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POST DATED PREGNANCY AND INTRA-UTERINE FETAL DEATH (IUFD) Dr. Pradeep  Garg Assistant Professor  Department of Obstetrics ...
IUFD   <ul><li>Definition  –  </li></ul><ul><li>IUFD denotes death of fetus in utero. </li></ul><ul><li>Etiology: </li></u...
<ul><li>Foetal </li></ul><ul><li>Congenital malformation  </li></ul><ul><li>Rh-incompatibility  </li></ul><ul><li>Post mat...
Diagnosis <ul><li>Symptoms - Absence of foetal movements  </li></ul><ul><li>Signs -  Retrogression of the positive breast ...
<ul><li>Sonography :   </li></ul><ul><li>(a) Lack of all foetal motions (including cardiac) </li></ul><ul><li>(b) Oligohyd...
Lab evaluation <ul><li>Maternal  </li></ul><ul><li>FBS, Platelet count, ICT, Kleihaur-Betke test, </li></ul><ul><li>LAC, A...
Complications  <ul><li>Psychological upset </li></ul><ul><li>Infection: Once the membranes rupture, infection, especially ...
Pregnancy Management <ul><li>Single or multiple gestation </li></ul><ul><li>Gestational age at death </li></ul><ul><li>The...
Management  <ul><li>Explain the problem  to the woman and her family. Discuss with them the options of expectant or active...
<ul><li>If induction  of labour is planned, assess the cervix </li></ul><ul><ul><li>If the cervix is favourable (soft, thi...
ANTEPARTUM  FETAL SURVEILLANCE <ul><li>The goal of Antepartum fetal surveillance is to prevent fetal death  </li></ul><ul>...
MODALITIES OF ANTEPARTUM FETAL SURVEILLANCE <ul><li>Fetal movement count </li></ul><ul><li>Non-stress test  </li></ul><ul>...
Fetal Movement Assessment <ul><li>Screening  method of fetal surveillance in low risk pregnancy. </li></ul><ul><li>Sophist...
Non-stress test <ul><li>Indirect measurement of uteroplacental insufficiency function. </li></ul><ul><li>Based on the prem...
NST: How to do it <ul><li>Patient in lateral tilt position </li></ul><ul><li>Accelerations peak (but do not necessarily re...
Biophysical Profile <ul><li>Includes : Fetal breathing, tone, somatic movements, liquor and NST  </li></ul><ul><li><= 4/ 1...
Death of one fetus  <ul><li>Incidence around 6.2% (8.4% in monochorionic & 4.1% in dichorionic)  ( Saito et al 1999 ) </li...
Death of one fetus <ul><li>The  most difficult  cases </li></ul><ul><li>those in which the fetal demise occurs in 1 fetus ...
Death of one fetus <ul><li>Management  </li></ul><ul><li>There may not be any benefit in immediate delivery  </li></ul><ul...
Morbid pathology of IUFD <ul><li>A dead fetus  undergoes an aseptic destructive process called   maceration . The  epiderm...
Post dated pregnancy (prolonged pregnancy, post term pregnancy,post maturity) <ul><li>Definition :  A prolonged pregnancy ...
Diagnosis  <ul><li>Record of the dates of the  LMP </li></ul><ul><li>Definitely known  date of ovulation , data based on b...
Diagnosis (contd…) <ul><li>A  sonographic scan  between the 10 and 12 weeks gives the assessment of gestational maturity w...
Dangers  <ul><ul><ul><li>Foetal: </li></ul></ul></ul><ul><ul><ul><li>During pregnancy :  Foetal hypoxia due to placental a...
<ul><li>Whenever possible, gestational age should be established by a first or an early second-trimester ultrasound examin...
<ul><li>Initiate semiweekly fetal testing (nonstress test and AFI at 41 weeks gestation). </li></ul><ul><li>Conservative m...
To see videos on laparoscopic gynae surgeries  please logon to   www .youtube.com   and type Pradeep aiims
<ul><li>For  queries mail me at </li></ul><ul><li>pkgarg_in2004@yahoo.com  </li></ul>
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POST DATED PREGNANCY AND INTRA-UTERINE FETAL DEATH (IUFD

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Transcript of "POST DATED PREGNANCY AND INTRA-UTERINE FETAL DEATH (IUFD"

  1. 1. POST DATED PREGNANCY AND INTRA-UTERINE FETAL DEATH (IUFD) Dr. Pradeep Garg Assistant Professor Department of Obstetrics and Gynaecology AIIMS, New Delhi
  2. 2. IUFD <ul><li>Definition – </li></ul><ul><li>IUFD denotes death of fetus in utero. </li></ul><ul><li>Etiology: </li></ul><ul><li>Pregnancy complications: </li></ul><ul><li>Pre-eclamptic toxaemia </li></ul><ul><li>Antepartum haemorrhage : placenta praevia, abruptio placentae </li></ul><ul><li>Pre- existing medical disease and acute illness </li></ul><ul><li>Chronic hypertension </li></ul><ul><li>Chronic nephritis </li></ul><ul><li>Diabetes </li></ul><ul><li>Severe anaemia </li></ul><ul><li>Hyperpyrexia </li></ul><ul><li>Syphilis, Hepatitis, toxoplasmosis etc. </li></ul>
  3. 3. <ul><li>Foetal </li></ul><ul><li>Congenital malformation </li></ul><ul><li>Rh-incompatibility </li></ul><ul><li>Post maturity </li></ul><ul><li>External version </li></ul><ul><li>Idiopathic 20 –30% </li></ul>IUFD (contd…)
  4. 4. Diagnosis <ul><li>Symptoms - Absence of foetal movements </li></ul><ul><li>Signs - Retrogression of the positive breast changes. </li></ul><ul><li>Per-abdomen- </li></ul><ul><li>Gradual retrogression of the height of the uterus </li></ul><ul><li>Uterine tone is diminished </li></ul><ul><li>Foetal movement are not felt during palpation. </li></ul><ul><li>Foetal heart sound is not audible </li></ul><ul><li>Investigations- </li></ul><ul><li>Straight- X-ray abdomen </li></ul><ul><li>Spalding sign: it usually appears 7 days after I.U.F.D. </li></ul><ul><li>Hyperflexion of the spine </li></ul><ul><li>Crowding of the ribs shadow </li></ul><ul><li>Appearance of gas shadow (Robert’s sign) : 12 hours </li></ul>
  5. 5. <ul><li>Sonography : </li></ul><ul><li>(a) Lack of all foetal motions (including cardiac) </li></ul><ul><li>(b) Oligohydramnios and collapsed cranial bones </li></ul><ul><li>Haematological examination: Rh-typing, VDRL, Blood sugar and urea </li></ul><ul><li>Postmortem studies </li></ul><ul><li>Cytogenetic study: In cases of congenital malformation of IUGR </li></ul>Diagnosis (contd…)
  6. 6. Lab evaluation <ul><li>Maternal </li></ul><ul><li>FBS, Platelet count, ICT, Kleihaur-Betke test, </li></ul><ul><li>LAC, ACL, </li></ul><ul><li>Fetal karyotype </li></ul><ul><li>Thrombophilia workup </li></ul><ul><li>PCR of fetal product for viral infectin </li></ul><ul><li>Amniotc fluid culture </li></ul><ul><li>Weekly fibrinogen </li></ul><ul><li>Fetal </li></ul><ul><li>karyotype </li></ul><ul><li>Postmortom examination </li></ul><ul><li>Fetogram </li></ul>
  7. 7. Complications <ul><li>Psychological upset </li></ul><ul><li>Infection: Once the membranes rupture, infection, especially by gas forming organism like CI. Welchi. </li></ul><ul><li>Blood coagulation disorders </li></ul><ul><li>During labour : Uterine inertia and PPH </li></ul><ul><li>Prevention of IUFD: </li></ul><ul><li>- Regular antenatal care </li></ul><ul><li>- 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. </li></ul>
  8. 8. Pregnancy Management <ul><li>Single or multiple gestation </li></ul><ul><li>Gestational age at death </li></ul><ul><li>The parents wish </li></ul>
  9. 9. Management <ul><li>Explain the problem to the woman and her family. Discuss with them the options of expectant or active management. </li></ul><ul><li>If expectant management is planned: </li></ul><ul><ul><li>Await spontaneous onset of labour during the next four weeks </li></ul></ul><ul><ul><li>Reassure the woman that in 90% of cases the fetus is spontaneously expelled during the waiting period with no complicatons. </li></ul></ul><ul><li>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) </li></ul>
  10. 10. <ul><li>If induction of labour is planned, assess the cervix </li></ul><ul><ul><li>If the cervix is favourable (soft, thin, partly dilated) labour using oxytocin. </li></ul></ul><ul><ul><li>If the cervix is unfavourable(firm, thick, closed) ripen the cervix. </li></ul></ul><ul><li>Note: Do not rupture the membranes. </li></ul><ul><li>If spontaneous labor does not occur within four weeks, platelets are decreasing and the cervix is unfavourable, ripen the cervix. </li></ul>Management (contd…)
  11. 11. ANTEPARTUM FETAL SURVEILLANCE <ul><li>The goal of Antepartum fetal surveillance is to prevent fetal death </li></ul><ul><li>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. </li></ul>
  12. 12. MODALITIES OF ANTEPARTUM FETAL SURVEILLANCE <ul><li>Fetal movement count </li></ul><ul><li>Non-stress test </li></ul><ul><li>Contraction stress test </li></ul><ul><li>Biophysical profile </li></ul><ul><li>Ultrasound doppler </li></ul>
  13. 13. Fetal Movement Assessment <ul><li>Screening method of fetal surveillance in low risk pregnancy. </li></ul><ul><li>Sophisticated fetal monitoring test are applied to only 10%-20% of obstetrics population. </li></ul><ul><li>Inexpensive & non-invasive </li></ul><ul><li>Most attractive & simple method is “ count to 10 ” technique. </li></ul>
  14. 14. Non-stress test <ul><li>Indirect measurement of uteroplacental insufficiency function. </li></ul><ul><li>Based on the premise that heart rate of the fetus that is not acidotic or neurologically depressed will accelerate with fetal movement. </li></ul><ul><li>Good indicator of normal fetal autonomic function </li></ul>
  15. 15. NST: How to do it <ul><li>Patient in lateral tilt position </li></ul><ul><li>Accelerations peak (but do not necessarily remain) at least 15 BPM above baseline </li></ul><ul><li>Last for 15 seconds </li></ul><ul><li>Reactive: 2 or more accelerations within 20 m period </li></ul><ul><li>Nonreactive: one that lacks sufficient accelerations </li></ul><ul><li>No contraindications </li></ul>
  16. 16. Biophysical Profile <ul><li>Includes : Fetal breathing, tone, somatic movements, liquor and NST </li></ul><ul><li><= 4/ 10  deliver </li></ul><ul><li>6/ 10  repeat test within 4-6 hours </li></ul><ul><ul><li>still 6 / 10  deliver </li></ul></ul><ul><ul><li>> 8 / 10  surveillance </li></ul></ul><ul><li>>= 8 / 10  surveillance </li></ul>
  17. 17. Death of one fetus <ul><li>Incidence around 6.2% (8.4% in monochorionic & 4.1% in dichorionic) ( Saito et al 1999 ) </li></ul><ul><li>Same sex twin are at highest risk </li></ul><ul><li>Fetal loss cause </li></ul><ul><li>1st-trimester losses : not determined </li></ul><ul><li>the later losses : twin-twin transfusion syndrome, severe IUGR, placental insufficiency, placental abruption </li></ul><ul><li>Fetal monitoring protocol: not predict most of these losses </li></ul>
  18. 18. Death of one fetus <ul><li>The most difficult cases </li></ul><ul><li>those in which the fetal demise occurs in 1 fetus of a </li></ul><ul><li>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 </li></ul><ul><li>phenomena that occurs later. </li></ul>
  19. 19. Death of one fetus <ul><li>Management </li></ul><ul><li>There may not be any benefit in immediate delivery </li></ul><ul><li>(esp. if the surviving fetuses are very preterm and other wise healthy) </li></ul><ul><li>-> pregnancy to continue may provide the most benefit. </li></ul><ul><li>DIC (disseminated intravascular coagulopathy) remains a theoretical risk, rarely occurs </li></ul><ul><li>-> Fibrinogen and fibrin degradation product levels can be </li></ul><ul><li>monitored serially until delivery and delivery can be </li></ul><ul><li>expedited if DIC develops </li></ul>
  20. 20. Morbid pathology of IUFD <ul><li>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. </li></ul>
  21. 21. Post dated pregnancy (prolonged pregnancy, post term pregnancy,post maturity) <ul><li>Definition : A prolonged pregnancy is 42 completed weeks of gestation. </li></ul><ul><li>Incidence : 4-19% of pregnancy reach or exceed 42 weeks </li></ul><ul><li>Etiology : </li></ul><ul><li>Maternal: </li></ul><ul><li>Heredity </li></ul><ul><li>High standard of living with sedentary habit </li></ul><ul><li>Elderly primigravida </li></ul><ul><li>Previous history of prolonged pregnancy (50% cases) </li></ul><ul><li>Fetal: </li></ul><ul><li>- Anencephaly </li></ul><ul><li>Placental </li></ul><ul><li>- Sulphatase deficiency </li></ul>
  22. 22. Diagnosis <ul><li>Record of the dates of the LMP </li></ul><ul><li>Definitely known date of ovulation , data based on basal body temperature (BBT) charts or sonographic dating . </li></ul><ul><li>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. </li></ul>
  23. 23. Diagnosis (contd…) <ul><li>A sonographic scan between the 10 and 12 weeks gives the assessment of gestational maturity with +/- range of 7 days. </li></ul><ul><li>Quickening </li></ul><ul><li>Fundal height at 28 weeks of gestation usually corresponds to 28 cm. </li></ul><ul><li>In case of discrepancy between the menstrual dates and clinical findings, and early sonographic scan should help in assessing gestational maturity. </li></ul>
  24. 24. Dangers <ul><ul><ul><li>Foetal: </li></ul></ul></ul><ul><ul><ul><li>During pregnancy : Foetal hypoxia due to placental aging. </li></ul></ul></ul><ul><ul><ul><li>During labour : Asphyxia and intracranial damage due to: </li></ul></ul></ul><ul><ul><ul><li>Pre-existing hypoxia </li></ul></ul></ul><ul><ul><ul><li>Increased incidence of difficult labour: Big size baby non moulding of head </li></ul></ul></ul><ul><ul><ul><li>Increase incidence of operative delivery </li></ul></ul></ul><ul><ul><ul><li>Scanty liquor amnii and less Wharton’s jelly in the cord favour cord compression. </li></ul></ul></ul><ul><ul><ul><li>Following birth: </li></ul></ul></ul><ul><ul><ul><li>Meconium aspiration syndrome </li></ul></ul></ul><ul><ul><ul><li>Maternal </li></ul></ul></ul><ul><li>Management : Expectant (fetal surveillance ) versus active management </li></ul>
  25. 25. <ul><li>Whenever possible, gestational age should be established by a first or an early second-trimester ultrasound examination. </li></ul><ul><li>Sweeping of the membranes at term decreased slightly the number of pregnancies reaching 40+ weeks gestation. </li></ul><ul><li>Consider induction of labor at or beyond 41 weeks gestation in patients with a favourable cervix </li></ul>Key points to remember
  26. 26. <ul><li>Initiate semiweekly fetal testing (nonstress test and AFI at 41 weeks gestation). </li></ul><ul><li>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. </li></ul><ul><li>Perinatal morbidity and mortality are significantly increased when gestational age at birth is 41 weeks or more. </li></ul>Key points to remember (contd…)
  27. 27. To see videos on laparoscopic gynae surgeries please logon to www .youtube.com and type Pradeep aiims
  28. 28. <ul><li>For queries mail me at </li></ul><ul><li>pkgarg_in2004@yahoo.com </li></ul>
  29. 29. Thank you
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