What can be missed that results in stillbirth?

From the Guidelines

Stillbirth can be missed due to inadequate monitoring of high-risk pregnancies, particularly those with fetal growth restriction (FGR), abnormal umbilical artery Doppler, and other maternal and fetal factors. According to the American College of Radiology, antenatal testing is crucial for identifying fetuses at increased risk for intrauterine death or injury from antepartum asphyxia 1. The Society for Maternal-Fetal Medicine recommends delivery at 37 weeks of gestation in pregnancies with FGR and an umbilical artery Doppler waveform with decreased diastolic flow, but without AEDV/REDV or with severe FGR with EFW less than the 3rd percentile 1.

Key Factors Contributing to Stillbirth

• Placental problems, such as placental abruption or insufficiency
• Birth defects, including genetic abnormalities
• Infections, such as cytomegalovirus, listeriosis, or group B streptococcus
• Umbilical cord complications, like knots or compression
• Maternal health conditions, including uncontrolled diabetes, hypertension, obesity, and autoimmune disorders
• Pregnancy complications, such as preeclampsia, gestational diabetes, or post-term pregnancy (beyond 42 weeks)

Importance of Prenatal Care

Regular prenatal care is essential for monitoring these risks, with special attention to fetal movement tracking in the third trimester. Any decrease in movement should prompt immediate medical attention, as this can be an early warning sign of fetal distress. The American College of Radiology emphasizes that a normal result for any test of fetal well-being is highly reassuring, and a false negative, defined as a stillbirth occurring within 1 week of a normal test result, is uncommon regardless of the test used 1.

Recommendations for High-Risk Pregnancies

Delivery at 37 weeks of gestation is recommended for pregnancies with FGR and an umbilical artery Doppler waveform with decreased diastolic flow, but without AEDV/REDV or with severe FGR with EFW less than the 3rd percentile. Additionally, delivery at 33-34 weeks of gestation is recommended for pregnancies with FGR and AEDV, and delivery at 30-32 weeks of gestation is recommended for pregnancies with FGR and REDV 1. These recommendations prioritize the reduction of stillbirth risk and emphasize the importance of individualized care for high-risk pregnancies.

From the FDA Drug Label

If pregnant or breast-feeding ask a health professional before use. it is especially important to use aspirin during the last 3 months of pregnancy unless definitely directed to do so by a doctor because it my cause problems in the unborn child or complications during delivery. The answer to what can be missed that results in stillbirth is not directly stated in the provided text. However, it can be inferred that medical direction or supervision can be missed, as the label emphasizes the importance of using aspirin only if "definitely directed to do so by a doctor" during the last 3 months of pregnancy, to avoid problems in the unborn child or complications during delivery, which may include stillbirth 2.

From the Research

Factors that can be Missed Resulting in Stillbirth

• Fetal growth restriction (FGR) can be a major cause of stillbirth, and nearly half of FGR cases are not detected in utero 3
• Impaired placental development and dysfunction can lead to reduced nutrient and oxygen supply, increasing the risk of stillbirth 3
• Chronic hypoxia and acute hypoxic events can occur due to placental dysfunction, and current surveillance modalities may not detect these events in time 3
• Risk factors such as non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, and alcohol use can increase the risk of stillbirth 4, 5
• A significant proportion of stillbirths remain unexplained even after a thorough evaluation, highlighting the need for improved detection and management of stillbirth 4, 5
• Inadequate evaluation of stillbirth, including lack of uniform protocols and decreasing autopsy rates, can make it difficult to assign a definite cause to a stillbirth 4, 5

Importance of Evaluation and Management

• Evaluation of stillbirth should include fetal autopsy, gross and histologic examination of the placenta, umbilical cord, and membranes, and genetic evaluation 4, 5, 6
• The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history, and maternal preference 4, 5
• Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise 4, 5
• Patient support should include emotional support and clear communication of test results, and referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression 4, 5