Intrauterine fetal demise (iufd)

Intrauterine fetal demise

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Intrauterine Fetal Death
(IUFD)
By
Ahmed ElbohotyMD, MRCOG
Assistant professor of obstetrics and gynecology
AinShams University
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Amplitude of the problem
•Stillbirth is a devastating complication of pregnancy,
which affects roughly 4000 families in the UK each
year.
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Definitions
•Late fetal losses–the baby is delivered between 22+0and 23+6weeks of pregnancy showing no signs of life, irrespective of when the death occurred.
•Stillbirths–the baby is delivered from 24+0weeks gestation showing no signs of life.
•Early neonatal deaths–death of a live born baby (born at 20 weeks gestation of pregnancy or later or 400g where an accurate estimate of gestation is not available) occurring before 7 completed days after birth.
•Late neonatal deaths–death of a live born baby (born at 20 weeks gestation of pregnancy or later or 400g where an accurate estimate of gestation is not available) occurring between 7 and 28 completed days after birth.
•Post-neonatal deaths–death of a live born baby (born at 20 weeks gestation or later or 400g where an accurate estimate of gestation is not available) occurring from the 28th day and before 1 year after birth.
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Reporting
•Births showing no signs of life (stillbirths and late
fetal losses):All births delivered from 22+0showing
no signs of life are eligible for notification
irrespective of when the death occurred.
•MBRRACE-UK PerinatalDeath Surveillance System
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Stillbirth
•Is ‘a baby delivered with no signs of life known to
have died after 24 completed weeks of pregnancy’.
•Intrauterine fetal death refers to babies with no
signs of life in utero.
•Stillbirth is common, with 1 in 200 babies born
dead.
•This compares with one sudden infant death per
10000 live births.
•About 99% of stillbirths in the world occur in low
and middle income countries.
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Classifications by the timing of fetal death
in relation to the onset of labour
–Antepartumstillbirth is where death occurred prior to
the onset of labour
–intrapartumstillbirth is where death occurred during
labour.
•In high income countries, less than 10% of stillbirths
are intrapartum.
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Stillbirths can be classified due to the
presumed cause:
•However, it is only in a minority of cases where the
cause of death is known with complete certainty.
•The difficulty in distinguishing between causes and
associations leads to problems in classification,
which are manifested by the presence of more than
40 current classification systems.
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Etiology
•the cause is unknown in 50% of cases
•Known causes or risk factors:
–it is only in a minority of cases where the cause of death
is known with complete certainty.
–The difficulty in distinguishing between causes and
associations leads to problems in classification, which
are manifested by the presence of more than 40 current
classification systems.
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Risk factor or a real cause
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Fetal and placental
•Chromosomal anomalies
•Birth defects
•Non immune hydrops
•Infections
•Abruption
•Cord accidents
•Placental insufficiency
•Intrapartumasphyxia
•Vasaprevia
•Twin to twin transfusion S
•Chrioamnionitis
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Transplacentalinfections
•Cytomegalovirus
•syphilis
•parvovirus B19
•listeria
•Rubella
•Toxoplasmosis
•Malaria parasitaemia
•Coxsackievirus
•Leptospira
•Q fever
•Lyme disease
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Maternal
•Antiphospholipidantibody
•DM
•Preeclampsia
•Trauma
•Sepsis
•Acidosis/ Hypoxia
•Uterine rupture
•Posttermpregnancy
•Drugs
•Thrombophilia
•Cyanotic heart disease
•Epilepsy
•Severe anemia20/03/2020Elbohoty
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Preventing stillbirth
•Modifying risk factors
•Use of antenatal interventions
•Management of complications during
pregnancy
•Timed delivery
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Modifying risk factors
•ANC (Assessing risk factors)
–Especially at the first antenatal visit
(obstetric history, diabetes and multiple
pregnancy)
–only accounted for 19% of the variability in
the risk of stillbirth at the population level
•Maternal position
–an association between non left sided sleep
position and stillbirth risk (A case–control
study)
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•Reducing smoking in pregnancy by carrying out
Carbon Monoxide (CO) test at antenatal booking
appointment to identify smokers (or those exposed
to tobacco smoke) and referring to stop smoking
service/specialist as appropriate.
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Risk assessment and surveillance for
fetal growth restriction
•Use supplied algorithm to aid decision making on classification of risk,
and corresponding surveillance of all pregnancies.
•For women at high risk of fetal growth restriction, fetal growth to be
assessed using serial ultrasound scans as per algorithm.
–Estimated fetal weight derived from ultrasound measurements recorded on a chart
•For low risk women, fetal growth to be assessed using antenatal
symphysis fundal height charts by clinicians trained in their use.
–All staff must be competent in measuring fundal height with a tape measure,
plotting measurements on charts, interpreting appropriately and referring when
indicated.
•Ongoing audit, reporting and publishing (on local dashboard or similar)
of Small for Gestational Age (SGA) birth rate, antenatal detection rate,
false positive rate and false negative rate.
•Ongoing case-note audit of selected cases not detected antenatally, to
identify learning and improve future detection20/03/2020Elbohoty
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Raising awareness of reduced fetal
movement
•Information and advice leaflet on reduced fetal
movement (RFM), based on current evidence, best
practice and clinical guidelines, to be provided to all
pregnant women by, at the latest, the 24th week of
pregnancy and RFM discussed at every subsequent
contact.
•Use provided checklist to manage care of pregnant
women who report reduced fetal movement, in line
with RCOG Green-top Guideline 5716
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Antenatal interventions
•The use of low dose aspirin in women
–high risk of pre-eclampsia(1 major or 2 moderate risk
factors)
–Having APS
•Use of LMWH for some groups ?
•Having APS especially who have poor obstetric outcome
•The 2014 Thrombophiliain Pregnancy PhophylaxisStudy (TIPPS),
failed to show any benefit of low-molecular-weight heparin on the
risk of pregnancy loss or placental-related complications among
women with thrombophilia.4
•A meta-analysis of smaller trials which demonstrated a protective
effect of antithrombotic therapy on the risk of perinataldeath
(60% reduction).20/03/2020Elbohoty
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Management of complications during
pregnancy
•US
•Doppler
•CTG
–Existing trial evidence suggests that use of non-
computerisedCTG in antenatal assessment of the fetus
shows a strong trend towards increasing the risk of
perinataldeath (relative risk for potentially preventable
death associated with use of CTG = 2.46, 95% CI 0.96–
6.30).
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Timed Delivery for high risk pregnancy
•For high risk woman or post term
pregnancy.
•For low risk:
–?? Consistent with the modelling, meta-analyses of RCTs
demonstrate that routine induction of labourat term reduces the
risk of perinataldeath by 50%.
–?? These observations make a case for offering induction of
labourto all women. Any benefits arising from this would have to
be balanced against the increased demands on maternity systems.
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Effective fetal monitoring during
labourInterventions
•All staff who care for women in labourare required to
undertake an annual training and competency
assessment on cardiotocograph(CTG) interpretation
and use of auscultation. No member of staff should
care for women in a birth setting without evidence of
training and competence within the last year.
•Buddy system in place for review of cardiotocograph
(CTG) interpretation, with a protocol for escalation if
concerns are raised. All staff to be trained in the review
system and escalation protocol.
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Diagnosis of IUFD
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•Real-time ultrasonography
–is essential for the accurate diagnosis of IUFD.
–It can be technically difficult, particularly in the presence
of maternal obesity, abdominal scars and
oligohydramnios, but views can often be augmented
with colourDoppler of the fetal heart and umbilical cord
•A second opinion should be obtained whenever
practically possible.
•Mothers should be prepared for the possibility of
passive fetal movement. If the mother reports
passive fetal movement after the scan to diagnose
IUFD, a repeat scan should be offered.
•Auscultation and cardiotocographyshould notbe used to investigate
suspected IUFD.20/03/2020Elbohoty
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Other findings by US:
•Collapse of the fetal skull with overlapping bones
•Hydrops
•Maceration resulting in unrecognisablefetal mass
•Intrafetalgas (within the heart, blood vessels and joints) is
another feature associated with IUFD that might limit the quality of
real-time images.
•Occult placental abruption might also be identified,
the sensitivity can be as low as 15%. Even large
abruptions can be missed
•The ultrasound findings of severe maceration and gross skin
oedemacan be discussed with the parents.
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Discussing the diagnosis and subsequent
care?
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Breaking bad news
-getting started
•Introduction, sympathy/condolence, etc
•If the woman is unaccompanied, an immediate offer should be made
to call her partner, relatives or friends.
•Go over common ground –briefly.
•Establish what she already knows
•Break the bad news gently, or in stages (if possible)
•Discussions should aim to support maternal/parental choice.
•Parents should be offered written information to supplement
discussions.
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Assessment
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•Maternal compromise and Urgencyof delivery
–Clinical assessment and laboratory tests should be
recommended to assess maternal wellbeing (including
coagulopathy) and to determine the cause of death, the
chance of recurrence and possible means of avoiding further
pregnancy complications.
•Additional care e.ghypertensive, DM,……
•Cause of IUFD
–Parents should be advised that nospecific cause is found in
almost half of stillbirths.
–Parents should be advised that when a cause is found it can
crucially influence carein a future pregnancy.
–Carersshould be aware that an abnormal test result is not
necessarily related to the IUFD; correlation between blood
tests and postmortem examination should be sought.
Further tests might be indicated following the results of the
postmortem examination.20/03/2020Elbohoty
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Clinical assessment
•History:
–when last fetalmovements were felt
–experience of abdominal pain
–vaginal bleeding/discharge
–Medical history (VTE, DM, PET, Thrombophilia, SLE, Autoimmune disease,…
–Social history (smoking, drug, domestic violence,....
–Current and previous Obstetric history including mode of previous deliveries, previous obstetric outcome, birth weight,...
•Assess the woman clinically:
–pulse, blood pressure, temperature, urinalysis,..
–abdominal examination: tense; tender uterus suggests abruptioplacentae
•IV access (if appropriate, e.g. suspected abruption, pre-eclampsia, chorioamnionitis)
•If there is constant abdominal pain and signs of shock, e.g. maternal tachycardia +/–hypotension in the absence of bleeding:remember concealed abruption. 20/03/2020Elbohoty
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laboratory tests
–full blood count
–urea and electrolytes
–liver function tests
–coagulation screen, and group and save +/–crossmatch
–Kleihauertest
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The Kleihauertest
•A Kleihauertest is recommended for all women to diagnose the cause of death as Major FMH is a silent cause of IUFD.
•Women who are rhesus D (RhD)-negative should be
–Given Anti-RhDgammaglobulinas soon as possible after presentation
–advised to have a Kleihauertest undertaken urgently
•to detect large feto–maternal haemorrhage(FMH)
•the dose of anti-RhDgammaglobulinshould be adjusted upwards
–The Kleihauertest should be repeated at 48 hours to ensure the fetal red cells have cleared
•If it is important to know the baby’s blood group; if no blood sample can be obtained from the baby or cord, RhDtyping should be undertaken using free fetal DNA (ffDNA) from maternal blood taken.
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InvestigationRelevance
Full blood count, urea and electrolytes, liver function tests,
CRP
Pre-eclampsia, haemorrhage, sepsis
Bile acidsObstetric cholestasis
Coagulation, fibrinogenDIC
KleihauerLarge feto–maternal haemorrhage and Can adjust anti-D
dose in RH-vewoman
Blood cultures, midstream urine sample, vaginal and
cervical swabs. Fetal blood and swabs, placental swab
Indicated if signs of infection are present
Viral screen : toxoplasmosis, other (congenital syphilis and
viruses), rubella, cytomegalovirus, Parvovirus B19
Toxoplasma, rubella, cytomegalovirus, herpes, , syphylis
Parvovirus B19
Random blood glucose and HbA1c(glycatedhaemoglobin)Diabetes
ThrombophiliascreenIndicated if evidence of growth restriction
Anti-red cell antibodiesHaemolytic disease Indicated if hydropspresent
Anti-Ro and anti-La antibodiesAutoimmune disease
Alloimmune antiplatelet antibodiesAlloimmunethrombocytopenia
Indicated if intracranial haemorrhageon postmortem
Urine for cocaine metabolitesOccult drug use
With consent, if presentation and history are suggestive
Fetal and placental tissue for karyotypeAneuploidy, single gene disorders, fetal sex (if appropriate)
Only with written consent; multiple samples advisable
(skin has higher culture failure rate than placenta
Postmortem examination (including placenta histology)Cause of intrauterine fetal death (parents should be
advised this will often not be possible)
Only with written consent; can be full or limited (external)
Parental bloods for karyotypeIndicated if fetal unbalanced translocation, other
aneuploidyor fetal genetic testing fails and chromosomal
abnormality suspected from history or postmortem
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Cause and association
•An abnormal result might not be linked to the IUFD
but rather be simply an incidental finding; for
example, factor V Leiden is present in about 5% of
the general population and will often be an
incidental finding.
•Comprehensive investigation can be important even
though one cause is particularly suspected.
•With a very obvious cause such as massive
abruption, nonlethal fetal malformations might be
identified at postmortem that would only have
been revealed had the baby lived.
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Delivery
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Timing
•Take into account the mother’s
preferences as well as her medical
condition and previous intrapartum
history.
•Immediate steps towards delivery:
–sepsis, preeclampsia, placental
abruption or membrane rupture or any
other condition can put the mother in
danger
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Delay the delivery•Well women with intact membranes and no laboratory
evidence of DIC
•More than 85% of women with an IUFD labour
spontaneously within three weeks of diagnosis.
•If a woman returns home before labour, she should be
given a 24-hour contact number for information and
support
•Disadvantages:
–prolonged intervals of delay can cause severe medical
complications and greater anxiety
–Mothers who contemplate prolonged expectant
management should have testing for DIC twice weekly and
should be informed that the appearance of the baby may
deteriorate and the value of a postmortem may be reduced.20/03/2020Elbohoty
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Mode
•Vaginal birth is the recommended mode of delivery
for most women because this will allow for the best
outcome for her recovery following birth and for
any future pregnancies.
•Caesarean birth will need to be considered with
some.
•For women with previous caesarean section, careful
discussion of the risks of labourinduction is
important.
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Induction
•A combination of mifepristoneand a prostaglandin
preparation should usually be recommended as the
first-line intervention for induction of labour.
–a combination of mifepristone200 mg followed by a
prostaglandin preparation 24–48 hours later
–Misoprostolcan be used in preference to prostaglandin
E2 because of equivalent safety and efficacy with lower
cost but at doses notcurrently marketed in the UK.
–Women should be advised that vaginal misoprostolis as
effective as oral therapy but associated with fewer
adverse effects.
•Mechanical methods for induction of labourin women with an IUFD should be
used only in the context of a clinical trial.20/03/2020Elbohoty
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Previous uterine scar
•Women undergoing VBAC should be closely monitored for features of scar rupture.
•Fetal heart rate abnormality, usually the most common early sign of scar dehiscence, does not apply in this circumstance. Other clinical features include maternal tachycardia, atypical pain, vaginal bleeding, haematuriaon catheter specimen and maternal collapse.
•Women with a single lower segment scar: induction of labourwith prostaglandin is safe but not without risk.
•Oxytocinaugmentation can be used for VBAC, but the decision should be made by a consultant obstetrician.
•Mifepristone alone (200 mg three times daily for 2 days) following IUFD increases the likelihood of spontaneous labourwithin 72 hours. Therefore, it can be considered for women with a previous uterine scar.20/03/2020Elbohoty
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2 CS or more
•Women with two previous LSCS should be advised
that in general the absolute risk of induction of
labourwith prostaglandin is only a little higher than
for women with a single previous LSCS.
•Women with more than two LSCS deliveries or
atypical scars should be advised that the safety of
induction of labouris unknown.
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Place of care
•Women should be cared for in an environment that
provides adequate safety according to individual
clinical circumstance.
•Women with no critical care needs should ideally be
able to choose between facilities which provide
adequate privacy.
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Labor facilities
•Maternity units should aim to develop a special
labourward roomfor well women with an
otherwise uncomplicated IUFD that pays special
heed to emotional and practical needs without
compromising safety.
•This can include a double bed for her partner or
other companion to share, away from the sounds of
other women and babies.
•Care in labourshould given by an experienced
midwife.
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Antibiotics
•Routine antibiotic prophylaxis shouldnot be
used.
•Intrapartumantibiotic prophylaxis for women
colonisedwith group B streptococcus is not
indicated
•Women with sepsis should be treated with
intravenous broad-spectrum antibiotic
therapy (including antichlamydialagents).
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Pain relief in labour?
•Women should be offered an opportunity to meet
with an obstetric anaesthetist.
•Diamorphineshould be used in preference to
pethidine.
•Regional anaesthesiashould be available for
women with an IUFD.
–Assessment for DIC and sepsis should be
undertaken before administering regional
anaesthesia.
–Maternal sepsis can result in epidural abscess
formation.20/03/2020Elbohoty
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Sexing the baby
•Parents can be advised before birth about the potential
difficulty in sexing the baby, when appropriate.
•Two experienced healthcare practitioners (midwives,
obstetricians, neonatologists or pathologists) should
inspect the baby when examining the external genitalia
of extremely preterm, severely macerated or grossly
hydropicinfants.
•If there is any difficulty or doubt, rapid karyotyping
should be offered using quantitative fluorescent
polymerase chain reaction (QF-PCR) or fluorescence in
situ hybridisation (FISH).
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cytogenetic analysis of the baby
•Karyotypingis important as about 6%of stillborn
babies will have a chromosomal abnormality
•Written consent should be taken for any fetal
samples used for karyotyping.
•Samples from multiple tissues should be used to
increase the chance of culture.
•More than one cytogenetic technique should be
available to maximisethe chance of informative
results.
•Culture fluid should be stored in a refrigerator and
thawed thoroughly before use.
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perinatalpostmortem examination
•Parents should be offered full postmortem examination to help
explain the cause of an IUFD.
•It provides more information than other (less invasive) tests and this
can sometimes be crucial to the management of future pregnancy.
•Individual, cultural and religious beliefs must be respected.
•Consent should be sought or directly supervised by an obstetrician or
midwife trained in special consent issues and the nature of perinatal
postmortem, including retention of any tissues for clinical
investigation, research and teaching.
•Parents should be offered a description of what happens during the
procedure and the likely appearance of the baby afterwards.
•Discussions should be supplemented by the offer of a leaflet.
•Written consent must be obtained for any invasive procedure on the
baby including tissues taken for genetic analysis.
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videos
•https://stratog.rcog.org.uk/presentation/43
•https://stratog.rcog.org.uk/presentation/44
•https://stratog.rcog.org.uk/presentation/45
•https://stratog.rcog.org.uk/presentation/46
•https://stratog.rcog.org.uk/presentation/47
•https://stratog.rcog.org.uk/presentation/48
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Types
–Fullpostmortem
–limitedexamination (sparing certain organs)
•should be discussed with a perinatalpathologist before being
offered.
–Less invasive methods such as needle biopsies
•X-rays can show skeletal defects that are difficult to identify or
categoriseon dissection.
•MRI can be a useful adjunct to conventional postmortem.
•Potential Alternatives
–Ultrasound and magnetic resonance imaging (MRI) should not yet
be offered as a substitute for conventional postmortem.
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PM
•All three examination types will involve the
examination of the placenta, cord as membranes as
they can help ascertain the cause of/factors
contributing to death.
•Postmortem examination should include external
examination with birth weight, histology of relevant
tissues.
•X-rays and macroscopic images may be taken to
help ascertain the cause of death if consented for
and will form part of the medical record.
•The examination should be undertaken by a
specialist perinatalpathologist.20/03/2020Elbohoty
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Placental histopathological abnormalities and poor
perinatal outcomes
•Indications of placental histology as
recommended by the Royal College of
Pathologists
•
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Process for storing and sending the
placenta
•Store the placenta at 4°C in a tightly sealed container.
•The placenta must not be frozen as freezing obliterates the important microscopic features.
•Check whether criteria are met for histology.
•Use the placental referral proforma to record relevant clinical details.
•Label the specimen container with the patient’s details.
•Submit the placenta to the laboratory in a fresh state.
•Formalin fixation is indicated if there is likely to be a delay in
•undertaking the examination, or when refrigerated storage is not available.
•Place the placenta in a sufficientsized container with an adequate volume of formalin to minimisedistortion of the placenta.
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Types of placental histology associated
with adverse pregnancy outcomes
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Clinical implications of placental
histology
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Options for suppression of lactation
•Women should be advised that almost one-third of
those that choose nonpharmacologicalmeasures
are troubled by excessive discomfort.
•Women should be advised that dopamine agonists
successfully suppress lactation in a very high
proportion of women and are well tolerated by a
very large majority; cabergolineis superior to
bromocriptine.
•Dopamine agonists should not be given to women
with hypertension or pre-eclampsia.
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Psychological problems can follow late
IUFD
•Carersmust be alert to the fact that mothers,
partners and children are all at risk of prolonged
severe psychological reactions including post-
traumatic stress disorder but that their reactions
might be very different.
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Interventions that might aid psychological
recovery
•Carersshould be aware of and responsive to possible
variations in individual and cultural approaches to
death.
•Counsellingshould be offered to all women and their
partners. Other family members, especially existing
children and grandparents, should also be considered
for counselling.
•Debriefing services must notcare for women with
symptoms of psychiatric disease in isolation.
•Parents should be advised about support groups.
•Bereavement officers should be appointed to
coordinate services.20/03/2020Elbohoty
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Evidence for seeing, holding, naming
and mementos?
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•Carersshould avoid persuading parents to have contact with their stillborn baby, but should strongly support such desires when expressed.
•Parents who are considering naming their baby should be advised that after registration a name cannot be entered at a later date, nor can it be changed.
•If parents do decide to name their baby, carersshould use the name, including at follow–up meetings.
•Parents should be offered, but not persuaded, to retain artefactsof remembrance
•Maternity units should have the facilities for producing photographs, palm and foot prints and locks of hair with presentation frames.
•Verbal consent should be sought from the parents and information governance regulations should be complied with for clinical photography.
•If the parents do not wish to have mementos, staff should offer to store them securely in the maternal case record for future access.
•It should be explained that clothes on a macerated baby might become stained.20/03/2020Elbohoty
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Legal aspects
•The following practice guidance is derived from statute and code of practice.
•Stillbirth must be medically certified by a fully registered doctor or midwife; the doctor or midwife must have been present at the birth or examined the baby after birth. (Statute)
•HM Coroner must be contacted if there is doubt about the status of a birth. (Statute)
•Police should be contacted if there is suspicion of deliberate action to cause stillbirth. (Statute)
•Fetal deaths delivered later than 24 weeks that had clearly occurred before the end of the 24th week do not have to be certified or registered.
•The baby can be registered as indeterminate sex awaiting further tests.
•The parents are responsible in law for registering the birth but can delegate the task to a healthcare professional.
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Additional arrangements
•The legal responsibility for the child’s body rests
with the parents but can be delegated to hospital
services.
•Parents should be allowed to choose freely about
attendance at a funeral service.
•A leaflet about the options should be available.
•Maternity units should provide a book of
remembrance for parents, relatives and friends.
•Carersshould offer parents the option of leaving
toys, pictures and messages in the coffin.
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Follow-up appointment & Preconcetionaladvice
•Parents should be advised about
–the cause of late IUFD
–chance of recurrence
–any specific means of preventing further loss.
•Discuss the potential benefit of delaying conception until severe
psychological issues have been resolved.
–mothers tend to experience greater anxiety when conception
occurs soon after a fetal loss
–partners are more likely to suffer anxiety if conception is
delayed.
•The meeting should be documented for the parents in a letter
that includes an agreed outline plan for future pregnancy.
•Contraceptive method.
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Risk factors modification:
–smoking cessation.
–avoid weight gain if they are already overweight (body
mass index over 25) and to consider weight loss.
–Proper control of any medical conditions
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•Carersshould ensure they read all the notes
thoroughly before seeing the woman.
•The history of stillbirth should be clearly marked in
the case record
•Women with a previous unexplained IUFD should
be recommended to have obstetric antenatal care.
•Women with a previous unexplained IUFD should
be recommended to have screening for gestational
diabetes.
•For women in whom a normally formed stillborn
baby had shown evidence of being small for
gestational age, serial assessment of growth by
ultrasound biometry + umblicalartery dopplerfrom
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Place of birth and Maternal care after
the next birth
•Previous unexplained IUFD is an indication to
recommend birth at a specialist maternity unit.
•Carersshould be vigilant for postpartum depression
in women with a previous IUFD.
•Carersshould be aware that maternal bondingcan
be adversely affected.
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Support group
•Stillbirth and Neonatal Death Society.SANDS UK.
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Each baby count
•https://www.rcog.org.uk/en/guidelines-
research-services/audit-quality-
improvement/each-baby-counts/
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SBA
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•A 42-year-old primigravidapresents at 40 weeks of gestation with reduced fetal movements. Intrauterine fetal death was diagnosed.
•She has refused induction of labourand prefers to wait for a few days more.
•What would be your management and follow up?
•Allow home and await eventsAllow home with daily hospital visitsNo further follow up requiredOffer caesarean sectionPlan for twice weekly blood tests to check for disseminated intravascular coagulation
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•A 35-year-old woman presents with an absence of fetal movements at 39 weeks of gestation. She is unfortunately diagnosed with an with an intrauterine fetal death and is understandably very upset. She mentions it was a low risk pregnancy and she had been seen by the community midwife two days ago and the baby was on the middle line on her graph. However, at delivery, the baby measures <5th centileon her customisedgrowth chart.
•Which investigation is likely to provide the most information about the cause of the IUD?
•Fetal blood and swabsMaternal biochemistry and full blood countPlacental histopathologyPostmortem examinationThrombophiliascreen
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•The correct asnweris postmortem
examination. Parents should be advised that
postmortem examination provides more
information than other (less invasive) tests
and this can sometimes be crucial to the
management of future pregnancy.
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•A primigravidawho attends for her anomaly scan at 21
weeks of gestation is unfortunately diagnosed with intrauterine demise. From the scan findings, this may
have occurred a few weeks ago. Membranes are intact and the cervix is closed.
•What is this woman at greatest risk of?
•Consumptive coagulopathy
Future infertilityRecurrent miscarriage
SepsisVenous thromboembolism
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•The correct answer is consumptive coagulopathy. A dead fetus, if retained, releases thromboplastinwhich may lead to disseminated intravascular coagulopathy(DIC). An intrauterine death (IUD) at >24 weeks of gestation if retained for up to 4 weeks carries a 10% risk of DIC, and beyond 4 weeks the risk increases to 30%. Though the percentage risk with an IUD below 24 weeks gestation may differ, cases of DIC can occur with miscarriage and fetal demise from as early as 17 weeks of gestation. There is also a small risk of sepsis.
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•A primigravidaat 31 weeks of gestation is seen in the antenatal clinic and mentions decreased fetal movements for 1 week. She does not give any other significant history of injury or bleeding. On examination, her observations are stable, the fundalheight corresponds to the gestation but the fetal heart could not be detected with a Doppler. All her routine antenatal investigations performed in the first trimester are normal. Her blood group is B negative with a negative indirect Coomb’stest performed at 28 weeks of gestation. A scan unfortunately shows no fetal heart present, which is confirmed by two sonographers.
•Which laboratory investigation is most urgently required?
•Bile saltsCoagulation studiesKleihauertestMaternal thrombophiliascreenRandom blood glucose and HbA1c
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•A 28-year-old presents to triage at 34 weeks of gestation with a history of reduced fetal movements over 5 days. She has had one delivery 3 years ago via emergency caesarean section for suspected fetal distress following meconiumstained liquor. She is very anxious and concerned about her baby. On examination her observations are normal. There is no history of bleeding or rupture of membranes. An ultrasound scan unfortunately shows an intrauterine death. After a careful and sensitive discussion regarding the safety and benefits of induction, a decision for induction of labouris made.
•What is the most appropriate management option for induction of labour?
•Induction with oxytocinMechanical methodsMechanical methods followed by oxytocinaugmentationMifepristone aloneMifepristone with low dose misoprostol
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