Diagnosis of Fetal Demise using Ultrasound

Diagnostic Approach

At 18 weeks gestation, ultrasound can reliably document absent cardiac activity, assess fetal anatomy for structural abnormalities that may have caused the demise, evaluate placental appearance, and measure amniotic fluid volume, as recommended by the American College of Radiology and the American Journal of Obstetrics and Gynecology 1, 2
The Society of Radiologists in Ultrasound recommends using the term "Diagnostic of Early Pregnancy Loss (EPL)" or "fetal demise" (specifically at ≥11 weeks gestation) when cardiac activity is absent, according to the American Journal of Obstetrics and Gynecology 1

Once fetal demise is confirmed at 18 weeks, active evacuation (not expectant management) is recommended due to increased risk of intrauterine infection, coagulopathy, and maternal sepsis with prolonged retention, as stated by the American College of Obstetricians and Gynecologists, although the citation is from Praxis Medical Insights, the fact remains the same 3

Invasive procedures like amniocentesis, placental tissue sampling, or umbilical cord sampling should only be considered after fetal demise is confirmed by ultrasound and if there is a clinical indication to determine the cause of death, as recommended by the American College of Obstetricians and Gynecologists 4, 5, 6
The Society for Maternal-Fetal Medicine recommends that diagnostic testing including chromosomal microarray analysis be offered when fetal growth restriction or malformations are detected, but this follows initial ultrasound diagnosis, not precedes it, with a focus on guiding future pregnancies 4, 5

A comprehensive ultrasound examination should assess any signs of hydrops, growth restriction, or other pathology, in addition to confirming absent cardiac activity, evaluating fetal anatomy, placental appearance, and amniotic fluid volume, as supported by evidence from the American Journal of Obstetrics and Gynecology 4, 5

The Society for Maternal‑Fetal Medicine recommends offering diagnostic testing, such as chromosomal microarray analysis, when fetal malformations are identified on ultrasound after confirmation of fetal demise. 8
The Society for Maternal‑Fetal Medicine recommends offering diagnostic testing, such as chromosomal microarray analysis, when fetal growth restriction was documented on ultrasound after confirmation of fetal demise. 8
The Society for Maternal‑Fetal Medicine recommends offering diagnostic testing, such as chromosomal microarray analysis, when there is an unexplained isolated fetal demise before 32 weeks gestation after comprehensive ultrasound assessment. 8

A comprehensive ultrasound at 18 weeks gestation should assess amniotic fluid volume to detect oligohydramnios or polyhydramnios, providing essential information for subsequent management decisions. 9