Zupan V, Gonzalez P, Lacaze-Masmonteil T, et al: Periventricular leukomalacia: risk factors revisited. Dev Med Child NeuroIt38:1061, 1996
DEFINITION OF FETAL MORTALITY ................. 645
CAUSES OF FETAL DEATH ......................... 645
RISK FACTORS ....................................... 646
EVALUATION OF THE STILLBORN FETUS .............. 646
PSYCHOLOGICAL ASPECTS. . . . . . . . . . . . . . . . . . . . . . . 648
PRIOR STILLBIRTH .............................. 648
CHANGES IN STILLBIRTH RATES ................... 649
In the latter months of pregnancy, the disappearance of oetal movements usualy directs the attention of the patient to the possibiliy of oetal death. The diagnosis of this condition, however, can be considered absolute ony after repeated examinations, when one has ailed to hear the oetal heart or perceive the movements of the child.
-J. Whitridge Williams (1903)
In Williams' time, absolute documentation of fetal death was frustrating for both patient and obstetrician. Now, sonography provides prompt conirmation, which allows expedient induction of labor and delivery. However, epidemiologically, defining and reporting fetal deaths was-and continues to be-a challenge. In response, eforts to standardize the deinition of stillbirth and analyze varying reports for application into clinical practice and public health policy are now being emphasized. Moreover, stillbirth research and prevention within the United States and abroad has expanded. Global public health eforts were stimulated in part by a six-part series in The Lancet.
his compilation was considered a call to action after the recognition that an estimated 2.65 million stillbirths occur each year and that 98 percent of stillborn fetuses are from low-and middle-income countries (The Lancei s Stillbirth Series Steering Committee, 201 la-). Unfortunately, progress in improving these rates has been slow, as outlined in The Lancet's subsequent five-part progress report, which emphasized the need for dedicated leadership, measured efects of interventions, and investigation into knowledge gaps (The Lancets Ending Preventable Stillbirths Series Study Group, 20 l6a-e).
In the United States, an estimated 1 million fetal losses are reported each year, and most occur before 20 weeks' gestation. Fetal mortality data from the National Vital Statistics system are usually presented for fetal deaths after the 20-week threshold (MacDorman, 2015). Using this definition, numbers of fetal deaths in the United States in 2013 slightly surpassed numbers of infant deaths (Fig. 35-1). As shown in Figure 35-2, 24.9% Undereage 28days 33.8% 16.1%
FIGURE 35-1 Percent distribution of fetal deaths at 20 weeks' gestation or more and of infant deaths: United States, 2013. (Data from MacDorman MF, Reddy UM, Silver RM: Trends in stillbirth by gestational age in the United States, 2006-201o2, Obstet Gynecol. 2015 Dec;126(6):1146-1150.) 0.7 0.6 0.5 ) 0.4�: 0.3 0.2 0.1 0.0 weeks of gestation: United States, 2013. (Redrawn from MacDorman
MF, Reddy UM, Silver RM: Trends in stillbirth by gestational age in the United States, 2006-2012, Obstet Gynecol. 2015 Dec;126(6): 1146-1o150.) fetal death rates are highest at the earliest and latest gestational ages, which suggests etiological diferences.