Intrauterine death ✅

Intrauterine death (IUD) refers to the death of the fetus after 20 weeks’ gestation but before birth. In the UK, fetal death at or after 24+0 weeks is recorded as a stillbirth. Causes are often multifactorial, involving maternal, fetal, placental, or cord issues. Early diagnosis and sensitive management are essential, including discussion of options and support.

👩 Maternal & Systemic Factors

• ⚡ Hypertensive disorders: Preeclampsia, chronic hypertension → placental insufficiency.
• 🍬 Diabetes mellitus: Poor control → malformations, macrosomia, placental dysfunction.
• 🧫 Infections: Syphilis, parvovirus B19, other TORCH infections contributing to fetal compromise.
• 🚬 Substance use: Smoking, alcohol, illicit drugs → abruption, hypoxia.
• 🩸 Thrombophilias: Antiphospholipid syndrome and inherited clotting disorders affecting placental perfusion.
• 🩹 Trauma: Maternal injury causing placental abruption or fetal hypoxia.

👶 Fetal Causes

• 🧬 Chromosomal abnormalities: Trisomies 13, 18, Turner syndrome.
• 🏥 Severe congenital anomalies: Complex cardiac, neural tube, or renal anomalies incompatible with life.
• 📉 Growth restriction: Severe IUGR due to chronic placental insufficiency.

🧬 Placental & Cord Causes

• 💥 Placental abruption: Premature separation → haemorrhage and acute hypoxia.
• 📦 Placental insufficiency: Reduced perfusion in hypertensive or metabolic disease.
• 🌀 Umbilical cord accidents: True knots, entanglement, or cord prolapse leading to acute compromise.

🔍 Diagnosis

Diagnosis is typically prompted by reduced or absent fetal movements and confirmed by imaging.

• 📡 Ultrasound: Confirm absence of fetal heartbeat and movements.
• 🩺 Doppler assessment: May aid in evaluating umbilical/placental circulation.
• 🧪 Maternal blood tests:
  • Group and save / full blood count
  • Infection screen including syphilis
  • Glucose monitoring in diabetes
• ✂️ Post‑delivery investigations:
  • Placental histology
  • Fetal post‑mortem (with consent)
  • Genetic/cytogenetic testing if indicated

🏥 Management

Once IUD/stillbirth is confirmed, care focuses on safe delivery planning and sensitive parental support. Women should be involved in joint planning and offered clear choices (expectant, induction, or caesarean if indicated).

• 🩺 Clinical stabilisation: Monitor maternal vitals and screen for coagulopathy (e.g., prolonged retention may increase risk of consumptive coagulopathy).
• 🎯 Discuss delivery options:
  • ⏳ Expectant management: May be reasonable short term if preferred and clinically safe.
  • 📈 Induction of labour: Prostaglandins (misoprostol or dinoprostone) ± oxytocin based on gestation and clinical context.
  • ✂️ Caesarean birth: Consider for standard obstetric indications or maternal request after counselling.
• 🧸 Post‑delivery care: Monitor blood loss, pain relief, and early bonding/parental time with the baby if families wish.

💞 Bereavement & Psychological Support

• 🤝 Provide support: Midwifery bereavement teams, psychological support referral and time for the family to spend with their baby if desired.
• 🗣️ Information & choices: Honest explanations of findings, investigations and future pregnancy planning.
• 🧠 Plan future antenatal care: Address modifiable risks, offer tailored surveillance in subsequent pregnancies.

⚠️ Complications & Safety Points

• ⚡ Coagulopathy (DIC): Rare but important if fetal retention prolonged without delivery.
• 🦵 Physical recovery: Pain control, monitoring for infection and haemorrhage postpartum.
• 📈 Audit/Morbidity review: Stillbirth reviews contribute to quality improvement.

🧠 Exam Tip: In OSCE/short answer questions, structure as: Definition → Risk factors → Diagnosis (ultrasound confirmation) → Management options (induction/expectant/caesarean) → Post‑delivery care → Bereavement support and future planning.

📚 NICE & UK AWHONN‑Aligned Guidance

• NICE NG207: Inducing labour (covers stillbirth induction principles)
• NICE CG192: Childbirth – support after stillbirth/miscarriage (psychosocial support)
• CG192 – Support when birth is traumatic (stillbirth section)
• NHS – Stillbirth information and support