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1/5/2021

Stillbirth Evaluation

Stillbirth is one of the more challenging physical, emotional, mental, and spiritual events a patient and their family may ever face. Stillbirth is one of the most adverse pregnancy outcomes and affects 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, cigarette smoking, and alcohol use. Race is a sociopolitical construct, not a biological identifier, however race remains a risk factor even after correcting for other risk factors, suggesting that racial bias may have a role. Potential etiologies include placental insufficiency, placental abruption, chromosomal or genetic abnormalities, infection, and cord events. American College of Obstetricians and Gynecologists recommended an extensive workup, including inspection, pathologic 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 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 valuable 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. If fetal growth restriction or maternal hypertensive disorder is identified, the workup should be extended to 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.

 

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