Care in pregnancies subsequent to stillbirth or perinatal death

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 5 – A N T E N ATA L C A R E

Care in Pregnancies Subsequent to Stillbirth or Perinatal Death Care in pregnancies subsequent to stillbirth or perinatal death. TOG 2021;23:48–59. doi:10.1111/tog.12708

4.8× 2.5% vs 0.4% 80–90% POOLED OR STILLBIRTH AFTER PRIOR SB RATE: PRIOR SB VS PRIOR LIVEBIRTH RECURRENCE RISK, CHI PLACENTAL LESION STILLBIRTH

DO N' T-M IS S FA C TS

1. Prior stillbirth: pooled OR 4.8 for recurrent stillbirth (2.5% vs 0.4%) – comparable to or greater than diabetes/hypertension as a risk factor

2. CHI recurrence 75–90% (rare, incidence 0.06%); VUE recurrence 25–50% – both need histology review + tailored therapy

3. Placental histology identifies cause of death in 95% of cases; reduces ‘unexplained’ rate from 30% to 10%

4. Aspirin 150 mg nocte before 16 weeks to ≥36 weeks – RR 0.41 for perinatal death

5. LMWH: no evidence for fetal benefit (EPPI, TIPPS negative) – use only for VTE risk, antiphospholipid syndrome, or CHI

6. CHI quadruple therapy (aspirin+LMWH+prednisolone+hydroxychloroquine): live births 32%→67%

7. IOL at term ↓perinatal mortality by 70%, no ↑CS risk; consider IOL from 38 weeks after prior SB for emotional reasons

8. Only 10% of parents get bereavement counsellor access despite 67% extra visits/70% extra scans – psychological support is the biggest care gap

PLACENTAL LESION RECURRENCE RISK

CHI 75–90% VUE 25–50% Maternal vascular malperfusion 10–25% Chorioamnionitis (if preterm) 10–25%

ABBREVIATION KEY

SGA — small for gestational age CoDAC — Causes of Death and Associated Conditions (classification system) FGR — fetal growth restriction PSANZ-PDC — Perinatal Society of Australia and New Zealand HIC/LMIC — high-income country / low- and middle-income country Perinatal Death Classification OR/HR/RR — odds ratio / hazard ratio / relative risk LMWH — low-molecular-weight heparin PAR — population attributable risk NICU — neonatal intensive care unit APH — antepartum haemorrhage IOL — induction of labour CHI — chronic histiocytic intervillositis EPAU — early pregnancy assessment unit VUE — villitis of unknown aetiology NICE — National Institute for Health and Care Excellence ICD-PM — International Classification of Diseases, perinatal mortality RCOG — Royal College of Obstetricians and Gynaecologists application (WHO) WHO — World Health Organization ReCoDe — Relevant Condition at Death (classification system)

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — Care in pregnancies subsequent to stillbirth or perinatal death. TOG 2021;23:48–59. doi:10.1111/tog.12708

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