This presentation is about still birth and changes that happens in intrauterine demised fetus

1. STILLBIRTH
ACCORDING TO WHO WHICH IS ACCEPTABLE IN PAKISTAN STILL BIRTH IS DEATH OF FETUS AFTER 28 WEEKS OF
GESTATION BUT BEFORE OR DURING BIRTH IS CLASSIFIED AS STILLBIRTH
THERE ARE 2.6 MILLION STILL BIRTH GLOBALLY WITH MORE THAN 7178 DEATHS DAILY

2. • Stillbirth mean no sign of life
• Fresh : Within 48 hrs before birth
• Mecerated: Beyond 48 hours before delivery

3. CAUSES
• Maternal
• Fetal
• Placental
• Uterine
• Amniotic fluid
• Umbilical cord
• Intrapartum
• Trauma
• Unknown etiology

4. MATERNAL CAUSES
• Diabetes
• Thyroid disease
• Essential hypertension
• Hypertensive disease of pregnancy
• Lupus or antiphospholipid syndrome
• Cholestasis
• Drug misuse
• Others

5. PLACENTAL
• Abruption
• Praevia
• Vasa praevia
• Other placental insufficiency
• Others

6. FETAL CAUSES
• IUGR
• Twin to twin transfusion syndrome
• Congenital anomaly
• Genetic disorder
• Infection
• Hydrops
• Non immune hydrops
• Isoimmunization

7. UMBILICAL CORD
• Cord prolapse
• ConstrictiConstricting loop or knot
• Velamentous insertion
• Other

8. AMNIOTIC FLUID
• Chorioamnionitis
• Oligohydromnios
• Polyhydromnios
• Others

9. UTERINE
• Rupture
• Uterine anomaly
• Other

11. INTRAPARTUM
• Asphyxia
• Birth trauma

12. TRAUMA
• External
• Iatrogenic

13. DIAGNOSIS
• The diagnosis of intrapartum fetal death should only be made by real time ultrasound
• Absent fetal cardiac Pulsation
• Roberts sign:
• Roberts sign refers to a radiological finding typically seen in cases of fetal death in utero.
It is characterized by the presence of gas in the heart and great vessels of the fetus,
visible on an X-ray.This sign is indicative of intrauterine fetal demise and is considered a
late finding, usually appearing 12 hours or more after fetal death has occurred.

14. • Helix sign :The Helix sign refers to a specific appearance observed on ultrasound
imaging.When a fetus has died in utero, the umbilical cord may sometimes take on a
coiled, twisted, or corkscrew-like appearance
• Hyperflexion sign:The hyperflexion sign is another ultrasound finding that can be
associated with fetal demise.This sign refers to the abnormal positioning of the fetal
limbs or neck, where there is excessive bending or flexing beyond the normal range. In
cases of fetal demise, the loss of muscle tone can lead to this hyperflexed position.

15. • Spalding sign :
• The Spalding sign is a significant ultrasound finding that indicates fetal demise. It refers to
the overlapping of the skull bones, which occurs due to the loss of fetal intracranial
pressure after death.This overlapping can be visualized on ultrasound and is a reliable
marker of fetal demise, especially in the second and third trimesters.The Spalding sign,
combined with other clinical findings such as the absence of fetal heartbeat and
movement, helps in confirming the diagnosis of fetal demise

16. SYMPTOMS
• Reduce or no fetal movement
• Decreased symphysiofundal height as compared to gestational age
• Per abdominal absent FHS

17. MANAGEMENT
• Expectant management :wait for spontaneous onset of labour Pains to deliver a dead fetus
• Good success rate
• Mostly women deliver within 4 weeks of gestation
• Complication :
• DIC
• It’s is dye to embolization of fetal thromboplastin and placental.dissue in to the mother causing DIC in
mother .it’s only 10 percent in first 4 weeks however beyond 4 weeks it’s 30 percent
• Mother should be tested for DIC twice a week during this period
• And should be encouraged for induction of labour rather than expectant management

18. INDUCTION OF LABOUR
• Mechanical :folleys catheter >dialate cervical canal
• Medical: mifepristone that is antiprotaglandin given in a dose of 200 mg after which 48 hrs later
we can use other drug
• It has been known to speed the induction to delivery time
• Misoprostol:
• Preferred drug for induction of labour in IUFD
• Dosage
• <26 weeks : 100 mg Q6H[max:800mg/day]

19. • >26 weeks :50mg Q4H[600mg/day]
• Previous scar : risk of induction of labour we will reduce the dose i-e low dose 25-50mg

20. POST NATAL MANAGEMENT
• Examination of the fetus
• Examination of the placenta
• Autopsy of the fetus
• Biopsy of the fetus – genetic testing
• If biopsy preferred then immediate termination of pregnancy is insisted as in IUFD fetal
autolysis is done which may destroy tissue blood genetic material
• Placental –genetic evaluation

21. Lactation suppression
• Simple measures such as right bra ,ice packs,analgesics can be used
• Drugs :
• Bromocriptine 1mg twice a day for 14 days
• Anti D administration if RH negative
• Contraception

22. INVESTIGATIONS
• Maternal investigations : CBC ,CRP,HbA1c ,blood culture. HVS ,Kleihauer test (fetal maternal hemorrhage in
addition to dose of anti D gamma globulin )
• Maternal infection screening that includes parvovirus,B19,rubella ,cytomegalovirus, herpes simplex, toxoplasmosis
gondii and others as indicated
• Thrombophilia and antiphospholipid screening
• Antibody screening and anti Ro and anti La antibody will be indicated if concern regarding fetal anaemia or hydrops
• Parental screening for fetal/neonatal alloimmune thrombocytopenia will be indicated If there is evidence of other
unexplained fetal bleeding
• Cytogenic analysis if there is evidence of dysmorphic features or a Congenital anomaly either from sample taken at
the time of postmortem or from placenta or cord at time of delivery

23. MANAGEMENT OF FUTURE PREGNANCY AND
PREVENTION
• Pregnancies occurring within 6 months of a stillbirth were associated with increased risk of preterm ,low birthweight ,and
small for gestational age babies and outcome
• Two interventions may assist in reducing stillbirth : firstly smoking
• Secondly overweight women BMI >30 kg/m2 should be advised to lose weight
• Adequate nutrition
• Healthy life style
• Screening and treatment of syphilis ,presumptive treatment of malaria ,insecticide treated mosquito nets ,birth
preparedness, access to emergency care ,cesarean section for breech presentation, elective induction for post term delivery
• Reducing risk of pre-eclampsia by low dose aspirin serial growth scans to assess fetal growth in cases of suspected growth
restriction and pre-eclampsia and cervical length assessment and possible cervical cerclage in cases of preterm labour