Benefits, harms, and costs
- 1The 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).
- 2At 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).
- 3Women 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).
- 4At 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).
- 5Routine 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).
- 6Low-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).
- 7Women 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).
- 8Decisions 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).
- 9Families 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).
- 10Adequate 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).
- 11Peer support is often beneficial for parents in pregnancies after stillbirth. Care providers should discuss and promote peer support options (GRADE: moderate).
- 12Women 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).
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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This consensus statement reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate and tailored to their needs.
This guideline was written using language that places women at the centre of care. That said, the SOGC is committed to respecting the rights of all people-including transgender, gender non-binary, and intersex people-for whom the guideline may apply. We encourage healthcare providers to engage in respectful conversation with patients regarding their gender identity as a critical part of providing safe and appropriate care. The values, beliefs and individual needs of each patient and their family should be sought and the final decision about the care and treatment options chosen by the patient should be respected.