Intrauterine Fetal Demise
A 37-year-old woman, gravida 3 para 1, at 28 weeks' gestation reports vaginal spotting 2 weeks ago and no fetal movement since. She has had no cramping and has passed no tissue. Fundal height measures 18 cm. Ultrasound shows no fetal cardiac activity and no fetal movement. Which of the following is the most likely diagnosis?
- A.Missed abortion
- B.Incomplete abortion
- C.Gestational trophoblastic disease
- D.Intrauterine fetal demiseCorrect
Explanation
Fetal death is classified by gestational age: loss before 20 weeks is abortion (miscarriage), while death at or after 20 weeks is intrauterine fetal demise, or stillbirth. This fetus died at 28 weeks, so the correct term is fetal demise regardless of the fact that the products have been retained. The clinical picture fits: absent fetal movements, a preceding episode of spotting, and a fundal height far smaller than dates because of fetal maceration, collapse of the fetal cranium and reduced amniotic fluid. Ultrasound demonstrating absent cardiac activity is the diagnostic gold standard and should be confirmed by a second operator. Management is induction of labour with vaginal misoprostol or oxytocin, with dilation and evacuation an alternative at earlier gestations; expectant management risks consumptive coagulopathy from thromboplastin release after several weeks of retention, so fibrinogen and platelets are monitored. Evaluation should include fetal autopsy, placental histology, karyotype or microarray, Kleihauer-Betke testing and screening for antiphospholipid syndrome and diabetes. Missed abortion is the identical pathophysiology but before 20 weeks. Incomplete abortion involves partial passage of products with cramping and bleeding, typically in the first trimester. Gestational trophoblastic disease presents with a uterus large for dates, markedly elevated beta-hCG and a snowstorm ultrasound pattern with no fetus.
Why each option
- A.
- Missed abortion describes retained non-viable products before 20 weeks; this pregnancy is at 28 weeks.
- B.
- Incomplete abortion involves partial passage of products with cramping and bleeding; she has passed no tissue and has no cramping.
- C.
- Molar pregnancy gives a uterus larger than dates, very high beta-hCG and a snowstorm pattern without a fetus.
- D.
- Correct. Absent fetal cardiac activity at or beyond 20 weeks with a size-less-than-dates uterus is intrauterine fetal demise.
Reference: ACOG Obstetric Care Consensus 10, Management of Stillbirth, 2020
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