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Iufd by dr shabnam

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Iufd by dr shabnam

  1. 1. INTRA UTERINE FETAL DEMISE DR SHABNAM NAZ ASSISTANT PROFESSOR CMC,SMBBMU LARKANA
  2. 2. IUFD <ul><li>Definition – </li></ul><ul><li>IUFD denotes death of fetus in utero or weighing >500gm or >24 weeks, before the onset of labour. </li></ul><ul><li>Incidence: </li></ul><ul><li>4.5/1000 </li></ul>
  3. 3. Etiology <ul><li>Unknown in 25 – 60% of cases </li></ul><ul><li>Identifiable causes can be attributed to </li></ul><ul><ul><li>Maternal conditions </li></ul></ul><ul><ul><li>Fetal conditions </li></ul></ul><ul><ul><li>Placental conditions </li></ul></ul>
  4. 4. Fetal causes -- 25-40% <ul><li>Chromosomal anomalies </li></ul><ul><li>Birth defects </li></ul><ul><li>Non immune hydrops </li></ul><ul><li>Infections </li></ul><ul><li>TORCH </li></ul>
  5. 9. Placental -- 25-35% <ul><li>Abruption </li></ul><ul><li>Cord accidents </li></ul><ul><li>Placental insufficiency </li></ul><ul><li>Intrapartum asphyxia </li></ul><ul><li>P Praevia </li></ul><ul><li>Twin-twin transfusion Synd: </li></ul><ul><li>Chorio-amnionitis </li></ul>
  6. 10. Cord prolapse
  7. 11. Calcification and haemorrhage in placenta
  8. 12. Vasa Previa
  9. 13. Maternal 5-10% <ul><li>Antiphospho-lipid antibody </li></ul><ul><li>DM </li></ul><ul><li>HTN </li></ul><ul><li>Trauma </li></ul><ul><li>Abnormal labor </li></ul><ul><li>Sepsis </li></ul><ul><li>Uterine rupture </li></ul><ul><li>Post-term pregnancy </li></ul><ul><li>Drugs </li></ul>
  10. 14. Ruptured uterus
  11. 15. <ul><li>Mom with no prenatal care delivers undiagnosed twins at EGA 34 weeks </li></ul>
  12. 19. Diagnosis to confirm iud <ul><li>history &examination </li></ul><ul><li>-Absence of fetal movements </li></ul><ul><li>-Retrogression of the positive breast changes. </li></ul><ul><li>Gradual retrogression of the height of the uterus </li></ul><ul><li>Uterine tone is diminished </li></ul><ul><li>Fetal movement are not felt during palpation. </li></ul><ul><li>Fetal heart sound are not audible </li></ul>
  13. 20. Diagnosis (contd…) <ul><li>Straight- X-ray abdomen </li></ul><ul><li>Spalding sign: it usually appears 7 days after I.U.F.D. </li></ul><ul><li>Hyperflexion of the spine </li></ul><ul><li>Crowding of the ribs shadow </li></ul><ul><li>( Robert’s sign ) Appearance of gas shadow in great vessels : 12 hours </li></ul>
  14. 21. cont <ul><li>Sonography : </li></ul><ul><li>absent fetal movements </li></ul><ul><li>Oligohydramnios and collapsed cranial bones </li></ul><ul><li>Spalding sign </li></ul>
  15. 22. Evaluation of iufd to detect the cause <ul><li>I-Maternal medical conditions </li></ul><ul><li>VTE/ PE </li></ul><ul><li>DM </li></ul><ul><li>HPT </li></ul><ul><li>Thrombophilia </li></ul><ul><li>SLE </li></ul><ul><li>Autoimmune disease </li></ul><ul><li>Severe Anemia </li></ul><ul><li>Epilepsy </li></ul><ul><li>Heart disease </li></ul><ul><li>II-Past OB Hx </li></ul><ul><li>Gestational HTN with adverse sequele </li></ul><ul><li>Placental abruption </li></ul><ul><li>IUFD </li></ul><ul><li>Recurrent abortions </li></ul><ul><li>Baby with congenital anomaly / hereditary condition </li></ul><ul><li>IUGR </li></ul>
  16. 23. Current Pregnancy Hx <ul><li>Maternal age </li></ul><ul><li>Gestational age at fetal death </li></ul><ul><li>HPT </li></ul><ul><li>DM/ Gestational D </li></ul><ul><li>Smoking , alcohol, or drug abuse </li></ul><ul><li>Abdominal trauma </li></ul><ul><li>Choliestasis </li></ul><ul><li>Placental abruption </li></ul><ul><li>PROM or prelabour ROM </li></ul>
  17. 24. <ul><li>FAIMLY HISTORY </li></ul><ul><li>Recurrent abortions </li></ul><ul><li>VTE/ PE </li></ul><ul><li>Congenital anomalies </li></ul><ul><li>Abnormal karyotype </li></ul><ul><li>Hereditary conditions </li></ul><ul><li>Developmental delay </li></ul>
  18. 25. 2-Evaluation of still born infants <ul><li>Infant desciption </li></ul><ul><li>Malformation </li></ul><ul><li>Skin staining </li></ul><ul><li>Degree of maceration </li></ul><ul><li>Color-pale ,plethoric </li></ul><ul><li>Umbilical cord </li></ul><ul><li>Prolapse </li></ul><ul><li>Entanglement-neck, arms, ,legs </li></ul><ul><li>Hematoma or stricture </li></ul><ul><li>Number of vessels </li></ul><ul><li>Length </li></ul><ul><li>Amniotic fluid </li></ul><ul><li>Color-meconium, blood </li></ul><ul><li>Volume </li></ul>
  19. 26. Knots in cord
  20. 29. EXAMINATION OF PLACENTA <ul><li>Placenta </li></ul><ul><li>Weight </li></ul><ul><li>Staining </li></ul><ul><li>Adherent clots </li></ul><ul><li>Structural abnormality </li></ul><ul><li>Velamentous insertion </li></ul><ul><li>Edema/ hydropic changes </li></ul><ul><li>Membranes </li></ul><ul><li>Stained </li></ul><ul><li>Thickening </li></ul>
  21. 31. Vasa Previa
  22. 32. 3. INVESTIGATIONS <ul><li>Maternal investigations: </li></ul><ul><li>CBC </li></ul><ul><li>Blood Group & antibody screen </li></ul><ul><li>HB A1 C </li></ul><ul><li>Kleihauer Baket test </li></ul><ul><li>Serological screening for Rubella CMV, Toxoplasmosis, Syphilis, Herpes & Parvovirus </li></ul><ul><li>Karyotyping of both parents </li></ul><ul><li>Hb electrophoresis' </li></ul><ul><li>Antiplatelet antibodies </li></ul><ul><li>Thrombophilia screening (ant thrombin iii, Protein C & S deficiency , factor IV leiden,Factor II mutation, lupus anticoagulant, anticardolipin antibodies) </li></ul><ul><li>DIC </li></ul>
  23. 33. cont <ul><li>Fetal investigations </li></ul><ul><li>Fetal autopsy </li></ul><ul><li>Karyotype </li></ul><ul><li>(specimen taken from cord blood, intracardiac blood, body fluids, skin, spleen, </li></ul><ul><li>Placental wedge, or amniotic Fluid) </li></ul><ul><li>Fetography </li></ul><ul><li>Radiography </li></ul>
  24. 34. cont <ul><li>Placental investigations </li></ul><ul><li>Chorionicity of placenta in twins </li></ul><ul><li>Cord thrombosis or knots </li></ul><ul><li>Infarcts, thrombosis, abruption, </li></ul><ul><li>Vascular malformations </li></ul><ul><li>Signs of infection </li></ul><ul><li>Bacterial culture for E coli, </li></ul><ul><li>Listeria, group B strept. </li></ul>
  25. 35. Pregnancy Management <ul><li>Single or multiple gestation </li></ul><ul><li>Gestational age at death </li></ul><ul><li>The parents wish </li></ul>
  26. 36. Management <ul><li>Explain the problem to the woman and her family. Discuss with them the options of expectant or active management. </li></ul><ul><li>If expectant management is planned: </li></ul><ul><ul><li>Await spontaneous onset of labour during the next four weeks </li></ul></ul><ul><ul><li>Reassure the woman that in 90% of cases the fetus is spontaneously expelled during the waiting period with no complicatons. </li></ul></ul><ul><li>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) </li></ul>
  27. 37. Management (contd…) <ul><ul><ul><ul><li>If induction of labour is planned, assess the cervix </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>If the cervix is favourable (soft, thin, partly dilated) labour using oxytocin. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>If the cervix is unfavourable(firm, thick, closed) ripen the cervix. </li></ul></ul></ul></ul></ul><ul><li>Note: Do not rupture the membranes. </li></ul><ul><li>If spontaneous labor does not occur within four weeks, platelets are decreasing and the cervix is unfavourable, ripen the cervix. </li></ul>
  28. 38. Complications <ul><li>Psychological upset </li></ul><ul><li>Infection: Once the membranes rupture, infection, especially by gas forming organism like CI. Welchi. </li></ul><ul><li>Blood coagulation disorders </li></ul><ul><li>During labour : Uterine inertia and PPH </li></ul>
  29. 39. Prevention of IUFD: <ul><li>Regular antenatal care </li></ul><ul><li>To screen out the at-risk patients to monitor carefully for the assessment of fetal well being and to terminate the pregnancy at the earliest evidences of fetal compromise. </li></ul>
  30. 40. Morbid pathology of IUFD <ul><li>A dead fetus undergoes an aseptic destructive process called maceration . The epiderm is the first structure to undergo the process, whereby blistering and peeling off of the skin occur. It appears between 12-24 hours after death. The foetus becomes swollen and looks dusky red. Gradually aseptic autolysis of the ligamentous structure and liquefaction of the brain matter and other viscera take place. </li></ul>
  31. 41. Moen Jo Daro Larkana Sindh

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