Intauterine fetal demise

Question 1

What is the definition of Intrauterine Fetal Demise (IUFD)?

Answer 1

IUFD is the death of the fetus at 24 weeks gestation or later, or when the fetus weighs more than 500 grams in utero. It occurs in 80-90% of cases, with women experiencing labor within 2-3 weeks. Retaining IUFD for 4-5 weeks is associated with a 25% risk of Disseminated Intravascular Coagulation (DIC)​

Question 2

What are the key components of diagnosing IUFD?

Answer 2

Diagnosis of IUFD involves:

History: Decreased or absent fetal movement.
Examination: No fetal heart sounds; fundal height may be less than expected.
Investigations: Ultrasound showing no fetal cardiac activity, possibly oligohydramnios, overlapping sutures, or abnormal curvature of the fetal spine. Additional tests include FBC, RBS, grouping, and VDRL​

Question 3

What is the recommended management for IUFD without chorioamnionitis or preeclampsia?

Answer 3

If IUFD is diagnosed without chorioamnionitis or preeclampsia, it is recommended to allow up to 3 weeks for spontaneous labor to occur, with weekly platelet monitoring

Question 4

How is labor induced in cases of IUFD at different gestational ages?

Answer 4

24-26 weeks gestation: Use 200 mcg Misoprostol PV every 4 hours until delivery.
28-40 weeks gestation: Use 25 mcg Misoprostol orally every 2 hours or 50 mcg PV every 6 hours until delivery.
If one prior low transverse caesarean delivery and ≤28 weeks gestation: Use 50 mcg Misoprostol every 4 hours until delivery.
For more than one prior low transverse caesarean delivery and ≤28 weeks gestation: Consult with a consultant​

Question 5

What are the considerations for induction of labor in IUFD cases with a history of caesarean delivery?

Answer 5

For IUFD with one or more prior low transverse caesarean deliveries and gestation greater than 28 weeks, Misoprostol should not be used. For a prior classical caesarean delivery, consult with a consultant, especially if the gestation is greater than 28 weeks​

Question 6

What are the steps to take if there are signs of infection or macerated stillbirth in IUFD?

Answer 6

First 24 hours: Administer Ampicillin 1 g every 6 hours plus Gentamicin 160 mg once. If necessary, switch to Ceftriaxone 1 g IV plus Flagyl 400 mg TDS PO.
Following 4 days: Continue with Amoxicillin 1 g TDS PO, plus Flagyl 400 mg TDS PO

Question 7

What is the importance of bereavement counseling and placental evaluation in IUFD?

Answer 7

Bereavement counseling and placental evaluation are crucial to provide emotional support to the patient and to investigate the cause of IUFD. A perinatal autopsy is recommended to help understand the risk of recurrence​

Question 8

Ultrasound scan signs seen in IUFD

Answer 8

1. Absent fetal heart tones
2. Absent voluntary muscle movements
3. Distorted appearance/ macerated
4. Spalding sign ( overlapping sutures)
5. Roberts sign ( gas shadow in the fetal heart)
6. Helix sign ( gas bubble in the umbilical arteries)
7. Ball Sign (hyperflexia of the spine )
8. Skin tissue edema ( >5mm)
9. echogenic amniotic fluid
   10.. thrombus in fetal heart