INTRAUTERINE FETAL DEATH

INTRAUTERINE FETAL DEATH
M. MTALIMANJA
LEARNING OBJECTIVES
• Define IUD
• Explain the predisposing factors to foetal death
• Describe the clinical manifestations and diagnosis of Intra- Uterine
Death
• Discuss the management of IUD once the IUD has occurred
DEFINITION
 Intrauterine death is death of the fetus after viability and before or
during birth
 Death of the fetus after viability (=/>28weeks) before or during
birth
 Also called stillbirth, intrauterine fetal demise (IUFD)
 Fresh still birth (if fetal heart rate was present at the start of birth)
INCIDENCE
• 32/1000 live births in developing countries and 5/1000 live births in
developed countries
CAUSES AND PREDISPOSING FACTORS
During pregnancy
• Chronic conditions ( UTI, diabetes, STIs, Malaria, cholera, RH
incompatibility.
• Chorioamnitis
• Trauma / accidents during pregnancy
• APH
• Placental abruption
• Oligohydromnious
• Placental insufficiency
READ about :TORCH
During labour
• Short cord
• Cord around the neck
• Cord prolapse
• True knots
• Prolonged and obstructed labour
• Malpresentations
• Anesthetic drugs
• Uterine rupture
• Maternal death
PATHOPHYSIOLOGY
• The fetus dies when the placental blood circulation to the fetus is
ceases and the fetal heart stops
• Stasis of the blood at the placental site causes the clotting of blood
and fibrinogen is activated to protect the mother from the clots
• Eventually fibrinogen gets exhausted and disseminated vascular
coagulation may develop within a period of weeks
• Maceration of the fetus starts within 6 hours of intrauterine death
• Aseptic autolysis takes place and pockets of dark fluid accumulates
under the fetuses skin
• The tissue gradually disintegrates causing the skin to peel off the
tissue
• The placenta and fetus may be green due to meconium
• The longer the fetus remains in utero the more macerated it becomes
• The skeleton of the fetus collapses as there's no any tissue to hold it
together and fetal skull bones begin to overlap
• Usually labour starts spontaneously within three weeks after the
death and a macerated fetus is expelled (70-90% of the cases)
• If spontaneous labour does not occur within four weeks there's an
increased risk of DIC
• Maceration summary
• First degree: starts within 24h
• Skin comes loose with hemorrhagic liquor and bulges (blisters)
• Second degree: starts between 24h to 48h
• The blisters burst and the amniotic liquor colors coffee color
• Third degree: starts after 72h
• Spalding’s sign
PREVENTION
• Antenatal care
 Identify women at risk
 Standard screening
 Early access
 Timely refferals
 Awareness of mother about danger signs
• Fresh stillbirth as an indicator for poor quality care
NB; sometimes fetuses die due to unknown reasons
DIAGNOSIS
• History
 Decreased or absent fetal movement
 Brownish vaginal discharge
 Presence of predisposing factors e.g preeclampsia,
infections….
• Exam
 No fetal heart heard
 Fundal height may be less than expected and fails to
increase from the previous visits
Confirmation of death
• No fetal heart heard with fetal scope
Ultrasound
• Fetal heart not detected
• Biparietal diameter shows no increase in growth at weekly intervals
• Loss of fetal structure
• Abnormal reduction in liquor
X-RAYS
• Positive Spalding's sign
• There's overlaping and angulation of cranial bones ( after a week )
• Later there's gross overlapping of the skull bones due to shrinkage of
the brain
 Check FBC, RBS (exclude diabetes), grouping, VDRL
 Fibrinogen <100mg/dl is abnormal!
MANAGEMENT
• The midwife does not tell the patient that fetus is dead until has been
seen by the doctor and uss has been done
• Management
• If no signs of chorioamnionitis or preeclampsia  allow up to 3
wks for spontaneous labour to occur (draw platelets every wk)
• If induction of labour, then:
 If GA 24 - 26 wks, then misoprostol 200 mcg PV every 4 hrs until
delivery.
 If GA 28- 40 wks, then misoprostol 25 mcg orally every 2 hours or 50
mcg PV every 6 hrs until delivery.
 If 1 prior low transverse caesarean delivery and ≤ 28 wks gestation,
then use misoprostol 50 mcg every 4 hours until delivery .
 If more than 1 prior low transverse caesarean delivery and ≤ 28 wks
gestation, then discuss plan with Consultant.
o If 1 or more prior low transverse caesarean deliveries and >28 wks
gestation, then NO misoprostol.
o If prior classical caesarean delivery discuss with Consultant.
• If ≤ 28 wks, may consider use of misoprostol as above.
• If > 28 wks then discuss and document > 1% risk of uterine rupture
and advise repeat caesarean delivery
• If augmentation of labour, then manage similar to live birth
• Ensure privacy to the extent possible
• Provide adequate analgesia
• Provide bereavement counseling
• Placental evaluation and perinatal autopsy recommended
• Counsel regarding risk of recurrence (depends on etiology)
• Management
▫ If Fibrinogen <100mg/dl give fresh blood before labour
• If failed induction after 24 hours, rule out ruptured uterus or extra
uterine pregnancy.
• If signs of infection or macerated stillbirth:
First 24 hrs:
First line: Ampicillin 1 g q6h plus Gentamicin 160 mg x 1
 Second line: Ceftriaxone 1 gram IV plus Flagyl 400 mg TDS PO
Following 4 days: Amoxicillin 1 g TDS PO, plus Flagyl 400 mg TDS PO
QUESTIONS
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