Care Around Stillbirth and Neonatal Death (CASaND) Clinical Practice Guideline

Management of a subsequent pregnancy

Care around loss - parent resources

Parents with a history of stillbirth are at an increased risk of stillbirth and other complications in subsequent pregnancies, including pre-eclampsia, SGA, fetal growth restriction (FGR), placental abruption, fetal distress, chorioamnionitis, preterm birth, and neonatal morbidity and death.^10,11 Strategies for reducing the risk of adverse outcomes in a subsequent pregnancy include addressing modifiable risk factors, monitoring the pregnancy (for example using ultrasound), and considering timing/mode of birth for the current pregnancy.

Getting the results of postmortem investigations was of paramount importance for couples whose babies had a genetic or congenital anomaly.

“…having a reason of course is huge. It was a 4% chance of it happening again.”

Bereaved parents, daughter stillborn.⁵

Modifiable risk factors

Modifiable risk factors for stillbirth include overweight (body mass index 25 to 29.9 kg/m²) and obesity (body mass index ≥30 kg/m²), smoking, FGR, hypertension, and diabetes.^7,11,30 Risk mitigation strategies should begin from the postpartum/preconception counselling visit and continue through subsequent pregnancies.

Evidence-based recommendation 5.6

Evidence quality: Moderate confidence

Review maternal risk factors and results of investigations from the previous pregnancy, with detailed clinical history and information from parents, to identify risks and opportunities to improve outcomes.

Be aware of and respectful of cultural, religious, and spiritual-based decisions around care following the death of their previous baby including (if any) postmortem investigations.

Evidence-based recommendation 5.7

Evidence quality: High confidence

At the initial antenatal care visit, explore parents’ expectations, concerns, and support needs including:

risk of recurrent perinatal death
number and timing of appointments
availability of support outside appointments and out of hours
need for and access to additional ultrasound scans, investigations, and monitoring
pregnancy milestones and settings that may evoke a heightened emotional response and require additional support
parents’ discomfort being around other pregnant women
options relating to timing and mode of birth.

Consensus-based recommendation 5.8

Consider early screening for gestational diabetes mellitus (GDM) in addition to routine screening at 26–28 weeks for women with a previous unexplained stillbirth.

Antenatal monitoring and targeted interventions

Fetal monitoring frequency and schedules should be based on obstetric history, screening findings, and parental preferences.^2,11 Women with a history of stillbirth with or without SGA/FGR may be at risk for FGR in the subsequent pregnancy and may benefit from serial growth ultrasound. Recommended monitoring and management of these pregnancies includes consideration of fetal growth ultrasound every 4 weeks from 24 weeks gestation, with additional ultrasounds as clinically indicated and standardised serial symphyseal fundal height (SFH) measurements at each antenatal visit from 24 weeks gestation. Serial fetal biometry measurements are recommended for detecting SGA/FGR.^31,32 Additional ultrasound investigations such as uterine artery Doppler, middle cerebral artery Doppler, cerebroplacental ratio and ductus venosus Doppler may be used to assist in the investigation and management of established FGR.⁷

Parents may benefit from additional support or scans at significant milestones in the pregnancy (such as at the gestational age at which their previous baby died). However, some parents may prefer not to have a scan unless it is clinically indicated^9,31,33 because increased monitoring and scans may provide only temporary reassurance and increase anxiety and fear.^2,11,31

Maternal perception of decreased fetal movement often precedes stillbirth.^34-36 All pregnant women should be routinely provided with verbal and written information about fetal movement, including what is considered normal, and what to do if fetal movements stop, decrease^11,37-39 or change. All women who report a concern about fetal movements to their healthcare professionals should be invited to the health service for assessment without delay.^37,40,41 The benefit of remote home monitoring is yet to be established in high-risk pregnancy populations and for women in pregnancies following loss.⁴²

Consensus-based recommendation 5.9

Determine fetal monitoring frequency based on obstetric history, the circumstances surrounding the index stillbirth or neonatal death, screening findings, and parental preferences.

Consider fetal biometry, amniotic fluid, and fetal Doppler every 4 weeks from 24 weeks’ gestation.
Consider additional support requirements for parents at significant milestones.

It is recognised that low-dose aspirin (LDA) is frequently used in clinical practice and there is no strong evidence of harm associated with its use. While LDA to prevent preterm pre-eclampsia is well established,^32,43,44 its routine use is not indicated for women with a history of stillbirth without other risk factors for preterm pre-eclampsia. There is no high-level evidence to support the use of LDA to prevent FGR and therefore there is practice variation.⁴⁵ In NZ, the Small for Gestational Age and Fetal Growth Restriction Clinical Practice Guideline⁴⁶ does recommend LDA to reduce the risk of developing FGR.

Consensus-based recommendation 5.10

Consider the use of low dose aspirin (LDA) prophylaxis in a pregnancy following loss if preterm pre-eclampsia, or other forms of placental dysfunction, was evident.

Suitable LDA dose is 100–150 mg from 12–36 weeks’ gestation.
LDA prophylaxis is not recommended for preventing early pregnancy loss, spontaneous preterm birth or in the context of prior unexplained stillbirth.

Low-molecular-weight heparin (LMWH) may be prescribed with the primary aim of preventing fetal complications among women with a history of stillbirth, although currently there is no high-level evidence for this use.⁴⁷ However, LMWH should be considered for women at high risk of maternal venous-thromboembolism due to antiphospholipid syndrome.⁴⁷ Further, unfractionated heparin (UFH) or LMWH given in combination with aspirin during pregnancy may increase live birth rates among women who have persistent antiphospholipid antibodies. However, this finding is from one study and the comparator was aspirin treatment alone.⁴⁵

Consensus-based recommendation 5.11

It is not recommended to routinely offer women low-molecular-weight heparin (LMWH) in pregnancies following stillbirth, unless there are other medical considerations or thrombophilia is present.

Timing and mode of birth

Healthcare professionals and parents should engage in open discussions and parent-centred decision making about the timing and mode of birth in subsequent pregnancies.¹¹ Currently, giving birth at 39 weeks’ gestation or beyond is recommended unless earlier birth is medically indicated.¹⁵ Emotional support is crucial for parents who have previously experienced stillbirth, and early birth may be required. For some parents, early term birth may be an opportunity for reducing risk of stillbirth, but this must be balanced with the risks of adverse outcomes for the newborn.^11,15

It is important for parents to receive care from consistent caregivers familiar with their prior experiences, plans, and birthing decisions to reduce distress and improve feelings of security.²⁴

There is no evidence about the role of caesarean birth for non-medical reasons in reducing perinatal death or morbidity for women with a history of stillbirth.¹ The option of a planned caesarean birth should form part of the parent-centred decision-making process.³¹ Women who have experienced a previous intrapartum stillbirth may be more likely to choose a planned caesarean birth.¹

Evidence-based recommendation 5.12

Evidence quality: Moderate confidence

To support parent-centred decision making, discuss timing and mode of birth and consider the circumstances of the previous stillbirth or neonatal death, current pregnancy, and emotional state of parents:

individualise counselling concerning timing and mode of birth
discuss planned birth from 39 weeks’ gestation
discuss the potential harm of early planned birth (such as increased chance of neonatal and longer-term adverse outcomes) before 39 weeks’ gestation.

Evidence indicates that specialist antenatal classes for bereaved parents are rarely provided, despite the benefits of group-based/peer antenatal support and education programmes for parents who have experienced loss.⁹

Evidence-based recommendation 5.13

Evidence quality: Moderate confidence

Offer parents individualised preparation for birth including:

a birth plan that details the likely location of the birth (for example avoiding birthing rooms where the previous baby died)
antenatal classes specific to pregnancy after loss including tailored education (such as on fetal movement) and support
an identifier in medical records to indicate parents have experienced a previous stillbirth or neonatal death.

Approach to care

Social and emotional support