2. Def: embraces all foetal deaths occurring
both during pregnancy,before or after 28/40
(antepartum) and during labour (intrapartum)
Before 28/40 usually called abortion and
missed if retained
For practical purposes ,we refer to
antepartum death beyond 28/40 usually MSB
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3. Aetiology
20-30 % unknown
Pregnancy complications
– PE-spasm of uteroplacental circulation leads to
reduction of placental blood flow and placental
insufficiency
– APH- both PP and abruption produce acute
placental insufficiency. Abruption causes more
deaths than PP because of its association with
PE
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4. Pre-existing medical diseases and acute illnesses
during pregnancy
– Chronic HTN-it produces placental insufficiency and usually
less lethal ,unless PE supervens
– Chronic nephritis-continuation beyond viability is rare and
foetal death occurs due to massive placental infarction
– DM- actual cause of death not clear.Atherosclerotic
changes in pelvic blood vessels may lead to plcental
insufficiency and fetal death.Associated factors
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5. – Such as PE,hydramnios,congenital malformation and
maternal ketosis may be responsible
– Syphilis- causes death by spirochaete affecting placenta
and foetus
– Hyperpyrexia-acute fever of mother over 39.4 centigrade
can kill fetus directly
– Severe anaemia –may cause foetal death through maternal
anoxaemia
– Chorioamnionitis-especially due to beta haemolytic
streptococcus
– Other rare causes-
hepatitis(viral),toxoplasmosis,HSV,CMV,Mumps
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6. Foetal causes
– Congenital malformation –incompatible with
independent existence
– RH-incompatibility –excessive haemolysis
produces foetal anaemia,anoxia and heart failure
– Postmaturity-cause unexpected death during
pregnancy due to placental insufficiency,worse in
labour
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7. Recurring mishaps in subsequent pregnancies
consider DM,RH incompatibilty,chronic
nephritis,thrombophilia,antiphospholipid syndrome
Morbid pathology-as dead fetus is sorrounded by
sterile liquor it undergoes an aseptic destructive
process known as maceration.Epidermis first to be
involved having,blistering and peeling off of the
skin.Appears 12-24 hours after death then other
organs –ligments,brain matter other vicera
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8. Diagnosis
Symptom –absence of foetal movements
Signs-retrogression of positive breast
changes after variable period of fetal death
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9. Per abdomen
– Gradual retrogression of the HOF
– Uterine tone is diminished and uterus feels
flaccid.Braxton-Hicks contraction is not easily felt
– Foetal movement not easily felt during palpation
– FHS not heard even by doppler
– Egg-shell crackling feel of the foetal head ,if
elicited is almost pathognomonic
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10. Investigations
Straight X-ray abdomen show varying degree
of
– Spalding sign –usually appears 7days after death
– Hyperflexion of the spine
– Crowding of ribs shadow-Bhudda`s sign
– Appearance of gas shadow(Robert`s sign) in the
chambers of the heart and great vessels appear
as early as 12 hours
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11. Ultrasound scan-the evidences are
– Lack of foetal motions (including cardiac) during
a 10 minute period
– Gradually ,oligohydramnios and collapsed cranial
bones are evident
Confirmation of diagnosis is made on repeated clinical
exams at intervals of one week supplemented by scan
or radiology
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12. Investigations protocol in IUD
Investigation protocol are directed
– To confirm the diagnosis by radiology or
sonography
– Estimate blood fibrinogen level perodically
,specially if the fetus is retained more than 2
weeks
– Find cause of death
– Blood tests consist of RH typing,VDRL,post
prandial sugar UE,creatinine
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13. Urine exam for casts and pus cells.Naked
eye exam of placenta and cord,swab from
placenta for bacteriology,virology including
histology and exam of baby including
autopsy may give clue as to cause of death
Cytogenetic study by karyotyping of baby is
helpful in presence of congenital
malformation or IUGR
X-ray bones might detect some skeletal abn
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14. Complications
– Psychological upset often a problem
– Infection –so long as the membranes are
intact,infection is unlikely but once membranes
rupture infection ,specially by gas forming
organisms like CL.welchi may occur
– Blood coagulation disorders-if retained for more
than 2 weeks(as occurs in 10-20%) there is
possibility of DIC
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15. – During labour –uterine inertia,retained placenta and PPH
Prevention-while can not be prevented ,following
guidelines help reduce incidence
– Regular ANC –prevent ,detect at the earliest and institute
effective therapy likely to cause foetal death
– To screen out the “at risk mothers” ,to monitor carefully for
the assessment of foetal well being and terminate the
pregnancy at the earliest evidence of foetal compromise
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16. Management
Expectant attitude(non-interference)
– Psychological morbity is high but is a safe
practice-assure
– 80% spontaneous expulsion in 2 weeks,if not
admit .
– Fibrinogen estimation done every week if not
twice if retained longer than 4 weeks Falling level
of up to 150mg% should be arrested by controlled
infusion of heparin
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17. Interference indicated :
– Psychological upset of the patient –common
– Manifestation of uterine infection
– Falling fibrinogen level-fibrinogen level should be
elevated well above the critical level before
interference
– Tendency of prolongation of pregnancy beyond 2
weeks
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18. Early termination is now favoured ,since
induction is more so give options!
Methods of induction
– Termination should always be done by medical
induction
Oxytocin infusion in ascalating doses up to 40 units
Prostaglandins
Prostaglandins then oxytocin
Mifepristone(RU486) then prostaglandins
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19. Suppression of lactation
What happens to lactation?
– Do no express
– Wear tight bra
– Medical suppression with dopamine agonists
such bromocriptine,carbegoline
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20. Will it happen again?
Need sympathetic handling
Allow grieving process
Name the child,take pictures
Help arrange funeral
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