Evaluation and Investigations:
Stillbirth is a profoundly distressing event that necessitates a structured and respectful clinical approach. A comprehensive approach to stillbirth evaluation and investigation involves clinical, pathological, genetic, and psychosocial considerations. Stillbirth evaluations are crucial for identifying potential recurrence risks and providing closure for families.
The SOGC Guideline No. 394 - Stillbirth Investigation outlines a systematic protocol for investigating stillbirth, with the objective of identifying underlying causes to guide future pregnancy care and provide closure for grieving families. The cornerstone of the evaluation includes a detailed maternal and family history, fetal and placental examination, and an array of maternal, fetal, and genetic investigations tailored to the specific clinical context.
A complete review of the maternal medical, obstetric, and current pregnancy history is essential, including known risk factors such as hypertension, diabetes, autoimmune disorders, advanced maternal age, smoking, and substance use. Certain maternal conditions such as intrahepatic cholestasis and thromboembolic disorders also contribute significantly to stillbirth risk. Additionally, illicit drug use and moderate to severe maternal anemia have been associated with adverse outcomes, underscoring the need for thorough history-taking and relevant laboratory testing.
From a fetal and genetic perspective, autopsy remains the gold standard for identifying congenital anomalies or structural abnormalities, with a diagnostic yield of over 40%. When autopsy is declined, non-invasive methods such as MRI or limited tissue sampling should be offered. Genetic testing via chromosomal microarray or karyotyping is particularly important in cases with dysmorphic features, hydrops, or suspected genetic syndromes. Fetal tissue for testing should be preserved appropriately, and consultation with genetics specialists is advised.
Placental pathology is another critical component. Histologic examination often reveals signs of placental insufficiency, infarction, infection, or abruption, particularly in growth-restricted fetuses. Umbilical cord abnormalities such as knots or thrombosis, as well as infections (e.g., Group B Streptococcus, CMV, Listeria), are frequently implicated. Cultures and histology of the placenta should be routine, and gross examination should be performed by the clinician at delivery.
Additionally, SOGC Guideline No. 369 - Management of Pregnancy Subsequent to Stillbirth emphasizes the need to evaluate recurrence risk and to collect all relevant clinical data at the time of stillbirth for appropriate counseling and management in subsequent pregnancies. It encourages offering all families placental pathology, autopsy or equivalent imaging, genetic evaluation, and tests for fetomaternal hemorrhage. These steps improve prognostic accuracy and support individualized care pathways.
Finally, it is critical that investigations are carried out with sensitivity and respect. The grieving family's cultural beliefs and consent must be prioritized, and where full autopsy is not acceptable, modified or non-invasive assessments should be pursued. By systematically applying evidence-based protocols while addressing individual circumstances, clinicians can better determine the cause of stillbirth in over half of cases and reduce recurrence risk in future pregnancies.