ABSENT FETAL MOVEMENTS
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.
The blood pressure is 137/73 mmHg and pulse 93/min. She is apyrexial. The symphysio- fundal 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.
· 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?
The baby needs delivery to avoid the possibility of sepsis or disseminated intravascular coagulopathy developing. This is normally achieved by induction of labour with mifepris- tone (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 sec- tions, 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, funeral or cremation plans.
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.
· 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)
· swabs for microscopy, culture and sensitivity from the fetus and placenta
· skin biopsy for karyotype
· post mortem (if agreed by parents)
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