1 / 11

IUFD

IUFD . Irene Hwang, PGY-1 3.10.09. Case. 2/17/09 HPI :

khoi
Download Presentation

IUFD

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. IUFD Irene Hwang, PGY-1 3.10.09

  2. Case 2/17/09 HPI: 23 yo G3P1011 @ 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 (102-132/ 50-90). Weight gain 158 189 (31 lbs). 1. IUGR dxed on 2/13/09 sono @ 31w. Fetus <3%tile. TORCH and thrombosis w/u negative. Amnio normal XY. PNL: wnl/ unremarkable Sonos:10/29/08 @ 15w3d. AFI nl. 11/19/08 @ 19w1d no anatomical anomalies. Fetus 20%tile.2/13/09 @ 31w1d: Fetus <3%tile. SD ratio 4.8. AFI 11.

  3. Case POB: 2004 ectopic  R lap salpingotomy. 2005 FT NSVD of 6lb female. No complications. PGyn: no cysts/ fibroids/ STIs/ abnlpaps.  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 G3P1011 @ 32w1d with IUGR fetus, now with IUFD and elevated BPs. • IUGR, DIC- Unclear etiology, history and PE c/w abruption. Admit to L&D for IOL. • Preeclampsia/ HELLP syndrome

  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. 0.4-0.9% • 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, microdeletionswith normal amnio • Congenital malformations: 15-20% Abd wall defects, NTDs, Potter syndrome, achondrogenesis, amniotic band syndrome • Fetomaternal hemorrhage • Umbilical cord complications: nuchal cord, knot • Hydropsfetalis

  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;360:114-8. • 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):1721-4. • Dynamed: Fetal death, 2009 Feb

More Related