Stillbirth evaluation: a stepwise assessment of placental pathology and autopsy

BACKGROUND: The American Congress of Obstetricians and Gynecologists places special emphasis on autopsy as one of the most important tests for evaluation of stillbirth. Despite a recommendation of an autopsy, many families will decline the autopsy based on religious/cultural beliefs, fear of additional suffering for the child, or belief that no additional information will be obtained or of value. Further, many obstetric providers express a myriad of barriers limiting their recommendation for a perinatal autopsy despite their understanding of its value. Consequently, perinatal autopsy rates have been declining. Without the information provided by an autopsy, many women are left with unanswered questions regarding cause of death for their fetus and without clear management strategies to reduce the risk of stillbirth in future pregnancies. To avoid this scenario, it is imperative that clinicians are knowledgeable about the benefit of autopsy so they can provide clear information on its diagnostic utility and decrease potential barriers; in so doing the obstetrician can ensure that each family has the necessary information to make an informed decision. OBJECTIVE: We sought to quantify the contribution of placental pathologic examination and autopsy in identifying a cause of stillbirth and to identify how often clinical management is modified due to each result. STUDY DESIGN: This is a cohort study of all cases of stillbirth from 2009 through 2013 at a single tertiary care center. Records were reviewed in a stepwise manner: first the clinical history and laboratory results, then the placental pathologic evaluation, and finally the autopsy. At each step, a cause of death and the certainty of that etiology were coded. Clinical changes that would be recommended by information available at each step were also recorded. RESULTS: Among the 144 cases of stillbirth examined, 104 (72%) underwent autopsy and these cases constitute the cohort of study. The clinical and laboratory information alone identified a cause of death in 35 (24%). After placental pathologic examination, 88 (61%) cases had a probable cause of death identified. The addition of autopsy resulted in 78 (74%) cases having an identifiable probable cause of death. Placental examination alone changed clinical management in 52 (36%) cases. Autopsy led to additional clinical management changes in 6 (6%) cases. CONCLUSION: This stepwise assessment of the benefit of both placental pathological examination and autopsy in changing probable cause of death beyond traditional clinical history and laboratory results emphasizes the need to implement more comprehensive evaluation of all stillbirths. With the aim of providing a cause of stillbirth to the parents, and to prevent future stillbirths, it behooves health care professionals to understand the value of this more comprehensive approach and convey that information to the bereaved parents.