Standard investigations for IUFD include maternal blood tests, Kleihauer test, serology for TORCH and syphilis, random blood glucose, HbA1c, and thyroid tests. Foetal and placental investigations include microbiology, karyotype, and post-mortem examination. Selective investigations may also be considered depending on clinical assessment and history, such as maternal coagulation tests if DIC is suspected, bacteriology if infection is suspected, and thrombophilia screening if placental disease is suspected. The diagnostic yield is highest with post-mortem examination of the baby and placenta, though consent is required. The cause remains unknown in about half of IUFD cases even after investigation.

1. Investigations for IUFD & SB
How to select ?
Evidence based review
Wafaa B. Basta
Specialist Gynaecology & Obstetrics at MTH, MRCOG
ERC MEMBER
EFSS & Deietta 14th Annual Conference Ras El-Bar 17th May 2012

2. • Devastating situation to be confronted with.
• Especially in fresh SB.
• Do we have to investigate or not?
• Timing of investigations !
• Standard & selective investigations !
• Foetal investigations!

3. Against !
• Expensive
• Limited recurrence
• Post-mortem: cultural believes, limited value.
• No cause in 50% of cases.
• No treatment.
• Guilty feeling --- fear of discovering a
negligence.

4. With !
• Assess maternal wellbeing &manage any
potentially life threatening maternal disease .
• Determine the cause of death which provide
the answer to the parents’ question ‘why?’
• Determine the chance of recurrence.
• Consider possible means of avoiding further
pregnancy loss.

5. Definitions
• Stillbirth (SB) is defined as ‘a baby delivered
with no signs of life, known to have died
after 24 completed weeks of pregnancy’.
• Late intrauterine foetal death (IUFD) refers to
babies with no signs of life in utero after 24
completed weeks of pregnancy.
The Perinatal Mortality Surveillance Report (CEMACH)

6. Causes (Ante-partum)
Common ante-partum causes include:
• Congenital malformation.
• Trans-placental infection
(TORCH,Syphilis,Listeria, Coxsackievirus,
leptospira, Q fever, and Lyme disease).
• Ante-partum haemorrhage.
• Foeto-maternal haemorrhage.
• Pre-eclampsia .
• Diabetes mellitus.3,4
• Other maternal diseases (SLE , epilepsy,....).

7. Causes (Intra-partum)
Common causes of intra-partum death:
• Placental abruption
• Cord prolapse.
• Uterine rupture.3,4
• Idiopathic hypoxia–acidosis.
• Maternal ascending infection(E. Coli ,Klebsiella,
Group B Strept, Enterococcus,
mycoplasma/ureaplasma, Haemophilus
influenzae , Chlamydia ).
• Foetal infection

8. How to investigate IUFD?
• Clinical assessment .
• Laboratory tests:
Standard routine investigations.
Selective investigations ,directed by clinical
assessment.

9. Standard Investigations
Maternal
• Standard haematology &
biochemistry.
• Kleihauer test
• Serology (TORCH& Syphilis)
• Random blood glucose
• HbA1c
• Thyroid function test
Foetal & placental
• Microbiology
• Karyotype & single gene
testing
• Post-mortem examination

10. Selective Investigations
Maternal
• Maternal coagulation times and
plasma fibrinogen
• Bacteriology (blood cultures
midstream urine, vaginal swabs
cervical swabs).
• Maternal Thrombo-philia Screen
• Immunological (Anti-red cell
antibody serology, Anti-Ro and
anti-La antibodies , Allo-immune
anti-platelet antibodies )
• Parental karyotype.
• Maternal urine for cocaine
metabolites .
Foetal & Placental
• NONE

11. Clinical Assessment (History)
Family history :
• Congenital anomalies
• Abnormal karyptype
• Hereditary conditions
• DM, HT
• VTE/ PE
• Consanguinity
Medical history :
• DM
• HT
• Heart disease
• SLE
• VTE/ PE
• Epilepsy
Past OB History :
• Baby with congenital anomaly
/ hereditary condition
• IUGR
• Pre-eclampsia
• Placental abruption
• IUFD
• Recurrent miscarriage

12. Clinical Assessment (History)
Current Pregnancy History :
• Maternal age
• Gestational age at fetal death
• Hypertension
• DM/ Gestational D
• Smoking , alcohol, or drug abuse
• Abdominal trauma
• Infection (fever, flu like
symptoms)
• Cholestasis
• Placental abruption
• Cord accident
• PROM
• Abnormal Foetal scan
o IUGR
o Macrosomia
o Hydrops
o Congenital anomalies
o Soft tissue markers
o Complications of multiple
gestation
• Confirmed Chromosomal
abnormalities by CVS,
amniocentesis
• Abnormal screening biochemical
tests.

13. Clinical Assessment (Examination)
To detect:
• Pre-eclampsia
• Chorio-amnionitis
• Placental abruption
• DIC

14. General principles of investigation
• No specific cause is found in almost half of
SB.
• An abnormal test result is not necessarily
related to the IUFD; maybe coincident.

15. Standard Investigations

16. Standard Investigations
Maternal
• Standard haematology &
biochemistry.
• Kleihauer test
• Serology (TORCH& Syphilis)
• Random blood glucose
• HbA1c
• Thyroid function test
Foetal & placental
• Microbiology
• Karyotype & single gene
testing
• Post-mortem examination

17. Maternal standard haematology and
biochemistry
• Blood group, Rh, antibody screen, FBC, renal function tests,
liver function tests, CRPs and bile salt .
 Used to evaluate:
1) Pre-eclampsia and its complications.
2) Multi-organ failure in sepsis or haemorrhage.
3) Organ function in presence of any underlying maternal
medical disorder.
4) Obstetric cholestasis
[ Evidence level 3]

18. Kleihauer Beteke Test
 Used to :
1) Detect lethal feto–maternal haemorrhage.
2) To decide level of requirement for anti- RhD gamma-
globulin.
• Kleihauer should be recommended for all women (not only
RhD-negative).
• Tests should be undertaken before birth as red cells might
clear quickly from maternal circulation .
• In RhD-negative women, a second Kleihauer test also
determines whether sufficient anti-RhD has been given.
[ Evidence level 2]

19. Maternal Serology
 Used to diagnose occult maternal-foetal infection.
• Viral screen (TORCH, Parvovirus B19)
• Treponemal serology for Syphilis.
• For tropical infections if suggestive histoty (e.g.travel to
endemic areas).
• Hydrops is not necessarily a feature of Parvovirus related
IUFD.
[ Evidence level 2+]

20. Maternal random blood glucose
 Used to detect occult maternal diabetes mellitus.
• Rarely a woman will have incidental type 1 diabetes
mellitus.
• Women with gestational diabetes mellitus return to normal
glucose tolerance within a few hours after late IUFD has
occurred .
[ Evidence level 3]

21. Maternal HbA1c
 Used to detect gestational diabetes.
• Most women with gestational diabetes mellitus have a
normal HbA1c ( test in future pregnancy )
• Might also indicate occult type 1 and type 2 diabetes .
[ Evidence level 2+]

22. Foetal and Placental Microbiology
 Used to diagnose foetal infections
• More informative than maternal serology for detecting viral
infections
• Need to be obtained using clean technique from:
1) Foetal cord or cardiac blood (in lithium heparin)
2) Foetal swabs (ear & throat)
3) Placental swabs (taken from between the amnion and the
chorion).
• Written consent advisable for cardiac bloods
[ Evidence level 2+]

23. Foetal and Placental Tissues for Karyotype
(Cytogenetic analysis)
 Used to detect:
1) Aneuploidy.(6% of SB)
2) Single gene disorders.
• Written consent essential.
• Send several specimens from multiple tissues – cell
cultures might fail.
• Culture fluid should be stored in a refrigerator and thawed
thoroughly before use.
• Culture potentially provides the greatest range of genetic
information (trisomies, monosomies, translocations and
major deletions).

24.  Peri-natal specimens suitable for karyotyping include:..
 Deep foetal skin, include underlying muscle(about 1 cm in length from
the upper fleshy part of the thigh).The skin can be closed with wound
adhesive strips and tissue adhesives, as higher rate of culture failure
(~60%).
 Placenta (approximately 1 cm diameter) should be taken from the fetal
surface close to the cord insertion ,has the advantages of being the most
viable and rapid tissue for cell culture, but has the disadvantages of
maternal contamination and placental pseudo-mosaicism.
 Foetal cartilage e.g. patella, but cartilage is harder to sample
 Amniocentesis can also provide cytogenetic results with rising evidence
of its higher success rate.
[ Evidence level 2+]
Foetal and Placental Tissues for Karyotype
(Cytogenetic analysis)

25. Post-mortem examination
• Post-mortem examination of the baby and placenta has the
highest diagnostic yield of all investigations.
• Written consent essential.
• The examination should be undertaken by a specialist peri-
natal pathologist.
• Parents who decline full post-mortem might be offered a
limited examination (sparing certain organs).
• Less invasive methods such as needle biopsies can be
offered.

26. Post-mortem examination
 Post-mortem examination should include :
• External examination of foetus, cord, membranes, placenta and amniotic
fluid with weight & length measurement as IUGR is a significant
association for late IUFD .
• Histology of relevant tissues .
• Placental pathology is useful and should be offered even if a post-mortem
examination of the baby is declined. It helps to show :chorionocity in
twins ,cord thrombosis or knots ,infarcts, thrombosis, abruption ,vascular
malformations and signs of infection.
• Medical imaging can act as an adjunct to full post-mortem:
o Skeletal X-ray: show skeletal defects that are difficult to identify on
dissection.
o MRI can be a useful adjunct to conventional post-mortem,
particularly of the brain and spinal cord .MRI is currently being
evaluated (MaRIAS trial)
o Ultrasound has been used to visualise foetal brain, cardiac, lung and
renal development when consent to autopsy has been withheld

27. Selective Investigations

28. Selective Investigations
Maternal
• Maternal coagulation times and
plasma fibrinogen
• Bacteriology (blood cultures
midstream urine, vaginal swabs
cervical swabs).
• Maternal Thrombo-philia Screen
• Immunological (Anti-red cell
antibody serology, Anti-Ro and
anti-La antibodies , Allo-immune
anti-platelet antibodies )
• Parental karyotype.
• Maternal urine for cocaine
metabolites .
Foetal & Placental
• NONE

29. Maternal coagulation times and
plasma fibrinogen
 Used to diagnose DIC
• Not a test for cause of late IUFD
• Maternal sepsis, placental abruption and pre-eclampsia
increase the probability of DIC
• Especially important if woman desires regional anaesthesia .
• Clotting studies, blood platelet count and fibrinogen level
should be repeated twice weekly in expectant management
as DIC occurs in 10% within 4 weeks after the date of late
IUFD, rising to 30% thereafter
[ Evidence level 3]

30. Maternal bacteriology
(blood cultures midstream urine, vaginal, cervical swabs )
 Used to detect suspected maternal bacterial infection
including Listeria monocytogenes and Chlamydia spp.
 Also used to direct maternal antibiotic therapy .
• Indicated in the presence of:
 Maternal fever.
 Flu-like symptoms.
 Abnormal liquor , (purulent appearance/offensive odour) .
 Prolonged ruptured membranes before late IUFD.
• Abnormal bacteriology is of doubtful significance in the
absence of clinical or histological evidence of chorio-
amnionitis.
[ Evidence level 1++]

31. Maternal Thrombo-philia Screen
 Used to diagnose maternal thrombophilia
• Indicated if evidence of foetal growth restriction or
placental disease
• The association between inherited thrombophilias and IUFD
is weak, and management in future pregnancy is uncertain
• if abnormal, repeat at 6 weeks
• Most tests are not affected by pregnancy
[ Evidence level 1++]

32. Thrombo-philia Screen
• Anti-thrombin levels(AT),
• Protein C activity (PC),
• Total and free protein S antigen (TPS,FPS)
• Inherited thrombophilia:
Factor V Leiden (FVL),
 Prothrombin G20210A mutation
(PTG20210A)
 Lupus anticoagulant(La)

33. Anti-red cell antibody serology
 Used to diagnose Immune haemolytic disease
• Indicated if fetal hydrops evident clinically or on post-
mortem
[ Evidence level 3]

34. Maternal anti-Ro and anti-La antibodies
 Used to diagnose occult maternal autoimmune disease.
• Indicated if evidence of hydrops, endo-myocardial fibro-
elastosis or AV node calcification at post-mortem.
[ Evidence level 3]

35. Maternal allo-immune anti-platelet
antibodies
 Used to diagnose allo-immune thrombocytopenia.
• Indicated if foetal intracranial haemorrhage found on post-
mortem
[ Evidence level 3]

36. Parental Bloods for Karyotype
 Used to detect :
1) Parental balanced translocation.
2) Parental mosaicism.
• Indicated if:
 Foetal unbalanced translocation .
 Other foetal aneuploidy, e.g. 45X (Turner syndrome)
 Foetal genetic testing fails and history suggestive of
aneuploidy (foetal abnormality on post-morterm,
previous unexplained IUFD, recurrent miscarriage)
[ Evidence level 3]

37. Maternal urine for cocaine
metabolites
Used to detect occult drug use.
• With consent, if history and/or presentation
are suggestive.
[ Evidence level 1++]

38. Is this applicable?

41. So, What we can do ?
• We can extend the use of the selective workup based on clinical
findings.
• For example, when clinical findings strongly suggest a cause for the
fetal demise (as cord accident , anencephaly, or previously known
lethal karyotype) either no further testing or limited testing is
performed.
• Fetal karyotype can be limited to cases when the fetus is dys-
morphic, has growth retardation, is hydropic, or has anomalies ,in
multiple pregnancy losses, or when a parent has a balanced
translocation or mosaic chromosomal pattern.
• If severe clinical abruption is present, testing can be limited to
toxicology screening and possibly a thrombo-philia workup.

42. Incidence and risk factors of fetal
death in Norway: a case-control study
• LINDA BJÖRK HELGADOTTIR, FINN EGIL SKJELDESTAD, ANNE FLEM
JACOBSEN,PER MORTEN SANDSET, EVA-MARIE JACOBSEN
• Article first published online: 4 MAR 2011
•Objective. To estimate incidence and risk factors for intrauterine
fetal death (IUFD) in a Norwegian study-population applying two
different control groups
•Conclusion.SGA has a strong association with IUFD, and the risk of
hypertensive disorders is mediated through SGA. The other risk
factors, except placental abruption, are of low prevalence and of
limited importance in the prevention of a relatively low incidence,
although dramatic, event like IUFD.

43. Guideline flowchart for diagnostic workup to
investigate cause of foetal death
Thesis, University of Groningen, The Netherlands ISBN: 978-90-367-4161-3
Methods
In a multicenter, prospective cohort study from 2002 to 2008, 1025 couples with
fetal death > 20 weeks of gestation were studied. An extensive non-selective
diagnostic workup was performed including maternal and fetal blood tests;
parental coagulation tests; microbiological cultures; autopsy; placental
examination; cytogenetic analysis; radiography and MRI. A multidisciplinary
panel classified cause of fetal death and the value of performed diagnostics for
allocating the cause.
Interpretation
Autopsy, placental examination, cytogenetic analysis and testing for fetal
maternal hemorrhage are the basic tests for all fetal deaths. On the basis of
these results or specific clinical characteristics further sequential testing is
indicated.

44. Basic investigation for all IUFD
1- review previous obstetric history, current pregnancy, antenatal investigations,
maternal and paternal family and personal history
2- Maternal FBC, Kleihauer test, collect and store serum for maternal virus
serology and vaginal-rectal swab mother; analyse selectively
3-Delivery
4-- External foetal examination: documentation of morphologic (ab)normalities
register birth weight and trimmed placental weight
5- Cytogenetic analysis
6-collect and store foetal and placental swabs, analyse selectively
7--Placental examination including histopathology
8- if autopsy consent with suspected congenital anomalies and recommended by
expert familiar with congenital anomalies MRI and radiography before autopsy
9-Autopsy
10- if no autopsy consent external foetal examination by expert familiar with
congenital anomalies including photographs, MRI and radiography

45. Selective investigation IUFD
 Suspected hypertensive disorders----- blood tests and test urine for
albumin.
 Suspected disturbed thyroid function -------TSH, T3,T4
 Suspected diabetes-related disease( macrosomia, a strong family history
of diabetes, or obesity)---------- glucose screening: as HbA1c and oral GTT
 If suspected drug use -------toxicology screen
 If signs of foetal hydrops------ antibody screening, parvo B19 & Hb-
electrophoresis
 If clinical signs of infection or signs of infection in placenta or at autopsy –
maternal viral serology, microbiology tests from mother, foetus, placenta
 In women with family history of hereditary thrombophilia or a personal
history of VTE------------ thrombo-philia work-up

46. Conclusion
• Foetal loss is a distressing situation for the lady ,family and
medical staff as well.
• Investigating the cause of death has many benefits .
• Meticulous history taking and clinical assessment is of at
most importance.
• There are routine standard tests & others arte selective
directed by clinical scenarios.

47. Conclusion
• Researches & recording are required to estimate main
causes of foetal death at local level, so, investigations could
be directed.
• In presence of lack of resources, selection of investigations
should be prioritized by most relevant and most informative
ones.
• Post-mortem examination should be re-included at least
external examination & placental histopathology.

48. ‘Not everything that is faced can be changed. But nothing can be
changed until it is faced’
James Arthur Baldwin