Despite advances in obstetric care, stillbirth affects a heart breaking number of families globally every year. A meta-analysis in PLoS Medicine reports a rising risk of stillbirth in later pregnancy, making late and term stillbirth an area of concern for clinicians and patients. Families in these situations find themselves facing distressing questions and decisions they weren't necessarily prepared for.
Healthcare providers can navigate this delicate situation with care and compassion by focusing on careful conversations, informed clinical judgment and shared decision-making.
Defining Early Stillbirth, Late Stillbirth and Term Stillbirth
The U.S. Centers for Disease Control and Prevention (CDC) defines stillbirth as fetal death after 20 weeks of pregnancy and before childbirth, although thresholds vary globally.
The agency further classifies stillbirth by gestational age into:
- Early: 20–27 weeks
- Late: 28–36 weeks
- Term: 37+ weeks
Stillbirth occurs in 1 in 160 deliveries in the United States, reports a recent consensus statement from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM). Stillbirth claims approximately 23,600 fetuses at 20 weeks or later each year, making it one of the chief pregnancy complications in America. Despite medical advances, the CDC finds that U.S. rates of stillbirth from 20 to 36 weeks of pregnancy have remained largely unchanged since 2014.
Globally, late stillbirth is the focus of tracking and measurement, as reporting is uneven. An estimated 2 million late stillbirths or term stillbirths were reported in 2019, finds a systematic analysis published in The Lancet in 2021. The analysis puts the global stillbirth rate at 13.9 stillbirths per 1,000 births, although rates vary widely from region to region. For example, West and Central Africa experienced the highest stillbirth rates in 2019, with 22.8 stillbirths for every 1,000 births, followed by southern and eastern Africa and south Asia.
As in the U.S., The Lancet finds that global progress in reducing stillbirth rates has trailed gains in other areas of medicine, such as with improvements in the survival rates of infants and children aged 5 and younger. The paper further points out the slow progress in preventing stillbirths over the last 20 years in vulnerable regions experiencing an outsized share of the condition.
Causes Remain Elusive
Globally, the absence of uniform standards and comprehensive reporting on stillbirth hinder a deeper understanding of its risks and causes, observes ACOG.
BMC Pregnancy and Childbirth adds that one-third to one-half of late stillbirths globally are unexplained, defying clinical understanding. In developed countries, the rate of unexplained late stillbirth is less, approximately 15 percent.
Regarding known causes, infection is linked to up to 20 percent of stillbirth cases in the industrialized world, ACOG reports, and even more in developing regions. Infection tends to cause early or late stillbirth rather than stillbirth at term. Meanwhile, placental abruption appears in 5–10 percent of stillbirths, while genetic abnormalities appear in up to 13 percent of cases. Fetal growth restriction is linked to stillbirth risk and is greatest in fetuses smaller than the third percentile for growth.
Stillbirth Risk
In industrialized nations, the U.S. Department of Health and Human Services identifies the top risk factors for stillbirth as:
- Non-Hispanic Black race
- Maternal age 35 or older
- Low socioeconomic status
- Diabetes, high blood pressure and/or obesity
- Tobacco, alcohol or illegal drug use
- Pregnancy with multiples
- Assisted reproductive technology
- Previous stillbirth
With patients who carry very high risk, the ACOG encourages counselling before and during pregnancy about effectively managing chronic conditions and proactively addressing modifiable risks. A meta-analysis in JAMA found even modest weight gain is associated with elevated risk, so maintaining a healthy body mass index (BMI) may be another goal to work toward.
Best Practices for Fetal Monitoring
For providers seeking the most effective schedule of fetal monitoring to reduce stillbirth risk, a recent Obstetric Care Consensus Statement from ACOG and SMFM suggests considering fetal surveillance at 32 weeks of pregnancy or sooner in certain cases. For example, with patients with troubling high-risk conditions, such as chronic hypertension with suspected fetal growth restriction, providers may wish to begin surveillance at the stage of pregnancy when a delivery might protect fetal health.
According to clinical guidance from ACOG and the American Institute for Ultrasound in Medicine, ultrasound remains the modality of choice when fetal growth disturbance is a concern. ACOG further suggests sonographic screening for fetal growth restriction after 28 weeks of pregnancy.
Although ultrasound monitoring of a small-for-gestational-age fetus aids in the identification of fetal growth restriction, Ultrasound in Obstetrics & Gynecology reports that more than 40 percent of stillbirths occur even after growth restriction is detected, thus underscoring the essential role of appropriate management when worrisome conditions are found. Notably, including Doppler velocimetry monitoring of fetal umbilical blood flow in conjunction with standard fetal surveillance, such as stress tests, may reduce fetal death risk by 29 percent.
When offering stepped-up surveillance, ACOG underscores the value of shared decision-making. Thoughtful conversations and collaborative care can help to soothe patients during this time of high anxiety and unease.
Stillbirth Delivery
When faced with the painful reality of stillbirth, patients may wish for delivery as soon as medically possible. Besides parental preference, joint guidance from ACOG and SMFM suggests considering their obstetric history and the fetus's gestational age at death when deciding on the method and timing of delivery in such cases.
Delivery options are either induction of labor or dilation and evacuation, each carrying differing risks and benefits, add ACOG and SMFM. Notably, for parents wishing to see or hold their child, dilation and evacuation may make that impossible. This method also may make it more difficult to identify genetic anomalies during autopsy, thereby thwarting an understanding of possible causes, which might inform future decision-making about parenthood.
For some, however, induction alone may not be possible. ACOG and SMFM confirm that carrying parents who choose induction may go on to require post-delivery dilation and curettage. Those early in the second trimester are particularly vulnerable to needing dilation and curettage to remove the placenta after delivery.
In cases of early stillbirth, the risk of infection and death following induction is greater in cases where fetal death occurs between 14 weeks and 24 weeks gestation. Similarly, comparative research in Obstetrics and Gynecology adds that dilation and evacuation is far safer and more effective than induction when performed to address fetal death between 13 weeks and 24 weeks of gestation.
With late stillbirth, ACOG and SMFM advise following the usual obstetric protocols when inducing labor. For patients at 28 weeks of pregnancy or less, a meta-analysis in Contraception reports both vaginal and oral misoprostol regimens were 100 percent effective in achieving uterine evacuation within 48 hours of administration among women in the second and third trimesters.
Planning for Pregnancy After Stillbirth
After the heartbreak of a stillbirth, the decision to try again may naturally fill your patient with unease. Experiencing a prenatal death profoundly alters the pregnancy experience, provoking conflicted emotions about future pregnancy and a lack of trust in a good outcome, observes a meta-synthesis in BJOG. Patients and their families may grapple with depression, anxiety and post-traumatic stress disorder as they grieve and process their loss.
Emotional and psychological support may improve parents' experiences with subsequent pregnancy, with ACOG further advising good communication and shared decision-making. A fetal autopsy is also encouraged. Findings of genetic defects or other known issues may give people relief as they weigh whether or not and how to proceed with another pregnancy.
As your patient looks toward the future, fears about a subsequent stillbirth are natural and unavoidable. Indeed, a systematic review and meta-analysis in the BMJ shows that pregnant people with a past stillbirth face an increased risk of another one.
Engaging in a gentle discussion of potential risks can assist your patient as they consider the prospect of pregnancy. As you open a dialogue about the path forward, they may be reassured that most parents go on to have healthy pregnancies and births after stillbirth.
