New Guidelines on Managing Stillbirths Issued by ACOG
Stillbirths are a devastating experience for women and families. Still births occur in approximately 1 out of every 160 deliveries in the United States. Approximately 25,000 are reported every year. In an effort to understand stillbirths better, the American College of Obstetrics and Gynecology (ACOG) have issued new guidelines.
Stillbirth is a fetal death that occurs at 20 weeks of gestation or later during pregnancy. Prior to 20 weeks, fetal losses are defined as miscarriages. Stillbirths represents 60% of all perinatal mortality in the US.
Those at highest risk of stillbirth are non-Hispanic black race, nulliparity (no previous births), advanced maternal age, and obesity. Black women have the highest stillbirth rate that is nearly twice that of white women even in those who receive good prenatal care. This disparity has been attributed to higher rates of diabetes, hypertension, placental abruption, and premature rupture of membranes among black women.
Hypertension and diabetes are two of the most common medical conditions that occur along with pregnancy. Both are associated with increased risk for stillbirths. Diabetic women have a two- to five-fold increased risk of stillbirth.
Obesity also increases the risk of both miscarriage and stillbirth even in obese women who don't smoke or have gestational diabetes. The risk of stillbirth increases as the BMI increases.
Multiple gestations also are related to higher stillbirth rates. A pregnancy with two or more fetuses has a stillborn rate four times higher than a single fetus pregnancy.
Women over 35 years old are at increased risk for stillbirth. This seems to be even more true for older women having their first pregnancy.
Even with the above knowledge, the causes of stillbirths are poorly understood. ACOG feels that the lack of uniform protocols for evaluating and classifying stillbirths in the US has hindered the study of specific causes. Often fetal death certificates are filled out before a full investigation has been completed.
Fetal growth restriction (FGR) is one known cause of stillbirth. FGR is when a fetus does not grow in size appropriately. FGR is associated with certain genetic defects, fetal infections, maternal smoking, hypertension, autoimmune disease, obesity, and diabetes.
Placental abruption is another common cause of stillbirth. It is a condition in which the placenta tears away from the uterine wall. Smoking, hypertension, illegal drug use (ie Cocaine), and preeclampsia all contribute to placental abruption.
Approximately 8-13% of stillborn fetuses have chromosomal and genetic abnormalities. Some of the most common ones include Down syndrome, Turner syndrome, Edward's syndrome, and Patau syndrome.
Umbilical cord problems and abnormalities are frequently blamed for stillbirths without excluding other causes.
The ACOG guides recommend clinicians promptly examine the fetus, placenta, and umbilical cord, and request an autopsy and a karyotype evaluation. A thorough maternal medical history should also be done.
ACOG recognizes that after a stillbirth it is important to be sensitive to the family's emotional state. Families may want to hold their baby and perform cultural or religious activities, such as baptism. This makes the issue of performing an autopsy especially sensitive, but the ACOG encourages clinicians to emphasize that the results may be valuable in planning future pregnancies.
If no autopsy is allowed, then examination can include photographs, X-rays, ultrasound, magnetic resonance imaging, and samples of skin or blood of the stillborn may help identify a cause of the stillbirth.
There is no sure-fire method to prevent stillbirths. Lifestyle modifications go a long way. Losing weight, quitting smoking, and abstaining from drugs and alcohol are all good changes to make becoming pregnant. Good glucose control in diabetic women before and during pregnancy is important.
Fretts RC, et al "Management of stillbirth" ACOG Practice Bulletin 2009.