In cases with significant growth restriction, with a family or personal history of thrombosis, or with severe placental pathology, testing for factor V Leiden mutation, prothrombin mutation, antithrombin level, and protein C and S activity may provide some information that could afect future pregnancy management (American College of Obstetricians and Gynecologists, 2016a). Our interpretation of relevant placental pathology includes derangements that stem from maternal vessel obstruction, which are described in Chapter 6. Although some have recommended routine evaluation of heritable thrombophilias, no evidence supports the clinical or financial eiciency of screening in an unselected population. Silver and colleagues (2016), with data from the Stillbirth Collaborative Research Network, found that most maternal and fetal thrombophilias were not associated with stillbirth and recommended against routine testing.
Parents are ofered and encouraged to allow a full autopsy. That said, valuable information can still be obtained from limited studies. Pinar and coworkers (2012) described the autopsy protocol used by the Stillbirth Collaborative Research Network. As an alternative, gross external examination combined with photography, radiography, MR imaging, bacterial cultures, and selective use of chromosomal and histopathological studies often aids determination.
A complete autopsy is more likely to yield valuable data. An analysis of 400 consecutive fetal deaths in Wales showed that autopsy altered the presumed cause of death in 13 percent and provided new information in another 26 percent (Cartlidge, 1995). Other investigators have found that autopsy results changed the recurrence risk estimates and parental counseling in 25 to 50 percent of cases (Faye-Petersen, 1999; Silver, 2007). For example, Miller and associates (2016) recently demonstrated that placental examination with autopsy altered future medical management in 45 percent of cases.
According to the survey by Goldenberg and coworkers (2013), most hospitals do not audit stillbirths. In other centers, however, maternal records and autopsy findings are reviewed on a monthly basis by a stillbirth committee composed of obstetricians, maternal-fetal medicine specialists, neonatologists, clinical geneticists, and perinatal pathologists. If possible, the cause of death is assigned based on available evidence. Most importantly, parents are then contacted and ofered counseling regarding the reason for the death, the potential recurrence risk, and possible strategies to avoid recurrence.
Fetal death is psychologically traumatic for a woman and her family. Further stressors are an interval of more than 24 hours between the diagnosis of fetal death and labor induction, not seeing her infant for as long as she desires, having no tokens of remembrance, and poor communication (Radestad, 1996; Siassakos, 2017). The importance of seeing and holding a stillborn fetus for parental psychological well-being was recently summarized by Kingdon and colleagues (2015). As discussed in Chapter 61 (p. 1176), a woman experiencing a stillbirth or early miscarriage is at increased risk for depression and should be closely monitored (Nelson, 2013).
Nuzum and coworkers (2014) reported that few obstetrical providers receive formal training in perinatal bereavement care. At Parkland Hospital, this care includes time with the infant, keepsake items, photographs, chaplaincy consultation, and bereavement support information. Care is coordinated through a dedicated nursing team ailiated with labor and delivery.