UNPREDICTED IUFD ON G3P2A0 31-32 WEEKS

GESTATION WITH PRETERM PREMATURE

RUPTURE OF MEMBRANES AND HISTORY OF
MIDTRIMESTER HEMORRHAGE CAUSED BY
LOW LYING PLACENTA

By:Anita Setiawati
 INTRODUCTION

Preterm rupture of membranes

Neonatal complications

Increases perinatal morbidity and mortality

 IDENTITY
NAME : Mrs. A
AGE : 35 y.o
ADDRESS : Cibarengkok Bandung
EDUCATION : Diploma 1
OCCUPATION : Official
MEDICAL RECORD : 0504 xxxx

DATE OF ADMISSION : July 30th, 2005 at 12.00

 ANAMNESIS
 Patient registered in Hasan Sadikin Hospital
G3P2A0  Chief complain : Excessive fluid from vagina

7½ month gestation

First leakage ± 5 hours before admission →

clear, foul- smelling amniotic fluid(-), fever(-)

History of
hospitalization (+)

History of midtrimester
Labor pain (-) hemorrhage (+)→low lying
placenta
 OBSTETRIC HISTORY
1. Sidoarjo Hospital. Aterm. 2700 g.Spontaneous deliv.♀.10
yo.alive
2. Sidoarjo Hospital. Aterm. 3000 g.Spontaneous deliv.♂.7
yo.alive.history of PROM

Additional anamnesis :
Marital history : ♀, 23 y.o, D1, official
♂, 25 y.o, D1, official
 Contraception : pill.1997-2004

 Last Menstrual Period : Dec, 25th 2004

 Estimed birth pregnancy : Oct, 1st 2005

 Prenatal care : Hasan Sadikin Hospital 10x

 USG : single, alive, head presentation, 31-32 weeks gest,AFI< 5,

low lying placenta.

 PATIENT’S HOME VISIT
• 300 m from nearest hospital
• 150 m from nearest midwife
 Pasteur

Sukajadi

Sederhana
 PHYSICAL EXAMINATION
 General Condition : composmentis, good
 Blood Pressure : 120/70 mmHg
 Pulse rate : 100 x/mnt
 Respiration Rate : 20 x/mnt
 Temperature : 36,50C
 Body Weight/Height : 57 kgs/149 cms
 Others : within normal limits
 EXTERNAL EXAMINATION

Fundal height : 29 cm above the symphisis

Abdominal circumference : 85 cm
Fetal position : Head U back at left 5/5
Fetal heart rate : 140-144 x/mnt
Uterine Contraction : (-)
Estimated fetal weight : 1500 grams
LABORATORY FINDINGS

Hemoglobins : 12,5 gr%

Leucocytes : 12.500/m3
Ht : 36 %
Trombocytes : 351.000/mm3
Inspeculo : Nitrazine test (+)
 1/3/05  (Ab. Imminens)
1
28/3/05  (Ab. Imminens)
2
27/4/05  (Ab. Imminens)
3
16/5/05  (Ab. Imminens)
Hystory of 4
hemorrhage 8/6/05  Midtrimester
5 hemorrhage
5/7/05  Midtrimester hemorrhage
6 
Hospitalization
7 30/7/05  PPROM


Went home without
Hospitalization doctor’s permission
 DIAGNOSIS

• G3P2A0 31-32 weeks gestation + PPROM +

history midtrimester hemorrhage ec. Low lying
placenta
 PLAN OF MANAGEMENT

• Hospitalization
• Antibiotic
• Corticosteroid
• Observation : general condition,vital signs,
FHR, uterine contraction
 30/7/05
OBSERVATION
31/7/05 • Vital sign : within N limit
• Uterine contraxtion (-)
1/8/05 • FHR (x)
NST • Antibiotic
3/8/05 • corticosteroid • Vital sign : within N limit
• Uterine contraction (-)
4/8/05 05.00 • FHR (+)
• Fetal movement (-) • antibiotic
• USG : IUFD
• Inpatient room consultant : induction of
labor
5/8/05
08.30
The baby was born
Mother was allowed to go
6/8/05 home
Hasil NST tgl. 03.08.2005
 Observation
FHR BP PR RR
Time UC Inforamtion
(x/mnt) (m mHg) (x/mnt) (x/mnt)

11.30-12.30 - - 120/80 80 20 -Misoprostol 50 μg

12.30-13.30 - - 120/80 80 20
13.30-14.30 - - 110/70 84 24
14.30-15.30 - - 110/70 84 24
15.30-16.30 - - 110/70 80 20
16.30-17.30 - - 120/70 80 20
Internal Examination at 17.30:
v/v : no abnormalities
p : S/C soft
 : closed
D/ G3P2A0 31-2 weeks gestation + PPROM + IUFD

T/ Consultant on duty :

- misoprostol 50 μg

- Observation vital sign, uterine contraction

 Observation
FHR BP PR RR
Time UC
(x/mnt) (m mHg) (x/mnt) (x/mnt)

17.30-18.30 - 120/80 80 20 -Misoprostol 50 μg

18.30-19.30 - 110/70 80 20
19.30-20.30 - 120/70 80 20
20.30-21.30 + 120/70 84 20
21.30-22.30 + 120/70 84 24
22.30-23.30 + 120/70 84 24

Internal Examination at 17.30:

v/v : no abnormalities
p : thick-soft
 : 1 finger
 Observation
FHR BP PR RR
Time UC
(x/mnt) (m mHg) (x/mnt) (x/mnt)

23.30-00.30 + 120/80 80 20 - Oxytocin infusion I →5 iu+

00.30-01.30 + 110/70 84 20 500 cc D5%: 20-60 gtt/

01.30-02.30 + 110/80 8 24
02.30-03.30 + 120/80 84 24
03.30-03.50 + 120/80 84 24

Internal Examination at 03.50:

v/v : no abnormalities
p : thick-soft
 : 1-2 cm
Amniotic membrane : (-) residual fluid was clear
Head : St.-2,SS unclear
 Observation
FHR BP PR RR
Time UC
(x/mnt) (m mHg) (x/mnt) (x/mnt)
05.50-06.50 6-7’ 1x/30”S 120/80 80 24 - Oxytocin infusion 2→5
06.50-07.50 5-6’ 1x/40”S 120/80 84 28 iu+ 500 cc D5%: 20-60
gtt/min
07.50-08.30 4-3’ 1x/45”S 120/80 88 28

08.00 : mother wanted to bear down

08.30 : born ♂ baby without any signs of life
BW : 1800 g BL : 44 cms
08.35 : born placenta spontaneous-completely
W : 400 g, 2 lobes I : 10x10x1 cm
II: 8x5x1 cm

D/ : P3A0 Preterm spontaneous delivery +

stillbirth + bilobate placenta
 PROBLEMS
1. What was the cause of IUFD in this case?
2. How was the antepartum assessment of this case?
3. How is the prognosis for next pregnancy in this
patient?
DISCUSSION
 1. What was the cause of IUFD in this case?
• Aburtion
• Chromosomal
• Previa
anomalies
Plasental • Placental disorder
• Nonchromosonal
birth defect 25-35%
• infection
Categories
Fetus
and causes
25-40% of fetal death
• Hypertensive
disorders
Maternal
• Diabetes
5-10%
• Sepsis
Unexplained • Drugs
25-35% • trauma
 PROM

Preterm (< 37 weeks) Term ( > 37 weeks)

• 2-5% of all pregnancies

• Complications:
• Preterm births  30-40% of all preterm birth
• Abruptio placenta,cord prolapse/cord compression,fetal
death,neonatal pulmonary hipoplasia,neonatal respiratory
distress,chorioamnionitis,fetal deformities,sepsis
Incidence of abruptio by advancing gestational
age at the time of PROM
50%
50% 44%
40%
30%
30%

20%

10%
13%
0%
< 20 20-40 25-28 29-32
 Chorioamnionitis

13% of overall pregnancies Clinical findings:

with PPROM in 26-34
weeks gestation
• Fever : > 380C
• Leukocytosis: >18000/mm3
• Uterine tenderness
• Foul-smelling amniotic fluid
• Tachycardia : maternal> 120 bpm
• FHR > 160 bpm
 Abnormal shape • Fenestrated placenta
• Multiple placentas
• Succentusiate lobes
• Membranaceous placenta
• Circumvallate placenta

Placental
disease Abnormal
Placental implantation
• Placental infarctions abnormalities
• Placental • Acreta
inflammationtmor of • Increta
the placenta • percreta
• Hypertrophic lesions
of the chorionic villi Placental
disfunction
Bilobate placenta
Bilobate placenta
Accessories placenta
Tripple placenta
Circummarginate Placenta
Circumvallate Placenta
Velamentous insertion
Placental Infarcts
Placental infarcts
PLACENTAL INFARCTS
Red Brown Infarcts
FALSE KNOT TRUE KNOT
Meconium staining
 These are two views of a bilobate placenta, where each of the
lobes (one on the anterior and one on the posterior aspects of
the uterine cavity) are marked with an *
The velamentous insertion of the cord (see
also Vasa previa) with branches supplying
the anterior and posterior lobes.
 The main part of the placenta is
posterior and the succenturiate lobe is
anterior
 2. How was the antepartum assessment
of this case?
PROM
20- < 28
weeks
28-36 weeks > 37 weeks

Induction of Conservative Induction of

labour 2 days labour

• Antibiotic •Infection
No complication •Fetal distress
• Steroids •Aonset of labour
• Antepartum assessment
Outpatient Iductuion of labour
 Fetal well
Antenatal Intranatal
being

• Clinical assesment • Monitoring FHR

• USG • Monitoring uterine
• DMFC
• Monitoring contraction
• Antenatal
• Fetal blood sampling
cardiotocography (NST)
• Biophysical ptofile • Partogram
 ULTRASONOGRAPHY
Real-time sonography:

It can be used for detection of :
1. Gestational age: by
measurement of gestational sac,
crown rump length, biparietal
diameter or femur length.
2. Viability of the fetus: by fetal
heart movement or fetal
movement.
3. Fetal weight.
4. Amniotic fluid volume.
5. Fetal breathing movement.
6. Placenta: location , size and
maturity.
8. Congenital anomalies.
Doppler ultrasound:

Principle:
It depends upon the reflection of the ultrasound
waves on the RBCs inside the blood vessels, so
the blood velocity and flow through these vessels
can be calculated
 NON STRESS TEST
Reactive Non reactive

• Base line rate : 120-160 bpm

• Variability: > 5 bpm
• Acceleration > 2 acceration in 20-
40 min,15 bpm,15 second
• Deceleration (-)
Suspicion of fetal Nonstress
compromise Nonreactive Biophysical
test profile†

Repeat depending Reactive *

upon indication

Oxytocin Normal
Negative Oligohydramnios
challenge test (adequate fluid) (< 2 cm) or AFI < 5

Repeat
Suspicious Positive Consider delivery
next day
 DFMC
(Daily fetal movement count)

Valid after 28-30 weeks pregnancy

Cardiff Sadovsky Other

 BIOPHYSICAL PROFILE
• Biophysical Profile (BPP)
• 5 item test of fetal well being.
Includes NST and ultrasound.
• Parameters: fetal muscle
tone, fetal movement, fetal
breathing movements,
amniotic fluid volume.
 • Normal : NST : reactive
Modified AF I : > 5 cm
biophysical profile • Abnormal : NST : non reactive
AF I : < 5 cm
In This case

 1x AFI < 5 cm
 3x reactive

Unreported

Unreported
Hasil NST tgl. 03.08.2005
3. How is the prognosis for next pregnancy
in this patient?

35% 32%
30%
25% 21%
20%
15%
10%
5%
0%
Naeye’s (1982) Asrat (recently)
 Detection of PPROM
Qualitative hCG
testing of
cervicovaginal

The vaginal
inflammatory
Midtrimester
MMP8 levels
 ETHICAL ISSUES

 According to the ethical issues associated with this

case, the assessment is low of standarization.

 Antepartum assessment based on ethic include

counseling, risk factor assessment, fetal-maternal
condition and complications therapy.
 CONCLUTION

• The cause of IUFD was unclear

- autopsy
- cytogenetic examination
• There’s lack of antepartum assessment
• Mother with previous PPROM has recurrency
for subsequent pregnancy