• Take a full history
  
  
• Enquire about fetal movements noting that passive movements after IUD can be felt.
  
  
• Perform basic maternal observations and an antenatal check including maternal heart rate, respiratory rate, blood pressure, temperature, urinalysis and abdominal palpation
  
  
• Diagnosis should be made by real time ultrasound assessment of fetal cardiac pulsation.
  
  
• A second person trained in ultrasound scanning should be present where possible.
  
  
• Where views are difficult to obtain colour doppler and umbilical cord doppler can be used
  
  
• If possible and confident to do so perform a single measurement such as head circumference HC/ abdominal circumference AC or  femur length FL to date pregnancy at this stage 
  
  
• Fetal hydrops, intra-fetal gas or overlapping skull bones may be seen and evidence of these should be documented.
  
  
• If possible try to have support with patient at the time of USS  – if not, once the diagnosis is confirmed offer to call a relative or friend for support
  
  
• Ensure that serious pathology has been excluded such as chorioamnionitis, pre-eclampsia, coagulopathy and abruption
  
  
• Women should be strongly advised to take immediate steps towards delivery if there is sepsis, pre- eclampsia, placental abruption or membrane rupture
  
  
• Take urgent bloods for Full blood count,  group and save and coagulation, CRP and baseline UE/LFT
  
  
• All women should have a have Kleihauer undertaken as soon as possible after presentation as the haemorrhage may have occurred some time before presentation. This allows diagnosis of any feto-maternal haemorrhage as possible cause of the IUD and allows timely administration of Anti-D should the woman be Rhesus negative.
  
  
• Where feto-materal haemorrhage has occurred the dose of Anti-D should be altered and a repeat Kleihauer should be performed at 48 hours to ensure fetal cells have been cleared.

Vaginal delivery

• A vaginal delivery can be achieved in 90% of women in 24hours following induction of labour with an IUD
  
  
• Benefits include recovery time and less time to discharge as well as reduced risks for future pregnancies.
  
  
• Those with group-B strep do not need intrapartum antibiotic prophylaxis
  
  
• If concerns regarding sepsis and infection follow appropriate antibiotic therapy guidance

Caesarean section

• On occasions maternal request for c-section can be considered along with her previous medical and obstetric history
  
  
• Those with a previous c-section should be discussed with the obstetric consultant on call and arrangements made to see an obstetric consultant to discuss delivery options.
  
  
• Those with 1 or 2 c-sections can be advised that IOL is safe but does come with a risk of uterine rupture.
  
  
• Those with 3 c-section scars or atypical scars should be advised that the safety of IOL is unknown

Expectant management

• 85% of women with a confirmed IUD will labour spontaneously within 3 weeks
  
  
• This is an uncommon management option
  
  
• Women who choose expectant management should be warned about the increasing risk of medical complications with prolonged expectant management and should be seen twice a week to exclude DIC and sepsis. The risk of DIC is 10% within the first 4 weeks and 30% thereafter. 
  
  
• Women should also be warned that the appearance of the baby may deteriorate and the value of post mortem examination can be affected with prolonged expectant management.

Reasons for intrauterine death will include congenital malformation, congenital fetal infection, antepartum haemorrhage, pre eclampsia and maternal diabetes mellitus. Intrapartum causes will be secondary to placental abruption, maternal and fetal infection, cord prolapse, uterine rupture and hypoxia-acidosis.

Directing investigations to detect causes and their indications are listed below

• Full blood count FBC, urea and electrolytes UE, liver function tests LFT’s , coagulation screen , Creactive protein CRP 
  To detect pre eclampsia, sepsis and it’s complications such as multi organ failure and disseminated intravascular coagulopathy DIC. 
  
  
• Kleihauer
  To detect late feto-maternal haemorrhage – in all women, not just rhesus negative. Where feasible this should be carried out as soon as possible to diagnosis of IUFD in all women. 
  
  
• Bacteriology , maternal blood cultures, mid stream urine specimen, high vaginal swab , cervical swab 
  Indicated if maternal fever and sepsis, flu like symptoms or abnormal liquor including prolonged rupture of membranes.
  
  
• Maternal serology 
  If maternal fetal infection suspected  e.g fetal hydrops can use booking serum for baseline serology. Parvovirus B19. rubella, CMV herpes and toxoplasma gondii . Treponemal serology can be checked on booking bloods. Consider checking other virus’ if the woman has travelled abroad to endemic areas.
  
  
• Maternal HBA1c
  May indicate type 1 or 2 DM. GDM patients may still have a normal HBA1c
  
  
• Thrombophilia screening
  Lupus anticoagulant and anticardiolipin antibodies should be performed at a later date (e.g post natal follow up) as pregnancy may affect the results
  
  
• Fetal and Placental swabs for microbiology
  Fetal ear and maternal and fetal surfaces of placenta should be swabbed.
  
  
• Placental tissue for karyotyping 
  Offer to all women - written consent is required . Cultures can sometimes fail.
• Post mortem examination
  

  We would encourage all women to have a full post mortem. This may lead to changes in future pregnancy management in up to 20% of cases. 

  Ideally this should be discussed by the on call consultant. If a full post mortem is not wished then the pros and cons of a limited post mortem should be discussed. Written consent is required. 

  If PM is declined, the baby should be examined by the on-call obstetrician and the findings documented.

The majority of women are suitable for vaginal delivery

Those with active bleeding, evidence of abruption or sepsis should be admitted. 

 Where no indications for admission and observation exist 

Administer Mifepristone 200mg orally + arrange admission to LABOUR SUITE 24-48 hours later

• Care should be provided by an experienced midwife in a private room where partners can stay overnight
  
  
• Prescribe all medications on a kardex to avoid delays on admission
  
  
• Side effects of mifepristone include abdominal cramp, rashes and headaches
  
  
• Contraindications include severe asthma, porphyria, renal or liver failure.
  
  
• Benefits include reduced time spent in hospital, reduced number of misoprostol doses and reduced risk of retained placenta
  
  
• Women should be encouraged to attend the department sooner if they have a fever, bleeding, pain or feel otherwise unwell – give contact number for labour suit directly. They will need support during this time
  
  
• If any concerns regarding sepsis initiate appropriate therapy- see antibiotic guideline
  
  
• If there are any patient concerns these women should be brought to labour suite immediately
  
  
• Women should be advised to avoid non steroidal analgesics
  
  
• Women should be warned about the possibility of feeling passive fetal movements

• 4 hourly observations to be completed either on a MEWS chart or the partogram from admission to labour suite.
  
  
• Partogram to be used and fully completed once labour commenced

Administer Misoprostol 50micrograms every 4 hours per vagina (5 doses)

• If after the 1st round of misoprostol (all 5 doses) delivery has not occurred inform the obstetric registrar who should perform a pelvic examination
  
  The obstetric consultant should advise a subsequent plan
  
  Repeat Misoprostol regime
  
  OR
  
  3mg prostin per vagina and repeat at 6 hours. If still undelivered / not in established labour a further discussion with the obstetric consultant should occur

• Labour should be actively managed and this includes the second and third stages
  
  
• ARM should not be performed unless discussed with senior obstetrician and very rarely before 4cm dilation as this may slow progress and increase the risk of infection. A potential exemption may be in the case of massive abruption and IUD where ARM may hasten the process.
  
  
• If there is delay in the second stage there should be a low threshold for consultant involvement as the lack of tone may make delivery of the baby more difficult.
  
  
• Active management of the third stage should occur in line with PPH risk assessment
  
  
• If the placenta appears incomplete and bleeding is ongoing evacuation of retained products of conception should be performed under anaesthetic.
  
  
• Care should be tailored to individual requests and needs where feasible.

This can be potentially difficult due to hydrops or maceration. Advise parents about this potential difficulty when appropriate

2 experienced healthcare professionals (midwives, obstetricians, neonatologists or pathologists ) should examine the baby if determination of sex is difficult. In some cases determination of sex may not be possible and pathology / karyotype will have to be awaited.  

• Post mortem examination should be discussed by the consultant on duty where possible – if not a senior doctor comfortable in discussing PM could take consent. Parents should be given written information by their midwife prior to a final discussion. Parental consent for PM must be documented in notes – also if declined.
  
  
• Perform a thromboprophylaxis risk assessment.
  
  
• Check rhesus status and ensure anti-D given if appropriate.
  
  
• Offer lactation suppression with cabergoline 1mg single dose - contraindicated in hypertensive women.
  
  
• Arrange for immediate discharge letter, appropriate venous thromboembolism risk assessment, pain relief and iron if required.
  
  
• Inform the community midwife / general practitioner and the woman’s lead consultant.
  
  
• Ensure all antenatal appointments have been cancelled
  
  
• Offer counselling services and support group information ( family bereavement service). The Child Bereavement Service will see families ≥23 weeks. Before this gestation referral should be made to SANDS or the Miscarriage Association.
  
  
• Discussion regarding contraception should occur before discharge
  
  
• Clear contact details for MAU or Labour Ward should be given to the parents in case of any postnatal concerns.
  
  
• Written information should be given to the parents to let them know a review of their pregnancy and delivery will take place. They should be given written information on how to contribute if they have specific questions they wish addressed.
  
  
• A Datix should be completed for all losses ≥22 weeks

This should be arranged by the lead consultant for that patient. On occasions a consultant colleague with significant involvement in the case may take over this responsibility.  

Follow up normally occurs 8-12 weeks following the event but patients should be informed that this can be re-arranged if they do not feel able to attend at that stage. 

Management plans for future pregnancies should be documented in the patient’s notes