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IUFD Irene Hwang, PGY-1 3.10.09. Case 2/17/09 HPI: 23 yo 32w1d by LMP 7/8/08 EDD 4/14/09 c/w 19w sono p/w decreased fetal movement and lower.

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Presentation on theme: "IUFD Irene Hwang, PGY-1 3.10.09. Case 2/17/09 HPI: 23 yo 32w1d by LMP 7/8/08 EDD 4/14/09 c/w 19w sono p/w decreased fetal movement and lower."— Presentation transcript:

1 IUFD Irene Hwang, PGY

2 Case 2/17/09 HPI: 23 yo 32w1d by LMP 7/8/08 EDD 4/14/09 c/w 19w sono p/w decreased fetal movement and lower abdominal cramps from 3pm yesterday. No LOF/VB. No h/o trauma to abdomen. No HA/visual changes/epigastic pain. Denied tobacco or cocaine use. Admitted to marijuana use during current pregnancy. Pt was given betamethasone on 2/13 and 2/14 for IUGR. Per EU records on 2/14, NST was reactive and BP was 127/60. PNI: Intake BP 102/50 ( / 50-90). Weight gain 158  189 (31 lbs). 1. IUGR dxed on 2/13/09 31w. Fetus <3%tile. TORCH and thrombosis w/u negative. Amnio normal XY. PNL: wnl/ unremarkable Sonos: 15w3d. AFI nl. 19w1d no anatomical anomalies. Fetus 20%tile. 31w1d: Fetus <3%tile. SD ratio 4.8. AFI 11.

3 Case POB: 2004 ectopic  R lap salpingotomy FT NSVD of 6lb female. No complications. PGyn: no cysts/ fibroids/ STIs/ abnl paps. 12/reg/5. PMH: spina bifida occulta, chronic lower back pain PSH: R lap salpingotomy Meds: PNV, Reglan, Zofran All: NKDA PE: BP 132/40  max 170/102 (Hydralazine 5mg IVP given) HR 74 T36.6 Abd: +fundal tenderness FHT: absent Toco: irritability SVE: 1/80/-2 BSUS: Absent fetal heart activity. Breech presentation. Minimal fluid.

4 A/P: Labs: 23 yo 32w1d with IUGR fetus, now with IUFD and elevated BPs. 1. IUGR, DIC- Unclear etiology, history and PE c/w abruption. Admit to L&D for IOL. 2. Preeclampsia/ HELLP syndrome INR 2.5Cr 1.2SGOT 46-57Hct 28Fibr <120 PT 22.8Uric acid 6.0SGPT 17-21WBC 30.2UA >300prot PTT 30LDH *hemPlt

5 Delivery 2/17/09 6:15am  Pt c/o pain. Female infant found to be delivered with approx 1000cc blood clot on bed. No FH/FM. Cord clamped x 2 and cut. Placenta promptly delivered spontaneously- 3v, intact. Fundus firm. Pitocin 20U in D5LR bolused and 1000mg cytotec given. No lacerations. Pt declined seeing fetus. Upon examination of fetus, no gross abnormalities- appeared SGA with small placenta.  BP 151/100  151/83. MgSO4 bolus given.

6 IUFD  Stillbirth = fetal death ≥ 20 weeks  Incidence in U.S %  Etiology:  Unexplained 25-60%: depending on classification system  IUGR: risk of IUFD in IUGR is 5-7x greater  Abruption: occurs in 10-20% of stillbirths (vs. 1%)  Infection  Chromosomal and genetic abnormalities: single gene defects, confined placental mosaicism, microdeletions with normal amnio  Congenital malformations: 15-20% Abd wall defects, NTDs, Potter syndrome, achondrogenesis, amniotic band syndrome  Fetomaternal hemorrhage  Umbilical cord complications: nuchal cord, knot  Hydrops fetalis

7 IUFD  Risk Factors  Pregravid obesity  Socioeconomic factors Race: black women 2x higher risk, even with adequate PNC  AMA  Multiple gestation  Smoking  Maternal medical disorders: DM, HTN, SLE, renal dz, thrombophilia, cardiac dz, thyroid dz, etc.  Previous IUFD and SGA

8 Management  Fetal karyotyping:  Amniocentesis more likely to yield viable cells prior to delivery  Fetal blood/ skin  Placental pathology  Laboratory work-up: KB, CBC, Chem, Utox, TFTs, thrombophilia, lupus anticoagulant, anticardiolipin  Induction vs. spontaneous labor (80-90% w/i 2 wks)  Vaginal misoprostol +/- oxytocin  Coagulopathy  Caused by gradual release of thromboplastin from placenta, usually after 4 weeks

9 Counseling  Giving bad news: straightforward, empathetic, without blame  Kubler-Ross stages of grief: denial, anger, bargaining, depression, acceptance  Induction after 24 hours vs. within 6 hours associated with increased risk for anxiety?  Contact with stillborn  Autopsy option  Fetal remains  Postpartum care: before and after discharge

10 Counseling  Increased risk for depression, anxiety, PTSD, decreased maternal-fetal attachment  In one study of 65 mothers of stillbirths, less incidence of adverse outcomes in mothers who did not have contact with the stillborn.  Recently bereaved women at higher risk for depression and anxiety in subsequent pregnancy.  Increased risk for subsequent stillbirth and complications including preeclampsia, abruption, preterm delivery, low birth weight

11 References  JAMA 2001 Jun 20;285(23):2978.  Am J Obstet Gynecol 2005 Dec;193(6):1923.  Hughes P, et al. Assessment of guidelines for good practice in psychosocial care of mothers after stillbirth: a cohort study. Lancet 2002 July;360:  Stillbirth as risk factor for depression and anxiety in the subsequent pregnancy: cohort study. BMJ 1999 Jun 26;318(7200):1721.  Stillbirth as risk factor for depression and anxiety in the subsequent pregnancy: cohort study. Hughes PM; Turton P; Evans. BMJ 1999 Jun 26;318(7200):  Dynamed: Fetal death, 2009 Feb


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