Essay 309 - IUD

The aim of initial assessment will be to rule out IUFD and placental compromise.I will take h/o duration of reduced fetal movements ,such complaint before,risk associated with placental compromise i.e IUGR ,PIH .Medical history including DM or vascular diease ,also drug history of smoking ,illicit drugs .I will enquire in sensitive manner about domestic violance especialy she is coming frequently to ER.I will ask about associated pain ,rupture of membrane or vaginal bleeding.

I will examine B.P and measure for protinuria to rule out PE.abdominal palpation for IUGR has limited sensitivity while measure of HOF and plotting on customised charts is associated with improved detection of small for gestational age.Also lie ,presentaion and estimated liquor and weight .

I will not use CTG or doppler sonicaid for fetal heart ,but ultrasound to visualise fetal cardiac activity.Incase i am not able to provide USG facility,will refer her to a place where it is available.

If fetal heart is positive than usg for fetal parameters \nd liquoer volume ,in case of small parameters and reduced amniotic fluid will arrange for umblical artery doppler.

(b)After confirming intrauterine death ,its better to take second opinion.If mother still complaining of passive movements ,repeat usg shud be done for her reassurance.

Next issue is to break bad news ,i will prefer to break in the presence of her partner or other family member.It should be in a very sensitive manner keeping her and family members psychological isssues in considerations.Furthur management would take place according to couple prefences .

Furthur investigations include blood group ,atypical antibodies to rule out alloimunisation,LFT ,RFT ,electrolytes and uric acid to rule out PE.,maternal blood culture ,urine analysis ,vaginal swabs and cervical swabs to rule out sepsis and chorioamnionitis.Klehaure test to know about fetomaternal HG which could be a cause of stillbirth ,irrespective of her rhD status.Maternal DM will be excluded by random blood sugar and HBA1C ,although this is normal in GDM.anti Ro and anti La antibodies ,antiphospholipd antibodies if associated with IUGR or aternal autoimune disease.In case of positive anticardiolipin igG and ig M shoulb be repeated after 6 months.Thrombophilia screening also .Thyroid function tests to know about subclinical hypothyroid which could be a cause.Also maternal blood for bacteriology including listeria monocytogenes and chlamydia,viral screening including toxoplasmosis ,CMV ,parvo virus and rubella if negative before.Also syphilis and malaria esp h/O recent travel and fever and chills.Coagulation profile to rule out DIC.

SO the aim of these investigations will be to rule out sepsis ,PE and chorioamnionitis,abruption ,which are indications of immidiate delivery.In case of their absence i can tell that she can delay delivery for short period i.e 48 hrs which could be associated with increased maternal morbidity.Mode of deliver will depend upon her wishes,previous mode of delivery .I will offer her mifeprostone 200 mg followed by misoprostol 100 microgram 4 hrly for 24 hours while reassuring that 90 percent of women will deliver within 24 hrs.In case of previous c/s mifeprostone alone or reduced dose of misoprostol after decision by consultant or mechanical methods should be considerd.C/s according to obstetric indictaions like major placenta previa.

B/f discussing mode and time of delivery i would offer her postmortem examination of baby ,so that cause,time ,associated anatomical abnormalities and risk of recurrence can be determined .while at the same time should clear that in half of cases no cause is detected.In case of refisal limited postmortem including baby examination ,weight ,radiological examination and tissue biopsy should be offered ,making it clear that it is associated with low detection rates than conventional postmortem which include xray ,autopsy bacteriologr ,fetal tissues ,placental tissues for cytogenetic abnormalities (bec karyotypic abnormalities 6%)After delivery placental,memranes for pathological examination.Postmorterm examination should be done after taking informed consent in the presence of trained midwife and senior obstetrician on standard parinatal consent form.

Delivery should be in a envirnment which is isolated and meets the requrements of couple and monitered by trained midwife.After delivery mom shuld not parsauded to hug or kiss the baby ,may be associated with maternal trauma.Baby photos,lock of hair should be saved after consent and given to parents if they wish.Still birth registration should be offered to be done by hospital or if they want it to be done by themselve relevent details provided.Cremation etc should be offered according to their religious and spirtual believes.Bereavemnt counselling ,SAND etc support groups provided.

Post natal breast care including sinle dose cabergoline to supress milk production.Contraception advice and follow up appointment at 6 to8 wks when all the tests results would be available and to discus about risk of recurrence ,prepregnancy counselling offer will be provided.Place of this appointment will be according to couple choice.

A

Her history is taken to detect the risk of intrauterine growth restriction, preeclampsia. Previous episode of decrease fetal movement, her social history of smoking, alcohol, and drug abuse noted. History of medical disorders as diabetes , her occupational history noted as working for long hours of standing may not allow her perceive the fetal movements. History of trauma asked. Assessment of her previous serum test for down syndrome, karyotype report, or diagnosis of any syndrome is done from her antenatal record. Her anomaly scan reviewed

Her blood pressure measured, urine for protein is checked. Abdominal examination is done to exclude small fetus and symphysiofundal height measured. assessment of fetal condition is done  by cardiotocography.

B

 If she is alone offer to be accompanied by her partner or relative. Explain that the fetus has died in unambiguous manner and express sorrow. She and her partner are allowed time to express their anger, shock. The health professional should not react to their anger. When the woman is ready to be respond again , ask her the events surrounding the decrease fetal movement as with time important information may get missed such as history of headache with proteinuria, trauma.

Symptoms of pain, bleeding, passage of liquor, fever, foul smelling vaginal discharge asked

Assessment is done to exclude any reason where emergency decision to deliver may be needed such as chorioamnionitis, and severe preeclampsia, abruption.

Along with previous examination cervical assessment for bishop score is done. Blood is taken for full blood count, liver function test, creatinine , electrolyte, coagulation profile, kleaihaur test (to assess fetomaternal hemorrhage).test for infections like toxoplasmosis, rubella, parvovirus(only if hydrops), syphilis is offered. Her random blood sugar level and total bile acid checked, test for thyroid function test (if history is suggestive ), .her urine is tested for urine protein and for toxic agent use with her permission. Further test such as anti red cell , antiplatelet antibody are offered after postmortem result.

 She is offered immediate induction versus expectant management. Mifepristone 200mg given 36 -48 hr. prior to misoprostol is the regime for induction. Woman who wants to wait should be explained that there is 10% chance of developing coagulopathy which increases further to more than 30% after 4 weeks. She is explained that The appearance of fetus will deteriorate and the  postmortem examination will be less informative. She should do blood test for coagulopathy twice a week. She is given information about postmortem examination as it can be useful to reach the diagnosis in 50% of cases and can modify the management if recurrent cause is found. She told that it will be done with her permission only but if she decline she is offered postmortem exam of placenta or limited tissue or x-ray, photographs. Selective tissue postmortem can take long time to return the organ and further delay the funeral so women should be appropriately informed and pathologist contacted to provide the accurate information. She is provided the information how to contact bereavement services who will help her in contacting the pathologist for postmortem, for registration, arranging funeral. She is also given information about support group such as SANDS(stillbirth and neonatal death society). She is provided adequate information and psychological support to make informed decision. The procedure of induction, continuous support during labor on one to one nurse basis and allowing to stay in place where care will not be compromised but away from routine labor room is offered. After delivery she is allow to hold the baby as per her wish and provided with mementoes. She is given advice regarding milk suppression( bromocriptine avoided in hypertension)  sinle dose of cabegoline is given and provided with advise about contraception. Follow up visit arranged.

a) Obtain history regarding symptoms of abdominal pain and vaginal bleeding which suggest abruptio placenta. Drug history such as opiod consumption which causes supressed fetal movements. Abdominal palpation to detect tenderness and contractions. Measurement of symphysio-fundal height plotted on a customized growth chart to detect small for gestational age. Blood pressure and urine protein to detect pre-eclampsia. Hand held Dopplar device used to detect fetal heart. Absent of fetal heart warrants real time ultrasound to demonstrate fetal heart activity. If fetal heart is detected, CTG is done to reassure her.

b) Sympathetic approach is used. Patient is encouraged to obtain presence and support from her partner or family members before breaking of bad news. Inform patient that it is not her fault and provide support. Offer information when she is ready and as much as she is able to cope. Discuss options of expectant management to await spontaneous delivery or earlier delivery via induction of labour or a Caesarean section. Inform patient that expectant management carries 10% risk of coagulopathy in the first 4 weeks and 30% thereafter. Twice weekly blood test is needed to detect coagulopathy. Inform that baby would likely be macerated at birth the longer it takes to deliver. Inform regarding induction of labour using Mifepristone and a prostaglandin. Labour would be more painful than spontaneous labour. A Caesarean section is offered if delivering a dead fetus vaginally is not acceptable to her. Implications to future pregnancy such as increased risk of placenta praevia and accreta and scar dehiscence is informed. Offer blood investigations to detect coagulopathy and  cause of fetal demise. Inform that most of the time no cause is found. If cause detected, it would influence management of future pregnancy. Offer full post mortem to detect cause of fetal demise. Partial post mortem is an option if she rejects a full post mortem. Inform that finds may be limited.  Consent needs to be obtained prior to post mortem. Her wishes should be respected at all times. Offer written information and leaflets regarding intrauterine death. Provide information on support group such as SANDS (Stillbirth and Neonatal Death Society). Offer counselling and pyscholagical support if needed.

We should ask her if she have any complain apart  from decrease fetal movement like abdominal pain , or vaginal bleeing , current pregnancy history , if she experience any fever , infection ,trauma ,or sexually transmitted diseases . past medical histtory of  DM , hypertention , thyroid  or thrombotic disease is important . We should ask about family history mainly congenital malformation , drug history if she is taking any teratogenic drugs or drug abuse . O/E pulse , BP , BMI ,abdominal examination for fundal hight , presentaion  fetal heart rate by hand held doppler  , tenderness or contraction . US to confirm dopplr finding .

A)Initial  assessment would aim at confirming fetal viability and fetal well being and identifying factors that increase the risk of IUGR and still birth.

I will enquire if this is first episode of reduced fetal movements or she had similar episodes earlier,as repeated episodes increase of  still birth.History of abdominal trauma ,or vaginal bleeding is taken.

Any history of viral infections ,malaria is enquired. History of smoking , or illicit drug intake.

USS is reviewed to see any congenital malformation of fetus, reduced liquor.

On examination BMI is noted as obesity  is also a risk factor for still birth .BP is noted.Urine tested for proteinuria

Abdominal examination is done for Fundal height, any abdominal tenderness ,Fetal heart is checked by hand held Doppler.CTG is done to assess fetal compromise.

If fetal heart rate is normal, no risk factors detected on history and CTG shows no fetal compromise, woman may be allowed to go home and advised to monitor fetal movements closely. She should return immediately if she has similar complains.

If her symtoms of reduced fetal movements persisit ,USS may be offered for fetal biometry .Biophysical has a role in case of repeated presentations as it has a good nega tive predictive value

Assessment and advice should be clearly documented.

B) An immediate offer should be made to call her husband or relatives, before breaking  the news of fetal death. This

is time of great psychological stress and she should be approached empathetically.

Woman’s wishes should be taken into consideration while planning further management.She should be advised abouts investigations and postmortem examination .With regards to delivery she can go for immediate induction of labor or expectant management .She should be provided with written information .

Investigations that are required include CBC for  Hb, platelets and blood group and Rh.If she is Rh –ve, immediately Kleihauer test should be done and and anti-D given. LFTs  ,CRP and serum urea ,creatinine and electrolytes are done.

TFTs, and RBS to detect occult GDM or thyroid disease.HbA1c is done to assess her blood sugar control. Clotting screen if there is risk of DIC. Maternal viral screening for TORCH and Syphilis. If there is evidence of infection swabs are taken for bacteriology. blood ,urine ,cervical and vaginal swabs.

Thrombophilia screening may be done if there is evidence of FGR .Anti-red cell antibodies, anti platelet antibodies ,anti Ro and antiLA  may be done if indicated. Parental karyotype may be required if there is fetal translocation or genetic testing has failed

Fetal investigations include fetal swabs  and placental swabs for microbiology. Fetal tissues,should be taken with consent for karyotype.

Parents should be advised that postmortwem examination is important as it can give valuable information about the cause of death and  for future pregnancy planning. It can be external or autopsy.Consent should be obtained sensitively as it is a traumatic issue for parents.

Pathology of cord ,membranes and placenta should be done even if parents decline postmortem.

She should be advised that labor will be induced by mefipristone and prostaglandins.If expectant management is continued for more than 48hrs ,she should test for DIC twice weekly.   Prolonged expectant management will deteriorate baby’s appearance and vaulue of postmortem examination will be reduced.

Vaginal delivery would be aimed. If parents wish they can hold the baby, Hand and foot prints and photographs of baby should be taken.

Cabergolin would be given for suppression of lactation. Bereavement counseling should be offered.

She should be reffered  to Support group i.e SANDS .Postnatal appointment is given at 6-8wks ,where results of investigations and contraception should be discussed.General advice about folic acid, rubella,and  smoking cessation is given,and also early booking in next pregnancy

a: I will review her ante-natal history looking for any episodes of trauma or ante partum hemorrhage or recent leaking liquor. I will ask her for any medical condtions such as ante-natal infections, medical conditions such as hypertension, diabetes or gestational diabetes which have been detected antenatally. Review her medical records to look for any fetal anomlies picked up on scan. Ask in detail with regards to the decreased fetal movements. Whether they were associated with blurring of vision, headache, epigastric pain which might point to pre clampsia as a cause or pain and bleeding which might point to abruptio as a cause. On phyisical examination, take her height weight, Blood pressure and BMI. Send urine to test for proteinuria. I will assess her with abdominal palpation to look for a woody hard uterus or whether abdomen is soft and non tender. Check symphisial fundal height to check uterus is to dates. On speculum examination, look for any leaking liquor or bleeding and do a digital vaginal examination to assess cervical dilation. Investigations will include a pre clampsia workup including full blood count, coagulation profile, liver function test, uric acid and group and save. Kleihaur test should also be sent if any fetal maternal hemorrage is suspected. A bedside ultrasound should be performed to confirm absence of fetal cardiac activity .

b: Patient should be approached in a senstive manner. The diagnosis of intra uterine fetal death should be explained to her in a sensitive manner , preferably in the presence of family members or the husband.she should be offered to consult for a second opinion. She should be co managed by a multi discliplinary team consisting of the specialist midwife, obstetrician and grief counsellor. She should be admitted to hospital for further management and provided with written information. she should be counselled and given options to mode of delivery. As she is a primip, she can choose to await spontaneous labour within 48 hours provided pre clampsia or Abruptio is not a cause for the intra uterine death. After 48 hours she should have induction of labour with prostaglandins. she should be counselled that delivery should be expedited to prevent Disseminated intravascular coagulation from setting in if there is evidence of abruptio. If she has pre clampsia ie the blood pressure is very high and there is proteinuria in the urine, delivery should be by caserean section if the cervix is not favourable. She should be given Rhogam if she is rhesus negative and a kleihaeur test carried out to quantify the amount of fetal maternal hemorrahge. The couple should be counselled for postmortem of the fetus as well as blood investigations for pre clampsia, autoimmune conditions, thrombophilias such as anti phospholipid syndrome as it can yield important information for her next pregnancy. Swabs from the placenta as well as the placenta should be sent for histology as well. Consent should be obtained in a sensitive manner. After delivery, the parents can hold the baby and prints of the baby can be taken if desired. Bereavement counselling should be offered.  Breast feeding suppression should be given in the form of cabergoline and the patient should be given a post natal appointment to review the results of the investigations in 6-8 weeks. COntraceptive advice should be given and advice for folic acid 3 months pre conception should be given if she desires another pregnancy.

(a)

I would ask about symptoms like abdominal pain, leaking liquor or vaginal bleeding. I would determine whether there have been any previous episodes of reduced fetal movements. Risk factors like maternal drug use or smoking should be enquired. On examination, blood pressure, pulse rate, temperature and BMI should be recorded. Abdomen should be palpated for tenderness or contractions. Symphysis fundal height should be measured and plotted on a customised growth chart to detect any IUGR. Speculum examination should be performed if history indicates rupture of membranes. Fetal heart should be examined using handheld doppler. Urine dipstick should be done to rule out pre-eclampsia.

(b)

I would inform the obstetrician consultant or senior on duty.  A call to her partner, relatives or friends should be offered if she is alone. I would explain IUD to the couple with empathy. They shall be allowed time them to react to the bad news. Then I shall discuss with her the management plan, i.e. expectant management or induction of labour. In the presence of sepsis, pre-eclampisa, placenta abruptio or ruptured membranes, immediate treatment and delivery should be advised; otherwise, labour and birth should take into account of her preference and a delay of labour for a short period is unlikely to cause physical harm to her. Vaginal birth is the recommended method of delivery for most women, and labour would be induced by combination of mifepristone and prostaglandin (misoprostol). It would be explained to her expectant management may be associated with increased anxiety, deteriorated appearance of baby and reduced value of postmortem. If she chooses to delay labour for longer than 48 hours, she would be advised to have DIC test twice weekly as there is 10% chances of DIC within 4 weeks from IUD and the risk increases thereafter. 

Investigations to identify possible causes of IUD should be offered, as it may help with grief and management of future pregnnacy; but they should be informed that among half of the cases, no causes may be found. Full or limited postmortem examination of the baby and placenta has the highest diagnostic value of all investigations; written consent should obtained and it would be absolutely contraindicated if couple do not wish to.

Intra-partum, adequate analgesics should be ensured, and epidural may be given in absence of coagulopathy or sepsis. Membranes should be kept intact for as long as possible. Avoid operative delivery or perineal lacerations to minimise trauma to the patient. Couple should be supported to have contact with the baby if they wish to. They should be offered to retain artefacts of remembrance. Suppression of lactation should be offered, including using supportive brassiere, ice pack or dopamine agonists, preferably cabergolin. Contraception should be discussed before home; patient should be advised to delay pregnancy until severe psychological issues resolved. As for recurrence in future pregnancy, it depends on the cause identified.

Parents should be advised about support groups, and bereavement counselling should be offered. All pending antenatal appointments should be cancelled and general physician and community midwife informed.

All written information would be given with 24 hour contact number.

(a) I would first confirm reduced fetal movement (less tan 10 movements in 2 hours). Ask about any previous episodes, antenatal history of antepartum haemorrhage, fetal anomalies, pre-eclampsia. Ask about associated abdominal pain, vaginal bleeding, and leaking liquor. Look for other risk factors for stillbirth such as smoking use, recreational drugs. Intake of sedating medications can cause reduced fetal movements. On examination, check temperature for sepsis, blood pressure and proteinuria for pre-eclampsia, body mass index (as maternal habitus can affect feeling of movements). Abdominal examination for symphysial-fundal height plotted on customized chart looking for small for gestational age. Check for abdominal tenderness. Do a fetal doptone, if negative, use real-time ultrasound to confirm intrauterine death (IUD). Do speculum if any leaking liquor or bleeding, and vaginal examination if any contractions.

(b) Explain the diagnosis sensitively, and get a second opinion to confirm IUD if necessary. If patient is alone, offer to call the partner or carer. Give the patient time to grieve. Offer management of either expectant or induction of labour (IOL). Explain expectant management success: 80% will deliver in 3 weeks, and poses little risk to mother in first 48 hours, however, risk of disseminated intravascular coagulation (DIVC) increases with time form 10% in 4 weeks to more than 30% after. Platelet count and clotting must be checked twice a week.

Assess maternal condition for coagulopathy, pre-eclampsia, chorioamnionitis, abruption, or ruptured membranes. These will need immediate inducation of labour instead. Explain success rates of IOL are 90% in 24 hours, but associated with more pain. Induction is with mifepristone and prostaglandins. Offer work-up to find out cause of IUD. Do baseline full blood count, urea and electrolytes, C-reactive protein, bile salts, and preeclampsia investigations like transaminases and bilirubin. If evidence of sepsis, do blood cultures, urine culture, and vaginal swabs. Do Kleihauer test for feto-maternal haemorrhage for all, and additionally all Rhesus negative mothers should be given Anti-D. Check random fasting blood glucose and HbA1c for diabetes mellitus, thyroid functions tests, and screen for intrauterine infections with TORCH screen (cytomegalovirus, rubella, parvovirus, herpes simplex and toxoplasmosis) and syphilis.  Antiphospholipid antibodies should be done. Other optional investigations include autoimmune screening and thrombophilia (especially if evidence of hydrops). Autoimmune platelet antibodies should be done if intracranial haemorrhage found on postmortem. Do maternal urine drug toxicology with mother consent if suspected. Parental karyotype necessary if fetal karyotype abnormalities found.

Fetal investigations include cord blood for intrauterine infection screen, fetal and/or placental tissue for karyotyping, and postmortem examination (all requiring parental informed consent). Explain what a postmortem entails, including that expectant management can alter appearance of baby and results of postmortem. Provide information for postmortem and disposal/burial arrangments.

Explain that no cause found in 50% of cases despite all tests, but comprehensive testing can provide crucial information for future pregnancy management. Give leaflets and support group information such as SANDS. Offer psychosexual counselling and berievement services, and include partner. Report all IUD to CMACE and fill up incident form for review at multidisciplinary meeting. After delivery, provide carbegoline to suppress breast milk production, and cancel all antenatal appointments and inform personnel involved in care. Remember to house mother away from maternity units at all times. 

a) History regarding if there is abdominal trauma and associated per vaginal bleeding to rule out abruption placenta should be asked.  She should also be asked regarding if there is leaking liquor, and contraction pain. 

On examination, Blood pressured and urine protein should be check to rule out late onset hypertension disease in pregnancy.  Presence of uterine tenderness is associated with abruption placenta or infection.  Fundal height should be measured and plotted at customised chart.  Handheld Doppler should be used to check for presence of fetal heart.  If it is not detected, ultrasound should be done to look for fetal viability.

b) Patient should be explained in empathetic way regarding intrauterine death (IUD).  Support in the form of partner or relative should be requested and once available if she wish, she should be given time alone with them. 

She should also be explained that she is not the cause of IUD.  She should be discussed regarding timing and mode of induction using mifepristone or prostaglandin and time required to deliver the fetus.  If she wishes to choose expectant management, increase risk of coagulopathy after 4 weeks of IUD therefore the need of screen for DIC twice weekly.  Appearance of baby would deteriorate with time and value of post morterm would be reducing if she choose expectant management as well as difficulty in sexing the baby. 

Full blood picture, urea and electrolyte, liver function test, coagulation profile should be taken as base line.  Kleihauer test should be done to see if there is feta materal haemorrhage as well as to calculate the dose of anti D needed if she is Rh-ve.  AntiD should be administerd as soon as possible.  Random blood sugar should be done to rule out occult diabetic.  Maternal serology testing such as cytomegaly virus, pavovirus B, toxoplasmosis, rubella should be done.  Thrombophillia screening should also be done. 

Vaginal examination should be done to assess cervical score prior to induction of labour.  Oral mifepristone followed by vaginal prostaglandin or misoprostol should be offered if she wish for induction.  Adequate pain relieve and support should be given throughout the delivery. 

Post-delivery she should be discussed regarding funeral arrangement and bereavement support should be given.  She should also be discussed regarding post mortem procedure, appearance of baby following the procedure, retained of tissue for research or teaching purpose.  In majority of cases, the cause is not found.  If she denied, limited post mortem should be done.  Placenta and fetal swab C&S should be done to look for any infection.  Fetal blood for serology should be sent as it is more informative than maternal serology.  Placental histology should also be requested.  If baby sexing is difficult, they can register the baby as indeterminate sex and changed after karyotyping or after full post morterm.  They can use the sex depending on earlier ultrasound scan finding.

Carbegolin should be given to stop lactation and analgesic for breast engorgement should be given.  All her future antenatal appointment should be counselled.    Contraception counselling should also be given. 

She should be given pre pregnancy clinic appointment to discuss regarding recurrent risk and treatable risk to reduce risk of IUD in future pregnancy depending on the result of investigation.

a) 

Confirm history of decreased fetal movements. Take a history of current pregnancy complications such as previous antepartum hemorrhage suggesting abruptio, preeclampsia, gestational diabetes, intrauterine growth restriction and fetal anomalies. Take a history for preexisting medical conditions such as hypertension, diabetes, thrombophilias. Ask for social risk factors such as smoking and ilicit drug use. Ask for abdominal pain and bleeding per vaginum. Check blood pressure and do urine dipstick for proteinuria. Examine symphyseal fundal height and plot against customized growth charts. Confirm fetal viability with handheld doppler. Do cardiotocogram to check fetal well-being. If decreased fetal movements confirmed or if syphyseal fundal height less than dates, do an ultrasound scan within 24 hrs to look at fetal growth and amniotic fluid volume.

b)

Explain diagnosis to patient sensitively. Allow her to contact family member or husband prior to further discussion. Allow time to grief. Offer option of seeking second opinion. Ask about symptoms of labour such as contractions and show. Do blood pressure and check urine dipstick for proteinuria. Do vaginal examination to assess cervical dilatation and effacement if symptoms of labour present. Do full blood count, renal function tests, liver function tests and clotting profile. Check maternal blood group, rhesus status and red cell antibodies. Do Khleihauer test to check for fetomaternal hemorrhage. Screen for diabetes using random blood glucose and HbA1c. Check TORCH panel and evidence of infection. Screen for thrombophilia by check protein C, protein S, factor V leiden and antithrombin III levels. Check antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies). Offer fetal karyotype. Offer postmortem and placental histology.  Explain what a postmortem entails. Written information should be given and formal consent obtained for a postmortem. Explain that investigations are carried out in order to identify potentially treatable and preventable causes, although in 50% of cases, the cause is unidentified. Explain management options including induction of labour with mifepristone and prostaglandins or expectant management. Expectant management carries a risk of disseminated intravascular coagulation and coagulation profile needs to be monitored. Expectant management may affect the appearance of baby and affect results of postmortem. Report stillbirth to the national registry. Fill incident form. Provide contact information to support groups (eg. SANDS) and written information. Postnatally, give cabergoline to suppress lactation. Give anti-D immunoglobulin if patient is Rhesus D negative. Arrange postnatal follow-up appointment to review results. Debrief and allow opportunity for couple to ask questions regarding events. 

1.    Any associated symptoms : pain, bleeding, leaking per vaginum.History of smoking ,drug abuse.Examination includes P/R, BP, Per abdomen: Fundal height ,tonically contracted uterus;note SFH. Auscultation done for fetal heart sounds,if not heard then confirmation done by real time ultrasound to see for cardiac activity. In case of doubt another opinion should be taken.

2.IUD is very distressing news and needs to be dealt with sensitively . immediate offer to call her partner or relative should be made. Woman should be advised that in the absence of any complicating factors she can go ahead with expectant management however there is a small of DIC (Disseminated intravascular coagulation).

So, for any expectant management for more than two weeks twice weekly coagulation profile should be done. Also that most would go under labour within the next days. Also, if she does not go into labour, it can be induced. This can be done by giving Mifepristone (600mg) stat then after 48 hours misoprostol induction (25-50mg) 4 hourly  is given.  She should be explained that only in around 50% cases the cause of death can be established. Also, she would require a battery of test to establish the cause. But if a cause is found it is very helpful in further management of next pregnancy. Tests included are FBC, serum biochemistry, GTT (75gm), coagulation profile, if features of infection are present then high vaginal swab, blood culture, and urine culture ,fetal swabs are included.

ABO-Rh, Kleihaurbetke test done for all women as soon as possible. Thyroid profile- T3, T4, TSH, VDRL. Maternal tests for anti- rho anti- la advised if abnormal findings of fetal heart on post-mortem.  Certain tests from the fetus may also be required. Most informative would be a post-mortem of the baby. However, written informed consent should be taken after explaining what all procedures would be done on the baby and that it would be treated with dignity. Any organs which need to be retained should be explained and formal consent taken. If parents do not agree then option for limited post mortem (after consulting pathologist) should be given. Blood from fetal heart, skin biopsy for karyotyping, MRI of baby, photographs, x-rays may be included in this to find any fetal anomaly. However, placental biopsy should always be done (especially so when post mortem of baby is refused). One cm square placental tissue from near the cord should be sent for biopsy.

Mother should be allowed to see and hold her baby. Proper burial should arranged for the baby. Registration of still birth should be done  by the parents, however they can ask the hospital do it for them. Milk suppression with cabergolin should be given and a follow up arranged at 6 week to explain findings of test result and any assess any psychological problems she would be facing. Local GP and community midwife should be informed about stillbirth and further antenatal appointments should be cancelled. Written information leaflet and list of support  groups like SANDS given.

A 25 year old low-risk primigravida presents at 36 weeks gestation with a 48 hour history of reduced fetal movements. (a) Discuss your assessment [5 marks]. (b) Intra-uterine death is confirmed by ultrasound scan. Discuss your subsequent management [15 marks].

I would confirm the history of reduced fetal movements and if this was the first episode of it as reduced fetal movements can be a recurrent complaint in  primigravidae. I would check her Blood pressure and the BMI. I would do palpate the abdomen to check for tenderness and tense consistency as this may be a sign of abruption .SFH is checked  against customized standards. hand held doppler is used to identify fetal heart and if present ctg will help to evaluate fetal well being. If Fh cannot be heard, real time Ultrasound should be done to confirm viability.

 Empathetic attitude is required in dealing with this situation  . The information should be given  by a senior consultant in the presence of both partners or with  another family member . Time should be given for the Feeling of shock and grief to settle down . I would  offer the women options of admission or to return back later and would inform her that delaying more than 48 hrs may put her at significant risk of bleeding. care plan comprising of induction and labour management should be made and documented The women should be counseled regarding need for Investigation to identify the cause of fetal demise which may require Blood samples & postmortem examination of the fetus, written consent should be taken for this . The women should be informed that fetus will be handled with dignity .Investigation for maternal well being including FBC, Urea , electrolytes, Liver function test should be requested . Viral markers of  rubella & toxoplasmosis should be sent to rule out infective cause. viral serology for Hepatitis, HIV& syphillis should be done .Further investigations of coagulation  should be done if platelet count is low or if there dis clinical evidence if DIC.Investigation to identify cause of IUD like Testing for thrombophilia should be offered .

Induction of labour should be offerd with Mifepristone and prostaglandin E2. Misoprostol will reduce the time to delivery but it it is not marketed in the uk.. IV line should be secured , Senior Midwife should  be involved during labour, The room for labour should be separate from other women and babies.  Adequate analgesia should be offered including epidural analgesia and  patient controlled analgesia., Obstetric anesthetist should be involved. Delivery should be supervised by obstetric consultant And care should be taken to avoid perineal tears. The parents should be given the option of being able to hold the baby.Bereavement team should be involved . if Postmortem is refused by the women , placenta and cord should be sent for cytogenetic analysis and pathological study. But the women must be informed that this may not give sufficient information

Postnatally the women should have continuity of care by the team . Lactation suppression with cabergoline should be offered .Further antenatal visits should be cancelled and the team caring for her including her GP And community midwife should be informed .  Follow up visit should be arranged after 6 wks contraception should be discussed, written infromtaion should be provided including information on support groups