Green–top Guideline No. 55 October 2010
baby delivered with no signs of life known to have died after 24 completed weeks of pregnancy’.
Intrauterine fetal death refers to babies with no signs of life in utero.
Stillbirth is common, with 1 in 200 babies born dead.3This compares with one sudden infant death per
10 000 live births.
- What is the optimal method for diagnosing late IUFD?
Real-time ultrasonography is essential for the accurate diagnosis of IUFD.
in the presence of maternal obesity, abdominal scars and oligohydramnios, but views can often be
augmented with colour Doppler of the fetal heart and umbilical cord.
secondary features might be seen:
collapse of the fetal skull with overlapping bones, hydrops, or maceration resulting in unrecognisable
fetal mass. Intrafetal gas (within the heart, blood vessels and joints) is another feature associated with
IUFD that might limit the quality of real-time images. - What is the best practice for discussing the diagnosis and subsequent care?
If the woman is unaccompanied, an immediate offer should be made to call her partner, relatives
or friends.
Discussions should aim to support maternal/parental choice.
Parents should be offered written information to supplement discussions - What are the general principles of investigation?
tests should be recommended to assess maternal wellbeing
(including coagulopathy) and to determine the cause of death, the chance of recurrence and
possible means of avoiding further pregnancy complications.
Parents should be advised that no specific cause is found in almost half of stillbirths
Another important purpose of investigation is to assess maternal wellbeing and ensure prompt
management of any potentially life-threatening maternal disease.
clinical examination for pre-eclampsia, chorioamnionitis and
placental abruption
- Are there any special recommendations for women with an IUFD who are rhesus D-negative?
Women who are rhesus D (RhD)-negative should be advised to have a Kleihauer test undertaken
urgently to detect large feto–maternal haemorrhage (FMH) that might have occurred a few days
earlier.
Anti-RhD gammaglobulin should be administered as soon as possible after presentation.
If there has been a large FMH, the dose of anti-RhD gammaglobulin should be adjusted upwards
and the Kleihauer test should be repeated at 48 hours to ensure the fetal red cells have cleared.
If it is important to know the baby’s blood group; if no blood sample can be obtained from the
baby or
cord, RhD typing should be undertaken using free fetal DNA (ffDNA) from maternal blood taken
shortly after birth.
Major FMH is a silent cause of IUFD and a Kleihauer test is recommended for all women to
diagnose the cause of death - What tests should be recommended to identify the cause of late IUFD?
Tests should be directed to identify scientifically proven causes of late IUFD.
Commonly associated antepartum conditions include
congenital malformation, congenital fetal
infection, antepartum haemorrhage, pre-eclampsia and maternal disease such as diabetes mellitus.
The common causes of intrapartum death
include placental abruption, maternal and fetal infection,
cord prolapse, idiopathic hypoxia–acidosis and uterine rupture
Transplacental infections associated with IUFD include cytomegalovirus,syphilis,and parvovirus B19 ) as
well as listeria, rubella,toxoplasmosis, herpes simplex,
coxsackievirus, leptospira, Q fever, and Lyme disease.Malaria parasitaemia has also been associated with
stillbirth
Ascending infection, with or without membrane rupture, with Escherichia coli, Klebsiella, Group B
Streptococcus, Enterococcus, mycoplasma/ureaplasma, Haemophilus influenzae and Chlamydia
are the more common infectious causes in developed countries,
- What precautions should be taken when sexing the baby?
Two experienced healthcare practitioners (midwives, obstetricians, neonatologists or
pathologists)
should inspect the baby when examining the external genitalia of extremely preterm, severely
macerated or grossly hydropic infants.
If there is any difficulty or doubt, rapid karyotyping should be offered using quantitative
fluorescent polymerase chain reaction (QF-PCR) or fluorescence in situ hybridisation (FISH).
Females can be mistaken for males, and vice versa. - What is best practice guidance for cytogenetic analysis of the baby?
Written consent should be taken for any fetal samples used for karyotyping.
Samples from multiple tissues should be used to increase the chance of culture.
More than one cytogenetic technique should be available to maximise the chance of informative results.
Culture fluid should be stored in a refrigerator and thawed thoroughly before use.
Karyotyping is important as about 6% of stillborn babies will have a chromosomal
abnormality - What is the guidance on perinatal postmortem examination for maternity clinicians?
Parents should be offered full postmortem examination to help explain the cause of an IUFD.
Parents should be advised that postmortem examination provides more information than other (less
invasive) tests and this can sometimes be crucial to the management of future pregnancy.
Attempts to persuade parents to choose postmortem must be avoided
individual, cultural and religious beliefs must be respected.
Written consent must be obtained for any invasive procedure on the baby including tissues taken for
genetic analysis.
Consent should be sought or directly supervised by an obstetrician or midwife trained
in special consent issues and the nature of perinatal postmortem, including retention of any tissues for clinical investigation, research and teaching.
Parents should be offered a description of what happens during the procedure and the likely
appearance of the baby afterwards.
This should include information on how the baby is treated with
dignity and any arrangements for transport.
Discussions should be supplemented by the offer of a leaflet.
Postmortem examination should include external examination with birth weight, histology of relevant
tissues and skeletal X-rays.
Pathological examination of the cord, membranes and placenta should be recommended whether or not
postmortem examination of the baby is requested.
The examination should be undertaken by a specialist perinatal pathologist.
Parents who decline full postmortem might be offered a limited examination (sparing certain organs),
but this is not straightforward and should be discussed with a perinatal pathologist before being
offered.
Less invasive methods such as needle biopsies can be offered, but these are much
less informative and reliable than conventional postmortem.
- What are the recommendations for timing and mode of birth?
should take into account the mother’s preferences as well as her medical condition and previous
intrapartum history.
Women should be strongly advised to take immediate steps towards delivery
if there is sepsis,
preeclampsia,
placental abruption or membrane rupture,
but a more flexible approach can be discussed if these factors are not present.
Women who delay labour for periods longer than 48 hours should be advised to
have testing for DIC twice weekly (Table 1).
If a woman returns home before labour, she should be given a 24-hour contact number for information
and support.
Women contemplating prolonged expectant management should be advised that the appearance of the
baby may deteriorate.
Vaginal birth is the recommended mode of delivery for most women, but caesarean birth will need to be
considered with some.
More than 85% of women with an IUFD labour spontaneously within three weeks of diagnosis.
If the woman is physically well, her membranes are intact and there is no evidence of pre-eclampsia,
infection or bleeding, the risk of expectant management for 48 hours is low.
There is a 10% chance of maternal DIC within 4 weeks from the date of fetal death and an increasing
chance thereafter.
- How should labour be induced for a woman with an unscarred uterus?
A combination of mifepristone and a prostaglandin preparation should usually be recommended
as the first-line intervention for induction of labour.
Misoprostol can be used in preference to prostaglandin E2 because of equivalent safety and
efficacy with lower cost but at doses lower than those currently marketed in the UK.
Women should be advised that vaginal misoprostol is as effective as oral therapy but associated
with fewer adverse effects.
In a study of a case series of 96 women with a late IUFD, the combination of mifepristone and
misoprostol gave an average duration of labour of 8 hours.
The addition of mifepristone appeared to reduce the time interval by about 7 hours compared
with published regimens not including mifepristone, but there was no other apparent benefit.
A single 200 mg dose of mifepristone is appropriate for this indication.
A review of misoprostol use for late IUFD recommended that the dose should be adjusted
according to gestational age
(100 micrograms 6-hourly before 26+6 weeks, 25–50 micrograms 4-hourly at 27+0
weeks or more, up to 24 hours).
mifepristone increase the sensitivity of uterus to PG, shorten the labour by 7hrs.
- What is best practice for induction of labour for a woman with a history of lower
segment caesarean section (LSCS)?
A discussion of the safety and benefits of induction of labour should be undertaken by a
consultant obstetrician.
Mifepristone can be used alone to increase the chance of labour
significantly within 72 hours (avoiding the use of prostaglandin).
Mechanical methods for induction of labour in women with an IUFD should be used only in
the context of a clinical trial.
Women with a single lower segment scar should be advised that, in general, induction of labour
with prostaglandin is safe but not without risk.
Misoprostol can be safely used for induction of labour in women with a single previous
LSCS and an IUFD but with lower doses than those marketed in the UK.
Women with two previous LSCS should be advised that in general the absolute risk of induction
of labour with prostaglandin is only a little higher than for women with a single previous LSCS.
Women with more than two LSCS deliveries or atypical scars should be advised that the safety of
induction of labour is unknown. - What are the recommendations for intrapartum antimicrobial therapy?
Women with sepsis should be treated with intravenous broad-spectrum antibiotic therapy
(including antichlamydial agents).
Routine antibiotic prophylaxis should not be used.
Intrapartum antibiotic prophylaxis for women colonised with group B streptococcus is not
indicated
13 .Are there any special recommendations for pain relief in labour?
Diamorphine should be used in preference to pethidine.
Regional anaesthesia should be available for women with an IUFD.
Assessment for DIC and sepsis should be undertaken before administering regional anaesthesia.
Women should be offered an opportunity to meet with an obstetric anaesthetist.
14 . What are the recommendations for women labouring with a scarred uterus?
Women undergoing VBAC should be closely monitored for features of scar rupture.
Oxytocin augmentation can be used for VBAC, but the decision should be made by a
consultant obstetrician.
Fetal heart rate abnormality, usually the most common early sign of scar dehiscence, does not
apply in this circumstance.
Other clinical features include maternal tachycardia, atypical pain, vaginal
bleeding, haematuria on catheter specimen and maternal collapse
- Where should women receive care before returning home?
Women should be cared for in an environment that provides adequate safety according to
individual clinical circumstance.
Women with no critical care needs should ideally be able to choose between facilities which
provide adequate privacy.
Some women have acute medical problems after birth, e.g. sepsis, pre-eclampsia, etc., with
continuing critical care needs.
Women without acute medical issues who do not want to return home immediately might wish
to receive care within the hospital but away from the maternity unit if such a facility is available.
What are the criteria for thromboprophylaxis?
Women should be routinely assessed for thromboprophylaxis, but IUFD is not a risk factor.
Heparin thromboprophylaxis should be discussed with a haematologist if the woman has DIC.
Given the association of late IUFD with
obesity, advanced maternal age, infection and maternal disease,
it is likely that many women with an IUFD fall into the moderate- or high-risk categories.
7.3 What are the options for suppression of lactation?
almost one-third of those that choose nonpharmacological measures are troubled by excessive
discomfort.
dopamine agonists successfully suppress lactation in a very high
proportion of women and are well tolerated by a very large majority;
cabergoline is superior to bromocriptine.
Dopamine agonists should not be given to women with hypertension or pre-eclampsia.
Estrogens should not be used to suppress lactation.
A double-blind randomised controlled trial of 272 women requesting lactation suppression
compared a single dose of cabergoline (1 mg) with bromocriptine (2.5 mg twice daily) for 14 days.
The two regimens had very similar effectiveness, but cabergoline was simpler to use and had
significantly lower rates of rebound breast activity and adverse events.
Dopamine agonists are contraindicated in women with hypertension or pre-eclampsia.
- What psychological problems can follow late IUFD?
Carers must be alert to the fact that mothers, partners and children are all at risk of prolonged
severe psychological reactions including post-traumatic stress disorder but that their reactions
might be very different.
Perinatal death is associated with increased rates of admission owing to postnatal depression.
Unresolved normal grief responses can evolve into post-traumatic stress disorder.
Women with poor social support are particularly vulnerable - What is best practice for use of interventions that might aid psychological recovery?
Carers should be aware of and responsive to possible variations in individual and cultural
approaches to death.
Counselling should be offered to all women and their partners.
Other family members, especially existing children and grandparents, should also be considered
for counselling.
Debriefing services must not care for women with symptoms of psychiatric disease in isolation.
Parents should be advised about support groups.
18. What recommendations should be made for pregnancy following unexplained late IUFD?
The history of stillbirth should be clearly marked in the case record and carers should ensure
they read all the notes thoroughly before seeing the woman.
Women with a previous unexplained IUFD should be recommended to have obstetric antenatal
care.
Women with a previous unexplained IUFD should be recommended to have screening for
gestational diabetes.
For women in whom a normally formed stillborn baby had shown evidence of being small for
gestational age, serial assessment of growth by ultrasound biometry should be recommended in
subsequent pregnancies.
- What recommendations should be made for the management of future delivery after
unexplained stillbirth?
Previous unexplained IUFD is an indication to recommend birth at a specialist maternity unit.
Previous IUFD related to a known non recurrent cause merits individual assessment for place of
birth.
Maternal request for scheduled birth should take into account the gestational age of the previous
IUFD, previous intrapartum history and the safety of induction of labour.
- What recommendations should be made for maternal care after the next birth?
Carers should be vigilant for postpartum depression in women with a previous IUFD.
Carers should be aware that maternal bonding can be adversely affected.
The birth of a healthy baby does not compensate for a previous loss and can trigger a
resurgence of grief; women might feel happy one moment and sad the next.
Depression in the third trimester is highly predictive of depression one year after subsequent
birth, particularly for women who conceive within less than 12 months from an IUFD.
Unresolved maternal grief may result in disorganisation of attachment with future babies
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