ACOG guidelines for stillbirth Mx

On February 20, the American College of Obstetricians and Gynecologists (ACOG) issued a new practice bulletin regarding the clinical management of stillbirth.
This practice bulletin by the ACOG Committee on Practice Bulletins reviews the definitions, management, evaluation, and preventive strategies for stillbirth.
Study Highlights

* The most prevalent risk factors for stillbirth in developed countries are non-Hispanic black race, nulliparity, advanced maternal age, and obesity.
* The US stillbirth rate is higher in non-Hispanic black women vs Hispanic, Asian, American Indian, and non-Hispanic white women (11.25 per 1000 vs 40.0 kg/m2 vs 5.5 per 1000 for nonobese women).
* Other risk factors for stillbirth are pregestational diabetes, history or family history of thromboembolism or multiple thrombophilias, multiple gestations, and past pregnancy complications (preterm delivery, growth restriction, or preeclampsia).
* Women with previous live born growth-restricted infant at less than 32 weeks of gestation vs women with previous stillbirth have 2-fold risk for subsequent stillbirth.
* Severity of fetal growth restriction is linked with increased cumulative stillbirth risk.
* Placental abruption is more likely to cause stillbirth in a preterm fetus.
* Past cesarean delivery has not clearly been linked with stillbirth.
* Abnormal karyotype rate is 8% to 13% of stillbirths, with a higher rate if anatomic abnormalities vs no abnormalities (> 20% vs 4.6%).
* Cell culture is unsuccessful in up to 50% of karyotype attempts.
* Dysmorphic features or skeletal anomalies are present in 20% and major malformations in 15% to 20%.
* Infection-related stillbirth is more common at less than 28 weeks of gestation vs term infant (19% vs 2%).
* Umbilical cord abnormalities occur in 30% of normal births but might be related to stillbirth if obstruction or circulatory compromise is noted and other causes are excluded.
* Discussion with parents should include referring to fetus by name; reasons for autopsy, procedures, and costs; and other evaluations.
* The most important evaluation tests are fetal autopsy; karyotype; and examination of the placenta, cord, and membranes.
* The fetus examination includes assessment of dysmorphic features; weight, length, and head circumference; foot length; photographs; autopsy; and whole-body radiographs with anterior-posterior and lateral views.
* Placenta examination includes gross and microscopic examination of the membranes and umbilical cord.
* Laboratory examination includes karyotype with permission or in situ hybridization if chromosomal culture is unsuccessful.
* Amniocentesis has the best yield for karyotyping.
* Postdelivery sampling includes the placenta or umbilical cord segment closest to the placenta, or fetal cartilage from the costochondral junction or patella.
* Maternal evaluation includes obstetric history; 3-generation pedigree; original medical records, gestational age by last menstrual period, examinations, laboratory tests, and ultrasonography; tests for lupus anticoagulant, anticardiolipin antibodies, human parvovirus B19, and thyroid-stimulating hormone.
* Delivery method and timing depends on gestational age, previous uterine scar, and maternal preference: before 28 weeks of gestation, vaginal misoprostol is most efficient; after 28 weeks of gestation, induction is appropriate if second-trimester dilation and evaluation are not available.
* Parental support includes emotional support, explanation of results, and possible referral for counseling.
* Recurrence risk after 20 weeks is 7.8 to 10.5 per 1000, with the highest risk before 37 weeks.
* Morbidity and mortality risks should be considered in decisions regarding preterm delivery.

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