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The purpose of this study was to determine the optimal gestational age of delivery of a patient with a prior stillbirth by accounting for common neonatal morbidities associated with early term delivery.
A decision-analytic model was designed using TreeAge software to determine the optimal gestational age for delivery of a theoretical cohort of 10,000 women with a history of a prior stillbirth. The model options ranged from delivery at 37 weeks up to 41 weeks' gestation. At each week the model accounts for expectant management with four possible outcomes: (1) spontaneous delivery; (2) medically-indicated delivery; (3) recurrent stillbirth; or (4) expectant management with scheduled induction. Probability and cost estimates were derived from published literature. Primary outcomes included recurrent antepartum stillbirth, neonatal death, respiratory complications, and cerebral palsy. Utility values were assigned to various outcomes and applied to life expectancy to generate quality-adjusted life years (QALYs).
Planned delivery at 38 weeks gestation leads to the best outcomes when considering risk of recurrent stillbirth, neonatal morbidities, and maximizing total QALYs (Table). In the cohort of 10,000 women, delivery at 38 weeks gestation leads to 6 fewer recurrent stillbirths than 39 weeks gestation, but 2 additional cases of neurodevelopmental morbidity. Sensitivity analyses confirm that delivery at 38 weeks was optimal assuming a women has a 1.03 to 5.97-fold greater risk for recurrent still birth in comparison to the general population. Above a 5.97-fold increase, delivery at 37 weeks gestation was shown to be optimal up to an 8.5-fold increased risk (Figure).
1Neonatal outcomes by gestational age of delivery for women with prior stillbirth (in theoretical cohort of 10,000 women)
Scheduled delivery at 38 weeks gestation is consistent with optimal outcomes in women with prior stillbirth as it decreases the risk of recurrence, while acceptably balancing the risk of early term neonatal morbidities.