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