WACHEMO UNIVERSITY

M/H/S/C NEMMH
DEPARTMENT OF MEDICINE
SEMINAR
STILL BIRTH
By –Esubalew Erkeno
Esuendale Anteneh
(C1 Students)
MODERATOR
Dr. Beyene
(OBGYN SPECIALIST)
1 03/29/2021
 Outline
• Introduction
• Definition
• Incidence and Epidemiology
• Etiology
• Risk Factors
• Diagnosis
• Complication
• Approach
History
Physical Examination
Investigation
Prevention
Management
• Psychological intervention 03/29/2021 2
 Introduction
• The terms fetal death, fetal demise, stillbirth, and
stillborn all refer to the delivery of a fetus showing no
signs of life.
• The terms will be used interchangeably
• Not all conceptions result in a live born infant. Of the
clinically recognized pregnancies, 10-15 % are lost.
• Almost 1% of women entering the 2nd half of pregnancy
will suffer the loss of their baby and many of these
women will experience a profound grief reaction.
03/29/2021 3
 Introduction cont…
• IUFD accounts for approximately half of the
perinatal mortality rate.
• Almost 80% of still births occur before term and
• More than half occur before 28 weeks.
• Still births are much more common with
decreasing gestational age.
• It is a common cause of serious psychological
morbidity.
03/29/2021 4
 Stillbirth
Definition
• Only deaths occurring in utero in which the fetus or neonate
weighs 500 gm or more (WHO).
• Only deaths occurring in utero in which the fetus or neonate
weighs 500 gm or more and/or deaths occurring at 22 weeks of
gestation or greater (ACOG).
• Only deaths occurring in utero in which the fetus or neonate
weighs 1000 gm or more and/or deaths occurring at 28 weeks of
gestation or greater (Ethiopia)
03/29/2021 5
 WHO Definition of Stillbirth

• Fetal death means death prior to complete expulsion or

extraction from the mother of a product of human conception
irrespective of the duration of pregnancy and which is not an
induced termination of pregnancy. The death is indicated by
the fact that after such expulsion or extraction, the fetus does
not breathe or show any other evidence of life such as beating
of the heart, pulsation of the umbilical cord, or definite
movement of voluntary muscles. Heartbeats are to be
distinguished from transient cardiac contractions; respirations
are to be distinguished from fleeting respiratory efforts or
gasps.
03/29/2021 6
 Incidence and epidemiology

• Rates of stillbirth in low income countries are

substantially higher (9 to 34/1000 births) than in high
income countries (3.1/1000).
• About 98 percent of stillbirths occur in low and
middle income countries.
• At least half of the stillbirths in low income countries
occur during labor and birth, in large part because of a
lack of skilled birthing attendants and facilities for
cesarean delivery.
03/29/2021 7
 Cont….

• The frequencies of the various etiologies of stillbirth

differ among racial groups.
• This may be related to genetic, as well as behavioral
and environmental, factors.
• A study from the United Kingdom observed that the
most important factor associated with antepartum
stillbirth among white women was placental
abruption, but among South Asian and black women
it was birth weight below 2000 g.
03/29/2021 8
 Etiology

• Unknown in 50% of cases

• Known causes
• Maternal 5-10%
• Fetal 25-40%
• Placental 20-35%
• Un explained 15- 35%

03/29/2021 9
 Etiology cont…

Unexplained still birth

*occurs in 25-60% of the cases
*there is no identifiable fetal ,
placental, maternal or obstetric
cause
*stillbirth occurring at near term are
more likely to be unexplained
03/29/2021 10
 Cont…
Fetal causes 25-40%
• Chromosomal anomalies
e.g trisomies 13 , 18 , 21
• Birth defects
e.g Neural tube defect, congenital heart deases
• Rh- isoimmunization
• Hydrops fetalis (Immune or Non-immune)
• Infections (Virus, Bacteria, Protozoa)
03/29/2021 11
e.g CMV , T. pallidium , Malaria …
 Cont…
Placental 25-35%
•Abruption major cause (8%)
•Cord accidents
•Placental insufficiency
•Placental infarct due to the fibrinoid trophoblastic degeneration,
calcification and Ischemic infarction due to spiral artery occlusion
•Placenta Previa
•Fetal-Maternal hemorrhage majorly due to trauma
•Twin - Twin transfusion Syndrome common cause for
monochromic multifetal pregnancy.
•Infections like Chrioamnionitis
03/29/2021 12
 Cont…
Maternal 5-10%
• Hypertensive disorder of pregnancy
• Diabetic Mellitus
• Infections CMV, Syphilis, rubella, mumps…etc
• Sepsis
• Abnormal labor (Prolonged or Obstructed)
• Trauma
• Anti phospholipids Antibodies
03/29/2021 13
 Cont…
• Chemical poisoning- e.g chronic lead poisoning
• Acidosis/ Hypoxia
• Uterine rupture (PROM)
• Postterm pregnancy
• Drugs (Alchol, Cigaratte Smoking…)
• Thrombophilia
• Cyanotic heart disease
• Epilepsy
• Severe anemia
• Un explained (15 – 35%)
03/29/2021 14
 Risk Factors

A few risk factors are broadly applied even though there

is a number of risk factors are present.
Maternal age is directly correlated with the stillbirth.
This is not associated with only of chromosomal
alteration but also maternal complication, that is age
related.
Stillbirth occur more primiparous women of a given
age than that of the multiparous women of comparable
age.
03/29/2021 15
 Risk factors
• Advanced maternal age (Age >35)
• African-American race
• Smoking
• Illicit drug use
• maternal medical diseases such as overt diabetes or chronic
hypertension
• Assisted Reproductive Technology (ART)
• Nulliparity
• obesity (pre pregnancy)
• Previous adverse pregnancy outcomes such as prior preterm birth or
growth-restricted newborn
03/29/2021 16
 Cont…
.

03/29/2021 17
 Diagnosis of IUFD
• SYMPTOMS—Absence of fetal movements which were
previously noted by the patient.
• SIGNS: Retrogression of the positive breast changes that occur
during pregnancy is evident after variable period following death
of the fetus.

Per abdomen
• Gradual retrogression of the fundal height and it becomes smaller
than the period of amenorrhea.
• Uterine tone is diminished and the uterus feels flaccid. Braxton-
Hicks contraction is not easily felt.
03/29/2021 18
• Fetal movements are not felt during palpation.
 Cont…
• Fetal heart sound is absent. Doppler ultrasound is better
than the stethoscope.
• Egg-shell crackling feel of the fetal head is a late feature.
• Laboratory
An abnormal blood level of HCG.
Urine pregnancy test could be positive or negative.
• Abdominal X-ray
Spalding’s sign- the irregular overlapping of the cranial
bones on one another and the rolled up appearance of the
fetal trunk.
03/29/2021 19
• Fig.
Straight X-ray of
abdomen showing
single fetus with
marked irregular
overlapping of the
skull bones
(Spalding sign) and
hyperflexion of
the spine.

03/29/2021 20
 Cont…
Robert’s sign- the appearance of gas bubbles in the
thoracic cavity of the fetus within the heart chambers or
great vessels.
Kehrer’s sign- hyper flexion of the spine.
• Sonography (definitive Dx)
Absent cardiac activity.
Absent fetal movement.
Oligohydraminous and collapsed cranial bones.
• CTG
• Amniocentesis-dark brown meat water like Amniotic
fluid.
03/29/2021 21
 Complications
1. Psychological upset or stress.
2. Intrauterine Infections.
3. Blood coagulation disorders.
due to release of tissue factor from the placenta into the
circulation
 DIC if the fetus is retained more than 4 weeks
4. During labor-uterine inertia, retained placenta, PPH
5. Risk of Recurrence
6. Maternal death
03/29/2021 22
 Approach

• Components
History
Physical Examination
Investigation
Prevention
Managment

03/29/2021 23
 EVALUATION OF THE
STILLBORN
• Determining the cause of fetal death aids maternal
psychological adaptation to a significant loss,
• helps assuage the guilt that is part of grieving,
permits more accurate counseling regarding
recurrence risk, and may prompt therapy or
intervention to prevent a similar outcome in the
next pregnancy.

03/29/2021 24
 Element of stillbirth evaluation
Patient history
• Family history
• Maternal history
• Obstetric history
• Current pregnancy
Maternal evaluation at time of demise
Placenta examination
Fetal autopsy
Fetal karyotype
03/29/2021 25
 Cont…

Post partum
• Protein s and protein c activity
• Parental karyotype
 in selected cases
• Indirect combs tests
• Glucose screening
• Toxicology screening

03/29/2021 26
 Hx
Symptoms
1. Cessation of fetal movements.
2. Regression of breast changes and milk
secretion may be initiated.
3. The abdomen is not enlarging or even get
smaller.
4. Dark brown vaginal discharge may be
present , Some women with stillbirth may
report vaginal bleeding, or abdominal pain
03/29/2021 27
Hx cont…

03/29/2021 28
Cont…

03/29/2021 29
Cont…
(PAST)

03/29/2021 30
Cont…

03/29/2021 31
 P/E
Signs
1. Uterus is smaller than the period of amenorrhea and does
not enlarge with repeated examination.
2. Fetal heart sounds are inaudible.
3. Fetus is felt like a soft homogenous mass with
undistinguished fetal parts.
4. Maceration of the fetal skin starts 12 hours after death
which can be detected after its birth.
5. BMI > 25
6. Other physical findings associated with RFs
03/29/2021 32
 Investigation

1. Ultrasound: the most accurate and rapid method which

shows:
i. absent fetal movements,
ii. absent fetal heart movement,
iii. Spalding sign: overriding of the skull bones due to softening of the brain
iv. oligohydraminos
v. Kehrer’s sign: Hyper flexion or angulations of the spines.
vi. Collapse of the thorax.
vii. Causative factors as congenital anomalies.

03/29/2021 33
Fig: Sonographic plate showing collapsed cranial bones—
03/29/2021 34

a late feature of IUD

 Cont…

2. Pregnancy test:
• becomes negative within 2 weeks but may
remain positive as long as there is living
chorionic tissues.
• Human Chorionic Gonadotrophin (hCG):
It has no practical value as it can be detected
up to few weeks after foetal death or delivery.
03/29/2021 35
 Cont…
3. Abdominal x-ray:- rarely done at present.
– The following features may be found
i. Spalding sign.
ii. Hyper flexion of the spines.
iii. Collapse of the thorax.
iv. Rarefaction of the fetal bones.
v. Gases in the fetal circulation.
vi. Causative factor as anencephaly and
Hydrops foetalis may be detected. 03/29/2021 36
 Cont…

4. Hematological examination:-
complete blood count
• Leukocytosis can be a sign of infection
• Thrombocytopenia can result from pregnancy induced hypercoagulability
Indirect combs' test is used
 to screen pregnant women for antibodies that may cause hemolytic
disease of the newborn.
 for compatibility testing, antibody identification, RBC phenotyping, and
titration studies.

03/29/2021 37
 Cont…
 Kleihauer-Betke test is a blood test used to measure the amount of fetal
hemoglobin transferred from a fetus to a mother's bloodstream.
>20%...+ve

It is usually performed on Rhesus-negative

mothers to determine the required dose of
Rho(D) immune globulin (RhIg) to inhibit
formation of Rh antibodies in the mother and
prevent Rh disease in future Rh-positive
children.
 Human parvovirus immunoglobulin
03/29/2021 38
 Cont…

Rh grouping
Post prandial blood sugar
Lupus anticoagulant
Thrombophilia studies
TORCH screening:-
serology for toxoplasmosis, rubella, CMV, HSV
5 . VAGINAL SMEAR
In intrauterine death : parabasal cells appear in the smear
03/29/2021 39
 Cont…
6.

7.

8.

03/29/2021 40
 Modalities of ante partum testing in
stillbirth are:-
Biophysical profile has five variables
 Fetal cardiotocography
 Fetal movement counting
 Amniocentesis
 Fetal breathing
 Fetal tone
A score of 8 or 10 (of a possible score of 10) is considered normal.
A score of 6 is considered equivocal, and a score of 4 or less is
considered abnormal.
The stillbirth rate within a week of testing for a normal BPp is
approximately 0.6–0.8 per 1000. 03/29/2021 41
Criteria for the biophysical profile test
Parameter Normal (2 points) Abnormal (0 points)

Reactive FHR At least two accelerations Less than two accelerations

in 20 minutes to satisfy the test in 20
minutes
Fetal breathing movements At least one episode of > None or less than 30s or
30s or >20s in 30 minutes 20s

Fetal activity / gross body At least three or two Less than three or two
movements movements of the torso or movements
limbs
Fetal muscle tone At least one episode of No movements or
active bending and movements slow and
straightening of the limb or incomplete
trunk
Qualitative Amniotic fluid At least one vertical Largest vertical
volume pocket> 2 cm or more in pocket</=2 cm
the vertical axis
03/29/2021 42
 Prevention strategies
 A systematic review identified the following ten interventions
as those with the best evidence for reducing the burden of
stillbirth worldwide during preconception, prenatal, antenatal
and intrapartum
 Periconceptional folic acid fortification
 Prevention of malaria
 Syphilis detection and treatment
 Hypertensive disorders of pregnancy detection and
management
 Diabetes of pregnancy detection and management03/29/2021 43
 Cont…

Fetal growth restriction detection and management

Post term pregnancy (≥41 weeks of gestation)
identification and induction
Skilled birth attendant at birth
Availability of basic emergency obstetric care
Availability of comprehensive emergency obstetric
care
03/29/2021 44
 Management of IUFD
• Once suspected IUFD should be confirmed by ultra sound with
a minimum of delay, once confirmed she should be told straight
away.
• After confirmation of fetal death, the next step is to counsel the
patients:
• Helping the couple to grieve appropriately can minimize
psychological sequale from this often devastating loss.
• After these two initial steps, subsequent clinical management is
largely discretionary.
• The emotional burden of carrying a dead fetus, however, often
for weeks can compound the misery experienced by the
patients.
• Thus either watchful waiting or uterine evacuation are
appropriate, so the women should choose after counseling
03/29/2021 45 about
the alternatives.
 Cont…
• If expectant management is planned
-reassure women that 90% of cases is spontaneously expelled
-wait for spontaneous onset of labor during the next four month.
• Consider active management
If - platelet number is decreasing
-fibrinogen level is decreasing
-fetus retained for more than 4 weeks
-features of infection
-mother requires

03/29/2021 46
Cont…

03/29/2021 47
 Cont…
Women who have had a previous cesarean delivery are at
higher risk of intrapartum uterine rupture than women with an
unscarred uterus, and the risk is even higher if they are induced
than if they enter labor spontaneously .
For this reason, prostaglandins for cervical ripening/labor
induction generally should be avoided.

03/29/2021 48
Mgt summary

Active mgt Expectant mgt

03/29/2021 49
 Psychological intervention
• Keep parents informed; be honest and forthright.
• Encourage the mother to make as many choices about her care as possible.
• Support parents in seeing, touching, or holding the still born.
• Describe the still born in detail, especially for couples who choose not to
see the still born.
• Allow photographs of the still born.
• Discuss subsequent pregnancy.
• Avoid the traditional advice of encouraging the family to embark soon on
another pregnancy as a “replacement” for the still born.
• Allowing early discharge with provisions for follow-up visits which
facilitates the resolution of grief.
• Keeping the mother away from rooms where there are 03/29/2021
mothers50with
newborns.
 References

1. DC Dutta’s textbook of obstetrics (7th edition)

2. Gabbe obstetrics (7th edition)
3. Up-to-date 21.6
4. William obstetrics ( 25th edition)

03/29/2021 51
03/29/2021 52