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Intrauterine Death

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Intrauterine Death

When a fetus that was expected to survive dies during birth or during the last half of pregnancy, it is known as intrauterine death. Once the fetus has died the mother still has compressions and the remains are delivered. The term is often used in distinction to live birth or miscarriage. Most intrauterine death happen in full term pregnancies.

Causes

The cause of intrauterine death is unknown in 25-60% of all cases. In cases where a cause is clearly determined, the cause of intrauterine death can be referred to fetal, maternal, or placental pathology. One potential study evaluated 64.9% of intrauterine death to placental pathology. The same study noted higher rates of intrauterine death secondary to placental pathology at late gestational age.

Maternal pathology includes

  • Prolonged pregnancy (>41 weeks)

  • Diabetes

  • Systemic lupus erythematosus

  • Antiphospholipid syndrome

  • Infection

  • Hypertension

  • Preeclampsia

  • Eclampsia

  • Hemoglobinopathy

  • Advanced maternal age

  • Rh disease

  • Uterine rupture

  • Maternal trauma or death

  • Inherited thrombophilias

Fetal pathology includes

  • Multiple gestations

  • Intrauterine growth restriction

  • Congenital abnormality

  • Genetic abnormality

  • Infection

  • Hydrops

Placental pathology involves

  • Cord accident

  • Abruption

  • Premature rupture of membranes

  • Vasa previa

  • Fetomaternal hemorrhage

  • Placental insufficiency

Symptoms

Certain signs and symptoms make a doctor guess a possible intrauterine death. These

  • A mother who notices the baby has stopped moving for a long period of time

  • A uterus or womb that fails to get bigger over time

  • An inability to hear the baby's heartbeat with a special heart monitor

  • Lack of movement of the baby or no heartbeat during a pregnancy ultrasound

  • An abnormal blood level of the hormone of pregnancy

Diagnosis

History and physical examination are of moderate value in the diagnosis of intrauterine death. In most patients, the only symptom is diminished fetal movement. An inability to obtain fetal heart modulates upon examination suggests intrauterine death; however, this is not diagnostic and death must be confirmed by ultrasonographic examination.

Intrauterine death is confirmed by visualization of the fetal heart and the absence of cardiac activity.

Treatment

Once the intrauterine death has been confirmed, the patient should be informed of her condition. Often, allowing the mother to see the lack of cardiac activity helps her to admit the examination.

Labor induction should be rendered after examination. Patient responses vary in regard to this suggestion; some wish to begin induction immediately, while others wish to delay induction for a period of hours or days until they are emotionally prepared.

Induction may be carried out with preinduction cervical ripening followed by intravenous oxytocin. Patients with a history of a prior cesarean delivery should be treated carefully because of the risk of uterine rupture, just as in any birth following cesarean delivery.

Early intrauterine death may be managed with laminaria insertion followed by dilatation and evacuation. In women with intrauterine death before 28 weeks' gestation, induction may be carried out using prostaglandin E2 vaginal suppositories (10-20 mg q4-6h), misoprostol (ie, prostaglandin E1) vaginally or orally (400 mcg q4-6h), and/or oxytocin. In women with intrauterine death after 28 weeks' gestation, lower doses should be used.

In women with no uterine scar, misoprostol (25 mcg q4-6h) may be dispensed for ripening after 28 weeks’ gestation. For women with a prior cesarean delivery, mechanical ripening can be carried out with a Foley catheter, and induction can be continued with oxytocin.

Pain management in patients undergoing induction of labor for intrauterine death is normally easier to manage than in patients with live fetuses. Higher doses of narcotics are available to the patient and often a morphine or Dilaudid PCA is adequate for successful pain control. If a patient desires superior pain control to intravenous narcotics, epidural anesthesia should be offered.

 

Complications

  • Disseminated intravascular coagulation (a syndrome set off by a number of medical conditions including malignancy, infection and liver disease, and leads to consumption of clotting factors in the blood)

Prevention

As many of the causes are unknown, prevention is difficult. Symptoms of bacterial infection, such as from a dental abscess, in pregnant women may also include peculiar periods of incoherence and symptoms of shock, and should be treated by a physician immediately. High blood pressure, diabetes and drug use should be modulated with physician's advice. Umbilical cord constriction may be recognized and discovered by ultrasound.

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