Intrauterine death of the fetus
In addition to cases in which the fetus dies during delivery as a result of asphyxia or difficult labour, others are seen in which it dies in utero before labour starts. This is usually followed by expulsion of the fetus from the uterus within a few days. In exceptional cases the dead fetus is not expelled from the uterus at once, but is retained for several weeks.Causes:
Pregnancy induced hypertension, essential hypertension and chronic renal disease.Diabetes mellitus.
Postmaturity.
Placental abruption.
Cord accidents.
Haemolytic disease.
Unexplained placental insufficiency.
Fetal malformation.
Infective diseases (any disease that causes high fever and toxic illness may cause fetal death, untreated syphilis, fetal infection with herpes virus or other viruses, severe rubella.
Pathological anatomy:
The fetus is usually born in a macerated condition. Its skin is peeling and stained reddish- brown by absorption of blood pigments. The whole body is softened and toneless; the cranial bones are loosened and easily moveable on one another. The amniotic fluid and the fluid in all the serous cavities contain blood pigments. Maceration occurs rapidly, and may be advanced within 24 hours of fetal death. Autopsy is advised in all cases.Diagnosis:
The woman may notice that the fetal movements have not been present for several days.
The breasts may diminish in size. Sometimes secretion of colostrum from the breasts occurs a few days after the death of the fetus.
In cases of hypertension the blood pressure sometimes falls.
The uterus may be found to be smaller than the duration of pregnancy.
Failure to hear the fetal heart sounds on careful auscultation.
U/S shows no evidence of cardiac activity. It will show overlapping and disalignment of the skull bones and occasionally the presence of gas in the fetal heart and great vessels.
Management:
In the majority of cases labour soon follows death of the fetus, but sometimes labour does not occur for several weeks.
Most mothers want to proceed to induction of labour and delivery as soon as possible. (if there is no contraindication of induction of labour).
There may be no urgent call for interference, unless the complications of disseminated intravascular coaggulopathy occur.
Amniotomy should not be done because of the risk of anaerobic uterine infection from growth of bacteria in the dead placental and fetal tissues if labour does not follow quickly.
Labour can usually be induced with vaginal prostaglandin pessaries or gel or extra-amniotic injections of prostaglandins.
It is also possible to induce labour by the intra-amniotic injection of prostaglandins and a hypertonic solution of urea.
Induction of labour can be done by using oxytocin drip.