4.2 Intrauterine Fetal Death

Question 1

HistoRY You are the anaesthetic registrar on call in the labour ward. You
are asked to review a 29-year-old female who is 28 weeks pregnant, gravida 4, para 3. She has presented to the labour ward with decreased fetal movement for the past 5 days. Subsequently after doing an ultrasound, the obstetricians have confirmed intrauterine fetal death. She is about to be induced. The midwives ask you to see patient and offer advice on subsequent pain management.

What would you do?

Answer 1

• Full history and examination, especially looking for associated
  problems (e.g. preeclampsia, haemorrhage, abruption,
  chorioamnionitis, DIC)
• Sensitive approach as likely to be upset
• Plan analgesia in a stepwise fashion with multi-modal approach

° Regular paracetamol +/− codeine,
progressing to opiates if required.

° PCA analgesia
(diamorphine/morphine preferable to pethidine),

some units also have protocols for remifentanil PCAs.

° Epidural analgesia:
Good analgesia but risk of clotting abnormality (DIC),
increasing risk of epidural haematoma and
subarachnoid haemorrhage.

Also increased risk of epidural abscess if raised temperature,
signs of sepsis especially in intrauterine fetal death.

Question 2

What investigations will you do
and why?

Answer 2

1. • FBC
     (may be anaemic if had antepartum haemorrhage,
     may have raised WCC associated with sepsis).
2. • U&E
     (may have multi-organ failure associated
     with haemorrhage or infection)
3. • Coagulation profile (risk of DIC)
4. • Blood cultures
     (maternal sepsis possible cause of fetal death)
5. • Group and save
     (as at risk of haemorrhage)
6. • 12-lead ECG (risk of arrhythmias with metabolic disturbance)

Question 3

Your examination and investigations yield the following:
Alert and talking patient
Heart rate 100 bpm
BP 90/60 mmHg
Temp 38.9°C
Hb 9.0 g/dL
WCC 22 × 109/L
Platelets 100 × 109/L
INR 1.7
Urea 12 mmol/L
Creatinine 90 μmol/L

What is your immediate management?

Answer 3

• Sepsis management as per surviving sepsis campaign
  (fluid resuscitation with crystalloid, early antibiotics, lactate measurement, close monitoring)
• Haematology involvement with regards to DIC and correction with blood
  products as necessary
• Nurse in obstetric HDU

Question 4

Which antibiotic would you choose to give this patient and why?

Answer 4

Broad-spectrum antibiotics (including anti-chlamydial) like clindamycin.

This is decided after discussion with the microbiologist.

Question 5

What do you think of a creatinine
of 90 μmol/L in a pregnant
woman?

Answer 5

It falls within the normal range of creatinine for women, but creatinine is
generally very low in pregnancy. Therefore, taken in context of this case,
it could represent early renal dysfunction secondary to sepsis.

Question 6

What is the incidence of intrauterine fetal death?

Answer 6

CMACE define intrauterine death as those babies with no signs of life in
utero.
(Stillbirth: baby born with no signs of life after 24/40.)

1 in 200 babies are born dead,

and the overall adjusted stillbirth rate is 3.9 per 1000.

Question 7

What are the causes of
intrauterine fetal death?

Answer 7

No specific cause is found in 50% of stillbirths.

The causes can be multiple and are as follows:

Maternal causes
1. * Preeclampsia
2. * Chorioamnionitis
3. * Placental abruption
4. * Antepartum haemorrhage
5. * Maternal disease (e.g. Diabetes Mellitus)

Fetal causes
1. * Cord prolapse
2. * Idiopathic hypoxia-acidosis
3. * Congenital malformations
4. * Congenital fetal infections