4. Patient has not perceived any fetal movements since
02 days
No c/o Pain in abdomen, Discharge per vaginum ,
Bleeding PV
No H/o Trauma, Fever, Intercourse
No history on any other comorbidity
7. 1st Trimester:
Spontaneous conception
Detected on UPT and
confirmed on USG /Booked
at MH Bhopal
No history of exposure to
radiations or any
teratogenic drugs/Drug
abuse
No h/o Hospitalisation
8. Investigations USG Treatment
Hb- 11.7 gm%
Patient’s Blood group: O Positive
Husbands Blood group- O Positive
Sr. TSH- 2.79 μIU/ml
BSL- F- 93 / PP- 118 mg/dl
DIPSI/ OGTT not done
HIV – Non Reactive
VDRL/ AntiHCV/ HBsAg- Negative
Urine Routine- WNL
NT NB Scan(5/5/21)
GA by LMP- 12 wk 05 days
SLIUF
NT- 1.1mm
NB- seen
USMA=12 weeks 3 days
Dual Marker – Low Risk
Tab.Folic Acid 5 mg x OD
9. On regular follow up at MH Bhopal and later Khadakwasla
First visit at CHSC on 19/6/ 21 at 19 weeks 03 days POG
Immunised with Inj DT 0.5 ml x 2 doses
Quickening @ 20 weeks
No history of pain abdomen / bleeding PV / leaking PV
No history of hospitalisation
10. Investigations USG Treatment
Hb- 11.2 gm%
Platelet- 2.3 lakh
OGTT- 87 /123/72 mg/dl
(24/7/21 / 24 wks 03 days)
ANOMALY SCAN(19/6/21)
GA by LMP- 19 weeks 03 days
• SLIUF
• Placenta- Ant/NP
• EFW- 314 GM
• AFI – Adequate
• USMA- 19 week 04 days
• No Gross Anomalies
Tab Iron BD
Tab Calcium OD
Tab FA 5mg OD
11. On regular follow up
3 Visits in 3rd trimester @
27 weeks/ 30 weeks/ 34 weeks at
Khadakwasla
Received 2nd dose of covid vaccine on 1 oct
21 at 34 weeks 2 days POG– post
which developed URTI
Continued on Iron and Calcium tablets
LEVEL III SCAN
(32 weeks)(18/9/21)
SLIUF
Longitudinal Lie
Cephalic Presentation
Cervical Length- 3.7 cm
AFI- 15 cm
UASD- 2.3
EFW-2.0 KG
USMA- 32 weeks 04 days
15. Average built & well nourished
Height: 160 cm, Wt: 72kg (Pre pregnancy Wt: 62 kg) BMI-24.21
PR: 82/min Regular, Normal Volume
BP: 116/82 mm Hg – Rt arm, sitting position
Pallor present/ No icterus/ edema/ cyanosis/ clubbing/ lymphadenopathy/ raised JVP
Thyroid examination: Normal, no thyromegaly
Breast Examination: Normal
16. Respiratory System:
Bilaterally equal breath sounds, No adventitious sounds
Cardiovascular System:
S1 & S2 Normal, No diastolic murmurs heard
Central Nervous System:
HMF – Normal
16
18. • Soft, Non tender
• Uterus relaxed and 36 weeks gravid size
• Longitudinal lie and cephalic presentation of the fetus
• SFH- 30 cm EFW- 2945 gm
• Foetal Heart Sounds NOT HEARD ON AUSCULTATION
PALPATION &
AUSCULTATION
19. Single Intrauterine Fetus
Cephalic Presentation
AFI – 12 cm /EFW – 2594 gms
Placenta on fundal wall
Umbilical cord – 3 vessels/ Normal cord
insertion
Cervical length – 3.5 cm/OS closed
FL/AC-21.63 – FL/BPD- 80.89
GA by LMP- 36 weeks 03 days
GA by USG – 34 weeks 04 days
NO FCA
Impression-
INTRAUTERINE FETAL
DEMISE
20. PRIMIGRAVIDA AT 36 WEEKS 03 DAYS POG
WITH NO COMORBIDITIES
WITH INTRAUTERINE FETAL DEMISE
IN LONGITUDINAL LIE CEPHALIC PRESENTATION
NOT IN LABOUR
21. Investigations- CBC / PTINR / Blood sugars/Urine R/M Examination
LFT with enzymes & RFT with electrolytes/Maternal
D-Dimer / FDP / Sr Fibrinogen
PAC for Epidural Analgesia
Pre induction cervical ripening -F/b Induction of labour
Foetal evaluation- Gross examination/ Autopsy / Chromosomal Study/Placental
histopathology
Maternal Evaluation - ACLA/APLA/ OGTT / Thyroid profile
23. Tab Mifepristone 200 mg
P/O given at 2200 hrs on
16/10/21
4 doses of Tab Misoprostol
25 mcg given on 18/10/21
• PV at 0000 hrs /0600 hrs
• PO at 1200 hrs / 1800 hrs
24. 1930 hrs/18 Oct 21 2200 hrs/18 oct 21 0430hr/ 19 Oct 21
Symptoms No complains of pain
abdomen/leaking pv/Bleeding pv
No complains Intermittent pain abdomen
since 2300 hrs on 18/10/21
Per Abdomen Uterus- 36 wk size/Relaxed
Longitudinal lie,Cephalic
presentation
Do- Do-
FHS ABSENT ABSENT ABSENT
P/V Cervix – Soft consistency/
Posterior in location/ 1.5 cm
dilated /Minimally effaced/ HS (-
3) /Membranes present
BISHOP’S SCORE-(3/13)
Pelvis seems adequate
Do- Cervix – Soft consistency/
Posterior in location/ 2 cm
dilated /Minimally effaced/
HS (-3) /Membranes present
BISHOP’S SCORE-(3/13)
Intervention Plan intracervical cerviprime gel
application
1st Cerviprime applied
intracervically
2nd Cerviprime applied
intracervically
25. 1030 hrs/19 oct 21
(under epidural analgesia)
1900 hrs/19 oct 21
(under epidural analgesia)
0600 hrs 20 oct 21
(under epidural analgesia)
Symptoms Intermittent pain abdomen
with increasing intensity
No complains Mild pain on and off
Per Abdomen Uterus- 36 wk size/Relaxed
Longitudinal lie,Cephalic
presentation
Uterus- 36 wk size/Relaxed
Longitudinal lie,Cephalic presentation
Soft , non tender,Uterus-
36 wk size/Relaxed
Longitudinal lie,Cephalic
presentation
FHS ABSENT ABSENT ABSENT
PV Cervix – Soft consistency/
Mid position/ 4 cm dilated
/40-50% effaced/ HS (-2)
/Membranes present
BISHOP’S SCORE-(7/13)
Cervix – Soft consistency/ Mid position/ 4 cm dilated
/40-50% effaced/ HS (-2) /Membranes present
BISHOP’S SCORE-(7/13)
Cervix – Soft consistency/
Mid position/ 4 cm dilated
/40-50% effaced/ HS (-2)
/Membranes present
BISHOP’S SCORE-(7/13)
Intervention Pitocin augmentation as per
high dose flexible regimen
started and the max dose was
reached at 1410 hrs (10.8
ml/hr ) – continued till 1800
hrs
Plan- Stop Pitocin and to shift back the patient to
ward
Restart Pitocin at 0600 hrs on 20/0ct/21
Pitocin augmentation as
per high dose flexible
regimen restarted at 0600
hrs (SRM @1215 Hrs-Less
liquor with thin MSL) and
continued till delivery of
the stillborn at 1419 hrs on
20 oct 21
26. (under epidural analgesia)
A Macerated stillborn was delivered
At 1419 hrs on 20/oct /21
After an induced labour with T Mifi 200 mg P/O + T. Misoprostol 25 ug PV * 4 tablets 6 hours apart F/b
Pitocin augmentation with high dose flexible regimen (over 48-72 hrs)
SRM – Less liquor - meconium stained
RMLE given and sutured in layers/ No other perineal tears occurred
A Macerated Male stillborn weighing 2.676 kgs was delivered
Placenta delivered at 1430 hrs in toto with membranes –Weighed 386 gms
Approx blood loss-300ml -No PPH- Uterus was well contracted post partum
27. No gross anomalies noted
Foetus weighed 2.67 kg – No FGR
noted
Rectum was patent-Meconium already
passed
Skin was macerated all over the
body/No rigor mortis noted- indicating
time of death more than 24 hrs
28. Placenta appeared normal
but was meconium stained
Weighed 380 gm
No abruption noted
Umbilical cord measured
35 cm was oedematous
All three vessels visualised
NO true or false knots seen
Cord was centrally attached
No missing cotyledons
31. ROUTINE UNEVENTFUL ANTENATAL PERIOD WITH REGULAR FOLLOW UPS
NO KNOWN RISK FACTOR/COMORBIDITIES
ONLY COMPLAINS OF ABSENT FETAL MOVEMENTS SINCE 2 DAYS /NO OTHER COMPLAINT LIKE PAIN
ABDOMEN/BLEEDING PV/LEAKING PV/DISCHARGE PV/FEVER
HISTORY THAT WAS DEVIATING FROM A ROUTINE ANTENATAL PERIOD WAS COVID VACCINATION 2 WEEKS
PRIOR TO IUFD(?)
LIQOUR WAS LESS WITH MECONIUM STAIN- INDICATING DISTRESS TO THE FETUS
POST DELIVERY- FETUS SHOWS NO ANOMALIES ON POSTMORTEM-
PERITONEAL FLUID CULTURES ISOLATED KLEIBSELLA PNEUMONIAE
PLACENTAL HPE SUGGESTIVE OF ACUTE CHORIOAMNIONITIS!
33. Stillbirth is one of the most common adverse outcome
occurring in 7.5 per 1000 births in the US and 35 per
1000 births in India
There are multiple attributable risk factors some of which
are modifiable but many are not
The study of specific cause of stillbirth has been
hampered by lack of uniform protocols to evaluate and
classify stillbirth and also due to decreasing autopsy rates
However, a significant proportion of stillbirth remain
unexplained even after thorough evaluation
34. It aids in maternal coping
Helps assuage any perceived guilt by the parents /even
doctors
Permits more accurate counselling regarding a recurrent
risk
Evaluation may prompt therapy or intervention to
prevent similar outcome in subsequent pregnancy
Identification of inherited syndromes provides useful
information for other family members
35. Death prior to complete expulsion
or extraction from mother of a
product of human conception
irrespective of duration of
pregnancy and which is not an
induced termination of pregnancy
Delivery of fetus showing no signs
of life -Absence of breathing,
heart beat, umbilical cord
pulsations, definitive voluntary
movements
Ref: Accepted definition by CDC based on WHO recommendations(2020)
36. Advanced maternal age > 35 yrs – most have lethal congenital anomalies
African-American Race- 2 times higher risk
Smoking/Illicit drug use-Maternal cocaine/Methamphitamine/Tobacco
Maternal medical diseases-Obesity/GDM/Chr HTN/acquired thrombophilias
Assisted reproductive technology
Nulliparity /Pregnancy in unmarried
Obesity
Prior adverse pregnancy outcome –Preterm births/FGR
41. Gross examination post
delivery-
Weight of the fetus
Head circumference
Length of fetus
Pictures of the fetus- All profiles of face and
body and focused pictures of limbs and face
42. Cytogenetic studies and Autopsy should be sent
only after written informed consent from the
parents
43. • Cord blood /Intracardiac blood taken after delivery
• Sent for cytogenetic studies/ Bacterial cultures/TORCH
Serology
44. Amniotic fluid obtained by amniocentesis at the time of prenatal
diagnosis of demise
Placental block measuring about 1x1 cm taken
below cord insertion site in unfixed specimen
Umbilical cord segment approximately 1.5 cm long
Internal Fetal Tissue specimen such as
costochondral junction or patella(skin not
recommended)
Other acceptable specimens:
45. Specimens are
placed in sterile
tissue culture
medium of
Ringer’s Lactate
and keep at room
temperature
when transported
to Laboratory
46. ACOG previously recommended
KAROTYPING of all stillbirths
But now, recommends High
resolution ,whole genome
sequencing
CHROMOSOMAL MICROARRAY
ANALYSIS- It doesn’t require
dividing cells and is therefore
more useful in fetal death
evaluation
47. Parents are offered
and encouraged to
allow a full autopsy
so that a cause of
death can be
assigned and parents
can be offered
counselling regarding
the cause of death
Gross external examination
combined with
Photography
Radiology-X-ray whole body
MR imaging
Bacterial cultures
Selective use of
chromosomal and
histopathological studies
48. Maternal blood is obtained to test for:
Kleihauer-Betke test
factor V Leiden mutation, prothrombin mutation, antithrombin
levels & protein C and S activity
Routine testing of Inherited thrombophilia's is not recommended
Ref: ACOG
53. Tendency of prolongation of
pregnancy beyond 2 weeks
Wish of the patient due to
psychological upset
Falling fibrinogen level-
(correct by transfusion before
interference)
Onset of uterine infection
54. ARM Contraindicated (risk of infection)
BISHOPS< 6 (I) PGE2 – Gel 6 hourly* 3 doses
(II) MISOPROSTOL
BISHOPS> 6 Oxytocin
Caesarean Only if obstetric indication/Emergency
Post LSCS for induction 1.Misoprostol can be safely used for- single
previous LSCS and an IUFD but with lower
doses
2. Women with two previous LSCS -absolute
risk is only a little higher
3. More than two LSCS deliveries or atypical
scars -safety of induction of labour is unknown.
56. Preconceptional or Initial Prenatal Visit
Detailed medical and obstetrical history
Review evaluation of prior stillbirth
Determination of recurrence risk
Discuss recurrence of comorbid obstetric complications
Smoking cessation
Preconceptional weight loss in obese women
Genetic counseling if family genetic condition exists
Diabetes screen
Thrombophilia screen: antiphospholipid antibodies (only if history indicates)
Support and reassurance
57. First Trimester
Dating sonography
First-trimester screen: pregnancy-associated plasma protein A,
human chorionic gonadotropin, and nuchal translucency (provides
risk assessment but doesn’t alter treatment)
Support and reassurance
58. Second Trimester
Fetal sonographic anatomical survey at 18–20 weeks’ gestation
Maternal serum screening (quadruple) or single-marker alpha fetoprotein if
first-trimester screening elected
Possible uterine artery Doppler studies at 22–24 weeks’ gestation
Support and reassurance
59. Third Trimester
Sonographic screening for fetal-growth restriction, starting at 28 weeks
Kick counts starting at 28 weeks
Antepartum foetal surveillance starting at 32 weeks or 1–2 weeks earlier than
prior stillbirth
Support and reassurance
60. Delivery
Elective induction at 39 weeks
Delivery before 39 weeks only with documented fetal lung maturity by
amniocentesis
61.
62. CRP/ Bile acids/HbA1c/TFT/ ?Kliehauer betke test(RCOG recommends for all)
Repeat Viral markers – HIV/HbsAg/Anti HCV/VDRL
Cultures-
Blood c/s , Urine c/s, Vaginal swab c/s
Endocervical swab for c/s , Amniotic fluid for c/s
Amniocentesis- for cytogenetic and also bacterial cultures and
? TORCH infections
Post delivery – Amniotic membrane under surface swab for c/s even in the
absence of rupture of membranes
Maternal evaluation after 6 weeks for acquired thrombophilias
