Intrauterine fetal demise

Background

• Defined as fetal death after 20 WGA (weeks gestational age)
  • Prior to 20 WGA, fetal loss is classified as spontaneous abortion
• Occurs in approximately 1 in 160 pregnancies
• Risk increases with advancing gestational age
• Most common causes include:
  • Placental abnormalities (e.g. abruption, insufficiency) — most common identifiable cause
  • Chromosomal/genetic abnormalities
  • Maternal conditions (preeclampsia, diabetes in pregnancy, chronic hypertension, thrombophilias, autoimmune disease)
  • Umbilical cord abnormalities (knots, prolapse, compression)
  • Intrauterine infection (e.g. chorioamnionitis, CMV, parvovirus B19, syphilis, listeria)
  • Fetal Hydrops
  • Cause remains unexplained in up to 25–60% of cases

Clinical Features

• Decreased or absent fetal movement (most common presenting complaint)
• Vaginal bleeding (may or may not be present)
• Uterine cramping or contractions
• Absence of fetal heart tones on Doppler
• Loss of pregnancy symptoms (e.g. breast tenderness, nausea)
• Uterus may be small for gestational age
• If prolonged fetal demise (retained > 3–4 weeks):
  • Signs/symptoms of DIC (bleeding, petechiae, ecchymosis)

Differential Diagnosis

Vaginal Bleeding in Pregnancy (>20wks)

• Emergent delivery
• Placental abruption
• Placenta previa
• Vasa previa
• Uterine rupture
• Preterm labor
• Vaginal trauma
• Placenta accreta
• Intrauterine fetal demise

Evaluation

• Ultrasound
  • Absence of fetal cardiac activity on real-time ultrasound is diagnostic
  • Should be confirmed by two experienced operators if any uncertainty
  • Additional findings: overlapping skull bones (Spalding sign), soft tissue edema, echogenic amniotic fluid
• Labs
  • CBC — evaluate for anemia, thrombocytopenia
  • Coagulation studies (PT/INR, PTT, fibrinogen) — screen for DIC
    • Risk of DIC increases significantly if fetus retained > 4 weeks
    • Fibrinogen < 200 mg/dL is concerning for consumptive coagulopathy
  • Type and screen (or crossmatch if actively bleeding)
  • Kleihauer-Betke test — to quantify fetomaternal hemorrhage, especially if Rh-negative mother
  • Consider: BMP, LFTs, UA, uric acid if preeclampsia suspected
• Fetal monitoring
  • No role for fetal heart rate monitoring once IUFD is confirmed

Management

• Hemodynamic stabilization
  • IV access, fluid resuscitation as needed
  • Transfuse blood products if evidence of hemorrhage or DIC
• Rh immunoglobulin
  • Administer RhoGAM to all Rh-negative mothers
  • Standard dose (300 mcg) covers up to 30 mL of fetal whole blood
  • Additional doses guided by Kleihauer-Betke results
• DIC management
  • If evidence of coagulopathy, correct with FFP, cryoprecipitate, and/or platelets as indicated
  • Target fibrinogen > 150–200 mg/dL
• Delivery planning
  • Induction of labor is the standard approach for most patients
  • Timing is generally at the discretion of OB; urgent delivery is indicated if:
    • Active hemorrhage
    • DIC
    • Sepsis/chorioamnionitis
    • Preeclampsia with severe features
  • Methods of induction vary by gestational age (misoprostol, oxytocin, or mechanical dilation)
  • Cesarean delivery is rarely indicated and should be avoided if possible given increased maternal morbidity without fetal benefit
• Supportive care
  • Emotional support is critical — grief counseling, social work involvement
  • Allow family time with the infant after delivery when desired
  • Pain management (including neuraxial analgesia for labor)

Disposition

• All patients with confirmed IUFD require admission and obstetric consultation
• Transfer to a facility with OB capability if diagnosed at a facility without obstetric services
• Urgent OB consultation if concurrent DIC, hemorrhage, sepsis, or preeclampsia
• Social work and/or chaplaincy involvement should be arranged early
• Postpartum considerations include:
  • Lactation suppression counseling
  • Grief support and follow-up
  • Autopsy and placental pathology (per patient preference) to determine etiology

See Also

• Spontaneous abortion
• Placental abruption
• Preeclampsia
• DIC
• Third trimester bleeding
• Chorioamnionitis

External Links

• ACOG Obstetric Care Consensus: Management of Stillbirth
• AAFP: Evaluation of Fetal Death