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Definition IUFD denotes death of fetus in utero. Etiology: Pregnancy complications: - Pre-eclamptic toxaemia - Antepartum haemorrhage : placenta praevia, abruptio placentae Pre- existing medical disease and acute illness - Chronic hypertension - Chronic nephritis - Diabetes - Severe anaemia - Hyperpyrexia - Syphilis, Hepatitis, toxoplasmosis etc.
IUFD
IUFD (contd)
Foetal - Congenital malformation - Rh-incompatibility
- Post maturity
External version
Idiopathic 20 30%
Diagnosis
Symptoms- Absence of foetal movements Signs- Retrogression of the positive breast changes. Per-abdomen- Gradual retrogression of the height of the uterus - Uterine tone is diminished - Foetal movement are not felt during palpation. - Foetal heart sound is not audible Investigations- 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 - Appearance of gas shadow (Roberts sign) : 12 hours
Diagnosis (contd)
Sonography : (a) Lack of all foetal motions (including cardiac) (b) Oligohydramnios and collapsed cranial bones Haematological examination: VDRL, Blood sugar and urea Postmortem studies Cytogenetic study: In cases of congenital malformation of IUGR Rh-typing,
Lab evaluation
Maternal
FBS, Platelet count, ICT, Kleihaur-Betke test, LAC, ACL, Fetal karyotype Thrombophilia workup PCR of fetal product for viral infectin Amniotc fluid culture Weekly fibrinogen
Fetal
karyotype Postmortom examination Fetogram
Complications
1. Psychological upset 2. Infection: Once the membranes rupture, infection, especially by gas forming organism like CI. Welchi. 3. Blood coagulation disorders 4. During labour : Uterine inertia and PPH
Prevention of IUFD:
- Regular antenatal care
- To screen out the at-risk patients to monitor carefully for the assessment of foetal well being and to terminate the pregnancy at the earliest evidences of foetal compromise.
Pregnancy Management
Single or multiple gestation Gestational age at death The parents wish
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)
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.
The goal of Antepartum fetal surveillance is to prevent fetal death Antepartum fetal surveillance are routinely use to assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions as well as those in which complication have developed.
Non-stress test
Indirect measurement of uteroplacental insufficiency function. Based on the premise that heart rate of the fetus that is not acidotic or neurologically depressed will accelerate with fetal movement. Good indicator of normal fetal autonomic function
NST: How to do it
Patient in lateral tilt position Accelerations peak (but do not necessarily remain) at least 15 BPM above baseline Last for 15 seconds Reactive: 2 or more accelerations within 20 m period Nonreactive: one that lacks sufficient accelerations No contraindications
Biophysical Profile
Includes : Fetal breathing, tone, somatic movements, liquor and NST <= 4/ 10 deliver
>= 8 / 10 surveillance
There may not be any benefit in immediate delivery (esp. if the surviving fetuses are very preterm and other wise healthy) pregnancy to continue may provide the most benefit. DIC (disseminated intravascular coagulopathy) remains a theoretical risk, rarely occurs Fibrinogen and fibrin degradation product levels can be monitored serially until delivery and delivery can be expedited if DIC develops
Etiology:
Maternal: - Heredity - High standard of living with sedentary habit - Elderly primigravida - Previous history of prolonged pregnancy (50% cases) Fetal: - Anencephaly Placental - Sulphatase deficiency
Diagnosis
Record of the dates of the LMP Definitely known date of ovulation, data based on basal body temperature (BBT) charts or sonographic dating.
A reliable clinical assessment of gestational size in the first trimester. This data may be fallacious in obese women, uncooprative patients, women with fibroids in the uterus or when a satisfactory pelvic examination has not been possible.
Diagnosis (contd)
A sonographic scan between the 10 and 12 weeks gives the assessment of gestational maturity with +/range of 7 days. Quickening
Fundal height at 28 weeks of gestation usually corresponds to 28 cm. In case of discrepancy between the menstrual dates and clinical findings, and early sonographic scan should help in assessing gestational maturity.
Dangers
Foetal:
During pregnancy: Foetal hypoxia due to placental aging. During labour: Asphyxia and intracranial damage due to: (a) Pre-existing hypoxia (b) Increased incidence of difficult labour: Big size baby non moulding of head (c) Increase incidence of operative delivery (d) Scanty liquor amnii and less Whartons jelly in the cord favour cord compression. Following birth: Meconium aspiration syndrome