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Stillbirth Evaluation

Stillbirth is one of the more challenging physical, emotional, mental, and spiritual events a patient and their family may ever face, affecting nearly 1 in 160 pregnancies in the United States. Stillbirth is defined as fetal death at 20 or more weeks of gestation. In developed countries, risk factors include non-Hispanic black race, nulliparity, advanced maternal age, obesity, pre-existing diabetes, assisted reproductive technology, multiple gestation, male fetal sex, obstetric history, cigarette smoking, and alcohol use. Race and marital status are sociopolitical constructs, not a biological identifiers, however race and un-married status are independently associated with stillbirth. Potential etiologies include placental insufficiency, placental abruption, chromosomal or genetic abnormalities, infection, and cord events. The American College of Obstetricians and Gynecologists recommends an extensive workup, including inspection of the fetus and placenta, pathologic evaluation/autopsy, genetic evaluation, and serologic evaluation. However, an individualized approach is appropriate based on patient preference.

A systematic approach to stillbirth evaluation is suggested, beginning with maternal chart review, fetal gross inspection, autopsy, and placental pathology. Several articles describe a streamlined and cost-conscious algorithm based on individualized clinical scenarios. The most useful tests in the evaluation of stillbirth are placental pathology and fetal autopsy, which confirm 64.6% and exclude 42.4% of potential causes. In patients who decline a full autopsy, external evaluation of the fetus may prove value, with careful attention to any dysmorphic features and measurements of weight, length, head circumference, foot length (prior to 23 weeks), and photographs of the whole body, frontal and profile views of the face, extremities, and palms, and close up views of any identified abnormalities. Whole body x rays may also be of value with anterior-posterior and lateral views. If a suspected fetal anomaly is noted, chromosomal microarray (if available) provides the highest yield.

If no clear etiology is determined, proceeding to genetic testing is advised. Genetic testing and testing for antiphospholipid antibody syndrome are useful in determining the cause in another 10% of cases. Traditional karyotype analysis is often of low yield given cell culture failure, whereas chromosomal microarray substantially increases the yielded results (87.4% vs 70.5%) because it can be done on nonviable tissue. Microarray also detects chromosomal deletions and duplications too small to be detected by karyotyping. Microarray can be performed via amniocentesis or tissue sampling.  In the absence of suspected fetal anomaly, preterm labor or infection, the workup should include testing for antiphospholipid antibody syndrome and screening for fetal-maternal hemorrhage. Intrapartum stillbirth should follow a similar workup, while preterm labor, chorioamnionitis, and preterm premature rupture of membranes require further testing based on clinical suspicion of infectious etiology.

Identification of potential causes of stillbirth is important not only for emotional closure but for accurate patient counseling regarding interventions to prevent stillbirth recurrence. Bereavement care needs to be individualized based on the patient and family personal, spiritual, cultural, and religious needs. Thoughtful evaluation of the medical history, placental pathology, fetal autopsy, chromosomal microarray, and consideration for fetal-maternal hemorrhage is advised in every case.

 

Further Reading:

American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine in collaboration with, Metz TD, et al. Obstetric Care Consensus #10: Management of Stillbirth: (Replaces Practice Bulletin Number 102, March 2009). Am J Obstet Gynecol. 2020;222(3):B2-B20. PMID: 32004519

Page JM, Christiansen-Lindquist L, Thorsten V, et al. Diagnostic Tests for Evaluation of Stillbirth: Results From the Stillbirth Collaborative Research Network. Obstet Gynecol. 2017;129(4):699-706. PMID: 28333795

 

Initial Approval: September 2020, Published January 2021, Reaffirmed May 2022, Revised May 2024. Revised February 2026.

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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