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Referral and warning signs
When to refer
Refer ALL women with suspected or confirmed IUFD to a hospital (H/RR) for confirmation, counseling, discussion of management options (expectant vs induction), induction of labour if chosen, and investigation into the cause.
Red flags
- Absent fetal movements confirmed by absent fetal heart tones/ultrasound.
- Signs of maternal sepsis (fever, tachycardia, hypotension).
- Signs of maternal coagulopathy (bruising, bleeding from sites).
- Severe maternal distress requiring immediate support.
Signs and symptoms
- Absence or cessation of fetal movements.
- Decrease/stagnation in uterine size (SFH).
- Absence of fetal heart sounds.
- Vaginal bleeding/brownish discharge.
- Signs of underlying cause.
Risk factors
- Unexplained.
- Congenital/Chromosomal abnormalities.
- Placental dysfunction (IUGR, abruption, previa).
- Maternal conditions (Diabetes, Hypertension/PET, SLE, APS, Severe anaemia, Infections - Malaria, Syphilis).
- Cord accidents.
- Feto-maternal haemorrhage.
- Post-term pregnancy.
- Multiple gestation.
- AMA.
- Obesity.
- Smoking/Substance misuse.
Diagnosis
Clinical assessment
Suspicion based on absent fetal movements/heart sounds.
Investigations
- Ultrasound Scan: Confirmatory. Shows absence of fetal cardiac activity.
- Maternal investigations (often post-delivery) for cause: Blood group/Ab screen, FBC, Coags (DIC risk if prolonged retention), Syphilis serology, TORCH (limited), GTT/HbA1c, Thrombophilia screen, Kleihauer-Betke.
Diagnostic criteria
Confirmation of absent fetal cardiac activity on ultrasound.
Management
Non-pharmacological management
- Breaking Bad News sensitively.
- Emotional/Psychosocial/Bereavement Support.
- Discuss Management Options: Expectant (await spontaneous labour - monitor infection/coagulopathy) vs Induction of Labour (IOL - preferred). C/S generally avoided.
- Post-Delivery: Offer seeing/holding baby, mementos. Respect cultural practices.
- Investigation of Cause: Offer autopsy, placental exam, genetics.
Pharmacological treatment
- Induction of Labour (Medical Management): Regimens depend on gestational age.
- - >=14 to <=28 weeks (UCG Focus):
- - Combined Regimen (Preferred): Mifepristone 200mg PO, followed 24-48h later by Misoprostol 400mcg Vaginally or Sublingually Q4-6H until delivery.
- - Misoprostol Alone: Misoprostol 400mcg Vaginally or Sublingually Q4-6H until delivery.
- - >28 weeks: Induction protocols similar to term pregnancy (e.g., Misoprostol for ripening if needed, followed by Oxytocin infusion). Requires hospital setting.
- Pain Management during Labour: Provide adequate analgesia (Paracetamol, NSAIDs, Opioids).
- Antibiotics: If signs of infection or prolonged retention/induction process.
- Anti-D Immunoglobulin: Give to Rh-negative women after delivery.
Monitoring
Monitor mother for signs of infection (fever, discharge), bleeding, and coagulopathy (especially if prolonged retention) during expectant management or induction. Monitor progress of labour if induced. Provide continuous emotional support.
Complications
- Maternal: Retained placenta, Postpartum haemorrhage, Infection/Sepsis, Coagulopathy/DIC (especially if retention >3-4 weeks), Uterine rupture (rare with induction), Psychological distress/Grief/Depression.
- Future Pregnancies: Increased risk of recurrence depending on the underlying cause. Psychological impact.
Prevention
- Good antenatal care to detect/manage risk factors (IUGR, diabetes, hypertension, post-term pregnancy).
- Prompt management of maternal infections.
- Fetal movement counting awareness by mother.
- Induction for specific indications (e.g., post-term).
- Addressing underlying causes identified from previous IUFD.
Patient education
- Sensitive communication of the diagnosis and confirmation (ultrasound).
- Explanation of management options (expectant waiting vs induction) with risks/benefits.
- Description of the labour process if induction is chosen.
- Pain relief options available.
- Importance of emotional support and acknowledging grief; offer bereavement resources.
- Discussion about investigating the cause (autopsy, placental exam, maternal tests) to inform future pregnancies.
- Contraception/Family planning advice for appropriate interval.
- Planning for future pregnancies (if desired) and potential management strategies.
Uganda-specific notes
IUFD/Stillbirth rates remain high. Access to ultrasound for confirmation is crucial but may not be universally available. Induction with Misoprostol is the common method in hospital settings. Psychosocial support services and comprehensive investigation of cause are often limited. Respectful bereavement care is vital.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.7