Welcome to case presentation

Presented by:
Dr. Nahin Afrin Sharna
Dr. Prayash Bhatta
(Intern doctors)

Dept. of Obstetrics and Gynaecology

 Particulars of the patient:
Name: Mrs. Jesmin
Age: 25 years
Sex: Female
Religion: Islam
Occupation: Housewife
Address: Moddho Begunbari, Dhaka
DOA: 12.04 .2021 @ 3:00pm
DOD: 15.04.2021 @ 11:00am
CHIeF COMPLAINTS

1. Amenorrhoea due to pregnancy for 32 weeks.

2. No fetal movement for 3 days.

3. Fever and lower abdominal pain for 2 days.

  HISTORY OF PRESENT ILLNESS

According to the statement of the patient, she was regularly menstruating

woman with average flow and duration 32 weeks back. Then, she developed
amenorrhoea due to pregnancy for 32 weeks which was confirmed by urine
strip test at home. It was her planned pregnancy and she was not on regular
antenatal checkup. Her pregnancy period was uneventful up to 32 weeks, then
she complaint of no perception of fetal movement for 3 days.She also complaint
of fever and lower abdominal pain for 2 days.Fever was low gradein nature,
remittant and she was unable to record temperature at home. Her bowel and
bladder habit are normal . With these complaints, she got admitted to this
hospital for further management.
Obstetric history:
• Married for: 11 year
• Para: 1(NVD)
• Gravida: 2nd
• ALC- 7 years

Menstrual history:
• Menstrual cycle: Regular
• Menstrual period: 4-5 days
• Menstrual Flow: Average
• LMP : she could not mention.
• EDD : 17/06/2021(acc. to USG)
Contraceptive history: OCP(for few years)

History of past illness: On 26/01/2021, she had symptoms of UTI(dysurea) and

vaginitis(itching on periurethral itching with whitish discharge).

Drug history: tab.rabeprazole(20mg), tab.cetrizine(10mg), Fungidal cream,

tab.cefuroxime(250mg), tab.terbinafine(250mg) on 26/01/2021

Personal history:
• Non-smoker, Doesn’t chew betel leaf and betel nut
Family history:
• Her all other family members are in good health.

Socio-economic history: She belongs to middle class family

Allergic history: Nothing significant
Immunization history: Immunized as per EPI schedule
General Examination:
• Appearance: normal
• Body built: well built
• Co-operation: Co-operative
• Decubitus: On choice
• Pulse: 80 b/min
• B.P. : 110/70 mm of Hg
• Temperature: 98 degree Fahrenheit
• Respiratory rate: 20 breaths/min
• Anemia: mild
• Jaundice: Non-icteric
• Cyanosis: Absent
• Edema: Absent
• Dehydration: present(mild)
 Systemic Examination

 Abdominal examination:
• Inspection:
normal in shape and size, umbilicus centrally placed.
• Palpation:
- Symphysio-fundal height: 26cm
- Fundal height: 28 weeks
- Fundal grip: broad irregular soft structure buttok
- Lateral grip: irregular structure in left side(probably limbs) & curve and soft structure on right
side(probably back)
- 1st pelvic grip: head
- 2nd pelvic grip: Head not engaged.
• Auscultation:
Fetal heart sound: Absent
 PERVAGINAL EXAMINATION :
OS: 1 cm
Station: 0
Show: present
Membrane: Intact
  Cardiovascular examination:

• Auscultation:
• 1st and 2nd heart sound are audible over all four areas.
• No added sound.

 Respiratory system examination:

• Auscultation:
• Vesicular breath sound with no added sound.
 Clinical DIAGNOSIS

2nd GRAVIDA WITH 32 WEEKS OF PREGNANCY

WITH INTRA UTERINE DEATH(IUD)
 Investigations:

On 12.04.2021
● Hb%-12.0 gm/dl
● PCV- 32%
● ESR- 38mm in 1st hr
● Bleeding time: 2 min 45 sec
● Clotting time: 6 min 30 sec
ON 12.04.2021:
• Plasma glucose - RBS: 5.3 mmol/L
• Prothrombin Time(INR): 1.0
• TSH: 2.34 uIU/ml
• D-Dimer: 0.45 mg/L
• On urine R/E: Pus cell:1-3/hpf & Epithelial cells: 0-2/hpf
● USG:
On 26.01.2021
→USG of prenacy profile:
Gestational age 19+ weeks with cephlic presentation
EDD: 8.9.2021
On 12.04.2021
→ USG of prenacy profile:
Gestational age 28 weeks with intrauterine fetal death.
EDD: 17.06.2021
 Salient features
Mrs. Jesmin, 25 years old normotensive, non diabetic hailing from Moddho Begun Bari, Tejgaon admitted to
this hospital on 12.04.2021@ 3: 00 PM with the complaints of amenorrhoea due to pregnancy for 32 weeks,
perception of less fetal movement for 3 days, and fever & lower abdominal pain for 2 days. According to the
statement of the patient, she was regularly menstruating woman with average flow and duration 32 weeks back.
Then, she developed amenorrhoea due to pregnancy for 32 weeks which was confirmed by urine strip test at
home. It was her planned pregnancy and she was not on regular antenatal checkup. Her pregnancy period was
uneventful up to 32 weeks, then she complaint of no perception of fetal movement for 3 days.She also complaint
of fever and lower abdominal pain for 2 days.Fever was low grade in nature, remittant and she was unable to
record temperature at home.Her adominal pain was of low grade in nature and was non radiating. Her bowel and
bladder habit are normal . With these complaints, she got admitted to this hospital for further management.
. On general examination, she was well looking, mildly anemic, non icteric, dehydrated, pulse 80b/ min, BP 110/
70 mm Hg. On abdominal examination, symphysio fundal height correspond to 28 weeks of pregnancy, on lateral
grip- curved soft structure was on right side(probably back) and soft irregular knob like structure( probably
limbs) was on left side, on 1st pelvic grip- head and on 2nd pelvic grip- head was not engaged. Her investigations
report reveals Hb%- 12.0 gm/dl, ESR- 38mm in 1st hr,Neutrophil- 69%,Prothrombin time(INR)-1.0, CRP-
9.1mg/dl, TSH- 2.34uIU/ml,D-dimer- 0.45mg/dl, Urine R/E- (0-2 pus cell) USG revealed gestational age 28
weeks 0 days with intra-uterine fetal death.(All investigations done on 12.04.2021 )
confirmatory diagnosis
2nd GRAVIDA WITH 32 WEEKS OF PREGNANCY
WITH INTRA UTERINE DEATH(IUD)
 TREATMENT
Order on admission
● Diet – Normal
● Cap.Cef 3- DS(40mg)
1+0+1
● Tab. Flamyd(500mg)
1+0+1
● Tab. Cytomis(200mcg)
½ tab stat on 13.04.2021 at 6:00 am
* Patient was advised to arrange 2 bags of fresh whole blood.
On next day:(13.04.2021)/ at 11.00 am
● Diet – Normal
● Inf.Lactoride (1L) + 10 Unit Linda DS
I/V - @ 30 drops/ min
● Inj. Ceftriaxone(1gm)
1 vial I/V stat
● Inj. Flamyd(500 mg)
1 bottle I/V stat
● Inj. Pantonix(40 mg)
1 vial I/V stat
● Supp. Glysup(2.5 mg)
3 stick P/R stat
● Inj. Algin(5mg)
I/V slowly SOS
 Confinement Note: 5:40 pm on 13/04/2021
 Mode of delivery: NVD
 Conducted by: Dr. Farzana, Dr. Shila, Dr. Sharna
 Procedure: Mrs. Jesmin, 25 yrs old, felt no fetal movement at her 32 weeks of pregnancy.
With all aseptic precautions, a dead male baby was delivered vaginally. Placents, cord &
membrane were delivered by controlled cord traction. Bleeding was average. There was
small perineal tear which was repaired in layers.Genital examination was done to exclude
the injury to vagina, cervix and rectum. The cord was encircled around the neck of the baby
On 13/04/2021 at 6:00 pm
● Diet: Normal
● Cap. Cef3 DS(400MG)
On 14/04/2021 at 12:00 pm
● Diet: Normal
1+0+1
● Tab. Cefa clav( 500 mg)
● Tab. Flamyd(400 mg)
1+0+1
1+1+1
● Tab. Flamyd(400 mg)
● Tab. Inflam(200mg)
1+1+1
1+1+1
● Cap.Nexum(20 mg)
● Cap.Nexum(20 mg)
1+0+1( ½ hrs B/M)
1+0+1( ½ hrs B/M)
● Tab.Algin ( 50 mg)
● Tab. Retinol forte(50,000 IU)
1+1+1
4 cap P/O stat
● Tab. Ceevit (250 mg)
● Tab. Ceevit (250 mg)
1+1+1
1+1+1
● Tab Xinc B
● Tab Xinc B
1+0+1
1+0+1 ● Tab. Caberol(0.5 mg)
● Tab. Caberol(0.5 mg) 1 tab stat PO and weekly for 3 weeks(each Tuesday)
1 tab stat PO and weekly for 3 weeks(each Tuesday) ● Supp.Voltalin(50 mg)
● Tab. Cytomis( 200 mcg) 1 stick P/R SOS
2 tab PO stat
*one unit of whole blood was transfused.
Treatment on discharge( On 15/04/2021)
● Tab. Cefaclav ( 500 mg)
1+ 0+ 1 – 5 days
Tab. Flamyd ( 500 mg)
1+0+1 – 5 days
● Cap. Nexum ( 20 mg )
1+0+1 - 1weeks
● Tab. Ceevit ( 250 mg )
1+0+0 (1 Month )
● Tab. Xinc B
0+1+0 (1 month )
● Tab. Caberol(0.5 mg)
1 tab stat PO and weekly for 3 weeks(each Tuesday)
Advice on discharge
● Take medicine regularly.
● Take healthy food and adequate amount of water.
● Avoid sexual intercourse for 6 weeks.
● Come for follow up after 5 days .
Avoid conception for 1 and half months
Any questions.