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INTRAUTERINE
DEATH
DR ILA
GUPTA
D.G.F.’S CME ON INDUCTION OF LABOUR ON 8TH NOVEMBER 2016
HOW TO DEFINE
IUD or STILL BORN
 fetal death after period of viability ( 28
weeks )
 24 weeks in USA
 24WEEKS OR >500 Gms by WHO
 ACOG refers to IUFD as the demise
occurring at or later than 20weeks.
Epidemiology
Prevalence of perinatal deaths in a
society is the direct indicator of the
quality of antenatal care in the country
Though the prevalence of IUFD has been
reduced to a minimum unavoidable rate
in developed countries; however it still
remains very high in underdeveloped
and developing countries.
Incidence
35/1000 in INDIA(32 in urban 39 in rural
area)
5- 7.5 /1000 in developing countries
ETIOLOGY
 Fetal causes (25-40%)
 Placental causes (15-25%)
 Maternal causes (5-10%)
 Unexplained causes (25-35%)
SIGNS AND SYMPTOMS
Symptoms
Decreased/absent movements (50%
cases)
 Bleeding per vaginum, Pain abdomen
On examination
 Stationary and decrease in fundal height
 Flaccid uterus/absent braxton-hicks
contraction
 Absent fetal movements and absent
heart sound
 Egg shell crackling feel of fetal head
DIAGNOSIS
 USG –absent fetal heart sound
 Doubly confirmed
Other features
 Scalp edema
 Collapsed and overlapping cranial
bones(spalding sign)
 Clue to diagnosis
 Oligoamnios ,abruption or fetal hydrops
X-ray is an old modality only useful in
medico legal cases.
INTRAUTERINE DEATH CME ON INDUCTION OF LABOUR ON 8TH NOVEMBER 2016, Dr sharda Jain Dr. Ila Gupta
INVESTIGATIONS
 - CBC,ABO/RH,VDRL, URIN E
 BS F AND PP, HBA1C
 ,TFT,KFT,
 COAGULATIONPROFILE,
 TORCH,
 ,LUPUS ANTI COOAGULANT, ACL
ANTIBODIES AND OTHER
THROMBOPHILIAS
TO CONTINUE………
 GROSS EXAM of placenta ,cord and
baby
 HISTOLOGY OF PLACENTA
 AUTOPSY OF BABY if allowed
 CYTOGENETCS STUDIES In case
of IUGR or cong malformation.
Degree of maceration
Grade 1 maceration
 Reddened skin 6-8 hours
Grade 2 maceration
 Skin slippage and peeling 8-12 hrs
Grade 3 maceration
 Extensive skin peeling
 Red Serous effusion in chest and
abdomen
 Aseptic autolysis of ligaments and
liquifaction of inner structures like brain
COMPLICATIONS
 Psychological upset
 Coagulopathies
 Infections
 During labor
 Uterine inertia
 Retained placenta
 PPH
 rupture uterus( high dose of
uterotonics)
 DIC
MANAGEMENT
Majority of women( up to 80%) goes in
spontaneous labor within two weeks of
fetal death.
INDICATION OF INDUCTION
 Psychological upset of patient and
relatives
 Falling fibrinogen level
 IUFD >2 weeks
 Onset of infection
Expectant
management
Spontaneous
delivery
Induction
induction
induction
1-IUFD for>2 wks
2-psychological stress
3-infection
4-Coagulation defect
i
Cervix
unfavorableCervix
favorable
Oxytocin
infusion
delivery
Pge2gel
Pge1 misoprost
Oxytocin
supplementation
METHODS OF INDUCTION
 Amniotomy is contraindicated
 Prostaglandins—E2 gel vaginally or
intra cervically 6 hrly up to 3 doses
 E1 –misoprost 50 mic gram vaginally
or orally 6 hrly
 Mefepristone 600 /200 can also be
given followed by misoproset
Continue…….
• Oxytocin
• method of choice( if bishop is >6).
dose 5-10 units in RL or NS with iv
infusion followed by escalating
• Dinoprostone (PGE2)
• 10 mg reservoir Intravaginal insert is a
novel technique can be used for ripening
Administration
Removal
INDICATION FOR LSCS
 Major degree of placenta previa
 Previous caesarean(2 or more)
 Transverse lie
 Obstructed labor
Guidance for examination of still
born infant
INFANT
 Gross exam -skin staining
 Color –pale, plethoric
 Degree of maceration
 Malformations
 PLACENTA
 Weight
 Structural abnormalities
 Hydropic changes
 Retroplacental clot
 Meconium staining
-----CONTINUE
MEMBRANES
 Meconium stained or cloudy
 Any thickening
 Foul smell
CORD
 Entanglement around neck
 Prolapse
 Length
 True or false knot
 Haematoma/strictures
 Wharton jelly normal or absent
Continue------
AMNIOTIC FLUID
Color -meconium/blood
Volume
consistency
Post delivery counselling
 Counsel for full autopsy
 Spend time with women and husband
and discuss the reason for IUFD
 Let her spend some time with infant if
she wants so
 Do not keep her with women with live
babies
 At follow up visit discuss the result of
autopsy and investigation and
planning for future pregnancy
TAKE HOME MESSAGE
 Ante-partum fetal death contributes to
about two thirds of prenatal mortality
 Incidence is still high in developing country
 In majority of cases cause is still unknown
 Pre and post delivery counseling is integral
part of management
 Induction is done with prostaglandinE 1or 2
gel or tab supplemented with oxytocin
 Amniotomy is contraindicated
 Maximum possible effort should be made to
establish the cause for better future outcome
ONE CAN NOT CHANGE
THE DESTINY BUT A
SINCERE EFFORT CAN
GIVE THIS MOTHER A
NEW FUTURE
ADDRESS
11 Gagan Vihar, Near
Karkari Morh Flyover,
Delhi - 51
CONTACT US
9650588339
9599044257
011-22414049
WEBSITE :
www.lifecareivf.in
www.lifecarecentre.in
www.lifecareabs.in
ISO 14001:2004 (EMS)
…..Caring hearts, healing hands
ISO 9001:2008
Helpline : 9599044257
Web.www.lifecareivf.in
Helpline : 9910081484
26
Year
In
your
servic
e

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INTRAUTERINE DEATH CME ON INDUCTION OF LABOUR ON 8TH NOVEMBER 2016, Dr sharda Jain Dr. Ila Gupta

  • 1. INTRAUTERINE DEATH DR ILA GUPTA D.G.F.’S CME ON INDUCTION OF LABOUR ON 8TH NOVEMBER 2016
  • 2. HOW TO DEFINE IUD or STILL BORN  fetal death after period of viability ( 28 weeks )  24 weeks in USA  24WEEKS OR >500 Gms by WHO  ACOG refers to IUFD as the demise occurring at or later than 20weeks.
  • 3. Epidemiology Prevalence of perinatal deaths in a society is the direct indicator of the quality of antenatal care in the country Though the prevalence of IUFD has been reduced to a minimum unavoidable rate in developed countries; however it still remains very high in underdeveloped and developing countries. Incidence 35/1000 in INDIA(32 in urban 39 in rural area) 5- 7.5 /1000 in developing countries
  • 4. ETIOLOGY  Fetal causes (25-40%)  Placental causes (15-25%)  Maternal causes (5-10%)  Unexplained causes (25-35%)
  • 5. SIGNS AND SYMPTOMS Symptoms Decreased/absent movements (50% cases)  Bleeding per vaginum, Pain abdomen On examination  Stationary and decrease in fundal height  Flaccid uterus/absent braxton-hicks contraction  Absent fetal movements and absent heart sound  Egg shell crackling feel of fetal head
  • 6. DIAGNOSIS  USG –absent fetal heart sound  Doubly confirmed Other features  Scalp edema  Collapsed and overlapping cranial bones(spalding sign)  Clue to diagnosis  Oligoamnios ,abruption or fetal hydrops X-ray is an old modality only useful in medico legal cases.
  • 8. INVESTIGATIONS  - CBC,ABO/RH,VDRL, URIN E  BS F AND PP, HBA1C  ,TFT,KFT,  COAGULATIONPROFILE,  TORCH,  ,LUPUS ANTI COOAGULANT, ACL ANTIBODIES AND OTHER THROMBOPHILIAS
  • 9. TO CONTINUE………  GROSS EXAM of placenta ,cord and baby  HISTOLOGY OF PLACENTA  AUTOPSY OF BABY if allowed  CYTOGENETCS STUDIES In case of IUGR or cong malformation.
  • 10. Degree of maceration Grade 1 maceration  Reddened skin 6-8 hours Grade 2 maceration  Skin slippage and peeling 8-12 hrs Grade 3 maceration  Extensive skin peeling  Red Serous effusion in chest and abdomen  Aseptic autolysis of ligaments and liquifaction of inner structures like brain
  • 11. COMPLICATIONS  Psychological upset  Coagulopathies  Infections  During labor  Uterine inertia  Retained placenta  PPH  rupture uterus( high dose of uterotonics)  DIC
  • 12. MANAGEMENT Majority of women( up to 80%) goes in spontaneous labor within two weeks of fetal death. INDICATION OF INDUCTION  Psychological upset of patient and relatives  Falling fibrinogen level  IUFD >2 weeks  Onset of infection
  • 13. Expectant management Spontaneous delivery Induction induction induction 1-IUFD for>2 wks 2-psychological stress 3-infection 4-Coagulation defect i Cervix unfavorableCervix favorable Oxytocin infusion delivery Pge2gel Pge1 misoprost Oxytocin supplementation
  • 14. METHODS OF INDUCTION  Amniotomy is contraindicated  Prostaglandins—E2 gel vaginally or intra cervically 6 hrly up to 3 doses  E1 –misoprost 50 mic gram vaginally or orally 6 hrly  Mefepristone 600 /200 can also be given followed by misoproset
  • 15. Continue……. • Oxytocin • method of choice( if bishop is >6). dose 5-10 units in RL or NS with iv infusion followed by escalating • Dinoprostone (PGE2) • 10 mg reservoir Intravaginal insert is a novel technique can be used for ripening Administration Removal
  • 16. INDICATION FOR LSCS  Major degree of placenta previa  Previous caesarean(2 or more)  Transverse lie  Obstructed labor
  • 17. Guidance for examination of still born infant INFANT  Gross exam -skin staining  Color –pale, plethoric  Degree of maceration  Malformations  PLACENTA  Weight  Structural abnormalities  Hydropic changes  Retroplacental clot  Meconium staining
  • 18. -----CONTINUE MEMBRANES  Meconium stained or cloudy  Any thickening  Foul smell CORD  Entanglement around neck  Prolapse  Length  True or false knot  Haematoma/strictures  Wharton jelly normal or absent
  • 20. Post delivery counselling  Counsel for full autopsy  Spend time with women and husband and discuss the reason for IUFD  Let her spend some time with infant if she wants so  Do not keep her with women with live babies  At follow up visit discuss the result of autopsy and investigation and planning for future pregnancy
  • 21. TAKE HOME MESSAGE  Ante-partum fetal death contributes to about two thirds of prenatal mortality  Incidence is still high in developing country  In majority of cases cause is still unknown  Pre and post delivery counseling is integral part of management  Induction is done with prostaglandinE 1or 2 gel or tab supplemented with oxytocin  Amniotomy is contraindicated  Maximum possible effort should be made to establish the cause for better future outcome
  • 22. ONE CAN NOT CHANGE THE DESTINY BUT A SINCERE EFFORT CAN GIVE THIS MOTHER A NEW FUTURE
  • 23. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339 9599044257 011-22414049 WEBSITE : www.lifecareivf.in www.lifecarecentre.in www.lifecareabs.in ISO 14001:2004 (EMS) …..Caring hearts, healing hands ISO 9001:2008 Helpline : 9599044257 Web.www.lifecareivf.in Helpline : 9910081484 26 Year In your servic e