What is the management approach for a 29-year-old woman, gravida 3 (G3), para 0 (P0), at 28 weeks and 4 days of gestation, presenting with decreased fetal movement and confirmed fetal demise?

Management of Confirmed Fetal Demise at 28 Weeks Gestation

The correct answer is (c): Amniocentesis before delivery has higher yield for chromosomes than post-delivery specimens.

Immediate Management: Cesarean Section is NOT Indicated

• Immediate cesarean delivery is contraindicated for intrauterine fetal demise (IUFD) in the absence of maternal indications 1
• Vaginal delivery is the preferred route for stillbirth, as there is no fetal benefit to cesarean section and it exposes the mother to unnecessary surgical risks 1
• The simplest and most effective method of delivery, particularly before 28 weeks and likely thereafter, is prostaglandin vaginal tablets to induce labor 1

Critical Diagnostic Workup: Timing Matters for Genetic Testing

Amniocentesis performed before delivery provides superior chromosomal analysis compared to post-delivery specimens because:

• Live fetal cells obtained via amniocentesis have higher culture success rates than post-mortem tissue 1
• Post-delivery specimens (placenta, cord blood, fetal tissue) undergo autolysis and cellular degradation, reducing karyotype yield 1
• Four special tests should be obtained to identify causes of "unexplained stillbirth": karyotype, listerial culture, fetomaternal hemorrhage testing, and lupus anticoagulant 1

Essential Pre-Delivery Testing Protocol

• Perform amniocentesis immediately if chromosomal analysis is desired, as this provides the highest diagnostic yield 1
• Obtain maternal blood for Kleihauer-Betke test (fetomaternal hemorrhage) 1
• Send maternal serum for lupus anticoagulant and antiphospholipid antibodies 1
• Plan for placental cultures for Listeria monocytogenes at delivery 1

Autopsy Rates: The Reality vs. Recommendation

• Autopsy rates for stillbirth are far below 80%, making option (b) incorrect 2
• While autopsy is recommended to determine etiology, actual consent and completion rates are substantially lower in clinical practice 2
• Approximately 50% of stillbirths remain unexplained even after thorough investigation 1

Stillbirth Definition: No Universal Standard

• There is NO universally accepted definition of stillbirth, making option (d) incorrect 2
• Different jurisdictions use varying gestational age cutoffs (20 weeks, 24 weeks, 28 weeks) and weight thresholds (350g, 500g) 2
• This case at 28 weeks 4 days meets all common definitions of stillbirth 2

Delivery Planning and Counseling

Mode of Delivery Decision Algorithm

• Vaginal delivery is strongly preferred unless maternal indications exist (prior cesarean with unfavorable cervix, placenta previa, maternal request after extensive counseling) 1
• Prostaglandin vaginal tablets (misoprostol or dinoprostone) are first-line for cervical ripening and labor induction 1
• Oxytocin augmentation may be added if needed after cervical ripening 1

Patient Counseling Points

• Explain that vaginal delivery is safest for the mother and preserves future fertility without cesarean scar complications 1
• Discuss the importance of autopsy and genetic testing for determining recurrence risk in future pregnancies 2
• Counsel that prior stillbirth increases risk of recurrence by 2-fold to 10-fold depending on etiology, presence of fetal growth restriction, and gestational age 2
• Address that subsequent pregnancies after unexplained stillbirth have increased intervention rates but not necessarily increased stillbirth risk 3

Common Pitfalls to Avoid

• Do not delay amniocentesis - waiting until after delivery significantly reduces chromosomal analysis success 1
• Do not perform routine cesarean delivery - this increases maternal morbidity without fetal benefit 1
• Do not assume autopsy will be performed - discuss importance with family immediately, as consent rates are low 2
• Do not miss the opportunity for complete evaluation - approximately 50% of stillbirths can have an identifiable cause if proper testing is performed 1