CASE STUDY ON INTRAUTERINE FETAL DEMISE

BSN 2A1-5 Mrs. Liza May Jecino, R.N., M.A.N.

OUR LADY OF FATIMA UNIVERSITY College of Nursing Regalado, Fairview, Quezon City

INTRODUCTION

Intrauterine Fetal Death Demise (IUFD) is the death of a fetus that occurs for no apparent reason in a normal, uncomplicated pregnancy. It happens in about 1 percent of pregnancies and is usually (depending on the resource) considered a fetal death when it occurs after the 20th week of pregnancy and/or weight equal to or more than 500 grams. It may be suspected when the mother ceases to feel fetal movement, and the obstetrician is unable to hear fetal heart tones. When the question of fetal death arises during labor, an internal fetal monitor can be applied to the presenting part. Maternal cardiac electrical activity can be transmitted through a dead fetus, however, so the rate and rhythm on the tracing should be compared with those of the mother. In this case, the fetus died in utero. The mother s preeclampsia and premature rupture of membranes contributed to it. The preeclamptic condition of the mother led to an oxidative stress in the fetus which was not given an immediate medical attention and so fetal respiration was arrested.

PATIENT S PROFILE NAME: Patient X AGE: 27 years old GENDER: Female DATE OF BIRTH: March 28, 1982 RELIGION: Catholic CIVIL STATUS: Married OCCUPATION: None ADDRESS: CSJDM, Bulacan DATE ADMITTED: August 11, 2011 DR. IN CHARGE: Dra. Del Rosario DIAGNOSIS: Intrauterine Fetal Demise

NURSING HISTORY

PRESENT MEDICAL HISTORY Patient X reported uterine contractions which occurred at 3am in the morning, Aug. 11, 2011 within patient s residence. Said that she had an increased urgency to urinate (it was the bag of water already broken; patient mistook it for urine). At 8am, patient decided to be brought to the hospital at once and I. E. was done. Nurse-on-duty checked for FHRT, but there were no audible sounds. Patient got request for ultrasound and confirmed the worst: fetus died in utero. She was given medications to induce labor. At 1pm of the same day, a still born female was delivered via Normal Vaginal Delivery. Obstetrical Hx: G2 P1 (T1 P0 A0 L1) LMP = December 12, 2010 AOG = 34-35 weeks Physical findings:
170/ 100

mmHg Preeclampsia

PAST MEDICAL HISTORY Patient X reported that she had already received 2 doses of Hepatitis B vaccine and 2 doses of Tetanus Toxoid acquired from the nearby health center in their barangay administered. Aside from the immunizations mentioned earlier, there were no other. She has no allergies whatsoever to any food or drug. Besides a slight pedal edema, patient has no known diseases during the course of her pregnancy but she reported that her mother had a history of hypertension. Also, someone from the immediate family has asthma. Patient X is not a smoker and doesn t drink alcoholic beverages. Activities of daily living include usual motherly household chores such a cooking, doing laundry works and being the all-around homemaker. She admits that she is not active in sports but considers her household chores as her daily exercise routine. Patient has usual diet of fish or pork, rice and vegetables.

LABORATORY FINDINGS URINALYSIS (July 28, 2011) Routine Urinalysis: COLOR: Amber CHARACTER: Turbid SPECIFIC GRAVITY: 1.020 REACTION: Acidic SUGAR: ALBUMIN: + PUS: 25-30/HPF RED BLOOD CELLS: 4-6/HPF EPITHELIAL CELLS: Few BACTERIA: Few MUCUS THREADS: Few CRYSTALS: Amorphous urates; few

IMPRESSION: - The patient has preeclampsia as for the proteinuria (CHON in urine). There was also an infection because of the Pus cells and RBCs found. There was also a bacterial count. There is probability of patient having UTI. URINALYSIS (August 11, 2011) Routine Urinalysis: COLOR: Straw TRANSPARENCY: Clear REACTION: Acidic SPECIFIC GRAVITY: 1.005 PROTEIN: Negative SUGAR: Negative *** SONOGRAPHIC REPORT (July 7, 2011) Pelvic Ultrasound: Within an enlarged uterus is a single, live fetus with a BPD of 7.0 cm and average FL of 5.4 cm. There is spontaneous movement and regular cardiac pulsation noted during the time of scan. The placenta is implanted in the posterior high-lying with no sign of previa. Amniotic fluid is adequate in amount. IMPRESSION: - Single intrauterine pregnancy about 26 weeks & 1 day AOG - Cephalic presentation at time of scan - Posterior high-lying placenta with grade 2 maturity - Normohydramnios - It s a BABY GIRL! - EDC = Sept. 28, 2011 FHRT = 145 bpm RED BLOOD CELLS: None found PUS CELLS: 0-2/HPF EPITHELIAL CELLS: ++ BACTERIA: MUCUS THREADS: + AMORPHOUS URATES: Trace

SONOGRAPHIC REPORT (August 11, 2011) Pelvic Ultrasound: Within an enlarged uterus is a single fetus with a BPD of 7.4 cm and average FL of 5.9 cm. the average gestational age is 29 weeks & 5 days. There is no spontaneous movements and regular cardiac pulsation noted during scan. The placenta is implanted in the posterior wall. IMPRESSION: - INTRAUTERINE FETAL DEMISE *** HEMATOLOGY (July 28, 2011) HEMOGLOBIN: 127 g/L HEMATOCRIT: 0.41 RBC: --WBC: 12.5 BLEEDING TIME: 1-5 minutes CLOTTING TIME: 1-5 minutes BLOOD TYPE: B positive Differential Count NEUTROPHILS: 0.72 LYMPHOCYTES: 0.20 EOSINOPHILS: 0.08 BASOPHILS: ---

HEMATOLOGY (August 11, 2011) HEMOGLOBIN: 128 g/L HEMATOCRIT: 0.41 RBC: --WBC: 28.3 BLEEDING TIME: 1-5 minutes CLOTTING TIME: 1-5 minutes BLOOD TYPE: B positive IMPRESSION: There is possible infection because of increased WBC count. Differential Count LYMPHOCYTES: 0.08 EOSINOPHILS: 0.03 MONOCYTES: 0

ANATOMY AND PHYSIOLOGY

I. Female Reproductive System a. External structures 1. Mons Veneris a pad of adipose tissue located over the symphysis pubis 2. Labia Minora two hairless folds of connective tissue 3. Labia Majora serves as protection for the external genitalia and the distal urethra and vagina b. Internal structures 1. Ovaries produces, matures and discharges ova (the egg cells) 2. Fallopian tubes conveys the ovum from the ovaries to the uterus and site of fertilization. 3. Vagina serves as the birth canal and the receptacle for penis during coitus 4. Cervix the opening where the fetus passes during childbirth 5. Ovaries the female gonads which secrete hormones and the ovum. 6. Uterus supports and nourishes the fetus during pregnancy; contracts to aid childbirth; sheds during menstruation

PATHOPHYSIOLOGY

Predisposing Factors: - Age: 27 y. o. - AOG: 34-35 weeks - Congenital anomalies

Precipitating Factors: - Late medical assistance - Preeclampsia of mother

Edema Premature labor as manifested by uterine contraction

Preeclampsia Elevated BP

Premature rupture of membranes (amnion)

Cord compression as a result of vasoconstriction

Took a long time for patient to be taken to hospital

Decreased blood flow and diminished O2 transfer in placenta

Oligohydramnios

Intrauterine Fetal Hypoxia

INTRAUTERINE FETAL DEMISE

Induced labor

Stillbirth

COURSE IN THE WARD AUGUST 11, 2011 Patient was admitted to hospital at about 8 o clock in the morning. I. E. was done to check if true labors already started. Nurse-on-duty checked for FHRT, but there were no audible heart sounds. Patient got request for ultrasound and confirmed that the fetus died in utero. She was given medications to induce labor. At 1pm of the same day, a still born female was delivered.

AUGUST 12, 2011 Patient seems normal as for her vital signs: BT: 36.8 c PR: 76 bpm RR: 17 cpm BP: 130/90 mmHg However, patient looks distraught most of the time. She has moments of blank stares and crying.

AUGUST 13, 2011 Patient s vital signs were normal: BT: 36.6 c PR: 70 bpm RR: 13 cpm BP: 130/100 mmHg Patient was crying and expresses negative thoughts about herself about the child s death. Patient complained of difficulty of breathing and was given oxygenation.

AUGUST 15, 2011 Patient was already discharged of the hospital after her sister paid the hospital bills.

DISCHARGE PLANNING MEDICATION - Continue taking the drugs prescribed by the physician as ordered.

EXERCISE - Patient can go back to her normal ADLs but should avoid strenuous activities for a while as to avoid fatigue.

HEALTH TEACHING - It is suggested to patient s family that it is better not to leave patient alone for the first few months as it is very likely that the patient might feel a sense of depression as for the loss of her child. - Divert patient s thoughts by immersing her into a light and pleasant conversation. - Suggest patient to attend Sunday masses in Church as to boost spirit and to prevent distress. - Explain to patient the loss of the child is not her fault and assist her in coping with the loss.

OUT-PATIENT FOLLOW UP - Patient can seek for counseling as for expected emotional distress accompanying fetal demise.

DIET - Patient can go back on eating her usual diet.

REFERENCES 1. http:/www.wikipedia.org 2. http:/www.nursingcrib.com/intrauterine-fetal-demise 3. Tortora, Gerard, Principles of Anatomy and Physiology, 12th Edition, 2010. Chapter 14: Female Reproductive Organs, pg. 1095-1112. 4. Pillitteri, Adele, Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th Edition, 2007. Chapter 4: Reproductive and Sexual Health, pg. 65-101. 5. http:/www.drugs.com 6. http:/www.miscarriage.about.com/.../g/intrauterine.htm 7. http:/www.drugs.com/cg/intrauterine-fetal-demise.html 8. http:/www.emedicine.medscape.com/article/1476919-overview