IUFD

Obstetric and Gynecology Department

Medical Faculty Brawijaya University/Saiful Anwar Hospital
Malang
 Definitions
• Fetal death
• Death prior to the complete expulsion or extraction from its mother of a
product of human conception, irrespective of the duration of pregnancy
and which is not an induced termination of pregnancy
• Delivery of a fetus showing no signs of life
• Absence of breathing, heart beat, umbilical cord pulsations,
definitive voluntary movements
• Excludes
• Transient cardiac contractions
• Fleeting respiratory efforts (gasps)
 Definitions
• Not all fetal deaths are stillbirths
• World Health Organization
• Fetal death late in pregnancy
• Allows each country to define gestational age at which fetal death is
considered stillbirth
• 16 to 28 weeks
• National Center for Health Statistics
• Most states use 20 weeks or a fetal weight of ≥ 350 g or ≥ 500 g
• 28 weeks (late stillbirth)
• Tennessee Code Annotated
• Fetal death ≥ 500 g or in the absence of weight, ≥ 22 completed weeks
gestation
 Incidence
• > 3 million stillbirths each year worldwide
• 2005 rate of 6.2/1000 total births in US
• Rate of early stillbirth has remained stable
• Rate of late fetal loss has decreased by 29% since 1990
• African Americans have 2x stillbirth rate as Caucasians
• DM, HTN, abruption, PPROM
 Etiology

• Unknown in 25 – 60% of cases

• Identifiable causes can be attributed to

1. Maternal conditions

2. Fetal conditions

3. Placental conditions
 Maternal Conditions
• Prolonged pregnancy • Eclampsia

• Diabetes (poorly controlled) •

• SLE • Rh disease
Hemoglobinopathy
• Infection • Uterine rupture
• Preeclampsia • Maternal trauma or death
• Advance Maternal Age • Inherited thrombophilia

Woods, Jessica R., and Alexander EP Heazell. "Stillbirth: is it preventable?." Obstetrics, Gynaecology & Reproductive
Medicine 28.5 (2018): 148-154.
 Fetal conditions

• Multiple gestation
• IUGR
• Congenital anomaly
• Genetic abnormality
• Infection
• Hydrops
 Placental Conditions

• Cord accident
• Abruption
• PROM
• Vasa previa
• Fetomaternal hemorrhage
• Placental insufficiency
Flow chart for fetal and placental evaLuation

Cunningham, F., et al. Williams obstetrics, 25. Mcgraw-

hill, 2018.
 Maternal Risk Factors
Developed Countries Developing Countries
• Obstructed prolonged labor and
• Congenital and karyotypic
associated asphyxia, infection,
anomalies
injury
• Growth restriction/placental
anomalies • Infection – syphilis and gram-
• Medical disease – diabetes, SLE, negative infection
renal disease, thyroid, cholestasis • Hypertensive disease –
• Hypertensive disease, complications of preeclampsia and
preeclampsia eclampsia
• Infection – Parvovirus B19, • Congenital anomalies
syphilis, streptococcal infection, • Poor nutritional status
listeria • Malaria
• Smoking
• Sickle cell disease
• Multiple gestation

Flenady, Vicki, et al. "Classification of causes and associated conditions for stillbirths and neonatal deaths." Seminars in Fetal
and Neonatal Medicine. Vol. 22. No. 3. WB Saunders, 2017.
Most Frequent Types of Stillbirth According
to gestasional age

24 - 27 weeks 28 - 37 weeks 37+ weeks

Infection (19%) Unexplained (26%) Unexplained (40%)

Abruptio placenta Fetal malnutrition Fetal malnutrition

(14%) (19%) (14%)

Anomalies (14%) Abruptio placenta Abruptio placenta

(18%) (12%)

Lawn, Joy E., et al. "Stillbirths: rates, risk factors, and acceleration towards 2030." The Lancet 387.10018 (2016): 587-
603.
 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
• Fetal heart sound is not audible
 INVESTIGATIONS

• USG (100%) + Associated features can be noted (oligo, hydrops)

• Straight- X-ray abdomen
 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
 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)
I. History
II. Gross examination
• SB infant
• umbilical cord
• placenta
• amniotic fluid
III. Fetal autopsy & karyotyping
IV. Placental investigations
V. Maternal Investigations
 I. History
Family Past Obstetrical
• Recurrent abortions • Baby with congenital anomaly /
• Congenital anomalies hereditary condition
• Abnormal karyotype • IUGR
• Hereditary conditions • Gestational HPT with adverse
• Developmental delay sequele
• Placental abruption
Maternal
• DM • IUFD
• HPT • Recurrent abortions
• Thrombophilias
• Autoimmune disease
• Severe Anemia
• Epilepsy
• Consanguinity
• Heart disease
 II. Gross Description
Amniotic fluid
Infant description 1. Color-meconium, blood
1. Malformation
2. Volume
2. Skin staining
Placenta
3. Degree of maceration
4. Color-pale , plethoric 1. Weight
2. Staining
Umbilical cord 3. Adherent clots
4. Structural abnormality
1. Prolapse 5. Velamentous insertion
2. Entanglement-neck, arms, legs
6. Edema/ hydropic changes
3. Hematoma or stricture
Membranes
4. Number of vessels
5. Length 1. Stained
2. Thickening
 III. Fetal Autopsy & Karyotyping

• These 2 are important tests in Still Birth evaluation

• 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
• Parents with multiple pregnancy losses (second or third trimester)
• For aneuploidy- FISH (Fluorescence in-situ Hybridization) , For small
deletions- CGH (Comparative Genomic Hybridization)
IV. Placental Investigations
• 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
 V. Maternal Evaluation
• CBC
• Diabetes testing (HbA1c, FBS)
• 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)
• 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
• Urine toxicology screening (cocaine, amphetamines are associated
with abruption)
MANAGEMENT
• 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
Induction of Labour

• 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
• 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)
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
 Complications

– Infection
– PPH
– Retained placenta
– Abruption
– DIC
– Shock, renal failure
– Sepsis
– Maternal death
 Post delivery
• Emotional support & Counseling as they at increased risk of
Still birth
• 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
Table Investigations Cause of IUFD with Appropriate Timings

Woods, Jessica R., and Alexander EP

Heazell. "Stillbirth: is it
preventable?." Obstetrics,
Gynaecology & Reproductive
Medicine 28.5 (2018): 148-154.
Management of Subsequent Pregnancy after Still birth

Cunningham, F., et al. Williams obstetrics, 25. Mcgraw-hill, 2018.

Unknown etiology in 25-60% IUFD cases
Optimal evaluation for future pregnancy
necessary
Evidence based models for evaluation
Counseling & support
Reassure and guide for future pregnancy
THANKYOU