INTRAUTERINE FETAL DEATH Dr.Ikhlas 31/3/2016
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BY: TAHER ALI TAHER
OBSTETRICS
Intrauterine fetal death:
Intrauterine fetal death: is defined as delivery of a baby with no sign of
life after 24 wks of pregnancy.
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Still birth rate is 5.5/1000 birth.
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It is recognized that IUFD is more common amongst certain groups
such as advanced maternal age ,obesity ,advanced gestation, social
deprivation are all associated with increased risk.
The possible cause of IUFD are:
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Fetal : cord accident , feto-fetal transfusion ,fetomaternal haemorrhage
, chromosomal and genetic causes, stuctural abnormality ,infection,
anaemia of fetal orgion.
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Direct maternal effect:
- obstetric cholestasis ,metabolic disturbances e.g diabetic
ketoacidosis.
- Reduced O2 states e.g cystic fibrosis ,obstructive sleep apnoea.
- Uterine anomaly e.g ashermans syndrome.
- Antibody production e.g RH-disease,congenital heart block.
-Maternal placental effects : pre-eclampsia ,renal disease ,
antiphospholipid syndromes ,thrombophilia , smocking ,drug abuse e.g
cocaine.
Note : 30-50% of IUFD is unexplained.
INTRAUTERINE FETAL DEATH Dr.Ikhlas 31/3/2016
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BY: TAHER ALI TAHER
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Diagnosis :
- IUFD presents with decreased fetal movement in as many as 50% of
cases .others present with an unexplained finding at routine U/S or
A/N visits or with signs of an acute events such as abrubtion ,
rupture membranes or the onset of labour . when IUFD is suspected
it is important to establish the dx as soon as possible.
- Fetal death must be dx by U/S.
- CTG can be very misleading as the heart rate tracing of an anxious
mother is usually identical to that of a fetus.
- U/S features :spalding sign (overlapping of the fetal skull bones
when the fetus has been dead for some time), oligohydromnia ,
signs of fetal hydrops.
- Measurements of Bp and urine analysis should be undertaken to
rule out significant pre-eclampsia.
- When the fetal death is due to an abruption clinical signs are usually
apparent .if it is felt that the fetus has been dead for some times
clotting screen should be performed to role out coagulopathy.
- Prevention of RH isoimmunization: massive feto-maternal
haemorrhage is one cause of fetal death and have occurred hours
or even days before clinical presentation. if the female is RH –VE
blood for kleihauer test should be taken and as soon as the dx for
an estimation of the volume Of feto-maternal transfusion and anti-
D should be given.
How to deliver ??
- vaginal deivery is the aim unless there are absolute indication for
C/S e.g placenta praevia,…..
- Patient should have full access to analgesia as recquired.
Induction of labour : there are various strategies has been used for
induction of labour .whichever method is used , it is important to
remember that complications such as uterine rupture and shoulder
dystochia can occur , these methods include :
- Third trimester termination achieved with standard PGE2
preparations.
- Other methods : combination of anti-progesterone (mifepristone)+
PG analogue (misopristol). the advantage of this protocol is that the
induction to delivery time is shorter , as follow :
INTRAUTERINE FETAL DEATH Dr.Ikhlas 31/3/2016
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BY: TAHER ALI TAHER
Mifepristone : 200mg 24-48 hrs before induction followed by 200
microgram orally every 3-4 hrs.
In gestations more than 34 wks dose of 100 microgram of misopristol
appear to be effective
When possible membranes should be left intact for as long as possible
as ascending infection can rapidly occur.
PPH is not uncommon especially where there is PE , abruption ,
prolonged fetal death , or infection . prolonged chorioamnioitis and
repeated small abrution predispose to retained placenta, when this
occur it should be delt quickly and Abprophylaxis given.
IX of the fetus :
- the fetus should be care fully examined after birth .the birth WT
should be recorded and the placenta weighted ..any dysmorphic signs
should be noted .
- Determination of the sex of the baby.
- Fetal karyotyping and infection screening.
- Fetal skin karyotyping.
- Full fetal x-ray.
IX of the mother :
IX of the mother should include the following:
- Maternal blood for : infection screen , lupus anti coagulant ,ACL abs
, thrombophilia screen) , kliehuer test ,anti Ro
- Maternal genital swabs if inf ction is suspected ,maternal urine for
drug screening.
- Placenta : swabs for infection should be taken(from between
membranes).
- Small sample send with saline for karyotype
- The whole placenta send for histopath.
- Suppression of lactation
- Good supportive bra ,NSAID
- Some female require additional pharmacological measures . single
dose of cabergoline (long acting dopamine agonist) but should not
be used in female with PET or a person with strong family history of
thromboembolic disease.
- First follow up visit should be within 6 wks. (THE END)