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CASE 1: MACERATED STILLBIRTH

B/O
Nor Malizah Binti Mamat
Nor Malizah binti Mamat
31 years old, G3 P2 @ 26W 1D
LMP : 3/8/16
EDD : 10/5/17
1ST SCAN : 12W 3D (p: 12W)
SS :19W 6D (p: 19W)

Height : 154cm BMI: 28.6kg/m


No significant past medical history
Allergy to seafood, develop rashes
No known allergy to medications

Past obstetric history :


Year GA Method Of Place Sex Weight Complication Breastfeed Current
Delivery Status
M Baby
1 2013 T SVD HTAA Girl 3kg Nil NNJ 6 Month Healthy

2 2015 T EM LSCS HTAA Boy 1.8kg Nil Nil 6 Month Healthy


For fetal
distress
Nor Malizah binti Mamat
31 years old, G3 P2 @ 26W 1D
ANTENATAL CHECK UP AT KK GAMBUT
21/10/16 BOOKING HB : 12.4 g/dl
11W 3D ANTENATALLY UNEVENTFULL BP : 90/60 mmhg
WT : 68kg
27/10/16 C/O NAUSEA & VOMITING, NO ABDOMINAL PAIN, NO PV BLEED HB : 12.4 g/dl
12W 3D UFEME: NITRITE +VE UTI BP : 110/80 mmhg
MOGTT X1 : NORMAL WT : 67.5kg (lost 0.5kg)
1ST SCAN DONE: SINGLETON, FH+, P: 12W
10/11/16 ANTENATALLY UNEVENTFUL BP : 110/70 mmhg
14W 1D WT : 67.5kg
16/11/16 ANTENATALLY UNEVENTFULL HB : 11.1 g/dl
15W BP : 100/70mmhg
WT : 69Kkg (gain 1.5kg)
12/2/16 ANTENATALLY UNEVENTFULL BP : 100/70mmhg
18W 5D
21/12/16 ANTENATALLY UNEVENTFULL HB : 12.2 g/dl
19W 6D 2nd SCAN DONE: SINGLETON, FH+, P: 18-19W BP : 100/60mmhg
WT : 69.5kg (gain 0.5kg)
11/1/17 ANTENATALLY UNEVENTFULL HB : 11.6 g/dl
22W 5D BP : 100/70mmhg
WT : 72kg (gain 2.5kg)
Nor Malizah binti Mamat
31 years old, G3 P2 @ 26W 1D

25/1/17 ANTENATALLY UNEVENTFULL BP : 100/60mmhg


24W 5D WT : 75kg (gain 3kg)

31/1/17 URINE ALBUMIN: 2+ BP : 120/90mmhg


25W 5D WT : 73.9kg (lost 1.1kg)
2/2/17 DIAGNOSED: BP : 160/90mmhg
1000H 1)SEVERE PRE ECLAMPSIA WT : 67.5kg (lost 6.4kg)
26W 1D 2)?IUGR WITH OLIGOHYRAMNIONS

ON EOD BP, NOTED BP HIGH


MILD PEDAL EDEMA
ALBUMIN 2+

GIVEN T. ADALAT 10MG BP: 140/88mmhg


TAS DONE AT
KK GAMBUT
s/t specialist:
FOR IM MGSO4 10MG
Singleton
TO SEND TO PE ROOM
P: 21-24W
EFW: 535g
AFI: 3cm
Nor Malizah binti Mamat
31 years old, G3 P2 @ 26W 1D
2/2/2017 (26W 1D) 2/2/2017

FIRST PRESENTATION AT PE ROOM


PE PROFILE
UFEME
HB : 14g/dL
LEU : NEG PLATELET : 287 x10^9/L
NITRITE : NEG BIL : 5.2
PROTEIN : 0.75 g/L
GLUCOSE: NORMAL ALT : 9 U/L TAS BY MO
KETONE : NORMAL ALP :14 U/L
BLOOD : 10.0 cells/unit
COLOUR : YELLOW
Singleton
UREA : 4.6 mmol/L
Cephalic
NA :134 mmol/L
K : 4.1 mmol/L FH ++
SEEN BY HO/MO, D/W SPECIALIST CL : 104 mmol/L
CREAT : 70 umol/L BPD : 61.7cm (25W)
1230H HC : 223cm (24W 2D)
URIC ACID : 444 umol/L AC : 160cm (21W 1D)
FL : 42.5 cm (24W)
IMP: SEVERE PE WITH HPT CRISIS EFW : 522g
AFI : 1.8cm
IUGR WITH OLIGOHYDRAMNIONS & AEDF
DOPPLER
(RI/PI): 1.0/2.69
Keep patient in PE room PLACENTA: POST, NOT LOW
Start T. Adalat 10mg TDS
Nor Malizah binti Mamat
31 years old, G3 P2 @ 26W 1D
2/2/2017
SEEN BY SPECIALIST
1625H

Explained regarding uncontrolled BP and the need for early delivery


Informed risk of IUD

PLAN
BP monitoring
Monitor FHR 4hourly
Continue Adalat
IM Dexamethasone 12mg STAT and 12 hour later
For IV MgSO4 4g bolus, followed by 1g/hour infusion for 24H
KIV IV Hydralazine bolus if BP >150/100mmhg
Scan by MFM tomorrow
Watch out sign & symptoms of IE and MgSO4 toxicity
Repeat PE profile on 6/2/17
Nor Malizah binti Mamat
3/2/2017 (26W 2D) 31 years old, G3 P2

SEEN BY SPECIALIST
1710H
PLAN
Continue IV MgSO4 infusion to complete @ 1830H, to T/O ANW acute bed after completed
Continue T. Nifedipine 10mg TDS
For repeat scan + doppler by MFM in ward
Continue observation

4/2/2017 (26W 3D)


SEEN BY SPECIALIST
1120H
PLAN
Continue T. Nifedipine 10mg TDS
To repeat scan MFM on Monday

5/2/2017 (26W 4D)


SEEN BY SPECIALIST
1000H
PLAN
Continue T. Nifedipine
Repeat scan and doppler CM
PE profile CM
Nor Malizah binti Mamat
31 years old, G3 P2
6/2/2017 (26W 5D)
TAS BY SPECIALIST
SEEN BY SPECIALIST
0940H Singleton
Cephalic PE PROFILE
FH absent
IMP: IUD likely due to SEVERE IUGR HB : 13.2g/dL
FL : 42.7cm PLATELET : 234 x10^9/L
with underlying SEVERE PE BIL : 4.1 umol/L
AFI : anhydramnions
Explained to patient and husband ALT : 10 U/L
PLACENTA: PP TYPE II ANT AST : 17 U/L
regarding the usg findings
Discussed mode of delivery SVD UREA : 6.2 mmol/L
Time of delivery as early as possible NA :132 mmol/L
K : 4.2 mmol/L
CL : 103 mmol/L
SEEN BY SPECIALIST CREAT : 67 umol/L

0635H URIC ACID : 409 umol/L


VE by specialist PLAN
V/V: NAD For IOL CM with 1.5mg PGE (if no
CX: 2CM, POST, SOFT contraindication)

OS: CLOSED Cont medication


ST: HIGH Cont BP monitoring
Nor Malizah binti Mamat
7/2/2017 (26W 6D) 31 years old, G3 P2

SEEN BY MO
0825H
BS + IOL BY MO - 1/13
PGE 3MG INSERTED AT POST FORNIX
PLAN
Rest in bed for 1H
VE on strong contraction/SROM/6H post PGE insertion

SEEN BY SPECIALIST
1015H
No contraction/pv bleed
PLAN
Continue IOL
IM Pethidine PRN

SEEN BY MO
1430H
Post PGEx1
BS 4/13
2nd PGE 3mg inserted
Nor Malizah binti Mamat
8/2/2017 (27W) 31 years old, G3 P2

SEEN BY MO
0715H
BS 4/13
Membrane intact, placenta felt at right side
Offer IM Pethidine, patient keen.

SEEN BY SPECIALIST
1445H
BS- 4/13
No placenta tissue felt
PLAN
Repeat BS CM by specialist
VE on strong regular contraction
IM Pethidine PRN
Nor Malizah binti Mamat
9/2/2017 (27W 1D) 31 years old, G3 P2

SEEN BY HO, S/T MO


0445H
VE:
V/V: NAD
CX: fully effaced
OS: 10cm
MI, Vertex
PLAN
Send patient to HRLR
Nor Malizah binti Mamat
31 years old, Para 3
SEEN BY MO
0515H
SVD with intact perineum
Delivered a baby girl MSB
BW: 500g
A/S: 0/0
EBL: 200mls

SEEN BY SPECIALIST
0950H
PLAN
T. Nifedipine 10mg TDS
Post SVD medication,T. Carbogeline 0.5mg STAT
For T. Aspirin 7mg OD on next pregnancy
T/O gynae ward, acute bed
For APS screening 6/52 postpartum
10/2/17
SEEN BY SPECIALIST
0910H

31 YO PARA 3
*patient request to go back home to take care of
DAY 1 POST SVD WITH INTACT PERINEUM other children
WITH UNDERLYING SEVERE IE

CURRENTLY
No IE symptoms
Latest BR controlled
Urine albumin: nil
BP Range (110-140/60-80)mmHg

VITAL SIGNS:
Stable PLAN
To inform KK for EOD BP monitoring
P/A: To start T Aspirin on next pregnancy
Soft Non Tender TCA 1/12 PNC HTAA
Uterus @ 16W size Continue T. Nifedipine
Well contracted Allow Discharge
DOCUMENTATION OF CASES OF IUD (MSB/FSB)
BY MO
B/O NOR MALIZAH BINTI MAMAT
RN 1008028
FETUS :
WT : 500 GRAM
APPEARANCE : MACERATED
HEAD : NORMAL
NECK : NORMAL
CHEST : NORMAL
ABDOMEN : NORMAL
*CARDIAC BLOOD FOR C+S & TORCHES
GENITALIA : FEMALE CANNOT BE SENT BECAUSE OF INADEQUATE
ANAL PATENCY : YES SAMPLE
LIMBS : NORMAL
HANDS, FEET,DIGITS : NORMAL
CORD LENGTH : 30CM
VESSEL : NORMAL
PLACENTA : 190 GRAM
SITE OF CORD INSERTION : PLACENTAL INFARCT AND CALCIFICATION
RETRO-PLACENTAL CORD : NO