Snapshot A 39-year-old G3P1011 presents to labor and delivery triage in the 28th week of gestation reporting decreased fetal movement. Fetal tracings show no fetal heartbeat present. Introduction Overview intrauterine fetal demise (IUFD) is defined as demise of the fetus after 20 weeks gestation or after weight ≥ 350 grams if gestational age unknown treatment usually involves medication or dilation and evacuation (D&E) depending on how far along the pregnancy is Associated conditions maternal medical conditions and comorbidities systemic lupus erythematosus antiphospholipid syndrome diabetes hypertension heart failure cholestasis of pregnancy thrombotic disorders thyroid disease Epidemiology Incidence 1/100 pregnancies Demographics women < 15 years old or > 30 years old non-hispanic black women are disproportionately affected Location intrauterine Risk factors advanced maternal age young maternal age substance use prior IUFD fetal growth restriction placental abnormalities multiple gestation infection congenital/genetic anomalies Presentation Symptoms common symptoms decreased patient-reported fetal movement decrease in pregnancy-associated symptoms can be asymptomatic Physical exam motion decreased fetal movement felt other fetal autopsy exam of placenta/cord Imaging Ultrasound indications decreased fetal movement views transvaginal findings presence of fetus absence of fetal heartbeat no fetal movement Studies Serum labs β-HCG pregnancy test remains positive because it continues to be produced by the placenta lupus anticoagulant antibodies anticardiolipin antibodies anti-β2-GP antibodies Kleihauer-Betke test complete blood count Urine labs recreational substances Invasive studies amniocentesis cell collection for causal analysis Other fetal stress test karyotype analysis Differential Fetal sleep state key distinguishing factor < 40 minutes duration of decreased fetal movement Fetal sedation from maternal sedatives key distinguishing factors history of maternal sedative ingestion resolves after sedative clears materno-fetal circulation Treatment Medical labor and induction indications vaginal birth safer than cesarean D&E is not available autopsy is desired < 28 weeks of gestation vaginal or oral misoprostol for induction (unfavorable cervix) or IV oxytocin (favorable cervix) ≥ 28 weeks of gestation induction done according to usual obstetric protocols NOTE - cesarean delivery is only for unusual cases increases the maternal morbidity dopamine agonists suppress lactation psychiatric counseling Surgical D&E best option < 24 weeks Complications Disseminated intravascular coagulation (DIC) incidence DIC causes 0.2% of all pregnancy related deaths a small proportion of those are caused by IUFD more rare than in the past given better detection rates of IUFD risk factors risk of DIC rises 48 hours after fetal death retained products of conception D&E treatment fluid resuscitation maintain oxygenation transfusion of RBCs, platelets, and coagulation factors fibrinogen replacement ensure removal of retained products of conception Sepsis incidence 10% risk factors delay to treatment intrauterine infection invasive intrauterine procedures chronic comorbid conditions treatment broad-spectrum antibiotic therapy supportive care