Case - IUFD

Maria Sarline R.
Openiano
MSU-College of Medicine
OB-GYNE Department
MEDICAL HISTORY
Date and Time of History: September 8, 2013; 4:05 AM
Identifying Data:
MM, 32 years old, female, Filipino. Islam, residing at Marawi Lanao del Sur, admitted for the first
time at Adventist Medical center last September 8, 2013 around 4 AM
Chief Complaint: Labor Pains
History of Present Illness:
6 days prior to admission, patient was apparently well and had her regular prenatal checkup at a
private obstetrician; Utrasound was done which revealed absence of fetal heart tones. Internal exam
was also done and revealed a closed cervix.
1 day prior to admission, patient had onset of hypogastric pain, nonradiating, Pain scale of 6/10,
characterized as 2-3 contractions in 10 minutes, with irregular interval and short duration. Persistence of
hypogastric pain with increasing intensity and frequency prompted admission.
Past Medical History:
No previous hospitalization
No history of surgeries done
No allergies to food and drugs
No maintenance medications taken
Menstrual History:
Patient had her menarche at the age of 15 years old, regular cycle of 28-32 days, 3-4 days
duration, and usually heavy on the first day, soaking 2-3 pads per day, (+) dysmenorrheal.
Obstetric History:
LMP: February 17, 2013
EDC: November 24, 2013
AOG:29 weeks by LMP
OB Index: G1P0
Prenatal check-up done at a private clinic
No. of visits: 3
Medications taken during pregnancy: Ferrous Sulfate, Calcium, Folic Acid
No illnesses during pregnancy
Gynecologic History:
(-) breast diseases
(-) STD
(-) gynecologic surgeries
Family History:
(+) Diabetes Mellitus, paternal side
(+) Hypertension, paternal side
(-) Asthma
(-) Malignancies
(-) PTB
Personal and Social History:
Unemployed
College graduate
Husband, 30 years old
NonSmoker
Non Alcoholic beverage drinker
Diet: fish, vegetables, rice
No regular exercise
Review of Systems:
General: ( -) weakness, (+ ) weight gain,5-10% (-) fever.
Skin: (-) rashes, (-) itching, (-) scars.
Head: (-) headache, (-) dizziness, (-) trauma.
Eyes: (-) excessive tearing, (-) sore eyes, (-) double vision.
Ears: (-) tinnitus, (-) vertigo, (-) discharges, (-) pain, (-) hearing loss.
Nose & Sinuses: (-) stuffy nose, (-) discharges.
Mouth & Throat: (-) mouth sores, (-) hoarseness, (-) sore throat.
Neck: (-) stiffness, (-) lumps, (-) vein engorgement.
Respiratory: (-) cough, (-) tachypnea, (-) dyspnea.
Cardiovascular: (-) palpitations, (-) chest pains, (-) elevated BP.
Gastrointestinal: (+) abdominal pain, (-) vomiting, (-) LBM.
Genito-urinary: (-) dysuria, (-) anuria, (-) hematuria, (-) vaginal discharges, (-) itching, (-) sores.
Musculo-skeletal: (-) muscle pain, (-) joint pain.
Neurologic: (-) fainting spells, (-) loss of sensation.
Hematologic: (-) easy brusing.
Psychiatric: (-) nervousness, (-) depression, (-) anxiety.
Endocrine: (-) sweating, (-) heat intolerance, (-) polydipsia.
PHYSICAL EXAMINATION
General Survey: Patient is conscious, coherent, NIRD, afebrile, ambulatory, in pain
Vital Signs:
BP=110/70mmHg
Weight=54 kgs
HR=86bpm
Height=5 feet
RR=24cpm
BMI= 23.27
Temp.=36.3OC,
HEENT: Pinkish palpebral conjunctiva, anicteric sclera, pupils equally reactive to light and accomodation,
moist lips and oral mucosa, uvula at midline
Neck: Supple, no neck vein engorgement, trachea at midline, no thyroid enlargement, no
lymphadenopathy
Chest and Lungs: Symmetrical, Equal Chest Expansion, Equal tactile fremitus, clear breath sounds, no
retractions, no crackles, no wheezes
Heart: PMI @ 5th ICS, Left midclavicular line, Normal rate @ 86/min, regular rhythm, no heaves, no
thrills, no murmurs
Abdomen:
Globular
(+) linea nigra and striae gravidarum
(-) scars, (-) lesions
Normoactive abowel sound
FH=22 cm
FHT= absent
(+) contractions
L1: cephalic
L2: fetal back on Left side
L3: breech
L4:
Pelvic Exam:
External Exam
Non-erythematous, no lesions, no excoriations, no masses
No inguinal adenopathy
Internal Exam
Cervix: 2 cm dilated, slightly effaced, BOW intact, station -1
Uterus: enlarged
Adnexae: (-) palpable mass
Discharge: (-) vaginal discharges
Extremities: Equal and Palpable dorsalis pedis and posterior tibialis pulses, crt = 2 sec, no edema
ADMITTING IMPRESSION:
Pregnancy Uterine, 29 weeks AOG by LMP, breech, in labor, intrauterine fetal demise
BASIS:
Absence of fetal heart tones

Absence of fetal movement
Small fundic height
Ultrasound result of intrauterine fetal demise
UPON ADMISSION
Patient was admitted under the service of OB-GYNE department
Consent secured
Vital signs monitored every 4 hours
Labs ordered: CBC, diff, blood type, HbsAg, CT, BT, UA, protime
Meds: Hyoscine-N-butyl bromide 1 amp slow IVTT q 6 hours
Eveprim I cap TID
I and O q shift
May have light meals, NPO in between except meds
To start venoclysis with D5LR 1 L to run for 8 hours
LAB RESULTS:
Urinalysis:
Color=pale yellow
Transparency=clear
Volume=25cc
Specific Gravity=1.005
pH=6.0
Protein = negative
Sugar= negative
Acetone = negative
Occult blood = negative
Bleeding time: 13
Clotting time: 436
HbsAg: Non-reactive
Blood Type: 0+
CBC
RBC
Hemoglobin
Hematocrit
WBC
Segmenters
Lymphocyte
Stabs
Result
4.26
128
0.38
13.43
0.79
0.16
0
Normal Values
4-6x1012/L
120-150 g/L
0.37-0.45
5-10 x 109 /L
0.50-0.65
0.25-0.35
0.05-0.10
Monocytes
0.03
0.03-0.07
Eosinophils
0.02
0.01-0.03
Basophils
0-0.01
Platelet count
264
140-450 x 109
WBC= 1-2/hpf
RBC= 0/hpf
Epith-squamous= +1
Epith-Round= occasional
Amorphous Sed= negative
Crystals= negative
Mucous = negative
Bacteria = occasional
COURSE IN THE WARD

Progress of Labor was monitored
4:30 am: 2cm dilated, station-1, slightly effaced, intact BOW, 3 contractions in 10 minutes, 40
seconds duration
6:00 am: 2 cm dilated, station-1, slightly effaced, intact BOW, 3-4 contraction in 10 minutes, 45
seconds duration
11:00 am: 3-4 cm dilated, station-1, slightly effaced, intact BOW, 6-7 contraction in 10 minutes,
45 seconds duration, (+) bloody show
Nubain 5 mg slow IVTT was given
Patient was transferred to Delivery Room at 2:10 PM and another dose of Nubain 5 mg IVTT was
given
DELIVERY TECHNIQUE:
Patient was placed in dorsal lithotomy position
Asepsis/Antisepsis technique done
Sterile drapes placed
Patient was allowed to bear down
Body delivered spontaneously followed by delivery of the aftercoming head, a stillbirth baby girl
weighing 1.246 kgs (2 lbs 12 oz) with CRL of 26 cm, CHL of 29 cm, cord length of 40 cm, (+)
constricted area noted in the cord at the level of the umbilicus
Placenta delivered spontaneously and complete with residual infarcts
Repair of 2nd degree laceration using vicryl 2-0
Hemostasis
Internal Exam done
Patient transported to room in fair condition with BP=100/60 mmHg
Patient was transported to room at 3:34 pm with the following orders:

o DAT when fully awake
o IVF (ongoing) D5LR 1 L + 20 Units Oxytocin x 8H
o IVFTF D5LR 1 L + 10 Units Oxytocin x 5 H
o Meds: Cefuroxime 500 mg BID x 7 days
Methylergometrine tab TID x 3 days
Multivitamins + Iron 1 cap OD x 1 month
o Use Gynepro for perineal hygiene BID
o Full body bath daily
o Keep uterus well contracted
o Refer for profuse vaginal bleeding and unstable vital signs
o Monitor vital signs q 15 mins for 2 hours, then q 30 mins for 2 hours, then q hourly for 4
hours, then q 4 hours thereafter
o Refer accordingly
The patient was apparently well with normal urine output and was discharged the following day
at around 5:50 PM with stable vital signs and no complaints such as fever, hypogastric pain,
perineal pain and profuse vaginal bleeding.
FINAL DIAGNOSIS:
Intrauterine Fetal Death secondary to cord stricture, delivered via normal spontaneous vaginal delivery,
a stillbirth baby girl BW= 1.246 kgs (2 lbs 12 oz) with CRL of 26 cm, CHL of 29 cm, cord length of 40 cm

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Maria Sarline R.

Absence of fetal heart tones

COURSE IN THE WARD

Patient was transported to room at 3:34 pm with the following orders:

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