Intrauterine fetal demise

Definition

• Death of fetus in the uterus antepartum after 20 weeks gestation
  • Also called intrauterine fetal demise (IUFD)
• Compared to stillbirth, where death is ante- or peripartum after 20 weeks gestation
  • Fresh: delivered within 24h of fetal death
    • Zero degree: red skin suggests less than 8h dead
  • Macerated: delivered after 24h of fetal death
    • First degree: peeling skin suggests more than 8h from death
    • Second degree: 2-7 days, effusion of skin
    • Third degree: >7 days, yellow liver
• Spontaneous abortion if less than 20 weeks gestation

Etiology

• Idiopathic, most commonly
• Maternal
  • Diabetes
  • Antiphospholid syndrome
  • TORCH syndrome
  • Preeclampsia
  • Quite rinse rupture
  • Porphyria
• Fetal
  • Multiple gestation
  • Growth restriction
  • Hydrocephalus
• Placental
  • Abruption
  • Insufficiency

Risk factors

• African-American
• Maternal infertility
• Maternal age >40 years
• Male fetus
• Multiple gestation
• Multiparty

Clinical Presentation

• Decreased fetal movement
• Absent fetal heart beat

Investigations

• Ultrasound for diagnosis
  • Spalding sign: overlapping fetal skull bones
  • Robert sign: gas in the heart and vessels
• Assess for DIC
  • Platelets
  • Fibrinogen
  • INR/PTT
• To investigate etiology
  • CBC
  • Blood glucose or HbA1c
  • Lupus anticoagulant
  • VDRL and TORCH screen
  • Placental culture
• Examine the fetus after delivery for signs of trisomies, hydrocephalus
  • X-ray
  • MRI
  • Autopsy

Management

• Diagnose with ultrasound
• Assess risk of DIC
• Deliver the fetus, preferably vaginally
  • Induction (preferred)
    • First-line:
      • Misoprostol 25-50mcg q4
      • If no progress after 24h, consider Caesarian section
    • Second-line: oxytocin
  • Expectant management
    • Expected to deliver in 1-2 weeks
    • Counsel the patient
    • Follow coagulation status to monitor for DIC
• Evaluate the fetus after delivery
• Counsel and reassure the parents
• Prevent breast milk
  • First-line: carbigoline once
  • Last-line: bromocriptine