CASE REPORT

Supervisor : dr. Fadjrir, SpOG

Mentor : dr. Juhriyani M. Lubis

Presenter :
Siska Febrina
Prisca Meirinda
Imy Ginting
PATIENT IDENTITY

Name : Mrs. E
Age : 25 years old
Religion : Moslem
Occupation : Housewife
Ethnicity : Jawa
Education : Senior High School
Address : Jl. Pelajar Timur Medan
Admission Date : August 24th, 2013
Admission Time : 11.59 pm
MR number : 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 : Labor Contraction
Description : 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 (+),
Hypertension (-)
History of Previous Treatment : -
Menstrual History

Menstrual Cycle : Regular

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

Blood Pressure : 130/80 mmHg
Pulse : 80 bpm
Respiratory Rate : 20 tpm
Temperature : 37,40C
Obstetric Examination
Abdomen : enlarged asimmetrically
SFH : 2 fingers below xyphoid
process (37cm)
Stretch : right
Bottom : head (floating)
Movement : (-)
Contraction : 1 x 20/ 10
FHR : (-)
EBW : 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 (37-
38) weeks
Laboratory Results
HB 9,5

HT 29,9%

RBC 4,5 x 106

WBC 10.700

KGD ad Random 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 Respirator Contraction Bleeding
Pressure y Rate
02.30 110/70 84 x/i 22 x/i strong 5 cc
mmHg
03.00 110/70 84 x/i 22 x/i strong 10 cc
mmHg
04.30 120/80 86 x/i 24 x/i strong 15 cc
mmHg
05.00 120/80 88 x/i 24 x/i strong 15 cc
mmHg
05.30 120/80 88 x/i 24 x/i strong 15 cc
mmHg
Laboratory results 2 hours after SVD
Hb 9,3 g%
Ht 29,7%
RBC 4,2. 106 /L
WBC 11.900 / L
PLT 245.000 /L
KGD nachter 242 mg/dl
KGD 2 jam PP 310 mg/dl
HbA1c 8%
D-Dimer 375
fibrinogen 4000
FOLLOW UP
26-08-2013 27-08-2013

Complain Fever (-) Fever (-)

Status Presens
Consciuosness Compos Mentis Compos Mentis
Blood Pressure 120/70 mmHg 110/70 mmHg
Heart Rate 86x/i 88x/i
Respiratory Rate 22x/i 22x/i
Temperature 37,6 C 37,3 C
 26-08-2013 27-08-2013
Status Obstetrikus
Abd: Soepel Abd: Soepel
SFH: Setentang SFH: Setentang
umbilikal umbilikal
Contraction: strength Contraction: strength
P/v = lochia rubra (+) P/v = lochia rubra (+)
Myction (+) N Myction (+) N
Defecation (+) N Defecation (+) N
Diagnosa Post SVD ec IUFD + Post SVD ec IUFD +
NH2 + DM type 2 NH3 + DM type 2
 26-08-2013 27-08-2013
Teraphy - Amoxicilin 3x500 mg - Amoxicilin 3x500 mg
- Asam Mefenamat - Asam Mefenamat
3x500 mg 3x500 mg
- Methyl ergomethrin - Methyl ergomethrin 3x1
3x1 - Diet MB
- Diet MB
Planning - - Discharged for
outpatient care
- Control internal policlinic
Case Analysis
Theory
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.
Case
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
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.
Case
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.

Vital signs are within normal limit. Obstetric examination

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
 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?