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Intrauterine fetal demise
- 1. INTRAUTERINE FETAL DEMISE/ DEATH KIPKORIR K NICKSON- MEDVI
- 2. Introduction Case study Definition of fetal death Epidemiology Aetiology Diagnosis/ clinical presentation Management Investigations and assessment Maternal studies Management of future pregnancy Summary
- 3. Introduction Loss of a fetus at any gestation is a fetal demise
- 4. CASE STUDY 29 yr para 1+0 G2 at GBD 37/40 with 1 previous scar ( emergency CS) due to fetal distress in 2014 HPI h/o loss of fetal movements 4/7 No h/o trauma, no h/o pv bleeding Booked at 16/40. Normal ANC follow up. Obs scan normal ITT injection On Fe supplements
- 5. PMSHX Non contributory FSHX Housewife. No substance us No FHx of chronic illnesses O/E Fair, afebrile, not pale/jaundiced/dehydrated/ cyanosed Vital signs; normal range P/A Pfannestiel scar, fundal height 34/40, longitudinal, cephalic, fetal heart tone absent V/E cervix 3cm long, <30% effaced, posterior, closed, firm Other systems normal
- 6. IMPRESSION; Intrauterine Fetal death at GBD 37/40 PLAN 1. Transabdominal ultasound spalding sign no fetal cardiac activity demonstrable at gestation 34 weeks 2 days 2. Arrange for delivery make decision on appropriate mode PGE2 pessary oxytocin drip (close monitoring)
- 7. Definition The National Centre for Health Statistics defines fetal death as death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy Death is indicated by -the fetus does not breathe or show any other evidence of life - Heartbeats are to be distinguished from transient cardiac contractions
- 8. It is further classified as Early( <20 weeks gestation) Intermediate ( 20- 27 wks gestation) Late (> 28 weeks gestation)
- 9. Epidemiology Worldwide, rate varies considerably Ranging from 5 in 1000 births in high income countries and 36 in 1000 births in developing countries
- 10. Aetiology Any pregnancy classified as a high risk pregnancy is at risk of IUFD Efforts should be directed towards the recognition of such early enough 25-60% of fetal demise has unexplained cause Incidence increases with increasing gestational age
- 11. Risk factors African American race Advanced maternal age History of fetal demise Maternal colonization with certain pathogens i.e GBS, ureaplasma urealyticum Obesity Paternal age Male fetal sex Multiple gestation Non vertex presentation
- 12. Maternal Post term pregnancy (>42wks) Diabetes( poorly controlled) Systemic lupus erythematosus Infection, viral; Parvovirus B19, CMV, Coxsackie. Bacterial; GBS, Listeria monocytogenes, E. coli. Parasitic; Toxoplasma gondii Chronic hypertension Preeclampsia Haemoglobinopathy Advanced maternal age Rh disease Uterine rapture Antiphospholipid syndrome Maternal death
- 13. Fetal Multiple gestation Intrauterine growth restriction Congenital abnormality Infection
- 14. Placental Cord accident Abruption Premature rapture of membranes Vasa previa
- 15. Diagnosis/ Clinical presentation H/o decreased fetal movement Inability to obtain fetal heart tones upon examination suggest fetal demise Confirmatory: By ultrasonographic examination. - Visualize fetal heart and note absence of cardiac activity -Overlapping of skull bones (Spalding sign) - Gas in great vessels ( Roberts sign) - Exaggeration of fetal spinal curvature and angulation
- 16. Management Psychological On confirmation of diagnosis, inform patient Counselling- stabilize patient emotionally If in U/S room, allowing mother to see lack of fetal cardiac activity helps to solidify the diagnosis Definitive Induce labour as soon as possible Dont delay > 3-4 weeks because hypofibrinogemia develops coz thrombopastic substances are released from degenerating POCs risk of coagulopathy
- 17. Induction Cervical assesment Pre- induction cervical ripening followed by IV oxytocin In h/o previous C/S, caution coz of risk of uterine rapture Early fetal demise managed by MVA or Dilatation and evacuation < 28/40 PGE2, PGE1 +/- oxytocin >28/40 lower doses should be used Pain management- higher doses of narcotics, if superior control is needed, epidural anaesthesia should be offered
- 18. Maternal and family History Past obstetric history: past fetal losses Review history of present pregnancy -Gestational age and fetal growth - Maternal perception of fetal mvmnts in recent past -h/o bleeding - elevated blood pressure - recent illness or possible viral exposure - medications during pregnancy - substance use
- 19. Review of ANC Lab investigations Fetal assessment( NST, BPP, Doppler studies) Review family history
- 20. Maternal studies U/S Blood; RBS/FBS, CBC, Coagulation profile, Blood group and Ab screen, VDRL Urine; Toxicology Kleihauer- Betke ( fetal- maternal haemorrhage) 10- 15% unexplained IUFD TORCH screen Autoimmune: ANA, anticardiolipin Ab, lupus anticoagulant Chronic medical conditions like high TSH
- 21. Stillbirth examination a) General; -state of preservation(fresh or macerated) -wt, size and if corr to gestational age - measurements: HC, circumference of chest and abdomen, crown-heel length - Color a) Craniofacial b) Neck
- 22. d) Trunk e) Extremities Grade of maceration Demise 0 parboiled reddened skin <8hrs 1 Skin slippage and peeling >8hrs 2 Extensive skin peeling Red serous effusions in chest and abd ( Hb staining) 2-7 days 3 Liver yellow brown Turbid effusion May be mummified >8 days
- 23. B) Autopsy -encouraged on all stillbirths -if patients resistant to idea, limited autopsy done - Post mortem MRI can also be done C) CORD Exam -Appearance and length in cms - no. of vessels - true knots( loose or tight) - cord blood( only if fresh stillbirth) for culture and cytogenic studies( DO NOT FREEZE)
- 24. D) PLACENTA Exam -Gross and microscopic exam -Clinically relevant findings expected in about 30% of studied placentas -send for culture. Sterile swab btwn amnion and chorion - cytogenetic studies
- 25. E) Clinical PHOTOGRAPHS - Get permission from parents - Essential in documentation of both normality and abnormality tog with descriptive P/E - get AP & PA views ( whole body incl limbs - Lateral and frontal views of the face - Photos of any abnormalities
- 26. F) RADIOGRAPHIC Studies - useful in documenting abnormalities primarily skeletal not detected on P/E - Incl. AP plain radiograph of the whole body incl limbs( place in anatomic position) - lateral view of the skull - take separate films if structural abn are present - if dwarfism present, additional AP and lateral views of the infant limbs, head and spine
- 27. Management of future pregnancy - Preconceptional counseling is helpful if congenital anomalies or genetic abnormalities are found - Genetic screening and detailed ultrasound can evaluate future pregnancies - In cases whwere cause is unkwown, patients are naturally distressed and anxious of its recurrence - Reassurance necessary eg by increasing fetal surveillance - Optimal management of chronic medical conditions is very important prior to the next pregnancy
- 28. SUMMARY Loss of a fetus at any gestation is fetal demise Keep in mind important and most common aetiological factors Diagnosis Evaluation Mx of future pregnancy
- 29. THANK YOU