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DESCRIPTION
Intrauterine Fetal Death Demise (IUFD) is the death of a fetus that occurs for no apparent reason in a normal, uncomplicated pregnancy. It happens in about 1% of pregnancies and is usually (depending on the resource) considered a fetal death when it occurs after the 20th week of pregnancy and/or weight equal to or more than 500 grams. The American College of Obstetrics and Gynecologists also recommends including deaths occurring at 22 weeks of gestation or greater (other groups use 20 weeks of gestation). Although this definition of fetal death is the most frequently used in medical literature, it is by no means the only definition in use. Even within the United States, the differences in the definitions used are substantial. The US National Center for Health Statistics, a division of the Centers for Disease Control and Prevention, periodically updates the Model State Vital Statistics Act and the regulations to assist states in developing vital statistics laws. They recommend reporting fetal deaths occurring in fetuses weighing 350 grams or more or those of 20 weeks of gestation or greater (see National Center for Health Statistics). This policy is, however, only a guideline and reporting practices vary among states.
In addition, not all states interpret the weeks of gestation in the same manner. In California, 20 weeks' gestation is worded "twenty utero gestational weeks" and has therefore been interpreted to be 23 weeks from the last menstrual period. (Implantation in the uterus does not occur until 1 week after fertilization.) Health care providers and midwives must check the reporting requirements for the state(s) in which they practice.
The 1997 fetal death reporting requirements from the National Center for Health Statistics:
- Gestation of 20 weeks or longer - Alabama, Alaska, California, Connecticut, Florida, Illinois, Indiana, Iowa, Maine, Maryland, Minnesota, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Texas, Utah, Vermont, Washington, West Virginia, Wyoming.
- All products of conception - American Samoa, Arkansas, Colorado, Georgia, Hawaii, New York, Northern Mariana Islands, Rhode Island, Virginia, Virgin Islands.
- Birth weight of 350 grams or more or gestation of 20 weeks or longer - Arizona, Delaware, Guam, Idaho, Kentucky, Louisiana, Massachusetts, Mississippi, Missouri, Montana, New Hampshire, South Carolina, Wisconsin.
- Birth weight of 400 grams or more or gestation of 20 weeks or longer - Michigan.
- Birth weight of 500 grams or more or gestation of 20 weeks or longer - District of Columbia.
- Birth weight of 350 grams or more - Kansas.
- Gestation of 16 weeks or longer - Pennsylvania.
- Birth weight of 500 grams or more - New Mexico, South Dakota, Tennessee.
- Gestation of 5 months or longer - Puerto Rico.
Generally speaking, a miscarriage is a fetal death which occurs prior to 20 weeks of gestation.
The mother's health is usually not jeopardized with intrauterine fetal demise.
The fetal death rate in the United States varies among races, but overall it is 6.8-6.9 deaths per 1,000 total births and accounts for approximately half the perinatal mortality (fetal and neonatal deaths). Worldwide, this rate varies considerably, depending on the quality of medical care available in the country in question and the definitions used for classifying fetal deaths. Under-reporting in developing nations is common, making comparisons even more difficult.
FREQUENT SIGNS AND SYMPTOMS
Signs and symptoms of pregnancy may subside.
No symptoms may occur in the early stages of pregnancy. The diagnosis is based on the absence of fetal heart tones, the lack of uterine growth or ultrasound studies during prenatal examinations.
In later stages of pregnancy, a woman may be aware of changes in the fetal movement (kicks) or that the movement has stopped.
CAUSES
Only rarely is the exact cause of the death obvious. Unexplained causes account for 25-60% of all fetal demise; the incidence increases with increasing gestational age. In cases where a cause is clearly identified, the cause of fetal death can be attributable to fetal, maternal, or placental pathology.
In some cases, examination of the stillborn fetus shows an abnormality in the umbilical cord, a problem with the placenta or the fetus. These problems include infections plus a variety of birth defects and genetic disorders.
POSSIBLE MATERNAL CAUSES
- Prolonged pregnancy (greater than 42 weeks).
- Diabetes (poorly controlled).
- Systemic lupus erythematosus.
- Infection.
- Hypertension.
- Preeclampsia.
- Eclampsia.
- Hemoglobinopathy.
- Advanced maternal age.
- Rh disease.
- Uterine rupture.
- Antiphospholipid syndrome.
- Acute, severe maternal hypotension.
- Maternal death.
POSSIBLE FETAL CAUSES
- Multiple gestations.
- Intrauterine growth restriction.
- Congenital abnormality.
- Genetic abnormality.
- Infection (i.e., parvovirus B-19, CMV, listeria).
POSSIBLE PLACENTAL CAUSES
- Cord accident.
- Abruption.
- Premature rupture of membranes.
- Vasa previa
RISK INCREASES WITH
Some maternal conditions which are known to increase the risk for fetal death, but in most cases, risk factors are unknown.
RISK FACTORS
- Multiple pregnancy.
- African American race.
- Advanced maternal age.
- History of fetal demise.
- Maternal infertility.
- Maternal hemoconcentration.
- Maternal colonization with certain pathogens (ie, GBS, Ureaplasma urealyticum).
- History of small for gestational age infant.
- Small for gestational age infant.
- Obesity.
- Paternal age.
PREVENTIVE MEASURES
There are no specific preventive measures known.
EXPECTED OUTCOME
The outcome will vary with the timing of the fetal death. Spontaneous labor often occurs within 2 weeks. Additional treatment options are available.
Both parents will go through a period of grief, which is the process of adapting to such a loss. Mothers, sometimes more than fathers, suffer from feelings of guilt and helplessness. Your prenatal health care support team shares the emotions of loss also.
MoonDragon's Pregnancy Information: Sudden Infant Death Syndrome (SIDS) - Contains valuable information about Grief and the Grieving process along with the steps involved with healing after the death of a baby.
Health care in subsequent pregnancies will be individualized depending on the needs of the patient and the cause of the previous fetal death if an explanation was discovered. More frequent prenatal visits may be appropriate and special tests may be recommended to help provide reassurance and to achieve a normal pregnancy outcome.
POSSIBLE COMPLICATIONS
Disseminated intravascular coagulation (DIC), a disruption of blood clotting mechanisms that can result in hemorrhage or internal bleeding, which may rarely develop relatively late after fetal death.
Infection.
TREATMENT
GENERAL MEASURES
DIAGNOSIS
History and physical examination are of limited value in the diagnosis of fetal death. In most patients, the only symptom is decreased fetal movement. An inability to obtain fetal heart tones upon examination suggests fetal demise; however, this is not diagnostic and death must be confirmed by diagnostic tests, such as x-rays, ultrasound (ultrasonography) and amniotic fluid studies. Fetal demise is diagnosed by visualization of the fetal heart and notation of the absence of cardiac activity.
Once the diagnosis of fetal demise has been confirmed, the patient should be informed of her condition. Often, allowing the mother to see the lack of cardiac activity helps to solidify the diagnosis. Care must be taken to be understanding of the patient's feelings and to give the patient time to adjust before proceeding with a discussion of further management. Usually, patients only require 5 or 10 minutes, or a phone call to a close friend or family member, before they are ready to discuss management options.
Labor should be induced as soon as possible after diagnosis. Patient responses vary in regard to this recommendation; some wish to begin induction immediately, while others wish to delay induction for a period of hours or days until they are emotionally prepared. In one study, postponing delivery for more than 24 hours after diagnosis has been associated with increased anxiety years after the event when compared with women whose labor is induced within 6 hours.
TREATMENT OPTIONS
Most women on learning that their fetus is dead prefer early evacuation of the uterus. Induction may be accomplished with preinduction cervical ripening followed by intravenous oxytocin. Patients with a history of a prior cesarean delivery should be treated cautiously because of the risk of uterine rupture, just as in any birth following cesarean delivery (VBAC - Vaginal Birth After Cesarean Delivery).
In the first trimester, this is usually done with suction curettage. Early fetal demise may be managed with laminaria insertion followed by dilatation and extraction. In the second trimester, it is more frequently accomplished with prostaglandin E (Prostin) suppositories, or suction curettage in combination with laminaria (a sterilized seaweed product that absorbs moisture and expands to gradually stretch the cervix). In the third trimester, it may be accomplished with the suction curettage in combination with laminaria or with intravenous oxytocin plus prostaglandin E.
PROSTAGLANDIN E1
In women with fetal death before 28 weeks' gestation, induction may be accomplished using prostaglandin E2 vaginal suppositories (10-20 mg every 4-6 h), misoprostol (ie, prostaglandin E1) vaginally or orally (400 mcg every 4-6 h), and/or oxytocin (preferred in women with prior uterine surgery). In women with fetal death after 28 weeks' gestation, lower doses should be used.
The American College of obstetricians and gynecologists guidelines for induction of labor states that prostaglandin E2 and misoprostol should not be used in women with a history of a prior uterine incision because of the risk of uterine rupture. In 2003, Dickinson and Evans reported on the efficacy of oral, vaginal, and combined administration of misoprostol for second-trimester induction and found that the superior regimen was misoprostol at 400 mcg vaginally every 6 hours. Pretreatment with antidiarrheal and antiemetic agents may reduce adverse effects. These effects are generally less common with misoprostol than with prostaglandin E2.
WAITING FOR SPONTANEOUS LABOR OPTION
An additional treatment option is to wait for spontaneous labor which usually occurs within 2 weeks, but may be longer. This is termed expectant therapy. Occasionally a woman will not expel the fetus, but instead, reabsorb it into her system (missed abortion).
When a dead fetus has been in utero for 3-4 weeks, fibrinogen levels may drop, leading to a coagulopathy. This is rarely a problem with singleton pregnancies because of earlier recognition and induction, another reason for patients to be encouraged to begin induction soon after the diagnosis. In some cases of twin pregnancies, depending on the type of placentation, induction after the death of a twin may be delayed to allow the viable twin to mature. In these cases, some perinatologists recommend checking a set of baseline coagulation labs at the time of fetal demise and only rechecking them if the clinical situation warrants. Other perinatologists do not recommend checking coagulation labs at all. Overall, the risk of developing disseminated intravascular coagulopathy is rare.
PAIN MANAGEMENT
Pain management in patients undergoing induction of labor for fetal demise is usually 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 sufficient for successful pain control. Should a patient desire superior pain control to intravenous narcotics, epidural anesthesia should be offered.
AFTERWARD
Examination of the stillborn fetus is usually performed to help determine any problems that might prove helpful in consideration and planning of subsequent pregnancies.
Other issues to be explored by the parents with the help of the health care provider team; whether or not to see, touch or photograph the infant; whether to name the infant; deposition of the remains (burial or cremation); and holding religious services.
Parental feelings of loss, guilt, loneliness, anxiety and hostility should be acknowledged and faced. Family and friends can help with sympathetic listening and close physical comforting. If severe grief lasts longer than several months, professional counseling is recommended. Both the parents are urged to join a grief support group (available in most communities).
MEDICAL MANAGEMENT OF FETAL DEATH IN UTERO
The loss of a fetus at any stage is a fetal demise. According to the 2003 revision of the Procedures for Coding Cause of Fetal Death Under ICD-10, the National Center for Health Statistics defines fetal death as "death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy. The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps." It is further classified as early (before 20 weeks' gestation), intermediate (20-27 weeks' gestation), or late (after 28 weeks' gestation).
Management of fetal death in utero has changed dramatically from earlier recommendations that regarded the event as a medically innocuous condition to be managed conservatively except under life-threatening circumstances, with 75% of women delivered within 2 weeks after fetal demise. After coagulopathy was observed in pregnancies complicated by fetal death in utero and with newer agents to effect cervical ripening and uterine contractions, the management of stillbirth has become more proactive. Investigations have evaluated the significance of a previous stillbirth, maternal serum biochemical markers, genetic causes, maternal complications of pregnancy, infective agents, intrapartum events, usefulness of autopsy examinations, and placental findings in the cause of fetal death. The one material complication frequently evaluated after the diagnosis of a fetal demise is the development of disseminated intravascular coagulopathy (DIC). Numerous publications have evaluated the causes of fetal death in utero, but except for the rarely encountered case of DIC, other maternal complications associated with the management and delivery of a stillbirth have not been assessed in a large investigation.
MEDICATION
Any medicines prescribed will depend on the type of treatment received.
ACTIVITY
Restrictions are usually not necessary unless associated with the delivery option.
Sexual intercourse should be avoided for 4 to 6 weeks. Starting another pregnancy should be delayed at least 6 months.
DIET
No special diet.
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You are pregnant and fail to gain weight or your abdomen is not increasing in size.
Your unborn child appears to have stopped moving.
Following the death of a fetus, you or a family member need help or emotional support in coping with the grief process.
Midwife: Checklist to Assist Grieving Parents
For Parents: Grieving For Parents - A Way To Heal - Loss of a Baby
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