Intrauterine fetal demise: Difference between revisions

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==Evaluation==
==Evaluation==
*'''Ultrasound'''
*Ultrasound
**Absence of fetal cardiac activity on real-time ultrasound is diagnostic
**Absence of fetal cardiac activity on real-time ultrasound is diagnostic
**Should be confirmed by two experienced operators if any uncertainty
**Should be confirmed by two experienced operators if any uncertainty
**Additional findings: overlapping skull bones (Spalding sign), soft tissue edema, echogenic amniotic fluid
**Additional findings: overlapping skull bones (Spalding sign), soft tissue edema, echogenic amniotic fluid
*'''Labs'''
*Labs
**[[CBC]] — evaluate for anemia, thrombocytopenia
**[[CBC]] — evaluate for anemia, thrombocytopenia
**[[Coagulation studies]] (PT/INR, PTT, fibrinogen) — screen for DIC
**[[Coagulation studies]] (PT/INR, PTT, fibrinogen) — screen for DIC
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**[[Kleihauer-Betke test]] — to quantify fetomaternal hemorrhage, especially if Rh-negative mother
**[[Kleihauer-Betke test]] — to quantify fetomaternal hemorrhage, especially if Rh-negative mother
**Consider: [[BMP]], [[LFTs]], [[Urinalysis|UA]], [[Uric Acid|uric acid]] if preeclampsia suspected
**Consider: [[BMP]], [[LFTs]], [[Urinalysis|UA]], [[Uric Acid|uric acid]] if preeclampsia suspected
*'''Fetal monitoring'''
*Fetal monitoring
**No role for fetal heart rate monitoring once IUFD is confirmed
**No role for fetal heart rate monitoring once IUFD is confirmed


==Management==
==Management==
*'''Hemodynamic stabilization'''
*Hemodynamic stabilization
**IV access, fluid resuscitation as needed
**IV access, fluid resuscitation as needed
**Transfuse blood products if evidence of hemorrhage or DIC
**Transfuse blood products if evidence of hemorrhage or DIC
*'''Rh immunoglobulin'''
*Rh immunoglobulin
**Administer [[RhoGAM]] to all Rh-negative mothers
**Administer [[RhoGAM]] to all Rh-negative mothers
**Standard dose (300 mcg) covers up to 30 mL of fetal whole blood
**Standard dose (300 mcg) covers up to 30 mL of fetal whole blood
**Additional doses guided by Kleihauer-Betke results
**Additional doses guided by Kleihauer-Betke results
*'''DIC management'''
*DIC management
**If evidence of coagulopathy, correct with FFP, cryoprecipitate, and/or platelets as indicated
**If evidence of coagulopathy, correct with FFP, cryoprecipitate, and/or platelets as indicated
**Target fibrinogen > 150–200 mg/dL
**Target fibrinogen > 150–200 mg/dL
*'''Delivery planning'''
*Delivery planning
**Induction of labor is the standard approach for most patients
**Induction of labor is the standard approach for most patients
**Timing is generally at the discretion of OB; urgent delivery is indicated if:
**Timing is generally at the discretion of OB; urgent delivery is indicated if:
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**Methods of induction vary by gestational age (misoprostol, oxytocin, or mechanical dilation)
**Methods of induction vary by gestational age (misoprostol, oxytocin, or mechanical dilation)
**Cesarean delivery is rarely indicated and should be avoided if possible given increased maternal morbidity without fetal benefit
**Cesarean delivery is rarely indicated and should be avoided if possible given increased maternal morbidity without fetal benefit
*'''Supportive care'''
*Supportive care
**Emotional support is critical — grief counseling, social work involvement
**Emotional support is critical — grief counseling, social work involvement
**Allow family time with the infant after delivery when desired
**Allow family time with the infant after delivery when desired

Latest revision as of 09:35, 22 March 2026

Background

  • Defined as fetal death after 20 WGA (weeks gestational age)
  • Occurs in approximately 1 in 160 pregnancies
  • Risk increases with advancing gestational age
  • Most common causes include:
    • Placental abnormalities (e.g. abruption, insufficiency) — most common identifiable cause
    • Chromosomal/genetic abnormalities
    • Maternal conditions (preeclampsia, diabetes in pregnancy, chronic hypertension, thrombophilias, autoimmune disease)
    • Umbilical cord abnormalities (knots, prolapse, compression)
    • Intrauterine infection (e.g. chorioamnionitis, CMV, parvovirus B19, syphilis, listeria)
    • Fetal Hydrops
    • Cause remains unexplained in up to 25–60% of cases

Clinical Features

  • Decreased or absent fetal movement (most common presenting complaint)
  • Vaginal bleeding (may or may not be present)
  • Uterine cramping or contractions
  • Absence of fetal heart tones on Doppler
  • Loss of pregnancy symptoms (e.g. breast tenderness, nausea)
  • Uterus may be small for gestational age
  • If prolonged fetal demise (retained > 3–4 weeks):
    • Signs/symptoms of DIC (bleeding, petechiae, ecchymosis)

Differential Diagnosis

Vaginal Bleeding in Pregnancy (>20wks)

Evaluation

  • Ultrasound
    • Absence of fetal cardiac activity on real-time ultrasound is diagnostic
    • Should be confirmed by two experienced operators if any uncertainty
    • Additional findings: overlapping skull bones (Spalding sign), soft tissue edema, echogenic amniotic fluid
  • Labs
    • CBC — evaluate for anemia, thrombocytopenia
    • Coagulation studies (PT/INR, PTT, fibrinogen) — screen for DIC
      • Risk of DIC increases significantly if fetus retained > 4 weeks
      • Fibrinogen < 200 mg/dL is concerning for consumptive coagulopathy
    • Type and screen (or crossmatch if actively bleeding)
    • Kleihauer-Betke test — to quantify fetomaternal hemorrhage, especially if Rh-negative mother
    • Consider: BMP, LFTs, UA, uric acid if preeclampsia suspected
  • Fetal monitoring
    • No role for fetal heart rate monitoring once IUFD is confirmed

Management

  • Hemodynamic stabilization
    • IV access, fluid resuscitation as needed
    • Transfuse blood products if evidence of hemorrhage or DIC
  • Rh immunoglobulin
    • Administer RhoGAM to all Rh-negative mothers
    • Standard dose (300 mcg) covers up to 30 mL of fetal whole blood
    • Additional doses guided by Kleihauer-Betke results
  • DIC management
    • If evidence of coagulopathy, correct with FFP, cryoprecipitate, and/or platelets as indicated
    • Target fibrinogen > 150–200 mg/dL
  • Delivery planning
    • Induction of labor is the standard approach for most patients
    • Timing is generally at the discretion of OB; urgent delivery is indicated if:
      • Active hemorrhage
      • DIC
      • Sepsis/chorioamnionitis
      • Preeclampsia with severe features
    • Methods of induction vary by gestational age (misoprostol, oxytocin, or mechanical dilation)
    • Cesarean delivery is rarely indicated and should be avoided if possible given increased maternal morbidity without fetal benefit
  • Supportive care
    • Emotional support is critical — grief counseling, social work involvement
    • Allow family time with the infant after delivery when desired
    • Pain management (including neuraxial analgesia for labor)

Disposition

  • All patients with confirmed IUFD require admission and obstetric consultation
  • Transfer to a facility with OB capability if diagnosed at a facility without obstetric services
  • Urgent OB consultation if concurrent DIC, hemorrhage, sepsis, or preeclampsia
  • Social work and/or chaplaincy involvement should be arranged early
  • Postpartum considerations include:
    • Lactation suppression counseling
    • Grief support and follow-up
    • Autopsy and placental pathology (per patient preference) to determine etiology

See Also

External Links

References

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