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Robert M.

Silver, MD
The death of a formed fetus is one of the most emotionally devastating events for parents and
clinicians. With improved care for conditions such as RhD alloimmunization, diabetes, and
preeclampsia, the rate of fetal death in the United States decreased substantially in the mid
twentieth century. However, the past several decades have seen much greater reductions in
neonatal death rates than in fetal death rates. As such, fetal death remains a significant and
understudied problem that now accounts for almost 50% of all perinatal deaths. The availability
of prostaglandins has greatly facilitated delivery options for patients with fetal death. Risk factors
for fetal death include African American race, advanced maternal age, obesity, smoking, prior
fetal death, maternal diseases, and fetal growth impairment. There are numerous causes of fetal
death, including genetic conditions, infections, placental abnormalities, and fetalmaternal
hemorrhage. Many cases of fetal death do not undergo adequate evaluation for possible causes.
Perinatal autopsy and placental examination are perhaps the most valuable tests for the
evaluation of fetal death. Antenatal surveillance and emotional support are the mainstays of
subsequent pregnancy management. Outcomes may be improved in women with diabetes,
hypertension, red cell alloimmunization, and antiphospholipid syndrome. However, there is
considerable room for further reduction in the fetal death rate.
(Obstet Gynecol 2007;109:15367)

regnancy loss is one of the most common obstetric

complications, affecting over 30% of conceptions.1


Most of these occur early in gestation, are due to
problems with implantation and may not be clinically
apparent. However, 1215% of conceptions result in
clinically recognized pregnancy loss. The majority of
these are first trimester miscarriages and fewer than
five percent of pregnancies are lost after 10 weeks of
gestation. These later losses (fetal deaths) are particularly
emotionally devastating for families and clinicians,
yet relatively little is known about second and
third trimester pregnancy loss. This article will review
the epidemiology, causes, management and evaluation
of fetal death.

OVERVIEW
Nomenclature of Pregnancy Loss
The terminology of pregnancy loss is confusing and
could potentially benefit from revision. Historically,
pregnancy losses before 20 weeks of gestation are
referred to as abortions, whereas those after 20 weeks
of gestation are termed fetal deaths or stillbirths.
These definitions are somewhat arbitrary, inconsistent
with advances in our understanding of reproductive
biology, and not clinically helpful. Instead, it may be
more useful to classify pregnancy losses in terms of
stages of gestational development. Pregnancy losses
could be defined in terms of developmental biology,
as preembryonic (anembryonic), embryonic, or fetal.
The expression blighted ovum should be abandoned
and replaced with anembryonic or preembryonic
pregnancy loss. The preembryonic period begins
from conception and lasts through 5 weeks of gestation
(based upon menstrual dating). The embryonic
period lasts from 6 through 9 weeks of gestation. At 10
weeks of gestation, the fetal period begins, extending
through delivery. Alternatively, losses less than 20
weeks gestation could be described as early (eg, less

than 10 weeks gestation) compared with late