Intrauterine death (IUD): Causes; Signs and Management

Intrauterine death refers to the death of the fetus occurring after 28th weeks of gestation resulting in a macerated stillbirth.  If the fetal death occurs before the 28th, the term “missed abortion” is used. 24 hours after the death of the fetus, aseptic degeneration called maceration occurs. Blisters first form on the skin which peels off easily. The rest of the body also undergoes degeneration later.

what is intrauterine death?

intrauterine death is defined as the death of baby in-utero which occurs after 28th weeks of gestation leading to a macerated stillbirth. It is a disheartening condition to both the mother and her partner.

Signs of Intrauterine fetal death(IUFD)

The midwife should be guided by the following findings in diagnosing intrauterine death:

  1. Failure of the pregnancy to progress as evidenced by lack of increases (or positive decrease) in the size of the uterus. The breasts may feel less heavy.
  2. Absence of fetal movements: the mother may be the first to complain of this.
  3. Absence of fetal heart sounds: This is not heard either use of fetoscope by the midwife or ultrasonography.
  4. A negative pregnancy test which is usually ordered by the doctor.
  5. Spalding’s sign: Spalding’s sign is the collapse and overriding of the skull bones at the suture lines. It occurs at the following shrinkage of the brain substance. Spalding’s sign is diagnosed radiologically 7-10 days following the death of the fetus. Overriding of the skull bones in also seen in cases of excessive moulding of the fetal head following prolonged labour even the fetus is not dead.
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The following are other radiographic signs suggestive of intrauterine demise:

  • Collapse of the vertebral column of the fetus: There is collapse of the longitudinal ligaments which support the vertebral column.  This causes squashing of the vertebra and hyperflexion of the fetal spine. It is diagnosed radiologically about 7 to 10 days after the fetal demise.
  • Gas bubbles in the body: The bubbles are seen in the large vessels such as the aorta, vena cava and the heart chambers. They may also be seen in the liver and the abdominal cavity of the fetus.

Causes of intrauterine death of the fetus

  1. Severe anaemia in pregnancy. This causes maternal and fetal hypoxia and eventually results in fetal death.
  2. Severe attack of malaria or any other causes of hyperpyrexia such as typhoid fever, and pyelonephritis.
  3. Dysenteries (e.g.  amoebic or bacillary dysentery)
  4. Smallpox and other severe viral infections
  5. Placental insufficiency resulting from severe pre-eclamptic toxaemia, eclampsia, chronic vascular hypertension (e.g. essential hypertension), chronic nephritis and postmaturity.
  6. Diabetes mellitus
  7. Congenital fetal abnormalities
  8. Rhesus incompatibility
  9. True knots in the cord

Intrauterine deaths occurring just before delivery are usually caused by accidents in labour such as cord prolapse, delay in second stage of labour or a generally prolonged and obstructed labour. Such intrauterine deaths result in the delivery of a fresh stillborn baby with no signs of maceration.

Sometimes, fresh stillbirth is also seen in in the presence of toxaemia of pregnancy and all other conditions mentioned above in which the extra strain of a difficult labour precipitates fetal death in-utero.

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The distinction between macerated and fresh stillbirth is essential. it enables the midwife to separate deaths occurring in-utero long before the onset of labour, as a result of a preventable  antenatal causes, form those occurring in labour.

It must, however, be emphasized that certain deaths occurring during labour may show maceration if labour is prolonged and unassisted. Maceration can take place within 12 to 24 hours after the fetal death.

Management of intrauterine death

All cases of intrauterine fetal death must be referred to the doctor. Usually is done until confirmatory x-ray diagnosis has been performed.

In the hospital, the patient is given medical induction of labour in the form of oil, enema, and bath followed by Pitocin (oxytocin) infusion or a high dose of quinine. Some obstetricians believe in giving a high dose of stilboestrol to sensitize the uterus to the action of oxytocins.

Surgical induction is NEVER CARRIED OUT in the presence of intrauterine death. Quite apart from the fact that the patient may fail to go into labour, artificial rupture of membranes in the presence of intrauterine death of the fetus is a highly dangerous procedure which may cause severe infection with anaerobic organisms resulting in gas gangrene and maternal death.

If medical induction fails at first, the doctor waits a few days and then tries again. In most cases, spontaneous labour occurs two or three weeks after the fetal death.

Complication of intrauterine death

An important cause for anxiety in cases of intrauterine fetal demise is the possibility of profuse haemorrhage from hypofibrinogenaemia.  This is usually does not occur until four week or more after fetal death and is not very common.

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prevention of intrauterine death

There are no specific way to prevent fetal death in-utero. However, encouraging mother to attend antenatal care regularly, improving in her nutrition and strictly takes the prescribed routine drugs can improve the fetal wellbeing and overall health of the mother. Every mother should try to utilize facility-based delivery where emergency obstetric care is readily available.