Table 35-3 lists an outlined approach for women with prior stillbirth. Importantly, these recommendations are based primarily on limited or inconsistent scientiic evidence or on expert opinions. Unfortunately, few studies address management of afected women. Those with modiiable risk factors for stillbirth, such as hypertension or diabetes, warrant speciic prevention strategies. Given that obesity has been identiied as a risk factor for stillbirth and other obstetrical complications, preconceptional weight loss would seem prudent. Logically, women with a prior fetal death due to placental vascular events, that is, placental insuiciency, are also at increased risk for subsequent adverse perinatal outcomes (Monari, 2016). According to Reddy (2007), because almost half of fetal deaths are associated with growth restriction, fetal sonographic anatomical assessment beginning at midpregnancy is recommended. his is followed by serial growth studies beginning at 28 weeks. Supplementation with vitamin C or E in pregnancy has not been demonstrated to reduce the risk of fetal death (Rumbold, 2015a,b).
Weeks and associates (1995) evaluated fetal biophysical testing in 300 women whose only indication was prior stillbirth. There was one subsequent stillbirth, and only three fetuses had abnormal testing results before 32 weeks. Notably, no relationship was found between the gestational age of the previous stillborn fetus and the incidence or timing of abnormal test results or fetal jeopardy in the subsequent pregnancy. These investigators concluded that antepartum surveillance should begin at 32 weeks or later in the otherwise healthy woman with a history of stillbirth. This recommendation is supported by the American College of Obstetricians and Gynecologists (2016a) with the caveat that it increases the iatrogenic preterm delivery rate. Although fetal movement counting strategies are routinely employed as described in Chapter 17 (p. 332), few data guide its use in clinical practice for those with a prior stillbirth (Mangesi, 2015).
Delivery at 39 weeks' gestation is recommended. Labor induction is suitable, and cesarean delivery is elected for those with a contraindication to induction. his timing minimizes
TABLE 35-3. Management of Subsequent Pregnancy after Stillbirth
Review evaluation of prior stillbirth
Determination of recurrence risk
Discuss recurrence of comorbid obstetric complications
Thrombophilia screen: antiphospholipid antibodies
First-trimester screen: pregnancy-associated plasma protein A, human chorionic gonadotropin, and nuchal
Sonographic screening for fetal-growth restriction,
Delivery before 39 weeks only with documented fetal aprovides risk modification but does not alter management. Modified from Reddy, 2007.
fetal mortality rates, although the degree of risk reduction may be greater for older women (Page, 2013).