TEALE FENNING

Nick Raine-Fenning · Posted: Mon Feb 26, 2007 5:33 pm Post subject: Intrauterine fetal death (IUFD)

You are called at 03.00 by the sister in charge of delivery suite. She is unable to locate the fetal heart in a patient who has presented with abdominal pain.

Describe your immediate assessment of the patient? (6 marks)

How would you proceed if intrauterine fetal death is confirmed? (6 marks)

What investigations would you undertake and why? (8 marks)
_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Xerxes I · Posted: Tue Jul 29, 2008 11:46 am Post subject:

You are called at 03.00 by the sister in charge of delivery suite. She is unable to locate the fetal heart in a patient who has presented with abdominal pain.

Describe your immediate assessment of the patient? (6 marks)

This is a very sensitive situation and its management requires a careful and sympathetic approach. An ultrasound scan should be performed as soon as posible afer a brief history and physical examination. History should include review of antenatal events, gestational age, significant risk factors and whether the fetal movements have been felt and any vaginal bleeding or abdominal pain. On abdominal examination, a woody hard and tender uterus is suggestive of abruption. A speculum examination can be deferred to after ultrasoun examination if there is no significant bleeding.
IUFD is confirmed if no heart activity can be seen despite a clear view of the fetal heart, doppler views of heart, aorta and umbilical cord can further confirm the diagnosis. If in doubt, a second opinion should be sought immediately.

If fetal heart is seen, the woman should be reassured and the reason for her attendance dealt with.

How would you proceed if intrauterine fetal death is confirmed? (6 marks)
the grief is as intense as losing a child and should be treated as such. the couple should be offered privacy in an appropriate place preferrabl away from the delivery suite or the antenatal ward and should be given enough time before any further decisions are made about the management except where there is immediate risk to the mother's health as in massive antepartum haemorrhage.
Consltant obstetrician should be involved at an early stage nd an uninterrupted consultation with the couple in a quiet room allowing enough time should be undertaken. The timing and method of delivery should be discussed. In the absence of contraindications for vaginal delivery (e.g previous classical caesarean section) this would be the method of delivery. the labour usually needs to be induced as if left too long, can cause Disseminated Intravascular coagulation. Adequate pain relief should be offered in labour.

What investigations would you undertake and why? (8 marks)

In most cases, a cause can not be found but every effort should be made to reach a diagnosis as this ccan have an effect on the management of future pregnancies. Fetal blood should be sent for full blood count to look for fetal anaemia, haemoglobin electrophoresis to look for haemoglobinopathies. A Kleuhauer test shoul be performed to assess any fetomaternal haemorrhage. Fetal Karyotyping can be performed using fetal blood to rule out any aneuploidy as the underlying cause.

Placenta shuld be thouroughly inspected for retroplacental clots suggesting abruption, caclifications suggesting placental insufficiency and true knots in the umbilical cord. Pacenta should be sent for histology.

Swabs should be sent from placenta, baby and the lower genital tract for culture and sensitivity.

Maternal serum should be sent for antiphospholipid and anticardiolipin antibodies. Random blood glucose ad thyroid function test should also be checkekd as both diabetes and thyroid disfunction are associated with IUFD.

there is more, .....

And finally postmortem should be offered, if not acceptable, talk about limited postmrotem, Xrays, MRI etc.

shachi · Joined: 10 Jun 2008 Posts: 16

I would add general examination , pulse and blood pressure to my immediate management as the patient might need resuscitation if unstable.
The diagnosis of IUD should always be confirmed by 2 persons.
I would add in modes of available analsgesia like oral(cocodamol, oromorph), injectable(pethidine, morphine), patient controlled analgesia, epidural and entonox.
When patient is ready, I would offer counselling and chaplaincy services.
Discuss burial/ cremation by hospital/self arranged, after delivery of baby.
Also I wasn't aware u could do karyotyping using fetal blood, we usually use fetal skin, hair etc.

Abik · Posted: Thu Aug 14, 2008 5:21 pm Post subject:

Hi guys.

Great plan S, I would like to commment!

What do we know?
Pain
No FH?

What don't we know?
other symptoms - pvb
stability of mother
anything more about the pain
gestation of the foetus
singleton?
previous obst hx
any previous medical hx - DM, severe cardiac, bowel, resp dis?

What do they want us to demonstrate?
that we know how to deal with term IUFD?
That we are looking out for pitfalls - unwell mum, twins, previability

Your immediate assessment of this patient should always begin with history so why not write that first - show that your mind is not muddled and you are not focussed on USS only.

Abik · Posted: Thu Aug 14, 2008 5:26 pm Post subject:

Abik · Posted: Thu Aug 14, 2008 5:35 pm Post subject:

Xerxes I · Posted: Thu Aug 14, 2008 9:19 pm Post subject:

All agreed, thanks Abi. it's interesting how when you look back at what you've written, you hate it. it's like listening to your recorded voice.

I see your point about grief intensity, I wanted to show that I don't underestimate the gravity of the situation. I guess first trimester miscarriage, IUFD, neonatal death, losing a 6 month child and losing a teenager are all losing a child but are they really the same? anyway, grief can not really be measured and the same principles apply to all.

Nick Raine-Fenning · Posted: Thu Aug 14, 2008 10:21 pm Post subject: