Late Intrauterine Fetal Death and Stillbirth Flashcards
What is the optimal method for diagnosing late IUFD?
- Auscultation and cardiotocography should not be used to investigate suspected IUFD.
- Real-time ultrasonography is essential for the accurate diagnosis of IUFD.
- Ideally, real-time ultrasonography should be available at all times.
- A second opinion should be obtained whenever practically possible.
- Mothers should be prepared for the possibility of passive fetal movement. If the mother reports passive
fetal movement after the scan to diagnose IUFD, a repeat scan should be offered.
What is the best practice for discussing the diagnosis and subsequent care?
- If the woman is unaccompanied, an immediate offer should be made to call her partner, relatives or friends.
- Discussions should aim to support maternal/parental choice.
- Parents should be offered written information to supplement discussions.
What are the general principles of investigation?
- Clinical assessment and laboratory tests should be recommended to assess maternal wellbeing (including coagulopathy) and to determine the cause of death, the chance of recurrence and possible means of avoiding further pregnancy complications.
- Parents should be advised that no specific cause is found in almost half of stillbirths.
- Parents should be advised that when a cause is found it can crucially influence care in a future pregnancy.
- Carers should be aware that an abnormal test result is not necessarily related to the IUFD; correlation between blood tests and postmortem examination should be sought. Further tests might be indicated following the results of the postmortem examination.
- Systems that use customised weight charts and capture multiple contributing factors should be used to
categorise late IUFDs.
Are there any special recommendations for women with an IUFD who are rhesus D-negative?
- Women who are rhesus D (RhD)-negative should be advised to have a Kleihauer test undertaken urgently to detect large feto–maternal haemorrhage (FMH) that might have occurred a few days earlier. Anti-RhD gammaglobulin should be administered as soon as possible after presentation.
- If there has been a large FMH, the dose of anti-RhD gammaglobulin should be adjusted upwards and the Kleihauer test should be repeated at 48 hours to ensure the fetal red cells have cleared.
- If it is important to know the baby’s blood group; if no blood sample can be obtained from the baby or
cord, RhD typing should be undertaken using free fetal DNA (ffDNA) from maternal blood taken shortly
after birth.
What tests should be recommended to identify the cause of late IUFD?
Tests should be directed to identify scientifically proven causes of late IUFD.
What precautions should be taken when sexing the baby?
- Parents can be advised before birth about potential difficulty in sexing the baby, when appropriate.
- Two experienced healthcare practitioners (midwives, obstetricians, neonatologists or pathologists) should inspect the baby when examining the external genitalia of extremely preterm, severely macerated or grossly hydropic infants.
- If there is any difficulty or doubt, rapid karyotyping should be offered using quantitative fluorescent polymerase chain reaction (QF-PCR) or fluorescence in situ hybridisation (FISH).
What is best practice guidance for cytogenetic analysis of the baby?
- Written consent should be taken for any fetal samples used for karyotyping.
- Samples from multiple tissues should be used to increase the chance of culture.
- More than one cytogenetic technique should be available to maximise the chance of informative results.
- Culture fluid should be stored in a refrigerator and thawed thoroughly before use.
What is the guidance on perinatal postmortem examination for maternity clinicians?
- Parents should be offered full postmortem examination to help explain the cause of an IUFD.
- Parents should be advised that postmortem examination provides more information than other (less invasive) tests and this can sometimes be crucial to the management of future pregnancy.
- Attempts to persuade parents to choose postmortem must be avoided; individual, cultural and religious beliefs must be respected.
- Written consent must be obtained for any invasive procedure on the baby including tissues taken for genetic analysis. Consent should be sought or directly supervised by an obstetrician or midwife trained in special consent issues and the nature of perinatal postmortem, including retention of any tissues for clinical investigation, research and teaching.
- Parents should be offered a description of what happens during the procedure and the likely appearance of the baby afterwards. This should include information on how the baby is treated with dignity and any arrangements for transport. Discussions should be supplemented by the offer of a leaflet.
- Postmortem examination should include external examination with birth weight, histology of relevant tissues and skeletal X-rays.
- Pathological examination of the cord, membranes and placenta should be recommended whether or not postmortem examination of the baby is requested.
- The examination should be undertaken by a specialist perinatal pathologist.
- Parents who decline full postmortem might be offered a limited examination (sparing certain organs),
but this is not straightforward and should be discussed with a perinatal pathologist before being
offered. - Less invasive methods such as needle biopsies can be offered, but these are much less informative and reliable than conventional postmortem.
- Ultrasound and MRI should not yet be offered as a substitute for conventional postmortem.
- MRI can be useful adjunct to conventionaLpostmortem.
What are the recommendations for timing and mode of birth?
- Recommendations about labour and birth should take into account the mother’s preferences as well as her medical condition and previous intrapartum history.
- Women should be strongly advised to take immediate steps towards delivery if there is sepsis, preeclampsia, placental abruption or membrane rupture, but a more flexible approach can be discussed if these factors are not present.
- Well women with intact membranes and no laboratory evidence of DIC should be advised that they are unlikely to come to physical harm if they delay labour for a short period, but they may develop severe medical complications and suffer greater anxiety with prolonged intervals. Women who delay labour for periods longer than 48 hours should be advised to have testing for DIC twice weekly (Table 1).
- If a woman returns home before labour, she should be given a 24-hour contact number for information and support.
- Women contemplating prolonged expectant MX should be advised that the value of postmortem may be reduced.
- Women contemplating prolonged expectant MX should be advised that the appearance of baby may deteriorate.
- Vaginal birth is the recommended mode of delivery for most women, but caesarean birth will need to be considered with some.
How should labour be induced for a woman with an unscarred uterus?
- A combination of mifepristone and a prostaglandin preparation should usually be recommended as first-line intervention for induction of labour.
- Misoprostol can be used in preference to prostaglandin E2 because of equivalent safety & efficacy with lower cost but at doses lower than those currently marketed in the UK.
- Women should be advised that vaginal misoprostol is as effective as oral therapy but associated with fewer adverse effects.
What is best practice for induction of labour for a woman with a history of lower segment caesarean section LSCS?
- A discussion of the safety and benefits of induction of labour should be undertaken by a consultant obstetrician.
- Mifepristone can be used alone to increase the chance of labour significantly within 72 hours (avoiding the use of prostaglandin).
- Mechanical methods for induction of labour in women with an IUFD should be used only in the context of a clinical trial.
- Women with a single lower segment scar should be advised that, in general, induction of labour with prostaglandin is safe but not without risk.
- Misoprostol can be safely used for induction of labour in women with a single previous LSCS and an IUFD but with lower doses than those marketed in the UK.
- Women with two previous LSCS should be advised that in general the absolute risk of induction of labour with prostaglandin is only a little higher than for women with a single previous LSCS.
- Women with more than two LSCS deliveries or atypical scars should be advised that the safety of induction of labour is unknown.
What are considered suitable facilities for labour?
- Women should be advised to labour in an environment that provides appropriate facilities for emergency care according to their individual circumstances.
- Maternity units should aim to develop a special labour ward room for well women with an otherwise uncomplicated IUFD that pays special heed to emotional and practical needs without compromising safety. This can include a double bed for her partner or other companion to share, away from the sounds of other women and babies.
- Care in labour should given by an experienced midwife.
What are the recommendations for intrapartum antimicrobial therapy?
- Women with sepsis should be treated with intravenous broad-spectrum antibiotic therapy (including antichlamydial agents).
- Routine antibiotic prophylaxis should not be used.
Intrapartum antibiotic prophylaxis for women colonised with group B streptococcus is not indicated.
Are there any special recommendations for pain relief in labour?
- Diamorphine should be used in preference to Pethidine.
- Regional anaesthesia should be available for women with an IUFD.
- Assessment for DIC and sepsis should be undertaken before administering regional anaesthesia.
- Women should be offered an opportunity to meet with an obstetric anaesthetist.
What are the recommendations for women labouring with a scarred uterus?
- Women undergoing VBAC should be closely monitored for features of scar rupture.
- Oxytocin augmentation can be used for VBAC, but the decision should be made by a consultant obstetrician.