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INTRA-UTERINE FETAL DEATH

(IUFD)

Abdul Hadi bin Abdullah


2/23

Definitiondeath prior to the complete expulsion or extractionfrom its mother of a product of human conception,

irrespective of the duration of pregnancy and which isnot an induced termination of pregnancy.

The death is indicated by the fact that after such

expulsion or extraction, the fetus does not breathe orshow any other evidence of life

2003 revision of the Procedures for Coding Cause of Fetal Death Under ICD-10, the

National Center for Health Statistics


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spontaneous losses occurring at >20 weeks

or

weighing >350 g


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Incidence

> 3 million death each year worldwide

2005 rate of 6.2/1000 total births in US

Rate of early IUD has remained stable

Rate of late fetal loss has decreased by 29% since

1990

African Americans have 2x IUD rate asCaucasians

DM, HTN, abruption, PPROM


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Etiology

Unknown in 25 60% of cases

Identifiable causes can be attributed toMaternal conditions

Fetal conditions

Placental conditions


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Maternal Conditions

Prolonged pregnancy

Diabetes (poorly controlled)

SLE

APAS

Infection

HTN

Preeclampsia

Eclampsia

Hemoglobinopathy

Rh disease

Uterine rupture

Maternal trauma or death

Inherited thrombophilia


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Fetal conditions

Multiple gestation

IUGR

Congenital anomaly

Genetic abnormality

Infection

Hydrops


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Placental Conditions

Cord accident

Abruption

PROM

Vasa previa

Fetomaternal hemorrhage

Placental insufficiency


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Diagnosis

Symptoms- Absence of foetal movements

Per-abdomen-

- Gradual retrogression of the height of the uterus

- Uterine tone is diminished

- Foetal movement are not felt during palpation.- Foetal heart sound is not audible

Investigations-

- X-ray abdomen- Spalding sign: it usually appears 7 days after I.U.F.D.

- Hyperflexion of the spine

- Crowding of the ribs shadow

- Appearance of gas shadow (Roberts sign) : 12 hours


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Sonography :(a) Lack of all foetal motions (including cardiac)

(b) Oligohydramnions and collapsed cranial bones

Diagnosis (contd)


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Lab evaluation


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Complications

1. Psychological upset

2. Infection: Once the membranes rupture, infection,especially by gas forming organism like CI. Welchi.

3. Blood coagulation disorders

4. During labour : Uterine inertia and PPH


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Pregnancy Management

Single or multiple gestation

Gestational age at death

The parents wish


15/23

Management

Explain the problem to the woman and her family.Discuss with them the options of expectant or activemanagement.

If expectant management is planned:

Await spontaneous onset of labour during the next fourweeks

Reassure the woman that in 90% of cases the fetus isspontaneously expelled during the waiting period with nocomplicatons.

If platelets are decreasing, four weeks have passedwithout spontaneous labour, fibrinogen levels are lowor the woman request it,consider active management(induction of labour)


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If induction of labour is planned, assess the cervix

If the cervix is favourable (soft, thin, partly dilated)

labour using oxytocin.

If the cervix is unfavourable(firm, thick, closed) for

IOL.

Note: Do not rupture the membranes.

If spontaneous labor does not occur within four weeks,

platelets are decreasing and the cervix is unfavourable,

for IOL.

Management (contd)


17/23

Management of Future

Pregnancy

If a particular medical problem is identified in the mother, it should be

addressed prior to conception. For example, tight control of blood

glucose prior to conception can substantially reduce the risk of

congenital anomalies in the fetus. Preconceptional counseling ishelpful if congenital anomalies or genetic abnormalities are found.

Genetic screening and detailed ultrasound can evaluate future

pregnancies.

Because a large number of etiologies of fetal demise exist, a provider

has difficulty determining risk of IUD for any particular pregnancy.

Although recurrent fetal loss is uncommon, patients are naturally

anxious. Most patients find increased fetal surveillance with the next

pregnancy reassuring, even though such testing is not clearly

beneficial.


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The ACOG recommends antepartum testing

starting at 32-34 weeks' gestation in an

otherwise healthy mother with history ofIUD.

Weekly biophysical profile or fetal heart

rate testing can be combined with maternalkick counts in the third trimester. For

patients who have experienced earlier loss,

frequent ultrasound is reassuring.


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Antepartum Surveillance

300 women with previous IUD

49% unexplained

1 recurrent IUD despite reassuring testing

Perinatal mortality 3.3/1000

Earliest delivery associated with a positive test result was 32

weeks

Weeks et al. Antepartum surveillance for a history of IUD: When to begin. AJOG

1995;172:486-92.


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Protocol may not be appropriate for all previous

IUDsNonrecurring conditions

Perinatal infection

Fetal anomalies Maternal trauma

IUDs following OB complications that can

recur but cannot be predicted Abruption

Prolapse

Uterine rupture

Antepartum Testing Protocol


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ACOG Practice Bulletin #102

Little evidence-based data to guide antepartum

surveillance with priorunexplained IUD

Antepartum testing may be initiated at 32 34 weeks

Associated with potential morbidity and costs

16.3% delivery at or before 39 weeks

1% delivery before 36 weeks

Management of IUD March 2009


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ACOG Practice Bulletin #102

Antenatal testing before 37 weeks gestation1.5% rate of iatrogenic prematurity for

intervention based on false-positive test

Excess risk of infant mortality due to late

preterm birth

8.8/1000 at 32 33 weeks gestation

3/1000 at 34 36 weeks gestation


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