4.11 Intrauterine foetal death


Foetal death from 23 weeks LMP, prior to labour. 

4.11.1 Diagnosis

Diagnosis is confirmed by ultrasound.

If ultrasound is not available, the following signs suggest foetal death but are not sufficiently sensitive to justify a hasty, rash decision. Errors are common. Repeat the exam, do not rush.
– 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.

4.11.2 Management

– If the mother has no life-threatening disorder:
• Treat any maternal pathology (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 (eclampsia, placenta praevia, abruptio placentae, intrauterine infection, severe maternal disease such as congestive heart failure): urgently induce labour.

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

– 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 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 postpartum period.
Inhibition of lactation may be of psychological importance for some women following intrauterine death (Chapter 11, Section 11.2.1).
Staff should avoid persuading parents to see and hold the neonate but should strongly support such desires when expressed (however, this is discouraged if the neonate has been mutilated in case of embryotomy or presents severe malformations). In this case, prepare the neonate as usual, cleaned and wrapped. The body must be given to the parents if they want to organize a funeral.

4.11.3 Induction of labour

– In the third trimester, if the cervix is favourable (Bishop's score ≥ 6): oxytocin and rupture membranes.
– In the third trimester, if the cervix is not favourable or in the second trimester, administer by order of preference: 

mifepristone
+
misoprostol 

mifepristone PO: 200 mg single dose
+
1 to 2 days later misoprostol as indicated below, depending on gestational age

or, if not available

misoprostol
alone

Between 23 and 26 weeks LMP
200 micrograms sublingually or intravaginally, every 4 to 6 hours until labour starts, to be repeated if necessary the following day

Between 27 and 33 weeks LMP
100 micrograms sublingually or intravaginally every 4 to 6 hours until labour starts, to be repeated if necessary the following day  

As of 34 weeks LMP
25 micrograms intravaginally every 6 hours or 25 micrograms PO every 2 hours, to be repeated if necessary the following day

– In case of prior caesarean section or grand multiparity or overdistention of the uterus, given increased risk of uterine rupture:
• If oxytocin is used, see Chapter 7, Section 7.4.4 for precautions for use.  
• If a misoprostol is used: 
Preferably use the combined regimen mifepristone + misoprostol, as fewer numbers of misoprostol doses are required.
Reduce the dose of misoprostol between 23 and 33 weeks LMP: 
- 23 to 26 weeks LMP: 100 micrograms every 6 hours 
- 27 to 33 weeks LMP: 50 micrograms every 6 hours
• Closely monitor the mother for possible signs of impending rupture (heart rate, blood pressure, uterine contractions, pain).
• As of 34 weeks LMP, consider using a Foley catheter 24 hours after administration of mifepristone and before administration of misoprostol in order to increase cervical dilation and reduce the total dose of misoprostol used.



Footnotes
Ref Notes
1

For patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.