GTG 55 | Late Intrauterine Fetal Death & Stillbirth

This post highlights the key updates from the November 2024 revision of GTG 55: Late Intrauterine Fetal Death (IUFD) and Stillbirth. These updates bring critical changes that are not only pivotal for clinical practice but also for anyone preparing for the MRCOG exams.

GTGs remain an invaluable resource for MRCOG preparation, and understanding these updates in depth is key to staying ahead. I’ve summarized the main points in this post, making it a concise and accessible guide for busy professionals.

I hope you find this post informative and helpful. Your feedback and suggestions to enhance future posts are always appreciated—feel free to share your thoughts in the comments!

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Definitions

Late Intrauterine Fetal Death

• Babies with no signs of life in utero after 24⁺⁰ completed wks of pregnancy

Stillbirth

• Baby delivered with no signs of life known to have died after 24⁺⁰ completed wks of pregnancy

Background & Epidemiology

• Late IUFD 1 in 250
• Sudden Infant death 1 per 10000 live births
• According to MBRRACE-UK National Perinatal Mortality Surveillance Report
• Extended perinatal mortality reduced by 18% ^{over 6 years} 
• Stillbirth reduced by just over 20%
• Stillbirths in 2021  3.54 per 1000 total births in UK
• Babies of women living in the most deprived areas – twice as likely to be stillborn
• Black & Black British ethnicity - twice stillbirth rates

Diagnosis of IUFD

• Avoid auscultation for fetal heart by Pinard stethoscope or Doppler USG or CTG 

Real-time USG

• Essential for accurate dx – allows direct visualization of fetal heart
• Offer discussion of USG findings with parents – for anticipated appearance of baby at birth & explain time of fetal death
• Sensitivity to diagnose occult placental abruption 15%
• Patient may have passive fetal movements; must counsel & may offer repeat scan 

Communicating the diagnosis 

• Provide written information
• Use clear language
• Avoid jargons
• Use professional interpreter
• Give time to absorb the news
• Support maternal/paternal choices

Labour & Birth

• Informed decision b/w parents & experienced obstetrician
• Consider woman’s choice, medical conditions & previous intrapartum history

Suitable Birth facilities  

• Depend on individual circumstances
• Special labour wards room with special focus on emotional & practical needs
• Care to be given by an experienced midwife + obstetrician

Options for birth   SVD  IOL ^{immediate/delayed}  CS  Expectant

Vaginal birth   

• Recommended for most women
• VD Emotionally distressing in IUFD 47% ^{vs 7% in live births}
• VD can occur within 24 hrs of IOL in ~90%
• ↑ shoulder dystocia, clinical chorioamniotis, PPH & retained placenta
• 4-fold ↑ in severe maternal morbidity

Caesarean Section  

• needed for some 
• ↓ perineal trauma, urinary incontinence & POP 
• ↑ surgical morbidity, ↑ risks for fertility & ↑ risks in future pregnancies

Timing of Birth

• No optimal interval to birth

Physically well + Intact membranes + No lab evidence of DIC

• can delay labour for 48 hours   
• if longer then must have testing for DIC
• 10% risk of DIC within 4 weeks
• Interval b/w dx & delivery can ↑ anxiety & DIC

Prolonged Expectant mx

• may ↓ diagnostic value of postmortem
• ≥24 hrs interval from dx to start of labour associated with ↑ risk of moderately severe anxiety or worse OR 4.8

Pool birth   

• Can be offered Late IUFD not a contraindication

Induction of labour

• First-line intervention   Combination of Mifepristone & Misoprostol

FIGO Misoprostol Dosing Regimen 2023
A single 200 mg Mifepristone followed by:
24+0 – 24+6 wks	400 μg misoprostol every 3 hrs
25+0 – 27+6 wks	200 μg misoprostol every 4 hrs
From 28+0 wks	25–50 μg vaginal misoprostol every 4 hrs or 50–100 μg oral misoprostol every 2 hrs

Mifepristone Use

Mifepristone + Misoprostol  vs misoprostol alone

• Significantly shorter time to birth 6.72 ±3.34 hrs vs 11.81 ±6.33 hrs
• Mean induction-birth interval shorter 9.8 vs 16.3
• Less # of misoprostol doses needed & earlier onset of labour
• Mifepristone prior to misoprostol ↑ chance of vaginal birth from 71% to 92%

Misoprostol  

• off-label in UK for IOL in stillbirth
• Vaginal as effective as oral with fewer side effects
• Both routes up to 100% effective in achieving birth at 48 hrs
• Preferable to prostaglandin E2 with equivalent safety, lower cost & lower doses

IOL with previous CS