What is the management approach for fetal demise (intrauterine fetal death)?

Management of Intrauterine Fetal Death (IUFD)

The management of intrauterine fetal death should focus on expeditious delivery while prioritizing maternal physical and psychological wellbeing, with the method of delivery determined by gestational age, maternal condition, and previous obstetric history.

Diagnosis Confirmation

• Real-time ultrasound visualization of absent fetal cardiac activity is the most accurate method of confirming fetal death 1
• Document absence of fetal heart activity for at least 30 seconds
• Confirm with a second healthcare provider when possible

Initial Assessment

• Comprehensive maternal evaluation to identify potential causes:
  • Detailed medical and obstetric history
  • Physical examination focusing on vital signs and evidence of infection
  • Laboratory tests:
    • Complete blood count
    • Coagulation profile (fibrinogen, PT/PTT, D-dimer)
    • Kleihauer-Betke test or flow cytometry to detect fetomaternal hemorrhage 2
    • Blood type and antibody screen
    • Glucose level
    • Thyroid function tests
    • Lupus anticoagulant and antiphospholipid antibodies 1
    • Infectious disease screening (TORCH, Listeria, parvovirus B19) 2

Management Options

Expectant Management

• May be appropriate for early gestational ages
• 80% of women will spontaneously labor within 2-3 weeks of fetal demise
• Risk of coagulopathy increases after 3-4 weeks of retained dead fetus
• Monitor maternal coagulation status weekly if expectant management exceeds 4 weeks

Medical Management (Preferred for most cases)

• Prostaglandin vaginal tablets are the most effective method for delivery of a dead fetus, especially before 28 weeks 1
• Regimens:
  • Misoprostol (dosing based on gestational age):
    • 13-26 weeks: 400-600 mcg vaginally every 3-4 hours
    • 27-42 weeks: 200-400 mcg vaginally every 4-6 hours
  • Mifepristone 200 mg orally 24-48 hours before misoprostol can increase efficacy
  • Oxytocin augmentation if needed after cervical ripening

Surgical Management

• Dilation and evacuation (D&E) may be considered up to 24 weeks if provider skilled in the procedure is available
• Consider induction of fetal demise before D&E at later gestational ages using:
  • Intracardiac potassium chloride
  • Intrafetal or intra-amniotic digoxin 3

Cesarean Delivery

• Generally not indicated for fetal demise unless there are maternal indications such as:
  • Previous classical cesarean section
  • Previous uterine surgery with entry into the endometrial cavity
  • Active genital herpes
  • Placenta previa or other contraindications to vaginal delivery

Special Considerations

Multiple Gestations with Single Fetal Demise

• Management depends on chorionicity and gestational age
• In dichorionic twins, expectant management with close monitoring of the surviving twin is often appropriate 4
• In monochorionic twins, risk to surviving twin is higher due to shared circulation:
  • Consider fetal MRI to assess for brain injury in surviving twin
  • Monitor for signs of twin anemia-polycythemia sequence (TAPS) 2
  • Weekly ultrasound and Doppler studies of surviving twin

Twin-Twin Transfusion Syndrome (TTTS) with Fetal Demise

• Fetal demise occurs in 24% of donors and 17% of recipients after laser therapy 2
• Survival of at least one twin can be expected in 50-70% of cases treated with laser therapy 2
• Death of one twin in monochorionic pair can result in neurological injury to the survivor including:
  • Periventricular leukomalacia
  • Intraventricular hemorrhage
  • Hydrocephaly
  • Porencephaly 2

Post-Delivery Evaluation

• Perinatal autopsy and placental examination are the most valuable tests for evaluation of fetal death 5
• Genetic testing (karyotype, microarray)
• Photographs and footprints for parents
• Consider whole body X-ray or MRI if autopsy declined

Psychological Support

• Provide emotional support and counseling resources
• Allow parents to see and hold the baby if desired
• Offer mementos (locks of hair, footprints, photographs)
• Discuss burial/cremation options
• Arrange follow-up appointment for psychological support
• Normalize feelings, positive or negative, and identify supportive resources 2

Follow-up Care

• Schedule post-delivery visit within 2 weeks
• Review autopsy and test results when available
• Discuss recurrence risk and preventive strategies for future pregnancies
• Provide contraceptive counseling if desired
• Screen for postpartum depression and complicated grief

Prevention in Future Pregnancies

• Preconception counseling and optimization of maternal health
• Early and regular prenatal care
• Management of any identified risk factors (diabetes, hypertension, etc.)
• Antenatal surveillance in subsequent pregnancies
• Consider low-dose aspirin if antiphospholipid syndrome identified 5
• Appropriate interpregnancy interval to reduce risk of recurrence 2

Common Pitfalls to Avoid

• Delaying diagnosis and management, which increases maternal psychological trauma
• Failing to obtain appropriate tests to determine cause of death
• Inadequate psychological support for the grieving family
• Missing underlying maternal conditions that could affect future pregnancies
• Neglecting to address both physical and mental health in follow-up care 2