Intrauterine fetal death refers to fetal death after 24 weeks of gestation or 500 grams. It occurs in 4.5 per 1,000 births and can be emotionally challenging for doctors, parents, and increases medical legal risk. Ultrasound is the most reliable diagnostic method to confirm absence of a fetal heartbeat. The main complications are postpartum hemorrhage and blood coagulation disorders.

2. Objectives
By the end of this lecture learners should be able to :
1- define intrauterine fetal death
2-know the incidence and the impact of intrauterine fetal death
3- identifies patient at risk of its occurrence
4- be able to diagnose such a condition , and can identifies
complications
5-mange intrauterine fetal death.

3. DEFINITION
Intrauterine fetal death refers to fetal death in utero after
24 completed weeks of gestation or weighing < 500
grams .

4. INCIDENCE:
4.5/1000 births

5. IMPACTS :
Emotionally challenging for:
• Doctors
• Parents
• Increases medico-legal risk
• Indicator of country’s health care.

6. CAUSES
No specific cause is found in 50% cases.
Age, weight, smoking, alcohol, infections, medical diseases,
auto-immune diseases, cholestasis, RH incompatibility,
abruptio-placentae, PROM, multifetal pregnancy, preterm
labor.
IUGR, congenital anomalies, infections, hydrops ( immune &
non immune ) G6PD deficiency, birth defects,
• Abruption • Cord accidents • Placental insufficiency
• Placenta previa • TTTS • Chorioamnionitis • PROM
•Feto-maternal hemorrhage ,Iatrogenic- ECV.
Maternal causes:
5-10 %
Fetal causes:
25-40%
Placental causes:
20-35%

7. DIAGNOSIS
History :
Absence fetal movements , Loss of signs & symptoms of pregnancy
Examination :
Decreased fundal height, and absent fetal movement.
Investigations :
Real-time ultrasonography is essential for the accurate
diagnosis of IUFD ( absent fetal cardiac pulsation , collapsed head and
collapsed fetal skeleton ), X-ray is diagnostic but obsolete.
A second opinion should be obtained

8. COMPLICATIONS
• Post Partum Hemorhage • BLOOD COAGULATION
DISORDERS
• PSYCHOLOGICAL UPSET • INFECTIONS ( purpural sepsis )

9. INVESTIGATIONS
Clinical assessment and laboratory tests should be recommended
to assess maternal wellbeing(including coagulopathy)and to determine
the cause of death, the chance of recurrence and possible means of
avoiding further pregnancy complications.
TESTS RECOMMENDED FOR WOMEN
• CBC, blood group, ESR • plasma fibrinogin •
Coagulation profile • PIH profile
• Kleihauer test, CRP, maternal ( serology , bacteriology, thyroid
function teste, and HbA1c).

10. LABOUR AND BIRTH
 Maternal medical condition and previous intra-partum history should
be taken in consideration in deciding route of birth.
 If there is sepsis, preeclampsia, placental abruption or membrane
rupture, immediate termination of pregnancy should be advised but a more
flexible approach can be discussed if these factors are not present.
 Vaginal birth is the recommended mode of delivery for most women.
Spontaneous vaginal delivery occurs within three weeks of diagnosis in
<85% of cases.
 In about 90% of women vaginal birth occurs within 24 hours
 Caesarean birth might be indicated if there is maternal indication.

11. INDUCTION OF LABOUR
 Misoprostol and prostaglandin E2 can be used for termination of pregnancy
with equivalent safety and efficacy with lower cost of Misoprostol.
 Vaginal misoprostol is as effective as oral therapy with fewer adverse
effects.
 Misoprostol can be safely used for induction of labor in women with a single
previous LSCS and an IUFD but with lower doses
 Women with more than two LSCS deliveries or atypical scars should be
advised that the safety of induction of labor is unknown
 Mechanical methods of induction might increase the risk of ascending
infection in the presence of IUFD

12. INTRAPARTUM ANTIBIOTIC
PROPHYLAXIS
Women with sepsis should be treated with intravenous broad- spectrum
antibiotic therapy (including anti-chlamydial agents) but routine antibiotic
prophylaxis should not be used.
WOMEN LABOURING WITH A SCARRED UTERUS
 Women undergoing VBAC should be closely monitored for features of scar
rupture.
 Oxytocin augmentation can be used for VBAC, but the decision should be
made by a consultant obstetrician.

13. PUERPERIUM
• Women should be cared for in an environment that provides
adequate safety according to individual clinical circumstance
• Some women have acute medical problems after birth, e.g. sepsis,
pre-eclampsia, etc., with continuing critical care needs.
• Heparin thromboprophylaxis should be discussed with a
haematologist if the woman has DIC.

14. LACTATION
 Women should be advised to use dopamine agonists to
suppress lactation it is well tolerated as cabergoline which is
found to be superior to bromocriptine in suppression of lactation.
 Dopamine agonists should not be given to women with
hypertension or pre-eclampsia.
 Estrogens should not be used to suppress lactation.

15. POSTMORTEM EXAMINATION
 Parents should be offered full postmortem examination to help
explain the cause of an IUFD.
 Postmortem examination should include external examination
with birth weight, histology of relevant tissues and skeletal X-
rays.
 Pathological examination of the cord, membranes and placenta
should be recommended whether or not postmortem examination
of the baby is requested. The examination should be undertaken
by a specialist perinatal pathologist.
 Parents who decline full postmortem might be offered a limited
examination (sparing certain organs).

16. FOLLOW UP
 The wishes of the woman and her partner should be considered
when arranging follow-up
 Women should be offered general pre-pregnancy advice.
 Women should be advised to avoid weight gain.

 Parents can be advised that the absolute chance of adverse
events with a pregnancy interval less than 6 months remains low
and is unlikely to be significantly increased compared with
conceiving later.

17. Summary
Fetal death is an emotional issue for both the patient and the
physician and may result on significant complications.
The most serious complication is hypo-fibrinogenemia which may
lead to life threatening coagulopathy.
Ultrasound provides the most reliable method of confirming the
diagnosis.