What is the diagnosis for a stillbirth (intrauterine fetal demise) at 22 weeks gestation?

From the Guidelines

The diagnosis for a stillbirth (intrauterine fetal demise) at 22 weeks gestation is confirmed by the absence of fetal heartbeat, umbilical cord pulsation, or definite movement of voluntary muscles after 20 completed weeks of gestational age, as defined by the standardization of definitions and reporting guidelines for pregnancy loss 1.

Diagnosis and Management

The diagnosis of stillbirth is based on the confirmation of fetal demise via ultrasound, which is essential for determining the absence of fetal viability. According to the lexicon for first-trimester ultrasound, fetal demise is used to describe the death of a fetus after 11 weeks 0 days of gestational age 1.

Key Considerations

Key considerations in the management of stillbirth include:

• Confirming fetal demise via ultrasound
• Discussing options with the patient, including labor induction and pain management
• Proceeding with delivery, typically using a combination of mifepristone and misoprostol or misoprostol alone if mifepristone is unavailable
• Offering psychological support, including grief counseling and follow-up care
• Monitoring for physical complications, such as hemorrhage, infection, and retained products of conception

Clinical Approach

A clinical approach to stillbirth should prioritize compassionate care, addressing both the medical needs and the significant emotional impact on the family. This includes offering time with the baby if desired, discussing options for autopsy, genetic testing, and placental pathology, and providing ongoing support and follow-up care. The standardization of definitions and reporting guidelines for pregnancy loss 1 provides a framework for consistent and accurate diagnosis and management of stillbirth.

From the Research

Diagnosis of Stillbirth at 22 Weeks Gestation

• The diagnosis of stillbirth, also known as intrauterine fetal demise, at 22 weeks gestation can be attributed to various factors, including umbilical cord stricture 2.
• A study published in the Taiwanese Journal of Obstetrics & Gynecology reported a case of umbilical cord stricture causing intrauterine fetal death in a 22-week fetus 2.
• The mechanism of cord stricture and how it leads to fetal death remain unknown, and the risk of recurrence is generally thought to be low 2.

Neonatal Outcome and Viability

• The limit of viability for neonates is a topic of discussion, and studies have shown that survival rates improve with increasing gestational age 3.
• A study published in The New England Journal of Medicine found that none of the 29 infants born at 22 weeks' gestation survived, whereas 6 of 40 (15%) born at 23 weeks, 19 of 34 (56%) born at 24 weeks, and 31 of 39 (79%) born at 25 weeks survived 3.
• The study also reported that the more immature the infant, the higher the incidence of neonatal complications, such as intracranial pathologic conditions, chronic lung disease, and retinopathy of prematurity 3.

Cost-Effectiveness of Neonatal Resuscitation

• A study published in Obstetrics and Gynecology evaluated the cost-effectiveness of neonatal resuscitation at 22 weeks of gestation and found that universal resuscitation would result in 373 survivors, but at a high cost 4.
• The study reported that the incremental cost-effectiveness ratio of universal resuscitation compared with no resuscitation was not cost-effective at $106,691/QALY 4.
• The authors concluded that neither selective nor universal resuscitation of 22-week neonates is a cost-effective strategy compared with no resuscitation 4.