IUFD Assignment and Grading Rubric

Here was the clinical scenario: 32yo G1P0 who presents at 36 wks to L&D for c/o decreased fetal movement and is found to have an IUFD. On US, there are overlapping skull bones and a femur length consistent w/ 30 weeks. Her cervical exam is: closed/3cm/-3. Pregnancy has been normal and uneventful up to this point.

Assignment: Write an admission order set that addresses this patient's needs. Compare your order set with mine and using the grading rubric provided, grade your order set (and mine if you'd like) and return your graded order set to me. This can be done on your paper copy or electronically. Due date: next Friday, 7/22/11.

PG's Explanation: I would have explained the finding of IUFD, offered her support and counseled her about options (immediate vs delayed induction of labor; consent for autopsy/burial; course of labor/preferences for pain management) and then written the following orders. At this gestational age and uterine size (36 weeks by dates and 30 weeks by size), labor induction and vaginal delivery would be the preferable route of delivery. With a cervix that is closed and long, there would be a need for cervical ripening either by mechanical or hormonal means). You should have referred to the "purple book" for the basic format of an order set. As to the approach to management, ACOG has written a practice bulletin that outlines this issue.

The finding of a 30 week size fetus at 36 week's of gestation raises an important question: is this a recent demise of a fetus that stopped growing and is IUGR or is did this demise happen remotely, ie 6 weeks ago and the fetus was appropriately grown and now has been retained for 6 weeks? The overlapping skull bones suggest that it happened awhile ago, but we cannot be certain. By

history and physical exam and prenatal labs, we could have likely ruled out many of the maternal causes of stillbirth, so glucose/thyroid testing would be non-productive. You could make an argument that many of the following tests are not cost-effective (especially the thrombophilia panel).

But, given the finding of growth parameters c/w 30 wks at 36 wks, IUGR/placental insufficiency may be part of the etiology. T

he highest-yield tests are going to be: autopsy, placental path and chromosomes.

Flow cytometry has replaced Kleihauer-Betke as the method for detecting fetal cells in the maternal circulation (to diagnose maternal-fetal hemorrhage; not an insignificant cause of third trimester IUFDs). B

ecause DIC can occur with late-presenting IUFDs (usually at least 28 days after the demise), anesthesia is likely to want to know her coagulation status before putting in an epidural catheter (if it is desired for pain control). [[ SBM ghosts: why is a fibrinogen ordered instead of a bleeding time/PT/PTT? Can you remember the clotting cascade; which pathway – intrinsic or extrinsic- would be activated in a retained IUFD and why?]]]

Don't forget the importance of psycho-social support. The recent series from the Lancet is an excellent resource on all things related to stillbirth, especially from a global health perspective. The link to the photographer's website who helped us put stillbirth into perspective is: www.toddhochberg.com

PG Order Set:

1) Admit to L&D for induction of labor

2) Dx: intrauterine fetal demise at 36 weeks, not in labor

3) Condition: stable but in need of emotional support

4) Maternal Vitals: per L&D protocol

5) Activity: up ad lib until epidural, then only with assistance

6) Diet: clears

7) IV: start peripheral IV with IVF: D₅.45NS @ 125cc/hr (total fluids)

8) Medications: misoprostol 50 micrograms per vagina to be placed by ROD; repeat dose in 4hrs at discretion of attending physician; pitocin per L&D protocol for labor (start at discretion of attending)

9) Labs: T&S, CBC, flow cytometry for fetal cells*, RPR, CMV/toxo/parvovirus IgG & IgM; Anticardiolipin abs (ACA IgG and IgM), thrombophilia panel (FVL mutation, PT mutation, ATIII level, Prot C&S levels); placenta and newborn to pathology with placental path and fetal autopsy requisition; ROD to obtain fetal tissue, place in culture media and send to genetics for karyotype; PT/PTT/Fibrinogen

10) Anesthesia consult

11) Perinatal Loss coordinator consult

12) Chaplain consult if desired by patient

Grading Rubric can be found here

Orientation Assignment

Ms. Smith is a 24 yo G2P0100. Her LMP/EDD and other info was provided in the handout in class. This patient differs in the fact that she does NOT have a hx of a prior vertical CD but the rest of the hx is the same (including the cerclage.

Your assignment is to write the admitting H&P.

Good Luck!

TBL Session F/U: Order Set for patient with IUFD at 36 weeks

Order set for 32yo G1P0 who presents at 36 wks to L&D for c/o decreased fetal movement and is found to have an IUFD.

I would have explained the finding of IUFD, offered her support and counseled her about options (immediate vs delayed induction of labor; consent for autopsy/burial; course of labor/preferences for pain management) and then written the following orders. By history and physical exam and prenatal labs, we could have likely ruled out many of the maternal causes of stillbirth, so glucose/thyroid testing would be non-productive. You could make an argument that if the fetus is not IUGR, then sending a thrombophilia work-up is not going to be helpful either. But many times, in order to not overlook anything, these labs are sent.

1) Admit to L&D for induction of labor

2) Dx: intrauterine fetal demise at 36 weeks, not in labor

3) Condition: stable but in need of emotional support

4) Vitals: per L&D protocol

5) Activity: up ad lib until epidural, then only with assistance

6) Diet: clears

7) IV: start peripheral IV with IVF: D₅.45NS @ 125cc/hr (total fluids)

8) Medications: misoprostol 50 micrograms per vagina to be placed by ROD; repeat dose in 4hrs at discretion of attending physician;pitocin per L&D protocol for labor (start at discretion of attending)

9) Labs: T&S, CBC, flow cytometry for fetal cells*, RPR, CMV/toxo/parvovirus IgG & IgM; Anticardiolipin abs, thrombophilia panel (FVL, PT mutation, ATIII, Prot C&S); placenta and newborn to pathology with placental path and fetal autopsy requisition; ROD to obtain fetal tissue, place in culture media and send to genetics; PT/PTT/Fibrinogen**

10) Anesthesia consult

11) Perinatal Loss coordinator consult

12) Chaplain consult if desired by patient

* flow cytometry has replaced Kleihauer-Betke as the method for detecting fetal cells in the maternal circulation

**because DIC can occur with late-presenting IUFDs (usually at least 28 days after the demise), anesthesia is likely to want to know her coagulation status before putting in an epidural catheter (if it is desired for pain control).

Answer to Monday's Question of the Day: Contraception for a patient w/ SLE

The question of contraception for a patient with SLE raises the issue of weighing benefits versus risks in a patient-centered context. First and foremost, pregnancy may be much riskier for this patient than any contraceptive, so it calls for a careful and thorough exploration of the patient's needs and the risks/benfits of various methods. As 2 students posted on the @OBGYNclerk twitter account, becasue a Mirena IUD is a progestin-only contraceptive, it may be the best alternative. In a recent article published in the August 2009 issue of Obstetrics & Gynecology, Dr. Culwell concludes: "Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives. The benefits of contraception for many women with SLE likely outweigh the risks of unintended pregnancy in this population. Women with positive antiphospholipid antibodies are not good candidates for combined hormonal contraception given their elevated baseline risk of thrombosis." You can read this article at: http://bit.ly/yr90D

TBL Session F/U: Order Set for patient with IUFD at 36 weeks

Order set for 32yo G1P0 who presents at 36 wks to L&D for c/o decreased fetal movement and is found to have an IUFD.

I would have explained the finding of IUFD, offered her support and counseled her about options (immediate vs delayed induction of labor; consent for autopsy/burial; course of labor/preferences for pain management) and then written the following orders. By history and physical exam and prenatal labs, we could have likely ruled out many of the maternal causes of stillbirth, so glucose/thyroid testing would be non-productive. You could make an argument that if the fetus is not IUGR, then sending a thrombophilia work-up is not going to be helpful either. But most often, so as to “cover all bases”, these labs are sent.

1) Admit to L&D for induction of labor

2) Dx: intrauterine fetal demise at 36 weeks, not in labor

3) Condition: stable but in need of emotional support

4) Vitals: per L&D protocol

5) Activity: up ad lib until epidural, then only with assistance

6) Diet: clears

7) IV: start peripheral IV with IVF: D₅.45NS @ 125cc/hr (total fluids)

8) Medications: misoprostol 50 micrograms per vagina to be placed by ROD; repeat dose in 4hrs at discretion of attending physician;pitocin per L&D protocol for labor (start at discretion of attending)

9) Labs: T&S, CBC, flow cytometry for fetal cells*, RPR, CMV/toxo/parvovirus IgG & IgM; Anticardiolipin abs, thrombophilia panel (FVL, PT mutation, ATIII, Prot C&S); placenta and newborn to pathology with placental path and fetal autopsy requisition; ROD to obtain fetal tissue, place in culture media and send to genetics; PT/PTT/Fibrinogen**

10) Anesthesia consult

11) Perinatal Loss coordinator consult

12) Chaplain consult if desired by patient

* flow cytometry has replaced Kleihauer-Betke as the method for detecting fetal cells in the maternal circulation

**because DIC can occur with late-presenting IUFDs (usually at least 28 days after the demise), anesthesia is likely to want to know her coagulation status before putting in an epidural catheter (if it is desired for pain control).

Concept Map for Fetal Death