Intrauterine Fetal Death

The student at the end should be able to : Diagnose IUD in acase with absent fetal movement. Classify the underlying causes. Exclude the underlying cause for fetal death by clinical evaluation and invstigations. Exclude DIC in a case of IUD. Outline the methods for delivery at a given gestational age .

Intrauterine fetal death Is fetal demise after 20 weeks gestation and before the onset of labour . IUD complicates 1% of pregnancies . > 50% of IUD cases are of unknown cause .

Causes of IUD Maternal causes: Fetal causes: -malformation (structural -hypertention . -Diabetes mellitus. -connective tissue disorder . -infection and septicaemia . Placental causes: -pl.dysfunction. -pl.previa,pl.infarction. -Twin twin transfusion s. -fetomaternal haemorrhage. Fetal causes: -malformation (structural and chromosomal) -infection;bacterial , viral. - immune haemolytic dis. -metabolic disease . - Cord accident (prolapse , thrombosis,strangulation, knots. Undetermined 50%

Diagnosis: Diagnosis of IUD : History : -absence of fetal movement . -history of predisposing disease. Examination : - small for date uterus . -absent fetal heart .

Investigation : -PT may be positive in cases when the placenta continue to produce hCG . -Ultrasound :confirm the diagnosis by the lack of fetal heart activity and fetal movement. collapse of fetal body and overlapping of the cranial bones .

Abdominal X-ray : rarely indicated , finding as: .Gas in the C-V system (within 3-4 days) .Overlapping of the fetal skull bone (spalding sign) due to liquefaction of the bones. .Marked curvature or angulation of the spine (maceration of the spinous ligaments ).

Amniocentesis : is rarely indicated. If done it will show a dark brown turbid fluid with marked elevation of the creatine phosphokinase .

Routine laboratory evaluation and follow –up of fetal death : Maternal – on detection : - FBS. - Platelate count ,fibrinogen . - Indirect coombs , Kliehauer test . - Anticardiolipins ,antinuclear AB ,lupus anticoagulant . - Fetal karyotype . - Polymerase chain reaction of fetal tissue to exclude fetal infection . -Amniotic fluid culture for CMV ,anaerobic and aerobic bacteria.

Maternal – subsequent : - Weekly fibrinogen measurements and platelate count if fetal death is more than 4 weeks . Fetal – delivery : - Repeat infection work up. -Karyotype (if not done antenatally). -Post mortem examination . -Fetogram (X ray ) for dysmorphic features.

Management of IUD pregnancy: Fetal demise before 13 weeks (missed abortion) is usually managed by dilatation and evacuation. After 13 - 28 week we have two different approaches : Expectant management : About 80 % of patients will experience spontaneous onset of labour within 2 -3 weeks of fetal demise. The remaining patient not delivered spontaneously we can deliver them by induction .

Induction of labour : The justification for this is to avoid : - Emotional burden on the mother of carrying dead fetus. - 10% risk of DIC if the fetus retained for 5 weeks. - Small possibility of intrauterine infection . Induction is carried by prostaglandin E2 supp. if the cervix is unfavorable ,intravenous oxytocin if the cervix is favorable .

After 28 weeks gestation : If the cervix is favorable for induction oxytocin is the drug of choice . Prostaglandin E2 supp. At this gestational age associated with increased risk of uterine rupture (use smaller dose ). In unfavorable cervix one or more laminaria tents is placed in the cervical canal to enhance ripening ,followed by serial daily oxytocin infusion .

Monitoring of Coagulopathy : Monitoring expectant management is by weekly fibrinogen ,platelate and haematocrit . If abnormality is detected further assessment is by prolonged prothrombin ,partial thromboplastin time and increased fibrinogen-fibrin degradation product . If mild DIC with absence of bleeding delivery is indicated . If sever DIC is noted or evidence of bleeding then correction of defect by cryoprecipitate and fresh frozen plasma prior to intervention .