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Gaby’s Green Top Guidelines > 2024 55 IUFD & Stillbirth > Flashcards

2024 55 IUFD & Stillbirth Flashcards

1
Q

What medications are 1st line for IOL in IUFD?

A

Mifepristone & misoprostol

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2
Q

What is the dosing regime for IOL in IUFD?

A

Mifepristone 200mg then:
* 24-24+6: miso 400 μg every 3 hours
* 25-27+6: miso 200 μg every 4 hours
* 28+: miso 25-50 μg PV every 4 hours or 50-100 μg every 2 hours PO
Otherwise can be bucc, SL, PV or PO

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3
Q

What is the recommended mode of birth for IUFD?

A
  1. Vaginal recommended for most
  2. Regimen uncertain for prev CS or transmural uterine scar
  3. Safety of IOL uncertain if 2+ prev CS or atypical scars
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4
Q

In what proportion of IUFD is a possible cause found & how?

A

Up to 75%
Postmortem
Cytogenetic testing
Placental histology

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5
Q

What are the definitions of IUFD & stillbirth?

A

No signs of life, known to have died after 24+0 completed wks of pregnancy
IUFD: in utero
Stillbirth: delivered

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6
Q

What is the rate of late IUFD?

A

1 per 250 babies

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7
Q

What is the rate of sudden infant death?

A

1 per 10,000 live births

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8
Q

How do living in a deprived area & black ethnicity affect rate of stillbirth?

A

Double

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9
Q

What is the most significant risk factor that could prevent stillbirth?

A

Screening for GDM

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10
Q

What are the modifiable, non-disease-specific risk factors for IUFD?

A
  1. Nulliparity
  2. Mat age > 35 or < 20
  3. Black, Asian, other non-white
  4. Previous stillbirth
  5. Previous PTB, PET, FGR
  6. Multiple pregnancy
  7. Post-dates > 41/40
  8. FGR &/or SGA <10th
  9. Low educational attainment
  10. Reduced fetal movements
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11
Q

What diseases increase the risk of IUFD?

A
  1. Thyroid disease
  2. Thrombophilia
  3. Malaria
  4. COVID
  5. Cholestasis
  6. SLE/APS
  7. Renal disease
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12
Q

What are the potentially modifiable risk factors for IUFD?

A
  1. Pre-existing HTN
  2. Obesity/overweight/weight gain
  3. Smoking >10/day
  4. Alcohol
  5. Illicit drug use
  6. Sleeping supine
  7. Living in most deprived area
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13
Q

What is the optimal method of diagnosing late IUFD?

A
  1. Ultrasound
  2. With 2nd opinion
  3. Not auscultation & CTG
  4. Prepare for possibility of passive fetal movement, offer repeat scan
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14
Q

What secondary features following IUFD might be seen on USS?

A
  1. Collapse of fetal skull with overlapping bones
  2. Hydrops
  3. Maceration
  4. Intrafetal gas in heart, blood vessels, joints
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15
Q

What is the best practice for communicating diagnosis of IUFD?

A
  1. Offer to call partner, family, friends
  2. Appropriate place
  3. Clear language, interpreter & LD change
  4. Give time to absorb, answer questions
  5. Support maternal/paternal choice
  6. Written info inc contact details & named HCP
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16
Q

What details of the birth plan should be discussed following IUFD?

A
  1. Mode of birth
  2. Pain relief
  3. Timings
  4. Memory-making opportunities
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17
Q

What are the options for mode of birth with IUFD?

A
  1. Spontaneous vaginal birth
  2. Immediate induction
  3. Delayed induction
  4. Caesarean birth
  5. Expectant management
18
Q

What are the potential methods of IOL with IUFD?

A
  1. Misoprostol
  2. +/- mifepristone
  3. Oxytocin infusion
  4. Mechanical methods
19
Q

What is the chance of DIC within 4 weeks of IUFD?

A

10%

20
Q

In IOL for IUFD, what proportion are born within 24 hours?

A

90%

21
Q

Which complications are increased with birth following IUFD?

A
  1. Shoulder dystocia
  2. Clinical chorioamnionitis
  3. PPH
  4. Retained placenta
  5. Blood transfusion
  6. DIC
  7. Acute renal failure
  8. Acute respiratory distress
  9. Sepsis & shock
  10. Hysterectomy
22
Q

What are the benefits of mifepristone over misoprostol alone?

A
  1. Shorter time to birth
  2. Increased chance of vaginal birth
  3. Lower number of misoprostol doses
23
Q

What investigations should be done in IUFD for all?

A
  1. Standard haematology & biochem
  2. CRP & bile salts
  3. Coagulation screen & fibrinogen
  4. Kleihauer inc if Rh +ve
  5. Cultures: blood, urine, vag, Cx
  6. Viral (& tropical infection) screen
  7. Random blood glucose + HbA1c
  8. Thyroid function
  9. Thrombophilia screen at 6 weeks
24
Q

What maternal investigations are done for specific indications in IUFD?

A
  1. Anti-red cell antibodies if hydrops
  2. Anti-Ro & anti-La antibodies if hydrops, endomyocardial fibroelastosis or AV node calcification
  3. Alloimmune antiplatelet antibodies if fetal intracranial haemorrhage
  4. Parental blood karyotype if fetal anomaly or failed test
  5. Toxicology if hx or presentation suggestive of use
25
Q

What does a postmortem examination include in IUFD?

A
  1. External
  2. Autopsy
  3. Microscopy
  4. XR
  5. Placenta & cord
  6. US/MRI
26
Q

What fetal & placental testing is done in IUFD in addition to postmortem?

A
  1. Microbiology: fetal blood, fetal swabs, placental swabs
  2. Cytogenetics: fetal cord, placenta
27
Q

What proportion of late IUFD is complicated by chorioamnionitis?

A

26%

28
Q

What proportion of women who choose not to use pharmacological measures to suppress lactation experience excessive discomfort?

A

1/3

29
Q

What medications are used to suppress lactation?

A

Dopamine agonists
Cabergoline 1mg single dose over bromocriptine 2.5mg BD for 14 days

30
Q

What medications should be considered after IUFD?

A

Lactation suppressants
Thromboprophylaxis
Anti-D if rhesus -ve

31
Q

What transplacental infections are associated with IUFD?

A
  1. Toxoplasmosis
  2. Rubella
  3. Cytomegalovirus
  4. Herpes simplex
  5. Syphilis
  6. Parvovirus
  7. Listeria
  8. Leptospira
  9. Lyme disease
  10. Coxsackivirus
  11. Q fever
32
Q

With IUFD, how can genital ambiguity be managed?

A
  1. Examination by 2 experienced HCPs
  2. Rapid genetic testing if in doubt: QF-PCR or FISH
  3. Parents can base decision on prior info eg scans
  4. Can be registered as indeterminate sex
33
Q

What % of babies have a cytogenetic anomaly?

A

6-13%

34
Q

How should placenta be stored prior to biopsy being taken?

A

Sterile tissue culture medium
Of lactated Ringer’s solution
Not formalin

35
Q

What proportion of postmortems for IUFD reveal information that affects Mx of the next pregnancy?

A

10%

36
Q

How many more times likely is subsequent IUFD?

A

5 times out of

37
Q

How should subsequent pregnancies be managed after IUFD?

A
  1. Consultant-led care, with continuity
  2. Serial growth scans
  3. Aspirin
  4. GDM screening
  5. Emotional support
  6. Offer planned birth by 39/40
38
Q

Which causes of IUFD are most likely to recur?

A

Placental causes
Preterm birth

39
Q

Who do all still births need to be reported to?

A
  1. MBRRACE
  2. National maternity & perinatal audit
  3. PMRT database
  4. MNSI: maternity & newborn safety investigations (if intrapartum)
40
Q

What is the timescale for maceration?

A

0-6 hours: little change, clear corneas
6-24 hrs: skin peeling on peripheries, bony prominences
1-2 days: more widespread skin peeling, bullae, discolouration of abdomen
2-3 days: haemolytic changes in cord, serosanguinous nasal fluid, fluid in body cavities, uniform pink tissues
4-7 days: skull bone separation, sunken eyes, mandible suture more mobile, periosteum & dura lifting
7+ days: brown discolouration
10-12 days: increasing fluid loss
Weeks: fetus papyraceous

Gaby’s Green Top Guidelines (51 decks)

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