Intrauterine Fetal Demise Flashcards
A 42 yo G2 P1001 at 40 weeks presents to Labor and Delivery stating, ”I haven’t felt the baby move in 6 hours!”
The L&D nurse is unable to obtain a fetal heart rate and calls you to assess the patient. There is no cardiac activity noted on ultrasound exam.
The patient undergoes induction of labor and has an uncomplicated vaginal delivery. She receives counseling and services from the hospital bereavement team. Pathological and genetic studies are sent. She awaits the results.
Intrauterine fetal demise (IUFD)
-fetal death prior to delivery
-MANY etiologies:
-Fetal anomalies
-Abnormal placentation
-Abruptio placentae
-Intrauterine growth restriction
-Hypertensive disorders of pregnancy
-Infection (parvovirus 19, syphilis, group B strep, listeriosis)
-Smoking
-Multiple gestation
Definition of fetal death (also known as stillbirth)
-The absence of:
-Breathing effort
-Heart rate
-Umbilical cord pulsations
-Definite movement of voluntary muscles
-Consult state laws regarding need to report such events
Incidence of IUFD
-1/160 deliveries
-Black patients: 11.25/1,000 deliveries
-Latina, Asian, Native American and Caucasian patients: <6/1,000 deliveries
Risk factors
-African ancestry (due to health care disparities)
-Nulliparity
-Advanced maternal age
-Pregestational diabetes mellitus
-Chronic hypertension
-Conception via in vitro fertilization
-Multiple gestation
IUFD: signs and symptoms
-Classic presentation: “I haven’t felt the baby move for [hours, days]”
-Absent FHR on monitor
-Different institutions have different protocols for diagnosis that may include an attending physician or maternal-fetal medicine specialist
Management of IUFD
-Due to the risk of maternal coagulopathy because of the release of tissue thromboplastin from nonviable fetal tissues, expeditious delivery is indicated via any of the following:
-Hysterotomy or Caesarean section
-Induction of labor with misoprostol and/or oxytocin, or
-Dilation and evacuation under anesthesia, or
Factors to consider in management of IUFD
-Does the patient wish to see the fetus?
-Will the patient request an autopsy?
-If the answer to either question is yes, then dilation and evacuation is not feasible
Management of fetus after delivery
-Possible studies to determine etiology of death
-Autopsy
-Placental pathology (send for medicolegal purposes)- protect yourself and give parents closure
-Genetic studies obtained via biopsy of quadriceps muscle
Management of patient and family after delivery
-Bereavement care
-Bereavement team usually consists of:
-Nursing staff
-Medical staff
-Social workers
-Pastoral care staff
-May provide memory box
-Cast of handprint and/or footprint
-Lock of hair
-Photos
-Cabergoline 0.5-1 mg PO once within 24 hours of delivery for suppression of lactation
-Ice packs and supportive bra for parturient to reduce breast engorgement
Care of a subsequent pregnancy in a patient with history of IUFD
-Patients with a history of IUFD have an increased risk 2.5 times higher of having another IUFD compared to women who have not had this outcome
-Provide individualized care
-Consider delivery between 37-38 weeks, 6 days, if indicated
Which of the following best identifies the reason that delivery is indicated at the time of dx of IUFD
-mental health of the parturient
-prevention of maternal hemorrhage
-identification of etiology of IUFD
lactation suppression
-Cabergoline 0.5-1 mg PO once within 24 hours of delivery for suppression of lactation
-Ice packs and supportive bra for parturient to reduce breast engorgement
