Signs - Retrogression of the positive breast changes.
Gradual retrogression of the height of the uterus
Uterine tone is diminished
Foetal movement are not felt during palpation.
Foetal heart sound is not audible
Straight- X-ray abdomen
Spalding sign: it usually appears 7 days after I.U.F.D.
Hyperflexion of the spine
Crowding of the ribs shadow
Appearance of gas shadow (Robert’s sign) : 12 hours
(a) Lack of all foetal motions (including cardiac)
(b) Oligohydramnios and collapsed cranial bones
Haematological examination: Rh-typing, VDRL, Blood sugar and urea
Cytogenetic study: In cases of congenital malformation of IUGR
FBS, Platelet count, ICT, Kleihaur-Betke test,
PCR of fetal product for viral infectin
Amniotc fluid culture
Infection: Once the membranes rupture, infection, especially by gas forming organism like CI. Welchi.
Blood coagulation disorders
During labour : Uterine inertia and PPH
Prevention of IUFD:
- Regular antenatal care
- To screen out the at-risk patients to monitor carefully for the assessment of foetal well being and to terminate the pregnancy at the earliest evidences of foetal compromise.
Single or multiple gestation
Gestational age at death
The parents wish
Explain the problem to the woman and her family. Discuss with them the options of expectant or active management.
If expectant management is planned:
Await spontaneous onset of labour during the next four weeks
Reassure the woman that in 90% of cases the fetus is spontaneously expelled during the waiting period with no complicatons.
If platelets are decreasing , four weeks have passed without spontaneous labour, fibrinogen levels are low or the woman request it,consider active management (induction of labour)
If induction of labour is planned, assess the cervix
If the cervix is favourable (soft, thin, partly dilated) labour using oxytocin.
If the cervix is unfavourable(firm, thick, closed) ripen the cervix.
Note: Do not rupture the membranes.
If spontaneous labor does not occur within four weeks, platelets are decreasing and the cervix is unfavourable, ripen the cervix.
ANTEPARTUM FETAL SURVEILLANCE
The goal of Antepartum fetal surveillance is to prevent fetal death
Antepartum fetal surveillance are routinely use to assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions as well as those in which complication have developed.
MODALITIES OF ANTEPARTUM FETAL SURVEILLANCE
Fetal movement count
Contraction stress test
Fetal Movement Assessment
Screening method of fetal surveillance in low risk pregnancy.
Sophisticated fetal monitoring test are applied to only 10%-20% of obstetrics population.
Inexpensive & non-invasive
Most attractive & simple method is “ count to 10 ” technique.
Indirect measurement of uteroplacental insufficiency function.
Based on the premise that heart rate of the fetus that is not acidotic or neurologically depressed will accelerate with fetal movement.
Good indicator of normal fetal autonomic function
NST: How to do it
Patient in lateral tilt position
Accelerations peak (but do not necessarily remain) at least 15 BPM above baseline
Last for 15 seconds
Reactive: 2 or more accelerations within 20 m period
Nonreactive: one that lacks sufficient accelerations
Includes : Fetal breathing, tone, somatic movements, liquor and NST
<= 4/ 10 deliver
6/ 10 repeat test within 4-6 hours
still 6 / 10 deliver
> 8 / 10 surveillance
>= 8 / 10 surveillance
Death of one fetus
Incidence around 6.2% (8.4% in monochorionic & 4.1% in dichorionic) ( Saito et al 1999 )
Same sex twin are at highest risk
Fetal loss cause
1st-trimester losses : not determined
the later losses : twin-twin transfusion syndrome, severe IUGR, placental insufficiency, placental abruption
Fetal monitoring protocol: not predict most of these losses
Death of one fetus
The most difficult cases
those in which the fetal demise occurs in 1 fetus of a
monochorionic twin pair monochorionic placentas contain vascular anastomoses that link the circulations of the 2fetuses the surviving fetus is at significant risk of sustaining damage caused by the sudden , severe and prolonged hypotension that occurs at the time of the demise or by embolic
phenomena that occurs later.
Death of one fetus
There may not be any benefit in immediate delivery
(esp. if the surviving fetuses are very preterm and other wise healthy)
-> pregnancy to continue may provide the most benefit.
DIC (disseminated intravascular coagulopathy) remains a theoretical risk, rarely occurs
-> Fibrinogen and fibrin degradation product levels can be
monitored serially until delivery and delivery can be
expedited if DIC develops
Morbid pathology of IUFD
A dead fetus undergoes an aseptic destructive process called maceration . The epiderm is the first structure to undergo the process, whereby blistering and peeling off of the skin occur. It appears between 12-24 hours after death. The foetus becomes swollen and looks dusky red. Gradually aseptic autolysis of the ligamentous structure and liquefaction of the brain matter and other viscera take place.
Post dated pregnancy (prolonged pregnancy, post term pregnancy,post maturity)
Definition : A prolonged pregnancy is 42 completed weeks of gestation.
Incidence : 4-19% of pregnancy reach or exceed 42 weeks
High standard of living with sedentary habit
Previous history of prolonged pregnancy (50% cases)
- Sulphatase deficiency
Record of the dates of the LMP
Definitely known date of ovulation , data based on basal body temperature (BBT) charts or sonographic dating .
A reliable clinical assessment of gestational size in the first trimester. This data may be fallacious in obese women, uncooprative patients, women with fibroids in the uterus or when a satisfactory pelvic examination has not been possible.
A sonographic scan between the 10 and 12 weeks gives the assessment of gestational maturity with +/- range of 7 days.
Fundal height at 28 weeks of gestation usually corresponds to 28 cm.
In case of discrepancy between the menstrual dates and clinical findings, and early sonographic scan should help in assessing gestational maturity.
During pregnancy : Foetal hypoxia due to placental aging.
During labour : Asphyxia and intracranial damage due to:
Increased incidence of difficult labour: Big size baby non moulding of head
Increase incidence of operative delivery
Scanty liquor amnii and less Wharton’s jelly in the cord favour cord compression.
Meconium aspiration syndrome
Management : Expectant (fetal surveillance ) versus active management
Whenever possible, gestational age should be established by a first or an early second-trimester ultrasound examination.
Sweeping of the membranes at term decreased slightly the number of pregnancies reaching 40+ weeks gestation.
Consider induction of labor at or beyond 41 weeks gestation in patients with a favourable cervix
Key points to remember
Initiate semiweekly fetal testing (nonstress test and AFI at 41 weeks gestation).
Conservative management (I.e. semiweekly, fetal testing) or active management (I.e induction of labor) are equally reasonable options for patients with an unfavourable cervix.
Perinatal morbidity and mortality are significantly increased when gestational age at birth is 41 weeks or more.
Key points to remember (contd…)
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