Abstract
Objectives
To provide an investigation protocol to help health care providers determine the cause
of a fetal death.
Options
Consideration has been given to protocols for the investigation of fetal death that
are currently available in Canada and in other countries.
Outcomes
Identification of possible causes of stillbirth and their relationship to future pregnancies.
Evidence
Articles related to the etiology of fetal death were identified in a search of PubMed
(June 2006 to September 2018), the Cochrane Library, and investigation protocols from
the American College of Obstetricians and Gynecologists, the International Stillbirth
Alliance Collaborative for Improving Classification of Perinatal Deaths, the Royal
College of Obstetricians and Gynaecologists, the Queensland clinical guidelines, and
the Reproductive Care Program of Nova Scotia.
Benefits
To provide better advice for women regarding possible causes of fetal death and implications
for future pregnancies.
Validation
The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee
and the Clinical Practice Obstetrics Committee of the Society of Obstetricians and
Gynaecologists of Canada. The level of evidence and quality of the recommendation
made was described using the Evaluation of Evidence criteria of the Canadian Task
Force on Preventive Health Care.
Recommendations
- 1A protocol should be used to investigate the possible cause of a fetal death (II-2A).
- 2The diagnostic workup after stillbirth should depend on the specific clinical features per case (II-2A).
- 3Parents should be advised that no specific cause is found in almost half of stillbirths (II-2B).
- 4Placental and cord examination, autopsy, and cytogenetic evaluation should be recommended to all parents, regardless of cultural background, to try to explain the cause of fetal death (II-2B).
- 5Autopsy examination may only be performed with the informed consent of the parents (III-A).
- 6In cases where parents do not consent for autopsy, minimally invasive postmortem examination should be offered using magnetic resonance imaging, where available, combined with less invasive histological tissue sampling (III-B).
Key Words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Obstetrics and Gynaecology CanadaAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Perinatal health indicators for Canada 2017.Public Health Agency of Canada, Ottawa2017: 28
- Classification of causes and associated conditions for stillbirths and neonatal deaths.Semin Fetal Neonatal Med. 2017; 22: 176-185
- An evaluation of classification systems for stillbirth.BMC Pregnancy Childbirth. 2009; 9: 24
- Making stillbirths visible: a systematic review of globally reported causes of stillbirth.BJOG. 2018; 125: 212-224
- Perinatal death investigations: What is current practice?.Semin Fetal Neonatal Med. 2017; 22: 167-175
- management of stillbirth.Obstet Gynecol. 2009; 113: 748-761
- Diagnostic tests for evaluation of stillbirth: results from the Stillbirth Collaborative Research Network.Obstet Gynecol. 2017; 129: 699-706
- Evaluation of stillbirth.Curr Opin Obstet Gynecol. 2018; 30: 130-135
- Green top guideline no. 55: late intrauterine fetal death and stillbirth.Royal College of Obstetricians and Gynaecologists, London2014
- Interventions for investigating and identifying the causes of stillbirth.Cochrane Database Syst Rev. 2018; 4CD012504
- Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis.Lancet. 2011; 377: 1331-1340
- Optimal “work-up” of stillbirth: evidence!.Am J Obstet Gynecol. 2012; 206: 1-2
- Queensland clinical guidelines: stillbirth care.Queensland government, Queensland2018
- Genetics and metabolic causes of stillbirth.Semin Perinatol. 2002; 26: 70-74
- Recurrence of stillbirth and second trimester pregnancy loss.Am J Med Genet A. 2016; 170A: 1174-1180
- Preconception venous thromboembolism and placenta-mediated pregnancy complications.J Thromb Haemost. 2015; 13: 1635-1641
- Stillborn infants: associated malformations.Birth Defects Res. 2018; 110: 114-121
- Karyotype versus microarray testing for genetic abnormalities after stillbirth.N Engl J Med. 2012; 367: 2185-2193
- Evaluation of 1025 fetal deaths: proposed diagnostic workup.Am J Obstet Gynecol. 2012; 206 (53.e1–12)
- Consanguineous marriage, prepregnancy maternal characteristics and stillbirth risk: a population-based case-control study.Acta Obstet Gynecol Scand. 2015; 94: 1095-1101
- Causes of death among stillbirths.JAMA. 2011; 306: 2459-2468
- Stillbirth in the pregnancy complicated by diabetes.Current Diab Rep. 2015; 15: 11
- The effect of hypertensive disorders in pregnancy on small for gestational age and stillbirth: a population based study.BMC Pregnancy Childbirth. 2004; 4: 17
- Stillbirth: the impact of antiphospholipid syndrome?.Lupus. 2017; 26: 237-239
- Hyperemesis, gestational hypertensive disorders, pregnancy losses and risk of autoimmune diseases in a Danish population-based cohort.J Autoimmun. 2012; 38: J120-J128
- Pregnancy outcomes in women with childhood-onset and adult-onset systemic lupus erythematosus: a comparative study.Rheumatol Int. 2016; 36: 1431-1437
- Pregnancy in cyanotic congenital heart disease.Outcome of mother and fetus. Circulation. 1994; 89: 2673-2676
- Maternal medical disease and stillbirth.Clin Obstet Gynecol. 2010; 53: 607-616
- Association between maternal haemoglobin and stillbirth: a cohort study among a multi-ethnic population in England.Br J Haematol. 2017; 179: 829-837
- Contemporary outcomes of sickle cell disease in pregnancy.Am J Obstet Gynecol. 2016; 215 (505.e1–5)
- Factor V Leiden, prothrombin G20210A, and methylene tetrahydrofolate reductase mutations and stillbirth: the Stillbirth Collaborative Research Network.Am J Obstet Gynecol. 2016; 215 (468.e1–17)
- Thrombophilia testing in pregnancy: should we agree to disagree?.J Perinat Med. 2015; 43: 269-272
- Inherited thrombophilia and pregnancy complications: should we test?.Semin Thromb Hemost. 2019; 45 ([erratum in Semin Thromb Hemost 2019;45:e1]): 50-60
- Inflammatory bowel disease in pregnancy: a population-based study of prevalence and pregnancy outcomes.BJOG. 2016; 123: 1862-1870
- Celiac disease and obstetric complications: a systematic review and metaanalysis.Am J Obstet Gynecol. 2016; 214: 225-234
- Outcomes of women delivering at very advanced maternal age.J Womens Health (Larchmt). 2018; 27: 1378-1384
- Stillbirth risk by maternal socio-economic status and country of origin: a population-based observational study in Spain, 2007-08.Eur J Public Health. 2012; 22: 524-529
- Association between stillbirth and risk factors known at pregnancy confirmation.JAMA. 2011; 18: 625-630
- Association between stillbirth and illicit drug use and smoking during pregnancy.Obstet Gynecol. 2014; 123: 113-125
- Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: a prospective population-based case-control study.Hepatology. 2014; 59: 1482-1491
- Intrahepatic cholestasis of pregnancy: maternal and fetal outcomes associated with elevated bile acid levels.Am J Obstet Gynecol. 2015; 212 (100.e1–7)
- Efficacy of ursodeoxycholic acid in treating intrahepatic cholestasis of pregnancy: a meta-analysis.Gastroenterology. 2012; 143: 1492-1501
- Intrahepatic cholestasis of pregnancy: a randomized controlled trial comparing dexamethasone and ursodeoxycholic acid.Hepatology. 2005; 42: 1399-1405
- Perinatal outcomes associated with intrahepatic cholestasis of pregnancy.J Matern Fetal Neonatal Med. 2018; 31: 1913-1920
- Intrahepatic cholestasis of pregnancy: a review of diagnosis and management.Obstet Gynecol Surv. 2018; 73: 103-109
- Stillbirth risk among fetuses with ultrasound-detected isolated congenital anomalies.Obstet Gynecol. 2014; 124: 91-98
- Fetal morbidity and mortality after acute human parvovirus B19 infection in pregnancy: prospective evaluation of 1018 cases.Prenat Diagn. 2004; 24: 513-518
- Human cytomegalovirus infection is detected frequently in stillbirths and is associated with fetal thrombotic vasculopathy.J Infect Dis. 2011; 203: 1526-1533
- Listeria monocytogenes: maternal-foetal infections in Denmark 1994-2005.Scand J Infect Dis. 2009; 41: 21-25
- Fetal growth and risk of stillbirth: a population-based case-control study.PLoS Med. 2014; 11e1001633
- Maternal and fetal risk factors for stillbirth: population based study.BMJ. 2013; 346: f108
- Outcome of pregnancy following second- or third-trimester intrauterine fetal death.Int J Gynaecol Obstet. 2014; 127: 275-278
- Risk of recurrent stillbirth: systematic review and meta-analysis.BMJ. 2015; 350: h3080
- Perinatal mortality associated with abruptio placenta in singletons and multiples.Am J Obstet Gynecol. 2005; 193: 198-203
- Fetal-maternal hemorrhage: a case and literature review.AJP Rep. 2012; 2: 7-14
- Stillbirths in singletons, dichorionic and monochorionic twins: a comparison of risks and causes.Eur J Obstet Gynecol Reprod Biol. 2013; 170: 131-136
- Intrauterine fetal death and stillbirth: guidelines for investigation.Reproductive Care Program of Nova Scotia, Halifax, NS2016
- Stillbirth evaluation: a stepwise assessment of placental pathology and autopsy.Am J Obstet Gynecol. 2016; 214 (115 e1–6)
- The stillbirth collaborative research network postmortem examination protocol.Am J Perinatol. 2012; 29: 187-202
- The Stillbirth Collaborative Research Network neuropathologic examination protocol.Am J Perinatol. 2011; 28: 793-802
- Minimally invasive perinatal autopsies using magnetic resonance imaging and endoscopic postmortem examination (“keyhole autopsy”): feasibility and initial experience.J Matern Fetal Neonatal Med. 2012; 25: 513-518
- Parental acceptance of minimally invasive fetal and neonatal autopsy compared with conventional autopsy.Prenat Diagn. 2014; 34: 1106-1110
- Radiographic evaluation of stillbirth: what does it contribute?.Am J Med Genet A. 2014; 164A: 2270-2275
- Systematic review of placental pathology reported in association with stillbirth.Placenta. 2014; 35: 552-562
- The possible role of intrauterine infections in unexplained second trimester abortions and macerated stillbirths: a study from a single center.J Perinatol. 2004; 24: 679-685
- Infection and stillbirth.Semin Fetal Neonatal Med. 2009; 14: 182-189
- Stillbirth with group B streptococcus disease worldwide: systematic review and meta-analyses.Clin Infect Dis. 2017; 65: S125-S132
- Prediction and prevention of recurrent stillbirth.Obstet Gynecol. 2007; 110: 1151-1164
- Abruptio placentae after auto accidents. A case-control study.J Reprod Med. 2000; 45: 6-10
- Intrahepatic cholestasis of pregnancy: Relationships between bile acid levels and fetal complication rates.Hepatology. 2004; 40: 467-474
- Placental abruption and adverse perinatal outcomes.JAMA. 1999; 282: 1646-1651
- The role of investigations for term stillbirths.J Obstet Gynaecol. 2004; 24: 133-134
- Relationship between obstetric history and Rh(D) alloimmunization severity.Arch Gynecol Obstet. 2008; 277: 245-248
- Ultrasonographic severity scoring of non-immune hydrops: a predictor of perinatal mortality.J Perinat Med. 2015; 43: 53-59
- Gestational syphilis and stillbirth in the Americas: a systematic review and meta-analysis.Rev Panam Salud Publica. 2015; 37: 422-429
- Maternal group B Streptococcus-related stillbirth: a systematic review.BJOG. 2015; 122: 1437-1445
- Congenital anomalies are an independent risk factor for neonatal morbidity and perinatal mortality in preterm birth.Eur J Obstet Gynecol Reprod Biol. 2000; 90: 43-49
- The placenta in intrauterine demise.APMIS. 2018; 126: 621-625
- Potentially preventable stillbirth in a diverse U.S. cohort.Obstet Gynecol. 2018; 131: 336-343
Article info
Publication history
No. 394, January 2020 (Replaces No. 178, June 2006)
Footnotes
This document reflects clinical and scientific consensus on 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 gendered language, but is meant to be inclusive of individuals, including gender diverse individuals who may not identify as women/female. The SOGC is committed to respecting the rights of all people for whom the guideline may apply, including but not limited to transgender, gender non-binary, and intersex people. The SOGC encourages healthcare providers to engage in respectful conversation with patients regarding their gender identity and their preferred gender pronouns, and to apply these guidelines as appropriate to meet each person's needs.
Identification
Copyright
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
