Preventing Stillbirths

Back in 1983 I had some success treating infections with a couple of moms who had had preterm stillbirths. I began to ask myself whether stillbirths, preterm births, and infertility were actually part of the same thing, all a continuum involving infection.

I read about infection, including mycoplasma and ureaplasma. At that time, the American College of Obstetricians and Gynecologists (ACOG) considered these organisms comensual, meaning they are present, but harmless.

I fully realize there are moms who have ureaplasma who seem to have no problems in pregnancy. On the other hand, for the women who had problems with stillbirth and had ureaplasma, my treating them allowed these women to become pregnant and have a normal pregnancy and delivery. This attention to infection combined with the kick test I wrote about last week produced very good results for moms who had had habitual pregnancy loss.

The U.S. statistics on stillbirths are grim. In the year 2022, there were 21,745 stillbirths in the U.S., or 65 babies per day. The U.S. maternal mortality rate is also far higher than in other developed countries. I have discussed maternal mortality in previous Substack articles. Clearly the U.S. has failed to address some of the underlying causes of maternal deaths and stillbirths.

An estimated 40 percent of stillbirths occur in labor. Women over 35 years have a greater risk of stillbirths. Women who carry their babies 42 weeks have a six times greater risk for stillbirth than those who deliver at 38 or 39 weeks.

Commonly cited causes of stillbirth include preterm labor, twin or triplet pregnancy, placental abruption, and placenta previa. Other causes often cited include pregnancy and childbirth related complications, maternal infections such as malaria, syphilis, and HIV, as well as maternal hypertension, diabetes, and a baby who is too small for gestational age.

Black women have significantly higher rates of maternal mortality than white women, and the rate of stillbirths among black women is more than twice that of white women. The Stillbirth Collaborative Research Network (SCRN) study found that the causes of stillbirth are different for black women, white women, and Hispanic women. For black women, stillbirths were more likely to be caused by infection or by complications of pregnancy and labor. Stillbirths for black women were more likely to occur before 24 weeks, or during labor and delivery.

Infection attributed to stillbirths in pregnancy include those of the mother, the womb, the placenta, or the baby. According to SCRN, stillbirths from E. coli, Group B strep, and enterococcus were the most common infections before 24 weeks of pregnancy.

Problems with the umbilical cord are also listed as a common cause of pregnancy loss, but in my experience, these problems are overrated. Many babies are born with knots in the cord or two or three loops around the neck. Generally speaking, these cord events have no consequence.

We’ve also heard a lot about influenza A and B. The problem with mothers who get any common viral illness during pregnancy is immune suppression. They don’t run a fever easily and they don’t have many early symptoms of being sick so they can develop a very significant pneumonia from many of the common viruses without many symptoms. Because their symptoms are so attenuated (deceptively mild) providers must be extremely alert and listen carefully for any possible warning signs or hints of trouble to come. Years ago, I had a mother with twins and several other children at home. She smoked and had chronic obstructive pulmonary disease (COPD). I hospitalized her many times for COPD exacerbations. I treated her early and vigorously on several occasions and managed to get her to 38 weeks when she delivered healthy twins.

I like to think of infertility, miscarriage, preterm birth, and stillbirths as being together on a continuum, with infertility being the most complicated, followed by miscarriage, preterm births, and stillbirths. I believe that approximately 50 percent of all of these issues are related to infections.

I once saw a young couple who had never been able to become pregnant. They had taught English as a second language in several countries. They had had in vitro on several continents. They told me they were leaving for Japan in 11 days so they gave me 11 days to succeed at what years of in vitro had not accomplished. I checked for everything I could think of and the ureaplasma test came back positive. I treated them both with doxycycline. They took off for Japan. I got a call two months later the woman was pregnant and I got a call about six months later she had delivered a healthy term baby girl vaginally.

Much controversy surrounds the whole issue of infection on a continuum from infertility to a still birth. Even more controversy surrounds the exact organisms. We have made some concessions recently to looking for infectious organisms as a cause of stillbirth. Again, the question is which organisms should we be looking for?

As a nation, we are failing at obstetrics. We need to pay more attention to finding and treating simple illnesses the right way at the right time and avoiding costly and unnecessary tragedies. We have recently documented that mycoplasma and ureaplasma kill sperm which can cause male factor infertility. Culturing and treating common infectious organisms is a very good way to address infertility and avoid preterm birth or stillbirth.

 I believe that preterm birth and infertility should actually be considered on a continuum, with each segment of the continuum offering an opportunity to prevent premature birth or stillbirth and treat infertility.

The fetal kick test is a very good way to avoid stillbirths at or near term. Add to that the treatment of infections known to interfere with pregnancy, and I believe we would be able to bring a significant decrease in the U.S. stillbirth rate.