Causes and Demographic Factors Affecting Intrauterine Fetal Death in a Tertiary Care Centre

doi:10.5083/ejcm/25-03-130

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Abstract
Keywords
Introduction
Materials And Methods
Results
Conclusion
References

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Research Article | Volume 15 Issue 3 (March, 2025) | Pages 749 - 755

Causes and Demographic Factors Affecting Intrauterine Fetal Death in a Tertiary Care Centre

Darapu Goutami

Jyothirmayi Ponnada

Balaga Jyothi Kiranam

Yogitha Raj

Assistant professor, GMC Srikakulam

Associate professor, GMC Srikakulam

Under a Creative Commons license

Open Access

DOI : 10.5083/ejcm/25-03-130

Received

Feb. 16, 2025

Revised

Feb. 27, 2024

Accepted

March 10, 2025

Published

March 27, 2025

Abstract

Aim: To review the causes of IUD and classify the causes into maternal, fetal and placental causes and further classify causes by relevant condition at death by ICD-PM classification.We intend to observe the causes of and demographic factors contributing to the burden of IUD.Using this data, the areas of action can be identified and measures can be formulated to reduce a significant number of perinatal mortalities.

Study design: prospective observational study

Study period : 1 year

Study population -All IUD cases admitted in the department of obstetrics and gynecology of Government medical College srikakulam during the study period.

Study is conducted after taking approval from the Hospital ethics committee.

Methodology: This is an observational study of data collected over one year (January 2024-December 2024) from a tertiary care centre in SRIKAKULAM India. The maternal demographic characteristics and causes of IUD were studied. The causes of IUD were classified into maternal, fetal and placental causes and relevant condition at death based on ICD-PM classification.

Results: In a study of 55 intrauterine deaths (IUDs), the majority of mothers (50.9%) were aged 20-25 years. Among them, 25.45% were primigravida and 54.54% were second gravida. Notably, 54.8% had three or more antenatal visits, while 94.54% were unbooked cases referred to GGH. Maternal conditions, including pre-eclampsia and diabetes, accounted for 58.18% of IUDs, with 87.27% occurring in the antepartum period. Of the IUD babies, 47.27% were female and 52.72% male; 65.45% were macerated and 34.54% fresh. Fetal causes contributed to 25.45% of cases, with prematurity noted in 76.36%. Four IUDs involved non-viable congenital abnormalities, and one case involved fetal demise in a twin pregnancy due to selective growth restriction. According to ICD-PM classification, hypertensive diseases were the most common maternal cause (75%), followed by gestational diabetes (18.75%).

Keywords

Intrauterine fetal death (IUD)

Fetal demise

Maternal age.

INTRODUCTION

According to the World Health Organization:

"Fetal death means death prior to complete expulsion or extraction from the mother of a product of human conception irrespective of the duration of pregnancy and which is not an induced termination of pregnancy..."

Fetal deaths are related to maternal, placental, or fetal complications. Prevention of IUFD is possible with early booking, adequate antenatal care, early identification of risk factors, and timely intervention.

To facilitate data comparison of perinatal deaths, the World Health Organization developed the International Classification of Diseases-10 Perinatal Mortality (ICD-PM).

Aim of the Study

To review the causes of IUD in a tertiary care hospital.

Using this data, identify areas of action and formulate measures to reduce perinatal mortalities

MATERIALS AND METHODS

Study Design:

Retrospective Observational Study

Study Period:

12 months (January 2024 - December 2024)

Study Population:

All IUD cases admitted in the Department of Obstetrics and Gynecology, Government Medical College, Srikakulam, Andhra Pradesh during the study period.

Ethical Approval: Study conducted after approval from the Hospital Ethics Committee.

Methodology

Deaths were grouped according to the timing of death and ICD-PM cause of death.
Maternal conditions at the time of perinatal death were assigned to each case.
Gestational age at death and previous obstetric history were noted.

Inclusion Criteria:

Cases of POG above 24 weeks and fetus weight above 500 grams were included.

Exclusion Criteria:

Cases below 24 weeks POG and fetuses weighing less than 500 grams.
Induced termination of pregnancy.
Neonatal deaths.

Observation Parameters:

Assessment of pelvis is done and details of the mode of delivery like vaginal delivery, operative vaginal delivery, LSCS are noted.

Details of the fetus like fresh death /macerated stillbirth, sex of the baby, weight, any obvious congenital malformations and birth injuries are noted.Placenta is examined to note any infarction, calcification, and retroplacental clots ,cord abnormalities like knots, cord around neck, and length of the cord ,color of the liquor was also noted.

RESULTS

Observations and Results

Total Number of Cases (12 Months Period):

55 cases
Average per month: 4-5 cases

Cases Breakup:

Booked cases in GMC: 3
Referred from outside: 52 (majority with medical complications)

Monthly Breakdown of IUD Cases:

Month	No. of IUDs
January	5
February	2
March	3
April	5
May	8
June	-
July	5
August	6
September	5
October	4
November	8
December	4

Gravida Distribution:

Gravida	No. of Cases (%)
G1	14 (25.45%)
G2	30 (54.54%)
G3	9 (16.36%)
G4	2 (3.63%)

Birth Weight Distribution:

Birth Weight (g)	No. of Cases
500-1000	14
1000-1500	7
1501-2000	11
2001-2500	11
2501-3000	5
3001-3500	6
3501-4000	1

Macerated	Fresh
36	19

FCH	MCH
26	29

Gestational Age in Weeks:

Gestational Age	No. of Cases
24-28	7
28-32	13
32-34	10
34-37	12
>37	13

Term	Pre- Term
13	42

Maternal Age	No. of Cases
<20	1
20-25	28
26-30	22
>30	4

Mode of Delivery:

Mode	No. of Cases
Vaginal	33
Cesarean	21
VBAC	1

Causes of IUD:

Maternal causes: 32 (58.18%)
Fetal causes: 14 (25.45%)
Placental/cord abnormalities: 8 (14.54%)
Unknown causes: 1 (1.81%)

Maternal Conditions (ICD-PM Classification):

Hypertensive disorders: 24 (75%)
Gestational diabetes: 6 (18.75%)

Other medical disorders

Dengue (1)
Apla(1)

Hypertensive disorders of pregnancy and its consequences

Abnormalities in placenta, umbilical cord and amniotic fluid

Cause	no of cases
meconium stained amniotic fluid	3
oligohydramnious	1
polyhydramnious	1
placenta previa	1
abruption	1
loop of cord around neck thrice	1

The ICD-PM system: perinatal causes of death, separated by timing of death, and maternal condition at the time of perinatal death

Antepartum death – 48 [87.27%]

Intrapartum death -7[12.72%]

Neonatal death

A1 Congenital malformations, deformations and chromosomal abnormalities

A2 Infection

I1 Congenital malformations, deformations and chromosomal abnormalities

I2 Birth trauma

N1 Congenital malformations, deformations and chromosomal abnormalities

N2 disorders related to fetal growth

N3 birth trauma

A3 Antepartum hypoxia

A4 Other specified antepartum disorder

I3 Acute intrapartum event

I4 Infection

I5 Other specified intrapartum disorder

N4 Complications of intrapartum events

N5 Convulsions and disorders of cerebral status

N6 Infection

N7 Respiratory and cardiovascular disorders

A5 Disorders related fetal growth

A6 Antepartum death of unspecified cause

I6 Disorders related to fetal growth

I7 Intrapartum death of unspecified cause

N8 Other neonatal conditions

N9 Low birthweight and prematurity

N10 Miscellaneous

N11 Neonatal death of unspecified cause

Maternal condition

M1 - Complications of placeta, cord and membranes
M2 - Maternal complications of pregnancy
M3 - Other complications of labour and delivery
M4- Maternal medical and surgical conditions
M5 - No maternal condition

Maternal conditions in ICD-PM and the main maternal conditions (defined by ICD-10) included in each group

ICD-PM maternal condition group -	Main maternal conditions included in group
M1:Complications of placenta, cord and membranes	1.Placenta praevia 2.Other forms of placental separation and haemorrhage 3.placental dysfunction, infarction, insufficiency 4. fetal–placental transfusion syndromes 5.prolapsed cord/other compression of umbilical cord 6.chorioamnionitis 7.Other complications of membranes
M2:Maternal complications of pregnancy	Incompetent cervix preterm rupture of membranes oligo/polyhydramnios ectopic pregnancy multiple pregnancy Maternal death Malpresentation before labour other complications of pregnancy
M3:Other complications of labour and delivery	1.Breech delivery and extraction 2.other malpresentation, malposition, and disproportion during labour and delivery 3. forceps delivery/vacuum extraction 4.caesarean delivery 5.Precipitate delivery 6.Preterm labour and delivery 7.Other complications of labour and delivery
M4:Maternal medical and surgical conditions	1.pre-eclampsia/eclampsia 2.Gestational hypertension 3.other hypertensive disorders 4. Renal and urinary tract diseases 5. Infectious and parasitic disease 6.circulatory and respiratory disease 7.nutritional disorders 8. injury 9. Surgical procedure 10.Other medical procedures 11.Maternal diabetes including gestational diabetes -6 12.Maternal anaesthesia and analgesia 13.Maternal medication 14. tobacco/alcohol /drugs of addiction 15.nutritional chemical substances 16.environmental chemical substances 17.Unspecified maternal condition
M5:No maternal condition	1.No maternal condition identified (healthy mother)

Maternal medical Condition
	M1 Complications of placenta, cord and membranes	M2 Maternal complications of pregnancy	M3 Other complications of labor and delivery	M4 Maternal medical and surgical conditions	M5 No maternal condition	Causes Total (%)
Causes of antepartum deaths	48-87.27%
A 1: Congenital malformations, deformations and chromosomal abnormalities					4	4- 7.27%
A 2: Infection				1		1 - 1.81%
A 3: Antepartum hypoxia	2	2	1	29		34- 61.81%
A 4: Other specified antepartum disorder		1		1		2 - 3.61%
A 5: Disorders related to foetal growth	7					7- 12.72%
A 6: Foetal death of unspecified cause

Causes of intrapartum death-7[12.72%]	M1 Complications of placenta, cord and membranes	M2 Maternal complications of pregnancy	M3 Other complications of labor and delivery	M4 Maternal medical and surgical conditions	M5 No maternal condition	Causes Total (%)
I 1: Congenital malformations, deformations and chromosomal abnormalities
I 2: Birth trauma						-
I 3: Acute intrapartum event	3	1	1	2		7- 12.72%
I 4: Infection						-
I 5: Other specified intrapartum disorder						-
I 6: Disorders related to foetal growth						-
I 7: Intrapartum death of unspecified cause						-
Unknown timing of death
total (%)	12 (21.83%]	4 (7.27%]	2 (3.63%)	33 (60%)	4 (7.27%]	55- (100%)

Results

There were 55 IUD’S in this year.
Majority of the mothers were in the age group of 20-25 years (50.9%).
45%were primigravida and 54.54% were second gravida.
8% had 3 or more antenatal visits.
54% were unbooked cases in GGH and are referred
Maternal conditions (pre-eclampsia, diabetes, pre-existing medical disorders) as a group were the cause of maximum number (18%) of IUD either directly or as a contributory risk factor.
27%% of the IUD occurred in the antepartum period. Ours being a referral centre, 94.54%subjects in the study were referred to us from other peripheral hospitals. 47.27% of the IUD babies were female, 52.72% of them were male.
45% were macerated and 34.54% were fresh IUD.
There were 14cases [45%] attributable to fetal causes.
Prematurity as a cause of IUD was seen in 42[76.36%]
4 IUDs had congenital abnormalities that were not compatible with life.
There was one case of fetal demise in twin pregnancy due to selective fetal growth
8 cases [54%] were attributable to placental, cord and liquor abnormalities .
In 1 [1.81%] case, no particular cause of IUD could be identified.

According to the ICD-PMclassification, among the maternal medical causes-hypertensive disease in pregnancy was the most common cause of IUD- 24[ 75% ] followed by gestational diabetes as it was seen in 6 mothers of IUD’S as the primary contributing factor- 18.75%.

CONCLUSION

Most IUDs in this study were due to maternal medical conditions, with hypertensive disorders being the most common cause.

To reduce IUFD cases:

Strengthen private healthcare regulations.
Equip peripheral health centers.
Implement an effective referral system.
Conduct regular facility-based reviews.
Ensure healthcare provider accountability.

Aiming for a single-digit stillbirth rate by 2030 is achievable with these intervention.

REFERENCES

Aminu M, Bar-Zeev S, White S, et al. Understanding cause of stillbirth: a prospective observational multi-country study from sub-Saharan Africa. BMC Pregnancy Childbirth. 2019;19:470.
Lawn JE, Blencowe H, Pattinson R, et al. Stillbirths: Where? When? Why? How to make the data count? Lancet. 2011;377(9775):1448–1463.
SRS Statistical Report 2013. Ministry of Home Affairs, Government of India.
Doke PP, Karantaki MV, Deshpande SR. Adverse pregnancy outcomes in rural Maharashtra, India (2008–09): a retrospective cohort study. BMC Public Health. 2012;12:543.
Lawn JE, Blencowe H, Waiswa P, et al. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 2016;387:587–603.
Blencowe H, Cousens S, Jassir FB, et al. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Lancet Glob Health. 2016;4:e98–e108.
Newtonraj A, Kaur M, Gupta M, et al. Level, causes, and risk factors of stillbirth: a population-based case-control study from Chandigarh, India. BMC Pregnancy Childbirth. 2017;17(1):371

European Journal of Cardiovascular Medicine

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