This document provides an overview of stillbirths including definitions, epidemiology, etiology, approaches to management of stillbirth cases and subsequent pregnancies. It notes that the stillbirth rate in India in 2021 was 12.4 per 1000 births. Investigating the causes of stillbirth involves examining the mother, fetus, placenta and membranes through history, examinations, tests and potentially an autopsy. Managing subsequent pregnancies after a stillbirth includes increased surveillance and optimizing any medical conditions to reduce recurrence risks. The aim is to reduce India's stillbirth rate to 10 per 1000 births by 2030.

1. An Update
Dr SHARDA JAIN
Still Birth:

2. CHALLENGES IN
FIELD OF
STILLBIRTH
ARE VAST
BUT FRESH
POSSIBILITIES
UNFURL !!

3. TRAINING
TRAINING
TRAINING

4. INDIA STILLBIRTH RATE 2021
12.4 (3.7- 22.5 ) /1000 BIRTHS (MOHFP)
OTAL 340600 /1.4 BILLION POPULATION
22 /1000-- 2009
AIM :- 10/1000
BY 2030

5. Overview
•Definition
•Epidemiology
•Etiology
•Approach to management
•Approach to management
of subsequent pregnancy
AIM :- 10/1000
BY 2030

6. Fetal Death
• Delivery of a fetus showing no signs of life irrespective of
POG ,which is not an induced termination
• Embryonic death: ≤12+6 weeks
• Early fetal death: 13-19+6 weeks
• Intermediate fetal death: 20-27+6 weeks
• Late fetal death: ≥28 weeks
• IRRELEVANT TO US

7. Fetal Death
•WHO: Each country to define the gestational age
for reporting purpose
•Terms fetal death, fetal demise, stillbirth, stillborn
used interchangeably
•ACOG / FOFSI recommends to use stillbirth

8. Fetal Death
•Fresh stillbirth: Baby born dead without signs of
disintegration <12 hrs
•Macerated stillbirth: signs of degeneration present,
>12 hrs
WHO ,2005

9. Defining Stillbirths
birth weight >1000g or 28 weeks POG
INDIA
AIM :- 10/1000 BY 2030

10. Defining Misscarriage /Stillbirths
Miscarriage
Defining StillbirthsDefining Stillbirths
Stillbirth

11. Epidemiology of Stillbirth
• 2021: 2 million stillbirths globally, 1 IN 16 SECS
• INDIA 3.4 /20 LAC= 17 %
• 50% intrapartum / 50 % NO cause found
• 3/4th occurred in south Asia & sub-Saharan Africa
*WHO 2021
• India stillbirth rate: 12/1000 births in21
*LANCET 2022

12. USA : 2.95 /1000
NO CHANGE IN LAST 2 DECADES

13. What is the issue?
•Devastating event for parents.
•For preventing stillbirths Understand why they
occur and identify preventable causes.
•Understanding
• Cope with grief
• Plan for future pregnancies

14. Etiology of Stillbirth
Multifactorial
Maternal Placental Fetal
Infections:
Maternal
& fetal
Unexplain
ed

15. CAUSES
MATERNA5-10 %
FETAL 25-40 %
PLACENTAL20-35 %
UNEXPLAINED15-25 %

16. Maternal causes

17. Fetal
causes:4X
Alloimmunisation- red
cell/platelet
Chromosomal/ genetic
abnormalities/
congenital
malformations
Complications of
multifetal gestation
Fetal Hydrops
FGR

18. Placental + UC
causes Placenta abruption
Placental previa
Uteroplacental insufficiency
Placental pathology
Chorionic intervillositis
Chronic villitis
Massive perivillous fibrin deposition
Umbilical cord complications

19. Infections
Bacterial
• Listeria
• Treponema
• Group B
streptococci
• E coli
• Ureaplasma
• Mycoplasma
• H Influenza
• Chlamydia
• Klebsiella
Viral
• CMV
• Parvovirus B19
• Enterovirus
• HSV-1,2
• Echovirus
• Rubella
• HIV
• Coxsackie
Parasitic
• Toxoplasma
gondii
• Malaria

20. Infections
Transplacental
CMV
Syphillis
Parvovirus B19
Listeria
Rubella
Toxoplasma
HSV
Coxsackie
Leptospira
Q fever
Lyme disease
Malaria parasitemia
Ascending infections
 E. Coli
 Klebsiella
 Group B streptococci
 Enterococci
 Mycoplasma
 Ureaplasma
 Haemophilus
influenzae
 Chlamydia

21. Unexplained stillbirth
•50% of the stillbirths
•Not attributed to an identifiable fetal, maternal,
placental or obstetrical etiology
•Common at near term
*WHO 2020

22. Intrapartum causes of SB
•Cord prolapse, vasa previa
•Placental abruption
•Obstructed labor & Birth trauma
•Malpresentation
•Uterine rupture
•Infections
•Fetal distress
•Unspecified

23. Classification: Etiologies
There are many many Classification systems used for
stillbirth
•WHO-ICD-PM, 2016
•CODAC (Causes Of Death and Associated
Condition), 2009
•ReCoDe ( Relevant Condition at Death), 2005

24. ReCoDe classification (Relevant Condition at Death)
Group Causes
A Fetus Lethal Congenital Anomaly, Infection(acute, chronic), Non
Immune Hydrops, Isoimmunization, Fetomaternal Hemorrhage,
complication of multifetal gestation , FGR
B Umbilical cord Prolapse, Constricting Loop Or Knot, Velamentous Insertion,
Others
C Placenta Abruption, Previa, Vasa Previa, Other Placental Insufficiency
D Amniotic fluid Chorioamnionitis, Oligohydramnios, Polyhydramnios
E Uterus Rupture, Uterine Anomalies
F Mother Diabetes, Thyroid Diseases, Hypertension, Hypertensive
Disorders In Pregnancy, Lupus Or Antiphospholipid Syndrome,
Cholestasis, Drug Misuse
G Intrapartum Asphyxia, Birth Trauma
H Trauma External, Iatrogenic
I Unclassified No relevant condition identified, no information available
*Gardosi et al, BMJ 2005

25. WHO – ICD-10
2016

26. PERINATAL CAUSES OF DEATH SEPARATED BY TIMING OF DEATH
2016

27. Maternal condition
•M1 :- Complications of placenta, cord and membranes
•M2 :- Maternal complications of pregnancy
•M3 :- Other complications of labour and delivery
•M4 :- Maternal medical and surgical conditions
•M5 :- No maternal condition
2016

28. CAUSES  in INDIA / DEV COUNTRIES
• OBSTETRIC CONDITION --30%
• PLACENTAL -- 23%
• FETAL ( GENETIC / STRUCTURAL ) --14 %
• INFECTIONS 13% - MORE PRETERM THAN TERM
• UMBLICAL CORD ABNORMALITIES -- 1O%
• HDP -10%
• MATERNAL MEDICAL CONDITIONS ie GDM--1O%

29. Approach to a case of stillbirth
•Establish the diagnosis
•Patient & relatives counselling & psychological
support
•Investigate the cause
•Delivery
•Management in subsequent pregnancy

30. Establish the Diagnosis
Accurate Diagnosis
Absent Fetal
Movements
ULTRASOUND,
Overlapping Skull
Bones & Skin Edema
Placental localization
& retroplacental clot

31. Establish the Diagnosis
Auscultation
CTG
Real time
USG
Mother may
percieve
passive fetal
movements
Offer repeat scan if
passive fetal
movements

32. Counselling  Emotional reactions
Disbelief
Anger
Shock
Guilt
Denial
Despair
Fear
Anxiety
Crying

33. Counselling: Breaking the news!
*RCOG 2010
Confirm
diagnosis
Private
space
Unhurried
manner

34. Counselling: Make them aware!
•No specific cause in ½ cases
•If cause found: Planning for future
•Further investigation if necessary
•Explain about fetal autospy
•Complications of fetal death

35. Investigating the cause
If obvious cause present- no further testing
(cord prolapse, anencephaly)
History
Maternal investigations
Evaluation of still born
Fetal investigations
Placental investigations

36. Investigating the cause
General Physical Examination
• General well being &mental state
• Vitals
• Systemic examination
• Per vaginum

37. Investigating the cause
Maternal Investigations
• Blood group, CBC,LFT,KFT, TFT ,RBS
• Coagulation test & DIC profile
• Urine: albumin/sugar/ketones
• USG: fetal presentation, lie, placenta position, RPC

38. Investigating the cause: Maternal investigations
RCOG GTG 2010
Test Purpose
CBC, LFT, KFT, CRP, DIC profile Maternal well being
Pre-eclampsia & complications
Sepsis
Bile salts ICP
Kleihauer betke test Feto-maternal haemorrhage
Decide dose of Anti-D
Repeat in case of Rh-D neg mother
Cultures Suspected infections
Prolonged IUFD
Viral screen
Syphillis
Tropical infections
Occult maternal-fetal infections
TORCH recommended
H/o Travel to endemic area
RBS, HbA1C Occult DM
TFT Occult maternal thyroid disease

39. Investigating the cause:
Evaluation of stillborn
Infant description
Malformation
Skin staining
Degree of
maceration
Color-pale, plethoric
Umbilical cord
 Prolapse
 Entanglement-
neck,arms, legs
 Hematoma or
stricture
 Number of
vessels
 length
Amniotic fluid
Color: meconium,
blood
volume
Membranes
 Stained
 Thickening
Placenta
Weight
Staining
Adherent clots
Structural
abnormality
Velamentous
insertion
Edema/ hydropic
changes

40. Test Purpose Remarks
Fetal & placental micobiology
Fetal blood
Fetal swabs
Placental swabs
Fetal infections More informative than
maternal serology for viral
infections
Fetal & placental tissue karyotyping
Deep fetal skin
Fetal cartilage
Placenta below cord insertion
Aneuploidy
Single gene
disorder
Consent
Postmortem examination
External
Autopsy
Microscopy
X-ray
Placenta & cord
Highest diagnostic
yield
Consent
RCOG 2010
Investigating the cause
Fetal and Placental investigations

41. Investigating the cause
• AUTOPSY :Gross & HPE of placenta ,Umblical cord
& FETAL MEMB by trained pathologist is most
important.
• If consent is not given for full autopsy of baby
A limited autopsy!
(external or internal examination limited to brain, spinal
cord, chest organ, tissue biopsy, USG, MRI, X-ray,
photographs, blood samples)
*ACOG practice Bulletin no 102, 2016

42. Investigating the cause
Indication for cytogenetic studies
•Congenital malformation
•FGR
•Non Immune Hydrops
•Ambiguous genitalia
•Dysmorphic features
•Parent carrier of balanced chromosomal
rearrangement
*ACOG Practice Bulletin no.102, 2016

43. Investigating the cause
At the time of diagnosis
Ultrasound scan
Maternal blood tests
Maternal toxicology
Maternal microbiology
After delivery
External examination
Infant blood tests
Infant microbiology
Placenta, membrane and cord
histopathology
Cytogenetic investigations
Postmortem examination
Postmortem Radiological
imaging
When to do?

44. Investigating the cause: Summary

45. Labour & Delivery
Timing &
Mode
Mother’s
preference
Previous intra-
partum history
Medical
condition

46. Delivery  Induce Or Wait?
Offer Both Options
• Spontaneous onset of labour will occur in 80% in 2 weeks
• Only 10% remain undelivered for > 3 weeks
• Delivery should not be delayed:
• Ruptured membranes
• Abruption
• Pre-eclampsia
• Sepsis

47. Delivery  Induce Or Wait?
If Mother Choose Expectant Management –
• Periodic follow up:
• Temperature
• Bleeding
• pain abdomen
• Labour
• emotional status
• CBC and coagulation profile twice in a week
10% Chance of maternal DIC within 4 weeks from
date of fetal death
( J Postgrad med ;1992)

48. Delivery: Induction
Unscarred Uterus Scarred uterus
Mifepristone – 1st line Mifepristone alone 200 mcg TDS x 48 hrs
Labor occurred in 63% vs 17 %(placebo)
Intravenous oxytocin vaginal misoprostol
Intravenous oxytocin vs vaginal misoprostol- Misoprostol more
effective
Dosage
• <26+6 wks: 100 mcg 6 hrly
• >27 weeks 25-50 mcg 4 hrly up to 24 hrs
• Caesarean delivery only for maternal indication
• Delivery plan: patient’s health, Obs history &
preferences

49. Delivery: Intrapartum management
Antibiotics
• Broad spectrum therapy if sepsis +
• Routine prophylaxis not recommended
Pain
• Pethidine
• Assess DIC & sepsis before considering regional
anesthesia
Support
• Heed emotional & practical needs
• Away from other women & babies

50. Post Delivery Care
•Patient & family allowed to see/hold the baby
•Grief counselling
•Lactation suppression
•Contraception

51. Subsequent pregnancy after
stillbirth
• Overall recurrence risk is increased to 2-10 folds
• Counselling ON prevention/ prediction
Unexplained 20-37 wk POG: 10 /1000 birth
Unexplained >37 wk POG: 2 /1000 birth
Preterm FGR live birth : 20/1000 birth

52. Probability: Subsequent pregnancy
Etiology with previous still birth Recurrence risk
Congenital anomalies Depends on Types of anomaly
Abruption 9-15%
Vasa previa/Umbillical cord abnormality Un determined
Turner syndrome Sporadic
Trisomy -21,18,13 Full mutation-1-2%
Autosomal recessive disorders 25%
X-linked disorders Increase in male offsprings
Infections Varies
Pre eclampsia 14%
IUGR 20%
Diabetes/chronic HTN EVERY CASE HAS POTENTIAL
Thrombophillia
APLA , Isoimmunisation

53. Management: Subsequent pregnancy
Preconception appointment/ Initial prenatal visit
• Review records
• Discuss possible etiologies and work up of previous SB
• Determine recurrence risk
• Detailed medical/obstetric history
• Optimise maternal medical conditions
• Change potentially modifiable factors
Smoking/illicit substance/alcohol cessation
Weight loss in obese
• Genetic counselling if family genetic condition
• Support & reassurance

54. Management: Subsequent pregnancy
Pregnancy –
•First Trimester
•Second Trimester
•Third Trimester
•Delivery

55. Management: Subsequent pregnancy
First trimester
• Dating USG- CRL
• IST TRIM SCREENING :PAPP-A & hCG, Nuchal
translucency
• Diabetes screen
• APLA/thrombophilia work up (only if indicative)
• TLC :Support & reassurance

56. Management: Subsequent Pregnancy
Second trimester
• Fetal anatomical survey at 18-20 weeks (level 2 USG)
• Quad screen – MSAFP, hCG, estriol, inhibin A IF
MISSED EARLY
• TLC :Support & reassurance

57. Management: Subsequent Pregnancy
Third trimester
• Rule out FGR
• Daily fetal kick Count starting 28 weeks
• Antepartum fetal surveillance - 32 weeks onwards
1-2 weeks earlier than GA of prev SB
• Support & reassurance

58. Management: Subsequent Pregnancy
Delivery
• No risk factor Elective induction at 39 weeks
• As per Medical indication
• Avoid scheduled delivery before 39 wks if previous still
birth is unexplained and previous delivery is uncomplicated

59. Management: Subsequent pregnancy
• Detection & management of
Hypertensive disorders & Diabetes
of pregnancy
• Syphilis detection and treatment
• Skilled birth attendant (SBA) at birth
• Availability of basic emergency
obstetric care
• Availability of comprehensive
emergency obstetric care
• Periconceptional folic acid
fortification
• Prevention of malaria
• FGR detection & management
• Post term pregnancy (≥41 wk)
identification & induction
To ↓ stillbirth
Summary of Preventing strategies

60. Take home message…
• STILLBRTH RATE 12/1000 incidence in india
• RISK FACTORS : < 15 ,>35 ,NULLIPARITY , BMI>30 ,SMOKING , MULTIPLE
GESTATION ,BOH ,PRETERM,FGR,STILLBIRTH
• CAUSES : OBSTETRIC-30 % ,PLACENTAL-24 %FETAL/GENETIC AB- 12, INFECTION-
10 %- &HDP- / DM --10 --20%
• NO CAUSE FOUND IN 50 %
• MOST IMPORTANT PART OF EVALUATION—MEDICAL / OBST HISTORY
GROSS/HPE OF PLACENTA /UMB CORD & FETAL MEMBRANES by trained person
• FEAL AUTOPSY BY TRAINED PATHOLOGIST

61. Take home message…
• FETO-MATERNAL HGE TESTING IN ALL
• CHROMOSOMAL MICROARRAY—FIRST LINE TESTING .COSTS—NO ISSUE
• APLA STUDY- DO IN ALL
• PARENTS SHOULD SEE & HOLD CHILD / PHOTO /HANDPRINTS+
PSYCHOLOGIC COUNCELLING
• SUBSQUENT PREGNANCY– SERIAL USD FOR FETAL GROWTH &
SURVEILLANCE
• ELECTIVE DELIVERY AT 39 WEEKS

62. Each Baby counts!!!
Each one of us can
make a difference!