ABSENT FETAL MOVEMENTS

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 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. 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.

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)

• Fetal:

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

• skin biopsy for karyotype

• post mortem (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.