Late intrauterine fetal death — structured SAQ (15 marks)

(a) Immediate assessment and communication — first 30 minutes (4 marks)

One mark per point, maximum four. ^[1][3]

• Confirm the diagnosis with real-time ultrasound by a senior operator — document absent fetal cardiac activity, fetal biometry, anatomy where visible, amniotic fluid, placental site, and any signs of maceration or hydrops.^[1]
• Break the news compassionately — eye contact, her name, a private room, her partner present, the offer of a support person and cultural or spiritual care; use clear words ('your baby has died', 'I am so sorry') and avoid 'fetal demise' or 'products'.^[3][4]
• Take a focused history for cause and examine the mother — recent illness, reduced movements and when, bleeding, trauma, drug use, family history of thrombosis or loss; blood pressure, temperature, fundal height, signs of preeclampsia, sepsis, or abruption.^[1]
• Stabilise co-existing maternal disease — preeclampsia (magnesium, blood pressure control), sepsis (cultures, antibiotics), abruption (resuscitation) — and activate the bereavement pathway with a named carer.^[1]

(b) The investigation bundle (5 marks)

One mark per named component with what it tests, plus the yield. Marks are lost for 'bloods and swabs' without specifics. ^[1]

• Maternal blood: full blood count, coagulation with fibrinogen, HbA1c, thyroid function, liver function and bile acids, syphilis serology and infection screen, and Kleihauer-Betke or flow cytometry for fetomaternal haemorrhage.^[1][7]
• Cytogenetics: chromosomal microarray, or karyotype where microarray is unavailable, performed after written consent.^[1][7]
• Perinatal autopsy: postmortem examination can provide information sometimes crucial to future-pregnancy management — offered with care and explicit consent; limited autopsy or post-mortem MRI offered for parents who decline a full autopsy.^[1][7]
• Placental histopathology: a core investigation — examination of the placenta and cord with histopathology, sent with the clinical context.^[1][7]
• The yield: with full investigation including autopsy and placental histology, a possible or probable cause of death is found in up to three-quarters of late IUFDs (RCOG GTG 55, Grade B).^[1]

(c) Plan for the birth (4 marks)

One mark per element. Marks are lost for omitting the mifepristone first-line recommendation or the gestation-specific misoprostol doses. ^[1][2]

• First-line induction: mifepristone 200 mg as a single dose followed by a prostaglandin (RCOG Grade B), which shortens the induction-to-delivery interval versus misoprostol alone.^[1][2]
• Misoprostol by gestation: at 28 weeks and beyond, 25 to 50 micrograms vaginal every 4 hours, or 50 to 100 micrograms oral every 2 hours (Grade C); lower doses at earlier gestations (200 micrograms every 4 hours at 25+0 to 27+6 weeks; 400 micrograms every 3 hours at 24+0 to 24+6 weeks).^[1]
• Mode of birth: vaginal birth is recommended for most women; caesarean is considered for specific indications (e.g. more than two lower-segment scars or atypical scar where induction safety is unknown).^[1]
• Analgesia: regional analgesia can usually be offered provided coagulation is normal — offer the best analgesia available for a labour the family will remember forever.^[1]

(d) The next-pregnancy plan (2 marks)

• Optimise and surveil: stop smoking, achieve a healthy weight, advise side-lying going-to-sleep position from 28 weeks; low-dose aspirin where a placental cause is identified; serial growth scans, uterine artery doppler where indicated, and a low threshold for investigating reduced fetal movements; consider earlier birth where a placental cause was found.^[1][7]
• Support: continuity of carer, a named team, active mental-health screening, and a documented recurrence-risk discussion (risk increased, magnitude modified by cause).^[1][5]