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Stillbirth

Stillborn

Stillbirth is defined as the occasion that a pregnant woman gives birth to a child that is dead and weighs more than a kilogram, or to a lifeless child after 28 weeks of gestation.


Presentation

Given that stillbirth implies the birth of a child that displays no signs of life, the presentation can only concern findings during gestation that may raise suspicion of a potential stillbirth.

Maternal conditions have to be detected early and monitored/managed in order to prevent them from leading to a stillbirth. A mother presenting with hypertension, diabetes, autoimmune diseases, renal dysfunction, congenital abnormalities and abnormalities regarding the placenta are at a higher risk of giving birth to a dead child. A fetus that seems to be failing to thrive also needs to be monitored, for it may be subject to complications that can lead to intrauterine death [18]. Placental function and structure also play a vital role in the wellbeing of the baby; a malfunctioning placenta can have devastating effects on the fetus, ranging from stillbirth to retardation and physical anomalies [19].

Burkina Faso
  • Faso. 17 School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi. 18 Food and Agriculture Organization of the United Nations, Libreville, Gabon. 19 Department of Community Health, Muhimbili University of[ncbi.nlm.nih.gov]
  • The high burden of infant deaths in rural Burkina Faso: a prospective community-based cohort study. BMC Public Health. 2012;12(1):739. View Article PubMed Google Scholar Jehan I.[doi.org]
Plethora
  • CONCLUSIONS: The plethora of systems in use, and continuing system development, hamper international efforts to improve understanding of causes of death.[ncbi.nlm.nih.gov]
Meningism
  • International Health Research. 7 Department of Pathology, Hospital Clinic of Barcelona, Universitat de Barcelona. 8 Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain. 9 Medical Research Council, Respiratory and Meningeal[ncbi.nlm.nih.gov]

Workup

Proper monitoring of the mother and fetus helps to screen for conditions that may lead to a stillbirth. Mothers that receive adequate care during gestation run considerably less risk of giving birth to a baby that is dead, compared to those who receive no treatment.

During pregnancy, both mother and fetus have to be monitored in terms of laboratory evaluation to assess renal, liver, pulmonary and cardiac function, regular blood pressure measurements, urinalysis to detect a potential infection and ultrasonographic monitoring of the child [20]. Should a mother have experienced prior stillbirth, a fetal autopsy can provide useful information regarding the cause of death [21]: in this way, the next pregnancy will be monitored in the appropriate direction, to ensure that the baby will not be subjected to the same conditions that lead to stillbirth. Fetal karyotype can be used in cases of augmented risk to check for abnormalities that could put the life of the fetus at risk [22] [23]. The fetus can also be monitored regularly in order to check for movement; a simple and not costly test which can provide an initial suspicion, if the child is found to have decreased movement [24] [25].

Lastly, Doppler ultrasonography can help to evaluate the adequacy of perfusion to the fetus, in cases of preeclampsia, eclampsia and in other circumstances.

Erythroblast
  • […] perinatal deaths, which included eight placental phenotypes of fetal vascular malperfusion and eight other placental phenotypes of various etiology (amnion nodosum, 2-vessel umbilical cord, villous edema, increased extracellular matrix of chorionic villi, erythroblasts[ncbi.nlm.nih.gov]
Plasmodium Falciparum
  • Plasmodium falciparum malaria detected at delivery in peripheral samples increased the odds of stillbirth (odds ratio [OR] 1·81 [95% CI 1·42-2·30]; I 2 26·1%; 34 estimates), as did P falciparum detected in placental samples (OR 1·95 [1·48-2·57]; I 2 33[ncbi.nlm.nih.gov]

Treatment

Treatment depends on the time when the stillbirth occurs, prior maternal history and preference.

If the stillbirth occurs before the 28th week of gestation, vaginal misoprostol or oxytocin is administered in order to induce labor and deliver the stillborn baby. In some cases, evacuation of the intrauterine contents occur spontaneously. Another alternative to oxytocin and misoprostol is surgical evacuation. Curettage may be further necessary in order to remove every placental fragment that may still reside in the uterus; there is a higher risk of placental parts remaining, if the baby is stillborn early during gestation.

As a complication of stillbirth, particularly in cases when the dead child has remained in the uterus for a long period of time, disseminated intravascular coagulation (DIC) may occur. The mother is in immediate need of blood or blood product replacement.

Lastly, psychological support is equally vital to the parents. Both mother and father can benefit from sessions with a grief counselor or therapist, in order to learn how to cope with loss and how to prepare for another pregnancy, if it is wished for.

Prognosis

A stillbirth has been associated with a higher risk of stillbirth in the next pregnancy, although there is scarce literary data for the assumption to be established as confirmed.

Etiology

In general, it is believed that stillbirths are a result of maternal exposure to toxic substances, maternal smoking, inadequate fetal nutrition and infections contracted by the mother during gestation [1]. The etiologies and risk factors concerning a potential stillbirth vary slightly, depending on whether the mother resides in the privileged or underdeveloped areas of the globe. With regard to the industrialized, privileged world, risk factors include [2] [3] [4]:

A study that analyzed data harvested from the region of Ghana outlined the following associations, regarding stillbirths in the developing world [5] [6]:

  • Age of the mother greater than 35 years old
  • Previous stillbirth
  • Primi- or multiparity
  • Lack of maternal and fetal care during gestation
  • Hemorrhage of the mother or fetus
  • Traumatization of the fetus/asphyxiation
  • Congenital abnormalities
  • Maternal medical conditions

It is known that half of the fetal death occur during the labor, and half prior to its onset. Even though stillbirths are common, particularly in the developing world, in many cases, autopsical studies cannot detect the cause of death [7] [8].

Epidemiology

On an international level, it is estimated that every year, approximately 3,000,000 stillbirths occur [9] [10]. Amongst these stillbirths, a staggering 98% of the cases concern Asia, Africa and generally mothers living in underprivileged regions of the world. It has also been observed that half of the stillbirths in these regions occur in rural settings and prior to the onset of labor.

It is believed that one of the primary factors leading to a stillbirth is the lack of a professional to aid during the labor.

Sex distribution
Age distribution

Pathophysiology

Stillbirth is an occurrence exhibiting various etiological and pathophysiological pathways.

Maternal infection plays an important role in giving birth to a baby with no signs of life via various mechanisms [11] [12] [13] [14] [15] [16]:

  • The fetus may die due to complications of the infections affecting firstly the mother, such as respiratory failure or hyperpyrexia.
  • The fetus may die due to an infected placenta that fails to provide adequate perfusion to the fetal body, although the latter has not contracted any microorganism.
  • The fetus may also be infected and die due to the infection or due to a developmental abnormality induced by the infection.

Prolonged labor is also a common cause of stillbirth in the developing world [17]: fetuses may die due to lack of oxygenation, infection or a traumatization; all three phenomena are common sequelae of a labor that lasts for a long period of time. Preeclampsia and eclampsia can also lead to a child being born dead, because the fetus fails to receive adequate nutrition and develop properly or is subject to a decreased amount of oxygenation while in the uterus.

Prevention

The most beneficial preventive measure that can be adopted by developing countries is providing proper maternal and fetal care and monitoring during pregnancy [26] [27] [28] [29]. It has been proven that the benefits of having professional care during pregnancy outweighs its costs and can definitely prevent many cases of stillbirth. The monitoring of the fetus and mother can help to detect conditions such as hypertension, diabetes, congenital abnormalities and many more others that can jeopardize the life of the child.

Developing countries could also benefit from the meticulous registration and documentation of stillbirths and from performing fetal autopsies, in order to study the causes of fetal intrauterine death.

Summary

Stillbirths primarily happen in the developing world and generally amongst people of a more underprivileged status. Most fetuses die before the beginning of labor and, although the phenomenon is relatively common on an international level, there is scarce literary data concerning it.

The majority of stillbirths have been associated with risk factors including maternal age greater than 35 years old, habits like smoking or exposure to toxic substances, scarce fetal nutrition, preeclampsia or eclampsia, infections contracted by the mother during pregnancy and former occurrences of stillbirth. A woman that has had multiple prior pregnancies or a medical history of a former stillbirth also displays a greater risk of giving birth to a lifeless child.

One of the most important factors that have been linked to a stillbirth, however, is the lack of professional care and monitoring during pregnancy. Proper pregnancy management can both help to diagnose in time conditions that may threaten the life of a fetus and reduce the duration of the labor. It is important to keep in mind that a prolonged labor also contributes to an increased fetal mortality.

In the occasions that a baby is stillborn, the evacuation of the uterus may be automatic or may require pharmacological or surgical treatment in order to take place. An autopsy of the stillborn fetus is the most useful tool in order to discover the etiology of the death and enables the parents and physicians to plan a future pregnancy. Parents that have gone through a stillbirth should consult a grief counselor, as psychological support is of the utmost importance in such occasions.

Patient Information

Stillbirth is defined as the giving birth to a dead child or a pregnancy that ends later than the 28th week of gestation, also with the giving birth to a lifeless child.

It is an occurrence that is more common to the developing world rather than the industrialized west; despite its increased frequency in some parts of the globe, it remains under-documented and scarcely studied. it is generally believed that certain risk factors contribute to a baby being born dead. these risk factors include:

Another important factor that greatly contributes to the loss of a child's life while still in the uterus is the lack of care during pregnancy. A professional can help to identify conditions that may put the child's life at risk and treat them, therefore preventing a stillbirth. After a mother gives birth to a baby that is born without signs of life, it is important to detect the causes of death, in order to prevent the same circumstances from arising in a future pregnancy. furthermore, the parents will definitely benefit from grief counseling, as the sessions can help them to recover from the devastating effect and regain emotional strength.

References

Article

  1. Lawn JE, Yakoob MY, Haws RA, Soomro T, Darmstadt GL, Bhutta ZA. 3.2 million stillbirths: epidemiology and overview of the evidence review. BMC Pregnancy Childbirth. 2009 May 7;9 Suppl 1:S2. doi: 10.1186/1471-2393-9-S1-S2.
  2. Getahun D, Ananth CV, Kinzler WL. Risk factors for antepartum and intrapartum stillbirth: a population-based study. Am J Obstet Gynecol. 2007 Jun;196(6):499-507.
  3. Salihu HM, Wilson RE, Alio AP, Kirby RS. Advanced maternal age and risk of antepartum and intrapartum stillbirth. J Obstet Gynaecol Res. 2008 Oct;34(5):843-50.
  4. Facchinetti F, Alberico S, Benedetto C, et al. Italian Stillbirth Study Group. A multicenter, case-control study on risk factors for antepartum stillbirth. J Matern Fetal Neonatal Med. 2011 Mar;24(3):407-10. doi: 10.3109/14767058.2010.496880.
  5. Ha YP, Hurt LS, Tawiah-Agyemang C, Kirkwood BR, Edmond KM. Effect of socioeconomic deprivation and health service utilisation on antepartum and intrapartum stillbirth: population cohort study from rural Ghana. PLoS One. 2012;7(7):e39050. doi: 10.1371/journal.pone.0039050.
  6. McClure EM, Nalubamba-Phiri M, Goldenberg RL. Stillbirth in developing countries. Int J Gynaecol Obstet. 2006 Aug;94(2):82-90.
  7. Fretts RC. Etiology and prevention of stillbirth. Am J Obstet Gynecol. 2005 Dec;193(6):1923-35.
  8. Silver RM, Varner MW, Reddy U, et al. Work-up of stillbirth: a review of the evidence. Am J Obstet Gynecol. 2007 May;196(5):433-44.
  9. Lawn JE, Blencowe H, Pattinson R, et al. Lancet's Stillbirths Series steering committee. Stillbirths: Where? When? Why? How to make the data count? Lancet. 2011 Apr 23;377(9775):1448-63. doi: 10.1016/S0140-6736(10)62187-3.
  10. Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth rates: delivering estimates in 190 countries. Lancet. 2006 May 6;367(9521):1487-94.
  11. Goldenberg RL, Thompson C. The infectious origins of stillbirth. Am J Obstet Gynecol. 2003 Sep;189(3):861-73.
  12. Di Mario S, Say L, Lincetto O. Risk factors for stillbirth in developing countries: a systematic review of the literature. Sex Transm Dis. 2007 Jul;34(7 Suppl):S11-21.
  13. Gibbs RS. The origins of stillbirth: infectious diseases. Semin Perinatol. 2002 Feb;26(1):75-8.
  14. Petersson K, Bremme K, Bottinga R, et al. Diagnostic evaluation of intrauterine fetal deaths in Stockholm 1998-99. Acta Obstet Gynecol Scand. 2002 Apr;81(4):284-92. Erratum in: Acta Obstet Gynecol Scand. 2003 Jan;82(1):102.
  15. Folgosa E, Osman NB, Gonzalez C, Hägerstrand I, Bergström S, Ljungh A. Syphilis seroprevalence among pregnant women and its role as a risk factor for stillbirth in Maputo, Mozambique. Genitourin Med. 1996 Oct;72(5):339-42.
  16. Southwick KL, Blanco S, Santander A, et al. Maternal and congenital syphilis in Bolivia, 1996: prevalence and risk factors. Bull World Health Organ. 2001;79(1):33-42. Epub 2003 Nov 5.
  17. Weiner R, Ronsmans C, Dorman E, Jilo H, Muhoro A, Shulman C. Labour complications remain the most important risk factors for perinatal mortality in rural Kenya. Bull World Health Organ. 2003;81(8):561-6. Epub 2003 Oct 14.
  18. Lalor JG, Fawole B, Alfirevic Z, Devane D. Biophysical profile for fetal assessment in high risk pregnancies. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000038. doi: 10.1002/14651858.CD000038.pub2.
  19. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD006066. Review. Update in: Cochrane Database Syst Rev. 2013;5:CD006066.
  20. Katz M, Meizner I, Insler V. Fetal Well-being: Physiological Basis and Methods of Clinical Assessment. CRC Press; 1990.
  21. Wapner RJ, Lewis D. Genetics and metabolic causes of stillbirth. Semin Perinatol. 2002;26(1):70–4.
  22. Christiaens GC, Vissers J, Poddighe PJ, de Pater JM. Comparative genomic hybridization for cytogenetic evaluation of stillbirth. Obstet Gynecol. 2000;96(2):281–6.
  23. Faye-Petersen OM, Guinn DA, Wenstrom KD. Value of perinatal autopsy. Obstet Gynecol. 1999;94(6):915–20.
  24. Velazquez MD, Rayburn WF. Antenatal evaluation of the fetus using fetal movement monitoring. Clin Obstet Gynecol. 2002;45:993–1004.
  25. Boehm FH, Gabbe SG. Putting it all together. Clin Obstet Gynecol. 2002;45:1063–1068.
  26. Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth rates: delivering estimates in 190 countries. Lancet. 2006 May 6;367(9521):1487-94.
  27. Haws RA, Yakoob MY, Soomro T, Menezes EV, Darmstadt GL, Bhutta ZA. Reducing stillbirths: screening and monitoring during pregnancy and labour. BMC Pregnancy Childbirth. 2009;9(Suppl 1):
  28. Jabeen M, Yakoob MY, Imdad A, Bhutta ZA. Impact of interventions to prevent and manage preeclampsia and eclampsia on stillbirths. BMC Public Health. 2011;11(Suppl 3):S6.
  29. Hofmeyr GJ, Haws RA, Bergstrom S, Lee AC, Okong P, Darmstadt GL, Mullany LC, Oo EK, Lawn JE. Ostetric care in low-resource settings: what, who, and how to overcome challenges to scale up? Int J Gynaecol Obstet. 2009;107(Suppl 1):S21–44.

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Last updated: 2019-07-11 22:36