POST DATED PREGNANCY AND INTRA-UTERINE FETAL DEATH (IUFD)

Dr. Pradeep Garg

Assistant Professor Department of Obstetrics and Gynaecology AIIMS, New Delhi

Definition IUFD denotes death of fetus in utero. Etiology: Pregnancy complications: - Pre-eclamptic toxaemia - Antepartum haemorrhage : placenta praevia, abruptio placentae Pre- existing medical disease and acute illness - Chronic hypertension - Chronic nephritis - Diabetes - Severe anaemia - Hyperpyrexia - Syphilis, Hepatitis, toxoplasmosis etc.

IUFD

IUFD (contd)
Foetal - Congenital malformation - Rh-incompatibility

- Post maturity
External version

Idiopathic 20 30%

Diagnosis
Symptoms- Absence of foetal movements Signs- Retrogression of the positive breast changes. Per-abdomen- Gradual retrogression of the height of the uterus - Uterine tone is diminished - Foetal movement are not felt during palpation. - Foetal heart sound is not audible Investigations- Straight- X-ray abdomen - Spalding sign: it usually appears 7 days after I.U.F.D. - Hyperflexion of the spine - Crowding of the ribs shadow - Appearance of gas shadow (Roberts sign) : 12 hours

Diagnosis (contd)
Sonography : (a) Lack of all foetal motions (including cardiac) (b) Oligohydramnios and collapsed cranial bones Haematological examination: VDRL, Blood sugar and urea Postmortem studies Cytogenetic study: In cases of congenital malformation of IUGR Rh-typing,

Lab evaluation
Maternal
FBS, Platelet count, ICT, Kleihaur-Betke test, LAC, ACL, Fetal karyotype Thrombophilia workup PCR of fetal product for viral infectin Amniotc fluid culture Weekly fibrinogen

Fetal
karyotype Postmortom examination Fetogram

Complications
1. Psychological upset 2. Infection: Once the membranes rupture, infection, especially by gas forming organism like CI. Welchi. 3. Blood coagulation disorders 4. During labour : Uterine inertia and PPH

Prevention of IUFD:
- Regular antenatal care

- To screen out the at-risk patients to monitor carefully for the assessment of foetal well being and to terminate the pregnancy at the earliest evidences of foetal compromise.

Pregnancy Management
Single or multiple gestation Gestational age at death The parents wish

Management
Explain the problem to the woman and her family. Discuss with them the options of expectant or active management. If expectant management is planned:
Await spontaneous onset of labour during the next four weeks Reassure the woman that in 90% of cases the fetus is spontaneously expelled during the waiting period with no complicatons.

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)

Management (contd)
If induction of labour is planned, assess the cervix

If the cervix is favourable (soft, thin, partly dilated) labour using oxytocin.
If the cervix is unfavourable(firm, thick, closed) ripen the cervix. Note: Do not rupture the membranes. If spontaneous labor does not occur within four weeks, platelets are decreasing and the cervix is unfavourable, ripen the cervix.

ANTEPARTUM FETAL SURVEILLANCE

The goal of Antepartum fetal surveillance is to prevent fetal death Antepartum fetal surveillance are routinely use to assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions as well as those in which complication have developed.

MODALITIES OF ANTEPARTUM FETAL SURVEILLANCE

Fetal movement count Non-stress test Contraction stress test Biophysical profile Ultrasound doppler

Fetal Movement Assessment

Screening method of fetal surveillance in low risk pregnancy. Sophisticated fetal monitoring test are applied to only 10%-20% of obstetrics population. Inexpensive & non-invasive Most attractive & simple method is count to 10 technique.

Non-stress test
Indirect measurement of uteroplacental insufficiency function. Based on the premise that heart rate of the fetus that is not acidotic or neurologically depressed will accelerate with fetal movement. Good indicator of normal fetal autonomic function

NST: How to do it
Patient in lateral tilt position Accelerations peak (but do not necessarily remain) at least 15 BPM above baseline Last for 15 seconds Reactive: 2 or more accelerations within 20 m period Nonreactive: one that lacks sufficient accelerations No contraindications

Biophysical Profile
Includes : Fetal breathing, tone, somatic movements, liquor and NST <= 4/ 10 deliver

6/ 10 repeat test within 4-6 hours

still 6 / 10 deliver > 8 / 10 surveillance

>= 8 / 10 surveillance

Death of one fetus

Incidence around 6.2% (8.4% in monochorionic & 4.1% in dichorionic) (Saito et al 1999) Same sex twin are at highest risk Fetal loss cause 1st-trimester losses : not determined the later losses : twin-twin transfusion syndrome, severe IUGR, placental insufficiency, placental abruption Fetal monitoring protocol: not predict most of these losses

Death of one fetus

The most difficult cases those in which the fetal demise occurs in 1 fetus of a monochorionic twin pair monochorionic placentas contain vascular anastomoses that link the circulations of the 2fetuses the surviving fetus is at significant risk of sustaining damage caused by the sudden , severe and prolonged hypotension that occurs at the time of the demise or by embolic phenomena that occurs later.

Death of one fetus

Management

There may not be any benefit in immediate delivery (esp. if the surviving fetuses are very preterm and other wise healthy) pregnancy to continue may provide the most benefit. DIC (disseminated intravascular coagulopathy) remains a theoretical risk, rarely occurs Fibrinogen and fibrin degradation product levels can be monitored serially until delivery and delivery can be expedited if DIC develops

Morbid pathology of IUFD

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.

Post dated pregnancy (prolonged pregnancy, post term pregnancy,post maturity)

Definition: A prolonged pregnancy is 42 completed weeks of gestation. Incidence: 4-19% of pregnancy reach or exceed 42 weeks

Etiology:
Maternal: - Heredity - High standard of living with sedentary habit - Elderly primigravida - Previous history of prolonged pregnancy (50% cases) Fetal: - Anencephaly Placental - Sulphatase deficiency

Diagnosis
Record of the dates of the LMP Definitely known date of ovulation, data based on basal body temperature (BBT) charts or sonographic dating.

A reliable clinical assessment of gestational size in the first trimester. This data may be fallacious in obese women, uncooprative patients, women with fibroids in the uterus or when a satisfactory pelvic examination has not been possible.

Diagnosis (contd)
A sonographic scan between the 10 and 12 weeks gives the assessment of gestational maturity with +/range of 7 days. Quickening

Fundal height at 28 weeks of gestation usually corresponds to 28 cm. In case of discrepancy between the menstrual dates and clinical findings, and early sonographic scan should help in assessing gestational maturity.

Dangers
Foetal:
During pregnancy: Foetal hypoxia due to placental aging. During labour: Asphyxia and intracranial damage due to: (a) Pre-existing hypoxia (b) Increased incidence of difficult labour: Big size baby non moulding of head (c) Increase incidence of operative delivery (d) Scanty liquor amnii and less Whartons jelly in the cord favour cord compression. Following birth: Meconium aspiration syndrome

Maternal Management: Expectant (fetal surveillance ) versus active management

Key points to remember

Whenever possible, gestational age should be established by a first or an early secondtrimester ultrasound examination. Sweeping of the membranes at term decreased slightly the number of pregnancies reaching 40+ weeks gestation. Consider induction of labor at or beyond 41 weeks gestation in patients with a favourable cervix

Key points to remember (contd)

Initiate semiweekly fetal testing (nonstress test and AFI at 41 weeks gestation). Conservative management (I.e. semiweekly, fetal testing) or active management (I.e induction of labor) are equally reasonable options for patients with an unfavourable cervix. Perinatal morbidity and mortality are significantly increased when gestational age at birth is 41 weeks or more.

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