intra uterine death lecture for UG

1. INTRA UTERINE FETAL
DEMISE
DR Sushma Sharma

2. IUFD
Definition –
IUFD denotes death of fetus in utero
or weighing >500gm or >24 weeks,
before the onset of labour.
Incidence:
4.5/1000

3. Etiology
• Unknown in 25 – 60% of cases
• Identifiable causes can be attributed to
•Maternal conditions
•Fetal conditions
•Placental conditions

4. Fetal causes --25-40%
•Chromosomal anomalies
•Birth defects
•Non immune hydrops
•Infections
• TORCH

9. Placental --25-35%
•Abruption
•Cord accidents
•Placental insufficiency
•Intrapartum asphyxia
•P Praevia
•Twin-twin transfusion Synd:
•Chorio-amnionitis

10. Cord prolapse

11. Calcification and haemorrhage in
placenta

12. Vasa Previa

13. Maternal 5-10%
•Antiphospho-lipid antibody
•DM
•HTN
•Trauma
•Abnormal labor
•Sepsis
•Uterine rupture
•Post-term pregnancy
•Drugs
•Thrombophilia
•Cyanotic heart disease
•Epilepsy
•Severe anemia
Unexplained 25-35%

14. Ruptured uterus

15. • Mom with no
prenatal care
delivers
undiagnosed
twins at EGA
34 weeks

19. Diagnosis to confirm iud
History &Examination
-Absence of fetal movements
-Retrogression of the positive breast changes.
- Gradual retrogression of the height of the uterus
- Uterine tone is diminished
- Fetal movement are not felt during palpation.
- Fetal heart sound are not audible

20. Diagnosis (contd…)
-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
- (Robert’s sign) Appearance of gas shadow in great
vessels : 12 hours

21. cont
Sonography :
(a) absent fetal movements
(b) Oligohydramnios and
collapsed cranial bones
Spalding sign

22. Spalding sign
Robert’s sign

23. Evaluation of iufd to detect the cause
• I-Maternal medical
conditions
• VTE/ PE
• DM
• HPT
• Thrombophilia
• SLE
• Autoimmune disease
• Severe Anemia
• Epilepsy
• Heart disease
II-Past OB History
•Gestational HTN with adverse sequele
•Placental abruption
•IUFD
•Recurrent abortions
•Baby with congenital anomaly / hereditary
Condition
•IUGR

24. Current Pregnancy History
• Maternal age
• Gestational age at fetal death
• HPT
• DM/ Gestational D
• Smoking , alcohol, or drug abuse
• Abdominal trauma
• Choliestasis
• Placental abruption
• PROM or prelabour ROM

25. FAMILY HISTORY
•Recurrent abortions
•VTE/ PE
•Congenital anomalies
•Abnormal karyotype
•Hereditary conditions
•Developmental delay

26. Evaluation of still born infants
• Infant desciption
• Malformation
• Skin staining
• Degree of maceration
• Color-pale ,plethoric
• Umbilical cord
• Prolapse
• Entanglement-neck, arms, ,legs
• Hematoma or stricture
• Number of vessels
• Length
• Amniotic fluid
• Color-meconium, blood
• Volume

27. Knots in cord

30. EXAMINATION OF THE PLACENTA
Placenta
•Weight
•Staining
•Adherent clots
•Structural abnormality
•Velamentous insertion
•Edema/ hydropic changes
Membranes
•Stained
•Thickening

32. Vasa Previa

33. INVESTIGATIONS
• Maternal investigations:
• CBC
• Blood Group & antibody screen
• HB A1 C
• Kleihauer Baket test
• Serological screening for Rubella CMV,
Toxoplasmosis, Syphilis, Herpes & Parvovirus
• Karyotyping of both parents
• Hb electrophoresis'
• Antiplatelet antibodies
• Thrombophilia screening (ant thrombin iii, Protein C &
S deficiency , factor IV leiden,Factor II mutation, lupus
anticoagulant, anticardolipin antibodies)
• DIC

34. Cont…
• Fetal investigations
• Fetal autopsy
• Karyotype
• (specimen taken from cord blood, intracardiac
blood, body fluids, skin, spleen,
Placental wedge, or amniotic Fluid)
• Fetography
• Radiography

35. Cont…
• Placental investigations
• Chorionicity of placenta in twins
• Cord thrombosis or knots
• Infarcts, thrombosis, abruption,
• Vascular malformations
• Signs of infection
• Bacterial culture for E coli,
• Listeria, group B strept.

36. Pregnancy Management
• Single or multiple gestation
• Gestational age at death
• The parents wish

37. Management
• 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)

38. Management
• Expectant approach: 80% goes into spontaneous
labour within 2-3 weeks
• Active approach: b/o emotional burden, risk of
chorioamnionitis, and 10% risk of DIC (if >5wks)
Induction of labour can be initiated at any time.
• Various modalities of induction

39. Management (contd…)
If induction of labour is planned, assess the cervix
• If the cervix is favourable (soft, thin, partly dilated) induce
labour using oxytocin./ PG
• If the cervix is unfavourable(firm, thick, closed) ripen the
cervix.
Note: Do not rupture the membranes.

40. Complications
1. Psychological upset
2. Infection: Once the membranes rupture, infection,
especially by gas forming organism like CI. Welchi.
3. Blood coagulation disorders… end result is DIC
4. During labour : Uterine inertia and PPH

41. Prevention of IUFD:
• Regular antenatal care
• To screen out the at-risk patients to
monitor carefully for the assessment of
fetal well being and to terminate the
pregnancy at the earliest evidences of fetal
compromise.

42. 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.

43. MACERATED STILLBORN

44. Questions?