Definition

The International Classification of Diseases, 10th revision (ICD-10) defines a fetal death as: “death prior
to the complete expulsion or extraction from its mother of a product of conception, irrespective of the
duration of pregnancy; the death is indicated by the fact that after such separation the fetus does not
breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord,
or definite movement of voluntary muscles without specification of the duration of pregnancy”.
WHO/ICD defines stillbirths as the death of a fetus that has reached a birth weight of 500 g, or if birth
weight is unavailable, gestational age of 22 weeks or crown-to-heel length of 25 cm. Within this category,
ICD classifies late fetal deaths (greater than 1000 g or after 28 weeks) and early fetal deaths (500–1000 g
or 22–28 weeks).

The legal requirements for registration of fetal deaths vary between and even within countries. WHO
recommends that, if possible, all fetuses and infants weighing at least 500 g at birth, whether alive or
dead, should be included in the statistics. The inclusion in national statistics of fetuses and infants
weighing between 500 g and 1000 g is recommended both because of its inherent value and because it
improves the coverage of reporting at 1000 g and over.

Definisi

ICD-10 mendefinisikan sebuah kematian janin sebagai; “kematian yang telah terjadi sebelum ekspulsi
komplit atau ekstraksi produk konsepsi ibu, yang tidak sesuai dengan usia kehamilan; kematian tersebut
diindikasikan dengan beberapa bukti, bahwa setelah proses lahiran janin tidak bernapas atau
menunjukkan tanda-tanda kehidupan, seperti berdetaknya jantung, adanya pulsasi tali pusat, atau
pergerakan otot-otot volunteer tanpa spesifikasi khusus dari usia kehamilannya.”

WHO/ICD mendefinisikan IUFD sebagai kematian janin yang telah mencapai berat ≤ 500 g. Jika data
berat lahir tidak tersedia, dapat merujuk usia kehamilannya yang setara ≤ 22 minggu, atau ukuran CRL
(Crown Rump Length) setara 25 cm. Bersamaan dengan kategori tersebut, ICD mengklasifikasikan late
fetal death adalah janin yang mencapai berat > 1000 g atau usia kehamilan ≥ 28 minggu) dan early fetal
death adalah berat janin di antara 500 – 1000 g atau usia kehamilan yang berada di antara 22-28 minggu.

The American College of Obstetricians and Gynecologists (ACOG) defines stillbirth as delivery of fetus
which shows no signs of life e.g. absence of breathing, heart beats, pulsations in umbilical cord are
absent, no voluntary movement of muscle. The suggested requirement is to report fetal deaths at 20 weeks
or greater of gestation (if the gestational age is known) or a weight greater than or equal to 350 g if the
gestational age is not known. The cut-off of 350 g is the 50th percentile for weight at 20 weeks gestation.

ACOG (American College of Obstetricians and Gynecologists) mendefinisikan IUFD sebagai lahirnya
janin yang tidak menunjukkan tanda-tanda kehidupan (contoh: ketidakadaan napas, detak jantung, pulsasi
dari tali pusar, dan pergerakan tonus otot secara volunteer). Persyaratan yang disarankan untuk
melaporkan kematian janin adalah usai kehamilan ≥ 20 minggu (jika usia kehamilan diketahui) atau berat
janin ≥ 350 g (jika usia kehamilan tidak diketahui). Titik potong dari berat janin 350 g adalah berat yang
sesuai dengan persentil 50th pada usia kehamilan 20 minggu.

Causes and Risk Factor

Penyebab dan Faktor Risiko

Traditionally, the causes of stillbirth have been differentiated in maternal, fetal, placental and external
factors. The most commonly quoted causes in the literature are as follows:

Secara tradisional, penyebab dari IUFD dibedakan berdasarkan faktor dari ibu, janin, dan faktor lain di
luar keduanya. Penyebab paling sering yang dikutip dari berbagai literatur adalah sebagai berikut:

-Maternal causes: Maternal infection is one of the most important causes for stillbirth [20]. Common
ascending infections (with or without membrane rupture) are due to Escherichia coli, Klebsiella, Group B
Streptococcus, Enterococcus, Mycoplasma/Ureaplasma, Haemophilus influenzae and Chlamydia [30],
[31]. In developing countries, other infectious agents can also be considered, e.g. malaria, syphilis and
HIV [5]. One database cohort study conducted in England assessing viral infections as a cause of fetal
loss in data from 1988 to 2008 concluded that more than one-third (37%) of the viral-attributed fetal
deaths occurred antepartum, from parvovirus (63%) or cytomegalovirus (33%) [32]. Diabetes mellitus,
thyroid abnormalities, hypertensive disorders, systemic lupus erythematosus, cholestasis of the
pregnancy, renal disease, sickle-cell disease and other maternal medical conditions are also causes for
stillbirth [2]. Anemia and nutritional deficiencies in the mother, common in low/middle-income countries,
have been long debated to be also a cause of stillbirths or other adverse pregnancy outcomes [5]. In
contrast, a high first hemoglobin measurement in early pregnancy has been shown to be associated with
an almost 2-fold increase in risk of stillbirth [33].

Penyebab dari Maternal: Infeksi maternal adalah salah satu penyebab terpenting terjadinya IUFD.
Beberapa infeksi jalur asendens yang umum (dengan atau tanpa rupturnya membrane) disebabkan oleh
Escherichia coli, Klebsiella, Group B Streptococcus, Enterococcus, Mycoplasma/Ureaplasma,
Haemophilus influenzae and Chlamydia. Pada beberapa negara berkembang, beberapa agen infeksi
lainnya dapat diperhitungkan, seperti; malaria, sifilis, dan HIV. Satu database dari penelitian kohort di
Inggris yang meneliti terkait infeksi virus sebagai salah satu penyebab terjadinya kematian janin,
berdasarkan data dari tahun 1988 hingga 2008, menyimpulkan bahwa lebih dari 1:3 (37%) dari kematian
janin yang dikaitkan dengan virus, terjadi pada antepartum, dari parvovirus (63%), atau sitomegalovirus
(33%). Diabetes mellitus, kelainan kelenjar tiroid, hipertensi, SLE, kolestasis pada kehamilan, penyakit
ginjal, anemia sel-sabit, dan kondisi medis maternal lainnya juga dapat menyebabkan IUFD. Anemia dan
defisiensi nutrisi pada ibu yang masih sering ditemukan pada negara-negara berkapita rendah atau
menengah, masih diperdebatkan sejak lama apakah menjadi salah satu penyebab terjadinya IUFD dan
penyebab keluaran buruk pada kehamilan. Secara jelas, tingginya kadar hemoglobin pada awal kehamilan
dihubungkan dengan meningkatnya risiko kehamilan mati hampir sebanyak dua kali lipat.

-Fetal causes: Among these, poor fetal growth or intrauterine fetal growth restriction (IUGR) is
considered one of the most frequent causes of stillbirth. Presumably, the growth restriction is due to a
placental dysfunction which may be related to numerous maternal diseases or infections described above
[34], [35], [36]. Other cited causes are: multiple gestation, congenital anomalies, genetic abnormalities,
fetal infection, and post maturity [19], [20], [37], [38]. The most common genetic etiology for stillbirth is
due to karyotype abnormalities, however many stillborn fetuses with normal karyotypes also have genetic
abnormalities [39].
-Penyebab dari Janin: Dari berbagai penyebab, buruknya kondisi pertumbuhan janin atau IUGR
ditentukan sebagai salah satu penyebab tersering terjadinya stillbirth. Tampaknya, terganggunya
pertumbuhan yang disebabkan karena disfungsi plasenta dihubungkan dengan banyaknya penyakit ibu
yang atau beragam infeksi seperti yang telah dijelaskan di atas. Berbagai penyebab lain yang dilaporkan:
Kehamilan ganda, anomali kongenital, kelainan genetic, infeksi pada fetus, dan kehamilan post matur.
Etiologi tersering yang menyebabkan kelainan genetik adalah akibat abnormalitas kariotipe, walaupun
banyak sekali janin yang hidup dengan kariotipe normal juga memiliki kelainan genetik.

-Placental causes include placental abruption, premature rupture of membranes, vasa previa,
chorioamnionitis, vascular malformations and umbilical cord accidents such as knots or abnormal
placement [21], [40].

-Penyebab dari Plasenta termasuk akibat abruptio plasenta, PROM (Premature Rupture of Membrane),
Vasa previa, chorioamnionitis, malformasi vaskular, dan kejadian-kejadian terkait tali pusar seperti lilitan
atau perlekatan yang abnormal.

-External causes: Some common examples are: antepartum mother's injuries/trauma or delivery/labor
incidents such as birth asphyxia and obstetric trauma. Where modern obstetric care is not available,
deaths can be frequent. It is estimated that in developing countries asphyxia causes around seven deaths
per 1000 births, whereas in developed countries this proportion is less than one death per 1000 births (5,
20). Availability of good delivery facilities also affects the pregnancy outcomes, as it was observed in a
study that availability of skilled attendant during delivery (one of the factors in delivery process) lead to
decline in stillbirth rate, however the authors concluded that this needs further analysis [41].

- Penyebab eksternal: Beberapa contoh yang sering adalah Trauma/Cedera atau kejadian saat proses
lahiran seperti asfiksia neonatorum dan trauma obstetrik. Dimana pelayanan obstetric modern tidak
tersedia, kematian janin menjadi ikut meningkat.Hal tersebut ditunjukkan dengan data bahwa di negara
berkembang, asfiksia neonatorum menyebabkan 7 kematian dari 1.000 lahiran, dibanding dengan negara
maju yang mempunyai angka <1 kematian janin per 1.000 jumlah lahiran. Ketersediaan fasilitas
melahirkan yang baik juga sangat mempengaruhi output dari kehamilan, sebagaimana yang telah diamati
dalam sebuah studi bahwa ketersediaan penolong yang professional dan terlatih pada saat proses lahiran
membuat angka IUFD menurun, walaupun penulis berkesimpulan bahwa studi tersebut masih perlu
dianalisis lebih lanjut.

There are many known epidemiological risk factors for stillbirth. Systematic reviews have confirmed very
early or advanced maternal age as risk factors. Moreover, nulliparous women have a higher risk of
stillbirth than multiparous women across all ages. Of these, nulliparous women aged 35 years and older
have been shown to have a 3.3-fold increase in the risk of unexplained fetal death compared with women
younger than 35 years of age. The odds ratio for maternal age 40 years and older is 3.7.

Begitu banyak faktor risiko berdasarkan epidemiologi untuk kasus janin IUFD. Beberapa ulasan
sistematik (Systematic Review) telah mengkonfirmasi bahwa kehamilan usia dini dan usia lanjut dari usia
ibu sebagai salah satu factor risiko. Lebih dari itu, perempuan nullipara memiliki risiko tinggi untuk
IUFD dibanding perempuan multipara dalam semua usia. Berdasarkan hal tersebut, wanita nullipara
dengan usia ≥35 tahun memiliki risiko 3.3 kali lipat terjadinya kematian janin yang tak diketahui
penyebabnya dibandingkan dengan wanita yang berusia <35 tahun. Odds rasio untuk usia ibu ≥40 tahun
adalah 3.7.

Other factors associated with increased risk of stillbirth are: body mass index (BMI) ≥30, smoking (which
includes active and passive smoking), substance abuse (especially cocaine, but also cannabis and alcohol),
and multifetal gestation, with significantly higher rates of stillbirth observed in monochorionic twins than
in dichorionic [2], [44], [45], [46], [47], [48]. One study showed that maternal overweight (i.e. Body Mass
Index ≥25) increases the risk of antepartum stillbirth, especially term antepartum stillbirth, whereas
weight gain per se during pregnancy was not associated with the risk of fetal death [49]. Women with a
previous stillbirth are well known to be at 5- to 10-fold increased risk of recurrence for stillbirth. Also AB
blood group appeared to be preferentially associated with stillbirth before 24 completed weeks of
gestation.

Faktor lain yang dihubungkan dengan meningkatnya risiko IUFD adalah, BMI ≥ 30, merokok (baik
perokokaktif maupun pasif), penyalahgunaan zat (khususnya kokain, juga alcohol dan ganja), dan
kehamilan multipel. Salah satu penelitian menunjukkan bahwa ibu yang mempunyai berat badan berlebih
(BMI ≥ 25) meningkatkan risiko IUFD antepartum. Namun, risiko tersebut tidak berhubungan dengan
kenaikan berat badan ibu pada saat kehamilan.

Globally, black women have 2.2 fold increased risk of stillbirth compared to white women [51]. The
black/white disparity in stillbirth hazard at 20–23 weeks is 2.75, decreasing to 1.57 at 39–40 weeks.
Medical, pregnancy and labor complications account for 30% of the risk of stillbirth in Blacks and 20% in
Whites and Hispanics. Trends have also show that stillbirth rates are slightly higher among male
compared to female fetuses [51]. Worldwide, 67% of stillbirths occur in rural families, where skilled birth
attendance and cesarean sections are much lower than that for urban births.

Secara global, wanita kulit hitam memiliki risiko 2.3 kali lipat untuk IUFD dibandingkan wanita kulit
putih. Di seluruh dunia, 67% IUFD terjadi pada daerah yang terpencil, dimana penolong persalinan yang
terlatih dan persalinan dibantu dengan sectio cesaria sangat rendah dibanding jumlah angka lahiran
masyarakatnya.

Diagnosis of stillbirth
There are diverse existing methods/criteria for identifying stillbirths:
Clinical signs: They are those that reflect absence of fetal vitality, either antepartum or by direct
examination postpartum:

a. Antepartum: mother does not feel fetal activity; the maternal weight is maintained or decreased, the
fundal height stops increasing or even decreases if the reabsorption of amniotic fluid occurs. At the
medical examination, intrauterine ascertainment of death is confirmed by the absence of fetal heart tones
before delivery by auscultation methods (e.g. using Pinard horn, handheld Doppler, fetoscopy, doptone or
stethoscope) or after electronic fetal heart monitoring/non-stress test. Auscultation of the fetal heart tones
by Pinard horn, stethoscope or even handheld Doppler is insufficiently sensitive for a confirmatory
diagnosis. In a series of 70 late pregnancies in which fetal heart tones were inaudible on auscultation, 22
were found to have viable fetuses [53]. Auscultation of fetal heart tones or misinterpreted experiences of
fetal movements can also give false reassurance [54]; maternal pelvic blood flow can result in an
apparently normal, but low, fetal heart rate pattern with handheld Doppler. The sign of Boero is the clear
auscultation of maternal aortic beats due to the eventual absorption of amniotic fluid. The fetus becomes
less perceptible to palpation as maceration progresses. The sign of Negri is the crackling or crepitation of
the fetal head during its palpation. Sometimes vaginal dark blood loss is noted, there might be increased
consistency of cervix because of the hormonal decline and also, appearance of secretion of colostrum in
the mammary glands, although these signs are not specific.

Diagnosis IUFD

Dalam hal ini banyak metode/kriteria yang bisa digunakan untuk mengidentifikasi IUFD:

Tanda Klinis: Berbagai ciri yang menggambarkan ketiadaan tanda vital janin, baik antepartum atau
melalui pemeriksaan langsung selama postpartum.

a. Antepartum: Ibu tidak merasakan adanya gerakan janin, berat ibu tidak bertambah atau bahkan
berkurang, tinggi fundus uteri tidak bertambah atau bahkan berkurng jika terjadi reabsorbsi dari cairan
amnion. Pada saat pemeriksaan medis, pemastian dari IUFD dikonfirmasi dengan absennya denyut
jantung janin dengan menggunakan stetoskop Laennec (Pinnard Horn Stethoscope), penggunaan
stetoskop biasa atau Doppler tidak cukup sensitive untuk mengkonfirmasi diagnosis IUFD. Dalam sebuah
penelitian yang melibatkan 70 pasien kehamilan lewat bulan dimana denyut jantung janin tidak terdengar
pada saat auskultasi, didapati mempunyai janin yang dapat terus hidup. Auskultasi dari denyut jantung
janin

b. Postpartum ascertainment of death is confirmed by Apgar scores of 0 at 1 and 5 min, absence of vital
signs including the documentation of no heart rate and respirations, absence of pulsation of the umbilical
cord, and no definitive movement of voluntary muscles. Heartbeats are to be distinguished from transient
cardiac contractions; respirations are to be distinguished from transient fleeting respiratory efforts or
gasps. Macroscopic appearance of the fetus may show signs of maceration and the level of maceration
can determine time of death. The earliest sign of macerations are seen in the skin 4–6 h after intrauterine
death; desquamated skin measuring 1 cm or more in diameter and red or brown discoloration of the
umbilical cord correlate with fetal death 6 or more hours before birth; desquamation involving the skin of
face, back or abdomen with 12 or more hours; desquamation of 5% or more of the body surface with 18
or more hours; moderate to severe desquamation, brown skin discoloration of the abdomen with 24 or
more hours and mummification is seen in fetuses who died 2 or more weeks before birth [55].

-Radiologic studies: In addition to the above clinical signs, other secondary features might be seen
antepartum if eventually imaging techniques such as X-ray radiography are used: collapse of the fetal
skull with overlapping bones due to liquefaction of the brain, hydrops, flattening of the cranial cavity,
head asymmetry, fall of the mandible (sign of open mouth), or fetal bunching due to a loss of the normal
curvature of the spine due to macerating spinal ligaments, which may appear completely collapsed
resulting in unrecognizable fetal mass. In addition, there might be also intra-fetal gas within the heart,
blood vessels and joints or a translucent peri-cranial halo due to accumulation of fluid in the subcutaneous
tissue; when the image is complete gives double cranial halo called “holy crown” [56], [57], [58], [59],
[60].
-Ultrasound (US): real-time ultrasonography is the gold standard for the accurate diagnosis of stillbirth
antepartum. The advantage of this method lies in the precocity with which the diagnosis can be made,
because real time ultrasound allows direct visualization of the fetal heart and the absence of cardiac
activity, absence of aortic activity and the absence of movements of the body or limbs of the fetus (to be
distinguished from periods of fetal physiological rest). Imaging can be technically difficult, particularly in
the presence of maternal obesity, abdominal scars and oligohydramnios, but views can often be improved
with new generation US or with color Doppler of the fetal heart and umbilical cord. Other secondary
signs that can be seen at US are: the accumulation of fluid in the subcutaneous tissue (anasarca), pleural
and peritoneal effusion, and the loss of the definition of fetal structures, which often reflect maceration.

Keluhan Utama: Hamil anak pertama, tidak merasakan adanya gerakan janin

Riwayat Penyakit Sekarang; Pada hari Minggu (22/10/2017) pukul 05.00 wib, os merasa gerakan janin di
dalam rahimnya berkurang. Malam harinya, os memeriksakan kondisinya serta janinnya ke bidan. Bidan
yang memeriksa mengatakan bahwa denyut jantung janinnya melemah. Bidan segera merujuk pasien ke
RS Kasih Ibu, Purworejo, lalu dirujuk lagi ke RSUD Dr. Tjitrowardojo Purworejo. Pasien belum
mengeluh ada kencang-kencang, air ketuban yang merembes, lendir darah yang keluar dari jalan lahir.
Gerak janin tidak terasa.

Riwayat Penyakit Dahulu: DM (-), HT (-), Asma (-), Jantung (-)

Riwayat Menstruasi:
 Menarche : 12 tahun  Keluhan saat haid: tidak ada keluhan
 Siklus Menstruasi : teratur, lama 7 hari,  HPMT : 03/02/2017
siklus 28 hari  HPL : 10/11/2017
Riwayat Pernikahan: Sudah menikah, 1x, saat usia 31 tahun

Riwayat Obstetrik: G1P0A0, uk 37+4 mgg

ANC: rutin, 8x selama kehamilan. Pada usia kehamilan 28 minggu, pasien pernah mengalami perdarahan
dari jalan lahir, darah segar, sehari 3x ganti celana dalam. Lalu pasien memeriksakan kondisinya ke Poli
Kandungan dan diberi obat Nifedipin.

Riwayat KB: belum pernah

Riwayat Imunisasi: Imunisasi TT sudah, 2x

Pemeriksaan Fisik

Keadaan Umum: Baik, Compos Mentis

Tanda-tanda Vital:
 TD: 112/68 mmHg  R: 20x/m
 N: 86x/m  t: 36.8 oC
Antropometri:
 BB sebelum hamil: 56 kg  IMT: 23.3 kg/m2
 BB saat ini: 75 kg  LLA: 24 cm
 TB: 155 cm
Kepala: normocephal, CA (-/-), SI (-/-)

Leher: Pembesaran kel. Tiroid (-), Kel. Limfonoid tidak teraba

Thoraks:

Pemeriksaan Obstetrik:

Inspeksi: Perut tampak buncit, letak sungsang, striae gravidarum (+), linea nigra (+), luka bekas
operasi/SC (-)

Palpasi :
 TFU 29 cm
 Leopold I : teraba satu bagian besar, bulat, keras, kepala
 Leopold II : Kanan : teraba bagian keras melebar seperti papan
Kiri : teraba bagian – bagian kecil janin
 Leopold III : Teraba satu bagian besar, lunak, bokong
 Leopold IV : 1/5, Bokong masih floating (belum masuk PAP)

His: (-)

Auskultasi: DJJ (-)

Kesan: TFU 29 cm tidak sesuai dengan hamil 37+4 minggu, letak sungsang, presentasi bokong, pu-ka,
DJJ (-), Janin intrauterine, tunggal, mati.