Obstetrics
Intra-uterine Fetal Death ( IUFD )Or stillbirth
Definition :
Is the delivery of the baby with no sign of life after 24 wks of pregnancy .Incidence :
5-5 per 100000 of delivered babies ( stillbirth rate )Association :
( The association is not the same as causation )This condition associated with :
- Advanced maternal age .
- Advanced gestation .
- Maternal obesity .
- Social deprivation .
* IUFD is more common with the above conditions .
Causes of IUFD :
1. Fetal :
* Cord accident ( e.g cord prolapsed ) ,knots , torsion , thrombosis .
* Feto fetal transfusion ( twin pregnancy ) .
* Chromosomal & genetic disease .
* Structural anomalies .
* Infection ( Bacterial , viral ) .
* Anaemia of Fetal origin ( e.g. Alfa - thalasemia major which is incompatible with life ) .
* Feto maternal haemorrhage .
2- Maternal ( Direct effect )
* Obstetrical cholestasis .* Metabolic disturbances ( diabetic ketoacidosis )
* Reduced O2 in pulmonary diseases cystic fibrosis &
obstructive sleep apnea .
* Uterine anomalies e.g. Asherman's syndrome which is intra uterine adhesion which is mainly occur after a vigorous uterine curettage & remove the endomatrium so the nutrient supply will be diminished & the fetus suffer from deficiency , hypoxia which lead to IUFD .
* Antibody production : Congenital heart block ( caused by SLE . anti Ro ) ., Rhesus disease ( Rh )
3- Maternal Placental effect :
* Pre-eclampsia ( PE ) .* Renal disease .
* Anti phospholipids syndrome .
* Thrmbophilia tendency to cause thrmbosis
Caused by genetic or acquired diseases .
* smoking
* Drug abuse e.g. cocaine .
* Abruption placenta ( AP ) .
* Although , 30 50 % of IUFD cases are unexplained .
Diagnosis :
The presentation is fetal movement in 50% of cases , others present with an unexpected finding or accidentally discovered during routine antenatal u/s which shows – ve fetal heart activity or with an acute event ( e.g. placental abruption ) , The CTG reveal ve fetal heart sound or present with rupture membrane ( complicated by cord prolopse ) present with active labour .
" The diagnosis must be established as soon as possible "
Note : Fetal death must be diagnosed by u/s not ( cardiotocography ) (CTG ) which is very misleading , because in IUFD the CTG may measure the maternal heart rate & consider it as fetal heart rate ( normally we can differentiate between fetal & maternal heart rate by measuring the rate , if it is 110 pbm or above it is fetal , but sometimes the mothers are anxious that lead to tachycardia confused with fetal heart rate )
U/S :
1. -Ve fetal heart activity .2. Oligohydromnios .
3. Spolding sign : Overlap of fetal skull bone ( the death for sometime )
Also we can find the sign of fetal hydrops .
At the sometime we should exclude acute conditions1. AP : Because it is an obstetrical emergency .
2. PE : We should measure the blood pressure & urinalysis to rule out significant pre-eclampsia .
If the cause of IUFD is AP the major signs will be of abruption :
1. Tender uterus .
2. Tetanic uterine contraction .
3. ve fetal cardiac activity .
4. Vaginal bleeding +ve or ve .
- If we suspect . that the fetus died for sometimes from " Spolding sign , oligohydromnios , hydrocele " we should send the mother for clothing screening to rule out disseminated intravascular coagulopathy " DIC " like : Complete blood count , platelet count , activated partial thromboplastin time ( PTT ) , prothrombin time ( PT ) , serum fibrinogen level .
If the mother was Rh-ve we must give anti-D ( anti-Rh ) . ( because massive feto- maternal transfusion is one cause of fetal death and may have occurred hours or even days before clinical presentation ) .
If the mother Rh-ve anti -D immunoglobulin& blood for kleihauer test which is a quantitative test for the measurement of volume of feta maternal transfusion : because the standard dose of anti-D covers only 15 cc of fetal blood " so we need to the dose of anti-D immunoglobulin to amount of fetal blood in maternal blood to prevent sensitization .
Management :
1. Psychological support .
2. Investigation for a cause .
3. Mode of delivery .
4. Prevent Rh Sensitization .
5. Suppression of lactation .
6. post-mortam examination .
7. follow-up
8. Management for future pregnancies .
Made of Delivery :
After emotional & psychological support of parents and family , The aim is vaginal delivery unless there is an absolute indication for C/S .Various strategies used for induction of labour after fetal death , it is important to remember that complications such as : rupture uterus & shoulder dystocia can occur and management must be safe .
Note : The patient should treated as in normal labour , so the progress of labour should be monitered ( only the fetal heart is not monitered ) .
* The 3rd trimester induction of labour is by :
1. Standard ( prostaglandin E2 ) ( PGE2 ) preparation .
2. Other method by anti progesterone (mifepristone) + prostaglandin analogue ( misoprostol ) .
The advantage of this protocol is the induction time is short .
Mifepreston 200 mg orally 24-48 hrs before induction then misoprostol 200 microgram vaginally , then 200 microgram every 3 4 hrs orally .* Difference between normal labour & induction of IUFD is the following :
1. The membrane should be intact as long as possible b/c of risk of choriomnionitis ( ascending infection & sepsis is rapidly occurred )
2. Post partum Haemorrhage not uncommon espically when PE , AP and prolong IUFD ( fetal death is of 4 wks duration or more ) .
3. risk of retained placenta because of prolong chorioamnionitis & repeated small abruption so antibiotic should be given .
Investigations for a cause :
Because of risk of recurrence , we try to find the possible treatable cause of IUFD :A) Investigations of the baby :
1. Careful exam . of the baby for structural anomalies .
2. Weigh the baby for possible macrosomia
( the normal birth weight 2.5 3.5 kg )
3. Weight the placenta " small baby = small placenta & vice versa " . & for morphologic abnormalities that is mostly occur in acute condition .
4. Determine the sex of the baby .
5. We need pediatrician help .
6. Fetal blood for infection screen & karyotype .
7. Fetal skin for karyotype " un available fetal blood "
8. Full fetal X-ray .
9. Amniotic fluid culture for cytomegalovirus, anaerobic and aerobic bacteria .
B ) Investigations of the mother :
1. Maternal blood infection & autoimmune disease like antinuclear antibody , lupus anticoagulant anticardiolipin antibody , SLE ( anti-Ro ) , Anti –La, thrmbophilia , Hb 1C ( for sugar level over last 10 weeks ) & never send for Random blood sugar b/c RBS return to normal after IUFD .2. Bile test to exclude intra hepatic cholestasis .
3. Kleihaure test regardless the B. group of the mother & should be done as soon as possible , otherwise the fetal RBCs will be lysed & disappeared from the blood .
4. Anti-Ro Ab if the fetus is hydrops SLE ( systemic lupus erythromatosis ) .
5. Maternal genital tract swab infection .
6. Maternal urine for drug screening .
Investigations of the placenta
1. Weigh the placenta .
2. Swab for infection .
3. Sample karyolype ( put in normal saline )
4. Whole placenta should be sent for histopathology calcification & thrombosis " e.g. SLE , PE ) .
Suppression of Lactation :
- Simple measure + analgesia ( NSAIDS )
because breast engorgement is painful .
- single dose of (cabergoline) long acting dopamine agonist highly effective .
contra indicated in patient .
1. patient with PE .2. Person or strong family history of thromboembolic disease .
Follow up
- Psychological support .The 1st follow up visit should be during or after the 1st 6 weeks ( peurperuim ) .
- The investigation should be repeated to identify the possible treatable cause & follow the previously set plan .
- If we dont reach a cause , we consider the next pregnancy is a high risk pregnancy .
Note :
Disseminated intravascular coagulopathy ( DIC ) :State characterized by degrees of decreased fibrinogen, plasminogen, antithrombin III , and platelets and increased fibrin degradation products , It occurs due to pathologic activation of the clothing cascade , which is demonstrable . with in 48hrs of the demis . The incidence of it increases with the duration of the delay , < 2% of these women experience a haemorrhagic complication .
- The coagulapathy resolves within 48 hrs of delivery .
Objective
The student should be known :
* Death of a fetus , whether anticipated or not , inevitable or not is a tragedy .
* The first and ongoing priority in management is emotional and psychological support of the parents and family .* The second priority is to find an explanation .
* The third priority is to implement an appropriate management strategy for future pregnancies .