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Obstetrics Simplified - Diaa M. EI-Mowafi

Placental Insufficiency
Perinatal mortality

Definition

It is a reduction in the placental functions.

Effects

  • In acute and /or severe cases: it leads to intrauterine foetal death.
  • In chronic and /or mild cases: it leads to intrauterine growth retardation.

Aetiology

  • Acute causes:
    • Tonically contracted uterus.
    • Placental separation.
    • Placental infarcts.
  • Chronic causes:
    • Causes of  IUGR.

Diagnosis and Management

See IUGR.

PERINATAL MORTALITY

It includes.

  • Stillbirth.
  • Early neonatal death (during the 1st week).

STILLBIRTH

Definition

It is a dead foetus delivered after 28 weeks of pregnancy or weighing 500 gm or more.

The American College of Obstetricians and Gynaecologists suggested a gestational age more than 20 weeks WHO suggested a gestational age more than 24 weeks.

This may be the result of:

  • Intrauterine foetal death: before the onset of labour.
  • Intranatal foetal death: during the course of labour.

Intrauterine Foetal Death (IUFD)

Aetiology

  • Maternal causes:
    • Hypertensive disorders with pregnancy.
    • Diabetes mellitus.
    • Infections: e.g. syphilis, rubella, smallpox, mumps, cytomegalovirus, measles, poliovirus, any acute infection.
    • Chemical poisoning: e.g. chronic lead poisoning.
  • Placental causes:
    • Placental insufficiency especially for acute causes as placental separation and infarcts.
  • Umbilical cord:
    • True knots.
  • Foetal causes:
    • Rh-isoimmunization.
    • Congenital anomalies.
  • Idiopathic.

Diagnosis

  • Symptoms:
    • Cessation of foetal movements.
    • Regression of breast changes and milk secretion may be initiated.
    • The abdomen is not enlarging or even get smaller.
    • Dark brown vaginal discharge may be present.
  • Signs:
    • Uterus is smaller than the period of amenorrhoea and does not enlarge with repeated examination.
    • Foetal heart sounds are inaudible.
    • Foetus is felt like a soft homogenous mass with undistinguished foetal parts.
    • Maceration of the foetal skin starts 12 hours after death which can be detected after its birth.
  • Investigations:
    • Ultrasound: the most accurate and rapid method which shows:
      • absent foetal movements,
      • absent foetal heart movement,
      • Spalding sign: overriding of the skull bones due to softening of the brain and absorption of C.S.F.
      • Hyperflexion or angulation of the spines.
      • Collapse of the thorax.
      • Causative factors as congenital anomalies.
    • Pregnancy test: becomes negative within 2 weeks but may remain positive as long as there is living chorionic tissues.
    • X-ray may show:
      • Spalding sign.
      • Hyperflexion of the spines.   
      • Collapse of the thorax.
      • Rarefaction of the foetal bones.     
      • Gases in the foetal circulation.
      • Causative factor as anencephaly and hydrops foetalis may be detected.

Complications

  • Intrauterine infection.
  • Disseminated intravascular coagulation if the foetus is retained more than 4 weeks.

Management

  • A wait for 2-3 weeks: Spontaneous expulsion usually occurs.
  • Induction of labour by prostaglandins and/or oxytocin is indicated in:
    • No expulsion after 3 weeks.  
    • Development of infection.
    • Development of DIC.          
    • Anxiety of the mother.
  • Surgical evacuation of the uterus abdominally: may be indicated in failure of prostaglandins.

N.B. Amniotomy is not used for induction of labour as it may predispose to infection.

Intranatal Death

Aetiology

  • Intrauterine asphyxia.
  • Intracranial haemorrhage.
  • Intranatal (congenital) pneumonia due to premature rupture of membranes.
  • Foetal birth injuries as fracture dislocation of cervical spines and rupture spleen.

NEONATAL DEATH

Definition

It is death of a liveborn infant in the first month after delivery.

Causes

  • During the 1st week (more common):
    • Prematurity.
    • Asphyxia neonatorum.
    • Congenital anomalies.
    • Birth trauma.
    • Respiratory distress syndrome.
    • Haemorrhagic and haemolytic diseases of the newborn.
  • After the 1st week (less common):
    • mainly due to infections.

Prevention

  • Proper antenatal care.
  • Antenatal treatment of maternal infections e.g.
    • Syphilis.
    • Toxoplasmosis.
    • Genital tract infections.
  • Antenatal treatment of maternal risk factors e.g.
    • Diabetes.
    • Hypertension.
    • Anaemia.
  • Tetanus toxoid vaccination to the mother to protect the foetus from tetanus neonatorum.
  • Proper management of preterm labour and care of prematures.
  • Proper intranatal protection against birth trauma and infections.

Dangerous Signs in The Newborn

  • Birth injuries.
  • Asphyxia neonatorum.
  • Prematurity.
  • Dysmaturity.
  • Congenital anomalies.
  • Petechiae (haemorrhagic disorders).
  • Jaundice (haemolytic disorders) .
  • Vomiting. Diarrhoea.
  • Abdominal distension.
  • Fever or hypothermia. 
  • Cyanosis.
  • Dyspnoea.
  • Bleeding or infection at the umbilical stump. No meconium for 48 hours.
  • No urine for 24 hours.

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