HS317b - Coding & Classification of Health Data
Class Discussion
Admission Date: Sept 18 Discharge Date: Sept 19
This 25 year old G4, P2, A1 patient who was at 39 weeks gestation. She had had a therapeutic abortion in 1977. She delivered her first baby in July 1982 at 38 weeks gestation; it was a 7 lb 1 oz female with slight cyanosis at birth but was otherwise well since then. In November 1985 she delivered her second child at 41 weeks gestation. It was a 24 hour labour and a live male weighing 6 lb 15 oz was delivered which is in good health at this time.
With this pregnancy she was at 39 weeks gestation. She was a smoker, but was otherwise quite healthy. She had seen the doctor during most of the pregnancy having seen me on May 26 and then again weekly since August 24th. When I saw her in May she was 22+ weeks gestation and the symphyseal fundal height was that of a 23 weeks pregnancy. Fetal heart was good and B.P. was good as well. I ordered an ultrasound which showed a live healthy appearing intrauterine pregnancy 22-23 weeks size suggesting a due date of about Sept 30.
The reassuring part about that ultrasound was that they had reported that the amount of amniotic fluid was normal.
I saw her in my office on Sept 16 at which time she was 38+ weeks gestation. Her weight was 164 lbs and B.P. was 130/80. Symphyseal fundal height was still 33 cm and was cephalic presentation. The fetal heart rate was 150/minute. She reported that the fetal movement was still OK. I recognized that the baby was not growing as it should and I felt that we should deliver the baby by next week at the latest. I also felt that there should be further investigations and a nonstress test was booked for Monday, Sept 19. An induction was booked for Wednesday, Sept 21.
The patient went home and she began contracting at about 0400 hours Sept 17. The contractions were not very strong and she did not feel that she had to come to the hospital. She finally came to the hospital at about 0100 hours Sunday morning, Sept 18. On questioning she could not remember when the baby had last moved although when she had been in my office on Sept 16 she said that the movement was still OK.
On examination she was found to have no fetal heart beat. This was confirmed with real time ultrasound. A fresh stillbirth was diagnosed.
An induction of labour was begun. An artificial rupture of the membranes was performed at 0220 hours and there was meconium in the amniotic fluid. She was dilated 2 cm at the time. A syntocinon drip was then begun and her contractions became more effective. The patient was requesting a C-section but it was felt that this was not indicated either for maternal or fetal indications.
She was fully dilated at 0944 hours. After a 2 minute second stage, at 0946 hours Sept 18 a stillborn female weighing 2020 grams was delivered.
No episiotomy was required. The placenta delivered at the same time as the fetus and was intact with 3 vessels but appeared to be affected with areas of infarction. Estimated blood loss about 350 ccs.
The mother did very well postpartum and there were no complications. She was deemed fit for discharge on Sept 19.
The initial report on the autopy showed a stillborn female, phenotypically normal. There was evidence of intrauterine growth retardation. There were petechial haemorrhages over the pericardial and pleural surfaces. The placenta showed meconium staining and scattered areas of infarction, moderately severe. There was no evidence of congenital anomaly, trauma or infection. In discussion with the pathologist, he felt that it did not seem that the placenta was infarcted enough to have caused the intrauterine death. He had noted that the mother showed macrocytosis in her red blood cell picture with an MCV of 102.2
Final diagnosis Fetal death in utero at 39 weeks of gestation
Intrauterine growth retardation probably due to placental insufficiency secondary to placental infarction.