Intrauterine fetal demise

Background

Defined as fetal death after 20 WGA (weeks gestational age)
- Prior to 20 WGA, fetal loss is classified as spontaneous abortion
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

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)

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

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)

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

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