Causes and Evaluation of Intrauterine Fetal Death
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Intrauterine death is an unfortunate incidence.Many of the causes are unknown.How to go about it is presented here.
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Causes and Evaluation of Intrauterine Fetal Death
- 1. March 9, 2015 1
- 2. INTRAUTERINE FETAL DEATH ….seeking answers Dr.Rakhi Gajbhiye MD Obstetrician & Gynaecologist Director, Mauli Women’s Hospital, Nagpur March 9, 2015 2
- 3. INTRAUTERINE FETAL DEATH (IUFD) Fetal death before onset of labour or fetus with no signs of life in utero after 20 weeks of gestation Definition varies : Gestational age | Birth weight WHO : An infant delivered without signs of life after 20 weeks of gestation or weighing >500 gms when gestation age is not known March 9, 2015 3
- 4. • WHO Definition(MacDorman 2012)- Fetal death means death prior to complete expulsion or extraction from the mother of a fetus irrespective of duration of pregnancy and which is not an induced termination of pregnancy. March 9, 2015 4
- 5. Still Birth - no evidence of life after birth beyond 20 weeks Still Birth Fresh (quality of Intra- partum care) Macerated (retained >12 hrs) IUD Early (20-27 weeks) Late (≥28 weeks) IUFD March 9, 2015 5
- 6. IMPACTS Emotionally challenging for: • Doctors • Parents Increases medicolegal risk Indicator of country’s health care system March 9, 2015 6
- 7. FREQUENCY Still Birth Rate : no. of SBs / Thousand Births • Complicates 1 % of pregnancies • In 50 % of cases cause is unknown Current Trends • 4.5 to 6.5(2.95) per thousand births in US • 22.1 per thousand births in India(2009) • Worldwide 18.9 / Thousand births (2009) Rate depends on medical care and reporting systemMarch 9, 2015 7
- 8. ETIOLOGY • Unknown in 50% of cases • Known causes S/No Causes % 1. Maternal 5-10 2. Foetal 25-40 3. Placental 20-35 4. Unexplained 15-35 March 9, 2015 8
- 9. MATERNAL CAUSES(RISK FACTORS) • Obesity (>30kg/m2): proven, modifiable, highest ranking • Maternal (>35yrs)/paternal age • Smoking/Alcohol/Drug abuse • Infections (malaria, hepatitis, influenza, syphilis, Toxoplasma, sepsis) • Medical ds –DM,HT,Thyroid Diseases • Pre-existing diseases (HD, Anaemia, Epilepsy) • Autoimmune Disorders (APS, SLE) • RH incompatibility • Hyperpyrexia • Thrombophilias • Trauma • Cholestasis of pregnancy • Obs cx – Abruption,PPROM,multifetal gestation • Labour related (preterm, dystocia, uterine rupture) March 9, 2015 9
- 10. FOETAL CAUSES • Multiple gestation • IUGR • Congenital anomalies • Infections • Hydrops (immune & non-immune) • G6PD deficiency • Birth Defects March 9, 2015 10
- 11. PLACENTAL CAUSES • Abruption • Cord accidents • Placental insufficiency • Placenta previa • TTTS • Chorioamnionitis • PROM • Feto-maternal hemorrhage Iatrogenic- ECV, Drug overdoses March 9, 2015 11
- 12. March 9, 2015 12
- 13. 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 March 9, 2015 13
- 14. INVESTIGATIONS • USG (100%) + Associated features can be noted (oligo, hydrops) • Straight- X-ray abdomen (obsolete) Robert’s sign : Appearance of gas shadow (in 12 hours) Spalding sign: Collapse skull bones (usually appears 7 days after ) Ball sign : Hyperflexion of the spine Helix sign : Gas in umbilical arteries Crowding of the ribs shadow March 9, 2015 14
- 15. SYSTEMATIC APPROACH TO EVALUATION • Varied recommendations based on experts opinion • Yet, no scientific effective evaluation plan • Study ongoing by Still Birth Collaborative Research Network • Optimal evaluation is must for • chance of recurrence • future preconceptional counseling • Pregnancy management • plan prenatal diagnostic procedures • neonatal management • Obvious cause - No further testing or limited testing (cord accidents, anencephaly) March 9, 2015 15
- 16. I. History II. Gross examination • SB infant • umbilical cord • placenta • amniotic fluid III. Foetal autopsy & karyotyping IV. Placental investigations V. Maternal Investigations March 9, 2015 16
- 17. Family • Recurrent abortions • Congenital anomalies • Abnormal karyotype • Hereditary conditions • Developmental delay Maternal • DM • HPT • Thrombophilias • Autoimmune disease • Severe Anemia • Epilepsy • Consanguinity • Heart disease Past Obstetrical • Baby with congenital anomaly / hereditary condition • IUGR • Gestational HPT with adverse sequele • Placental abruption • IUFD • Recurrent abortions I. History March 9, 2015 17
- 18. Infant description • Malformation • Skin staining • Degree of maceration • Color-pale , plethoric Umbilical cord • Prolapse • Entanglement-neck, arms, legs • Hematoma or stricture • Number of vessels • Length Amniotic fluid • Color-meconium, blood • Volume Placenta • Weight • Staining • Adherent clots • Structural abnormality • Velamentous insertion • Edema/ hydropic changes Membranes • Stained • Thickening II. Gross Description March 9, 2015 18
- 19. • These 2 are important tests in SB evaluation (Pinar, 2014) • Crucial for future pregnancy • Appropriate consent req to take fetal tissue,Autopsy • Ideally should be done by perinatal pathologist • If denied, post mortem MRI should be considered • Radiographs if indicated for skeletal abnormalities • Photographs III. Fetal Autopsy & Karyotyping March 9, 2015 19
- 20. • Fetal karyotyping (ACOG recom in all cases) esp- - Dysmorphic fetus, FGR - Hydropic - Signs of chromosomal anomaly Samples- • Amniocentesis –highest yield • 3ml fetal blood from umbilical vs and or cardiac puncture-heparinized bulb • If blood not obtained ACOG(2012)recommends at least 1 of the foll samples - 1) Pl block 1x1cm RL 2) cord 1.5cm 3) costocondral junction or patella(skin not . recommended) March 9, 2015 20
- 21. • Parents with multiple pregnancy losses (second or third trimester) • For aneuploidy- FISH, For small deletions- CGH March 9, 2015 21
- 22. • Chorionicity • Cord knot, vessels, thrombosis • Infarcts, thrombosis, abruption • Vascular malformations • Signs of infection • Placental block(1x1 cm) below cord insertion • Umbilical segment (1.5 cm) • Placental swabs for infections • Bacterial cultures for E. Coli, Listeria IV. Placental Investigations March 9, 2015 22
- 23. • CBC • Hb electrophoresis • Diabetes testing (HbA1c, FBS)(Silver,2013) • TFT • Additional Tests • Kleihauer Betke (for all women, before birth), in Rh- D negative second test after antidote • Serological Tests (TORCH, Syphilis, Parvovirus) ?? in all cases, opinion varies, rarely helpful If clinical findings suggest intrauterine infection (i.e., those with IUGR, microcephaly) V. Maternal Evaluation March 9, 2015 23
- 24. • Antiphospholipid (LA,ACA), Antiplatelet Ab if ICH detected • ?? Thrombophilias screening (6 weeks postpartum) - factor V leiden mutations & deficiencies, antithombin III, protein C & S Current ACOG practice bulletin does not recommend in cases of pregnancy loss • Bile acids (Cholestasis of preg)- important cause, recurrence in 80% cases • High vaginal & cervical swab for C & S • Urine toxicology screening (cocaine, amphetamines are associated with abruption) March 9, 2015 24
- 25. • Depends on: • Single or multiple gestation • Gestation age at death • Parents wish (varied response) – Expectant approach • 80% goes in labour with in 2-3 weeks • Emotional burden, risk of Chorioamnionitis & DIC – Active approach MANAGEMENT March 9, 2015 25
- 26. • Fetal death <28weeks • Mifepristone 200 mg followed by Misoprostol 400 µg 4 - 6 hourly most effective with shortest I-D interval • Fetal death >28weeks • Cervical ripening (mechanical or chemical) followed by Oxytocin induction Induction of Labour March 9, 2015 26
- 27. • WHO regimen of Misoprostol in IUD cases • IUFD at term – 25 µg 6 hourly 2doses, if no response increase to 50 µg 6 hourly, do not exceed 4 doses. • Do not use Oxytocin in 8hrs of using Misoprostol • Contraindicated in previous CS cases (WHO) March 9, 2015 27
- 28. • RCOG & NICE Regimen • <26 weeks - 100 µg 6hrly (max 4 doses) • >27 weeks - 25-50 µg 4hrly (max 6 doses) • Use of PGs is associated with increase risk of uterine rupture in cases of previous scar • Membranes should not be ruptured as long as possible • Pain management should be offered • Keep watch on CBC, coagulation profile, signs of infection • Active management of III stage of labour • Keep blood and blood products ready March 9, 2015 28
- 29. Complications – Infection – PPH – Retained placenta – Abruption – DIC – Shock, renal failure – Sepsis – Maternal death March 9, 2015 29
- 30. • Emotional support & Counseling as they r at increased risk of PPD(Nelson,2013) • Keep in non maternity ward • Suppression of lactation (tight breast support, dopamine agonists, estrogen) • Counsel for future pregnancy, early ANC visit, preconceptional testing • Assurance in cases of non recurring causes • Contraceptive counseling Post delivery March 9, 2015 30
- 31. Management of future preg(RCOG) Preconception or initial prenatal visit • Detailed medical and obstetric history • Evaluation and workup of previous stillbirth • Determination of recurrence risk • Smoking cessation • Weight loss in obese women (preconception only) • Genetic counselling if family genetic condition exists • Medical prob like Diabetes should be managed prior • Thrombophilia workup: antiolipid antibodies (only if specifically indicated) • Risk of recurrence is 7-10 / 1000 birth • Support and reassuranceMarch 9, 2015 31
- 32. First trimester • Dating sonography • First-tri screen: pregnancy-associated plasma protein A, b HCG, and nuchal translucency* • Folic acid Second trimester • Fetal ultrasonographic anatomic survey at 18–20wks • Maternal serum screening (Quadruple) marker • Blood investigations March 9, 2015 32
- 33. Third trimester • Sonographic screening for fetal growth restriction after 28 weeks of gestation • Admission at critical period in high risk cases • Kick counts starting at 28 weeks of gestation • Antipartum fetal surveillance starting at 32 wks or 1–2 wks earlier than prior stillbirth (ACOG recommends at 32-34 wks in otherwise normal preg) • Weekly FHR , BPP, Doppler • Support and reassurance March 9, 2015 33
- 34. STRATEGIES FOR PREVENTION • No sure fire method to prevent • Loosing weight, life style modifications • Women should try to optimize their health prior to pregnancy • Enough Folic acid before they get pregnant • Good preconception and prenatal care • Women with DM –tight control before and during pregnancy • Educate women not to delay pregnancy March 9, 2015 34
- 35. • Still birth AUDIT COM – comprising of Obs,neo,geneticists,neo patho. • According to survey by Goldenberg n coworkers (2013) most hosp do not audit SB March 9, 2015 35
- 36. Unknown etiology in 25-60% IUFD cases Optimal evaluation for future pregnancy necessary Evidence based models for evaluation & future m/m Counseling & support groups should be involved Allow parents to sit and pray in isolation, take photographs, footprints, preserve lock of hair and name the child Reassure and guide for future pregnancy March 9, 2015 36
- 37. “When you loose a person you love so much, surviving the loss is difficult” March 9, 2015 37
- 38. March 9, 2015 38