The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- In low-risk women with unexplained stillbirth the risk of recurrence stillbirth after 20 weeks of gestation is estimated at 7.8–10.5/1,000 with most of this risk occurring before 37 weeks of gestation.
- The most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, and obesity (Table 1 in the original guideline document).
- The risk of subsequent stillbirth is twice as high for women with a prior live born, growth restricted infant delivered before 32 weeks of gestation than for women with a prior stillbirth.
- Amniocentesis for fetal karyotyping has the highest yield and is particularly valuable if delivery is not expected imminently.
The following recommendations and conclusions are based primarily on limited or inconsistent scientific evidence (Level B):
- In the second trimester, dilation and evacuation can be offered. Labor induction also is appropriate at later gestational ages, if second trimester dilation and evacuation is unavailable, or based on patient preference.
- Induction of labor with vaginal misoprostol is safe and effective in patients with a prior cesarean delivery with a low transverse uterine scar before 28 weeks of gestation.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- The most important tests in the evaluation of a stillbirth are fetal autopsy; examination of the placenta, cord, and membranes; and karyotype evaluation.
- Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, religious leader, peer support group, or mental health professional may be advisable for management of grief and depression.
Definitions:
Levels of Evidence
I Evidence obtained from at least one properly designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled trials without randomization.
II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.
II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.
Grades of Recommendation
Level A: Recommendations are based on good and consistent scientific evidence.
Level B: Recommendations are based on limited or inconsistent scientific evidence.
Level C: Recommendations are based primarily on consensus and expert opinion.
