1. Fetal DeathCh 13 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study

2. APGO Educational Topic 21 • A. Describe the common causes of fetal death in each trimester. • B. Describe the symptoms, physical findings and diagnostic methods to confirm the diagnosis of fetal death. • C. Describe the maternal complications of fetal death, including DIC. • D. Counsel the patient experiencing death of the fetus. USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

3. Fetal Death • IUFD • Fetal death after 20 weeks EGA but before the onset of labor. • Complicates 1% of pregnancies. • Shift from expectant management to active management. USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

4. Common Causes • Unknown or indeterminate in approx 50% of cases. True Knot http://pathologyoutlines.com/images/placentatrueknot.jpg USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

5. Common Causes • Hypertensive Diseases (Pre-E, Eclampsia) • Diabetes Mellitus • Erythroblastosis Fetalis • Umbilical Cord Accidents (true knot, prolapse) • Congenital Anomalies • Infections (Fetal or Maternal) • Hemorrhage (Abruption) • Thrombophilias (antiphospholipid antibodies) USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

6. Infection - TORCH • Toxoplasmosis • Rubella • CMV • HSV • Parvo-virus • Listeria USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

7. Gestational HSV Infection http://www.nature.com/jp/journal/v22/n1/images/7210584f1.jpg USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

8. Patient Presentation • Subjective decreased fetal movements • Uterus FH is small for EGA • No fetal heart tones with doppler • Will still have pos hCG • Ultrasound • No Fetal Movement • No Fetal Cardiac Activity USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

9. Diagnostic Methods for IUFD No FCA No movement http://www.slredultrasound.com/ThermalImages/Pelvic/IUFD1.jpg USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

10. Maternal ComplicationsDisseminated Intravascular Coagulopathy • Decreased platelets • Decreased fibrinogen • Increased PT/PTT (Clotting times) • Clinical bleeding / oozing from all sites • Decreasing H/H RX involves DELIVERY, pRBC’s, FFP, PLATELETS, Supportive Management USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

11. Maternal Complications • Depression, Anxiety, Psychosocial • Anxiety with future pregnancies • May have repeat losses (depending on causes) • Bleeding ---> can lead to DIC but may only require blood product replacement • Pain, Infection (similar to any other delivery) USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

12. Management = Delivery • Attempt for SVD • Expectant vs. Active management • Active Management • Cytotec • Pitocin • Pain Management • PCA (Pt Controlled Analgesia) • Epidural USUHS MSIII Ob/Gyn Clerkship Self Directed Studies