Fetal Death

Fetal Death = IUFD

 IUFD = Stillbirth
 Fetal death after 20 weeks EGA but before
the onset of labor.
 Incidence in U.S. 0.4-0.9%
 Complicates 1% of pregnancies.
 Shift from expectant management to active
management.

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 Common Causes

True Knot

 Unknown or indeterminate in approx 50% of cases.

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 IUFD
 Etiology:
Unexplained 25-60%: depending on classification
system
IUGR: risk of IUFD in IUGR is 5-7x greater
Abruption: occurs in 10-20% of stillbirths (vs. 1%)
Infection Fetal/ Maternal
Chromosomal and genetic abnormalities: single
gene defects, confined placental mosaicism,
microdeletions with normal amnio
Congenital malformations: 15-20% Abd wall
defects, NTDs, Potter syndrome, achondrogenesis,
amniotic band syndrome
Fetomaternal hemorrhage
Umbilical cord complications: nuchal cord, knot
Hydrops fetalis
 Common Causes
 Hypertensive Diseases (Pre-E, Eclampsia)
 Diabetes Mellitus
 Erythroblastosis Fetalis
 Umbilical Cord Accidents (true knot, prolapse)
 Congenital Anomalies
 Infections (Fetal or Maternal)
 Hemorrhage (Abruption)
 Thrombophilias (antiphospholipid antibodies)

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 IUFD
Risk Factors
Pregravid obesity
Socioeconomic factors
Race: black women 2x higher risk, even with
adequate PNC
Multiple gestation
Smoking
Maternal medical disorders: DM, HTN, SLE,
renal dz, thrombophilia, cardiac dz, thyroid
dz, etc.
Previous IUFD and SGA
 Infection - TORCH
 Toxoplasmosis
 Rubella
 CMV
 HSV

 Parvo-virus
 Listeria
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 Gestational HSV Infection

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 Patient Presentation

 Subjective decreased fetal movements

 Uterus FH is small for EGA
 No fetal heart tones with doppler
 Will still have pos hCG
 Ultrasound
 No Fetal Movement
 No Fetal Cardiac Activity

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 Diagnostic Methods for IUFD

No FCA
No movement

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 Maternal Complications
Disseminated Intravascular Coagulopathy

 Decreased platelets
 Decreased fibrinogen
 Increased PT/PTT (Clotting times)
 Clinical bleeding / oozing from all sites
 Decreasing H/H
RX involves DELIVERY, pRBC’s, FFP, PLATELETS,
Supportive Management

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 Maternal Complications

 Depression, Anxiety, Psychosocial

 Anxiety with future pregnancies
 May have repeat losses (depending on causes)
 Bleeding ---> can lead to DIC but may only
require blood product replacement
 Pain, Infection (similar to any other delivery)

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 Management = Delivery
 Attempt for SVD
 Expectant vs. Active management
 Active ManagementInduction vs. spontaneous
labor (80-90% w/i 2 wks)
Vaginal misoprostol +/- oxytociPain
Management
 PCA (Pt Controlled Analgesia)
 Epidural

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 Management
 Fetal karyotyping:
Amniocentesis more likely to yield viable cells
prior to delivery
Fetal blood/ skin
 Placental pathology
 Laboratory work-up: KB, CBC, Chem, Utox, TFTs,
thrombophilia, lupus anticoagulant,
anticardiolipin
 Coagulopathy
Caused by gradual release of thromboplastin
from placenta, usually after 4 weeks
 Counseling

 Giving bad news: straightforward, empathetic,

without blame
 Kubler-Ross stages of grief: denial, anger,
bargaining, depression, acceptance
 Induction after 24 hours vs. within 6 hours
associated with increased risk for anxiety?
 Contact with stillborn
 Autopsy option
 Fetal remains
 Postpartum care: before and after discharge
 Counseling

 Increased risk for depression, anxiety, PTSD,

decreased maternal-fetal attachment
In one study of 65 mothers of stillbirths, less
incidence of adverse outcomes in mothers who
did not have contact with the stillborn.
Recently bereaved women at higher risk for
depression and anxiety in subsequent
pregnancy.
 Increased risk for subsequent stillbirth and
complications including preeclampsia, abruption,
preterm delivery, low birth weight