Fetal Demise: Causes, Diagnosis, Treatment, and Complications

I. Definition

Fetal demise, also known as stillbirth, is the death of a fetus in the uterus before the 20th week of pregnancy.

II. Causes

Maternal Factors

• Medical Conditions:
  • Preeclampsia, chronic hypertension, heart disease, kidney disease, liver disease, endocrine disorders, infections…
• Infections: Viral, bacterial, parasitic…
• Lifestyle: Smoking, alcohol consumption, drug use, unsafe medication…
• Environmental Factors: Exposure to toxic chemicals, radiation, environmental pollution…

Fetal Factors

• Congenital Anomalies: Chromosomal abnormalities, congenital heart disease, brain defects, limb malformations…
• Genetic: Inherited genetic disorders from parents, such as sickle cell disease, cystic fibrosis…

Placental Factors

• Umbilical Cord Abnormalities: Umbilical cord knot, short umbilical cord, umbilical cord around the fetus’s neck…
• Placental Disorders: Placental abruption, placenta previa, placental aging…
• Amniotic Sac Abnormalities: Premature rupture of membranes, polyhydramnios…

III. Diagnosis

Fetal Demise < 20 Weeks

Signs of Pregnancy

• Dark red or brown vaginal bleeding, with no abdominal pain.
• Uterus size smaller than expected for gestational age.

Ultrasound

• No fetal heartbeat detected.
• Empty, misshapen, or distorted amniotic sac.

Differentiation

• Molar pregnancy: Ultrasound reveals a “snowflake” pattern.
• Ectopic pregnancy: Ultrasound shows a pregnancy outside the uterus.
• Uterine fibroids: Ultrasound shows a mass within the uterus.

Fetal Demise > 20 Weeks

Signs of Pregnancy

• Signs of fetal death: No fetal movement, decreasing abdominal size.
• Uterus size smaller than expected for gestational age.
• No fetal heartbeat detected.

Ultrasound

• Halo sign: Hypoechoic rim around the skull due to scalp detachment.
• Spading 1: Folded skull bones.
• Spading 2: Overlapping vertebrae.
• Devel sign: Bright ring around the head.
• Roberts sign: Air bubbles in the fetal heart chamber or excessive amniotic fluid thickness.

X-ray

• Images of folded skull bones and overlapping vertebrae.

IV. Treatment

Medical Treatment

• Misoprostol (Alsoben) 200 mcg:
  • Fetal demise < 8 weeks:
    • Single dose of 2 tablets placed in the vagina.
    • Clean the cervical mucus before insertion.
    • Repeat after 6 hours if no abdominal pain, maximum 3 doses/24 hours.
    • Pain ==> miscarriage occurs, use 2 vials of oxytocin 5UI after the miscarriage.
    • If discharge persists after 24 hours, replace the tablet in the vagina.

Surgical Treatment

• Dilation and curettage (D&C) or surgical evacuation under ultrasound guidance.

V. Complications

• DIC (Disseminated Intravascular Coagulation): High risk when fetal demise over 4 weeks.
• Infection: Higher risk when membranes have ruptured.
• Psychological: Emotional distress, depression, anxiety…

VI. Forms of Fetal Demise

• Fetal resorption: Only the amniotic sac remains (early weeks).
• Fetal maceration: (Weeks 3-4).
• Fetal mummification: (More than 5 months).

VII. Role of Prostaglandins

• First trimester: Expulsion of the fetus.
• Third trimester: Initiation of labor.
• Postpartum: Prevention of postpartum hemorrhage.

VIII. Prostaglandin Dosage

• Fetal demise BCTC < 12 cm: Use 2-3 tablets simultaneously, doses 4 hours apart, not exceeding 3 doses/24 hours.
• Second and third trimesters: Lower dose.

IX. Bleeding in the Second and Third Trimesters

Causes

• Placental abruption: Dark, watery blood, not clotting, abdominal pain.
• Placenta previa: Sudden, recurrent, heavier bleeding with each episode.
• Molar pregnancy: Initial dark red bleeding, small amounts.
• Miscarriage, ongoing miscarriage: Bright red bleeding.
• Ectopic pregnancy: Dark red blood, not clotting.

X. Necessary Tests

• CBC (Complete Blood Count):
  • Coagulation Profile: Monitor fibrinogen levels when pregnancy is more than 2 weeks.
• Ultrasound: Small fetus, decreasing hCG levels => treatment.

XI. Prevention

• Pre-pregnancy health checkups.
• Adhere to a balanced diet, supplement with adequate folic acid.
• Avoid stimulants and unsafe medications.
• Control existing chronic diseases effectively.
• Limit exposure to toxic chemicals, radiation, and environmental pollution.
• Engage in moderate physical activity and maintain emotional well-being.

This information is for general knowledge only and should not replace medical advice from a qualified healthcare professional. Consult a doctor for prompt advice and treatment.