Fetal death, missed abortion, and intrauterine death

A baby can die at any time during pregnancy. What you can do about it depends on whether he dies before or after 18 weeks. Before this time his death is termed a missed abortion, after it he is an intrauterine death.

Before 18 weeks a dead baby is usually aborted without his mother knowing that he is dead. Occasionally however, the abortion is delayed for several weeks (a missed abortion). When this happens the only sign of fetal death is that her uterus fails to grow. Or, she may have a threatened abortion which stops bleeding, and is followed by a brown discharge and no further periods. Although the loss of a baby may be tragic, a missed abortion has few risks, there is little risk of a clotting defect this early in pregnancy, and provided nobody interferes, she runs no risk of infection.

After about 18 weeks: (1) a mother is aware of the death of her baby (intrauterine death) because the fetal movements stop, or do not occur when they should (18 to 22 weeks in a primip, 16 to 20 weeks in a multip). (2) The fetal heart cannot be heard when it should be (28 weeks), but remember that this is an unreliable sign, especially if she is fat, or has polyhydramnios. Listen to it electronically if you can. (3) The height of her fundus, as found by palpation, fails to match that expected from her dates. Instead, it either remains stationary or falls (M 6.4). For this sign to be useful, the height of her fundus above her symphysis pubis must be measured accurately with a tape measure. So, when fetal death is suspected, impress this on your midwives. (4) There are radiological signs of fetal death, but they are not easy before 28 weeks. The most reliable ones are overlapping of the bones of the baby's skull (Spalding's sign), hyperflexion of his spine, and gas in his great vessels. Endocrine tests for pregnancy take 4 or even 8 weeks to become negative, so they are of little value.

If you do nothing, there is an ninety per cent chance that she will deliver her baby in 4 weeks, whatever the duration of her pregnancy. But, as long as he remains inside her, she runs the remote but serious risk of a serious coagulation defect, and catastrophic bleeding. This risk is low initially, but increases with time, particularly after he has been dead 4 to 6 weeks. Rupturing the membranes to induce labour is dangerous, because the dead fetal tissues are easily infected by anaerobes. The following regime attempts to balance these risks. Use oxytocin and/or prostaglandins. The sensitivity of her uterus to prostaglandins remains constant, but its sensitivity to oxytocin increases with each gestational week.

Prostaglandins are expensive. The most commonly used one is PGE[,2] or dinoprostone (''Prostin' E[,2] Upjohn). You can use: (1) A solution of prostaglandin instilled into the extra-amniotic space through a Foley catheter. (2) Pessaries or tablets in the posterior fornix (19.3).

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THE DEAD BABY DEATH BEFORE 18 WEEKS [s7](missed abortion) If a mother's uterus is small for her gestational age, perhaps with a brownish vaginal discharge, suspect the death of her baby. Monitor the growth of her uterus carefully. If he is dead, it will not grow, and may even become smaller. Pregnancy tests become negative. Methods of detecting the fetal heartbeat vary in their sensitivity: ultrasound scanning detects it at 8 weeks, Doppler ultrasound at 10[nd]16 weeks, and an ordinary stethoscope at 20[nd]28 weeks.

THE DIFFERENTIAL DIAGNOSIS includes a normal pregnancy of shorter duration (wrong dates), a slow-leaking ectopic pregnancy, a false pregnancy, and fibroids.

MANAGEMENT. You can, if you wish do nothing for several weeks. Spontaneous abortion will inevitably follow. Alternatively:

If her uterus is smaller than 10 weeks (a small [f41]orange), you can do a ''D and C', either using the ordinary method (16.2) or a Karman curette. Give her perioperative chloramphenicol and metronidazole (2.9) when you do this (one contributor considers this unnecessary). Dilate her cervix up to at least Hegar 10. If possible, ''prime' her cervix with prostaglandins beforehand. Either, (1) put a 0.5 mg tablet of prostaglandin E[,2] in her cervix, and repeat this 6-hourly for 24 hours. Or, (2) place 3 mg prostaglandin E[,2] vaginal tablets in her vagina 6 hourly. Or, (3) use a newer preparation, gemeprost (''Cervagem').

If you are using a Karman curette, dilate her cervix to 8 Hegar and then use a Number 8 Karman curette with a vacuum of up to 500 mm Hg. Continue until her uterus is empty, and you can feel her uterus tight round the curette.

If her uterus is larger than 10 weeks, don't attempt an ordinary ''D and C'. Instead, either use oxytocin and/or prostaglandins, see below. Or, dilate her uterus to 11 Hegar, and use a No 10 Karman curette, which is safe up to 12 weeks[md]but not beyond!.

CAUTION ! Attempting to do a ''D and C' on a uterus larger than this can cause disastrous bleeding, and perhaps infection. We have advised a 10-week threshold rather than the more normal 12 weeks, to allow for a margin of error.

DEATH AFTER 18 WEEKS [s7](intrauterine death) A mother notices that fetal movements stop, or do not occur when they should (at 18 weeks). Or, a midwife fails to hear the fetal heart after 24 weeks. If possible, confirm the absence of the fetal heartbeat with Doppler ultrasound. During 2 to 4 weeks observe if her uterus fails to grow or gets smaller.

CAUTION ! A pregnancy test is no use at this stage. It may be positive when the baby is dead.

THE DIFFERENTIAL DIAGNOSIS includes: (1) A normal pregnancy of shorter duration (wrong dates). (2) A hydatidiform mole. (3) Polyhydramnios (her uterus will be large for her dates). (4) Multiple gestation with small fetuses. (5) An abdominal pregnancy. (6) Ascites, an ovarian tumour, fibroids, or a false pregnancy.

MANAGEMENT. Do nothing for a month after the fetal movements have stopped. Explain carefully why you are doing nothing. She may find this difficult to understand and her husband may try to persuade you to act prematurely. Explain that, if you attempt induction by the method below, it may fail and she may need a few days rest before you try again.

If she is still undelivered a month after fetal movements have stopped, consider induction. Before you induce her, check her clotting time (16.13).

AN ESCALATING OXYTOCIN DRIP. Use this regime from about 10 (before which it is unnecessary), until about 28 weeks when the method in Section 19.3 is indicated. See also Section 18.4a on oxytocin. Her uterus is less likely to rupture in early pregnancy, so start with 5 units of oxytocin in 500 ml of Ringer's lactate or saline, at 25 drops a minute. You may find that labour does not start until the following day. If this fails, repeat the drip the next day with 25 units in 500 ml. If necessary, wait and repeat it in another week. If this does not work, wait and try a third time. You may have to give her up to 100 units in 500 ml (the absolute maximum). Usually, much less is necessary.

EXTRA SPECIAL CAUTION ! is necessary when you use oxytocin at this stage of pregnancy! (1) You may have to use large doses. Oxytocin has an antidiuretic effect, so you can overload her with fluid, so that she develops water intoxication (rare). So: (a) increase the strength of the infusion, rather than the volume you give, (b) give it in Ringer's lactate or saline, rather than 5% dextrose, and (c) give it for a day and then stop. (d) Don't give more than 3 litres of fluid in 24 hours. (e) Keep a fluid- balance chart; if she has a positive fluid-balance of more than 2 litres stop the drip. Because of these dangers some obstetricians wait to let nature take its course between 14 and 28 weeks. (2) Oxytocin can rupture the uterus as early as 18 weeks, so don't give more oxytocin than you need.

If she becomes drowsy or has convulsions while on an oxytocin drip, she has probably developed water intoxication. Stop the drip and let her kidneys excrete the water. Give her a slow infusion of 5% sodium chloride (if you have it).

If an escalating oxytocin drip fails, and the products of conception have not been expelled within 2 to 4 weeks of presention, refer her to an expert. If you cannot refer her, see below.

EXTRA[nd]AMNIOTIC PROSTAGLANDINS. The indications are: (1) The termination of pregnancy after 14 weeks. (2) Missed abortion (intrauterine death) after 14 weeks. (3) The evacuation of a hydatidiform mole.

CAUTION ! With both methods follow the manufacturer's instructions carefully.

Using a Foley catheter (the preferred method). Using a Cusco's speculum and sponge forceps pass a sterile 12 to 14 Ch Foley catheter with a 30 ml balloon gently through her cervix into her extra-amniotic space. A Foley catheter of this size will always enter a pregnant cervix.

Now inject prostaglandin E[,2] in the following regime.

Prepare a solution containing 100 micrograms in 1 ml (add 0.5 ml of a 10 mg/ml solution to 50 ml of diluent). Fill the dead space in the catheter system with the dilute drug solution. Then inject 1 ml of solution through the catheter initially, followed by 1 or 2 ml 2-hourly to maintain regular contractions. Go on until the catheter falls out.

Alternatively, cut the tip off the Foley catheter, pass an infant feeding-tube through it, and push the catheter through her cervix, so that the balloon lies just above her internal os. Through the feeding tube instil PG F[,2]alpha (dinoprost) 5 mg diluted with 4 ml of sterile isotonic saline. Repeat this 2- hourly until she has adequate contractions.

The Foley catheter will always be expelled eventually. Most obstetricians would give her an oxytocin drip at the same time; a few consider this dangerous, and only give oxytocin if prostaglandins fail to establish contractions in 6 hours.

Using dinoprostone (PGE[,2]) vaginal tablets. The standard tablets are 3 mg (''Prostin' Upjohn, expensive). To terminate her pregnancy, insert 3 mg vaginal tablets in her posterior fornix 4-hourly up to a total of 6 tablets in 24 hours. This will usually evacuate her uterus within 12 hours. If it has not succeeded in 24 hours, try another method, or wait for 2[nd]3 days and try again.

CAUTION ! Don't rupture her membranes. It may hasten delivery, but it is not worth the risk. See also Stop Press.

THE DEAD BABY [s7]at term or during labour See also Sections 18.4 and 18.7.

A dead baby is usually easy to deliver when he has died as the result of gestational hypertension or abruption, because he is usually small and is often macerated. But if he died because labour was obstructed, delivery is more difficult. Caesarean section might seem to be the obvious answer. Unfortunately, if his head is impacted deep in her pelvis, removing it from her uterus at Caesarean section is difficult. She also runs the serious immediate risk of septic shock and peritonitis, and the later one of a scar in her uterus. Provided his head is well down in her pelvis, an operative vaginal delivery, if necessary a destructive one, will be safer. If it is high, you will have to section her.

DIFFICULTIES [s7]with a dead baby before about 30 weeks If you are NOT SURE IF A BABY IS DEAD OR NOT, wait, and see her again in 2 weeks. If necessary, wait 4 weeks. By this time it should be clear if he is dead or not.

If delivering a dead baby late in pregnancy or at term is complicated by SEVERE BLEEDING, disseminated intravascular coagulation (DIC) is a possibility, so see Section 19.11a. Maintain her blood volume, and try to give her fresh blood. If bleeding is not controlled by two doses of ergometrine with oxytocin (''Syntometrine'), or by ergometrine alone, intravenously or intramuscularly, give her a prostaglandin such as dinoprost (''Prostin F[,2][ga]') 250 to 500 [gm]g directly into the myometrium through her abdominal wall. Try compressing her uterus, pack it for 24 hours, and then remove the pack. This is a useful temporary measure for any bleeding uterus, and may save the need to do a laparotomy. If this fails to control bleeding, tie her internal iliac arteries (3.5). If this too fails, remove her uterus (20.12). Give her fresh blood.

If oxytocin and prostaglandins FAIL TO EXPEL A DEAD BABY (rare), suspect an extrauterine pregnancy (16.6).

If she has FEVER and GASTROINTESTINAL SYMPTOMS while she is having prostaglandins, these are probably side-effects. They are much less likely when lower doses are instilled through a Foley catheter.