Case 74: Absent fetal movements

 CASE 74: ABSENT FETAL MOVEMENTS

History

A 34-year-old woman at 32 weeks and 4 days’ gestation in her first pregnancy complains of

reduced fetal movements. She normally feels the baby move more than 10 times each day but

yesterday there were only two movements and today there have been none. She has no significant medical, obstetric or gynaecological history. In this pregnancy she booked at 10 weeks’

gestation and all her booking blood tests were normal except that she was discovered not to

be immune to rubella and postnatal vaccination was planned. Her 11–14-week scan, nuchal

translucency test and anomaly scan were all normal.

Examination

The blood pressure is 137/73 mmHg and pulse 93/min. She is apyrexial. The symphysiofundal height of the uterus is 31 cm and the fetus is breech on examination. The fetal

heart is auscultated with hand-held Doppler and no heartbeat is heard. An ultrasound

scan is therefore arranged immediately, which confirms the diagnosis of intrauterine

fetal death.

Questions

• How should this case be managed?

• Are there any factors in the history or examination to indicate the cause of fetal

death and what investigations should be performed to establish a possible cause?100 Cases in Obstetrics and Gynaecology

204

ANSWER 74

Immediate management

The baby needs delivery to avoid the possibility of sepsis or disseminated intravascular coagulopathy developing. This is normally achieved by induction of labour with mifepristone (an

antiprogestogen) followed 48 h later by misoprostol (a prostaglandin analogue) to induce

contractions. The woman can go home temporarily after the mifepristone to avoid the added

stress from being on an antenatal or postnatal ward.

In labour, adequate analgesia is essential and patient-controlled analgesia (PCA) is useful.

Rarely there are contraindications to vaginal delivery, such as previous caesarean sections, in

which case operative delivery may be necessary.

The couple should be seen as soon as possible by a bereavement midwife to discuss the loss,

and funeral or cremation plans.

Cause of intrauterine death

In this history the only potentially significant factor is the lack of rubella immunity. This is

unlikely to be significant, but rubella immunoglobulin (IgG) should be checked to exclude

recent infection.

The examination is normal except for the tachycardia, which may relate to anxiety and should

be rechecked.

! Possible causes of intrauterine death

• Maternal:

• diabetes

• infection (e.g. parvovirus, listeria)

• thrombophilia (e.g. antiphospholipid syndrome)

• Fetal:

• chromosomal abnormality (e.g. trisomy)

• other genetic abnormality (e.g. Gaucher’s disease)

• haemolytic disease

• cord incident (e.g. ‘knot’ in cord)

• Placental:

• placental abruption

• uteroplacental insufficiency (e.g. secondary to pre-eclampsia)

• postmaturity

• Unexplained

Investigations

• Maternal:

• full blood count and coagulation screen (to exclude disseminated intravascular

coagulopathy/thrombocytopenia secondary to fetal death)

• random blood glucose and haemoglobin (Hb)A1c

• Kleihauer test (for fetal cells in the maternal circulation, implying significant

fetomaternal haemorrhage)

• anticardiolipin and lupus anticoagulant (for antiphospholipid syndrome)Case 74: Absent fetal movements

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• Fetal:

• swabs for microscopy, culture and sensitivity from the fetus and placenta

• skin biopsy for karyotype

• postmortem (if agreed by parents)

KEY POINTS

• Intrauterine death is commonly unexpected and unexplained.

• Induction of labour should be arranged as soon as possible as there is a risk of the

development of sepsis or disseminated intravascular coagulopathy.