<aside> 💡 Most stillbirths are associated with uncomplicated pregnancies

</aside>

Patients with a previous stillbirth are 2-10 times more likely to have another.  However, the exact risk for recurrence and appropriate prevention strategies (eg, increased antenatal surveillance) indicated during future pregnancies will depend on the underlying cause of the first stillbirth

| Definition | • Absent fetal cardiac activity at ≥20 weeks gestation and prior to delivery. • Patients often have decreased or absent fetal movement. | | --- | --- | | Risk factors | • Aneuploidy • Fetal or placental anomalies • Fetal growth restriction • Congenital infection • Substance use (eg, tobacco, cocaine) • Maternal conditions (eg, hypertension, diabetes mellitus) | | Evaluation

pathophysiology of IUFD can be maternal, fetal, or placental in origin. | Fetal • Autopsy • Gross & microscopic examination of placenta & umbilical cord • Karyotype/genetic studies Maternal (details below) • Kleihauer-Betke test • Antiphospholipid antibodies • Coagulation studies (For history of recurrent pregnancy loss, family or personal history of venous thrombosis, or fetal growth restriction) | | Diagnosis | • Ultrasound → absence of fetal cardiac activity that is consistent with fetal demise | | Management

| 20-23 weeks • Dilation & evacuation OR vaginal delivery** ≥24 weeks • Vaginal delivery** **CS by maternal choice if history of prior classical CS/myomectomy. | | Complications | Coagulopathy after several weeks of fetal retention | | Counseling | the parents should be informed as empathically as possible (eg, "I am sorry for your loss"). Because the diagnosis can be overwhelming, the next steps in management should be presented as gently and clearly as possible.

Patients with stillbirth require delivery. The safest mode is induction of labor for vaginal delivery. Medically stable patients, such as this one with normal vital signs and laboratory results, can undergo induction of labor immediately or within a week if the parents require additional time to process the diagnosis. This time frame is recommended because prolonged fetal retention increases the risk for maternal coagulopathy; therefore, waiting for spontaneous labor is not recommended

Identifying a possible cause not only provides patients with an answer, but also helps determine the recurrence risk and optimal management of future pregnancies.  Even after thorough evaluation, up to half of IUFDs have no identifiable cause.  Therefore, patients should be counseled in advance that testing may be negative. |

<aside> 💡 Two of the highest-yield tests for identifying the cause are placental evaluation and fetal autopsy. Gross and microscopic placental evaluation can reveal evidence of placental thrombosis, abruption, infection, and other placental disease. Fetal autopsy can estimate the time of death, identify anatomic anomalies, and facilitate additional genetic studies.

</aside>

placental evaluation is always performed to identify potential causes of stillbirth because the placenta lies at the maternofetal interface.

Patients who decline fetal autopsy are still recommended to undergo noninvasive fetal evaluation (eg, external examination for dysmorphic features, MRI) and evaluation of the placenta, fetal membranes, and umbilical cord.  In addition, maternal testing for other causes of stillbirth (eg, antiphospholipid antibody syndrome, fetomaternal hemorrhage) should be performed.  However, even after thorough evaluation, up to half of stillbirths have no identifiable cause.

Chromosomal abnormalities are common causes of first-trimester spontaneous abortions. However, at ≥20 weeks gestation, genetic abnormalities typically cause anomalies (eg, cardiac defect) that are visible during ultrasonography.

Some medications (eg, ACE inhibitors, lithium) are teratogens and cause congenital anomalies; other substances (eg, cocaine) can cause placental abruption, obstetric hemorrhage, and IUFD.  However, corticosteroid and bronchodilator inhalers are not associated with IUFD.

<aside> 💡 Fetal, not maternal, karyotyping can identify genetic causes of stillbirth (eg, trisomy 18).

</aside>

<aside> 💡 Although patients with an IUFD may opt for cesarean delivery, it is not typically recommended because there is increased risk for maternal morbidity and because vaginal deliveries for stillborn infants are usually successful regardless of breech presentation. In addition, immediate delivery is not indicated in this patient.

</aside>

<aside> 💡 In addition, dilation and evacuation (D&E) is not recommended at ≥24 weeks gestation due to increased fetal size, which increases the risk for maternal complications (eg, uterine perforation, cervical laceration). D&E may be indicated at <24 weeks gestation in patients whose condition is medically unstable and who require expedited delivery.

</aside>

Patients with previous antepartum fetal demise must be carefully monitored during their pregnancy to prevent recurrence. In addition to ruling out complicating medical conditions, they should receive two to three ultrasounds across the gestation to determine age, congenital anomalies, and amniotic fluid volume, along with routine monitoring of fetal growth. Additionally, women with an unexplained late-term stillbirth at greater than 32 weeks’ gestation should undergo weekly nonstress testing in the third trimester starting at 32 weeks’ gestation.

Choice B)  Kick counting has not been shown to prevent stillbirth recurrence, and recommending more frequent prenatal visits is inappropriate without knowing the cause of this patient's stillbirth.