eMedicine Specialties > Obstetrics and Gynecology > Obstetrical Complications

Evaluation of Fetal Death

Author: James L Lindsey, MD, Staff Physician, Santa Clara Valley Medical Center, Affiliated Clinical Associate Professor, Stanford School of Medicine, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center
Contributor Information and Disclosures

Updated: Dec 18, 2008

Definition of Fetal Death

The loss of a fetus at any stage is a fetal demise. According to the 2003 revision of the Procedures for Coding Cause of Fetal Death Under ICD-10, the NationalCenter for Health Statistics defines fetal death as "death prior to the complete expulsion or extraction from its 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."  

In the United States, the term stillbirth or fetal demise does not have a standard definition.

For statistical purposes, fetal losses are classified according to gestational age. A death that occurs prior to 20 weeks' gestation is usually classified as a spontaneous abortion; those occurring after 20 weeks constitute a fetal demise or stillbirth. Many states use a fetal weight of 350 g or more to define a fetal demise.

Although this definition of fetal death is the most frequently used in medical literature, it is by no means the only definition in use. Even within the United States, the differences in the definitions used are substantial.

In addition, not all states interpret the weeks of gestation in the same manner. In California, 20 weeks' gestation is worded "twenty utero gestational weeks" and has therefore been interpreted to be 23 weeks from the last menstrual period. (Implantation in the uterus does not occur until 1 wk after fertilization.) Physicians must check the reporting requirements for the state(s) in which they practice.

Frequency of Fetal Death

In 2003, data from the National Center for Health Statistics showed a US national average fetal mortality rate of 6.9 deaths per 1000 births. Worldwide, this rate varies considerably depending on the quality of medical care available in the country in question and the definitions used for classifying fetal deaths. Underreporting in developing nations is common, which makes comparisons even more difficult.

Diagnosis of Fetal Death

History and physical examination are of limited value in the diagnosis of fetal death. In most patients, the only symptom is decreased fetal movement. An inability to obtain fetal heart tones upon examination suggests fetal demise; however, this is not diagnostic and death must be confirmed by ultrasonographic examination.

Fetal demise is diagnosed by visualization of the fetal heart and the absence of cardiac activity.

Management of Fetal Death

Once the diagnosis of fetal demise has been confirmed, the patient should be informed of her condition. Often, allowing the mother to see the lack of cardiac activity helps her to accept the diagnosis.

Labor induction should be offered after diagnosis. Patient responses vary in regard to this recommendation; some wish to begin induction immediately, while others wish to delay induction for a period of hours or days until they are emotionally prepared.

When a dead fetus has been in utero for 3-4 weeks, fibrinogen levels may drop, leading to a coagulopathy. This is rarely a problem because of earlier recognition and induction. In some cases of twin pregnancies, induction after the death of a twin may be delayed to allow the viable twin to mature.

Induction may be accomplished with preinduction cervical ripening followed by intravenous oxytocin (see Cervical Ripening). Patients with a history of a prior cesarean delivery should be treated cautiously because of the risk of uterine rupture, just as in any birth following cesarean delivery (see Vaginal Birth After Cesarean Delivery).

Early fetal demise may be managed with laminaria insertion followed by dilatation and extraction. In women with fetal death before 28 weeks' gestation, induction may be accomplished using prostaglandin E2 vaginal suppositories (10-20 mg q4-6h), misoprostol (ie, prostaglandin E1) vaginally or orally (400 mcg q4-6h), and/or oxytocin (preferred in women with prior uterine surgery). In women with fetal death after 28 weeks' gestation, lower doses should be used.

The AmericanCollege of Obstetricians and Gynecologists guidelines for induction of labor states that prostaglandin E2 and misoprostol should not be used in women with a history of a prior uterine incision because of the risk of uterine rupture. In 2003, Dickinson and Evans reported on the efficacy of oral, vaginal, and combined administration of misoprostol for second-trimester induction and found that the superior regimen was misoprostol at 400 mcg vaginally every 6 hours.¹

Pain management in patients undergoing induction of labor for fetal demise is usually easier to manage than in patients with live fetuses. Higher doses of narcotics are available to the patient and often a morphine or Dilaudid PCA is sufficient for successful pain control. Should a patient desire superior pain control to intravenous narcotics, epidural anesthesia should be offered.

See Media file 1 for an example of a checklist that can be used in the management of fetal demise.

Causes of Fetal Death

The etiology of fetal demise is unknown in 25-60% of all cases. In cases where a cause is clearly identified, the cause of fetal death can be attributable to fetal, maternal, or placental pathology.

Maternal

• Prolonged pregnancy (>42 wk)
• Diabetes (poorly controlled)
• Systemic lupus erythematosus
• Antiphospholipid syndrome
• Infection
• Hypertension
• Preeclampsia
• Eclampsia
• Hemoglobinopathy
• Advanced maternal age
• Rh disease
• Uterine rupture
• Maternal trauma or death
• Inherited thrombophilias

Fetal

• Multiple gestations
• Intrauterine growth restriction
• Congenital abnormality
• Genetic abnormality
• Infection (ie, parvovirus B19, CMV, listeria)
• Hydrops

Placental

• Cord accident
• Abruption
• Premature rupture of membranes
• Vasa previa
• Fetomaternal hemorrhage
• Placental insufficiency

Risk factors (weak predictive value)

• African American race
• Advanced maternal age
• History of fetal demise
• Maternal infertility
• History of small for gestational age infant
• Small for gestational age infant
• Obesity
• Paternal age

Maternal Studies

Maternal studies that should also be considered during the workup of a fetal demise include the following:

• Diabetes testing using hemoglobin A1C and a fasting blood glucose
• Syphilis screening using the VDRL or rapid plasma reagent test
• Thyroid function testing (ie, TSH, FT4)
• Urine toxicology screening

The above tests have traditionally been a part of an evaluation for the etiology of fetal demise. If diabetes screening has been performed during the prenatal period, repeat testing for diabetes is probably not necessary. Similarly, if the patient has no signs or symptoms of thyroid disease, thyroid dysfunction is unlikely to be the cause of the demise. However, these tests are inexpensive and normal results may be reassuring to the patient.

Additional tests that should be considered are as follows:

• Antibody screening
• CBC count with platelet count
• Kleihauer-Betke test
• Lupus anticoagulant and anticardiolipin antibody testing: See Antiphospholipid Antibody Syndrome and Pregnancy.
• Thrombophilia panel: Authorities disagree as to whether this panel should be performed for all cases of intrauterine fetal demise. Inherited thrombophilias are not uncommon in the general population but are probably rare causes of fetal demise. While some authorities (including ACOG) recommend maternal testing in all cases of fetal demise, a more selective approach is to limit testing to patients who have a history of venous thrombosis, a positive family history, placental infarction, severe preeclampsia occurring in the second or early third trimester, abruption, or intrauterine growth retardation.
• Infection: See Bacterial Infections and Pregnancy. Infection is a cause of fetal demise. The frequency is higher in developing countries. Autopsy and histologic evaluation of the placenta is probably the best way to document an infectious etiology for a fetal demise.
  
  Authority opinions vary as to which panel of tests is appropriate. Traditionally, most authorities have recommended obtaining TORCH (toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus) antibody titers. In reality, this is rarely helpful in the diagnosis. In addition, it is questionable whether cytomegalovirus virus causes fetal demise. If no obvious cause for the demise is established or if clinical signs or symptoms suggest infection, consider testing for (1) cytomegalovirus (acute and chronic titers), (2) rubella virus (acute and chronic titers, if not immune), (3) parvovirus (acute and chronic titers), and (4) Toxoplasmosisgondii (acute and chronic titers) and (5) syphilis. A more cost-effective approach is to limit testing for cytomegalovirus, rubella virus, and T gondii to those patients in whom clinical findings suggest the possibility of intrauterine infection (ie, those with intrauterine growth restriction, microcephaly).

Evaluation of Fetal Demise

The following provides a summary of the current status of testing for fetal demise. This is adopted with permission from the work of Dr. Robert M. Silver and the Stillbirth Collaborative Research Network.

Commonly accepted tests

• Thorough maternal history
• Fetal autopsy
• Placental evaluation
• Karyotype
• Indirect coombs test
• Serologic test for syphilis
• Testing for fetal-maternal hemorrhage (Kliehauer-Betke or other)
• Urine toxicology screen
• Parvovirus serology

Useful in some circumstances

• Thrombophilia evaluation to include the following:
• Lupus anticoagulant
• Anticardiolipin antibodies
• Factor V Leiden
• Prothrombin mutation
• Protein C, protein S, and antithrombin III deficiency

Uncertain utility

• TSH
• Hemoglobin A1C
• TORCH titers
• Placental cultures
• Testing for other thrombophilias

Developing technology

• Comparative genomic hybridization
• Testing for single gene mutations
• Testing for confined placental mosaicism
• Nucleic acid-based testing for infection

Management of Future Pregnancy

If a particular medical problem is identified in the mother, it should be addressed prior to conception. For example, tight control of blood glucose prior to conception can substantially reduce the risk of congenital anomalies in the fetus. Preconceptional counseling is helpful if congenital anomalies or genetic abnormalities are found. Genetic screening and detailed ultrasound can evaluate future pregnancies. In some cases, such as cord occlusion, the patient can be assured that recurrence is very unlikely.

Fetal death of unknown cause is a special problem. Although recurrent fetal loss is uncommon, patients are naturally anxious. Most patients find increased fetal surveillance with the next pregnancy reassuring, even though such testing is not clearly beneficial. Weekly biophysical profile or fetal heart rate testing can be combined with maternal kick counts in the third trimester. For patients who have experienced earlier loss, frequent ultrasound is reassuring.

Optimal management of chronic medical conditions is important prior to the next pregnancy.

Multimedia

(Enlarge Image)

Media file 1: This is an example of a checklist to be used following fetal death. Courtesy of Santa Clara Valley Medical Center.

Keywords

evaluation of fetal death, stillbirth, fetal demise, perinatal death, pregnancy loss after 20 weeks' gestation, fetal heart tones, fetal movement, fetal surveillance, induction, oxytocin, preinduction cervical ripening, antiphospholipid syndrome, cord occlusion, abruptio placentae, pregnancy loss, fetal death, fetal death evaluation, fetal demise evaluation, evaluation of fetal demise

Thanks to Dr. Robert M. Silver and the Stillbirth Collaborative Research Network.

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