Chapter 3. Recommendations and best practice statements across the continuum of abortion care

Intrauterine fetal demise (IUFD): Recommendations 32-33

3.4.4 Intrauterine fetal demise (IUFD)

Fetal demise (fetal death) refers to situations in which the fetus is no longer alive, but the uterus has not yet started to expel its contents and the cervical os remains closed (152). The diagnosis is made by ultrasound scan following the clinical findings, which can include vaginal bleeding, absent fetal heart sounds on electronic auscultation, a failure to feel fetal movements or a uterus that is significantly smaller than the expected size (152). IUFD may be managed expectantly, or treated surgically (D&E) or medically.

CLINICAL SERVICES Recommendation 32: Medical management of IUFD at gestational ages ≥ 14 to ≤ 28 weeks

For medical management of IUFD at ≥ 14 to ≤ 28 weeks: Suggest the use of combination mifepristone plus misoprostol over misoprostol alone.

  • Suggested regimen: 200 mg mifepristone administered orally, followed 1–2 days later by repeat doses of 400 μg misoprostol administered sublingually or vaginally every 4–6 hours.* The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.
  • Alternative regimens: repeat doses of 400 μg misoprostol administered sublingually or vaginally every 4–6 hours.*

Remarks:

  • Evidence from clinical studies indicates that the combination regimen is more effective than the use of misoprostol alone.
  • Pregnancy tissue should be treated in the same way as other biological material unless the individual expresses a desire for it to be managed otherwise.

* Misoprostol can be repeated at the noted interval as needed to achieve success of the abortion process. Providers should use caution and clinical judgement to decide the maximum number of doses of misoprostol in pregnant individuals with prior uterine incision. Uterine rupture is a rare complication; clinical judgement and health system preparedness for emergency management of uterine rupture must be considered with later gestational age.

Source: Recommendation 2 carried forward from WHO (2018) (120). Wording has been revised to match that used for Recommendation 31 on missed abortion.

SERVICE DELIVERY Recommendation 33 (NEW): Medical management of intrauterine fetal demise (IUFD) at gestational ages ≥ 14 to ≤ 28 weeks

Type of health worker Recommendation Rationalea
Traditional and complementary medicine professionals Suggest

Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.

Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a In addition, these professionals have been recommended to provide medical abortion at < 12 weeks (Recommendation 28). The expert panel affirmed that the potential to increase equitable access to quality abortion care in regions where such professionals constitute a significant proportion of the health workforce is high.
Auxiliary nurses/ANMs Suggest

Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.

Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a In addition, these health workers have been recommended to provide medical abortion at < 12 weeks (Recommendation 28). The expert panel determined that this option is feasible and acceptable with the potential to increase equitable access to quality abortion care.
Nurses Suggest

Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.

Although insufficient direct evidence was found for the safety and effectiveness of this option, these health workers are often responsible for the monitoring and care of women from the time of misoprostol administration to completion of the abortion. Women often find abortion care provided by nurses to be more acceptable compared with other health workers (moderate-certainty evidence).
Midwives Suggest

Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.

Although insufficient direct evidence was found for the safety and effectiveness of this option, these health workers are often responsible for the monitoring and care of women from the time of misoprostol administration to completion of the abortion. Women often find abortion care provided by midwives to be more acceptable compared with other health workers (moderate-certainty evidence).
Associate/advanced associate clinicians Suggest

Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.

Although insufficient direct evidence was found for the safety and effectiveness of this option, these clinicians routinely carry out tasks of similar complexity, such as vacuum aspiration and manual removal of placentas (138). These clinicians are often present at higher-level facilities where care is provided in advanced gestation. A trained specialist medical practitioner may not always be present at a higher-level facility and the potential to sustain services for advanced gestational ages is increased with more than one trained provider on site.
Generalist medical practitioners Recommend Although insufficient direct evidence was found for the safety and effectiveness of this option, these professionals routinely carry out tasks of similar or greater complexity (e.g. conducting deliveries, manual removal of placentas, vacuum aspiration). The potential benefits of this option outweigh the harms, and the intervention has proven feasible in several settings. A specialist medical practitioner may not always be available on site and therefore this option may increase equitable access to quality abortion care.
Specialist medical practitioners Recommend Within their typical scope of practice,b therefore no assessment of the evidence was conducted.
Note: This is a new recommendation. There was no recommendation on medical management of IUFD in WHO’s 2015 guideline on health worker roles (23), but a clinical services recommendation on this intervention was provided in WHO’s WHO’s 2018 guideline, Medical management of abortion (120). Due to the lack of direct evidence on this topic and the similarity between the two tasks, Recommendation 30 for medical abortion at ≥ 12 weeks of gestation was applied here. A summary of the evidence is presented in Supplementary material 3, EtD framework on Medical management of intrauterine fetal demise.

a For this and all health worker recommendations, given the limited evidence for many of the health worker–task combinations, the discussions of the expert panel focused on the competency framework in WHO’s 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women’s values and preferences.

b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

Medical abortion for pregnancies at gestational ages ≥ 12 weeks has been practised and researched as a facility-based procedure during which women should remain under observation until the process is complete.

Implementation considerations
  • Any regulation around the management/disposal of pregnancy remains and birth or death certificates should not pose a burden or a breach of confidentiality for women or providers.

KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO MANAGEMENT OF IUFD

  • Everyone has a right to privacy and confidentiality in sexual and reproductive health (SRH) care.
  • Abortion regulation should be human rights and evidence based.
  • States must ensure adequate access to essential medicines in an affordable and non-discriminatory manner.
  • Everyone has the right to scientific progress and right to health, which requires the availability and accessibility, acceptability, and quality of medical abortion. This means that States should ensure access to abortion medicines, and that evidence-based standards and guidelines for the provision and delivery of SRH services, are (i) in place and (ii) routinely updated to incorporate medical advancements.

For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.