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).