Most pregnancy loss occurs during the first trimester, and it is estimated that after 20 weeks’ gestation fewer than 1% of all pregnancies end with fetal death. Of these, approximately a third occur with no explicable fetal or maternal cause.
Problems and special considerations
Intrauterine death may cause major obstetric as well as psychological sequelae. It is unusual in the UK for intrauterine death to remain undiagnosed for several days, but if this situation arises it is potentially life-threatening, since the mother is at risk of developing disseminated intravascular coagulation (DIC) and sepsis.
Fetal death occurring during the second half of pregnancy may be suspected by the mother when she fails to feel fetal movements. The diagnosis is confirmed by an absent fetal heartbeat on ultrasonography. In the majority of cases, the pregnancy will have been progressing apparently normally until shortly before fetal death occurs, and the diagnosis is devastating for the mother and her partner. The psychological as well as the medical wellbeing of the parents must be considered.
Labour will normally be induced at the earliest possible opportunity after diagnosis of intrauterine death, and adequate analgesia must be provided. Vaginal delivery is the mode of delivery recommended by the Royal College of Obstetricians and Gynaecologists, but some women may be delivered by caesarean section in the presence of a maternal indication. Coagulation may become deranged secondary to the release of tissue thromboplastin from the fetus, which does not usually occur until 3-5 weeks after intrauterine death, or from the placenta if there has been any placental separation. Coagulopathy may also be triggered by an intrauterine infection or uterine perforation, and in some of these cases may develop without an obvious risk factor.
All the potential complications of labour and delivery may occur, including slow progress in labour, difficulty with delivery and postpartum haemorrhage. While the use of oxytocics is not limited by concerns about fetal welfare, the risk of overstimulating uterine contractions and causing uterine rupture must be considered, especially in the multiparous woman or the woman with a uterine scar. It may, very occasionally, be necessary for the obstetrician to perform destructive procedures to the fetus to achieve vaginal delivery, or alternatively to perform hysterotomy. Intrapartum care of the mother is stressful and traumatic not only for the mother and her partner but also for midwifery and medical staff.
Management options
Analgesia for labour should be discussed with the mother and her midwife before active labour begins. Parenteral opioids (usually diamorphine) are often used, sometimes with sedatives such as benzodiazepines. If opioid analgesia is used, consideration should be given to the use of intravenous patient-controlled analgesia (PCA), although extreme care should be taken to provide adequate observation and monitoring if remifentanil PCA is used. This is because reported cases of respiratory or cardiac arrest with remifentanil PCA have often been in women with intrauterine death, presumably because these are more likely to be managed in quiet and darkened rooms with minimal disturbance.
Epidural analgesia can provide more effective pain relief without clouding maternal consciousness. Although this may appear distressing for the mother at the time, parents often appreciate memories of seeing and holding their baby. Epidural analgesia is contraindicated if there is a coagulopathy, although DIC is rarely seen in practice. Units should have guidelines on the management of these women, including the need for coagulation studies.
The anaesthetist should be aware of the possible risks of uterine rupture and postpartum haemorrhage in multiparous women.
Following delivery, the parents are usually encouraged to see and hold their dead baby. Photographs of the baby should be taken and kept with the medical records even if the parents do not wish to see the baby. The obstetric and midwifery staff should ensure that help is available for registering the stillbirth, discussing post-mortem examination and making any funeral arrangements.
Intrauterine death of one twin is a recognised risk of monochorionic twin pregnancy. Recommended management is usually conservative, although there have been recent reports that early delivery (by hysterotomy) of the dead twin improves outcome for the remaining twin. The psychological sequelae for both the parents and the surviving twin may be particularly difficult to deal with and may persist into the surviving twin’s adult life.
Key points
• Intrauterine death is devastating for the parents; it is often completely unexpected and occurs towards the end of an apparently normal pregnancy.
• Standard obstetric management is induction of labour, with the aim of achieving vaginal delivery whenever possible.
• The obstetric anaesthetist should be able to advise about suitable analgesia, and should be available to deal with any complications of vaginal delivery.
• The situation demands the highest standard of communication skills and sensitivity from all medical and midwifery staff.
• The presence of coagulopathy or sepsis may have implications for regional anaesthesia.
Further reading
Royal College of Obstetricians and Gynaecologists. Late Intrauterine Fetal Death and Stillbirth.
Green-top Guideline 55. London: RCOG, 2010. www.rcog.org.uk/en/guidelines-research-servi ces/guidelines/gtg55 (accessed December 2018).