Ep 139: Stillbirth

Young couple visiting old male doctor

Today’s episode is about stillbirth. This is a difficult topic but I’ve actually had several people reach out to me about it. I see stillbirths maybe a handful of times a year, so it’s not extremely common, but common enough that it’s important to talk about.

Stillbirth rates have been decreasing over recent decades. This is surely due in part to advances in medical care, however prenatal care only accounts for a fraction of the causes of stillbirth. In fact, over a quarter of stillbirths are unexplained. The factors that we can pinpoint are not necessarily straight-forward. Of course age and overall health going into pregnancy are important determinants, but one of the biggest factors is actually being black. Episode 117 on Maternal Morbidity and Mortality goes into some of the statistics on the dangers of being black and giving birth in the American medical system.

There are some trends we can look at, such as when in pregnancy a stillbirth is most likely to occur or which medical conditions can contribute, but ultimately there is no reliable way to predict stillbirth and proper prenatal care plus identifying and treating any conditions promptly is the best we can do. Not all stillbirths can be prevented but there are a lot of common sense measures moms can take.

In this Episode, You’ll Learn About:

  • What is the definition of stillbirth
  • How common is it
  • When in pregnancy is stillbirth most likely to occur
  • What are the risk factors
  • How does race factor into stillbirth rates
  • What are the most common causes
  • What are some strategies for prevention

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Ep 139: Stillbirth

Nicole: Trigger warning: in today's episode, I'm talking about stillbirth. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello there. Welcome to another episode of the podcast. This is episode number 139. Thank you for being here with me today. So today's episode is about stillbirth, and I know that this is a difficult topic, but I've actually had several people reach out to me about it, both asking some general information, as well as some folks who have unfortunately experienced stillbirth and wanting to know how to move forward with another pregnancy. So in this episode of the podcast, you're going to learn about stillbirth. You'll learn the definition of stillbirth, the incidence, which is how frequently it happens, uh, risk factors for stillbirth, what causes stillbirth- spoiler alert most of the time we actually don't know what causes stillbirth and then some strategies to prevent a first stillbirth as well as a recurrent stillbirth. All right, now, before we get into the episode, I have a couple of really important announcements.

Nicole: Number one, I want to learn more about you who is listening to this podcast. So I have created this super short audience survey for you to take. It's a drnicolerankins.com/survey. It's not that many questions. Most of them, you can click on really quickly and get through the survey in just a few minutes. As a gift for completing the survey, I am offering four $50 Amazon gift cards. So just go to drnicolerankins.com/survey. You have to complete the survey by November 30th in order to be entered to win one of those gift cards. But again, please fill out that audience survey its drnicolerankins.com/survey. I would really, really appreciate it. Now, the second important announcement is that at the end of this call at the end of the month, actually on November 22nd, I am doing a brand new class it's called How To Make A Birth Plan The Right Way. I've held back in my language and saying, you know, the way that anyone or anyone does something is wrong.

Nicole: Um, I never wanted to make anyone feel like they were doing something bad or it wasn't right. And by that, I mean, lots of people put information out there about birth plan templates and forms and things like that. And I had to realize that I can separate that process from the person. So I also realized that I feel like I've held back a little bit on talking about some of the problems in our system. Obviously it's something that I have talked about before, but I do tread this sort of line where I still work as a physician and I don't- and so I have to work with other physicians, and I don't want to fearmonger and paint like this horrible bleak picture of the obstetric care system in the United States, because there are many, many great providers out there, but I need to talk about those problems and go at it a little bit harder.

Nicole: I need to go at it a bit harder with the way some of the things that folks are doing things are wrong and I can separate the process from the person. So I say all that to say, is that in this brand new class, I am going all in, really pulling back the curtain on some things you need to do in order to have a birth plan and make it the right way. Now, this is actually going to be a paid class. There's going to be a lot of added content. I'm completely redoing the class that, um, is currently free. However, before it becomes a paid class, I'm going to offer it for free. On Monday, November 22nd, I will do it live twice that day. And I will also release it as a private podcast. So go to drnicolerankins.com/register. You can sign up and you have to sign up in order to get the replay video, and also to get that private podcast version of the course of the class rather, drnicole rankins.com/register. I am super excited to offer this be the really, really important and powerful new class, How To Make A Birth Plan The Right Way. Again, this drnicolerankins.com/register. I will see you there on November 22nd. All right. So let's get into this episode about stillbirth. So the first thing we want to talk about is what exactly is stillbirth? What defines a stillbirth? So the United States National Center for Health Statistics, as part of the CDC, defines stillbirth as a fetal death or loss that occurs after 20 weeks of pregnancy and either before or during delivery. So after 20 weeks and before, or during delivery, it's further divided into early stillbirth, which is considered to be between 20 and 27 completed weeks of pregnancy and late stillbirth, which is 28 to 36 completed weeks of pregnancy. And then term stillbirth, which is 37 weeks or more would be a term stillbirth.

Nicole: Now these divisions of, of, um, early, late in term are a little bit arbitrary, but it does help with some comparison for international data. It also separates out those early stillbirths, which are a little bit different, and they're actually harder to prevent from those late stillbirths. So that's why those category categorizations exist, but they are a little bit arbitrary. There also is some inconsistency in the way stillbirth is reported. States have varying reporting requirements regarding fetal deaths. Actually, it's not a uniform character's characterization of how fetal death is defined. Now, most states do report fetal deaths that are greater than 20 weeks or 350 grams for the birth weight, if the gestational age is unknown. So for example, someone has a fetal death, they hadn't gotten prenatal care, or they hadn't had an ultrasound yet. If the baby at birth weighs more than 300 or 50, more than 350 grams, and that would be classified as a fetal death as well.

Nicole: Okay. So how common is stillbirth? So stillbirth is not common, but it's also not uncommon. And I say that in the sense that it's not something that I see frequently, but I do see it a handful of times per year, I would say. So, um, some harder data and numbers behind that. The, the rate of stillbirth estimate is roughly six per 1000 live births and stillbirths. So to pull that out into, in terms of how many births happen in the U S each year, so six per 1000 live births and stillbirths, there are roughly 4 million births each year. So when you look at six per 1000, that actually adds up to 24,000 stillbirths a year. And that's a pretty big number when you spread it across all of the OB providers in the United States, you know, individually, we each don't see a lot of stillbirths, but again, not a small amount of stillbirths, but 24,000 is a big number.

Nicole: Now, thankfully, that rate has been decreasing over several decades. Um, it has been a little bit steady in the last few years, but overall has been decreasing. And I think that's part of that is due to better prenatal care. And I'll talk about some of those prevention strategies in just a bit. Now, in terms of when stillbirths happen about 50% of stillbirths will occur between 20 and 27 weeks. And even most of those will be between 20 and 23 weeks. So half of stillbirths are in that earlier part of pregnancy, the other 50% are at greater than 28 weeks. And when you break it down after 28 weeks, um, the rates are higher between 28 to 31 weeks. And then it's lower between 32 and 36 weeks, and then lower still after 37 weeks. So again, most stillbirths happen earlier in pregnancy and the risk of stillbirth decreases as you get closer to term. So what are some risk factors for stillbirth? I'm going to start off with some maternal risk factors, and we're going to start first with what are called social or demographic factors. One of the biggest factors is being black.

Nicole: The fetal mortality rate, which is a slightly different way of talking about stillbirth, is highest for a non-Hispanic black women. That's 10.53 deaths per 1000 live births. And it's lowest for non-Hispanic white women, 4.88 deaths per 1000 live births and fetal deaths. Some of this is thought to be due to a lack of access to quality care. However, black women still experience much higher rates of stillbirth, even when they have adequate access to prenatal care. Um, of course, racism plays a factor in this as well. There is some contribution of perhaps being in poor health before you get to pregnancy, having lower income and stress, also higher rates of infection, but many of those things are also tied back to racism as a contributing factor.

Nicole: All right, moving on younger and older age are also risk factors for stillbirth. The stillbirth rate is lowest for women who are between 25 to 34, it's higher for teenage women or teenage girls. I should say, actually teenagers that are at a higher risk for a lot of pregnancy complications. Um, younger and older spectrums put you at risk for pregnancy complications. So higher for teenagers, also higher for women who are over 35 and then even a little higher still for women who are over 40. And sometimes people related to older age, well, maybe people are more likely to have health problems like hypertension and diabetes and, and chromosome problems. But actually when you adjust for those things, older age by itself is an independent risk factor for stillbirth. Okay. Some other factors, unmarried status, not being married is a risk factor for, for stillbirth. The risk for unmarried non-Hispanic white women was 44% higher than higher than for married non-Hispanic white women. That difference is smaller for black women. It's about a 14% difference and smaller for Hispanic women. It's about 11% difference. I think some of that may be due to culturally in Hispanic cultures and, and, and black cultures, and may be more likely that people cohabitate and have long-term partnerships, but not necessarily be married.

Nicole: Okay. When we look at parity, meaning how many children that you've had, there is an increased risk for stillbirth, for those who have never had a child before. So for your first birth, and then also once you've had three or more children that increase risk of stillbirth is there as well. Okay. Also having had a bad outcome and a pregnancy before, and I shouldn't say bad, I should say maybe an adverse outcome in pregnancy before, if you had a previous preterm birth, if you had a previous small baby, those things can put you at increased risk for having a stillbirth in a subsequent pregnancy. And that risk increases as the gestational age of the preterm birth decreases. So the earlier you had a preterm baby, then the higher your risk of having a stillbirth in a future pregnancy. Similarly, if your baby was very small, then the smaller your baby was then the higher, the risk of stillbirth with the another subsequent pregnancy.

Nicole: And then of course, one of the highest risk factors for stillbirth is having had a previous stillbirth. So women who had a stillbirth in their first pregnancy are three times more likely to experience a stillbirth in their second pregnancy compared with women who had a live birth in their first pregnancy and the risk of stillbirth in a subsequent pregnancy is estimated to be about nine to 20 per 1000 live births and stillbirths. And that's up from a background rate of about six per 1000 live births and stillbirths. Now, one thing that is a bit controversial in terms of the risk of stillbirth is actually cesarean birth. Um, there has been an association actually between unexplained stillbirth and a prior cesarean birth that has been observed in a few small studies. Um, it's theoretically possible that scar tissue from a previous cesarean birth might lead to abnormal placenta function.

Nicole: And that can lead to stillbirth. Again, this is controversial and not a lot of data to support that, but I thought I would mention it as the information is out there. Okay. Let's talk about some medical risk factors for stillbirth. And as I go through these numbers, I want you to remember that the overall rate background rate, when you put everyone together who has stillbirth, that rate is about six per 1000. And when you look specifically at low risk pregnancies, that number is about one per 1000 or less or less actually. Now keep in mind, some people have multiple risk factors. And the reason that I'm talking about this in a little bit more detail is because often labor induction is given as a reason to prevent stillbirth in specific populations. And you're going to hear like, if the overall rate is six per 1000, you're going to hear some of the numbers that I say for conditions like diabetes and hypertension.

Nicole: Don't feel like they're necessarily that far off from that, but keep in mind that often people have multiple factors and when you combine things together, it really can increase the risk. Okay. So let's talk about diabetes. Um, women with diabetes are definitely at an increased risk of stillbirth, particularly near term, for those who are treated with just diet alone. The risk is about six to 10 per 1000 live births and stillbirths. And if you're treated with insulin, then that risk is estimated to be between six to 35 per 1000. So on the low end, it's about the same as that background rate. That includes everybody, but it can certainly get to be quite high if you're on insulin. So this is why we typically recommend labor induction for those with diabetes. We believe that babies have died diabetic mothers are at increased risk for stillbirth because when the baby has high blood sugar, then it increases their insulin levels.

Nicole: And that will increase the oxygen consumption for the baby. And if there is not enough oxygen available, because there are issues with the placenta, then that can cause stillbirth. Also sometimes moms with diabetes have vascular disease in their blood vessels, and that can lead to reduce blood flow through the placenta. And that can also lead to stillbirth. Okay. So let's talk about hypertensive disorders and I'm going to talk about chronic hypertension, which is hypertension that existed prior to pregnancy, preeclampsia, which develops during pregnancy and then preeclampsia with severe features, which is when you have and organ dam damage from preeclampsia. Those are all the spectrum of conditions, but I'm going to talk about each one separately because the numbers are slightly different. So chronic hypertension, if you had high blood pressure before pregnancy, then the risk of stillbirth is about six to 25 per 1000.

Nicole: If you have preeclampsia developed preeclampsia and it doesn't have severe features and severe features are things like headache, your blood pressure is really high 160 over 110. Um, it involves your liver and involves your kidneys. Those are the things that make it severe. So if you don't have those severe features, your risk of stillbirth is between nine to 51 per 1000 and then preeclampsia with those severe features, then it goes up even more to 12 to 29 per 1000. And that's per 1000 live births and stillbirths. We believe that this is mostly due to placenta insufficiency where the blood pressure issues affect the ability of the placenta to nourish the baby. Another risk factor for stillbirth is obesity and the stillbirth rate, um, among folks who are obese is estimated to be between 13 to 18 per 1000 live births and stillbirths.

Nicole: And that is an independent risk factor. Um, just obesity alone. Often again, sometimes obesity may go along with high blood pressure or diabetes, so that can further increase the risk. So those are the more common areas or risk factors for stillbirth. Some less common ones are substance abuse. Smoking in particular definitely increases the risk of stillbirth. And the more you smoke, the higher, the risk of stillbirth, if you smoke more than 10 cigarettes a day, then your risk of stillbirth is two to threefold. Actually nicotine replacement can help women stop smoking and doesn't actually appear to increase the risk for stillbirth compared with non-smoking women. So, um, that's a really important factor is a nicotine replacement to help reduce that risk. And some other less common things that are risk factor for stillbirth are Antifa antiphospholipid antibody syndrome. I'm not going to go into that in detail, but if you know that you have it, you know that you have it.

Nicole: Um, there are some isolated what's called inherited thrombophilias. These are actually not an increased risk factor for stillbirth. So something like factor five Leiden, prothrombim gene mutation, protein S, protein C, deficiency antithrombin deficiency, none of those actually increase your risk for stillbirth. Antiphospholipid antibody syndrome is the only one of that sort of thrombophilia area that can increase your risk of stillbirth. Some other conditions that will increase your risk of stillbirth are lupus, kidney disease, low thyroid, high thyroid. So hypothyroidism, hyperthyroidism, also sleep disorders in pregnancy like sleep apnea will increase your risk of stillbirth. Assisted reproductive technology is, will slightly increase the risk of stillbirth. And then, um, also cholestasis of pregnancy can increase the risk of stillbirth to about 12 to 30 per 1000 live births. So that's why we recommend coli induction. When people have cholestasis of pregnancy, we had a birth story episode recently where someone was induced for that.

Nicole: Okay. So those were maternal factors. Some fetal factors are multiple gestation. Um, mortality increases with the increasing number of babies. It's 2.5 higher for twins and singletons, five fold higher risk for triplets or more than the Singleton stillbirth rate. We believe that this is due to complications related to the placenta, and also the potential of the umbilical cords. Other fetal factors, stillbirth is more common among male than female babies. It's just slightly higher. The rate for males was 6.23 stillbirths per 1000 births versus 5.74 stillbirth per 1000 for females. Also post term pregnancy, and that is greater than 42 weeks, um, the rate of stillbirth is about twice the rate at 37 weeks, and then it's even higher at 43 weeks. The absolute number is about 14 to 40 per 1000 live births and stillbirths at 42 weeks. And I'm going to talk about our prevention strategy, which is often, sometimes mentioned of labor induction to prevent stillbirth, but really that risk doesn't go up really high until after 42 weeks.

Nicole: All right. So let's talk about what causes stillbirth. Well, stillbirth in general, we believe is a mix of what happens with mom, what happens with the baby and what happens with the placenta. Um, all of those can contribute in varying ways to stillbirth. Unfortunately, however, it can be challenging to, to figure out how much each one of those contributes, what each one of those contributes and how they came together in order to result in a stillbirth. So for that reason, roughly twenty-five or up to 60% of stillbirths are actually unexplained. And that means we can't attribute it to any specific fetal placental or maternal factor. There's just not enough information for us to make a decision definitively about what led to a stillbirth. So again, 25 to 60% will be unexplained. They're more likely to be unexplained if it's a stillbirth that occurs near term, as opposed to a stillbirth that occurs earlier in gestation, about two thirds of unexplained, fetal deaths that occur after 35 weeks of gestation in one study.

Nicole: Also some of the reason why things are unexplained is because some of the information that we can get from examining the baby in autopsy, we don't have, because not everyone agrees to have an autopsy done of their baby. So some of it is that we don't have that information, but still in general, most stillbirths are unexplained and we don't know why. Okay. So when we do know the reasons about 15 to 20% of stillbirths, that baby will have a major malformation. And though that may be something like anencephaly, which is missing part of the brain, there's some other brain conditions that can happen. Like encephalocele, hydrocephaly, there's some heart conditions that can be associated with stillbirth, like hypoplastic left heart, um, having what's called a single cardiac ventricle. Um, also some gastrointestinal conditions can be associated with stillbirth like gastroschisis or omphalocele. So roughly 15 to 20% of babies who are stillborn have a major malformation, like one of those. Another big contributor to stillbirth is fetal growth restriction, meaning the baby is just not growing well.

Nicole: And the rate of stillbirth among babies that have fetal growth restriction is estimated to be between 10 up to 47 per 1000 live births and stillbirths. And it increases with increasing severity of growth restriction. We think that this is thought to be due to something going wrong with the placenta and that's affecting the ability of the baby to grow. So this is why we usually recommend labor and Doug not usually always recommend labor induction when a baby is not growing well, particularly once the baby gets towards term. Infection accounts for about 10 to 25% of stillbirths in what's called a high-income country like the United States, um, that is usually usually related to a preterm birth, more so than a term birth. Usually it comes when there is rupture of membranes early, and then the baby subsequently passes away after that near the limits of viability.

Nicole: So around that 23, 24 week mark placenta problems can also lead to stillbirth. Placenta abruption is a big contributor contributed about 10 to 20% of all stillbirths. Placenta abruption is when the placenta Premus prematurely separates away from the wall of the uterus. When that happens, the baby's life line blood supply oxygen supply is going to be cut off. That risk of stillbirth is highest when more than 50% of the placenta surface has separated because you can actually have small placenta abruptions and the placenta is able to still nourish the baby. Its when you have a big placenta abruption that is going to put you at risk for stillbirth. There also some rare things like structural abnormalities in the placenta, vascular malformations, um, very, very rarely like abnormal growths or things in the placenta that can lead to stillbirth as well.

Nicole: One of the more common things that is cited as a reason for stillbirth in the third trimester is umbilical cord complications, like a cord wrapped around a baby's neck or a cord is, um, twisted or cord has, what's called a stricture in it where there's a thin area, or it has a single umbilical artery. However, although this is often cited as a reason for third trimester stillbirth in particular, um, actually things like nuchal cord is like the core being wrapped around the baby's neck, knots in the cord. Those are actually pretty common, very, very common actually, uh, happen in up to 30% of pregnancies at term. And constriction of the cord is very that's severe enough to actually kill a baby is actually very, very rare. So because of that, we really should only attribute the cause of death to a nuchal cord or a knot in the court only after making sure other causes have been properly and fully evaluated and ruled out as the reason for the stillbirth.

Nicole: Okay. And then some other less common reasons for stillbirth hydrops Fatalis, hydrops Fatalis is when there's abnormal fluid that collects in spaces in the baby, whether it's in the abdominal cavity, that's ascites, whether it's in the lungs, that's pleural effusions, around the heart, that's pericardial effusions that can lead to stillbirth. That is very rare. Also fetal arrhythmia. So abnormalities in the baby's heart rate. Um, if that's unrecognized that can lead to stillbirth, that also is very rare, um, fetal maternal hemorrhage, meaning that the baby's blood supply leaks into mom's blood supply, um, that happens at about 5% of stillbirths. That is very rare. There's an increased risk of that happening after some sort of trauma. So that's why we monitor for that after maternal trauma. For example, if you were in a bad car accident, if you fell and directly hit your belly, then those are reasons or increased risk for fetal maternal hemorrhage, but that's rare.

Nicole: And then finally, genetic abnormalities are actually a rare cause of stillbirth. Um, because most genetic abnormalities are actually lethal. Uh, most people will have a miscarriage. There are some genetic abnormalities like trisomy 21, 18 13 monosomy X, which is also Turner syndrome, um, can lead to an increase risk of fetal death, but many of those result in live births. So again, most of the time stillbirth is not related to a genetic abnormality because those pregnancies are going to end in the first trimester. So let's finish up with ways to prevent stillbirth. Now, unfortunately, there is no reliable way to predict stillbirth. There's no tests that can be done. There's no equations, there's no models, really nothing that we can do to reliably predict whether or not someone is going to have a stillbirth. We do know there are some things that increase risk factors for stillbirth, but we can't reliably reliably predict it.

Nicole: So I'm going to talk about this in terms of first preventing the first stillbirth. And then I'll talk about preventing recurrent stillbirth. So preventing the first stillbirth involves things that we actually pretty routinely do in prenatal care. They have evolved to be a routine part of prenatal care. So those things include having a skilled attendant at birth, having comprehensive emergency services available for obstetric care. And this one is one that is going to sound unusual, but detection and treatment of syphilis. Syphilis can actually increase the risk of stillbirth. That's one of the reasons why, um, testing for syphilis is actually part of prenatal labs and required by law in most states. It's very uncommon these days, but we still test for it. It does still show up from time to time. Also detecting and managing hypertensive disorders, preconception folic acid fortification, in order to reduce the risk of neural tube defects, and then subsequent stillbirth. Of course, detecting and managing diabetes in pregnancy detecting and managing growth restriction in pregnancy, and then establishing an accurate due date so that we can identify pregnancies that are post-term and post-term is greater than 42 weeks, and then offering induction in those situations. So really preventing that first stillbirth revolves around just optimizing and really honing on honing in on doing those things. Actually studies in high income countries like the U S, show that it's actually sub optimal medical care, that accounts for anywhere from 10, even up to 60% of stillbirth. So we really need to be making sure that we're doing all of those things that we mentioned and offering the best possible prenatal care available.

Nicole: Another thing that's really important is addressing modifiable risk factors like reducing weight, um, smoking cessation, avoiding alcohol or drugs. This really lends to the importance of inter conception care. Its one of the things that we have done a disastrously poor job in the United States. It's why, um, laws and Medicaid expansion has been pushed in order to provide care for at least up to a year postpartum. It used to be like six weeks postpartum because we're understanding that what happens in between pregnancies has a huge effect on what happens during pregnancy and in some ways you're too late when you're addressing prac factors in pregnancy, you do much better when you address factors before pregnancy. So addressing modifiable risk factors is really important. Also things like limiting the number of embryos that are transferred during IVF in order to reduce the number of babies to multiple gestation will reduce stillbirth.

Nicole: I'm doing ugh I'm a little bit tongue tied today, doing prenatal screening and then diagnostic testing and offering the option of ending any pregnancies that have any major congenital abnormalities that we know are associated with fetal death. Even if the baby is born alive, like anencephaly, that will slightly decrease the risk of stillbirth, but not by much now, something that is often touted as a way to help reduce stillbirth is monitoring fetal movement with kick counts. And unfortunately studies have not shown that monitoring fetal movements with kick counts have necessarily decreased the risk of stillbirth, I actually did a podcast episode on this feeling your baby move it's episode 16, it'll be hard for you to get to through, um, the podcast players, because I think most of them only show the last 100 episodes, but you can get to it on my website at drnicolerankins.com/episode16. If you want to know more details about that, I'm certainly not saying that kick counts don't have value because they do, but the data shows that, or there's not a lot of strong data that shows that monitoring kick counts helps.

Nicole: Okay. Now, something that often gets talked about, especially among my obstetric colleagues is induction for low risk women at term, in order to reduce the risk of stillbirth. Now, very clearly the risk of stillbirth is much higher after 42 weeks. However, in low risk pregnancies, the risk of stillbirth at term is actually pretty low it's 0.14. And this is one of the largest studies that that was done that looked at about 15 million pregnancies and 17,000 stillbirths. The risk of stillbirth at 39 weeks was 0.14 per 1000 pregnancies, 0.33 at 40 weeks, 0.8 at 41 weeks and 0.88 at 42 weeks. So among strictly low risk pregnancies, the risk of stillbirth is low. Furthermore in what's called the arrive trial, which has been talked about a lot in terms of labor induction, where it was planned induction of labor at 39 weeks to 39 weeks and four days versus expected management.

Nicole: Although that trial did show a decrease in the rate of cesarean birth by a small amount, it did not show a reduction in any adverse perinatal outcomes, including stillbirth. So that largest randomized control trial did not show a benefit for stillbirth in re in relation to induction for low risk women, really induction as a benefit or as a reason to reduce stillbirth. We know that its been official 42 weeks or later, but at between 39 and 42 weeks, it's only going to incur minimal benefit when I was in practice in the office. Right now, or for the foreseeable future forever, like I'm never going back to the office because I don't like being in the office. I work as a hospitalist. When I was in the office, I don't do office practice anymore. I only work in the hospital as a hospitalist, but when I was in the office in terms of offering induction as a strategy for reducing the risk of stillbirth, I wouldn't offer it until 41 weeks.

Nicole: So I would offer induction or start to do testing at 41 weeks and then offer it from there as a risk factor for reducing stillbirth. It does not significantly reduce the risk of stillbirth before forty one, forty two weeks. Okay. Finally, let's talk about strategies for preventing a recurrent stillbirth. One of the most important things is to try as best that we can to figure out what caused the first stillbirth to see if it's anything that can be addressed. And that is done through a maternal evaluation, where there are some lab studies and things that we can check. I'm not going to go through what all of those are. Um, also an evaluation of the baby to really look at the baby and actually an autopsy, if people agree to it, is helpful as well as genetic testing. And then finally a thorough evaluation of the placenta, preferably by a pathologist. Pathologists are the ones who look at the placenta.

Nicole: So preferably by a pathologist who is experienced and likes to look at the placenta, those are the things that we really want to do. So first try to figure out what caused the first stillbirth. Some other things that are important would be optimizing medical status. So if you had diabetes, making sure your diabetes under good control, if you had thyroid disease, making sure your thyroid is under good control, hypertension, making sure blood pressure is under good control, of course, discussing smoking cessation and trying to optimize weight. Now, there actually is no defined, like optimal time in between getting pregnant again after a stillbirth. So really what we advise women is to just delay getting pregnant until they feel like they have gotten some closure from the previous stillbirth and, you know, feel comfortable getting pregnant. Again, typically that's going to take between six to 12 months.

Nicole: Also keep in mind that women are more vulnerable to post-traumatic stress in the next pregnancy. If the conception occurs very soon after the loss, also more vulnerable to stress during the subsequent pregnancy, if they deliver the next baby around the same time as their first infants death. Now, as far as management during the pregnancy, definitely have more ultrasounds, tend to have at least three ultrasounds during the pregnancy, if not more to monitor the baby's growth appropriately, especially if the prior stillbirth was related to growth. So definitely expect that you would have more ultrasounds during pregnancy also expect that you would have what's called antepartum fetal monitoring. So that's when twice a week you're put on the monitoring and put on a monitor and check the baby's heart rate. Sometimes also check the baby's fluid as well. And that's definitely going to start at around 32 weeks.

Nicole: Uh, if you had a stillbirth at greater than 32 weeks, typically we start the monitoring at 32 weeks. It's not quite as clear when to start monitoring if you had a stillbirth before 32 weeks, because we just don't have a lot of data that, um, testing before 32 weeks is helpful. But if you had a term stillbirth, then you can definitely expect that you're going to have more closer monitoring with those twice a week or sometimes once a week. So if it could be once a week, but once or twice a week, what's called MSTs, sometimes check the fluid, and you're going to have more frequent ultrasounds. Now, another thing that we also may do is low dose aspirin. We know that low dose aspirin definitely reduces the risk of stillbirth or reduces the risk of developing preeclampsia, which we know can be associated with stillbirth.

Nicole: And there is some limited evidence that even outside of reducing preeclampsia that low dose aspirin may also reduce the risk of stillbirth. The evidence isn't strong enough that we need to routinely recommend it. But low-dose aspirin is definitely going to help for women who, who are at high risk of developing preeclampsia and things that can put you at high risk are being obese, being African-American, just those two things alone are reasonable, according to the US preventative services taskforce, to offer you a low-dose aspirin for preeclampsia. So it actually doesn't take much for folks to reach the criteria to get that. And then the final thing is timing of delivery. Um, it can be really stressful when you get to be close to the time when the stillbirth occurred. I mean, it can have a lot of psychological trauma and, and difficulty. However, we really don't recommend, there's not a lot of evidence to recommend scheduling induction before 39 completed weeks.

Nicole: Um, if the stillbirth was unexplained and the current pregnancy is uncomplicated. So if the testing looks good, the baby is growing well, then we really don't need to do induction before 39 weeks. However, in some circumstances for the psychological benefit of the mother, we may need to induce earlier than that and weigh the risk and benefits. Typically would definitely not be before 37 weeks, but sometimes there may be 38 weeks. Um, but there really isn't a defined reason or studies that show that you have to induce before 39 weeks. All right. So just to recap, stillbirth is defined as a loss after 20 weeks of pregnancy, the stillbirth rate in the US is about six deaths per 1000 live births and fetal deaths that accounts or amounts to about 24,000 stillbirths in the US each year. Some risk factors for stillbirth are black race, older maternal age, younger maternal age, obesity, multiple gestation, medical problems like hypertension, diabetes, low thyroid, high thyroid, um, smoking, pregnancy complications like growth restriction. Stillbirth can be contributed to or caused by maternal fetal and placental factors.

Nicole: However, 25 to 60% of stillbirths are actually unexplained. Unfortunately we don't have a great way to predict stillbirth some strategies to prevent stillbirth revolve around really just making sure we're providing excellent prenatal care and identifying and treating any conditions promptly. Induction will definitely lower the risk of stillbirth in pregnancies with complication. However, induction will not lower the risk of stillbirth in low risk pregnancies, um, before 42 weeks. And then finally, if you've had a previous stillbirth, you definitely want to optimize your health in between pregnancies with the next pregnancy, you should get more frequent ultrasound exams and antenatal testing, low dose aspirin also may be an option for you, induction before 39 weeks is not recommended, but it may be in order for your own mental health. All right. So there you have it. Be sure to subscribe to the podcast in Apple Podcasts or listening to me right now, leave an honest review on Apple Podcast.

Nicole: If you're so inclined, I do appreciate it. Don't forget to fill out that audience survey. It's drnicolerankins.com/survey. You can win one of four $50 Amazon gift cards. If you fill out the survey by November 30th and be sure to register for this amazing new class that I've created, How To Make A Birth Plan The Right Way. That's drnicolerankins.com/register. I'll be doing that class live on November 22nd. So that's it for this episode do come on back next week. And until then, I wish you a beautiful pregnancy and birth. Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast. Head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class, on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.

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