Intrauterine Death

Question 1

A 27-year-old female has been reviewed in the maternity day assessment unit for decreased foetal movements. An ultrasound scan confirms intrauterine death at 34 weeks.

What is the incidence of intrauterine death?

Answer 1

• Approximately 5 per 1000 births.
• Approximately 20% of these (1:1000) occur at or near term (>36 weeks of gestation).
• An early stillbirth occurs between 20 and 27weeks gestation; a late stillbirth occurs between 28 and 36 weeks gestation.

Question 2

What are the main causes of intrauterine death?

Answer 2

• Multiple factors can result in poor uterine function, including:
• Pre-eclampsia.
• Systemic lupus erythematous or other causes of hypercoagulability.
• Clotting disorders (haemophilia is high-risk).
• Maternal medical conditions e.g. diabetes, heart disease, thyroid disease or infection.
• Alcohol, recreational drug use e.g. cocaine and/or smoking.
• Birth defects (25% of stillbirths).
• Infection: either viral or bacterial directly affecting the foetus, or leading to sepsis in the mother. Common bacteria include group B streptococcus, E. coli, klebsiella, enterococcus, haemophilus influenza and mycoplasma. Rubella, herpes, Lyme disease and malaria are also well recognised.
• Trauma – can result in uterine injury, rupture, abruption or direct foetal injury.
• Intrahepatic cholestasis of pregnancy (ICP).

Question 3

What are the main causes of intrauterine death?

Continued…

Answer 3

Antenatal causes:
* Congenital malformations or infections.
* Maternal diabetes mellitus.
* Pre-eclampsia.

Intrapartum causes:
* Maternal sepsis.
* Placental abruption.
* Uterine rupture.
* Excessive frequency of uterine contractions.
* Umbilical cord compression.

Question 4

What are the key aspects in the management of this patient?

Answer 4

1) Supportive, 2) method of delivery, 3) pain management

Supportive:
* Care of the patient and partner to be provided by a senior midwife trained or experienced in intrauterine deaths.

• The patient should be managed in a room ideally located away from the main labour ward.

Method of delivery:
* The decision should be made by the senior obstetric team; most of these patients deliver vaginally but a caesarean section may be indicated in some cases.

• Attempts should be made to determine the cause of intrauterine death, as this may affect management of both the current delivery, and future pregnancies.

Question 5

What are the key aspects in the management of this patient?

Continued…

Answer 5

Pain management:
* The anaesthetist should be notified and assess the patient early.

• The patient can be offered a variety of modes of analgesia including oral medication, intravenous agents and neuraxial blockade.
• The patient should be assessed regularly and care should be taken to monitor her clotting and markers of infection. Derangements may
  preclude neuraxial blockade.

Question 6

The patient has a heart rate of 135 and a temperature of 39.6°C. You are asked to review her urgently.

How do you proceed?

Answer 6

This patient is showing signs of sepsis and needs urgent management including a rapid ABCDE assessment and instigation of treatment according to the local sepsis bundle.

• Immediate review of the patient and early escalation to senior obstetric and anaesthetic teams.
• Management of the patient should be in a high dependency area or intensive care if appropriate.
• Ensure large bore intravenous access, fluid resuscitation, anti-pyretic (paracetamol), and intravenous broad-spectrum antibiotics.
• Monitoring to include basic observations, urine output, full blood count, clotting and serial lactate levels.

Question 7

What are the risk factors for the development of sepsis in pregnant patients?

Answer 7

Pregnancy impairs the immune system

Obstetric:

• Procedures during pregnancy e.g. amniocentesis, cervical suture.
• Prolonged labour or rupture of membranes.
• Caesarean section.
• Retained placenta.

Non-obstetric:

• Comorbidities: raised BMI, diabetes mellitus, immunosuppressed state.
• Ethnic minority or poor socioeconomic status.