4.11 Intrauterine foetal death

Foetal death during the second or third trimester of pregnancy, prior to labour.

4.11.1 Diagnosis

– Absence or cessation of foetal movements—the usual reason for consultation.
– Fundal height too small for gestational age, or decrease in fundal height from a prior visit.
– Absence of foetal heart tone.
– Sometimes, breast engorgement indicating the end of the pregnancy.

None of these signs is sufficiently sensitive to justify a hasty, rash decision. Errors are common. Repeat the exam, do not rush. Diagnosis can be confirmed by ultrasound.

4.11.2 Management

– If the mother has no life-threatening disorder:
• Treat any maternal disorders (anaemia, malaria, etc.).
• If it is certain that the foetus is dead, induce labour.
• If there is any uncertainty, see the woman again at regular intervals (e.g., once a week) and wait for labour to start spontaneously; this generally occurs within 15 to 20 days of foetal death.

– If the mother has a life-threatening disorder:
Urgently induce labour in the event of eclampsia, placenta praevia, abruptio placentae, intra-amniotic infection, severe maternal disease (e.g., congestive heart failure).

– If the amniotic sac has been ruptured for more than 12 hours: antibiotic therapy (Section 4.9.3) and induction of labour.

– Induction of labour:

• In the third trimester, if the cervix is favourable: administer oxytocin and rupture membranes.

• If the cervix is not favourable or in the second trimester:
Administer the combination mifepristone if available + a prostaglandin:
mifepristone PO: 600 mg once daily for 2 days followed on the third day by a prostaglandin (see doses below).
or a prostaglandin alone:
misoprostol intravaginally into the posterior fornix, every 6 hours, until labour begins (max. 3 doses within 24 hours, to be repeated on the following day if required): 200 micrograms in the second trimester or 100 micrograms in the third trimester or 50 micrograms in the ninth month.
dinoprostone gel (1 mg in 3 g of gel): 1 mg intravaginally into the posterior fornix every 6 hours, maximum 3 within 24 hours.

• In case of prior caesarean section or grand multiparity, given increased risk of uterine rupture:
The combination mifepristone + prostaglandin should be favoured to reduce the number prostaglandin doses required.
Reduce by half the doses of oxytocin or misoprostol.
Do not give more than 3 doses of misoprostol or dinoprostone.

– During labour, in cases of malpresentation or foetopelvic disproportion: try everything possible to avoid a caesarean section; accept a long labour, and perform destructive delivery. Caesarean section should only be performed as a last resort.
Caesarean section is performed right away only in cases of complete placenta praevia and/or haemorrhage, where there is a risk of maternal death or uterine rupture.

– Carefully examine the placenta (possibility of retained fragments).

– Perform a manual exploration of the uterus if there is retained placenta or any sign of bleeding (coagulation disorders). Give routine antibiotic prophylaxis (cefazolin or ampicillin slow IV1 , 2 g as a single dose).

– After delivery:
Mothers are at risk of psychological problems after a stillbirth; perinatal death is associated with increased rates of postpartum depression.
Psychological support should be offered to all women at the maternity hospital and in post-partum period.
Inhibition of lactation is of psychological importance for some women following intra uterine death (see Chapter 11, Section 11.2.1).
Staff should avoid persuading parents to see and hold the infant but should strongly support such desires when expressed (however, this is discouraged if the infant has been mutilated in case of embryotomy or presents severe malformations). In this case, prepare the infant as usual, cleaned, wrapped. The body must be given to parents if they want to organize a funeral.

Ref Notes
1 For patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV, 900 mg as a single dose.