Makindo Medical Notes

Intrauterine death (IUD) refers to the death of the fetus after 20 weeks of gestation but before birth. The causes are often multifactorial, and may involve maternal, fetal, or placental factors.

Maternal Causes

• Hypertensive Disorders: Preeclampsia, eclampsia, and chronic hypertension can lead to placental insufficiency and fetal death.
• Diabetes Mellitus: Poorly controlled diabetes can result in congenital malformations, macrosomia, or placental insufficiency.
• Thrombophilias: Conditions like antiphospholipid syndrome or inherited thrombophilias (e.g., Factor V Leiden) can cause placental infarctions or clotting disorders, leading to IUD.
• Infections: Maternal infections such as cytomegalovirus (CMV), syphilis, listeriosis, toxoplasmosis, and parvovirus B19 can cross the placenta and cause fetal death.
• Substance Abuse: Smoking, alcohol, or drug use (e.g., cocaine, opioids) can cause placental abruption or growth restriction, increasing the risk of IUD.
• Autoimmune Disorders: Conditions such as systemic lupus erythematosus (SLE) can cause placental vasculopathy and fetal death.
• Trauma: Motor vehicle accidents, falls, or physical trauma can lead to placental abruption or direct fetal injury.

Fetal Causes

• Congenital Anomalies: Severe malformations (e.g., anencephaly, cardiac defects) can lead to fetal demise, especially if incompatible with life.
• Chromosomal Abnormalities: Conditions such as trisomy 13, trisomy 18, or Turner syndrome may cause IUD, often in early gestation.
• Fetal Infections: Infections such as CMV, rubella, and syphilis can lead to severe fetal complications or death.
• Intrauterine Growth Restriction (IUGR): Restricted fetal growth due to placental insufficiency can increase the risk of stillbirth.

Placental Causes

• Placental Abruption: Premature separation of the placenta from the uterine wall, leading to haemorrhage and fetal hypoxia.
• Placental Insufficiency: Conditions such as preeclampsia can impair placental blood flow, leading to chronic hypoxia and IUD.
• Placenta Previa: Placental implantation over the cervical os may lead to bleeding and fetal compromise.
• Umbilical Cord Complications: True knots, cord prolapse, or cord entanglement can cause acute fetal hypoxia and death.

Diagnostic Tests for Intrauterine Death

The diagnosis of IUD is often made based on clinical findings (e.g., decreased fetal movements) and confirmed by imaging and laboratory investigations.

• Ultrasound:
  • Absence of Fetal Heartbeat: Real-time ultrasound can confirm the absence of fetal cardiac activity.
  • Fetal Biometry: Assess fetal size and growth to determine the timing of death.
  • Amniotic Fluid Assessment: Oligohydramnios or polyhydramnios may provide clues to underlying causes.
• Doppler Ultrasound: To assess placental or umbilical cord blood flow in suspected placental insufficiency or umbilical cord complications.
• Laboratory Tests:
  • Thrombophilia Screen: To identify underlying maternal thrombophilia (e.g., antiphospholipid syndrome).
  • Infection Screen: Serology for infections such as CMV, parvovirus B19, syphilis, toxoplasmosis, and rubella.
  • Maternal Blood Glucose: To check for uncontrolled diabetes.
  • Kleihauer-Betke Test: To detect fetal-maternal haemorrhage in cases of trauma or placental abruption.
• Amniocentesis: To test for chromosomal abnormalities or fetal infections, particularly if structural anomalies are noted on ultrasound.
• Autopsy and Placental Examination: Recommended after delivery to provide further insight into the cause of IUD.

Management of Intrauterine Death

Once IUD is confirmed, the management focuses on delivering the fetus and providing psychological support to the family.

Delivery

• Expectant Management: In some cases, spontaneous labor may occur within a few days to weeks of fetal demise. However, prolonged retention of a dead fetus can lead to maternal complications such as disseminated intravascular coagulation (DIC).
• Induced Labor:
  • Prostaglandins: Misoprostol or dinoprostone may be used for cervical ripening and induction of labor.
  • Oxytocin: Used to induce labor in cases where the cervix is favorable or following prostaglandin use.
• Dilation and Evacuation (D&E): May be performed in cases of fetal death during the second trimester, depending on gestational age and maternal preference.

Psychological Support

• Counseling: Parents should be offered bereavement counseling to cope with the emotional impact of losing a child.
• Memory-Making: Encouraging the family to create memories (e.g., photos, footprints) can help with the grieving process.
• Follow-Up: Regular follow-up visits are essential to assess the mother’s physical and psychological recovery. Testing for causes of IUD (e.g., infection screening, thrombophilia workup) may be done after delivery.

Postpartum Care

• Address complications such as postpartum haemorrhage or DIC, especially in prolonged cases of IUD.
• Provide contraception counseling, especially if the cause of IUD is related to preventable factors (e.g., poor diabetes control, thrombophilias).

Future Pregnancy Planning

• Investigate and address any underlying cause of IUD (e.g., thrombophilia, diabetes, infections) to improve future pregnancy outcomes.
• Offer preconception counseling for risk factor management, such as weight control, control of chronic conditions, or thromboprophylaxis in subsequent pregnancies.