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Stillbirth affects nearly 1 in 160 pregnancies in the United States and 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 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. Traditionally, the American College of Obstetricians and Gynecologists recommended an extensive workup, including inspection, pathologic evaluation, and serologic evaluation. Currently, a stepwise approach is preferred.
Several articles describe a streamlined and cost-conscious workup. 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. Genetic testing and testing for antiphospholipid antibody syndrome are useful in determining the cause in another 10% of cases. A systematic approach to stillbirth evaluation is suggested, beginning with maternal chart review, fetal autopsy, and placental pathology. If no clear etiology is determined, proceeding to genetic testing is advised. 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. If a suspected fetal anomaly is noted, chromosomal microarray (if available) provides the highest yield. 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. A stepwise workup can provide answers while remaining cost-conscious. Thoughtful evaluation of the medical history, placental pathology, fetal autopsy, chromosomal microarray, and screening for fetal-maternal hemorrhage is advised in every case.
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
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