This document discusses intrauterine fetal demise (IUFD), also known as stillbirth. It defines IUFD as the death of a fetus in the uterus after 20 weeks of gestation. The document then covers the objectives, incidence, causes and risk factors, maternal complications, types and classifications, diagnosis, and management of IUFD. It describes the various placental, fetal, and maternal conditions that can potentially lead to IUFD, such as preeclampsia, fetal growth restriction, and maternal infections. Methods for diagnosing IUFD include ultrasound, biophysical profile, and Doppler velocimetry. Postmortem examination of the fetus and placenta is also discussed.

1. Intrauterine Fetal Demise
( IUFD )
BY
DR/ KARIMAREDA
ASS. LECTURER OF OBS.& GYNA
AL AZHAR UNIVERSITY
UNDER SUPERVISION
PROF.DR/ HANAA OMAR
PROF. OF OBS. & GYNA
AL AZHAR UNIVERSITY

2. Intrauterine Fetal
Demise
( IUFD )

3. Objectives :
 Definitions
 Incidence
 Causes and risk fators
 Maternal complications
 Types and classification
 Diagnosis
 Management
 Postmortem examination
 Management of future pregnancy

4. What Is the Intrauterine Fetal Demise?
Intrauterine fetal demise
occurs when a fetus shows no signs of Life in utero , characterized as the
absence or lack of ( breathing, heartbeats ,pulsation of umblical cord and
defined movements of voluntary muscles) ,irrespective of the duration of
pregnancy .
Other Def ; IUFD occurs when baby dies in utero after the second
trimester (after 20 weeks of gestation).
Miscarriage is a fetal death in the uterus before 20 wks.

5. Still birth is fetal death at the time of delivery or
fetal death after a defined gestational age and or fetal
weight or both.
ACOG : at or greater than 20 wk gestational age or at birth with fetal weight greater
than or equal 350 gram.
° Early: less than completed 20 wk of gestation
° intermediate : 20 to 27 wk , and
° Late : 28 wk or more .
WHO : At or greater than 20 wk gestation or at abirth weight greater than
or equal to 500 gm if gestational age is unknown .
UK : late intrauterinefetal death ( IUFD : after 24 completed wks of pregnancy) of
singletone fetus .

6. Incidence
 Globally:
2,65 million stillbirths occur each year.
Intrauterine fetal demise is the 5th leading cause of death worldwide .
Unexplained stillbirth is reported in 76 % of cases .
98 % of global stillbirths occur in low and middle income countries.
 UK : 1 in 200 babies born dead .

7. What are the causes and risk fators of IUFD
1. Unexplained causes
2. Placental Risk Factors
3. Fetal Risk Factors
4. Maternal Risk Factors

8. Causes and risk fators of IUFD (Cont.)
1-Unexplained causes(Idiopathic)
occur in 30% of cases (as IUGR) but more sever and
not managed.

9. 2-Placental Risk Factors
 Fetomaternal hemorrhage (placenta transfers blood from the fetus to the
mother)
 Placental abruption OR placenta previa(separation of placenta from the uterus
wall) is found in 6% of stillbirths .
 Placental insufficiency (no enough oxygen and nutrients getting to the fetus)
 PROM and chorioamnionities.
 Vasa preavia.
 Prolapsed pulsated cord.
 True knot of the cord.
 Umbilical cord accident (compression, twisting, knotting, etc.)

10. 3-Fetal Risk Factors
 Hereditary or genetic abnormalities (CFMF)
-Genetic abnormalities,as cystic fibrosis,sickle cell ds and Tay Sachs ds
-Congenital birth defects ( structural or functional anomalies)
1:5 still birth or IUFD d.t
-chromosomal abnormalities as Turner S(XO in 23%),
Down S (triosmy 21 in 23 %),
Edward S (Triosmy18 in 21%) , and patau S(triosmy 13 in 8 %)
-neural tube defect
-malformation syndroms

11. Fetal Risk Factors (Cont.)
 Fetal infection, such as fifth disease or listeria, from the mother while in the
uterus e.g. STORCH
 Multiple fetuses in the uterus at one time (TTTS)
 Slow growth in the uterus (also called fetal growth restriction, or FGR)
- due to problems with the placent
- increase risk of IUFD 7 times than in normal baby and
-the risk of stillbirth is relative to the degree of growth restriction .
 Rh isoimmunization
 Post term pregnancy (38-40 wks )

12. 4-Maternal Risk Factors
 Advanced maternal age (35 years or older) increase risk for stillbirth
At age of 40, the risk is 1/116 for nullipara and 1/304 for multipara.
 Chronic Matrnal DS :
Diabetesthat is poorly controlled .
DM Increase risk of still birth up to 5 times.
Athird of stillbirth associated with DM occur at term
The highest rate of still birth occur at 38wk for type 1 DM and at 39wk for
type 2 DM.
Hypertension(high blood pressure)
Preeclampsia or eclampsia (can cause high blood pressure, protein in the urine, and
seizures)
 Rh Disease: which include sever anaemia,jaundice,brain damage,heart failure and
stillbirth.

13. Maternal Risk Factors (cont.)
 Obesity: BMI > 30KG/M2 is independent risk factor,
8 per 1000 for BMI 30 39.9kg/m2 and 11/1000 for BMI>40kg/m2.
 Autoimmune ds:APS , SLE
 Intrahepatic cholestasis
 post term or Pregnancy lasting longer than 38 weeks
 Ruptured uterus which can lead to severe bleeding and suffocation
 Maternal infection :(5% to 22% )
Bacterial (e.g E.coli) , viral (CMV,RUBELLA), Parasite (Malaria).
N.B : Sexually transmitted ds (HIV- syphilis ) ,Malaria are the highest risk .

14. Maternal Risk Factors (cont.)
 Use of alcohol, drugs,smoking,cocaine or tobacco during
pregnancy increase risk of placental abruption.
 Polyhdraminos
 Oligohydraminos
 Parity : more common in PG
 Maternal hypoxia
 Complicated birth as breeh baby , obstructed labor

15. Maternal Risk Factors (cont.)
There Is large gap between no of fetal death experienced by A frican
American women and white women d.t socioeconomic barriers and
possibly genetic predispositions.
Socioeconomic barriers prevent mothers from accessing good
prenatal care leading to unrealized problems putting mothers and his
baby greater risk for compliations , leading to higher rate of fetal
death.
 Race and Ethinicity

16. Maternal Risk Factors (cont.)
 Domesti violence
The mental and physical trauma from doestic violence (DV) Can
be traumatizing ,affecting victims of all races, ethnicities and ages.
When combined with pregnancy , the physical harm and emotional
trauma from abuse can irease risk of IUFD or still birth.

17. Maternal Risk Factors (cont.)
 History of high risk pregnancy or previous still birth
women wiho previously have astill birth or miscarriage are up to 10 times to have
complications during future pregnancies.History of complication such as FGR or preterm
delivery,increase the higher risk of facing the complications or new difficulties with
subsequent pregnancies.
N.B :
Fetal growth restriction and placental abnormalities are the most prevalent causes of
stillbirth.

18. Maternal complicationsof IUFD
1-psychological upset :especially if PG.
2- Infections.
3- DIC : 4 weeks after iufd dt release of thromboplastin like
substance.
4- During labor : inertia ,chorioamnionitis , PPH .
5- During puerperium :
6- Complications of the cause :as DM or PIH.

19. What are the Types and classifications of IUFD ?
Early
Fetal death occurring between weeks 20 and 27 of pregnancy is an early- term
IUFD.
Late
Fetal death occurring between weeks 28 and 36 of pregnany is alate
term IUFD.
Term
Once apregnancy reaches 37 week or more , it is considered aCompleted or term
pregnancy.

20. Other Classification of IUFD
1- Ante-partumIUFD (during pregnancy)
macerated stillbirth .
2 – IntrapartumIUFD(during labor )
fresh stillbirth .

21. HOW to diagnose a case of IUFD ?
 History & Symptoms :
 Absent fetal movement
 Regression of pregnany symptoms .
 Maternal history : Age , gravidity , parity , HTN,DM, autoimmune ds ,exposure to
infection(CMV-Toxoplasma, syphilis……).
 Family history :genetic disorders , reccurent miscarriage or stillbirth.
 Current pregnancy H : bleeding, trauma,exposure to drugs or radiation,wt gain
,infection(STD),HTN,DM,Anaemia,fetal anomaly or FGR.
 Past obstetric H: preterm labor,stillbirth or iufd,IUGR, or pregnancy complication (
preeclampsia,DM,DVT,Pulm.embolism or blood transfusion)
 Immunization H: endemic ds such as measles.
 Social H: Jop,nutrition,DV,travel history,contact with animals.
 Prenatal H: CBC,Syphilis,Hbs Ag,HIV,DM, aneuploidy.

22. Other symptoms
 Cramping
 Infection or high fever
 No fetal movement or heartbeat seen on ultrasound
 Pain in the abdomen
 Vaginal bleeding or spotting

23. HOWto diagnose a case of IUFD ?(cont.)
Examination
 General EX : -vital {wt,BP,HR,RR,Temp}
- mental
-chest & heart:tachypnea,shortness of breath,rales or crackles,cardiac rhythm
-lower limbs :edema,rash,itching,petechiae,reflexes.
 Abdominal EX : signs of trauma ,abd.contour,abd.pain and tenderness, contractions,symphysis
fundal height , absent uterine and fetal tone ,no fetal movment
 Auscultation : No fetal heart sound.
 Local EX : Pelvic – bleeding , discharge,cervical tenderness and dilatation

24. HOWto diagnose a case of IUFD?(cont.)
Investigation :
1. Diagnosis of IUFD
1. Diagnosis of etiology(no specific cause in almost half of stillbirths)
-Basic test : Maternal
Fetal following birth
- Tests according to risk factor.
3. Diagnosis of possible complications (DIC- Rh isoimmunization )

25. 1- Diagnosis of IUFD
 Biophysical Profile: An ultrasound and a non-stress test are
performed to check for vital signs in the fetus.
 Doppler Velocimetry: Sound waves are used to determine if there is
blood moving through the fetus, uterus, and placenta.
 Non-Stress Test: An electronic fetal monitor is used to check for a
heartbeat while the mother is lying down.
 Ultrasound: Images of the uterus are used to check for signs of movement
and life.

26. 2- Diagnosis of etiology
Basic tests
 Maternal basic tests :
1- Maternal haematology & biochemistry
(CRP and bile salt )
2- Kleihauer test : -looking for fetal RBC in maternal circulation.
-recommended for all women (not only Rh negative).
- detect fetomaternal haemorrhage.
-should be done before birth as RBC clear quickly from maternal blood.
-can be replaced by flow cytometry (more sensitive and accurate)

27.  Basic tests (Cont.)
 Maternal basic tests :
3- Maternal serology
for occult maternal –fetal infection : e.g
Rubella,parvovirus B19,
CMV,HS,HIV
Toxoplasma and Syphilis.
4-Maternal random blood glucose
5-Maternal HbA1c
6-Maternal thyroid function (TSH-FT3 and FT4)

28.  Basic tests (Cont.)
 Fetal basic tests following birth
1- Fetal and placental microbiology :
a- fetal blood cord or cardiac blood
b- fetal swabs in lithium heparin
c-placental swabsconsent).
a-deep fetal skin ,
2-Fetal and placental tissues for karyotyping and gene testing :need
a –deep fetal skin
b -fetal cartilage,
c -placenta
3-Postmortem examination (need consent )
a-External examination: for wt &length as IUGR is significant cause for late IUFD.
b-Autopsy c-Microscopy
d-X-ray e-placenta and cord

29.  Maternal tests based on risk detection
1. Maternal bacteriology :
 blood culture ,urine, vaginal and cervical swab
 indicated in . Maternal fever, . flu-like symptoms,
. purulent or offensive odour . Prolonged ROM
2. Maternal thrombophilia screen:
 indicated in .FGR .Placental disease
3. Anti-red cell antibody serology :
 indicated in hydrops fetalis evident .
4. Maternal alloimmune antiplatelet antibodies, alloimmune thrombocytopenia

30.  Maternal tests based on risk detection
5. Maternal anti-RO and anti-La antibodies :
 indicated in hydrops ……
6. Parental blood for karyotype
 indicated in
. Fetal unbalanced translocation
. Fetal aneuploidy,e,g . Turner s (45x)
. Fetal genetic testing fails and history suggestive of aneuploidy
as reccurent miscarriage,previous unexplained iufd or fetal
abnormality on postmorterm
7.Maternal urine for cocaine metabolites

31. 3- Diagnosis of possible complications
 Diagnosis of DIC:
 moderate risk of DIC 10% in 4wks after late IUFD rising to 30% thereafter.
 EREZ score used to diagnose DIC
a- platelet count <50 = 1 50 – 185 = 2 > 185 = 0
b- prothrombin time(second ) <0.5=0 0.5 – 1 = 5 1 – 1.5= 25
c-fibrinogen (gm/L) 3= 25 3 – 4 = 6 4 - 4.5= 1 >4.5=0
 EREZ score obtained by adding score of (a+b+c ) , if greater than 26 predicts ahigh probability for
DIC even in absence of clinical symptoms.
 FDP are excluded from the score ??

32. 3- Diagnosis of possible complications
 Diagnosis of Rh isoimmunization
 Kleihauer test
. In Rh negative women to decide for anti- D Ig dose.
 Anti-RhD gammaglobulin
 If FMH is sever , the dose of anti-D Ig should be adjusted upwards
And kleihauer test should be repeated at 48 hours to be sured that fetal red cells have
cleared.
 Free fetal DNA(ffDNA)from maternal blood taken shortly after birth
if the fetal blood sample canot be obtained from baby or cord .

33. How to manage acase of IUFD and
What are the treatment options ???

34. Management :
 Fetal death < 24 weeks
 1- Dilatation and evacuation
 2- Medical induction
 Fetal death > 24 weeks
 1- Expectant management
 2 -IOL in unscared uterus
 3 -IOL in scared uterus : -p1cs
-p2cs

35.  Fetal death < 24 weeks
 1- Dilatation and evacuation :
 Do Dilatation of cx and manual removal of the content of conception
 Done when stillbirth occur before formation of fetal bone .
 Manual removal of conceptus that had formed soft bone should be avoided as
it may lead to injury of uterus and cx.
 Generally, it is avoided if fetal size is more than12 -14 wks by US size not GA.
 The risk of this procedure is greater when the fetus measure > 14wks in size.

36.  Fetal death < 24 weeks
 2- Medical induction :
 Using misoprostol
 up to 26wks,give misoprostol 100mcg /6h for maximum of 4 doses.
 If first dose not result in adequate contraction ,the dose maybe doubled up to
400mcg.
 maximumdose not eceed 1600mcg.
 vaginal labor can done in placenta previa in pregnanc<24wks but after 24wks cs
is indicated as per guidelines of placenta previa .

37.  Fetal death > 24 weeks
1- Expectant management
 If women is physically well,
intact membrane,
no evidence of preeclampsia,
infection, bleeding,
no laboratory evidence of DIC
 Require good reasurrance
 Duration: 48 hours
 But pt may develop sever complication and sever anexity with prolonged intervals.
 Women who delay > 48 hours should be advised that :
 The value of postmortem may be reduced.
 The appearance of babymay deteriorated.
 Testing for DIC twice weekly.

38.  Fetal death > 24 weeks
2 – Induction of labor in unscarred uterus
 Acombination of mifepristone and prostaglandin preparation
 is the 1st line for induction of labor :
. Mifepristol A single 200 mg +
. Misoprostol can be used in preference to prostaglandin E2 because of the same
safety and efficacy with lower cost
 Dose adjusted according to gest. Age (RCOG)
. 100 mcg / 6 hours before 26+6 wks
. 25 – 50 mcg / 4 hours at 27 wks or more , up to 24 hours.
. WHO :25 mg / 6 hours 2 doses, if no response increase to 50 mg/6hours(not > 4 doses)
.Do not use oytocin in 8 hrs of using misoprostol.
. Contraindicated in previous cs cases (WHO-2015)
 Vaginal misoprostol is effective as oral therapy but less side effects( diarrhea , vomiting, shivering &
pyrexia )

39.  Fetal death > 24 weeks
3– Induction of labor in scarred uterus
 Discussion about safety and benefits of induction of labor and also use of oxytocin in VBAC In IUFD
taken by consultant obstetrician.
 Mifepristone used alone( 200mg/8 hrs ),
 Women with single CS,- prostaglandin is safe but not without risk .
- Misoprostol can be used safely in p1cs but with lower doses
(25-50 mcg/h /24h).
 Women with two previous cs, give prostaglandin but with little dose than in P1CS.
 Women with more than two LSCS or atypical scar ,the safety of induction of labor is unkwon.
 VBAC should be closely monitored for features of ruptured scar

40.  Intrapartumantimicrobial therapy
 Sepsis : give IV broad spectrum AB
e.g : Antichlamydial agents
 Routine AB prophylaxis should not be used .
 Intrapartum AB prophylaxis for women colonized with group B
strept is not indicated.

41.  Pain relief in labor
 Diamorphine is better than pethidine.
 Diamorphine & morphine have greater analgesic effect and longer duration of
action than pethidine.
 Regional anaesthesia should be available for women with IUFD.
- DIC increase chance of subdural epidural hematoma with regional
anaesthesia.
- Maternal sepsis can result epidural abscess formation.
 Keep watch on CRP ,Coagulation profile ,signs of infection .
 Active management of 3rd stage labor to avoid PPH .
 Keep blood and blood products ready.

42. Managementof labor(cont.)
(postmortem examination)
 Examination of the baby:
 Done shortly after birth by the birth attendant and pathologist.
 Examine the following and put in chart :
1- Measure: wt, length, HC, foot length (<23 wks ,foot length can estimate GA ).
2- Facial features: ears, eyes , nose , mouse ,cranium.
3- Neck & back: cystic hygroma, spina bifida, abnormal pigmentation .
4- skin : maceration, sloughing, color.

43.  Examination of the baby:
5- cord insertion : central , marginal , membranous.
6-Abdominal wall
7- Gender : ambiguous,female,male.(2 healthcare practitioners vs karyotyping
).
8- Extremities, digits,palmer creases .
9-photograph & record .
10 - Autopsy- Imaging- chromosomal study – lab testing.

44.  Examination of the afterbirth
1-Membranes:
- take photographs of maternal and fetal sides of placenta.
- note insertion type of membrane , color and sheen .
2- Umblical cord : look for
 Location and type of cord insertion
 Length of umblical vs,intravascular umb thrombi,and length of cord
 False or true cord knots or twists
 Cord edema , hge, laceration, or avulsion .

45.  Examination of the afterbirth (Cont.)
3- Placenta :
 Weigh placenta after it is drained of blood.
 Measure the longest and shortest dimension.
 Note any extra lobes or unusual shape.
 Record thickest and thinnest measurement.
 Examine all surfaes
 Note any lesions found and take photographs.
4- Microscopic examination of placenta

46.  Management of puerperium
1- Thromboprophylaxis
 Women should be routinely assessed for thromboprophylaxis, but
IUFD not risk factor.
 late IUFD with obesity, advanced maternal age, infection and
maternal ds , put the patient in moderate or high risk categories.
 Heparin as thromboprophylaxis should be discussed with a
hematologist if the women has DIC .

47. Management of puerperium(cont.)
2- Suppression of lactation
 Dopamine agonist successfully suppress lactation in high proportion of
women but may be tolerated by very large majority.
 Cabergoline is superior to bromocriptine.
 Dopamine agonist should not given to women with hypertension or
preeclampsia.
 Estrogen not given to suppress lactation b.c unproven benefit and increase
thromboembolic risk.
 One third of those that choose non pharmacological measures suffer by
excessive discomfort.

48. Management of puerperium (cont.)
3 – Recommendation for Rh D negative women:
 RCOG recommend that the performance of kleihauer test
must be undertaken to all women urgently after stillbirth to
detect FMH and give anti-RhD Immunoglobulin in 72 hours
from sensitizing event.
 The dose should be increased in large FMH.
 If kleihauer test still remains positive , baby blood group
should be typed by conventional serology on umblical cord or
by FFD from maternal blood with making D.D between large
FMH and RhD negative baby.

49.  Managementoffuture pregnancy
(preventionofrecurrentIUFD)
Prevention strategies- initial prenatal visit :
 No sure methods to prevent fetal death.
 Weight loss in obese women (preconceptional only).
 Life style modifications and smoking cessation .
 Folic acid before they get pregnant.
 Tight control of DM before and during pregnancy.
 Genetic counselling if family genetic condition exists.
 Thrombophilia workup: antipholipid AB(Only if indicated ).
 Risk of recurrence is 7-10 /1000 birth.
 Support reassurance.
 Detailed medical obstetric history.

50.  Managementof future pregnancy
(prevention of recurrent IUFD )(cont.)
First trimester :
 Dating US
 1ST Trimester screen : PAPP-A , HCG and NT .
 Support and reassurance.
Second trimester :
 Fetal US anatomic survey at 18 – 20 wks of gestation .
 Maternal serum screen (quadruple) or single alpha fetoprotein.
 Support and reassurance

51.  Management of future pregnancy
(prevention of recurrent IUFD )(cont.)
Third trimester :
 US screening for FGR after 28 weeks.
 Fetal kick awareness starting at 28 weeks.
 Antepartum fetal surveillance starting at 32 wks and 1-2 wks earlier than prior stillbirth .
 Support and reassurance.
Delivery :
 Elective induction at 39 wks.
 Delivery before 39wks only with documented lung maturity (amniocentesis ).

52. Thank You