Dead fetus syndrome (DFS) in 2017 - a no more existing entity ? From individual patients to pathophysiological insights

F. Bergmann1, A. Czwalinna2, H. Groening1, R. Schwerdfeger1, R. Schild1, U. Budde2 (1Hannover, Germany, 2Hamburg, Germany)

Women issues in thrombosis and hemostasis
Date: 17.02.2017,
Time: 17:15 - 18:15

Objective: Multifetal pregnancy reduction and selective termination increased dramatically after widespread use of assisted reproductive technology. Usually the procedure is performed early in pregnancy – however we report on a case, in which the procedure (cord-occlusion) had to be performed in gestational week 22 to rescue one twin. The second twin had had developed severe hydrops fetalis due to a complex congenital heart defect. However, no information is published regarding a rare, very high risk pregnancy with monochoriotic-diamnotic twins in case of DFS. Those twins share the same placenta, therefore necrotic fetal tissue will be washed into the second twin and the mother, continuously.

Methods: In case of DFS: Established recommendations are to check platelet count, fibrinogen, antithrombin to detect DIC.If levels are changing to remove the dead fetus immediately from the mother to avoid the so called dead fetus syndrome (DFS): the retention will cause low grade DIC with fibrinogen <1.5 g/l, platelet count <100/nl. DIC is anticipated when the dead fetus remains more than 5 weeks in utero. Nowadays an extremely rare complication which is usually avoided by early detection and intervention. It is caused by washed in necrotic fetal tissue into maternal circulation and induction of inflammatory cytokines.

Results: In gestational week 26 we were asked by the obstetricians to recommend screening tests to detect possible DIC/DFS in the woman described (see tab.1). Unfortunately worsening of lab data challenged us to discuss an intervention. Reading older recommendation the obstetrician and the coagulation specialists were afraid of what might happen. We assumed low grade DIC and decided to start low dose heparin. At 34 weeks coagulation tests normalized. The surviving twin developed normally, regular uterine artery perfusion and mother’s health remained stabile. At 37 week elective c-section was performed.

Conclusion: In Germany there is no longer enough experience with coagulation abnormalities resulting from DFS. Even in our practice we have not seen a single case for more than 20 years! Due to the further uneventful course of the pregnancy, we decided from week to week not to treat dramatic “lab results”. In retrospect, the observational approach in such a rare case was correct. It is necessary to collect again experience on DFS in 2017 when a high risk pregnancy benefits from modern technology.