Intrauterine Fetal Death

Death of the fetus in utero before delivery, most commonly used to describe death from 24 weeks gestation onward (stillbirth, definitions of the specific gestational threshold vary by country), distinguished from earlier pregnancy loss (miscarriage).

Causes include placental insufficiency and FGR, placental abruption, cord accident, congenital anomaly, infection, maternal medical conditions (diabetes, hypertension, obstetric cholestasis), and, in a substantial proportion, no cause is identified despite thorough investigation.

Maternal report of reduced or absent fetal movements is the most common presenting feature, and any such report warrants prompt assessment. Absence of fetal heart sounds on auscultation or handheld Doppler.

Real-time ultrasound confirming absence of fetal cardiac activity is the definitive diagnostic test, and should be performed by an appropriately experienced practitioner, ideally with a second confirmatory opinion given the profound implications of the diagnosis.

• Breaking the news requires sensitivity, clarity, and time, delivered by an experienced clinician in a private setting, with the woman's partner or support person present where possible
• Investigation for cause, offered but not mandatory, and tailored to maternal preference: maternal bloods (FBC, coagulation profile given DIC risk with retained dead fetus, HbA1c, thyroid function, Kleihauer test, maternal infection screen, thrombophilia screen where indicated, antibody screen), placental and fetal examination (with parental consent), and, where accepted, postmortem examination, which remains the single most informative investigation where consent is given
• Mode of delivery: vaginal birth is generally recommended as the preferred mode in the absence of a specific contraindication (previous classical cesarean, placenta praevia), given the lower maternal morbidity compared with cesarean; induction with mifepristone 200 mg PO followed 24 to 48 hours later by misoprostol (dose and route per local protocol, commonly vaginal or oral, repeated at intervals) is standard, with dosing adjusted downward for a previous cesarean scar given rupture risk
• Coagulopathy risk (from thromboplastin release with prolonged fetal retention) increases with time since death, and coagulation should be monitored, particularly if delivery is delayed beyond 2 to 3 weeks from confirmed death
• Anti-D prophylaxis for Rh negative women
• Lactation suppression counseling and, if desired, pharmacological suppression (cabergoline 1 mg PO single dose, given within the first days postpartum) offered
• Bereavement support, memory-making opportunities (holding the baby, photographs, mementos) offered per parental wishes, and referral to bereavement counseling and support services
• Future pregnancy counseling: discussion of recurrence risk (generally low if no specific cause identified, higher with an identified recurrent risk factor such as antiphospholipid syndrome), and a plan for increased surveillance in a subsequent pregnancy

Referral: obstetric-led care throughout; bereavement support and counseling services; genetics or maternal-fetal medicine input where a specific recurrent cause is identified.