Intrauterine Fetal death (IUFD / IUD)

Intrauterine Fetal death (IUFD / IUD)

Define :  Antepartum death occuring beyond 28 weeks  of pregnancy is termed as intrauterine death (IUD).

We have described in article :

Causes of Intrauterine Fetal death (IUFD / IUD).

Management of Intrauterine Fetal death (IUFD / IUD).

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

Investigation of Intrauterine Fetal death (IUFD / IUD).

Treatment of Intrauterine Fetal death (IUFD / IUD).

Complication of Intrauterine Fetal death (IUFD / IUD).

Prevention of Intrauterine Fetal death (IUFD / IUD).

of Intrauterine Fetal death (IUFD / IUD)

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 : 

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.

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  1. April 19, 2023

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