Stillbirth: Symptoms, Types, Causes and Treatment

Stillbirth is one of the most heartbreaking outcomes in pregnancy, affecting millions of families worldwide each year. While the loss itself is devastating, understanding the symptoms, types, causes, and approaches to treatment is crucial for both prevention and compassionate care. In this comprehensive article, we break down the essential aspects of stillbirth, with evidence from the latest research, to provide clarity and support for families, caregivers, and health professionals.

Symptoms of Stillbirth

Stillbirth can be a silent tragedy, often occurring without warning. However, there are certain symptoms and signs that may indicate a problem and should prompt immediate medical attention. Recognizing these symptoms early can sometimes make a difference in outcomes and allows for timely intervention.

Symptom	Description	Timing	Source(s)
Decreased Fetal Movement	Noticeable reduction or absence of baby’s kicks or movements	Late pregnancy (usually after 20 weeks)	4
No Fetal Heartbeat	Absence of heartbeat on ultrasound or Doppler	Any time after 20 weeks	4
Vaginal Bleeding	Unexplained or heavy bleeding	Any time in pregnancy	4
Sleep Changes	Excessive sleep duration, daily naps	Last month of pregnancy	2
Maternal Distress	Unexplained anxiety, depression, PTSD symptoms post-event	After stillbirth	1

Table 1: Key Symptoms

Recognizing the Warning Signs

Decreased Fetal Movement

One of the earliest and most concerning symptoms is a noticeable reduction in fetal movement. Expectant mothers are often advised to monitor their baby's kicks, especially in the third trimester. If movements become less frequent or stop altogether, it's important to contact a healthcare provider immediately. This can be a sign of fetal distress or demise, though there are also benign causes for occasional changes in movement 4.

Absence of Fetal Heartbeat

If no fetal heartbeat is detected during a routine prenatal visit using a Doppler device or ultrasound, this is a key diagnostic sign of stillbirth. This finding typically prompts further evaluation and confirmation 4.

Vaginal Bleeding

While some light spotting can be normal in pregnancy, unexplained or heavy vaginal bleeding may indicate serious complications, including placental abruption or preterm labor—both of which can be associated with stillbirth 4.

Maternal Sleep Patterns

Recent research has found associations between certain sleep patterns—such as sleeping more than nine hours a night, taking daily daytime naps, and positive screenings for sleep-disordered breathing—and an increased risk of late stillbirth. Interestingly, restless sleep may be protective 2.

Emotional and Psychological Symptoms

After a stillbirth, parents—especially mothers—are at increased risk for depression, anxiety, and post-traumatic stress disorder (PTSD). These symptoms may persist for months or even years after the event and warrant professional support 1.

Types of Stillbirth

Understanding the types of stillbirth helps in clarifying the timing and potential causes, which is important for both clinical management and research.

Type	Definition	Timing	Source(s)
Early Stillbirth	Fetal death between 20–27 weeks gestation	20–27 weeks	4 8
Late Stillbirth	Fetal death at or after 28 weeks gestation	≥28 weeks	2 4 8
Antepartum	Fetal death before onset of labor	Before labor	4 12
Intrapartum	Fetal death during labor/birth process	During labor	10 13

Table 2: Stillbirth Types

Breaking Down the Classifications

Early vs. Late Stillbirth

• Early stillbirth is defined as fetal death occurring between 20 and 27 completed weeks of gestation.
• Late stillbirth refers to fetal deaths at 28 weeks gestation or later. This category is especially important as many interventions and preventive strategies are focused on this period 4 8.

Antepartum vs. Intrapartum

• Antepartum stillbirth: The fetus dies before the onset of labor. Most stillbirths globally are antepartum, especially in settings where access to care is limited 4 12.
• Intrapartum stillbirth: The fetus dies during labor. In high-resource countries, intrapartum stillbirths are rare due to effective obstetric care, while in low-resource settings, the majority of intrapartum deaths are linked to the absence or delay of such care 10 13.

Contextual Considerations

• Stillbirth definitions and classifications may vary by country or health system, but these categories are widely used in research and clinical practice 8.

Causes of Stillbirth

The causes of stillbirth are diverse and often multifactorial. Understanding these causes can guide prevention, management, and support for affected families.

Cause Category	Examples	Relevance/Notes	Source(s)
Maternal Health	Obesity, diabetes, hypertension, age	Major modifiable risk factors	4 6
Infections	Syphilis, malaria, bacteria, viruses, protozoa	Leading cause in low-income settings	5 7 9 10
Placental Disorders	Placental abruption, insufficiency	Associated with growth restriction	4 6
Fetal Factors	Congenital anomalies, growth restriction	May be detected via ultrasound	4 6
Socioeconomic Factors	Poor access to care, low income, malnutrition	Higher rates in low-resource settings	4 12
Sleep-Related Risks	Sleep-disordered breathing, long sleep duration	Emerging evidence	2
Unknown/Unexplained	No clear cause identified	Significant proportion	4 8

Table 3: Causes of Stillbirth

Key Categories and Mechanisms

Maternal Health and Pre-Existing Conditions

• Obesity: The risk of stillbirth increases with higher maternal BMI. Obese mothers face a two-fold risk compared to lean women, with the risk rising further in severely obese women. Obesity is linked to stillbirths from placental diseases, hypertension, and fetal anomalies 6.
• Hypertension and Diabetes: These conditions can compromise fetal oxygen and nutrient supply, increasing the risk of fetal death 4 6.

Infections

• Global Impact: Infections account for up to 50% of stillbirths in low- and middle-income countries, but 10–25% in high-income countries 5 7.
• Types: Syphilis, when prevalent, is the most significant infectious cause and is highly preventable with screening and treatment. Malaria, especially in first-time infections during pregnancy, is another major cause. Other implicated infections include E. coli, group B streptococci, parvovirus, Toxoplasma, and Listeria 5 7.
• Prevention: Strategies such as malaria prophylaxis, syphilis screening/treatment, and vaccination are effective in reducing infection-related stillbirths 7 9 10.

Placental and Fetal Factors

• Placental Abruption/Insufficiency: Disruption of placental function can lead to fetal hypoxia and demise. Placental diseases are a major cause, particularly in the context of maternal obesity or hypertension 4 6.
• Congenital Anomalies and Growth Restriction: Structural or genetic abnormalities can result in nonviable pregnancies 4 6.

Socioeconomic and Environmental Influences

• Access to Care: Lack of antenatal and emergency obstetric care increases risk, particularly for intrapartum stillbirths 4 10 12 13.
• Malnutrition and Environmental Exposures: Maternal malnutrition and harmful exposures (e.g., indoor air pollution) are linked to higher rates of stillbirth in resource-limited settings 12.

Sleep-Related Risks

• Recent studies show that certain sleep characteristics, like long sleep duration and daily napping, may increase the risk of late stillbirth, highlighting the importance of maternal sleep assessment in prenatal care 2.

Unknown Causes

• A significant proportion of stillbirths remain unexplained, even after thorough investigation. This underscores the complexity of fetal demise and the need for ongoing research 4 8.

Treatment of Stillbirth

"Treatment" in the context of stillbirth refers not only to the medical management following the loss but also to prevention strategies, psychological support, and respectful care for bereaved families.

Intervention	Focus/Approach	Evidence/Impact	Source(s)
Medical Management	Delivery options, post-mortem examination	Ensures safe care, clarifies cause	4 11
Prevention	Screening, infection control, nutrition, emergency obstetric care	Proven to reduce rates in high-risk settings	9 10 12 13
Psychological Support	Counseling, memory-making, support groups	Reduces mental health burden	1 11
Healthcare Training	Staff education, care protocols	Improves quality of care	11

Table 4: Approaches to Stillbirth Treatment

Medical Management

• Safe Delivery: After diagnosis, the focus is on safe delivery of the fetus, which may involve induction of labor or, rarely, cesarean section depending on maternal health and preferences 4.
• Post-Mortem Evaluation: Autopsy and placental examination can help determine the cause, especially in unexplained cases. This information is valuable for future pregnancies 4 11.

Prevention Strategies

• Antenatal Interventions: Screening and treatment for infections (especially syphilis and malaria), nutritional supplementation, and management of chronic conditions (like hypertension and diabetes) have been shown to reduce stillbirth rates 9 10 12.
• During Labor: Access to timely emergency obstetric care—including cesarean section for obstructed labor or fetal distress—can prevent many intrapartum stillbirths, particularly in low-resource settings 10 13.
• Behavioral and Nutritional Interventions: Smoking cessation, improved maternal nutrition, and birth preparedness all contribute to prevention, though more research is needed on some interventions 9 12.

Psychological and Emotional Support

• Aftercare: Parents experiencing stillbirth face an increased risk of depression, anxiety, and PTSD. Supportive counseling, opportunities for memory-making, and tailored postnatal information are vital to their well-being 1 11.
• Care Practices: Compassionate communication, privacy, and the option for parents to see and hold their baby are important elements of bereavement care 11.

Healthcare System and Staff Training

• Provider Education: Training healthcare professionals in stillbirth care improves outcomes for families and reduces barriers to effective support 11.
• Continuity of Care: Clear pathways and supportive systems ensure that families receive consistent, high-quality care during and after stillbirth 11.

Conclusion

Stillbirth remains a complex and deeply impactful event for families and health systems worldwide. While some causes are preventable, others remain elusive, highlighting the need for continued research and compassionate care.

Key Takeaways:

• Symptoms: Decreased fetal movement, absence of heartbeat, abnormal sleep patterns, and psychological distress are warning signs and consequences of stillbirth 1 2 4.
• Types: Classified by timing—early or late, antepartum or intrapartum—helping guide diagnosis and prevention 2 4 8 10 12 13.
• Causes: Range from maternal health, infections, placental disorders, and socioeconomic factors to sleep-related risks and unknown origins 2 4 5 6 7 8 9 10 12.
• Treatment: Encompasses medical management, prevention, emotional support, and healthcare system improvements to reduce incidence and support families 1 4 9 10 11 12 13.

Ongoing research, improved healthcare access, and empathetic support systems are essential to reduce the burden of stillbirth and to support those affected by this profound loss.