia
17. Cor biloculare, mitral atresia, transposition
of great arteries, absent radius and left thumb, microtia
18. Turner syndrome (45,X); no karyotype:
tetralogy of Fallot with pulmonary atresia
19. Holoprosencephaly and ASD II
20. Trisomy 21: endocardial cushion defect
21. Trisomy 13: membranous VSD,
ASD II, coarctation of aorta
22. Myelomeningocele: hypoplastic
right ventricle and pulmonary artery,
dilated left ventricle and right atrium
23. Trisomy 21: endocardial cushion defect
24. Marker chromosome: ASDII
25. Trisomy 18: polyvalvular dysplasia of
heart valves, membranous VSD
26. VACTERL: double outlet right ventricle,
pulmonary atresia, mitral atresia
27. Private syndrome: HLHS, agenesis of
corpus callosum, nephromegaly,
aberrant subclavian artery
(rt), camptodactyly
28. Tetralogy of Fallot with pulmonary
atresia, absence of patent ductus
arteriosus and multiple congenital anomalies
29. Trisomy 13: double outlet right ventricle, VSD
117
30. Trisomy 18: polyvalvular dysplasia of
heart valves, bicuspid aortic valve
31. Trisomy 21: ASD II, hydrops placentalis
3 32. Dilated heart with mild biventricular
2 hypertrophy in infant with lower
1 urinary tract obstruction
1 33. Trisomy 21: tetralogy of Fallot with VSD and ASD II
1 34. VACTERL: dysplastic tricuspid and
1 mitral valves, thick broad leaflets,
1 hypoplastic right ventricle, persistent
left superior vena cava
1 35. Heterotaxy: situs inversus, valvar
3 pulmonary stenosis, subvalvar aortic
14 stenosis, endocardial cushion defect
36. Trisomy 18: endocardial cushion defect
37. Trisomy 18: endocardial cushion defect
38. Trisomy 13: hypoplastic left heart syndrome
39. Trisomy 18: VSD
40. Trisomy 21: membranous VSD
41. Trisomy 21: VSD (probe patent)
Severity scale: ** 5 severe, handicapping; *** 5 moderate, fixable.
ASD, atrial septal defect; ASD, II, atrial septal defect, secundum;
HLHS, hypoplastic left heart syndrome; VACTERL, a syndrome of
vertebral, anal, cardiac, tracheo-esophageal, renal and limb defects;
VSD, ventricular septal defect.
between 20 and 35, and 20.3% over 35 years old. For
comparison, the age distribution of the mothers of 67
infants with preaxial polydactyly, identified in this Surveil-
lance Program, was 6% less than 20, 68.7% between 20
and 35, and 35.4% over 35 (Nasri et al., 2014) with the
difference not significant (p 5 0.16).
Discussion
The findings in these 127 malformed stillborn fetuses con-
firm the observations made previously in several studies:
(1) the frequency of malformations in stillborn infants
(8.5%) is much higher than the rate in live-born infants
and elective terminations because of anomalies (2.4%); (2)
there is a much higher frequency of lethal phenotypes
among stillborn infants than in live-born infants; (3) the
rate of intrauterine growth restriction (37%) is much
higher than live births (10%); (4) several abnormalities
are much more common among the stillborn fetuses than
in live-born infants: the most common chromosome triso-
mies, 45,X, triploidy, anencephaly, lower urinary tract
obstruction, and cyanotic heart defects (Table 3), such as
hypoplastic left heart syndrome and tetralogy of Fallot
with pulmonary atresia.
118 STILLBORN INFANTS: ASSOCIATED MALFORMATIONS

TABLE 3. Comparison of Prevalence Rates of Malformations among Stillbirths and Live-born Infants

Rate among all

Malformed Malformed liveborn infants and
stillborn infants Rate among all liveborn infants fetuses in elective Degree of
(1972–2012) stillborn infants (1972–2012) termination increase in
n 5 127 n 5 1496 n 5 7,020 n 5 289,365 stillbirths Z-Testa

Chromosome abnormalities

Trisomy 21 15 1.003% 484 0.168% 6.3 X <0.00001

Trisomy 18 9 0.602 92 0.032 18.8 <0.00001

Trisomy 13 5 0.334 36 0.013 25.7 <0.00001

45,X 5 0.334 80 0.028 11.9 <0.00001

Triploidy 3 0.201 42 0.015 13.4 <0.00001

Neural tube defects

Anencephaly 17 1.136 88 0.031 36.7 <0.00001

Cleft lip with or without cleft palate; 3 0.201 203 0.071 2.8 0.6

Cleft palate alone

Lower urinary tract obstruction 5 0.334 48 0.017 19.6 <0.00001

Holoprosencephaly 3 0.201 28 0.010 20.1 <0.00001

Heart defects: isolated and syndromic

Hypoplastic left heart syndrome 6 0.401 66 0.023 17.4 <0.00001

Tetralogy of Fallot with/without 6 0.401 111 0.039 10.3 <0.00001

pulmonary atresia

Atrial septal defect, secundum 5 0.334 220 0.076 4.4 0.0004

Ventricular septal defect 5 0.334 682 0.237 1.4 0.44

Aortic stenosis/bicuspid aortic valve 3 0.201 82 0.028 7.2 0.0001

Endocardial cushion defect 4 0.267 17 0.006 44.5 <0.00001

Double outlet right ventricle 3 0.201 32 0.011 18.3 <0.00001

a
A Z-score test is used to assess statistically the difference between two populations (i.e., stillborn vs. live births and elective terminations) on a
characteristic (i.e., the presence of specific malformations). The null hypothesis is that there is no difference between the two population pro-
portions. Testing was performed at the 0.05 significance level. All p-values remain significant when adjusted for multiple comparisons using
the false discovery rate, with the exception of cleft lip with or without cleft palate and ventricular septa defect. The false discovery rate is a
method for controlling the rate of type I errors in hypothesis testing when multiple comparisons are performed.

Previous studies of the chromosome trisomies 21, 18,
and 13 have shown that their frequency is increased in
miscarriages (Menasha et al., 2005) as well as stillborn
fetuses. In a study of 1813 affected fetuses, 37.1% of those
with trisomy 21 died before 24 weeks of gestation and
30.2% (32/106) of the fetuses with trisomy 18 were still-
born (Won et al., 2005). Among 411 fetuses with trisomy
13 diagnosed prenatally, 49% of those pregnancies ended
as either miscarriages or stillbirths between 12 weeks of
gestation and term (Morris and Savva, 2008).
45,X has been shown to be a common finding in spon-
taneous abortions (Warburton, 1987; Hook and Warbur-
ton, 2014) as well as in stillborn fetuses. It has been
postulated that the fetus with only 45,X, and no 46,XX/
45,X mosaicism, is much less likely to survive to a term
life birth (Hook and Warburton, 2014). A total of 26
(3.3%) of 789 (1:30) stillborn infants in the Wisconsin
Stillborn Service Program had Turner (45,X syndrome), a
rate much higher than the rate of 45,X in newborn
infants: 1 in 2500 to 1 in 3000 live-born infants with half
45,X and the other half mosaicism for 45,X and other
abnormalities of one X chromosome (Sybert and McCau-
ley, 2004). Pauli and Reiser (1994) identified 24 fetuses
with the “jugulolymphatic obstruction sequence,” many of
whom were 45,X. An increased frequency of 45,X was
identified, also, in this study (Table 3). This was the case
despite the fact that many stillborn fetuses did not have
successful chromosome analysis. In addition, ascertain-
ment of newborn infants with 45,X in this malformations
Surveillance Program was limited to those affected
BIRTH DEFECTS RESEARCH 110:114–121 (2018)
TABLE 4. Seven Main Heart Defects Being Screened for in Critical Congenital
Heart Disease Screening Programs for Newborn Infants
Hypoplastic left heart syndrome
Pulmonary atresia
Tetralogy of Fallot
Total anomalous pulmonary venous return
Transposition of the great arteries
Tricuspid atresia
Truncus arteriosus
Source: Mahle et al; 2009.
infants who had an associated malformation, such as
coarctation of the aorta.
Anencephaly was the most common malformation iden-
tified. One infant had both anencephaly and a lumbosacral
myelomeningocele, a more severe phenotype that was more
common in regions with nutritional deficiency (Moore et al.,
1997).
Lower urinary tract obstruction is a heterogeneous
group of anomalies, which includes urethral atresia and ste-
nosis, prune belly syndrome, and posterior urethral valves
(Malin et al., 2012). Pauli (1994) used the term “lower mes-
odermal defects” to describe 17 affected infants identified in
the first 1130 referrals in the Wisconsin Stillbirth Service
Program. This phenotype included infants with urethral
agenesis or lower urinary tract obstruction and is similar to
the abnormalities of five infants identified in this study. The
enlarged bladder can affect the blood supply to the legs and
produce severe limb deficiencies, as was observed in one of
the infants identified in this Surveillance Program, described
by Genest et al. (1991).
The analysis of 167 stillborn infants with heart defects
in the Wisconsin Stillbirth Service Program concluded that
many heart defects (83%) contributed to the fetal death
(Jorgensen et al., 2014). The most common heart defects
were severe cyanotic lesions, such as hypoplastic left heart
syndrome and tetralogy of Fallot with pulmonary atresia,
and ventricular and atrial septal defects. Their findings
were similar to the types of heart defects identified in this
study (Tables 1 and 2). Both of these analyses of the heart
defects in stillborn infants identified several of the severe
heart defects whose detection is the goal of the new
screening programs for critical congenital heart disease in
newborn infants (Table 4) (Mahle et al., 2009). This obser-
vation suggests that many affected fetuses do not survive
to birth, which underscores the importance of early detec-
tion in affected live-born infants soon after birth.
Holoprosencephaly has been shown to be much more
common in spontaneous abortions and stillbirths than in
live-born infants. For example, in the analysis of 44,000
abortions, primarily elective, in Japan, the prevalence rate
119
for holoprosencephaly was 1:250 (Yamada et al., 2004).
The prevalence rate of holoprosencephaly in Atlanta, Geor-
gia, among 734,000 births (1968–1992) was 0.12/1000 or
1:8,333 (Rasmussen et al., 1996). An increased frequency
of stillbirth has been observed in several population-based
studies of holoprosencephaly (Whiteford and Tolmie,
1996; Rasmussen et al., 1996).
A causal relationship between the CLP or cleft palate
alone and fetal death has been postulated by some investi-
gators (Dronamraju and Bixler, 1983), but disputed by
others (Menegotto and Salzano, 1990). Among 789 still-
births evaluated in the Wisconsin Stillbirth Service Program,
there were 16 fetuses with cleft palate and 12 with cleft lip
(CL) or CLP, excluding the fetuses with midline CL deformity
(Pauli and Reiser, 1994). This rate is much higher than the
rates of 0.5/1000 for “isolated” CL with or without cleft pal-
ate and 0.2/1000 for “isolated” cleft palate alone identified
in newborn infants in the Active Malformations Surveillance
Program (Holmes, 2012). No increase in the frequency of CL
or CLP was identified in this study (Table 3) (p 5 0.6).
One limitation of this analysis is the fact that the findings
focus on the phenotypes of the fetuses with malformations
and could not be extended to an assessment of relevant medi-
cal findings in their mothers during pregnancy, such as the
presence of hypertension, pre-eclampsia, obesity, and smoking,
as well as findings in diagnostic tests, such as antiphospholipid
antibodies, glucose tolerance tests, tests for infections such as
parvovirus and syphilis, and chromosome analysis, was noted
by the Stillbirth Collaborative Research Network (Page et al.,
2017). Likewise, the assessment of the heart defects was at
autopsy and did not include findings during pregnancy, such
as signs of dysfunction of the heart or arrhythmia.
Another limitation was the fact that 69 (54%) of the 127
malformed stillborn infants did not have chromosome anal-
ysis. The most common findings identified were the three
most common trisomies (21, 18, 13), 45,X, and triploidy
(Table 1). Chromosome analysis was attempted on fetal tis-
sue from many more of these 127 stillborn fetuses, but was
not successful because of a failure of cell growth. No infants
had chromosome microarray studies, which could have
been successful because cell division is not required. The
increased detection of chromosome abnormalities by micro-
array testing was confirmed in the Stillbirth Collaborative
Research Network (Reddy et al., 2012). In the analysis of tis-
sue samples from 532 stillborn infants, microarray analysis
yielded results in 87.4% in comparison to 70.5% from chro-
mosome analysis. In the analysis of 67 stillbirths with
anomalies, the yields were 29.9% from microarray com-
pared with 19.4% from chromosome analysis (p 5 0.008).
An important advantage of the microarray testing was the
fact that a significant deletion, such as 22q11.2, could be
identified in the affected fetus, which could lead to the
detection of the same abnormality in a mildly affected
parent (Raca et al., 2009; Reddy et al., 2012). This would
120
provide more insightful counseling for risks in future
pregnancies.
Summary: This evaluation of all of the malformed
stillborn infants demonstrates the value of an autopsy and
chromosome analysis, preferably chromosome microarray
analysis. It showed that the malformations identified were
more severe than those identified in live-born infants. The
presence of so many severe heart defects showed that only a
portion of those affected fetuses are alive at birth. The find-
ings in the autopsy and the examination of the placenta will
improve the counseling of the parents regarding risks in
future pregnancies. The use of the chromosome microarray
will improve the identification of associated chromosome
abnormalities.
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