Causes of Intrauterine Fetal death (IUFD / IUD):

The fetal deaths are related to maternal placental or fetal complications.

A) Idiopathic (25-35%).

B) Maternal causes (5-10%).

1. Hypertensive disorders : pre – eclampsia, chronic HTN, chronic nephritis.
2. Medical disorders : GDM, severe anaemia (due to any causes), SLE.
3. Hyperpyrexia (>39.4 degree C).
4. Abnormal labour : prolong labour, obstructed laour, ruptured uterus.
5. Post dated pregnancy.
6. Maternal infection : Hepatitis, Polimyelitis, herpes simplex, influenza, mumps, toxoplasmosis, malaria etc.
7. Anti-phospholipid syndrome : IgG from women with anti – phospholipid antibodies increases placenta thromboxane production without affecting prostacyclin production, which conducts to thrombosis of placenta uterus junction.
8. Hereditary thrombophilias.

C) Fetal causes (25-40%) : 

• Fetal chromosomal abnormalities and malformations.
• Fetal infections : Rubella, CMV, Parvovirus -B19 and chorioamnionits.
• Rh- incompatibility.
• Non – immune hydrops.
• Placental insufficiency.

D) Placental (20 – 35%) : 

• APH.
• Placental insufficiency.
• Cord accidents (prolapse, true knot and cord round the neck).
• Twin – Twin transfusion syndrome (TTTS).

E) Latrogenic : 

1. External version.
2. Others : 

• Post – term pregnancy
• Drugs (Quinine beyond therapeutic level).
• Placental infection.

Causes of Intrauterine Fetal death (IUFD / IUD) : 

1. Maternal chronic medical disorder : Diabetes mellitus, hypertension, Chronic nephritis.
2. Maternal infection : HBV, Toxoplasmosis, Measles, Mumps, Rubella, CMV infection etc.
3. Rh- incompatibility.
4. Anti – phospholipid syndrome.

Mention 6 causes of IUFD : 

1. Idiopathic
2. Pre – eclampsia.
3. Eclampsia
4. APH.
5. Fetal chromosomal anomalies.
6. Maternal severe anaemia.

Clinical features of Intrauterine Fetal death (IUFD / IUD) : 

Symptoms of Intrauterine Fetal death (IUFD / IUD) :

: Absence of fetal movements which were previously noted by the patient.

Sign of Intrauterine Fetal death (IUFD / IUD) : 

• Height of the uterus : Gradual retrogression of the fundal height and it becomes smaller than the height of the uterus.
• Uterine tone : Diminished and the uterus feels flaccid.
• Braxton – Hick’s contraction : Not easily felt.
• Fetal monuments : Not felt during palpation.
• Fetal heart sound : Absent in a previously audible pregnancy. Doppler ultrasound is better than stethoscope.
• Egg-shell crackling feeling of the fetal head : Late feature.

Investigation of Intrauterine Fetal death (IUFD / IUD) : 

1. Ultrasonography : Confirmatory ( on fetal movement, no FHR and collapsed cranial bones).
2. Straight X – ray abdomen : Rarely done at present (reveals spalding sign – irregular overlapping of cranial bones : hyperflexion of the spine, crowding of the rib shadow and appearance of gas shadow – Robert’s sign).
3. Estimation of fibrinogen level and PTT (partial thromboplastin time) : In the fetus which is retained for > 2 weeks.
4. Hematological examination : (To find out the cause)

• Complete blood count : TC,DC, ESR, & Hb%
• ABO blood grouping and Rh typing.
• VDRL
• RBS
• HBA1C.
• Serum creatinine
• Thyroid profile.
• TORCH screening.
• Lupus anticoagulant
• Anti – cardiolipin antibody.

Treatment of Intrauterine Fetal death (IUFD / IUD): 

A) Non – interference / expectant treatment : 

1. Spontaneous expulsion occurs in 80% cases within 2 weeks of death.
2. Reassurance and psychological support.
3. The patient may remain at home with the advice to come to the hospital for delivery.
4. Monitoring : by estimation of Fibrinogen level (every day or at least twice a week). A falling fibrinogen level approaching 150 mg / di should be treated by controlled infusion of heparin.

B) Interference / termination :  The indications of interference are –

1. Refractory cases or fails in expectant treatment.
2. Psychological upset (common).
3. Manifestation of uterine infection.
4. Falling fibrinogen level.
5. IF duration is more than 2 weeks : Hospitalization and medical induction of labour.

• When cervix favourable  : Oxytocin infusion (I/V) –> IF fails —>Repeat. Oxytocin with vaginal prostaglandin supplementation.
• When cervix unfavourable : PGE2 gel intra – cervical or PGE1 tab. (vaginal or oral) : may have to be repeated after 6-8 hours —> If fails —> Supplementation with oxytocin infusion.

Indication of caesarean section in IUD.

Indications of C/S in IUD : (C /S in IUD is limited and should be avoided as best as possible).

• Major degree placenta praevia.
• Previous C /S (two or more).
• Transverse lie.

Prevention of Intrauterine Fetal death (IUFD / IUD) : 

1. Pre – conceptional care : It is essential to prevent it’s occurrence in the high risk group.
2. Regular antenatal check- up : To prevent, detect at the earliest and institute effective therapy likely to cause fetal death.
3. Screening out at risk mother : To monitor carefully for the assessment of fetal wellbeing and to terminate pregnancy with the earliest evidences of fetal compromises.

Complication of Intrauterine Fetal death (IUFD / IUD) : 

1. Psychological upset of the mother.
2. Infection : If the membranes are ruptured there is chance of infection especially by gas forming organisms like Cl. Welchii. The dead tissue favors their growth with disastrous consequences.
3. Blood coagulation disorders : If the fetus is retained for more than 4 weeks (10 -20% cases), there is a possibility of defibrination from ‘silent’ disseminated intravascular coagulopathy (DIC). It is observed predominantly in retained dead fetus of Rh incompatibility.

• Cause : It is due to gradual absorption of thromboplastin, liberated from the dead placenta & decidua, into the maternal circulation, which activates the extrinsic pathway of coagulation system.

  4. During labour : 

• Uterine inertia
• Retained placenta.
• Postpartum haemorrhage.

Why ARM is contraindicated in IUFD?

ARM is contraindicated in case of IUFD due to chance of chorioamnionitis.