Delivery Timing for Pregnant Patients with History of Fetal Demise
Pregnant patients with a history of prior fetal demise should be delivered at 37-38 weeks of gestation in the absence of other complications, balancing the risk of recurrent stillbirth against the complications of prematurity. 1
Evidence-Based Delivery Timing
The Society for Maternal-Fetal Medicine provides clear guidance that in the absence of clinical deterioration or other indication for earlier intervention, delivery by 37-38 weeks should be considered for pregnancies with concerning features including history of fetal demise. 1 This recommendation prioritizes prevention of recurrent stillbirth while minimizing neonatal morbidity from prematurity.
Key Considerations for Timing
Development or worsening of concerning findings in a pregnancy that has reached approximately 34 weeks would be a reasonable indication for delivery, though care should be individualized based on the specific clinical scenario. 1
Antepartum surveillance is appropriate when the pregnancy has reached viable gestational age (≥23 weeks) and when findings from surveillance will assist with delivery timing decisions. 1
The rationale for earlier delivery (37-38 weeks versus 39-40 weeks) stems from the increased risk of recurrent fetal demise, which must be weighed against the relatively modest increase in neonatal complications at late preterm/early term gestations. 1
Antenatal Management Prior to Delivery
Antenatal corticosteroids should be administered if delivery is anticipated before 33 6/7 weeks, or between 34 0/7 and 36 6/7 weeks in women at risk of delivery within 7 days. 2
Magnesium sulfate for neuroprotection should be given for anticipated delivery before 32 weeks gestation. 2
Serial antepartum surveillance should be implemented once viability is reached, with the frequency and modality determined by any coexisting complications (such as fetal growth restriction, hypertension, or other high-risk features). 1
Special Circumstances Requiring Modified Timing
Earlier Delivery Indications
For twin pregnancies complicated by twin-twin transfusion syndrome with single fetal demise after treatment, full-term delivery at 39 weeks of the surviving co-twin is recommended to avoid complications of prematurity unless other indications for earlier delivery exist. 1
Fetal growth restriction with abnormal Dopplers requires gestational age-specific delivery timing: 30-32 weeks for reversed end-diastolic velocity, 33-34 weeks for absent end-diastolic velocity, and 37 weeks for decreased diastolic flow. 2
Any evidence of fetal compromise, maternal complications (preeclampsia, hemorrhage), or other obstetric emergencies would necessitate earlier delivery regardless of gestational age. 1
Mode of Delivery
Cesarean delivery should be considered based on standard obstetric indications including fetal presentation, prior uterine surgery, and evidence of fetal compromise. 1
The history of prior fetal demise alone does not mandate cesarean delivery, but if delivery is indicated for concerning surveillance findings or fetal deterioration, cesarean delivery may be appropriate depending on the clinical scenario. 1
Common Pitfalls to Avoid
Do not delay delivery beyond 38 weeks in patients with prior unexplained fetal demise, as the risk of recurrent stillbirth increases with advancing gestational age while neonatal outcomes at 37-38 weeks are excellent. 1
Ensure delivery occurs at a facility with appropriate neonatal intensive care capabilities if delivery is planned before 37 weeks, particularly before 34 weeks when neonatal complications are more common. 1
Do not rely solely on biophysical profile or cardiotocography for surveillance in high-risk pregnancies; incorporate additional assessment modalities as clinically indicated. 2
Coordinate care between maternal-fetal medicine and neonatology services when delivery is anticipated before 26 weeks or at extremely low birth weights. 2