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Stillbirth
Background
Overview
Definition
Stillbirth is defined as the death of a fetus in utero or the delivery of a fetus with no signs of life at ≥ 20 weeks of gestation.
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Pathophysiology
The pathophysiology of stillbirth often involves impaired placental function, which can lead to fetal growth restriction or preterm labor. Other factors include genetic abnormalities, infections, fetal-maternal hemorrhage, umbilical cord complications, and various maternal medical conditions.
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Epidemiology
The incidence of stillbirth in the US is estimated at 5.96 per 1,000 births, with 3.01 per 1,000 for early stillbirths (20-27 weeks of gestation) and 2.97 per 1,000 for late stillbirths (> 28 weeks of gestation).
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Risk factors
Several risk factors are associated with stillbirth, including advanced maternal age, obesity, pre-existing diabetes, chronic hypertension, smoking, alcohol use, nulliparity, multiple gestation, and non-Hispanic Black race.
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Disease course
The clinical course of stillbirth can vary, but it often involves a period of decreased fetal movement followed by the absence of fetal heart tones.
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Prognosis and risk of recurrence
The prognosis for future pregnancies after a stillbirth depends on the underlying cause and the presence of any modifiable risk factors.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of stillbirth are prepared by our editorial team based on guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG 2025,2016), the Endocrine Society (ES 2024), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023,2020,2018,2014), and the American College of Obstetricians and Gynecologists (ACOG 2020,2012).
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Screening and diagnosis
Diagnostic investigations
History and physical examination: as per RCOG 2025 guidelines, elicit a detailed history to guide subsequent investigations into the cause of stillbirth.
B
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Laboratory tests
Fetal examination
Diagnostic procedures
Placental and cord examination: as per RCOG 2025 guidelines, obtain a pathological examination of the cord, membranes, and placenta in all cases of stillbirth.
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Fetal autopsy and cytogenetic evaluation
Minimally invasive postmortem examination
Medical management
Antibiotic prophylaxis: as per RCOG 2025 guidelines, do not use routine antibiotic prophylaxis.
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Thromboprophylaxis
RhD immunoglobulin
Therapeutic procedures
Mode of delivery
As per RCOG 2025 guidelines:
Offer vaginal birth for most patients, but consider performing Cesarean delivery for some.
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Recognize that late intrauterine fetal demise is not a contraindication to pool birth in suitable circumstances.
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Induction of labor
Specific circumstances
Single fetal demise in multiple gestation: as per SOGC 2023 guidelines, obtain color Doppler ultrasound in case of death of one monochorionic twin early in pregnancy to exclude twin reversed arterial perfusion sequence by confirming the absence of blood flow in the suspected demised twin.
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Patients with antiphospholipid syndrome
Patient education
Preventative measures
Follow-up and surveillance
Suppression of lactation: as per RCOG 2025 guidelines, discuss lactation, milk donation, and milk suppression with patients.
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Antenatal surveillance
Management of subsequent pregnancy (monitoring)
Management of subsequent pregnancy (low-dose aspirin)
Management of subsequent pregnancy (thromboprophylaxis)
Management of subsequent pregnancy (timing of delivery)
Management of subsequent pregnancy (psychosocial support)