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

Approach to investigations for perinatal deaths

The approach to investigations into perinatal deaths should take into account the most common causes and risk factors within the particular setting of these deaths,38 the value of investigations, the specific clinical circumstances including timing of the death (intrapartum or antepartum stillbirth or neonatal death), and parent preferences. Congenital anomaly is the most frequent classified cause of perinatal deaths in Australia and Aotearoa New Zealand.7,8 Spontaneous preterm birth, often associated with ascending infection, also makes an important contribution to perinatal deaths and is the major cause of neonatal deaths.7,8 Placental insufficiency (with fetal growth restriction) is another important contributor to perinatal deaths.7,8,39 Factors that increase the risk of stillbirth include pre-existing diabetes and hypertension, maternal overweight or obesity, smoking during pregnancy, advanced maternal age, and previous stillbirth.39,40

Although a cause of death may not be found, a negative result may still be valuable to inform future pregnancy planning and parents’ coping with the loss of their baby.

The goal of investigation is to ensure that the most valuable information is obtained from an objective and cost-effective range of tests. Value can be measured according to whether the test identified a new diagnosis, or excluded or confirmed suspected causes.41

While evidence is limited to inform the optimal investigation protocol for stillbirths, there is growing consensus across guidelines internationally.6 A review of existing national guidelines for stillbirth6 from the UK,42 USA,43 Canada,44 and Australia and Aotearoa New Zealand45 showed agreement on a core set of investigations, with additional investigations undertaken depending on initial findings and clinical scenario. For example, thrombophilia testing is now usually recommended in the presence of placental complications, such as fetal growth restriction.6 The use of a rapid placental examination46 and imaging prior to a decision for autopsy47 has been proposed. However, further evaluation of these approaches is needed.

Neonatal deaths can result from disorders of the newborn, the placenta, or the woman. While there are limited studies to guide specific investigation protocols for neonatal deaths,48 many core investigations for stillbirth may also apply to neonatal deaths. However, due to the presence of a wide range of aetiological, clinical, and geographic circumstances across the spectrum of neonatal deaths, the nature of investigations undertaken may vary widely. For example, the investigation of the collapse and death of a newborn receiving standard hospital postnatal care will require a very different investigative approach to that of a baby born at 24 weeks gestation who eventually succumbs to the complications of prematurity after a lengthy course of neonatal intensive care. 

Approaches for alternative less invasive investigations (including imaging), where autopsy is declined by parents, are becoming more standardised.47,49 However, access to high quality imaging services in Australia and Aotearoa New Zealand is a limitation.

Depending on the circumstances of a perinatal death (for example family/whānau wishes, access to services), it may not be feasible for some investigations to be carried out. Situations will exist where the cause of death is already known (for example an unequivocal diagnosis from prenatal testing). However, as selective investigative approaches may result in important diagnoses being missed, a non-selective approach using the core investigations should be the standard initial approach for all perinatal deaths.

Strong multidisciplinary partnerships are essential to ensure optimal investigation of perinatal deaths. The relative merits of the available investigations should be considered on an individual case basis involving consultation between the healthcare team (including the pathologist, obstetrician and/or neonatologist, radiologist, and geneticist) and the parents. Good communication between neonatal and maternity care teams is important to ensure appropriate investigation of neonatal death — for example in the case of suspected neonatal congenital infection.  

Clinical reference guides for health care professionals on the recommended core and additional investigations for stillbirth and neonatal deaths are provided. Please see Appendix 6A: Stillbirth investigations flowchart and Appendix 6B: Neonatal death investigations flowchart.  

Further details on additional investigations are also provided under Additional investigations in specific clinical scenarios.

Evidence-based recommendation 6.8

Evidence quality: Moderate confidence

The recommended core set of investigations, with further investigations based on the clinical circumstances, should be considered routine practice for all perinatal deaths.

  • In some circumstances it may not be appropriate to undertake all core investigations (for example where cause has been unequivocally determined antenatally).
  • Ideally, an individualised approach should be developed through multidisciplinary team discussion including the lead obstetrician, neonatologist/paediatrician, pathologist, radiologist, and geneticist, considering the clinical circumstances and the parents’ wishes. 

Refer to Appendix 6A: Stillbirth investigations flowchart and Appendix 6B: Neonatal death investigations flowchart

Communication and decision making
Core investigations
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Western Pacific Regional Office of the International Stillbirth Alliance
Coordinating Centre, Stillbirth and Neonatal Death Alliance, Perinatal Society of Australia and New Zealand

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