Clinical Utility of Stillbirth Investigations in Australia: A Cohort Study

BACKGROUND: Stillbirths impact over two million parents globally every year. Despite current knowledge, technology, and investigations, many stillbirths remain unexplained and are not fully investigated. An important step forward in addressing this gap is determining which investigations produce the highest utility in identifying the cause of death (COD). AIMS: The objective of this study is to identify and define the usefulness or utility of investigations in determining COD among a cohort of stillbirths. MATERIALS AND METHODS: Prospective cohort study from 2013 to 2018 comprising 695 stillbirths. An expert panel blinded to COD assessed the clinical utility of investigations using a purpose-built tool. A stepwise approach was applied, categorising investigations into three groups: clinical and laboratory investigations; placental pathology; and autopsy examination. Clinical utility of the investigations was defined as the proportion of cases in which each test contributed to the identification of the COD. RESULTS: Placental pathology had the highest clinical utility (87%), followed by comprehensive maternal history (82%), genetic analysis (75%), maternal blood investigations for infection (64%), fetal-maternal haemorrhage (FMH) (57%), and fetal autopsy (47%). Placental pathology and genetic analysis were useful across all clinical scenarios, while autopsy was most beneficial when the clinical scenario was unknown. A COD was established in 528 cases (76%), with 310 cases (47%) identified post-placental examination. CONCLUSIONS: The investigations with the highest clinical utility were placental pathology, comprehensive maternal history, genetic analysis, maternal blood investigations, FMH, and fetal autopsy. This study supports a core set of investigations, supplemented by selective tests based on the clinical scenario.