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Intrauterine Fetal Death (IUFD) -EBM.pdf

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Intrauterine Fetal Death (IUFD) -EBM.pdf

  1. 1. INTRAUTERINE FETAL DEATH (IUFD) 1 LMO EMMANUEL MUSONDA. Bsc.CS 17-May-21
  2. 2. DEFINTION • IUFD REFERS TO THE DEATH OF THE FETUS IN UTERO AFTER 24 COMPLETED WEEKS OF GESTATION OR WEIGHING >500g • OCCURRING BOTH DURING PREGNANCY (ANTEPARTUM DEATH) OR DURING LABOR (INTRAPARTUM) • THUS FOR PRACTICAL PURPOSE, ANTEPARTUM DEATH OCCURRING BEYOND THE PERIOD OF VIABILITY IS TERMED AS INTRAUTERINE DEATH. IT USUALLY RESULTS IN THE DELIVERY OF A MACERATED FETUS. 2 LMO EMMANUEL MUSONDA. Bsc.CS 17-May-21
  3. 3. ETIOLOGY THEY CAN BE CLASSIFIED AS; ➢MATERNAL ➢FETAL ➢PLACENTAL ➢OTHERS; IATROGENIC AND IDIOPATHIC (UNEXPLAINED) 17-May-21 LMO EMMANUEL MUSONDA. Bsc.CS 3
  4. 4. MATERNAL CAUSES (RISK FACTORS) • MEDICAL DISEASES – DM, HTN, THYROID DISEASES • PRE-EXISTING DISEASES (HD, ANAEMIA, EPILEPSY) • INFECTIONS (MALARIA, HEPATITIS, INFLUENZA, SYPHILIS,TOXOPLASMA, SEPSIS) • OBESITY: PROVEN, MODIFIABLE • AUTOIMMUNE DISORDERS (SYSTEMIC LUPUS ERYTHEMATOSUS [SLE} AND ASLO ANTIPHOSPHOLID SYNDROME (APS): PRESENCE OF LUPUS ANTICOAGULANT, ANTICARDIOLIPIN ANTIBODIES CAUSED DECIDUAL VASCULOPATHY WITH FIBRINOID NECROSIS, PLACENTAL VASCULAR ATHEROSIS AND INTERVILLOUS THROMBOSIS) • THROMBOPHILIAS: FACTOR V LEIDEN, PROTEIN C, PROTEIN S DEFICIENCY, HYPERHOMOCYSTEINEMIA. MECHANISM IS SIMILAR TO APS • HYPERPYREXIA • RH INCOMPATILITY, CHOLESTASIS OF PREGNANCY • ABRUPTION, PPROM, MULTIPLE GESTATION • LABOUR RELATED (PRETERM, DYSTOCIA, UTERINE RUPTURE, PROLONGED OR OBSTRUCTED LABOUR • SMOKING/ALCOHOL/DRUG ABUSE • ADVANCED MATERNALAGE (>35YRS) 17-May-21 LMO EMMANUEL MUSONDA. Bsc.CS 4
  5. 5. FETAL CAUSES • INRAUTERINE FETAL GROWTH RESTRICTION: SIGNIFICANT INCREASE IN THE RISK OF STILLBIRTH. IT IS ASSOCIATED WITH: ➢ FETAL ANEUPLOIDIES ➢ FETAL INFECTION ➢ MATERNAL SMOKING ➢ HYPERTENSION ➢ AUTOIMMUNE DISEASE ➢ OBESITY ➢ DIABETES • CHROMOSOMAL AND GENETIC ABNORMALITIES • STRUCTURAL ANOMALIES • INFECTIONS (VIRUS, BACTERIAAND CHORIOAMNIONITIS) • RH INCOMPATIBILITYAND HYDROPS (IMMUNE AND NON-IMMUNE) • MULTIPLE GESTATION, G6PD DEFICIENCY 17-May-21 LMO EMMANUEL MUSONDA. Bsc.CS 5
  6. 6. PLACENTAL CAUSES • PLACENTAL ABRUPTION.; MOST COMMON CAUSE • CORD ACCIDENTS (PROLAPSE, TRUE KNOT, CORD AROUND THE NECK) • PLACENTAL INFARCTION AND PLACENTAL INSUFFICIENCY • PLACENTAL OR MEMBRANE INFECTION; CHORIOAMNIONITIS • PROM • PLACENTA PREVIA • TWIN-TWIN TRANSFUSION SYNDROME.(TTTS) • FETO-MATERNAL HEMORRHAGE IATROGENIC – ECV, DRUG OVERDOSES 17-May-21 LMO EMMANUEL MUSONDA. Bsc.CS 6
  7. 7. OTHER CAUSES IATROGENIC • EXTERNAL CEPHALIC VERSION • DRUGS (QUININE BEYOND THERAPEUTIC DOSE) IDIOPATHIC • CAUSE REMAINS UNKNOWN EVEN WITH THOROUGH CLINICAL EXAMINATION AND INVESTIGATIONS 17-May-21 LMO EMMANUEL MUSONDA. Bsc.CS 7
  8. 8. CAUSES OF FETAL DEATH BASED ON TRIMESTER T1 (1-13 WEEKS) • CHROMOSOMAL ABNORMALITIES • ENVIRONMENTAL FACTORS (E.G. MEDICATIONS, SMOKING, TOXINS) • MATERNAL ANATOMIC DEFECTS (E.G. MULLERIAN DEFECTS) • ENDOCRINE FACTORS (E.G. PROGESTERONE INSUFFICIENCY, THYROID DYSFUNCTION, DIABETES) • UNKNOWN T2 (14-27 WEEKS) • ANTICARDIOLIPIN ANTIBODIES • ANTIPHOSPHOLIPID ANTIBODIES • CHROMOSOMAL ABNORMALITIES • ANATOMIC DEFECTS OF UTERUS AND CERVIX • ERYTHROBLASTOSIS • PLACENTAL PATHOLOGICAL CONDITIONS (E.G. CIRCUMVALLATE PLACENTATION, PLACENTA PREVIA) T3 (28 WKS-TERM) • ANTICARDIOLIPIN ANTIBODIES • PLACENTAL PATHOLOGICAL CONDITION (E.G. CIRCUMVALLATE PLACENTATION, PLACENTA PREVIA, ABRUPTION PLACENTAE) • INFECTIONS (E.G. TOXOPLASMOSIS, CMV, PARVOVIRUS) 17-May-21 LMO EMMANUEL MUSONDA. Bsc.CS 8
  9. 9. MORBID PATHOLOGY • THE DEAD FETUS UNDERGOES AN ASEPTIC DEGENERATIVE PROCESS CALLED MACERATION. • THE EPIDERMIS 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 FETUS BECOMES SWOLLEN AND LOOKS DUSKY RED. GRADUALLY ASEPTIC AUTOLYSIS OF THE LIGAMENTOUS STRUCTURE AND LIQUEFACTION OF THE BRAIN MATTER AND OTHER VISCERA TAKE PLACE. • THE CHANGES VARY IN DEGREE AND ARE RESPONSIBLE FOR THE CHARACTERISTIC RADIOLOGICAL SIGNS. 9 DC DUTTA 17-May-21
  10. 10. DIAGNOSIS REPEATED EXAMINATIONS ARE OFTEN REQUIRED TO CONFIRM THE DIAGNOSIS. • SYMPTOMS—ABSENCE OF FETAL MOVEMENTS WHICH WERE PREVIOUSLY NOTED BY THE PATIENT. • SIGNS: RETROGRESSION OF THE POSITIVE BREAST CHANGES THAT OCCUR DURING PREGNANCY IS EVIDENT AFTER VARIABLE PERIOD FOLLOWING DEATH OF THE FETUS. ON HISTORY: BEFORE 20 WEEKS’ GESTATION, THE MOST COMMON FINDING IS UTERINE FUNDUS LESS THAN DATES PER ABDOMEN • GRADUAL RETROGRESSION OF THE FUNDAL HEIGHT AND IT BECOMES SMALLER THAN THE PERIOD OF AMENORRHEA. • UTERINE TONE IS DIMINISHED AND THE UTERUS FEELS FLACCID. BRAXTON-HICKS CONTRACTION IS NOT EASILY FELT. • FETAL MOVEMENTS ARE NOT FELT DURING PALPATION. • FETAL HEART SOUND IS ABSENT. DOPPLER ULTRASOUND IS BETTER THAN THE STETHOSCOPE. • EGG-SHELL CRACKLING FEEL OF THE FETAL HEAD IS A LATE FEATURE 17-May-21 DC DUTTA 10
  11. 11. INVESTIGATIONS • SONOGRAPHY—EARLIEST DIAGNOSIS IS POSSIBLE WITH SONOGRAPHY. THE EVIDENCES ARE: (A) LACK OF ALL FETAL MOTIONS (INCLUDING CARDIAC) DURING A 10 MINUTE PERIOD OF CAREFUL OBSERVATION WITH A REAL-TIME SONAR IS A STRONG PRESUMPTIVE EVIDENCE OF FETAL DEATH (B) GRADUALLY, OLIGOHYDRAMNIOS AND COLLAPSED CRANIAL BONES ARE EVIDENT (FIG. 21.1). • STRAIGHT X-RAY ABDOMEN—RARELY DONE AT PRESENT. THE FOLLOWING FEATURES MAY BE FOUND IN VARYING DEGREE, EITHER SINGLY OR IN COMBINATION. SPALDING SIGN (FIG. 21.2)—THE IRREGULAR OVERLAPPING OF THE CRANIAL BONES ON ONE ANOTHER IS DUE TO LIQUEFACTION OF THE BRAIN MATTER AND SOFTENING OF THE LIGAMENTOUS STRUCTURES SUPPORTING THE VAULT. IT USUALLY APPEARS 7 DAYS AFTER DEATH. SIMILAR FEATURES MAY BE FOUND IN EXTRA-UTERINE PREGNANCY WITH THE FETUS ALIVE. • HYPERFLEXION OF THE SPINE (BALL SIGN) IS MORE COMMON. IN SOME CASES HYPEREXTENSION OF THE NECK IS SEEN. CROWDING OF THE RIBS SHADOW WITH LOSS OF NORMAL PARALLELISM. APPEARANCE OF GAS SHADOW (ROBERT’S SIGN) IN THE CHAMBERS OF THE HEART AND GREAT VESSELS MAY APPEAR AS EARLY AS 12 HOURS BUT DIFFICULT TO INTERPRET. WHEN DETECTED, PROVIDES CONCLUSIVE EVIDENCE. • BLOOD—TO ESTIMATE THE BLOOD FIBRINOGEN LEVELAND PARTIAL THROMBOPLASTIN TIME PERIODICALLY, WHEN THE FETUS IS RETAINED FOR MORE THAN 2 WEEKS 11 DC DUTTA OBSTETRICS 17-May-21
  12. 12. 17-May-21 DC DUTTA 12
  13. 13. 17-May-21 DC DUTTA 13
  14. 14. RECOMMENDED EVALUATION FOR A STILLBIRTH • HEMATOLOGICAL EXAMINATION CONSISTS OF ABO AND RH GROUPING, KLEIHAUER-BETKE TEST, VDRL, POSTPRANDIAL BLOOD SUGAR, HBA1C, UREA, CREATININE ESTIMATIONS, THYR6OID PROFILE, TORCH SCREENING, LUPUS ANTICOAGULANT, ANTICARDIOLIPIN ANTIBODIES AND THROMBOPHILIA STUDIES. URINE EXAMINATION FOR CASTS AND PUS CELLS. THOROUGH EXAMINATION OF THE INFANT AND PLACENTA SHOULD BE DONE: • INFANT—FOR MALFORMATIONS, UMBILICAL CORD FOR ENTANGLEMENT, NUMBER OF VESSELS, PLACENTA FOR MECONIUM STAINING, MALFORMATIONS AND THE RESPECTIVE WEIGHTS ARE TO BE RECORDED. • AUTOPSY AND CHROMOSOME STUDIES ARE DONE FOR FETUSES WITH ANOMALIES AND DYSMORPHIC FEATURES. IT IS ALSO DONE IF THERE IS HISTORY OF RECURRENT STILLBIRTHS OR IF EITHER PARENT IS A CARRIER FOR BALANCED TRANSLOCATION. FETAL SKIN, BLOOD ARE USUALLY TAKEN. FOR CYTOGENETIC STUDIES TISSUES MUST CONTAIN SOME VIABLE CELLS. 17-May-21 DC DUTTA 14
  15. 15. COMPLICATIONS • PSYCHOLOGICAL UPSET OFTEN BECOMES A PROBLEM. • INFECTION—SO LONG AS THE MEMBRANES ARE INTACT, INFECTION IS UNLIKELY BUT ONCE THE MEMBRANES RUPTURE, INFECTION, ESPECIALLY BY GAS FORMING ORGANISMS LIKE CL. WELCHII MAY OCCUR. THE DEAD TISSUE FAVORS THEIR GROWTH WITH DISASTROUS CONSEQUENCES. • BLOOD COAGULATION DISORDERS ARE RARE. IF THE FETUS IS RETAINED FOR MORE THAN 4 WEEKS (10–20%), THERE IS A POSSIBILITY OF DEFIBRINATION FROM ‘SILENT’ DISSEMINATED INTRAVASCULAR COAGULOPATHY (DIC). IT IS DUE TO GRADUAL ABSORPTION OF THROMBOPLASTIN, LIBERATED FROM THE DEAD PLACENTAAND DECIDUA, INTO THE MATERNAL CIRCULATION. • DURING LABOR—UTERINE INERTIA, RETAINED PLACENTAAND POSTPARTUM HEMORRHAGE. 17-May-21 DC DUTTA 15
  16. 16. PREVENTION THE OVERALL RISK OF RECURRENCE OF STILL BIRTH VARIES BETWEEN 0 AND 8 PERCENT. THE CONDITIONS THAT RUN THE RISKS OF RECURRENCE ARE: HEREDITARY DISORDERS, DIABETES, HYPERTENSION, THROMBOPHILIAS, PLACENTAL ABRUPTION AND FETAL CONGENITAL MALFORMATIONS. WHILE IUD CANNOT BE TOTALLY PREVENTED, THE FOLLOWING GUIDELINES MAY HELP TO REDUCE ITS RECURRENCE : • PRE-CONCEPTIONAL COUNSELING AND CARE IS ESSENTIAL TO PREVENT ITS OCCURRENCE IN THE HIGH RISK GROUP. • PRENATAL DIAGNOSIS —CVS OR AMNIOCENTESIS IN SELECTED CASES (P. 107). • TO SCREEN THE “AT-RISK MOTHERS” DURING ANTENATAL CARE. CAREFUL ASSESSMENT OF FETAL WELL-BEING AND TO TERMINATE PREGNANCY WITH THE EARLIEST EVIDENCES OF FETAL COMPROMISE. 17-May-21 DC DUTTA 16
  17. 17. MANAGEMENT • BREAKING THE BAD NEWS TO THE MOTHER AND THE FAMILY MEMBERS IS A DIFFICULT TASK. THIS IS MAINLY DUE TO THE FEAR OF BEING BLAMED FOR THE POOR OUTCOME AND FOR THE MEDIC/LEGAL PROBLEMS. TO LISTEN TO THE PATIENT AND HER FAMILY MEMBERS ACTIVELY AND THEN TO ANSWER THEIR CONCERNS ARE IMPORTANT. IT NEEDS PROFESSIONAL SKILLAND ABILITIES. • EXPECTANTATTITUDE (NON-INTERFERENCE): THE PATIENT AND HER RELATIVES ARE LIKELY TO BE UPSET PSYCHOLOGICALLY BUT THEY SHOULD BE ASSURED OF SAFETY OF NON- INTERFERENCE. IN ABOUT 80% OF CASES, SPONTANEOUS EXPULSION OCCURS WITHIN 2 WEEKS OF DEATH. THE PATIENT MAY REMAIN AT HOME WITH THE ADVICE TO COME TO THE HOSPITAL FOR DELIVERY. FIBRINOGEN ESTIMATION SHOULD BE DONE WEEKLY. • REASONS FOR EARLY DELIVERY: (I) RELIABLE DIAGNOSIS COULD BE MADE WITH REAL TIME ULTRASONOGRAPHY QUICKLY; (II) PROSTAGLANDINS ARE AVAILABLE FOR EFFECTIVE INDUCTION AND; (III) COMPLICATIONS COULD BE AVOIDED. • INDICATIONS OF EARLY INTERFERENCE. (I) PSYCHOLOGICAL UPSET OF THE PATIENT (COMMON). (II) MANIFESTATIONS OF UTERINE INFECTION. (III) TENDENCY OF PROLONGATION OF PREGNANCY BEYOND 2 WEEKS. (IV) FALLING FIBRINOGEN LEVEL (RARE) DC DUTTA 17 17-May-21
  18. 18. METHODS OF DELIVERY—THE DELIVERY SHOULD ALWAYS BE DONE BY MEDICAL INDUCTION: A COMBINATION OF MIFEPRISTONE AND A PROSTAGLANDIN PREPARATION IS RECOMMENDED AS THE FIRST LINE CHOICE FOR INDUCTION. • OXYTOCIN INFUSION—THIS IS WIDELY PRACTICED AND EFFECTIVE IN CASES WHERE THE CERVIX IS FAVORABLE. TO BEGIN WITH, 5–10 UNITS OF OXYTOCIN IN 500 ML OF RINGER’S SOLUTION IS ADMINISTERED THROUGH INTRAVENOUS INFUSION DRIP. CONSECUTIVE TWO BOTTLES MAY BE ADMINISTERED AT A TIME. IN CASE OF FAILURE, AN ESCALATING DOSE OF OXYTOCIN IS USED ON THE NEXT DAY. TO START WITH, A DRIP IS SET UP WITH 20 UNITS OF OXYTOCIN IN 500 ML OF RINGER’S SOLUTION AND RUN 30 DROPS PER MINUTE (80 MU/MINUTE). THE STRENGTH OF THE DRIP MAY BE INCREASED TO 40 UNITS AFTER THE FIRST BOTTLE, IF THE CONTRACTION FAILS TO START. IF THE UTERUS STILL REMAINS REFRACTORY, THE SAME PROCEDURE IS REPEATED AFTER VAGINAL ADMINISTRATION OF PROSTAGLANDIN GEL. ONE SHOULD EXCLUDE THE POSSIBILITY OF SECONDARY ABDOMINAL PREGNANCY IF REPEATED ATTEMPTS FAIL TO START LABOR. • PROSTAGLANDINS: VAGINAL ADMINISTRATION OF PROSTAGLANDIN (PGE2) GEL OR LIPID PESSARY HIGH IN THE POSTERIOR FORNIX IS VERY EFFECTIVE FOR INDUCTION WHERE THE CERVIX IS UNFAVORABLE. THIS MAY HAVE TO BE REPEATED AFTER 6–8 HOURS. THE PROCEDURE MAY BE SUPPLEMENTED WITH OXYTOCIN INFUSION. • MISOPROSTOL (PGE1) 25–50 mg EITHER VAGINALLY OR ORALLY IS ALSO FOUND EFFECTIVE VAGINAL ROUTE USE IS MORE EFFECTIVE COMPARED TO ORAL ROUTE. MISOPROSTOL MAY BE REPEATED AT EVERY 4 HOURS. PLACE OF CESAREAN SECTION IN A CASE WITH IUD IS LIMITED. MAJOR DEGREE PLACENTA PREVIA, PREVIOUS CESAREAN SECTION (TWO OR MORE) AND TRANSVERSE LIE ARE THE COMMON ONES. EVERY ATTEMPT SHOULD BE MADE TO AVOID A HYSTEROTOMY 17-May-21 DC DUTTA 18
  19. 19. INTRAPARTUM ANTIBIOTIC PROPHYLAXIS • WOMEN WITH SEPSIS SHOULD BE TREATED WITH INTRAVENOUS BROAD- SPECTRUM ANTIBIOTIC THERAPY (INCLUDING ANTICHLAMYDIALAGENTS) • ROUTINE ANTIBIOTIC PROPHYLAXIS SHOULD NOT BE USED • NOTE; MECHANICAL INDUCTION MIGHT INCREASE THE RISK OF ASCENDING INFECTION IN THE PRESENCE OF IUFD. 17-May-21 LMO EMMANUEL MUSONDA. Bsc.CS 19
  20. 20. • BEREAVEMENT MANAGEMENT AND PUERPERIUM: THE MEDICAL TEAM AND THE NURSING STAFF SHOULD PROVIDE ALL THE SUPPORT AND SYMPATHY TO THE BEREAVED COUPLE. THE COUPLE SHOULD BE EXPLAINED IN SIMPLE TERMS ABOUT THE POSSIBLE CAUSE OF FETAL DEATH. A PSYCHOLOGIST OR A COUNSELOR MAY SEE THEM TO SUPPORT. RECOVERY IN POSTPARTUM WARD IS BETTER AVOIDED. THE RISK OF POSTPARTUM DEPRESSION IS HIGH. THE COUPLE IS SEEN IN THE POSTPARTUM CLINIC AFTER SIX WEEKS. THE INVESTIGATION REPORTS ARE REVIEWED AND COUNSELING FOR FUTURE PREGNANCY IS DONE. 17-May-21 DC DUTTA OBSTETRICS 20
  21. 21. LACTATION • WOMEN SHOULD BE ADVISED THAT DOPAMINE AGONISTS SUCCESSFULLY SUPRRESS LACTATION IN A VERY HIGH PROPORTION OF WOMEN AND ARE WELL TOLERATED BY A VERY LARGE MAJORITY; CABERGOLINE IS SUPERIOR TO BROMOCRIPTINE • DOPAMINE AGONISTS SHOULD NOT BE GIVEN TO WOMEN WITH HYPERTENSION OR PRE-ECLAMPSIA. • ESTROGENS SHOULD NOT BE USED TO SUPPRESS LACTATION. 17-May-21 LMO EMMANUEL MUSONDA. Bsc.CS 21
  22. 22. 17-May-21 DC DUTTA 22
  23. 23. “ ” LIFE SO SHORT, THE CRAFT SO LONG TO LEARN. —HIPPOCRATES THE END THANK YOU 23 LMO EMMANUEL MUSONDA. Bsc.CS 17-May-21

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