IUFD(INTRA UTERINE FETAL DEATH).pptx

IUFD(INTRA UTERINE FETAL DEATH).pptx

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  IUFD(INTRA UTERINE FETALDEATH)
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   Definition : Intrauterine fetal death (IUD) embraces all fetal death weighing 500 gm or more occurring both during pregnancy (antepartum death) or during labour (intrapartum).  Thus, Antepartum death occurring beyond the period of viability is termed as intrauterine death.  WHO definition:  Fetal death means death prior to complete expulsion or extraction of mother of a fetus irrespective of duration of pregnancy and which is not an induced termination pregnancy. 
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   ETIOLOGY:  Causes Maternal: 5-10%  Placental : 20-35%  Fetal : 25-40%  Unknown: 25-35%
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  1.Maternal 5-10%  Hypertensivedisorder in pregnancy.  Diabetes in pregnancy.  Infections(malaria,hepatitis, influenza, toxoplasma&syphili  Hyperpyrexia  Antiphospholipid syndrome  Thrombophilis  Abnormal labour  Post term pregnancy  Systemic lupus erythematosus. 2.Fetal25-40%  Chromosomal abnormalities  Major structural anomalies  Infections  Rh- incompatibility  Non immune hydrops  Growth restriction
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  3.Placental20-35%  Antepartum haemorrhage. Cord accident  Placental insufficiency  Twin transfusion syndrome(TTTS) 4.Iatrogenic  Beyond dose.  External cephalic version  Drugs. 5.Idiopathic 25-35%  Causes remains unknown even with through clinical examination and investigations.
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  DIGNOSIS:  Repeated examinationare often required to confirm the diagnosis.  SYMPTOMS:  Absence of fetal movements which were previously noted by the patient.
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  SIGNS: retrogression ofthe positive breast changes that occur during pregnancy is evident after variable period following death of the fetus.  Per abdomen:  Gradual retrogression of the fundal height and it becomes smaller than the period of amenorrhoea.  Uterine tone is diminished and the uterus feels flaccid. Braxton-Hicks contraction is not easily felt.  Fetal movements are not felt during palpation  .Fetal heart sound is absent. Doppler ultrasound is better than the stethoscope.  Egg-shell crackling feel of the fetal head is late feature.
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   INVESTIGATION: Sonography:  Earliestdiagnosis is possible with Sonography.  The evidences are:  Lack of all fetal motions during a 10minute period of careful observation with a real-time sonar is a strong presumptive evidence of fetal death.  Gradually, oligohydramnios and collapsed cranial bones are evident.
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   Straight X-rayabdomen: Rarely done at present . The following features may be found in varying degree either singly or in combination.  Spalding sign –  The irregular overlapping of the cranial bones on one another is due to liquefaction of the brain matter & softening of the ligamentous structures supporting the vault. It usually appears 7 days after death.  Similar features may be found in extra-uterine pregnancy with the fetus alive
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   Hyperflexion ofthe spine is more common. In some cases hyperextension of the neck is seen.  Crowding of the ribs shadow with loss of normal parallelism.  Roberts sign : Appearance of gas shadow in the chambers of the heart and great vessels may appear as 12 hours but difficult tointerpret. When detected provides conclusive evidence.  Blood: To estimate the blood fibrinogen level and partial thromboplastin time periodically, when the fetus is retained for more then 2 weeks
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   COMPLICATION:  PsychologicalUpset often becomes a problem.  Infection: so long as the membranes rupture infection especially by gas forming organisms like Cl.welchii may occur. The dead tissue favours their growth with disastrous consequences.  Blood coagulation disorders are rare. If the fetus is retained for more than 4 weeks(10- 20%),there is a possibility of defibrination from silent disseminated intravascular coagulopathy (DIC).It is due to gradual absorption of thromboplastin, liberated from the dead placenta and decidua, into the maternal circulation.
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   During labor:Uterineinertia, retained placenta and postpartum haemorrhage.  PPH (postpartum hemorrhage)  Placental abruption  Shock, renal failure  Sepsis   Maternal death 
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   MANAGEMENT Prevention :the overall risk of recurrence of still birth varies between 0-8%. The conditions that run the risks of recurrence are:  hereditary disorders  diabetes  hypertension  thrombophilias  placental abruption  fetal congenital malformation
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   pre-conceptional counsellingand care.  Pre-natal diagnosis  To screen the “at-risk mothers” during antenatal care. Carefull assessment of fetal well being and to terminate pregnancy with the earliest evidence of fetal compromise.
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   EXPECTANT ATTITUDENON INTERFERENCE:  In about 80% of cases, spontaneous expulsion occurs within 2 weeks of death.  Fibrinogen estimation should be done weekly.  REASONS FOR EARLY DELIVERY:  Reliable diagnosis could be made with real time ultrasonography quickly.  Prostaglandins are available for effective induction.  Complication should be avoided.
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   INDICATIONS OFEARLY INTERFERE:  Psychological upset of the patient.  Manifestation of uterine infection  Tendency of prolongation of pregnancy beyond 2 weeks.  Falling fibrinogen level.   METHODS OF DELIVERY: The delivery should always be done by medical induction.  OXYTOCIN INFUSION :Very effective in cases where the cervix is favourable  *5-10units with 500ml of Ringer’s solution is administered through intravenous infusion drip.  * 20units with 500ml of Ringer’s solution and run with 30drops in case of failure  *if the uterus still remains refractory, the same procedure is repeated after vaginal administration of prostaglandin gel.
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   Prostaglandins: Vaginaladministration of prostaglandin (PGE2) gel or lipid pessary high in the posterior fornix is very effective for induction where the cervix is unfavourable .  It is repeated after 6-8 hours and may be supplemented with oxytocin infusion.  Misoprostol (PGE1):  25-50µ either vaginally or orally is also found effective.  Vaginal route use is more effective compared to oral route. May be repeated for every 4 hours.
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