Intrauterine Fetal Demise (IUFD)

Clinical description

Intrauterine fetal demise (IUFD) is death of the fetus ≥ 24 wks gestation or > 500 grams in utero. 80-90% of women experience labour within 2-3 wks. IUFD retained for ≥ 4-5 wks is associated with a 25% risk of DIC.

Signs and symptoms

History Decreased or absent fetal movement Exam No fetal heart heard. Fundal height may be less than expected InvestigationsUS with no fetal cardiac activity (verified by 2 health care providers), may also note oligohydramnios, overlapping sutures, abnormal curvature of the fetal spine; Check FBC, RBS, grouping, VDRL

Treatment

• If IUFD and no chorioamnionitis or preeclampsia, then may allow up to 3 wks for spontaneous labour to

occur (draw platelets every wk)

• If induction of labour, then:
• If GA 24 - 26 wks, then misoprostol 200 mcg PV every 4 hrs until delivery (see Abortion

Protocol).

• If GA 28- 40 wks, then misoprostol 25 mcg orally every 2 hours or 50 mcg PV every 6 hrs until

delivery (see Induction of Labour Protocol).

• If 1 prior low transverse caesarean delivery and ≤ 28 wks gestation, then use misoprostol 50 mcg

every 4 hours until delivery (see Abortion Protocol).

• If more than 1 prior low transverse caesarean delivery and ≤ 28 wks gestation, then discuss plan

with Consultant.

 Consider foley bulb followed by oxytocin at same rate as labour augmentation.

• If 1 or more prior low transverse caesarean deliveries and >28 wks gestation, then NO

misoprostol.

• If prior classical caesarean delivery discuss with Consultant.

 If ≤ 28 wks, may consider use of misoprostol as above.

 If > 28 wks then discuss and document > 1% risk of uterine rupture and advise repeat caesarean delivery.

• If augmentation of labour, then manage similar to live birth
• Ensure privacy to the extent possible
• Provide adequate analgesia
• Provide bereavement counseling
• Placental evaluation and perinatal autopsy recommended
• Counsel regarding risk of recurrence (depends on aetiology)
• If failed induction after 24 hours, rule out ruptured uterus or extrauterine pregnancy.
• If signs of infection or macerated stillbirth:
• First 24 hrs:

 First line: Ampicillin 1 g q6h plus Gentamicin 160 mg x 1  Second line: Ceftriaxone 1 gram IV plus Flagyl 400 mg TDS PO

• Following 4 days: Amoxicillin 1 g TDS PO, plus Flagyl 400 mg TDS PO