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Intrauterine death

Specialties > Obstetrics

Differential Diagnosis Schema 🧠

Maternal Factors

  • Hypertensive disorders: Conditions like pre-eclampsia and eclampsia can lead to placental insufficiency and intrauterine death.
  • Diabetes: Poorly controlled diabetes can result in fetal macrosomia, congenital anomalies, or placental insufficiency.
  • Thrombophilias: Conditions such as antiphospholipid syndrome increase the risk of placental thrombosis and fetal demise.
  • Infections: Maternal infections like cytomegalovirus (CMV), syphilis, or listeriosis can cause fetal death.
  • Substance use: Smoking, alcohol, or drug use, particularly cocaine, can lead to placental abruption and fetal death.
  • Advanced maternal age: Increases the risk of chromosomal abnormalities and placental complications leading to stillbirth.
  • Trauma: Physical trauma, such as a motor vehicle accident, can cause placental abruption and fetal demise.
  • Obesity: Maternal obesity is associated with an increased risk of stillbirth due to conditions like gestational diabetes and hypertensive disorders.

Placental Factors

  • Placental abruption: Premature separation of the placenta from the uterine wall, leading to acute fetal hypoxia and death.
  • Placental insufficiency: Chronic reduced blood flow to the fetus, often due to pre-eclampsia or maternal hypertension.
  • Placenta previa: Low-lying placenta that can cause severe bleeding and compromise fetal oxygenation.
  • Placental infarction: Areas of dead tissue within the placenta, reducing its ability to supply the fetus with nutrients and oxygen.
  • Vasa previa: Fetal blood vessels crossing the cervical os, at risk of rupture during labor, leading to exsanguination.
  • Chorioamnionitis: Infection of the placental tissues can lead to fetal sepsis and death.
  • Umbilical cord accidents: Includes cord prolapse, knotting, or true knots, leading to acute hypoxia.
  • Twin-twin transfusion syndrome (TTTS): In monochorionic twin pregnancies, unequal blood flow between twins can cause death of one or both fetuses.
  • Amniotic band syndrome: Bands of amniotic tissue constrict fetal parts, leading to severe deformities or death.

Fetal Factors

  • Chromosomal abnormalities: Trisomy 13, 18, 21, and monosomy X (Turner syndrome) can result in intrauterine death.
  • Congenital anomalies: Severe structural defects, such as neural tube defects or congenital heart disease, may be incompatible with life.
  • Intrauterine growth restriction (IUGR): Poor fetal growth due to placental insufficiency or maternal factors increases the risk of stillbirth.
  • Fetal infections: Infections like parvovirus B19, toxoplasmosis, or rubella can cause fetal demise.
  • Fetal anemia: Can result from Rh incompatibility or fetal-maternal hemorrhage, leading to hydrops fetalis and death.
  • Multiple pregnancy: Increased risk of complications such as TTTS, IUGR, and preterm birth leading to stillbirth.
  • Fetal hypoxia: Chronic or acute lack of oxygen due to umbilical cord issues, placental insufficiency, or maternal factors.
  • Fetal arrhythmias: Abnormal heart rhythms can lead to heart failure and intrauterine death.
  • Fetal tumors: Rare but can cause significant physiological stress on the fetus, leading to demise.
  • Non-immune hydrops fetalis: Severe fetal edema not related to Rh disease, often due to congenital infections or heart defects.

Key Points in History 🥼

Maternal History

  • Previous obstetric history: History of stillbirths, miscarriages, or preterm births increases the risk of recurrence.
  • Hypertensive disorders: Document any history of pre-eclampsia, gestational hypertension, or chronic hypertension.
  • Diabetes: Assess for pre-existing or gestational diabetes and its management during pregnancy.
  • Infections: History of infections during pregnancy, including TORCH infections (Toxoplasmosis, Other agents, Rubella, CMV, Herpes simplex).
  • Substance use: Record any use of tobacco, alcohol, or illicit drugs during pregnancy.
  • Trauma: History of any physical trauma or significant stressors during pregnancy.
  • Family history: Any family history of genetic disorders, thrombophilia, or recurrent pregnancy loss.
  • Advanced maternal age: Increases risk of chromosomal abnormalities and placental insufficiency.
  • Obstetric interventions: Consider any recent procedures like amniocentesis or chorionic villus sampling.
  • Maternal perception of fetal movements: Decreased or absent fetal movements are often a critical sign of fetal distress or demise.
  • Nutrition and weight gain: Assess maternal nutrition and weight gain during pregnancy.
  • Screening tests: Review results of antenatal screening tests, including ultrasounds and blood tests.
  • Psychosocial factors: Consider the impact of stress, anxiety, or depression on maternal health and pregnancy.
  • Exposure to environmental hazards: Consider any potential exposures to toxins, radiation, or infectious agents.
  • Medication use: Review any medications taken during pregnancy, including over-the-counter and herbal supplements.
  • Rh status: Document maternal Rh status and any sensitization concerns.
  • Travel history: Consider exposure to infections or environmental factors during travel.

Possible Investigations 🌡️

Laboratory Tests

  • Full blood count: To assess for anemia, infection, or thrombocytopenia.
  • Blood glucose levels: To assess for gestational diabetes.
  • Coagulation profile: To evaluate for thrombophilia or disseminated intravascular coagulation (DIC).
  • TORCH screen: To assess for infections that can cause intrauterine death.
  • Liver function tests: To check for conditions like HELLP syndrome.
  • Thrombophilia screen: To assess for inherited or acquired thrombophilic conditions.
  • Kleihauer-Betke test: To assess for fetal-maternal hemorrhage.
  • Thyroid function tests: To rule out thyroid disorders.
  • Parvovirus B19 serology: To assess for parvovirus infection.
  • CMV and toxoplasmosis serology: To evaluate for these infections.

Imaging

  • Ultrasound: To confirm fetal demise, assess for placental abruption, and evaluate fetal anatomy.
  • Doppler ultrasound: To assess umbilical artery and middle cerebral artery blood flow, which can indicate fetal anemia or hypoxia.
  • Fetal echocardiography: In cases of suspected fetal heart defects or arrhythmias.
  • MRI: Rarely used, but can provide detailed imaging of the fetus if ultrasound findings are inconclusive.

Postmortem Examination

  • Full autopsy: Recommended to determine the cause of death and identify any congenital anomalies or infections.
  • Placental histology: To assess for evidence of infection, infarction, or other placental pathology.
  • Genetic testing: Considered if a chromosomal abnormality is suspected, including karyotyping and microarray analysis.
  • Toxicology screen: To assess for maternal substance use that could have contributed to fetal demise.
  • Microbiology cultures: To identify any infections in the fetus or placenta.
  • Fetal MRI: Occasionally used in cases where autopsy is declined, to gain further anatomical detail.

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Obstetrics