Stillbirth: Causes, Diagnosis, Management, and Complications

1. Definition:

Stillbirth refers to the death of a fetus in the womb after 20 weeks of pregnancy. It’s a common occurrence, affecting approximately 10-20% of pregnancies. The causes of stillbirth are diverse, ranging from maternal factors, fetal factors, or a combination of both.

2. Diagnosis:

2.1. Symptoms:

• Vaginal bleeding: Blood is usually dark brown, may be scant or heavy, and can be continuous or intermittent.

• Abdominal pain: Pain can be mild or severe, depending on the extent of bleeding and placental detachment.

• Breast tenderness subsiding

• Psychological changes: Feelings of sadness, anxiety, restlessness, etc.

2.2. Tests:

• Ultrasound: Ultrasound is the most reliable diagnostic tool for stillbirth. The doctor will assess if the fetus has a heartbeat and if the fetal size corresponds to the gestational age.

• Note:

• Accurate gestational age determination is crucial for reliable ultrasound results, especially in early pregnancies.

• The presence of a fetal heartbeat is a crucial indicator of stillbirth. However, it needs to be assessed in conjunction with other signs like fetal size, position, and amniotic fluid volume for accurate diagnosis.

• Blood tests:

• Beta-hCG: Decreases after 24-48 hours in cases of stillbirth.

• Progesterone: Levels are low in stillbirth.

• Amniocentesis: May be used to determine the cause of stillbirth.

2.3. Diagnostic Challenges:

• Small stillbirth: Difficulties in early detection and prenatal examination.

• Misdiagnosis with other conditions: Vaginal bleeding during pregnancy can have various causes, requiring differentiation from stillbirth, ectopic pregnancy, miscarriage, placenta previa, etc.

3. Complications:

3.1. Psychological Complications:

• Emotional Impact: Stillbirth can severely impact the emotional well-being of pregnant women, especially those who have been trying to conceive for a long time.

• Negative emotions: Sadness, anxiety, guilt, self-blame, depression, etc.

• Relationship impact: Stillbirth can affect relationships with partners, family, and social circles.

3.2. Health Complications:

• Infection: Stillbirth can lead to uterine infection, potentially endangering the mother’s health.

• Vaginal bleeding: The longer the stillbirth persists, the higher the risk of vaginal bleeding.

• Coagulation disorders: Prolonged stillbirth can cause coagulation disorders, increasing the risk of maternal mortality.

4. Management:

• Principle: Preference for vaginal delivery of the stillborn fetus, except in cases requiring surgical intervention to save the mother.

• Management methods:

• Medication:

• Misoprostol: Used to stimulate uterine contractions and expel the stillborn fetus.

• Note: Misoprostol dosage varies depending on fetal size.

• Small fetus: 1-2 tablets of 200 mcg.

• Large fetus: 1/4-1/8 tablet of 200 mcg.

• Close monitoring of uterine contractions and vaginal bleeding is necessary.

• Surgery:

• Dilation and curettage (D&C): Indicated for small stillbirths.

• Cesarean section: Indicated in cases of:

• Abnormal fetal presentation

• Placenta previa

• Conjoined twins

• Large fetus

• Follow-up: After management, close monitoring of vaginal bleeding, uterine contractions, and overall maternal health is essential.

5. Causes:

• Maternal factors:

• Medical conditions: Diabetes, high blood pressure, thyroid disorders, autoimmune diseases, etc.

• Lifestyle: Smoking, alcohol consumption, drug use, stress, malnutrition, etc.

• Age: Stillbirth is more prevalent in older mothers.

• Fetal factors:

• Congenital malformations: Severe congenital defects can cause stillbirth.

• Chromosomal abnormalities: Chromosomal abnormalities are the most common cause of stillbirth.

• Genetic disorders: Genetic disorders can affect fetal development.

• Other factors:

• Infections: Infections during pregnancy can cause stillbirth.

• Trauma: Abdominal trauma can cause stillbirth.

• Placental abruption: Premature placental detachment can cause stillbirth.

• Placenta previa: Placenta previa can cause vaginal bleeding and stillbirth.

• Ectopic pregnancy: A condition where a fertilized egg implants outside the uterus, often causing vaginal bleeding and severe abdominal pain.

6. Differentiating from other conditions:

• Stillbirth: Dark brown, foul-smelling blood.

• Ectopic pregnancy (GEU): Blood originates from the fallopian tube – vagina, continuous, and intermittent.

• Miscarriage: Heavy bleeding, often accompanied by severe abdominal pain.

7. Signs of Miscarriage:

• Ultrasound: Images showing placental detachment, with greater detachment indicating a poorer prognosis.

• Low placental detachment: Rapid bleeding.

• High placental detachment: Continuous bleeding.

• Amniotic fluid:

• Brown amniotic fluid: Indicates fetal demise within the womb, causing contamination of the amniotic fluid.

• Foul-smelling amniotic fluid: Indicates fetal demise within the womb, causing contamination of the amniotic fluid.

• Pear-shaped amniotic fluid: Caused by decreased amniotic sac elasticity.

8. Bleeding in the Third Trimester:

• Placenta previa: Heavy bleeding, painless.

• Stillbirth: Dark brown, foul-smelling blood.

• Placental abruption: Non-clotting blood, often accompanied by severe abdominal pain.

9. Note:

• Regular prenatal checkups are crucial for early detection of stillbirth and other pregnancy complications.

• Seek medical attention for any unusual symptoms during pregnancy.

• Do not self-medicate or attempt to manage stillbirth without a doctor’s supervision.

10. Prevention:

• Manage medical conditions effectively.

• Maintain a healthy lifestyle: Consume a balanced diet, engage in regular exercise, minimize stress.

• Avoid smoking, alcohol, and drug use.

• Attend prenatal appointments regularly and follow doctor’s instructions.

• Get vaccinated against sexually transmitted infections.

• Undergo reproductive health assessments before pregnancy.

11. Conclusion:

Stillbirth is a serious issue affecting the mother’s physical and mental well-being. Seeking medical help for prompt diagnosis and treatment is crucial. Prevention is key, and following a doctor’s advice can safeguard both the mother and the fetus’s health.