musculo scelatal system

1. Intrauterine Fetal Death
(IUFD)
1

2. Objectives
2
At the conclusion of this session, you will be able to:
1. Discuss common causes of fetal death in late trimester of
pregnancy.
2. Discuss symptoms and diagnosis of fetal death.
3. Discuss management of the patient with a fetal death or a
history of fetal death in a prior pregnancy

3. IUFD
3
• Deaths occurring in utero in which the fetus or
neonate weighs >500 gm and/or deaths occurring at
22 wks of or greater (ACOG)
• Only deaths occurring in utero in which the fetus or
neonate weighs >1000 gm and/ or deaths occurring >
28wks of gestation (Ethiopia)

4. Why concern?
• There are nearly 2 million stillbirths every year – one every
16 seconds. Over 40% of all stillbirths occur during labour.
• In 2014, the WHO endorsed the Every Newborn Action
Plan (ENAP), which includes a global target of 12 or fewer
third trimester (late) stillbirths per 1,000 total births in
every country by 2030.
• In 2021, 139 mainly high-income and upper middle-income
countries had met this target, but 56 countries will not each
the ENAP target by 2030 if further efforts are not made.
• If current trends continue, 15.9 million babies will be
stillborn; nearly half of these (7.7 million, 48%) will occur in
sub-Saharan Africa.

7. Causes of IUFD
Maternal factors (5-10%)
DM and HTN disorders in pregnancy
Maternal infections (malaria, hepatitis, influenza, toxoplasma,
syphilis)
Hyperpyrexia (temp > 39.4°C)
Antiphospholipid syndromes (APS)
Systemic lupus erythematosus
Thrombophilias: Factor V Leiden, protein C, protein S
deficiency, hyperhomocysteinemia
Abnormal labor (prolonged/obstructed labor, ruptured uterus)
Post-term pregnancy

8. Causes of IUFD
b. Fetal (25–40%)
Chromosomal abnormalities
Major structural anomalies
Infections (virus, bacteria, chorioamnionitis).
Rh-incompatibility
Non-immune hydrops
Growth restriction

9. Causes of IUFD
C. Placental (20–35%)
Antepartum hemorrhage
Cord accident (prolapse, true knot, cord around the neck)
Twin transfusion syndrome (TTTS)
Placental insufficiency
D. Iatrogenic
External cephalic version
Drugs (quinine beyond therapeutic doses)
E. Idiopathic (25–35%)

10. Stillbirth and Associated Factors Among Women Who
Gave Birth at Hiwot Fana Specialized University
Hospital, Harar, Eastern Ethiopia

11. Diagnosis
11

13. Patient Presentation
6/9/2023
• Subjective decreased fetal movements
• Pregnancy symptoms absent or diminishing
• White milk expression during pregnancy
• Egg- shell cracking feel of the fetal head (late
feature)
• Uterus FH is small for EGA
• No fetal heart tones with doppler
• Will still have positive or negative hCG

14. Diagnosis
Abdominal X-ray
 Spalding’s sign- the irregular overlapping of the
cranial bones on one another and the rolled up
appearance of the fetal trunk
 Robert’s sign- the appearance of gas bubbles in the
thoracic cavity of the fetus within the heart
chambers or great vessels.
 Kehrer’s sign- hyperflexion of the spine

16. Diagnosis
• Sonography
Absent cardiac activity.
Absent fetal movement.
Oligohydraminous
collapsed cranial bones
Fetal pleural effusion
Hyperextended spine
• CTG
• Amniocentesis-dark brown meat water like AF

17. Work Up of a Patient with IUFD
• ABO and Rh grouping
• VDRL
• Post prandial blood sugar (FBS) level
• Thyroid profile
• TORCH screening
• Lupus anticoagulant and anticardiolipin Abs
• CBC
• U/A & Urine toxicology screen
• Direct/Indirect coomb’s (anti body screen)
• Prothrombin time (PT), Partial
thromboplastin time (PTT)
• Platelet count, Fibrinogen level

18. aPTT :30-40 sec
PTT: 60-70 sec
PT: 11-12.5 sec
INR: 0.8 to 1.1
Platelet: 150-400k

19. Management
6/9/2023
1. Watchful expectancy
2. Immediate induction of labor
The mother must be involved in the decision.
1. Watchful expectancy:
Weekly determination of fibrinogen levels,
hematocrit and platelet count should be done
and monitored during the period of expectant
management

20. Management
6/9/2023
• Expectant management is also not possible in
the phase of obstetric complications like
PROM,
Chrioamnionitis
Rh isoimmunization
 severe maternal disease (e.g CHD)

21. Management
6/9/2023
2. Induction of labor
Justifications for early intervention include
the emotional burden on the patient associated
with carrying a dead fetus
the slight possibility of chorioamnionitis
the 10% risk of DIC when a dead fetus is
retained for more than 5 weeks in the 2nd or 3rd
trimester.

22. Management
6/9/2023
• Induction should always be on elective basis,
unless emergency conditions arise like
chorioamnionitis
If the cervix is favorable, then start induction
with oxytocin drip
For unfavorable cervix, priming cervix with
misoprostol vaginally 25 - 50 microgram every 4
- 6 hours (2 to 3 doses are usually enough )
followed by oxytocin drip after 4 hours of the
last dose of misoprostol

23. Management
6/9/2023
 In case of malpresentations or CPD/FPD during
labor, try everything possible to avoid C/S
 Perform destructive delivery when pre-requisites
are fulfilled
 Care should be taken to prevent maternal injury
 Cesarean section is done only as last resort, or if a
clear cut indication for cesarean section is present.

24. 6/9/2023

25. Follow-up
6/9/2023
It is important to determine the cause of a
fetal death so that the parents can be
counseled, that will help to describe risk of
recurrence and help to develop the plan for
care of subsequent pregnancy.
The care giver should write a detailed note
describing the stillborn (sex, birth weight,
grade of the maceration, look for
malformations, growth restriction or hydropic
features

26. Prevention
6/9/2023
Proper antenatal care.
1. Antenatal treatment of maternal infections
e.g.- Syphilis. - Toxoplasmosis. - Genital tract
infections.
2.Antenatal treatment of maternal risk factors
e.g.- Diabetes. - Hypertension. - Anaemia.
3. Tetanus toxoid vaccination to the mother to
protect the foetus from tetanus neonatorum

27. 27

28. Maternal Complications
6/9/2023
• Depression
• Anxiety
• Psychosocial
• Anxiety with future pregnancies
• May have repeat losses (depending on causes)
• Bleeding ---> can lead to DIC
• Pain
• Infection

29. Patient Teaching
29
All pregnant women should be counselled
regarding:
Normal fetal activity,
Avoidance of high-risk behaviours (including
smoking and substance use),
Avoiding infectious complications (parvo exposure,
Listeria exposure),
Symptoms to report to their care providers that could
signal fetal danger

30. Prevention
30
The prevention of IUFD rests on the provision of
prenatal care to identify pregnancies at risk or in
jeopardy.
Careful evaluation of a prior fetal death can provide
invaluable information to allow appropriate
intervention and surveillance of future pregnancies to
prevent loss