Updated: 10/28/2020

Intrauterine Fetal Demise

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  • 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

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Questions (2)

(M2.OB.17.4869) A 30-year-old G3P0 woman who is 28-weeks pregnant presents for a prenatal care visit. She reports occasionally feeling her baby move but has not kept count over the past several weeks. She denies any bleeding, loss of fluid, or contractions. Her previous pregnancies resulted in spontaneous abortions at 12 and 14 weeks. She works as a business executive, has a history of previous blood clots, and has had no surgeries. She states that she hired a nutritionist and pregnancy coach to ensure good prospects for this pregnancy. On physical exam, fetal heart tones are not detected. Abdominal ultrasound shows a 25-week fetal demise. The patient requests an autopsy on the fetus. What is the best next step in management?

QID: 109564
1

Caesarean delivery

0%

(0/66)

2

Induction of labor at term

8%

(5/66)

3

Dilation and curettage

5%

(3/66)

4

Dilation and evacuation

5%

(3/66)

5

Induction of labor now

82%

(54/66)

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