later pregnancies. American College of Obstetricians and Gynecologists' guidelines state that antepartum testing is appropriate beginning at 32 to 34 weeks' gestation in apparently normal pregnancies following prior stillbirth. One of the means of assessment in women with prior stillbirth is maternal assessment of fetal movement using ''kick counts'' to detect decreased movement. One study found that women who kept track of fetal movement had fewer stillbirths than the control group that just reported on fetal movement at prenatal visits. However, another study found no advantage of routine fetal movement counting over informal inquiry about movements during antenatal care. Women with a prior stillbirth should be encouraged to monitor fetal movement starting at 26 to 28 weeks' gestation, with follow-up fetal surveillance if decreased movement is apparent.Therapies for preventing recurrent stillbirth include prophylactic heparin, or the combination therapy of low molecular-weight heparin and low-dose aspirin for women with antiphospholipid antibody syndrome or thrombophilias. Thrombophilias are associated with a 3.6-fold increased risk of stillbirth, although their presence cannot be considered to be causative for stillbirth as many women with normal pregnancies test positive for them. Thrombophilias are more apt to be a factor in fetal death if FGR, placental infarction, and abnormal Doppler velocimetry are present. One study showed improved live birth rates in mothers with prior stillbirth who tested positive for a thrombophilia when given 40 mg/d enoxaparin for 8 weeks. Further studies are needed, however to determine if this should be extended to all women with prior stillbirth and positive thrombophilia screening. Information on the use of low-dose aspirin for prevention of stillbirth is lacking. Two studies have indicated that low-dose aspirin may improve pregnancy outcomes after a prior stillbirth.Management of a pregnancy after a prior stillbirth requires diligence from the time before conception/first prenatal visit to delivery. A detailed history, an evaluation to determine recurrence risk, smoking cessation, weight loss in obese women, and genetic counseling are critical management tools to be considered initially. During the first trimester, standard screening tests including ultrasonography should be done to assess gestational age and screen for diabetes and the presence of antiphospholipid antibodies and thrombophilias. During the second trimester, a fetal anatomic survey at 18 to 20 weeks and uterine artery Doppler studies at 22 to 24 weeks should be performed. Screening for maternal serum AFP, b-hCG, estriol, and inhibin-A should be performed. During the third trimester, starting at 28 weeks, serial ultrasonographic studies should be done to rule out FGR and fetal movement counting by the mother should begin. Antepartum fetal surveillance should start at 32 weeks or 1 to 2 weeks earlier than the gestational age of the previous stillbirth. Delivery should be by elective induction at 39 weeks or befo...

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