PERINATAL MORTALITY

(MACERATED STILL
BIRTH)
Jun 2015
Edited by:

MOTHER DETAILS

RN :
Name :
NRIC
: 800817-06-5278
Age
: 27 years old
Education :
Occupation : Housewife
Nationality : Malaysian
Religion : Islam
Gravida
: 2Parity : 1
Date of Birth : 18/6/2015 @ 1.55am
Date of Death : 18/6/2015 @ 1.55am
Gestation
: 37 weeks of POA
Death Classification
: IUD (Macerated Still Birth)
Berat Lahir : 1.36 kg

PAST OBSTETRIC HISTORY

BI
L

Year

Conception

Type of
delivery

Place of
birth

Gender

Birth
weight

Mothers
complicati
on

PRIMIGRAVIDA

Childs
Complicat
ion

Babys
conditio
n
present

ANTENATAL SCREENING

VDRL
: Non Reactive
Blood Group
: O
Rhesus Factor
: Positive
HIV / Rapid test
: Non Reactive
Thalassemia screening : Non Reactive
BFMP
: Negative

Mothers tagging as GREEN TAGGING

MOTHERS AND FAMILY MEDICAL

HISTORY

Mother

Family

Non- smoker
Not known
medical
illness
Premorbidly
obesity with
BMI: 38.6

Mother:DM
and
Hypertensio
n on
treatment
Father: IHD
on

CURRENT ANTENATAL VISIT

ANC Clinic visit: 8x

Home visit: 1x

Hospital visit: 2x

Immunisation history:
- ATT Dose 1: 8/10/14
- ATT Dose 2 : in November 2014 (not due yet)

ANTENATAL HISTORY
Date

POA

Comment

18/6/2014 @1000H
@ KKIA Bandar Pekan

8 weeks POA

Wt booking >80kg
BMI 38.6
Family hx: DM/HPT/IHD

Urine alb/sug: -ve/-ve

HB: 13.6 g/dl
BW: 88kg
BP: 120/70
No edema

SFH: non
palpable

Otherwise, mother is healthy, no

active complaints
Advised given:
-Maternal clothes in pregnancy
-Diet modification
- Cleanliness in pregnancy
- T. Hematinic
- Iodine salt 0.5kg given
Plan:
- Refer doctor for RME 1 on
23/6/2014
- Refer SN utk

ANTENATAL HISTORY
Date

POA

Comment

23/6/2014
@ KKIA Bandar Pekan

9 weeks POA

RME 1 done by Dr Tan Du Ping

c/o nausea and vomiting 2 weeks
Otherwise, mother is healthy, no
active complaints

Urine alb/sug: -ve/-ve

HB:BW: - kg
BP: 110/70
No edema

***
MGTT x1 done
VDRL/ABO/RH taken

SFH: non
palpable

Scan done:
CRL 11mm 7W2D
Plan:
Repeat scan at 20 weeks of POA
Tab metachlorpramide 1/1 TDS and
syr MMT 10mls TDS
TCA STAT if in labor/ IE
Next TCA 16/7/2014
Advised given:
-Maternal clothes in pregnancy
-Diet modification
-Cleanliness in pregnancy

ANTENATAL HISTORY
Date

POA

Comment

3/7/2014 @ ED Hospital
Pekan

11 weeks
1day POA

Alleged fall on the floor 1/7

Post trauma, pain over right second
toe
Seen by Dr. Muhyiddin:
o/e deformity at right second toe
Swollen, redness, reduce ROM due
to pain
Patient not consented for xray
Proceed with CMR under LA
Plan:
Buddy splint
TCA ortho clinic 2/52 to review
symptoms (17/7//14)
Tab PCM 1g PRN

ANTENATAL HISTORY
Date

POA

Comment

16/7/2014 @1010H
@ KKIA Bandar Pekan

12 weeks of
POA

Weight reduced 1kg within 1 month

On and off vomiting (condition
improved)

Urine alb/sug: -ve/-ve

HB:11 g/dL
BW: 87 kg
BP: 110/70
No edema

SFH: not
palpable

Noted hx of fell down on 3/7/2014

TCA hosp pekan 17/7/2014
Advised given:
-Maternal risk and growing fetal
-Diet modification
-Cleanliness in pregnancy
-T. Hematinic
-Iodine salt 0.5kg given
- Next TCA 31/7/2014
- Repeat scan 9/9/2014

ANTENATAL HISTORY
Date

POA

Comment

31/7/2014 @0950H
@ KKIA Bandar Pekan

14 weeks of
POA

Mother is healthy. No active

complaints

Urine alb/sug: -ve/-ve

HB: - g/dL
BW: 88 kg
BP: 110/70
No edema

SFH:
Palpable

Advised given:
-Maternal risk and growing fetal
-Breastfeeding awareness
-The risk of abortion
-Diet modification
-Cleanliness in pregnancy
-T. Hematinic
-Iodine salt 0.5kg given

MGTT x1:

-Next TCA 26/8/2014

-Repeat scan and MGTT at 28 weeks

ANTENATAL HISTORY
Date

POA

Comment

26/8/2014
@ KKIA Bandar Pekan

18 weeks ++
of POA

Mother is healthy. No active

complaints

Urine alb/sug: -ve/-ve

HB:11 g/dL
BW: 89 kg
BP: 110/70
No edema

SFH: palpable

Advised given:
-Maternal risk and growing fetal
-Breastfeeding awareness
-The risk of abortion
-Diet modification
-Cleanliness in pregnancy
-T. Hematinic
-Iodine salt 0.5kg given
-Next TCA 25/9/2014

ANTENATAL HISTORY
Date

POA

Comment

26/8/2014
@ LR

18 weeks ++
of POA

5 adult at home, no kids

House area clean and in good
condition.

Urine alb/sug: -ve/-ve

HB:BW: BP: 110/70
No edema

SFH: palpable
Mother is healthy. No active
complaints
Advised given:
-Maternal risk and growing fetal
-Breastfeeding awareness
-The risk of abortion
-Diet modification
-Cleanliness in pregnancy
-T. Hematinic
-Iodine salt 0.5kg given
-Next TCA 25/9/2014

ANTENATAL HISTORY
Date

POA

Comment

25/9/2014 @ LKD

22 weeks ++
of POA

Weight increase 3kg in 1month

Urine alb/sug: -ve/-ve

HB: 11.2g /dL
BW: 93 kg
BP: 120/70
No edema

SFH: palpable
at 22 weeks
of POA

Mother is healthy. No active

complaints
Advised given:
-Maternal risk and growing fetal
-Breastfeeding awareness
-The risk of abortion
-Diet modification
-Cleanliness in pregnancy
-T. Hematinic
-Iodine salt 0.5kg given
Plan:
- Refer FMS for maternal obesity
on 9/10/2014
- Next TCA 2/10/2014

ANTENATAL HISTORY
Date

POA

Comment

2/10/14 @ LKD

23 weeks ++
of POA

Weight reduced 0.5kg in 1 week

Urine alb/sug: -ve/-ve

HB: - g/dL
BW: 92.5 kg
BP: 110/70
No edema

SFH: palpable
at 24 weeks
of POA
Cephalic
FHR +ve
FM +ve

Mother is healthy. No active

complaints
Advised given:
-Maternal risk and growing fetal
-Breastfeeding awareness
-The risk of abortion
-Diet modification
-Cleanliness in pregnancy
-T. Hematinic
-Iodine salt 0.5kg given
Plan:
- Refer FMS for maternal obesity
on 9/10/2014
-Next TCA 8/10/2014

ANTENATAL HISTORY
Date

POA

Comment

8/10/14 @ LKD

24 weeks ++
of POA

Weight reduced 0.5kg in 1 week

Urine alb/sug: -ve/-ve

HB: - g/dL
BW: 92 kg
BP: 110/70
No edema

SFH: palpable
at 24 weeks
of POA
Cephalic
FHR +ve
FM +ve

Mother is healthy. No active

complaints
ATT first dose given
Advised given:
-Maternal risk and growing fetal
-Breastfeeding awareness
-The risk of abortion
-Diet modification
-Cleanliness in pregnancy
-T. Hematinic
-Iodine salt 0.5kg given
Plan:
- Refer FMS for maternal obesity

ANTENATAL HISTORY
Date

POA

Comment

9/10/2014 @ KK Peramu
Jaya, 0852H

24 weeks ++ of
POA

Seen by Dr Yusnita, FMS:

SFH: palpable at
24 weeks of POA
Cephalic
FHR +ve
FM +ve

Issue:
1. Maternal obesity (BMI: 38.6)
-. MGTT normal
-. Snoring + ?apneic spell
-. No chestpain/SOB/calf pain
-. No BA/rhinitis allergy
US Scan done: 9/10/14 @1011H
BPD: 60.9mm 24w0D
FL : 44.4mm 25w4D
FTA: 30.8mm 24w3D
Total: 24w4D
EFW: 768g
Cephalic, PUS low lying
FH seen, FM seen
Plan:
-. Refer ENT for OSA assessment
-. FLP/ECG. If TC more than 6.5, for
MOPD appt
-. Repeat US scan at 30-32weeks for

ANTENATAL HISTORY
Date

POA

Comment

16/10/2014 @ LKD

25 weeks ++
of POA

Mother is healthy. No active

complaints

Urine alb/sug: -ve/-ve

HB: - g/dL
BW: 92.5 kg
BP: 110/70
No edema

SFH: palpable
at 26 weeks of
POA
Cephalic
FHR +ve (146
bpm)
FM +ve

Advised given:
-Maternal risk and growing fetal
-Breastfeeding awareness
-The risk of abortion
-Diet modification
-Cleanliness in pregnancy
-T. Hematinic
-Iodine salt 0.5kg given
Plan:
- Next TCA 3/11/2014
FLP:
Cholesterol: 5.28mmol/L
Trigliseride: 2.09mmol/L
Plan:

ANTENATAL HISTORY
Date

POA

4/11/2014 @ KKIA Bandar 28 weeks of

Pekan
POA

Urine alb/sug: -ve/-ve

HB: - g/dL
BW: 92.5 kg
BP: 110/70
Edema both legs

SFH: palpable
at 26 weeks of
POA
Cephalic
FM +ve

Comment
Seen by Dr Aida:
Mother is healthy
Not in labor, no IE symptoms, FM
felted- good, no fever
US scan done:
Cephalic, singleton, PUS- not low
FH seen, FM seen
Parameters:
BPD: 68mm 26w6D
FL : 40mm 22w6d
FTA: 212mm 25w4d
Total: 25w1D
EFW: 758g, AFI 9cm
Plan:
-Repeat scan at 30-32 weeks
-MGTT at 28weeks and at 34weeks
-ENT appointment for OSA
assessment as planned

ANTENATAL HISTORY
Date

POA

Comment

6/11/2014 @ KKIA Bandar

Pekan

28 weeks ++ of
POA

Patient came for MGTT at 28 weeks

Urine alb/sug: -ve/-ve

HB: - g/dL
BW: - kg
BP: not documented

No FH
documented
No FM
documented

c/o abdominal pain 1/7

Last meal at 8pm 15/11/2014
No contraction pain
No LL, no PV bleeding
Claimed FM felted
History of gastritis on syr MMT prn
Doctor not around in clinic
(attended meeting in PKD)
Was informed by sister Junaidawati
via phone
Plan by Dr. Aida (verbally)
IM ranitidine stat given @12noon and to
reassess patient later KIV to send to
hospital if pain persist
At 1250H, reassess patient back
Pain reduced
Patient requested to go back home
Advised by sister Junaidawati
TCA STAT if increase in pain, PV

RETROSPECTIVE ENTRY AS NOT DOCUMENTED

IN ANC BOOK
Plan by Dr Aida (verbally):
1. Informed by sister Junaidawati via phone regarding the patients
complaint
Plan:
IM ranitidine stat given @12noon and to
reassess patient later KIV to send to
hospital if pain persist.
2. Informed by SN Laili at 1250H patient still having pain but
reduced
Plan:
To send patient to Hospital stat as pain still persist and no doctor
around.

HOSPITAL SETTING

Mother went to Hospital Pekan in the evening

(around 1400H -1500H) as complaints of PV
bleeding and lower abdominal pain .
US scan: no fetal heart seen
Investigation:
FBC 6/11/2014: hb 10.9 ht 31.8 plt 265
Delivered baby boy, MSB, BW: 1.36kg
7/11/2014@0155H
Placenta complete, baby grossly normal baby with
no obvious deformity

FINAL DIAGNOSIS

Classification of Death:
Intra-Uterine Death followed by SVD of
Macerated
Stillbirth (MSB)
(Not preventable)

ASSOCIATED CONDITIONS
No Unknown
Yes
Hypertensive Disorders of Pregnancy

Diabetes Mellitus

Vaginal Bleeding

Anemia in pregnancy (Hb H)

Prolonged Rupture of Membrane

Preterm Labor

Heart Disease(Mild MVP)

SUBSTANDARD MANAGEMENT
Yes

Failed to inform senior

Failed to diagnose early

Inappropriate management

No

/
/

Late referral

High risk to junior

Poor resuscitation

SUBSTANDARD MANAGEMENT
Failed

to update and informed leader for a proper

current progress/plan.
Failed to follow ordered given by a leader.
Poor documentation:
Not properly document a recent order from leader
No AOR form

CONTRIBUTORY FACTORS
Yes

Patient/ Family:

Personnel/Facility

No
/
/

POSTNATALLY

Admitted in hospital Pekan from 6/11/2014 till

8/11/2014
Discharge on 8/11/2014 @ 1530H
Was given tab cabergoline 1mg 1/7
TCA O&G clinic 3/12 to review blood result.
Advised for family planning. (Patient keen for
condom)
TCA Postnatal clinic 1/12 on 8/12/14
TCA Hospital Pekan PNC in February 2015.
Pap smear 3/12

Thank you