IUFD Flashcards
(9 cards)
IUFD
Fetal deaths weighing 500 gram or more occurring both during pregnancy (antepartum death) or during labor
(intrapartum).> 20 wks gestation
Fetal death after 20 weeks’ gestation but before the onset of labor.
Pathology of IUFD
Dead fetus undergoes an aseptic degenerative process called maceration.
1
st structure to undergo this process of maceration within 12–24 hours after death is the epidermis,
Results in skin blistering and peeling off
Fetus becomes swollen and appear dusky red.
Then aseptic autolysis of ligamentous structure, liquefaction of brain matter and other viscera gradually occur
CAUSES
IUFD Clinical features
1) Symptoms
a) Absence of fetal movements.
b) Absence of fetal heart
c) Absence of uterine growth
d) Decrease or disappearance in pregnancy symptoms (e.g., nausea, breast tenderness)
e) Vaginal bleeding
f) Labor/contractions
2) Signs
a) Retrogression of +ve breast changes occur after variable period following IUFD.
b) Per abdomen
* Gradual retrogression of HOF - uterus is smaller than period of amenorrhea.
* Diminished uterine tone and the uterus feels flaccid
* Impalpable fetal movements.
* Absent Fetal heart sound on auscultation.
c) Egg-shell crackling feel of the fetal head is a late feature
DIAGNOSTIC Investigations
a) Confirmed by U/Sound: absence of fetal cardiac activity & lack of fetal movement
* Oligohydramnios
* Collapsed cranial bones
b) ↓ Serial ß-hcg
c) Straight X-ray abdomen- no routinely done.
* Spalding sign- Appears 7 days after death
* Irregular overlapping of cranial bones due to liquefaction of brain matter
and softening of vault supporting ligamentous structures.
* Ball sign- Hyperflexion of the spine is more common.
* Crowding of ribs shadow with loss of normal parallelism
* Helix sign – gas in the umbilical vein
* Robert’s sign- Appearance of gas shadow in heart chambers & great vessels.
* Appear as early as 12 hrs but hard to interpret but if present provide
conclusive evidence.
d) Coagulation profile- blood fibrinogen level, PT and aPTT periodically
IUFD work up to establish cause
a) Blood evealuation consists
ABO and Rh grouping,
Hb electrophorersis
HbA1c
Kleihauer-Betke test- done detected to identifying fetal erythrocytes in maternal blood circulation
VDRL,
Postprandial blood sugar, HbA1c,
Urea, creatinine,
Thyroid profile,
TORCH screening, Parovirus and cultures for Listeria
Lupus anticoagulant, anticardiolipin antibodies and thrombophilia studies ((antithrombin, Protein C & S,
factor IV Leiden, Factor II mutation).
b) Urine- for casts and pus cells, M/C/S.
c) Infant and placenta examination:
Infant- for malformations, umbilical cord for entanglement, number of vessels
Placenta- for meconium staining, malformations and record respective weights.
Autopsy and chromosome studies- for fetuses with anomalies and dysmorphic features.
Cytogenetic studies tissues- Fetal skin, blood
d) complete autopsy
Complications of IUFD
a) Psychological upset
b) Infection: unlikely if membranes are intact, but once they rupture, infection, especially by gas forming organisms
like Cl. welchii may occur as dead tissue favors their growth
c) Coagulopathy- if retained for > 4 weeks (10–20%) caused by defibrination from ‘silent’ DIC due to gradual
absorption of thromboplastin, liberated from the dead placenta and decidua, into the maternal circulation
d) During labor
Uterine inertia, retained placenta and postpartum hemorrhage.
IUFD Management
Two different approaches: watchful expectancy and induction of labor.
In about 80% of cases, spontaneous expulsion occurs within 2 weeks of death.
Do weekly Fibrinogen estimation, along with a hematocrit and platelet count.
* Decreasing, fibrinogen level of 300 mg/dL may be an early sign of consumptive coagulopathy
Conservative approach may prove unacceptable due to pt’s feeling of personal loss, guilt & significant anxiety
Mgt depends on
Single or multiple gestation
Gestation age at death
Parents wish
Induction of labor
For those who fail to go into labor spontaneously is active intervention
Fetal death <28 weeks- mifepristone 200mg followed by misoprostol 400mcg 4-6hourly
Fetal death > 28 weeks- cervical ripening (mechanical/chemical) followed by oxytocin induction.
Medical induction:
a) Oxytocin infusion: effective if the cervix is favorable
* Initially begin with, 5–10 units of oxytocin in 500 ml of R/L IV infusion
* If that failures, escalating dose on the next day to 20 units of oxytocin in 500 ml of R/L, and run 20-
40 drops/min
* If uterus is refractory to above regimen, repeat after vaginal administration of prostaglandin gel.
b) Prostaglandins: PGE2 gel (dinoprostone [Prostin E2]) or lipid pessary inserted in posterior fornix is
very effective where cervix is unfavorable
* Misoprostol (PGE1) 25–50 μg either vaginally or orally. Repeat every 4 hours
* Do not exceed 4 doses
* Contraindicated in previous C/section, myomectomy, history of bronchial asthma or active
pulmonary disease
In mild DIC, in the absence of bleeding, deliver by the most appropriate means.
If clotting is severely defective with evidence of bleeding, give platelets, FFP and blood volume support before
any intervention
Indications of early interference in IUFD
a) Psychological upset of the patient—common
b) Associated uterine infection
c) Prolongation of pregnancy beyond 2 weeks after IUFD
d) Falling fibrinogen level (rare)
