Care of Late Intrauterine Fetal Death and Stillbirth
Scope and Definitions
- Covers late intrauterine fetal death (IUFD) — death of a singleton fetus in utero after 24+0 completed weeks — and care before, during, and after birth, plus care in a future pregnancy.
- Excludes the viability threshold (22+0-23+6 weeks), multiple pregnancy with a surviving co-twin, death following feticide, and delayed delivery of a fetus papyraceous.
- Late IUFD occurs in approximately 1 in 250 births in the UK.
Diagnosis
- Real-time ultrasonography is essential for accurate diagnosis and should be available at all times; a second opinion should be obtained where practically possible.
- Auscultation (Pinard or Doppler) and cardiotocography should not be used to investigate suspected IUFD — they are insufficiently accurate and can give false reassurance.
- Mothers should be warned that passive fetal movement can still be felt after confirmed death; a repeat scan should be offered if reported.
Investigation of Cause
- Clinical and laboratory tests should be recommended to assess maternal wellbeing (including coagulopathy) and to determine the cause of death, recurrence risk, and means of avoiding future complications (Grade D).
- With full investigation (postmortem plus placental histology), a possible or probable cause is found in up to three-quarters of late IUFDs (Grade B). Placental pathology and postmortem are individually the most useful single tests.
- Recommended maternal tests: full blood count/biochemistry with CRP and bile salts, coagulation screen and fibrinogen (repeated twice-weekly if labour is delayed), a Kleihauer test for all women (not only RhD-negative) to detect large feto-maternal haemorrhage, bacteriology (blood/midstream urine/vaginal and cervical swabs) if infection is suspected, viral/tropical serology, random glucose and HbA1c, thyroid function, and a thrombophilia screen where placental disease or FGR is present.
- All women should be offered postmortem examination, genetic (cytogenetic) testing, and placental pathology (Grade B) — this combination has been shown to be the most useful set of investigations. Consent for any invasive procedure must be written; attempts to persuade parents either way must be avoided.
- Rhesus D-negative women should have an urgent Kleihauer test and anti-RhD Ig as soon as possible after presentation (most benefit within 72 hours, some benefit up to 10 days).
Labour and Birth
- The mode and timing of birth should be an informed decision made jointly with the parents and an experienced obstetrician. Vaginal birth is recommended for most women, but caesarean birth needs to be considered for some (Grade D).
- Immediate steps toward delivery should be advised where there is sepsis, pre-eclampsia, placental abruption, or membrane rupture; a more flexible, expectant approach can be discussed where these are absent.
- A combination of mifepristone plus a prostaglandin (usually misoprostol) is the first-line induction regimen (Grade B). A single 200 mg dose of mifepristone is followed by gestation-adjusted misoprostol dosing. Vaginal misoprostol is as effective as oral therapy with fewer adverse effects.
- For women with a single previous lower-segment caesarean, induction with misoprostol between 13+0 and 27+6 weeks can be used at lower doses; safety beyond two previous caesareans or with atypical scars is unknown.
Bereavement, Postnatal and Follow-Up Care
- Parents should be offered the opportunity to see, hold, and spend time with their baby, with memory-making options (photographs, hand/foot prints, memory box) actively supported, following the National Bereavement Care Pathway.
- Lactation suppression, milk donation, and contraception should be discussed before discharge; cabergoline is preferred pharmacologically over bromocriptine for lactation suppression (Grade A).
- Late IUFD is an independent risk factor for VTE (up to six-fold increase); thromboprophylaxis should be routinely assessed.
- A follow-up appointment (typically 6-12 weeks) should review postmortem/placental results, explain the likely cause, and outline a plan for any future pregnancy.
Care in a Future Pregnancy
- Previous unexplained late IUFD carries an almost 5-fold increased recurrence risk and should prompt obstetrician-led antenatal care with continuity of carer.
- Low-dose aspirin (150 mg) should be offered in all subsequent pregnancies following late IUFD associated with placental dysfunction, pre-eclampsia, or unexplained cause.
- Serial fetal biometry, amniotic fluid assessment, and umbilical artery Doppler should be offered from 26-28 weeks given the 2-3 fold increased risk of a subsequent SGA infant.
- At 39+0 weeks and beyond, induction of labour or birth should be offered/discussed, as this is not associated with increased caesarean rate, assisted birth, or neonatal morbidity; there is no evidence to support unindicated birth before 37 weeks.
High-Yield Exam Points
- Auscultation/CTG must never be used to diagnose IUFD — real-time ultrasound is mandatory.
- The trio of postmortem examination + placental histology + cytogenetic testing should be offered to all women — together they find a probable cause in up to 75% of cases.
- Kleihauer testing is recommended for all women with late IUFD, not just RhD-negative women, because large feto-maternal haemorrhage is a silent cause of death.
- First-line induction is mifepristone (single 200 mg dose) plus gestation-adjusted misoprostol dosing.
- In a subsequent pregnancy: low-dose aspirin from early pregnancy plus serial growth/Doppler surveillance from 26-28 weeks, with induction/birth offered at 39 weeks.
Source: RCOG Green-top Guideline No. 55 (2nd edition) (Published online 28 October 2024; next review 2027)
Read the original on rcog.org.uk
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