What to do if You Have Experienced a Stillbirth After 20 Weeks of Pregnancy

This study examined the association between first-pregnancy stillbirth and subsequent adverse perinatal outcomes. This study used birth certificates, hospitalization, and outpatient encounter files to examine the first two singleton deliveries at 20-44 weeks gestation from 1991-2008 (N=71,315). Multivariable logistic regression models (statistical models that examine the simultaneous interactions of multiple variables) were used to assess the association.

Stillbirth was observed in 5.3 of 1000 first deliveries. There was an increased risk of ischemic placental disease, fetal distress, chorioamnionitis, extremely preterm birth, and early neonatal mortality in pregnancies after stillbirth versus after live birth. Interpregnancy intervals of less than two and more than four years after stillbirth increased the risk of ischemic placental disease and spontaneous preterm birth. Risks vary by stillbirth subtype. A first-pregnancy stillbirth may increase adverse perinatal outcomes in subsequent pregnancies.

Clinical implications:

1. A strong association exists between stillbirth in the first pregnancy and subsequent adverse outcomes such as fetal death, extreme prematurity, intrauterine growth restriction (IUGR), fetal distress, and chorioamnionitis.
2. The cause of such adverse outcomes is usually chronic and recurrent. This indicates that there are underlying issues that are present in subsequent pregnancies.
3. The most typical causes of these complications are related to maternal and/or paternal blood clotting disorders and autoimmune disorders. These disorders are associated with poor placenta development. 
4. The placenta should be thoroughly examined during pregnancy using ultrasound and pathologic examination after birth. A pathologist experienced in perinatal pathology should be the only one to assess the placenta.
5. Couples with a history of stillbirth should be thoroughly investigated before pregnancy for thrombophilic abnormalities and, if present, be treated accordingly during the pregnancy.
6. Couples with a history of stillbirth should also be thoroughly investigated before pregnancy for immune system disorders (autoimmunity) and if found, to be treated accordingly.
7. The best way to monitor future pregnancies in such patients is using fetal and maternal placental Doppler and high-resolution ultrasound with power color Doppler; this is the best and most reliable way to monitor treatment success and prevent perinatal adverse events. 
8. All patients with a stillbirth after 20 weeks gestation should be seen by a high-risk specialist experienced in clotting and immune system disorders before a new pregnancy.

Reference: The association between stillbirth in the first pregnancy and subsequent adverse perinatal outcomes (American Journal of Obstetrics and Gynecology 2009; 201; 378.e1-6)