CASE REPORT

Supervisor : dr. Fadjrir, SpOG Mentor : dr. Juhriyani M. Lubis Presenter : Siska Febrina Prisca Meirinda Imy Ginting

PATIENT IDENTITY
Name Age Religion Occupation Ethnicity Education Address Admission Date Admission Time MR number

: Mrs. E : 25 years old : Moslem : Housewife : Jawa : Senior High School : Jl. Pelajar Timur Medan : August 24th, 2013 : 11.59 pm : 89.49.33

HISTORY TAKING
Mrs. E, 25 years old, G3P1A0, Moslem, Jawa, Senior High School, Housewife, wife of Mr. T, 45 years old, Moslem, Jawa, Senior High School, entrepreneur, came to ER Dr. Pirngadi General Hospital with
Chief Complain Description

: Labor Contraction

: It has been experienced by the patient since August 23th, 2013 at 08.30 PM, with bloody show and history of water broke was not found. History of abdominal massaged was not found. History of traditional drugs consumption. Patient couldnt feel fetal movement since one day ago. History of traumatic and antepartum haemorrhage was not found. Nocturia (+) 3 times, patient complaint always hungry and thristy since 3 years ago. Defecation is normal. : Diabetes Mellitus (+), Hypertension (-)

History of Previous Illness

History of Previous Treatment : -

Menstrual History

Menstrual Cycle Cycle Length Menstrual Duration Menstrual Volume Complain during menstruation Last Menstrual Period Expected Date of Delivery Antenatal Care

: Regular : 28 days : 6-7 days : 1-2 menstrual pad / days : dismenorrhea (-) : November 25th, 2012 : September 12th, 2013 : Never

Labor History
Male, term, Spontaneous Vaginal Delivery,

midwife, clinic, 3000 grams, 4 years old, alive. Male, term, Spontaneous Vaginal Delivery, midwife, clinic, 4000 grams, dead within 5 days after labor 2 years ago. This pregnancy

Present State
Sensorium Blood Pressure Pulse Respiratory Rate Temperature

: compos mentis : 130/80 mmHg : 80 bpm : 20 tpm : 37,40C

Obstetric Examination
Abdomen SFH

process Stretch Bottom Movement Contraction FHR EBW

: enlarged asimmetrically : 2 fingers below xyphoid (37cm) : right : head (floating) : (-) : 1 x 20/ 10 : (-) : 3600-3800 grams

Vaginal Examination
Cervix closed Gloves : bloody show (-), water (-), bisoph

score 3

USG : TRANSABDOMINAL SONOGRAPHY

Singleton, head presentation, fetal death Fetal movement (-), Fetal heart rate (-) Placenta corpus anterior grade III BPD = 90,9 mm FL = 68,8 mm AC = 343,2 mm AFI = 8 EFW = 3260 grams Conclusion : IUFD + Intrauterine Pregnancy (3738) weeks

Laboratory Results
HB HT RBC WBC KGD ad Random 9,5 29,9% 4,5 x 106 10.700 319

DIAGNOSIS IUFD+ MG+ IUP (38-40) weeks + Head Presentation + before inpartu + DM type 2 THERAPY IVFD Ringers Lactate 20 drips/ minute PLANNING Spontaneus vaginal delivery Ripening cervix with baloon catheter before oxytocin induction

Spontaneous Vaginal Delivery Report

At 01.00 pm, September 25th, 2013 patient felt longer, stronger, and closer contractions and the urge to strain, vaginal examination was done with complete dilatation. Labor management was started : The patient was laid in gynecologic bed with Mc Robert position with intravenous catheter. Bladder was emptied and vulva hygiene was done. With adequate contraction, head of fetus was sighted in introitus vagina and stayed than make episiotomy mediolateral.

 With subsequent adequate contraction, patient was encouraged to strain and head was born

started with posterior fontanella, anterior fontanella, forehead, face, chin and the rest of head. After external rotation, with the helpers hand on biparietal, head is pulled gently downwards to deliver anterior shoulder and pulled upwards to deliver posterior shoulder. Then the head was held on one hand and the other hand following along on the back simultaneously to deliver the body.

 At 01.30 pm was born a male baby

Umbilical cord was clamped in two point,

then cut in between. Baby was born with weight 4000 grams, body length 50 cm, head circumference 34 cm, Apgar Score : 0, anal verge positive.

 Then Oxytocin 10 IU intramuscular was injected on

thigh Placenta was delivered with controlled umbilical cord stretching, intact, weight 500 grams, with 16 cotyledons (all intact). The passage was evaluated, found perineal laceration grade II Then the laceration was sutured with chromic catgut 2-0 Evaluation of bleeding : 150 cc Patients condition after SVD : stable

 THERAPY IVFD Ringers Lactate + Oxytocin 10 IU drip 20

drips/minute Viccilin inj. 1 gram/ 8 hours Asam mefenamat tab 3x500 mg Methyl ergomethrin tab 3 x 1

Planning :
Laboratory 2 hours after SVD KGD Nachter KGD 2 hours PP HbA1C D-dimer Fibrinogen Consult internist

Fourth Stage Observation

Time Blood Pulse Pressure Respirator y Rate Contraction Bleeding

02.30
03.00 04.30 05.00 05.30

110/70 mmHg
110/70 mmHg 120/80 mmHg 120/80 mmHg 120/80 mmHg

84 x/i
84 x/i 86 x/i 88 x/i 88 x/i

22 x/i
22 x/i 24 x/i 24 x/i 24 x/i

strong
strong strong strong strong

5 cc
10 cc 15 cc 15 cc 15 cc

Laboratory results 2 hours after SVD

Hb Ht 9,3 g% 29,7%

RBC
WBC PLT KGD nachter KGD 2 jam PP HbA1c D-Dimer fibrinogen

4,2. 106 /L
11.900 / L 245.000 /L 242 mg/dl 310 mg/dl 8% 375 4000

FOLLOW UP
26-08-2013 Complain Status Presens Consciuosness Blood Pressure Heart Rate Respiratory Rate Temperature Compos Mentis 120/70 mmHg 86x/i 22x/i 37,6 C Compos Mentis 110/70 mmHg 88x/i 22x/i 37,3 C Fever (-) 27-08-2013 Fever (-)

26-08-2013
Status Obstetrikus Abd: Soepel

27-08-2013
Abd: Soepel

SFH: Setentang
umbilikal Contraction: strength P/v = lochia rubra (+)

SFH: Setentang
umbilikal Contraction: strength P/v = lochia rubra (+)

Myction (+) N
Defecation (+) N Diagnosa

Myction (+) N
Defecation (+) N

Post SVD ec IUFD + Post SVD ec IUFD +

NH2 + DM type 2

NH3 + DM type 2

26-08-2013
Teraphy - Amoxicilin 3x500 mg - Asam Mefenamat 3x500 mg - Methyl ergomethrin 3x1 - Diet MB Planning -

27-08-2013
- Amoxicilin 3x500 mg - Asam Mefenamat 3x500 mg - Methyl ergomethrin 3x1 - Diet MB - Discharged for outpatient care - Control internal policlinic

Case Analysis
Theory Case

Intrauterine fetal death that occurs after 20 weeks and fetal weight more than 500 grams. In cases where a cause of fetal death is clearly identified, it can be attributable to maternal, fetal, or placental pathology. From maternal, preexisting dibetes (poorly controlled) is also important contributors to stillbirth.

In this case based on last menstrual period, obstetric examination and USG found IUFD + IUP (36-38) weeks In this patient was found uncontrol DM with KGD ad random 315 mg/dl, KGD nachter 242 mg/dl, KGD 2 hours pp 310 mg/dl, and HbA1C 8%.

Theory

Case

Fetal demise is diagnosed by history taking and physical examination. In most patients, the symptom is absence of fetal movement. And inability to obtain fetal heart tones upon examination. Confirmed by USG, visualization of fetal heart and absence of cardiac activity.

From history taking patient was complaining the absence of fetal movement. from physical diagnostic fetal movement wasnt palpable. From auscultation fetal heart rate cannot be monitored.

Clinical Summary
Mrs. E, 25 years old, G3P1A0, Moslem, Jawa,

Senior High School, Housewife, wife of Mr. T, 45 years old, Moslem, Jawa, Senior High School, entrepreneur, came to ER Dr. Pirngadi General Hospital with chief complain: Labor Contraction It has been experienced by the patient since August 23th, 2013 at 08.30 PM, with bloody show and history of water broke was not found.

 History of abdominal massaged was not found.

History of traditional drugs consumption. Patient couldnt feel fetal movement since one day ago. History of traumatic and antepartum haemorrhage was not found Nocturia (+) 3 times, patient complaint always hungry and thristy since 3 years ago. Defecation is normal. History of Previous Illness : Diabetes Mellitus (+) History of Previous Treatment : -

 Last menstrual period of the patient is November 25th

2012 and Expected Date of Delivery September 12th2015, with never antenatal care. Labor history first kid is Male, term, Spontaneous Vaginal Delivery, midwife, clinic, 3000 grams, 4 years old, alive. Second kid is Male, term, Spontaneous Vaginal Delivery, midwife, clinic, 4000 grams, dead within 5 days after labor 2 years ago. And the last is this pregnancy. showed abdomen enlarged asimmetrically, with SFH 2 fingers below xyphoid process (37 cm), stretch right, bottom head, movement (-), contraction 1 x 20/ 10, FHR (-) and EBW: 3600-3800 grams

Vital signs are within normal limit. Obstetric examination

 From vaginal examination, the findings are Cervix

closed. Gloves : bloody show (-), water (-). Bisoph score 3 USG TAS showing IUFD + Intrauterine Pregnancy (37-38) weeks Laboratory: randomized blood glucose 319 mg/dl
The patient was diagnosed IUFD+ MG+ IUP (38-40) weeks + Head Presentation + before inpartu + DM type 2

 The patient was plan for spontaneous vaginal delivery At 01.30 PM, August 25th, 2013 was born a male baby, with weigh 4000 grams, body length 50 cm, head circumference 34 cm, Apgar Score : 0, anal verge positive. Patients condition after SVD : stable The patient was then monitored for 1 day with stable condition and then discharged as outpatient the day after and consult to internal

polyclinic.

Problems
What is the causes of fetal death from this case? What can we do the prevent this case to not

reoccur?