by Dotun Ogunyemi, MD and Craig L. Bissinger, MD, FACOG
What is a still birth?
A still birth is a baby that is born after 20 weeks of pregnancy with no signs of life. Before 20 weeks, it's usually called a miscarriage.
Still births occur about four to nine cases for every 1,000 births. In areas that are not very high risk usually occurs about four in every 1,000 births. In areas of high pregnancy risk, it occurs in about nine in every 1,000 births.
What are some of the common causes of still birth?
Still births may occur because of a problem with the baby. One of the commonest problems with the babies that are born still birth are babies of a chromosome abnormality. Normal people are 45 chromosomes. Some babies are found with either too many or too few chromosomes. This results in a still birth.
Another problem with a baby is if the baby has a birth defect. Birth defects could affect the brain, their heart or the kidneys or any parts of the baby. If a baby is found with a birth defect, that quickly increases the chance that a baby may not survive.
Other causes may include infection. If the mother has an infection of syphilis, toxoplasmosis, a cytomegalovirus -- this effects the baby, may cause the baby not to survive. Sometimes the mother's membranes are ruptured and bacteria from the vagina may actually rise into inside of the womb and this may effect the baby and this may also make the baby not survive.
Problems of the mother can also result in the baby not surviving. If the mother has significant disease like severe hypertension, diabetes that has not been controlled, this can effect the pregnancy. Sometimes some mothers form antibodies that effect their pregnancy. The most common one is called the antiphospholipid antibodies and this may be associated with the baby not surviving.
If the mother used any kind of drugs, for example, alcohol -- too much alcohol can effect the baby. Cigarette smoking may also do the same thing and especially drugs like cocaine can definitely effect the baby. Occasionally there may be some accident in which the baby starts bleeding into the mother and that may make the baby not survive.
Sometimes the placenta itself may have a problem, either the placenta separates suddenly or sometimes the placenta is so poorly formed that it is not working well. Very rarely you might have a problem with the baby's cord. The baby's cord may become entangled or form a knot, and if there is a knot then blood cannot flow to it and this can result in the baby not surviving.
How is a still birth diagnosed?
To make a diagnosis of still birth usually the mother comes and says the baby has not been moving. This is why it's very important for pregnant women to note how often their babies move. After the mother comes and says the baby is not moving, we usually do an ultrasound and on ultrasound you can either see that the baby is not moving at all or the cessation of the heart movement.
What kind of testing is done?
DOTUN OGUNYEMI, MD: We usually do the diagnosis by ultrasound and on ultrasound you can look at things that can help you detect what may be wrong with the baby. On ultrasound, you can look to see whether there are any obvious defects of the baby like, for example, maybe the baby's heart does not look normal or the baby's brain does not look normal, or there is something wrong with the kidneys or with the baby's abdomen.
Also you can look at the amount of fluid around the baby. If the amount of fluid around the baby has decreased, that may suggest that the placenta is not working well. If the fluid around the baby has increased, that may suggest that the baby has a chromosome abnormality.
Finally, while doing the ultrasound, we can offer the amniocentesis to the mother. The amniocentesis is the procedure that withdraws a few drops of fluid from around the baby. This can be sent to the lab to check for the baby's chromosomes, so you can know whether the baby has a chromosome abnormality or not. This can also be sent to check for the various infections like the toxoplasmosis and the cytomegalovirus that I mentioned because this may also have an effect on the baby's surviving.
On the mother, we can do a lot of blood testing. We can test to see whether the mother has any evidence of the viral infection. We can check the mother's blood by a specialized test called a Kleihhauer-Becke test to see whether there has been evidence that the baby has been hemorrhaging into the mother. We can check the mother's blood sugar level to make sure she is not diabetic. We can check her thyroid level to make sure that the thyroid is working normally. And we can also check for disorders that increase the risk that the mother's placenta may clot. This would include diseases like the antiphospholipid antibody syndrome, automimmune disorders and protein S or protein C deficiency.
Finally when the baby is born, it is important to send the placenta for pathology because the placenta pathology can tell you whether there is any infection of the placenta, whether the placenta itself was malfunctioning and not working well. We can also get cultures from the placenta to see whether parts of the cord were from an infection of the placenta. Finally, it is important to sometimes send the baby for autopsy to examine the baby by the pathologist to see whether there are any defects inside the baby that may not be detected on the outside.
How do you go about effecting delivery?
Once we make a diagnosis of a still birth, obviously the mother has to deliver. There are two main methods of delivery. If the pregnancy is less than 22-24 weeks, some specialists may do a surgical procedure. The advantage of the surgical procedure is that it is short and is relatively painless. Otherwise, most parents probably delivery using some medications to induce labor. In that process it usually may be long but the advantage is that the baby is delivered intact and the mother may bond with the baby. The baby can also be sent for autopsy. Or the parents can decide to do some kind of burial services if they so choose.
How would you manage a subsequent pregnancy?
It depends on whether we found a cause for the still birth. In most studies that look at still births, you can usually find a cause in half of the cases. If there is a cause, that needs to be treated. For example, if the mother has severe diabetes or she has severe hypertension, that needs to be treated before she gets pregnant. If she has the antiphospholipid antibody disease or other disease that increase the risk for excessive clot in the placenta, she may need to be put on heparin during the pregnancy. If there is any infection, then that may need to be treated. If there is a risk for birth defect or chromosome abnormalities, she may need to have an amniocentesis done in the next pregnancy on every ultrasound to make sure that baby does not have that problem.
If it's unexplained, that is, we cannot find any cause why the still birth occurred, the next pregnancy is still somewhat high risk. It would be suggested that the mother live a very good lifestyle -- no smoking, no drinking, use of vitamins and also use folic acid. When she gets pregnant we'd like to do an ultrasound very early to make sure that the pregnancy is viable. And we'll probably also may have her using baby aspirin because that may sometimes help in the pregnancy.
During the pregnancy we will want to do ultrasound regularly to make sure the baby is growing well. And once she gets into the last three months of pregnancy, we want to start doing testing of the baby once a week to make sure the baby is doing fine.
The mother should probably be delivered when she gets 37 weeks to make sure that we get a live baby.
What kind of emotional support is available for families experiencing still birth?
Usually most hospitals have a support system that includes the nurse, a social worker, a psychologist and a minister that can help the mother and the family during the acute phase of bereavement. After the mother has gone home, most communities and most hospitals have therapies where there are groups of people that can lend support. There are actually some other programs where you may have somebody who have gone through the same process, call at home and offer words of encouragement. Some hospitals have very nice books with poems and a list of resources that you can follow on. Finally, there has been a lot of online programs that offer support services for people who have been bereaved.
Craig L. Bissinger, MD is a board certified Obstetrician/Gynecologist practicing in Parsippany, NJ. Dr. Bissinger is vice-chairman of the Department of OB/GYN at Morristown Memorial Hospital where is is also actively involved in teaching medical students and residents.
Dotun Ogunyemi, MD practices at Morristown Memorial Hospital in Morristown, New Jersey. He is a Clinical Associate Professor of Women's Health and Obstetrics at the University of Medicine and Dentistry, New Jersey.