Abstract
Stillbirth is a common and devastating pregnancy complication. The aim of this study was to review and compare the recommendations of the most recently published guidelines on the investigation and management of this adverse outcome. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), the Perinatal Society of Australia and New Zealand (PSANZ), the Society of Obstetricians and Gynecologists of Canada (SOGC) on stillbirth was carried out. Regarding investigation, there is consensus that medical history and postmortem examination are crucial and that determining the etiology may improve care in a subsequent pregnancy. All guidelines recommend histopathological examination of the placenta, genetic analysis and microbiology of fetal and placental tissues, offering less invasive techniques when autopsy is declined and a Kleihauer test to detect large feto-maternal hemorrhage, whereas they discourage routine screening for inherited thrombophilias. RCOG and SOGC also recommend a complete blood count, coagulopathies' testing, anti-Ro and anti-La antibodies' measurement in cases of hydrops and parental karyotyping. Discrepancies exist among the reviewed guidelines on the definition of stillbirth and the usefulness of thyroid function tests and maternal viral screening. Moreover, only ACOG and RCOG discuss the management of stillbirth. They agree that, in the absence of coagulopathies, expectant management should be considered and encourage vaginal birth, but they suggest different labor induction protocols and different management in subsequent pregnancies. It is important to develop consistent international practice protocols, in order to allow effective determination of the underlying causes and optimal management of stillbirths, while identifying the gaps in the current literature may highlight the need for future research.
Highlights
Stillbirth is defined as fetal death after a prespecified gestational age and/or fetal weight, both of which have historically lacked uniformity among different countries [1]
Royal College of Obstetricians and Gynecologists (RCOG) has adopted the definition of the Perinatal Mortality Surveillance Report (CEMACH) according to which stillbirth is defined as “the delivery of a baby with no signs of life known to have died after 24 completed weeks of pregnancy” [30]
A careful documentation of antepartum hemorrhage or infection, as well as previous adverse pregnancy outcomes, are required to facilitate investigation; this statement is based on a systematic review and meta-analysis which proved that the risk of stillbirth in subsequent pregnancies is higher in women who experience a stillbirth in their first pregnancy (OR: 4.83; 95% CI: 3.77–6.18) [21] and on a retrospective cohort study which showed that complicated first births of liveborn infants are associated with an increased risk of unexplained stillbirth in the pregnancy [22]
Summary
Stillbirth is defined as fetal death after a prespecified gestational age and/or fetal weight, both of which have historically lacked uniformity among different countries [1] It is a common pregnancy complication, occurring in approximately one in 160–200 deliveries per year, despite the advances in obstetric care [2, 3]. The aim of this descriptive review was to synthesize and compare current recommendations from influential guidelines on the investigation and management of stillbirth This medical society points out that real-time ultrasonography is the optimal method for the diagnosis of intrauterine death and should be preferred over auscultation and cardiotocography, as it allows the direct visualization of the fetal heart, and the detection of secondary features, such as hydrops, collapse of fetal skull and maceration [31]. A prospective study of 808 families who suffered a stillbirth showed that parental choices vary widely and, clinicians should provide personalized care based on their preferences [32]
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