INTRA-UTERINE FETAL DEATH (IUFD)

Abdul Hadi bin Abdullah

Definition
death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy.
The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life
2003 revision of the Procedures for Coding Cause of Fetal Death Under ICD-10, the National Center for Health Statistics

 spontaneous losses occurring at >20 weeks or weighing >350 g

Incidence
> 3 million death each year worldwide 2005 rate of 6.2/1000 total births in US Rate of early IUD has remained stable Rate of late fetal loss has decreased by 29% since 1990 African Americans have 2x IUD rate as Caucasians DM, HTN, abruption, PPROM

Etiology
Unknown in 25 60% of cases
Identifiable causes can be attributed to
Maternal conditions
Fetal conditions Placental conditions

Maternal Conditions
Prolonged pregnancy Eclampsia Diabetes (poorly controlled) Hemoglobinopathy SLE APAS Infection HTN Preeclampsia Rh disease Uterine rupture Maternal trauma or death Inherited thrombophilia

Fetal conditions
Multiple gestation IUGR

Congenital anomaly
Genetic abnormality

Infection
Hydrops

Placental Conditions
Cord accident
Abruption PROM Vasa previa Fetomaternal hemorrhage Placental insufficiency

Diagnosis
Symptoms- Absence of foetal movements Per-abdomen- Gradual retrogression of the height of the uterus - Uterine tone is diminished - Foetal movement are not felt during palpation. - Foetal heart sound is not audible Investigations- X-ray abdomen - Spalding sign: it usually appears 7 days after I.U.F.D. - Hyperflexion of the spine - Crowding of the ribs shadow - Appearance of gas shadow (Roberts sign) : 12 hours

Diagnosis (contd)
Sonography : (a) Lack of all foetal motions (including cardiac) (b) Oligohydramnions and collapsed cranial bones

Lab evaluation

Complications
1. Psychological upset 2. Infection: Once the membranes rupture, infection, especially by gas forming organism like CI. Welchi. 3. Blood coagulation disorders 4. During labour : Uterine inertia and PPH

Pregnancy Management
Single or multiple gestation Gestational age at death The parents wish

Management
Explain the problem to the woman and her family. Discuss with them the options of expectant or active management. If expectant management is planned:
Await spontaneous onset of labour during the next four weeks Reassure the woman that in 90% of cases the fetus is spontaneously expelled during the waiting period with no complicatons.

If platelets are decreasing, four weeks have passed without spontaneous labour, fibrinogen levels are low or the woman request it,consider active management (induction of labour)

Management (contd)
If induction of labour is planned, assess the cervix

If the cervix is favourable (soft, thin, partly dilated) labour using oxytocin.
If the cervix is unfavourable(firm, thick, closed) for IOL. Note: Do not rupture the membranes. If spontaneous labor does not occur within four weeks, platelets are decreasing and the cervix is unfavourable, for IOL.

Management of Future Pregnancy

If a particular medical problem is identified in the mother, it should be addressed prior to conception. For example, tight control of blood glucose prior to conception can substantially reduce the risk of congenital anomalies in the fetus. Preconceptional counseling is helpful if congenital anomalies or genetic abnormalities are found. Genetic screening and detailed ultrasound can evaluate future pregnancies. Because a large number of etiologies of fetal demise exist, a provider has difficulty determining risk of IUD for any particular pregnancy. Although recurrent fetal loss is uncommon, patients are naturally anxious. Most patients find increased fetal surveillance with the next pregnancy reassuring, even though such testing is not clearly beneficial.

 The ACOG recommends antepartum testing starting at 32-34 weeks' gestation in an otherwise healthy mother with history of IUD. Weekly biophysical profile or fetal heart rate testing can be combined with maternal kick counts in the third trimester. For patients who have experienced earlier loss, frequent ultrasound is reassuring.

Antepartum Surveillance
300 women with previous IUD
49% unexplained 1 recurrent IUD despite reassuring testing

Perinatal mortality 3.3/1000

Earliest delivery associated with a positive test result was 32 weeks

Weeks et al. Antepartum surveillance for a history of IUD: When to begin. AJOG 1995;172:486-92.

Antepartum Testing Protocol

Protocol may not be appropriate for all previous IUDs Nonrecurring conditions Perinatal infection Fetal anomalies Maternal trauma IUDs following OB complications that can recur but cannot be predicted Abruption Prolapse Uterine rupture

ACOG Practice Bulletin #102 Management of IUD March 2009

Little evidence-based data to guide antepartum surveillance with prior unexplained IUD Antepartum testing may be initiated at 32 34 weeks Associated with potential morbidity and costs 16.3% delivery at or before 39 weeks 1% delivery before 36 weeks

ACOG Practice Bulletin #102

Antenatal testing before 37 weeks gestation
1.5% rate of iatrogenic prematurity for intervention based on false-positive test

Excess risk of infant mortality due to late preterm birth

8.8 / 1000 at 32 33 weeks gestation 3 / 1000 at 34 36 weeks gestation