IUFD

1
IUFD

• Irene Hwang, PGY-1
• 3.10.09

2
Case

• 2/17/09
• HPI
• 23 yo G3P1011 _at_ 32w1d by LMP 7/8/08 EDD 4/14/09
  c/w 19w sono p/w decreased fetal movement and
  lower abdominal cramps from 3pm yesterday.  No
  LOF/VB.  No h/o trauma to abdomen.  No HA/visual
  changes/epigastic pain. Denied tobacco or
  cocaine use.  Admitted to marijuana use during
  current pregnancy.  Pt was given betamethasone on
  2/13 and 2/14 for IUGR. Per EU records on 2/14,
  NST was reactive and BP was 127/60.
• PNI Intake BP 102/50 (102-132/ 50-90). Weight
  gain 158? 189 (31 lbs).
• 1. IUGR dxed on 2/13/09 sono _at_ 31w. Fetus
  lt3tile. TORCH and thrombosis w/u negative.
  Amnio normal XY.
• PNL wnl/ unremarkable
• Sonos10/29/08 _at_ 15w3d. AFI nl. 11/19/08 _at_
  19w1d no anatomical anomalies. Fetus
  20tile.2/13/09 _at_ 31w1d Fetus lt3tile. SD
  ratio 4.8. AFI 11.

3
Case

• POB 2004 ectopic ? R lap salpingotomy. 2005 FT
  NSVD of 6lb female. No complications.
• PGyn no cysts/ fibroids/ STIs/ abnl paps. 
  12/reg/5.
• PMH spina bifida occulta, chronic lower back
  pain
• PSH R lap salpingotomy
• Meds PNV, Reglan, Zofran
• All NKDA
• PE
• BP 132/40 ?? max 170/102 (Hydralazine 5mg IVP
  given) HR 74 T36.6
• Abd fundal tenderness
• FHT absent
• Toco irritability
• SVE 1/80/-2
• BSUS Absent fetal heart activity. Breech
  presentation. Minimal fluid.

4
A/P

• Labs
• 23 yo G3P1011 _at_ 32w1d with IUGR fetus, now with
  IUFD and elevated BPs.
• IUGR, DIC- Unclear etiology, history and PE c/w
  abruption. Admit to LD for IOL.
• Preeclampsia/ HELLP syndrome

INR 2.5 Cr 1.2 SGOT 46-57 Hct 28 Fibr lt120
PT 22.8 Uric acid 6.0 SGPT 17-21 WBC 30.2 UA gt300prot
PTT 30 LDH hem Plt 52-40-17-14
5
Delivery

• 2/17/09 615am
• Pt c/o pain. Female infant found to be delivered
  with approx 1000cc blood clot on bed. No FH/FM.
  Cord clamped x 2 and cut. Placenta promptly
  delivered spontaneously- 3v, intact. Fundus
  firm. Pitocin 20U in D5LR bolused and 1000mg
  cytotec given. No lacerations. Pt declined
  seeing fetus. Upon examination of fetus, no
  gross abnormalities- appeared SGA with small
  placenta.
• BP 151/100? 151/83. MgSO4 bolus given.

6
IUFD

• Stillbirth fetal death 20 weeks
• Incidence in U.S. 0.4-0.9
• Etiology
• Unexplained 25-60 depending on classification
  system
• IUGR risk of IUFD in IUGR is 5-7x greater
• Abruption occurs in 10-20 of stillbirths (vs.
  1)
• Infection
• Chromosomal and genetic abnormalities single
  gene defects, confined placental mosaicism,
  microdeletions with normal amnio
• Congenital malformations 15-20 Abd wall
  defects, NTDs, Potter syndrome, achondrogenesis,
  amniotic band syndrome
• Fetomaternal hemorrhage
• Umbilical cord complications nuchal cord, knot
• Hydrops fetalis

7
IUFD

• Risk Factors
• Pregravid obesity
• Socioeconomic factors
• Race black women 2x higher risk, even with
  adequate PNC
• AMA
• Multiple gestation
• Smoking
• Maternal medical disorders DM, HTN, SLE, renal
  dz, thrombophilia, cardiac dz, thyroid dz, etc.
• Previous IUFD and SGA

8
Management

• Fetal karyotyping
• Amniocentesis more likely to yield viable cells
  prior to delivery
• Fetal blood/ skin
• Placental pathology
• Laboratory work-up KB, CBC, Chem, Utox, TFTs,
  thrombophilia, lupus anticoagulant,
  anticardiolipin
• Induction vs. spontaneous labor (80-90 w/i 2
  wks)
• Vaginal misoprostol /- oxytocin
• Coagulopathy
• Caused by gradual release of thromboplastin from
  placenta, usually after 4 weeks

9
Counseling

• Giving bad news straightforward, empathetic,
  without blame
• Kubler-Ross stages of grief denial, anger,
  bargaining, depression, acceptance
• Induction after 24 hours vs. within 6 hours
  associated with increased risk for anxiety?
• Contact with stillborn
• Autopsy option
• Fetal remains
• Postpartum care before and after discharge

10
Counseling

• Increased risk for depression, anxiety, PTSD,
  decreased maternal-fetal attachment
• In one study of 65 mothers of stillbirths, less
  incidence of adverse outcomes in mothers who did
  not have contact with the stillborn.
• Recently bereaved women at higher risk for
  depression and anxiety in subsequent pregnancy.
• Increased risk for subsequent stillbirth and
  complications including preeclampsia, abruption,
  preterm delivery, low birth weight

11
References

• JAMA 2001 Jun 20285(23)2978.
• Am J Obstet Gynecol 2005 Dec193(6)1923.
• Hughes P, et al. Assessment of guidelines for
  good practice in psychosocial care of mothers
  after stillbirth a cohort study. Lancet 2002
  July360114-8.
• Stillbirth as risk factor for depression and
  anxiety in the subsequent pregnancy cohort
  study. BMJ 1999 Jun 26318(7200)1721.
• Stillbirth as risk factor for depression and
  anxiety in the subsequent pregnancy cohort
  study. Hughes PM Turton P Evans. BMJ 1999 Jun
  26318(7200)1721-4.
• Dynamed Fetal death, 2009 Feb