Understanding IUFD and Prolonged Pregnancy: Causes, Risks, and Management

1. IUFD & PROLONGED PREGNANCY BY KAJALI CAMARA

2. IUFD • Definition: is fetal death after 20 weeks’ gestation but before the onset of labour. • Complicates 1% of pregnancies

3. INCIDENCE • The fetal death rate in the United States varies among races, but overall it is 6.8-6.9 deaths per 1,000 total births and accounts for approximately half the perinatal mortality (fetal and neonatal deaths). • Worldwide, this rate varies considerably, depending on the quality of medical care available in the country and the definitions used for classifying fetal deaths. • Under-reporting in developing nations is common, making comparisons even more difficult.

4. CAUSES [RISK] • Only rarely is the exact cause of the death obvious. • Unexplained causes account for 25-60% of all fetal demise; the incidence increases with increasing gestational age. • In cases where a cause is clearly identified, the cause of fetal death can be attributable to: • - fetal, • - maternal, or • - placental pathology.

5. POSSIBLE MATERNAL CAUSES • Prolonged pregnancy (greater than 42 weeks). • Diabetes (poorly controlled). • Systemic lupus erythematosus. • Infection. • Hypertension. • Preeclampsia. • Eclampsia. • Hemoglobinopathy. • Advanced maternal age. • Rh disease. • Uterine rupture. • Antiphospholipid syndrome. • Acute, severe maternal hypotension. • Maternal death.

6. POSSIBLE FETAL CAUSES • Multiple gestations. • Intrauterine growth restriction. • Congenital abnormality. • Genetic abnormality. • Infection (i.e., parvovirus B-19, CMV, listeria).

7. POSSIBLE PLACENTAL CAUSES • Cord accident. • Abruption. • Premature rupture of membranes. • Vasa previa

8. RISK FACTORS • Multiple pregnancy. • African American race. • Advanced maternal age. • History of fetal demise. • Maternal infertility. • Maternal hemoconcentration. • Maternal colonization with certain pathogens (ie, GBS, Ureaplasma urealyticum). • History of small for gestational age infant. • Small for gestational age infant. • Obesity. • Paternal age.

9. FREQUENT SIGNS AND SYMPTOMS • Signs and symptoms of pregnancy may subside. • No symptoms may occur in the early stages of pregnancy • The diagnosis is based on the absence of fetal heart tones, the lack of uterine growth or ultrasound studies during prenatal examinations. • In later stages of pregnancy, a woman may be aware of changes in the fetal movement (kicks) or that the movement has stopped. • Reduce fundal height

10. Diagnosis • History and physical examination are of important value in the diagnosis of fetal death. • In most patients, the only symptom is decreased fetal movement. An inability to obtain fetal heart tones upon examination suggests fetal demise; • however, this is not diagnostic and death must be confirmed by diagnostic tests such as: • x-rays, • ultrasound (ultrasonography) and • amniotic fluid studies. • Fetal demise is diagnosed by visualization of the fetal heart and notation of the absence of cardiac activity.

11. Cont…. • Once the diagnosis of fetal demise has been confirmed, the patient should be informed of her condition. • Often, allowing the mother to see the lack of cardiac activity helps to solidify the diagnosis. • Care must be taken to be understanding of the patient's feelings and to give the patient time to adjust before proceeding with a discussion of further management.

12. management • professional counseling is recommended .[ sensitive & empathy] • The patient need support, information, and their immediate questions [cause of the dead] answered. • They should be offered bereavement counseling. • Help in funeral arrangement. • They should be reassured that the death fetus if left in the uterus will not cause any harm in the following 3 weeks [80 % deliver].

13. Cont.. • The woman may choose to wait spontaneous labour OR labour induced. • If spontaneous labour is the choice then, the patient is monitored expectantly [80 % goes into labour ]. Assure the pt that the baby may be macerated • Active approach: b/o emotional burden, risk of chorioamnionitis, and 10% risk of DIC (if >5wks) • Induction of labour can be initiated at any time.

14. Induction of labour • If the patient prefer to induce then the cervix is ripen with ripenning agents such as Mesoprostol , And then induce labour. • F/U: to determine any retained product, cause of death. Screening for diseases, infections (TORCH), and chromosomal anomalies. • Manage next pregnancies as high-risk. • F/U 6 WK, do all the necessary investigations and the pt be seen by a consultant. • Surgery may be indicated if induction of labour fail occur. • Antibiotic before and after surgery

15. COMPLICATIONS • Disseminated intravascular coagulation (DIC), a disruption of blood clotting mechanisms that can result in hemorrhage or internal bleeding, which may rarely develop relatively late after fetal death. • Infection. • Deprssion • Retain products • endometritis

16. . • PROLONGED PREGNANCY

17. Concept • Prolonged pregnancy means a pregnancy that has extended beyond 42 weeks of gestation. • This is counting from the onset of her last menstrual period, or an ultrasound scan within the first 20 weeks of pregnancy. • Prolonged pregnancy, ‘post-term’ and ‘post-mature’ mean exactly the same thing.

18. incidence • The incidence of post-term pregnancy is 3-12% for prolonged pregnancy.

19. CAUSES • The causes of post-term births is unknown • Incorrect dates account for two-thirds of "post-term" pregnancies. • Post term birth are likely when the mother has experienced a previous post-mature birth. • Post-term pregnancy is rarely associated with low estrogen levels, including anencephaly, fetal adrenal hypoplasia, absence of fetal pituitary, estrogen precursor deficiency, or placental sulfatase deficiency.

20. CLINICAL FEATURES • Different babies will show different symptoms of postmaturity. • The most commons symptoms are: • dry skin, • overgrown nails, • creases on the baby's palms and soles of their feet, • minimal fat, • a lot of hair on their head, • and either a brown, green, or yellow discoloration of their skin. • Doctors diagnose post-mature birth based on the baby's physical appearance and the length of the mother's pregnancy.[

21. Methods of monitoring postterm babies • Fetal movement recording:Regular movements of the baby is the best sign indicating that it is still in good health. The mother should keep a "kick-chart" to record the movements of her baby. Less than 10 movements in 12 hours is not a good sign and a doctor should be contacted. If there is a reduction in the number of movements it could indicate placental deterioration. • Electronic fetal monitoring:Electronic feotal monitoring uses a cardiotocograph to check the baby's heartbeat and is typically monitored over a 30-minute period. If the heartbeat proves to be normal the doctor will not usually suggest induced labor.

22. CONT…. • Ultrasound scan:An ultrasound scan evaluates the amount of amniotic fluid around the baby. If the placenta is deteriorating, then the amount of fluid will be low and induced labor is highly recommended. • Biophysical profile : A biophysical profile checks for the baby's heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid surrounding the baby. • Doppler flow study: Doppler flow study is a type of ultrasound that measures the amount of blood flowing in and out of the placenta.

23. treatment INDUCTION OF LABOUR EXPECTANT MNAGEMENT

24. EXPECTANT MNAGEMENT • If the pt. choose to be manage expectantly • It recommend • • fetal heart rate monitoring two times a week, and • • an ultrasound scan to assess the amount of amniotic fluid around the baby. • At these visits pts well-being is also assessed.may detect a medical reason for the baby to be born. If this is the case it will be fully discussed with the pt

25. cont • The following precautions should be taken in consideration: • 1.Decrease fetal movement warrants an immediate biophysical profile evaluation • 2.Abnormal biophysical profile , decrease amniotic fluid • 3.Abnormalities in the nonstress test mandate induction or a backup test • 4.A large or compromise fetus may require CS

26. induction • Assessing the cervix: If ripen then induction can be done If not ripen then u need ripen it before induction

27. COMPLICATION • Perinatal mortality increases after 40 weeks, and the rate doubles by 42 weeks; at 44 weeks the perinatal mortality rate is 4-6 times greater than the mortality rate of a term gestation. Maternal, fetal, and neonatal morbidity also increase after 42 weeks. • Maternal Complications. The risk of cesarean birth more than doubles after 42 weeks gestation; CPD; Arrested progress of labour; Oligohydraminious ; • Neonatal complications of post-term pregnancy include :macrosomia, shoulder dystocia, brachial plexus injuries, and meconium aspiration, malformation,malnutrition.

28. The End • Thanks