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No. 369-Management of Pregnancy Subsequent to Stillbirth

      Abstract

      Objective

      The primary objective of this consensus statement is to develop consensus statements to guide clinical practice and recommendations for antenatal care, intrapartum care, and the psychosocial considerations necessary in the care of pregnant women with a history of stillbirth.

      Intended users

      Clinicians involved in the obstetric management of women with a history of stillbirth or other causes of perinatal loss

      Target population

      Women and families presenting for care following a pregnancy affected by stillbirth or other causes perinatal loss

      Evidence

      This document presents a summary of the literature and a general consensus on the management of pregnancies subsequent to stillbirth and perinatal loss. Medline, EMBASE, and Cochrane databases were searched using the following key words: previous stillbirth, perinatal loss, subsequent pregnancy. The results were then studied, and relevant papers were reviewed. The references of the reviewed studies were also searched, as were documents citing pertinent studies. The evidence was then presented at a consensus meeting, and statements were developed. Due to lack of evidence, care pathways of specialty clinics were consulted.

      Validation methods

      The content and guidelines were developed by the primary authors in consultation with the meeting attendees. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Table 1). The interpretation of strong and weak recommendations is described in Table 2. The Summary of Findings is available upon request.

      Benefits, harms, and costs

      A multidisciplinary approach in the provision of antenatal and intrapartum care to women and families with a history of stillbirth and perinatal loss was explored. While there is a lack of evidence in this area, members of the working group are providing care to women and families around the world and are sharing their knowledge and experience to help guide care.

      Guideline update

      Evidence will be reviewed 5 years after publication to evaluate whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.

      Sponsors

      This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada and the Women and Babies Program at Sunnybrook Health Sciences Centre.

      Recommendations

      • 1
        The single most important risk factor for recurrent stillbirth is the history of previous stillbirth. Women's recurrence risk can be stratified based on the known cause of index stillbirth and other known maternal risk factors (GRADE: high).
      • 2
        At the time of stillbirth, tests should be conducted in accordance with the clinical picture. All parents should be offered an autopsy or equivalent, placental pathology, genetic testing from fetal source, and testing for feto-maternal hemorrhage (GRADE: moderate).
      • 3
        Women with a history of stillbirth are at higher risk of other adverse pregnancy outcomes, such as preterm birth, low birth weight, and placental abruption (GRADE: moderate).
      • 4
        At the initial booking visit, if the previous stillbirth was not adequately investigated, it should be noted that no universal tests are recommended. Clinical history and workup at the time of stillbirth should be used to guide testing on a case-by-case basis (GRADE: moderate).
      • 5
        Routine biochemical assessment of placental function and routine uterine artery Doppler are not universally recommended due to poor predictive value and absence of their roles in adjusting the risk stratification, given there is already a high risk of recurrence (GRADE: moderate).
      • 6
        Low-dose aspirin may reduce the risk of perinatal death in women at risk for placental insufficiency. Some women with a history of stillbirth may fall into this category (GRADE: high).
      • 7
        Women with a history of stillbirth may be at risk for fetal growth restriction in the subsequent pregnancy and may benefit from serial growth ultrasound (GRADE: high). While there is limited evidence supporting routine biophysical profile studies, some women and their families may benefit from increased surveillance, while others will find the increased monitoring to contribute to their anxiety. Fetal surveillance frequency and schedules should be determined with consideration for medical history, the circumstances surrounding the index stillbirth, and parental preferences (GRADE: moderate).
      • 8
        Decisions around timing of birth should incorporate the circumstances surrounding the previous stillbirth, the clinical picture of the current pregnancy, and the emotional state of the woman and her family, while taking into account the known drawbacks of birth prior to 39 weeks. In select cases, there may be a role for early term (37–39 weeks) birth. There is no evidence for delivery before 37 weeks based on the risk factor of stillbirth alone (GRADE: moderate).
      • 9
        Families are uniquely impacted by prior stillbirth. Stillbirth is a life-changing event for families, with ongoing psychological, physical, and social costs that carry into a subsequent pregnancy and beyond. Families have increased psychosocial needs in pregnancies after stillbirth. Current pregnancy management systems and processes should strive to adequately address these needs (GRADE: high).
      • 10
        Adequate care provision includes consistent and timely medical and psychosocial care, services, and support by skilled and familiar care teams knowledgeable about the pervasive impact of stillbirth on the subsequent pregnancy and beyond. All care for families with prior stillbirth should be focused on protecting and promoting the health of the woman and her family, as well as informed choice (GRADE: high).
      • 11
        Peer support is often beneficial for parents in pregnancies after stillbirth. Care providers should discuss and promote peer support options (GRADE: moderate).
      • 12
        Women and families who undergo prior stillbirth are very likely to need emotional support, and the entire family should be provided with opportunities for support during pregnancy and postpartum. Numerous adverse psychological sequelae are associated with pregnancies after stillbirth, including depression, post-traumatic stress, and anxiety. In some people, elevated rates of anxiety and depressive symptoms are shown throughout pregnancy and the postnatal period. Diverse grief reactions are also displayed and should be acknowledged. Care providers should promote family strengths and provide psychosocial screening, targeted follow-up, referrals, and treatment as appropriate (GRADE: high).

      Key Words

      Abbreviations:

      CI (confidence interval), CTG (cardiotocography), GRADE (Grading of Recommendations Assessment, Development and Evaluation), LDA (low-dose aspirin), NST (non-stress test), OR (odds ratio), PAPP-A (pregnancy-associated plasma protein A)
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