The World Health Organization (WHO) of Intrauterine Death is the demise of a foetus on and after twenty weeks of gestation.
It came as a rude awakening at 2.300 hours that eventful morning when sleep seem to have taken hold of hard working citizens who deserved a good night rest. Apparently the phone must have been ringing but instead of the surgeon getting up, he went into slumber. I guess it must have been the music of the ringtone of the phone. This is the reason I advise that those involved in emergency and life saving services should make sure that their phone ringtones are harsh and loud. This way you are easily aroused when a call comes in instead of going deep into a dream land with the ringtone of the phone sounding like a lullaby. The ambulance driver had to do the needful; he banged on the gate! He did not only wake up the surgeon but those in the neighbourhood. The price you pay for living with a surgeon in the same neighbourhood.
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At that time of the day there usually were no rooms for pleasantries, the surgeon wanted to get to the root of the matter. The history was straightforward; the patient in question was seen during antenatal visit four days ago with confirmed features in keeping with intrauterine foetal death at term. It was a very distressing situation for the caregiver and the patient. The patient was so shell shocked that
she just wanted to get out of the hospital before she lost her sanity. There was no room for canceling and suggestions for the way forward. And quite naturally in this environment the next port of call was a prayer house where she went for her baby to be revived. Of cause this was not to be but instead fell into labour on her sixth day of visit. She stayed an additional three days in the prayer house before she decided to go back to the hospital.
On presentation the doctor was able to augment the labour and extract the now macerated dead baby. From the stench in the labour room it was obvious that severe infection had set in. As a routine, antibiotics had been commenced before the dead foetus came out. All seemed to be quiet until two hours later after the delivery when the first bleeding occurred. It was heavily clotted and the ensuing blood was bright red in color .As a routine the caregiver had administered medications to enhance uterine muscle contraction while at the same time compressing the uterus manually and packing the vagina with sanitary pads. An intravenous line with a big bore canula had been quickly set up.
Not long after these measures, the pads were soaked with blood and there was another gush. It was at this point that I came into the picture. By the time I got to the health facility the patient had bled four times and was already having the first pint of blood and intravenous plasma expanders to prevent shock. At the stage the Diagnosis was not in doubt. The patient had developed Disseminated Intravascular Coagulopathy leading to clotting challenge and massive bleeding. We have dealt with this condition in our recent outings in this column. Our concern today is the relationship between intrauterine death and severe haemorrhage in pregnancy.
The World Health Organization (WHO) of Intrauterine Death is the demise of a foetus on and after twenty weeks of gestation. This is based on the fact that with the state of the art technology in the management of neonates babies delivered from twenty weeks of gestation can be salvaged. In our tropical environment with resource constraint, this might be a challenge. The causes of intrauterine death may include hypertension in pregnancy, Eclampsia, placenta and umbilical cord complications, Malaria infection in our environment, foetal defects and poor nutritional status. The commonest cause of this condition in our environment in its most acute form is abruptio placenta; a situation where there is separation of the placenta from the endometrium while the baby is still in utero. This is com- monly sequel to rupture of blood vessel in the placenta bed due to high pressure. The clinical course could be precipitous and the outcome a calamity.
With respect to other causes of intrauterine death the poser is always how long a dead foetus should be allowed to stay in the mother’s uterus. The truth is that there is no basis for this type of debate. A dead foetus has no business remaining in the uterus of an expectant mother even when the amniotic membrane is still intact. Some have argued that as long as the membrane is not ruptured the chances of intrauterine infection or chorioamnionitis is reduced. This argument does not take into consideration endogenous bacteraemia, which is bacteria circulating in the blood that has not reached the significant level of causing sepsis.
One of the challenges in this environment is the over reliance on spirituality and superstition. Even after an expectant mother had confided in the caregiver of failure to feel foetal movements and have this confirmed with ultrasonography, she’ll still want to go home and come back later! When they insist on doing that just know that they have gone to seek a spiritual consult. And on getting there most of the times, matters are not helped but rather the situation is compounded. This is contrary to expectant mothers in some climes who would find carrying dead foetus very traumatizing and would want it expelled from their body as soon as possible.
For the reminders intrauterine foetal death could lead to life threatening infection resulting in septic shock. One of the most dreaded complications of intrauterine death is acute renal failure. This could be as a result of immune complex deposition n the Bowman’s capsules of the renal tubules or acute necrosis (cell death) of the tubules as a result of hypovolaemic and/or septic shock. This commonly results from the small vessels known as vasa recta being damaged. And the most dreaded reality of this condition is the very high maternal mortality rate associated with it.
Thus the take should not be how long fa dead foetus should be left in the uterus but how fast and safe this should be done. Currently the use of synthetic PROSTAGLANDIN E has become very popular. Success is measured on the basis of how fast the dead foetus is expelled within the first 72 hours after the commencement of induction. It must be stated that this can fail resulting in operative or surgical extraction of the dead baby. It is expedient to terminate the pregnancy as soon as the diagnosis of intrauterine foetal death is made.