2. DEFINTION
• IUFD REFERS TO THE DEATH OF THE FETUS IN UTERO AFTER 24
COMPLETED WEEKS OF GESTATION OR WEIGHING >500g
• OCCURRING BOTH DURING PREGNANCY (ANTEPARTUM DEATH) OR
DURING LABOR (INTRAPARTUM)
• THUS FOR PRACTICAL PURPOSE, ANTEPARTUM DEATH OCCURRING
BEYOND THE PERIOD OF VIABILITY IS TERMED AS INTRAUTERINE
DEATH. IT USUALLY RESULTS IN THE DELIVERY OF A MACERATED
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3. ETIOLOGY
THEY CAN BE CLASSIFIED AS;
➢MATERNAL
➢FETAL
➢PLACENTAL
➢OTHERS; IATROGENIC AND IDIOPATHIC (UNEXPLAINED)
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4. MATERNAL CAUSES (RISK FACTORS)
• MEDICAL DISEASES – DM, HTN, THYROID DISEASES
• PRE-EXISTING DISEASES (HD, ANAEMIA, EPILEPSY)
• INFECTIONS (MALARIA, HEPATITIS, INFLUENZA, SYPHILIS,TOXOPLASMA, SEPSIS)
• OBESITY: PROVEN, MODIFIABLE
• AUTOIMMUNE DISORDERS (SYSTEMIC LUPUS ERYTHEMATOSUS [SLE} AND ASLO
ANTIPHOSPHOLID SYNDROME (APS): PRESENCE OF LUPUS ANTICOAGULANT, ANTICARDIOLIPIN
ANTIBODIES CAUSED DECIDUAL VASCULOPATHY WITH FIBRINOID NECROSIS, PLACENTAL
VASCULAR ATHEROSIS AND INTERVILLOUS THROMBOSIS)
• THROMBOPHILIAS: FACTOR V LEIDEN, PROTEIN C, PROTEIN S DEFICIENCY,
HYPERHOMOCYSTEINEMIA. MECHANISM IS SIMILAR TO APS
• HYPERPYREXIA
• RH INCOMPATILITY, CHOLESTASIS OF PREGNANCY
• ABRUPTION, PPROM, MULTIPLE GESTATION
• LABOUR RELATED (PRETERM, DYSTOCIA, UTERINE RUPTURE, PROLONGED OR OBSTRUCTED
LABOUR
• SMOKING/ALCOHOL/DRUG ABUSE
• ADVANCED MATERNALAGE (>35YRS)
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5. FETAL CAUSES
• INRAUTERINE FETAL GROWTH RESTRICTION: SIGNIFICANT INCREASE IN THE
RISK OF STILLBIRTH. IT IS ASSOCIATED WITH:
➢ FETAL ANEUPLOIDIES
➢ FETAL INFECTION
➢ MATERNAL SMOKING
➢ HYPERTENSION
➢ AUTOIMMUNE DISEASE
➢ OBESITY
➢ DIABETES
• CHROMOSOMAL AND GENETIC ABNORMALITIES
• STRUCTURAL ANOMALIES
• INFECTIONS (VIRUS, BACTERIAAND CHORIOAMNIONITIS)
• RH INCOMPATIBILITYAND HYDROPS (IMMUNE AND NON-IMMUNE)
• MULTIPLE GESTATION, G6PD DEFICIENCY
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6. PLACENTAL CAUSES
• PLACENTAL ABRUPTION.; MOST COMMON CAUSE
• CORD ACCIDENTS (PROLAPSE, TRUE KNOT, CORD AROUND THE
NECK)
• PLACENTAL INFARCTION AND PLACENTAL INSUFFICIENCY
• PLACENTAL OR MEMBRANE INFECTION; CHORIOAMNIONITIS
• PROM
• PLACENTA PREVIA
• TWIN-TWIN TRANSFUSION SYNDROME.(TTTS)
• FETO-MATERNAL HEMORRHAGE IATROGENIC – ECV, DRUG
OVERDOSES
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7. OTHER CAUSES
IATROGENIC
• EXTERNAL CEPHALIC VERSION
• DRUGS (QUININE BEYOND THERAPEUTIC DOSE)
IDIOPATHIC
• CAUSE REMAINS UNKNOWN EVEN WITH THOROUGH CLINICAL
EXAMINATION AND INVESTIGATIONS
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9. MORBID PATHOLOGY
• THE DEAD FETUS UNDERGOES AN ASEPTIC DEGENERATIVE PROCESS CALLED
MACERATION.
• THE EPIDERMIS 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 FETUS BECOMES SWOLLEN AND LOOKS DUSKY RED. GRADUALLY
ASEPTIC AUTOLYSIS OF THE LIGAMENTOUS STRUCTURE AND LIQUEFACTION
OF THE BRAIN MATTER AND OTHER VISCERA TAKE PLACE.
• THE CHANGES VARY IN DEGREE AND ARE RESPONSIBLE FOR THE
CHARACTERISTIC RADIOLOGICAL SIGNS.
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10. DIAGNOSIS
REPEATED EXAMINATIONS ARE OFTEN REQUIRED TO CONFIRM THE DIAGNOSIS.
• SYMPTOMS—ABSENCE OF FETAL MOVEMENTS WHICH WERE PREVIOUSLY NOTED BY THE PATIENT.
• SIGNS: RETROGRESSION OF THE POSITIVE BREAST CHANGES THAT OCCUR DURING PREGNANCY IS
EVIDENT AFTER VARIABLE PERIOD FOLLOWING DEATH OF THE FETUS. ON HISTORY: BEFORE 20
WEEKS’ GESTATION, THE MOST COMMON FINDING IS UTERINE FUNDUS LESS THAN DATES
PER ABDOMEN
• GRADUAL RETROGRESSION OF THE FUNDAL HEIGHT AND IT BECOMES SMALLER THAN THE PERIOD
OF AMENORRHEA.
• 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 A LATE FEATURE 17-May-21
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11. INVESTIGATIONS
• SONOGRAPHY—EARLIEST DIAGNOSIS IS POSSIBLE WITH SONOGRAPHY. THE EVIDENCES ARE: (A) LACK OF ALL
FETAL MOTIONS (INCLUDING CARDIAC) DURING A 10 MINUTE PERIOD OF CAREFUL OBSERVATION WITH A REAL-TIME
SONAR IS A STRONG PRESUMPTIVE EVIDENCE OF FETAL DEATH (B) GRADUALLY, OLIGOHYDRAMNIOS AND
COLLAPSED CRANIAL BONES ARE EVIDENT (FIG. 21.1).
• STRAIGHT X-RAY ABDOMEN—RARELY DONE AT PRESENT. THE FOLLOWING FEATURES MAY BE FOUND IN VARYING
DEGREE, EITHER SINGLY OR IN COMBINATION.
SPALDING SIGN (FIG. 21.2)—THE IRREGULAR OVERLAPPING OF THE CRANIAL BONES ON ONE ANOTHER IS DUE TO
LIQUEFACTION OF THE BRAIN MATTER AND 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.
• HYPERFLEXION OF THE SPINE (BALL SIGN) IS MORE COMMON. IN SOME CASES HYPEREXTENSION OF THE NECK IS
SEEN. CROWDING OF THE RIBS SHADOW WITH LOSS OF NORMAL PARALLELISM. APPEARANCE OF GAS SHADOW
(ROBERT’S SIGN) IN THE CHAMBERS OF THE HEART AND GREAT VESSELS MAY APPEAR AS EARLY AS 12 HOURS BUT
DIFFICULT TO INTERPRET. WHEN DETECTED, PROVIDES CONCLUSIVE EVIDENCE.
• BLOOD—TO ESTIMATE THE BLOOD FIBRINOGEN LEVELAND PARTIAL THROMBOPLASTIN TIME PERIODICALLY, WHEN
THE FETUS IS RETAINED FOR MORE THAN 2 WEEKS
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14. RECOMMENDED EVALUATION FOR A STILLBIRTH
• HEMATOLOGICAL EXAMINATION CONSISTS OF ABO AND RH GROUPING, KLEIHAUER-BETKE
TEST, VDRL, POSTPRANDIAL BLOOD SUGAR, HBA1C, UREA, CREATININE ESTIMATIONS,
THYR6OID PROFILE, TORCH SCREENING, LUPUS ANTICOAGULANT, ANTICARDIOLIPIN
ANTIBODIES AND THROMBOPHILIA STUDIES. URINE EXAMINATION FOR CASTS AND PUS
CELLS. THOROUGH EXAMINATION OF THE INFANT AND PLACENTA SHOULD BE DONE:
• INFANT—FOR MALFORMATIONS, UMBILICAL CORD FOR ENTANGLEMENT, NUMBER OF
VESSELS, PLACENTA FOR MECONIUM STAINING, MALFORMATIONS AND THE RESPECTIVE
WEIGHTS ARE TO BE RECORDED.
• AUTOPSY AND CHROMOSOME STUDIES ARE DONE FOR FETUSES WITH ANOMALIES AND
DYSMORPHIC FEATURES. IT IS ALSO DONE IF THERE IS HISTORY OF RECURRENT
STILLBIRTHS OR IF EITHER PARENT IS A CARRIER FOR BALANCED TRANSLOCATION. FETAL
SKIN, BLOOD ARE USUALLY TAKEN. FOR CYTOGENETIC STUDIES TISSUES MUST CONTAIN
SOME VIABLE CELLS.
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15. COMPLICATIONS
• PSYCHOLOGICAL UPSET OFTEN BECOMES A PROBLEM.
• INFECTION—SO LONG AS THE MEMBRANES ARE INTACT, INFECTION IS UNLIKELY BUT
ONCE THE MEMBRANES RUPTURE, INFECTION, ESPECIALLY BY GAS FORMING ORGANISMS
LIKE CL. WELCHII MAY OCCUR. THE DEAD TISSUE FAVORS 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 PLACENTAAND
DECIDUA, INTO THE MATERNAL CIRCULATION.
• DURING LABOR—UTERINE INERTIA, RETAINED PLACENTAAND POSTPARTUM
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16. PREVENTION
THE OVERALL RISK OF RECURRENCE OF STILL BIRTH VARIES BETWEEN 0 AND 8
PERCENT. THE CONDITIONS THAT RUN THE RISKS OF RECURRENCE ARE:
HEREDITARY DISORDERS, DIABETES, HYPERTENSION, THROMBOPHILIAS,
PLACENTAL ABRUPTION AND FETAL CONGENITAL MALFORMATIONS. WHILE IUD
CANNOT BE TOTALLY PREVENTED, THE FOLLOWING GUIDELINES MAY HELP TO
REDUCE ITS RECURRENCE :
• PRE-CONCEPTIONAL COUNSELING AND CARE IS ESSENTIAL TO PREVENT ITS
OCCURRENCE IN THE HIGH RISK GROUP.
• PRENATAL DIAGNOSIS —CVS OR AMNIOCENTESIS IN SELECTED CASES (P. 107).
• TO SCREEN THE “AT-RISK MOTHERS” DURING ANTENATAL CARE. CAREFUL
ASSESSMENT OF FETAL WELL-BEING AND TO TERMINATE PREGNANCY WITH THE
EARLIEST EVIDENCES OF FETAL COMPROMISE.
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17. MANAGEMENT
• BREAKING THE BAD NEWS TO THE MOTHER AND THE FAMILY MEMBERS IS A DIFFICULT TASK.
THIS IS MAINLY DUE TO THE FEAR OF BEING BLAMED FOR THE POOR OUTCOME AND FOR THE
MEDIC/LEGAL PROBLEMS. TO LISTEN TO THE PATIENT AND HER FAMILY MEMBERS ACTIVELY
AND THEN TO ANSWER THEIR CONCERNS ARE IMPORTANT. IT NEEDS PROFESSIONAL SKILLAND
ABILITIES.
• EXPECTANTATTITUDE (NON-INTERFERENCE): THE PATIENT AND HER RELATIVES ARE LIKELY
TO BE UPSET PSYCHOLOGICALLY BUT THEY SHOULD BE ASSURED OF SAFETY OF NON-
INTERFERENCE. IN ABOUT 80% OF CASES, SPONTANEOUS EXPULSION OCCURS WITHIN 2 WEEKS
OF DEATH. THE PATIENT MAY REMAIN AT HOME WITH THE ADVICE TO COME TO THE HOSPITAL
FOR DELIVERY. FIBRINOGEN ESTIMATION SHOULD BE DONE WEEKLY.
• REASONS FOR EARLY DELIVERY: (I) RELIABLE DIAGNOSIS COULD BE MADE WITH REAL TIME
ULTRASONOGRAPHY QUICKLY; (II) PROSTAGLANDINS ARE AVAILABLE FOR EFFECTIVE
INDUCTION AND; (III) COMPLICATIONS COULD BE AVOIDED.
• INDICATIONS OF EARLY INTERFERENCE. (I) PSYCHOLOGICAL UPSET OF THE PATIENT
(COMMON). (II) MANIFESTATIONS OF UTERINE INFECTION. (III) TENDENCY OF PROLONGATION
OF PREGNANCY BEYOND 2 WEEKS. (IV) FALLING FIBRINOGEN LEVEL (RARE)
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18. METHODS OF DELIVERY—THE DELIVERY SHOULD ALWAYS BE DONE BY MEDICAL INDUCTION:
A COMBINATION OF MIFEPRISTONE AND A PROSTAGLANDIN PREPARATION IS RECOMMENDED AS THE FIRST LINE
CHOICE FOR INDUCTION.
• OXYTOCIN INFUSION—THIS IS WIDELY PRACTICED AND EFFECTIVE IN CASES WHERE THE CERVIX IS FAVORABLE.
TO BEGIN WITH, 5–10 UNITS OF OXYTOCIN IN 500 ML OF RINGER’S SOLUTION IS ADMINISTERED THROUGH
INTRAVENOUS INFUSION DRIP. CONSECUTIVE TWO BOTTLES MAY BE ADMINISTERED AT A TIME. IN CASE OF
FAILURE, AN ESCALATING DOSE OF OXYTOCIN IS USED ON THE NEXT DAY. TO START WITH, A DRIP IS SET UP WITH 20
UNITS OF OXYTOCIN IN 500 ML OF RINGER’S SOLUTION AND RUN 30 DROPS PER MINUTE (80 MU/MINUTE). THE
STRENGTH OF THE DRIP MAY BE INCREASED TO 40 UNITS AFTER THE FIRST BOTTLE, IF THE CONTRACTION FAILS TO
START. IF THE UTERUS STILL REMAINS REFRACTORY, THE SAME PROCEDURE IS REPEATED AFTER VAGINAL
ADMINISTRATION OF PROSTAGLANDIN GEL. ONE SHOULD EXCLUDE THE POSSIBILITY OF SECONDARY ABDOMINAL
PREGNANCY IF REPEATED ATTEMPTS FAIL TO START LABOR.
• PROSTAGLANDINS: VAGINAL ADMINISTRATION OF PROSTAGLANDIN (PGE2) GEL OR LIPID PESSARY HIGH IN THE
POSTERIOR FORNIX IS VERY EFFECTIVE FOR INDUCTION WHERE THE CERVIX IS UNFAVORABLE. THIS MAY HAVE TO
BE REPEATED AFTER 6–8 HOURS. THE PROCEDURE MAY BE SUPPLEMENTED WITH OXYTOCIN INFUSION.
• MISOPROSTOL (PGE1) 25–50 mg EITHER VAGINALLY OR ORALLY IS ALSO FOUND EFFECTIVE VAGINAL ROUTE USE IS
MORE EFFECTIVE COMPARED TO ORAL ROUTE. MISOPROSTOL MAY BE REPEATED AT EVERY 4 HOURS.
PLACE OF CESAREAN SECTION IN A CASE WITH IUD IS LIMITED. MAJOR DEGREE PLACENTA PREVIA, PREVIOUS
CESAREAN SECTION (TWO OR MORE) AND TRANSVERSE LIE ARE THE COMMON ONES. EVERY ATTEMPT SHOULD BE MADE
TO AVOID A HYSTEROTOMY
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19. INTRAPARTUM ANTIBIOTIC PROPHYLAXIS
• WOMEN WITH SEPSIS SHOULD BE TREATED WITH INTRAVENOUS BROAD-
SPECTRUM ANTIBIOTIC THERAPY (INCLUDING ANTICHLAMYDIALAGENTS)
• ROUTINE ANTIBIOTIC PROPHYLAXIS SHOULD NOT BE USED
• NOTE; MECHANICAL INDUCTION MIGHT INCREASE THE RISK OF ASCENDING
INFECTION IN THE PRESENCE OF IUFD.
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20. • BEREAVEMENT MANAGEMENT AND PUERPERIUM: THE MEDICAL
TEAM AND THE NURSING STAFF SHOULD PROVIDE ALL THE
SUPPORT AND SYMPATHY TO THE BEREAVED COUPLE. THE COUPLE
SHOULD BE EXPLAINED IN SIMPLE TERMS ABOUT THE POSSIBLE
CAUSE OF FETAL DEATH. A PSYCHOLOGIST OR A COUNSELOR MAY
SEE THEM TO SUPPORT. RECOVERY IN POSTPARTUM WARD IS
BETTER AVOIDED. THE RISK OF POSTPARTUM DEPRESSION IS HIGH.
THE COUPLE IS SEEN IN THE POSTPARTUM CLINIC AFTER SIX
WEEKS. THE INVESTIGATION REPORTS ARE REVIEWED AND
COUNSELING FOR FUTURE PREGNANCY IS DONE.
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21. LACTATION
• WOMEN SHOULD BE ADVISED THAT DOPAMINE AGONISTS SUCCESSFULLY
SUPRRESS LACTATION IN A VERY HIGH PROPORTION OF WOMEN AND ARE WELL
TOLERATED BY A VERY LARGE MAJORITY; CABERGOLINE IS SUPERIOR TO
BROMOCRIPTINE
• DOPAMINE AGONISTS SHOULD NOT BE GIVEN TO WOMEN WITH HYPERTENSION
OR PRE-ECLAMPSIA.
• ESTROGENS SHOULD NOT BE USED TO SUPPRESS LACTATION.
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