Intrauterine fetal demise: Difference between revisions

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== Definition ==
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== Background ==
   
  +
=== Definition ===
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* Death of fetus in the uterus antepartum after 20 weeks gestation
  
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** Also called intrauterine fetal demise (IUFD)
  
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* Compared to stillbirth, where death is ante- or peripartum after 20 weeks gestation
  
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** Fresh: delivered within 24h of fetal death
  
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*** Zero degree: red skin suggests less than 8h dead
  
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** Macerated: delivered after 24h of fetal death
  
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*** First degree: peeling skin suggests more than 8h from death
  
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*** Second degree: 2-7 days, effusion of skin
  
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*** Third degree: >7 days, yellow liver
  
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* Spontaneous abortion if less than 20 weeks gestation
  
   
  +
*Death of fetus in the uterus antepartum after 20 weeks gestation
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== Etiology ==
  
  +
**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===
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* Idiopathic, most commonly
  
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* Maternal
  
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** Diabetes
  
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** Antiphospholid syndrome
  
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** TORCH syndrome
  
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** Preeclampsia
  
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** Quite rinse rupture
  
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** Porphyria
  
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* Fetal
  
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** Multiple gestation
  
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** Growth restriction
  
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** Hydrocephalus
  
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* Placental
  
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** Abruption
  
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** Insufficiency
  
   
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*Idiopathic, most commonly
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== Risk factors ==
  
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*Maternal
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**[[Diabetes mellitus]]
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**[[Antiphospholid antibody syndrome]]
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**[[TORCH syndrome]]
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**[[Preeclampsia]]
  +
**Quite rinse rupture (??)
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**[[Porphyria]]
  +
*Fetal
  +
**[[Multiple gestation]]
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**[[Intrauterine growth restriction]]
  +
**[[Hydrocephalus]]
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*Placental
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**[[Placental abruption]]
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**[[Placental insufficiency]]
   
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===Risk factors===
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* African-American
  
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* Maternal infertility
  
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* Maternal age >40 years
  
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* Male fetus
  
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* Multiple gestation
  
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* Multiparty
  
   
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*African-American
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== Clinical Presentation ==
  
  +
*Maternal infertility
  +
*Maternal age >40 years
  +
*Male fetus
  +
*Multiple gestation
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*Multiparty
   
  +
==Clinical Manifestations==
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* Decreased fetal movement
  
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* Absent fetal heart beat
  
   
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*Decreased fetal movement
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== Investigations ==
  
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*Absent fetal heart beat
   
  +
==Investigations==
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* Ultrasound for diagnosis
  
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** Spalding sign: overlapping fetal skull bones
  
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** Robert sign: gas in the heart and vessels
  
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* Assess for DIC
  
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** Platelets
  
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** Fibrinogen
  
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** INR/PTT
  
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* To investigate etiology
  
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** CBC
  
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** Blood glucose or HbA1c
  
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** Lupus anticoagulant
  
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** VDRL and TORCH screen
  
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** Placental culture
  
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* Examine the fetus after delivery for signs of trisomies, hydrocephalus
  
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** X-ray
  
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** MRI
  
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** Autopsy
  
   
  +
*Ultrasound for diagnosis
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== Management ==
  
  +
**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==
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* Diagnose with ultrasound
  
  +
−
* Assess risk of DIC
  
  +
*Diagnose with ultrasound
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* Deliver the fetus, preferably vaginally
  
  +
*Assess risk of DIC
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** Induction (preferred)
  
  +
*Deliver the fetus, preferably vaginally
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*** First-line:
  
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**Induction (preferred)
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**** Misoprostol 25-50mcg q4
  
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***First-line:
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**** If no progress after 24h, consider Caesarian section
  
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****[[Misoprostol]] 25-50 mcg q4h
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*** Second-line: oxytocin
  
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****If no progress after 24h, consider Cesarean section
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** Expectant management
  
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***Second-line: [[oxytocin]]
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*** Expected to deliver in 1-2 weeks
  
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**Expectant management
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*** Counsel the patient
  
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***Expected to deliver in 1-2 weeks
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*** Follow coagulation status to monitor for DIC
  
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***Counsel the patient
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* Evaluate the fetus after delivery
  
  +
***Follow coagulation status to monitor for [[DIC]]
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* Counsel and reassure the parents
  
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*Evaluate the fetus after delivery
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* Prevent breast milk
  
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*Counsel and reassure the parents
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** First-line: carbigoline once
  
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*Prevent breast milk
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** Last-line: bromocriptine
  
  +
**First-line: [[cabergoline]] once
  +
**Last-line: [[bromocriptine]]
   
 
[[Category:Obstetrical medicine]]
  
[[Category:Obstetrical medicine]]

Latest revision as of 22:19, 7 August 2020

Background

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

Risk factors

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

Clinical Manifestations

  • 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 25-50 mcg q4h
        • If no progress after 24h, consider Cesarean 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
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