The document discusses intrauterine fetal demise (IUFD), defined as the death of a fetus weighing over 500g or over 24 weeks gestation before the onset of labor. It notes that the cause is unknown in 25-60% of cases. Identifiable causes include maternal conditions like diabetes or hypertension, fetal conditions like birth defects or infections, and placental conditions like abruption or insufficiency. Evaluation of an IUFD involves examining the mother's medical history and current pregnancy, evaluating the stillborn infant, investigating the placenta, and certain laboratory tests. Management depends on factors like gestation, number of fetuses, and the parents' wishes regarding expectant or active management such as labor induction. Complications can

1. INTRA UTERINE FETAL DEMISE DR SHABNAM NAZ ASSISTANT PROFESSOR CMC,SMBBMU LARKANA

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

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 : absent fetal movements Oligohydramnios and collapsed cranial bones Spalding sign

22. 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 Hx Gestational HTN with adverse sequele Placental abruption IUFD Recurrent abortions Baby with congenital anomaly / hereditary condition IUGR

23. Current Pregnancy Hx 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

24. FAIMLY HISTORY Recurrent abortions VTE/ PE Congenital anomalies Abnormal karyotype Hereditary conditions Developmental delay

25. 2-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

26. Knots in cord

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

31. Vasa Previa

32. 3. 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

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

34. 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.

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

36. 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)

37. Management (contd…) If induction of labour is planned, assess the cervix If the cervix is favourable (soft, thin, partly dilated) labour using oxytocin. If the cervix is unfavourable(firm, thick, closed) ripen the cervix. Note: Do not rupture the membranes. If spontaneous labor does not occur within four weeks, platelets are decreasing and the cervix is unfavourable, ripen the cervix.

38. Complications Psychological upset Infection: Once the membranes rupture, infection, especially by gas forming organism like CI. Welchi. Blood coagulation disorders During labour : Uterine inertia and PPH

39. 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.

40. 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.

41. Moen Jo Daro Larkana Sindh