Reducing Stillbirth Risk in a Setting of Incomplete Understanding

Stillbirth remains a persistent obstetric challenge in the United States, with approximately 21,000 cases each year and little change in the rate over the past two decades.

In a recent article published in JAMA Insights, Cleveland Clinic maternal-fetal medicine specialists Adina R. Kern-Goldberger, MD, MPH, and Jennifer L. Bailit, MD, MPH, along with Uma M. Reddy, MD, MPH, Columbia University, review factors associated with stillbirth and outline opportunities to reduce risk.

“Preventing stillbirth remains a challenge, both because it can be difficult to identify which pregnancies are at highest risk and because we still do not fully understand why some stillbirths occur,” says Dr. Kern-Goldberger, first author. “At the same time, we know that up to about 25% of stillbirths are preventable. That creates opportunities to reduce risk through preconception counseling, prenatal care and appropriate antenatal surveillance.”

Background

Stillbirth, the authors note, is defined as death of a fetus at 20 or more weeks of gestation or weighing at least 350 g. Eighty-three percent occur antenatally and 17% occur during labor. No clear etiology is identified in as many as 40% of stillbirths.

Maternal factors associated with increased stillbirth risk include:

• chronic illness, such as diabetes and hypertensive disorders
• obesity
• multiple gestation
• tobacco and other substance use
• demographic factors, including Black race
• advanced maternal age, especially age 40 and older
• previous stillbirth

Placental and umbilical cord causes include:

• placental insufficiency
• placental abruption
• umbilical cord occlusion

A two-tiered strategy

All patients benefit from standard prenatal care that incorporates blood pressure monitoring and screening for gestational diabetes, with ultrasonography when abnormal fetal growth is suspected.

The authors also describe a two-tier prevention strategy for patients at higher risk.

First, clinicians can help patients reduce modifiable risks of stillbirth before and throughout pregnancy. Patients should be supported in efforts such as controlling high blood pressure, establishing glycemic control and eliminating tobacco and other substance use.

“Ideally, we are able to work with women before pregnancy or early in pregnancy to identify modifiable risk factors and optimize chronic conditions,” says Dr. Bailit. “We know that conditions such as hypertension and diabetes can increase the risk of stillbirth, and better management of those conditions may help reduce that risk.”

Second, patients at higher risk may be candidates for antenatal testing to identify potential problems. Nonstress tests and biophysical profiles can help assess fetal well-being and identify risksrelated to placental insufficiency. Doppler velocimetry of the umbilical artery may be performed in fetuses with growth restriction.

Evidence for some prevention tools is limited and overuse can lead to anxiety, unnecessary interventions and iatrogenic preterm birth. Clinicians and patients should consider risks and benefits and make decisions together.

“These can be difficult conversations, but they matter,” says Dr. Bailit. “Patients benefit when we are clear about what we know and are proactive about steps we can take to support a healthy pregnancy.”