Causes
In approximately 50% of intrauterine fetal deaths, the exact cause cannot be definitively determined. However, when identifiable, the most common underlying factors include placental or umbilical cord abnormalities, fetal developmental anomalies, infections, fetal growth restriction, and maternal conditions such as diabetes, hypertension, thyroid disease, and autoimmune disorders. Other potential contributors include accidents or trauma during pregnancy.
Additional risk factors encompass a history of previous intrauterine fetal loss, low socioeconomic status, maternal obesity, advanced maternal age, smoking, use of cocaine or other illicit substances, certain medications, radiation exposure, previous cesarean section, and post-term pregnancy.
The recurrence risk is approximately 8–10%. Women with a prior stillbirth face an increased likelihood of placental abruption, preterm birth, low birth weight, and cesarean delivery in subsequent pregnancies. Therefore, emotional support for grieving families, comprehensive counseling to assess recurrence risk, and systematic evaluation with individualized treatment planning are essential components of care.
Clinical Approach
The most critical step in identifying the cause of stillbirth is a postmortem examination (autopsy). When performed by a trained and experienced pathologist, a detailed autopsy includes systematic assessment of the fetus, placenta, and umbilical cord, with investigations for possible infections, genetic or metabolic abnormalities, and structural defects.
Given the elevated recurrence risk, close monitoring in subsequent pregnancies is of paramount importance.
Biochemical biomarkers are also used to help determine the risk of fetal demise. Abnormal levels of PAPP-A, AFP, and hCG detected in first- and second-trimester screening tests may indicate an increased likelihood of later complications.
In particular, low PAPP-A levels are often associated with preterm birth and low birth weight. Consequently, in patients with a history of stillbirth, screening results are interpreted with heightened vigilance. If any suspicious findings arise, the expectant mother is scheduled for more frequent evaluations, and fetal well-being is monitored continuously through ultrasound and laboratory assessments throughout pregnancy.
Case Example
A 30-year-old woman presented to our center with a history of intrauterine fetal demise at 28 weeks in her previous pregnancy. Her family history was notable for diabetes mellitus. At the initial evaluation, the patient underwent a 50-gram oral glucose tolerance test, as well as TSH, T3, and T4 measurements to rule out diabetes and thyroid disorders.
At 12 weeks of gestation, an ultrasound assessment evaluated nuchal translucency, nasal bone presence, and ductus venosus blood flow. Concurrently, maternal blood was tested for first-trimester screening markers (PAPP-A and hCG). PAPP-A levels were found to be low, prompting closer ultrasound monitoring of cervical length and fetal growth parameters to evaluate the risk of preterm birth.
The family received comprehensive counseling and psychological support throughout the process. The care plan emphasized frequent follow-up, early detection of complications, and multidisciplinary management aimed at achieving a successful pregnancy outcome.
