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 (for DIC if retained or expectant management), HbA1c (undiagnosed diabetes), thyroid function, liver function and bile acids (cholestasis), syphilis serology and infection screen, and Kleihauer-Betke or flow cytometry for fetomaternal haemorrhage — flow cytometry is the more accurate method.^[1]
• Cytogenetics: array comparative genomic hybridisation (array CGH) preferred over conventional karyotype, performed after written consent, on amniotic fluid, fetal tissue, or placenta.^[1]
• Perinatal autopsy: the single highest-yield investigation, offered with care and explicit consent; limited autopsy or post-mortem MRI offered for parents who decline a full autopsy.^[1]
• Placental histopathology: mandatory, the single most commonly abnormal test — send fresh with clinical context.^[1]
• 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 to 28 weeks; 400 micrograms every 3 hours at 24 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 is not contraindicated if 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; 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 (commonly 37 to 39 weeks) where a placental cause was found.^[1][5]
• Support: continuity of carer, a named team, active mental-health screening, and a documented recurrence-risk discussion (approximately two- to five-fold increased risk of recurrence).^[1][6]