IUFD-INTRAUTERINE DEMISE The American College of Obstetricians and Gynecologists (ACOG) guidelines for

Definition of Fetal Death
The loss of a fetus at any stage is a fetal demise. According to the 2003 revision of the
Procedures for Coding Cause of Fetal Death Under ICD-10, the National Center for
Health Statistics defines fetal death as "death prior to the complete expulsion or
extraction from its mother of a product of human conception, irrespective of the
duration of pregnancy and which is not an induced termination of pregnancy. The death
is indicated by the fact that after such expulsion or extraction, the fetus does not
breathe or show any other evidence of life, such as beating of the heart, pulsation of the
umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be
distinguished from transient cardiac contractions; respirations are to be distinguished
from fleeting respiratory efforts or gasps." 
In the United States, the term stillbirth or fetal demise does not have a standard
definition.
induction of labor states that prostaglandin E2 and misoprostol should not be used in
women with a history of a prior uterine incision because of the risk of uterine rupture. In
2003, Dickinson and Evans reported on the efficacy of oral, vaginal, and combined
administration of misoprostol for second-trimester induction in women without a
uterine scar and found that the superior regimen was misoprostol at 400 mcg vaginally
every 6 hours.2 A meta-analysis of the use of misoprostol for induction in the second and
third trimester showed efficacy of multiple routes (vaginal, oral, sublingual), frequencies
(every 3-12 h), and dosages (100-400 mcg).3
Pain management in patients undergoing induction of labor for fetal demise is usually
easier to manage than in patients with live fetuses. Higher doses of narcotics are
available to the patient and often a morphine or Dilaudid PCA is sufficient for successful
pain control. Should a patient desire superior pain control to intravenous narcotics,
epidural anesthesia should be offered.

For statistical purposes, fetal losses are classified according to gestational age. A death Causes of Fetal Death
that occurs prior to 20 weeks' gestation is usually classified as a spontaneous abortion;
those occurring after 20 weeks constitute a fetal demise or stillbirth. Many states use a The etiology of fetal demise is unknown in 25-60% of all cases. In cases where a cause is

fetal weight of 350 g or more to define a fetal demise. clearly identified, the cause of fetal death can be attributable to fetal, maternal, or
placental pathology. One prospective study attributed 64.9% of fetal death to placental
Although this definition of fetal death is the most frequently used in medical literature,
pathology overall. The same study noted higher rates of fetal demise secondary to
it is by no means the only definition in use. Even within the United States, the
placental pathology at late gestational age.4
differences in the definitions used are substantial.
Maternal
In addition, not all states interpret the weeks of gestation in the same manner. In
California, 20 weeks' gestation is worded "twenty utero gestational weeks" and has
 Prolonged pregnancy (>42 wk)
therefore been interpreted to be 23 weeks from the last menstrual period.
 Diabetes (poorly controlled)
(Implantation in the uterus does not occur until 1 wk after fertilization.) Physicians must
 Systemic lupus erythematosus
check the reporting requirements for the state(s) in which they practice.
 Antiphospholipid syndrome
 Infection
Diagnosis of Fetal Death
 Hypertension

History and physical examination are of limited value in the diagnosis of fetal death. In  Preeclampsia

most patients, the only symptom is decreased fetal movement. An inability to obtain  Eclampsia

fetal heart tones upon examination suggests fetal demise; however, this is not  Hemoglobinopathy

diagnostic and death must be confirmed by ultrasonographic examination.  Advanced maternal age
 Rh disease
Fetal demise is diagnosed by visualization of the fetal heart and the absence of cardiac
 Uterine rupture
activity.
 Maternal trauma or death
Management of Fetal Death
 Inherited thrombophilias
Once the diagnosis of fetal demise has been confirmed, the patient should be informed Fetal
of her condition. Often, allowing the mother to see the lack of cardiac activity helps her
to accept the diagnosis.
 Multiple gestations
Labor induction should be offered after diagnosis. Patient responses vary in regard to  Intrauterine growth restriction
this recommendation; some wish to begin induction immediately, while others wish to  Congenital abnormality
delay induction for a period of hours or days until they are emotionally prepared.  Genetic abnormality
When a dead fetus has been in utero for 3-4 weeks, fibrinogen levels may drop, leading  Infection (ie, parvovirus B19, CMV, listeria)
to a coagulopathy. This is rarely a problem because of earlier recognition and induction.  Hydrops
In some cases of twin pregnancies, induction after the death of a twin may be delayed Placental
to allow the viable twin to mature.

Induction may be accomplished with preinduction cervical ripening followed by  Cord accident
intravenous oxytocin (see Cervical Ripening). Patients with a history of a prior cesarean  Abruption
delivery should be treated cautiously because of the risk of uterine rupture, just as in  Premature rupture of membranes
any birth following cesarean delivery (see Vaginal Birth After Cesarean Delivery).  Vasa previa
Early fetal demise may be managed with laminaria insertion followed by dilatation and  Fetomaternal hemorrhage
evacuation. In women with fetal death before 28 weeks' gestation, induction may be  Placental insufficiency
accomplished using prostaglandin E2 vaginal suppositories (10-20 mg q4-6h), Risk factors (weak predictive value)
misoprostol (ie, prostaglandin E1) vaginally or orally (400 mcg q4-6h), and/or oxytocin
(preferred in women with prior uterine surgery). In women with fetal death after 28  African American race
weeks' gestation, lower doses should be used.  Advanced maternal age
 History of fetal demise
  Maternal infertility
 History of small for gestational age infant
 Small for gestational age infant
 Obesity
 Paternal age
Fetal karyotype can be obtained from a sample of amniotic fluid (preferred), fetal blood,
or fetal tissue (skin or fascia lata). Fetal karyotype should be considered in all cases. It is
especially important if the fetus is dysmorphic, has growth retardation, is hydropic, or
has anomalies or other signs of chromosomal abnormality. Chromosomal analysis
should also be considered in patients with multiple pregnancy losses, especially with a
history of second- and third-trimester losses or when a parent has a balanced
translocation or mosaic chromosomal pattern. Many authorities (including the ACOG
committee on evaluation of stillbirth) recommend obtaining this test in every fetal
demise.
A summary of the protocol for the fetus and placenta is as follows:
 Careful inspection
 Placental cultures for suspected listeria infection (To obtain placental
cultures, separate the amnion and the chorion and submit a culture
specimen using Stuart media.)
 Radiographs, if indicated
 Autopsy
 MRI, if no autopsy
 Fetal karyotype
Maternal Studies
Maternal studies that should also be considered during the workup of a fetal demise
include the following:
 Diabetes testing using hemoglobin A1C and a fasting blood glucose
 Syphilis screening using the VDRL or rapid plasma reagent test
 Thyroid function testing (ie, TSH, FT4)
 Urine toxicology screening
The above tests have traditionally been a part of an evaluation for the etiology of fetal
demise. If diabetes screening has been performed during the prenatal period, repeat
testing for diabetes is probably not necessary. Similarly, if the patient has no signs or
symptoms of thyroid disease, thyroid dysfunction is unlikely to be the cause of the
demise. However, these tests are inexpensive and normal results may be reassuring to
the patient.
Additional tests that should be considered are as follows:
 Antibody screening
 CBC count with platelet count
 Kleihauer-Betke test
 Lupus anticoagulant and anticardiolipin antibody testing: See
Antiphospholipid Antibody Syndrome and Pregnancy.
 Thrombophilia panel: Authorities disagree as to whether this panel should
be performed for all cases of intrauterine fetal demise. Inherited
thrombophilias are common in the general population but are probably
rare causes of fetal demise. A multicenter, prospective, observational
cohort study concluded that there was no association between
prothrombin G20210A mutation and pregnancy loss, preeclampsia,
abruption, or SGA neonates in a low-risk population.6 While some
authorities (including ACOG) recommend maternal testing in all cases of
fetal demise, a more selective approach is to limit testing to patients who
have a history of venous thrombosis, positive family history, placental
infarction, severe preeclampsia in the second or early third trimester,
abruption, or intrauterine growth retardation. The ACOG is now
recommending thrombophilia testing only in selected cases. The value of
thrombophilia testing in any circumstance in obstetrics has recently been
questioned.7
 Infection: See Bacterial Infections and Pregnancy. Infection is a cause of
fetal demise. The frequency is higher in developing countries. Autopsy and
histologic evaluation of the placenta is probably the best way to document
an infectious etiology for a fetal demise.
Authority opinions vary as to which panel of tests is appropriate.
Traditionally, most authorities have recommended obtaining TORCH
(toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus)
antibody titers. In reality, this is rarely helpful in the diagnosis. In addition,
it is questionable whether cytomegalovirus virus causes fetal demise. If no
obvious cause for the demise is established or if clinical signs or symptoms
suggest infection, consider testing for (1) cytomegalovirus (acute and
chronic titers), (2) rubella virus (acute and chronic titers, if not immune), (3)
parvovirus (acute and chronic titers), and (4) Toxoplasmosisgondii (acute
and chronic titers) and (5) syphilis. A more cost-effective approach is to
limit testing for cytomegalovirus, rubella virus, and T gondii to those
patients in whom clinical findings suggest the possibility of intrauterine
infection (ie, those with intrauterine growth restriction, microcephaly).
Testing for Fetal Demise
The following provides a summary of the current status of testing for fetal demise. This
is adopted with permission from the work of Dr. Robert M. Silver and the Stillbirth
Collaborative Research Network.
Commonly accepted tests
 Thorough maternal history
 Fetal autopsy
 Placental evaluation
 Karyotype
 Indirect Coombs test
 Serologic test for syphilis
 Testing for fetal-maternal hemorrhage (Kliehauer-Betke or other)
 Urine toxicology screen
 Parvovirus serology
Useful in some circumstances
Thrombophilia evaluation to include the following:
 Lupus anticoagulant
 Anticardiolipin antibodies
 Factor V Leiden
 Prothrombin mutation
 Protein C, protein S, and antithrombin III deficiency
Uncertain use
 TSH
 Hemoglobin A1C
 TORCH titers
 Placental cultures
 Testing for other thrombophilias
Developing technology
 Comparative genomic hybridization
 Testing for single gene mutations
 Testing for confined placental mosaicism
 Nucleic acid-based testing for infection
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 is helpful if congenital anomalies or genetic abnormalities are found. Genetic
screening and detailed ultrasound can evaluate future pregnancies. In some cases, such
as cord occlusion, the patient can be assured that recurrence is very unlikely.
Fetal death of unknown cause is a special problem. Because a large number of etiologies
of fetal demise exist, a provider has difficulty determining risk of stillbirth for any
particular pregnancy. Evidence-based models such as Active Management of Risk In
Pregnancy At Term (AMOR-IPAT) are being created in an effort to better estimate this
risk.8 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. The ACOG recommends antepartum testing
starting at 32-34 weeks' gestation in an otherwise healthy mother with history of
stillbirth.9 Weekly biophysical profile or fetal heart rate testing can be combined with
maternal kick counts in the third trimester. For patients who have experienced earlier
loss, frequent ultrasound is reassuring.
Optimal management of chronic medical conditions is important prior to the next
pregnancy
NOTE: Definition: Intrauterine fetal demise is the clinical term for the death of
a baby in the uterus, during pregnancy and before birth. The term is usually
used for pregnancy losses that happen after the 20th week of gestation.
Also Known As: Stillbirth
Alternate Spellings: Intrauterine Demise, Fetal Demise, Fetal Death