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Updated: Oct 28 2020

Intrauterine Fetal Demise

3.0

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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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