---

CASE № 34 - Complete Detailed Analysis

---

PRELIMINARY CALCULATIONS & CASE INTERPRETATION

• Multipara: first fetal movement (quickening) felt at 8 March 2012
• In multiparas, quickening occurs at ~18 weeks
• From 8 March to 3 August 2012 = approximately 21 weeks elapsed
• Therefore: gestational age on admission = ~18 + 21 = approximately 39 weeks (term pregnancy)

• Headache + blurred vision
• Contractions every 2-3 min lasting 30 sec (active labor)
• Green (meconium-stained) amniotic fluid
• No fetal heartbeat detectable (intrauterine fetal death / IUFD)
• Complete cervical dilatation (10 cm)
• Head pressed against entrance to pelvis (head at brim / not engaged)
• BP 160/100 mmHg
• History: edema, proteinuria 0.6 g/L, BP 150/100 mmHg two weeks prior

---

QUESTION 1: DIAGNOSIS

Pregnancy 39 weeks. Second (multipara) delivery. Active first stage of labor progressing to fully dilated cervix. Intrauterine fetal death (IUFD). Meconium-stained amniotic fluid. Severe Preeclampsia (BP 160/100, proteinuria, headache, visual disturbances). Relative cephalopelvic disproportion (head pressing at brim, not engaged despite full dilatation).

• SBP ≥160 or DBP ≥110 (present: 160/100)
• Headache (present)
• Visual disturbances - blurred vision (present)
• Proteinuria ≥0.3 g/24h (present: 0.6 g/L)

---

QUESTION 2: PLAN FOR MANAGEMENT OF LABOR AND SEQUENCE OF EVENTS TO HELP THE MOTHER

Immediate Priorities (Simultaneous)

• Hydralazine 5-10 mg IV bolus, repeat every 20 min (first-line per Williams Obstetrics)
• OR Labetalol 20 mg IV, doubling doses every 10 min (max 300 mg total) - Rosen's Emergency Medicine confirms: "labetalol 20 mg IV bolus, repeat q10 min PRN up to 300 mg/total dose"
• OR Nifedipine 10 mg orally (calcium channel blocker, rapid acting)
• Target: DBP 90-100 mmHg (do NOT drop too rapidly - risks uteroplacental insufficiency)
• Avoid: ACE inhibitors, ARBs (contraindicated in pregnancy)

• Loading dose: 4-6 g IV over 15-20 minutes
• Maintenance: 2 g/hour IV infusion (Rosen's Emergency Medicine / Williams Obstetrics - Parkland protocol)
• Monitor for toxicity: loss of deep tendon reflexes (at ~10 mg/dL), respiratory depression (at ~12 mg/dL), respiratory rate every 1 hour
• Antidote for MgSO4 toxicity: Calcium gluconate 1 g IV slowly
• Maintain urine output >25 mL/hour
• MgSO4 is continued for 24 hours postpartum

• Bedside ultrasound: absent fetal cardiac activity
• No fetal heart sounds on auscultation / Doppler
• Document by senior obstetrician
• Inform the mother and family with empathy

• Two large-bore IV lines
• CBC (check for thrombocytopenia - HELLP syndrome), platelet count
• LFTs (HELLP - elevated liver enzymes)
• Urea, creatinine (renal involvement)
• Coagulation studies: PT, APTT, fibrinogen (risk of DIC with IUFD)
• Urine output: urinary catheter - maintain >25 mL/hr
• Limit IV fluids (avoid pulmonary edema in preeclampsia)

• Cervix FULLY dilated (10 cm)
• Head is at brim (not engaged) - this is an anomaly: full dilatation with unengaged head is concerning for cephalopelvic disproportion (CPD)
• Active contractions: 2-3 min, 30 sec each (adequate by frequency but short duration)
• IUFD confirmed
• Meconium-stained liquor (fetus already dead, so this is evidence of prior distress before death)

• If CPD is ruled out (adequate pelvis, asynclitism, position correction possible): Continue augmenting labor carefully - oxytocin augmentation if contractions inadequate, with expectation of vaginal delivery
• If CPD confirmed or labor is obstructed: Cesarean section is the safest option for the mother
• Forceps: Head must be engaged and at station +2 or lower - currently NOT applicable because head is at brim (not engaged)

• Continuous BP monitoring every 15-30 minutes
• Urine output hourly
• Reflexes, consciousness level, respiratory rate
• Repeat labs in 6 hours or sooner if condition changes

• Aim for vaginal delivery if no CPD
• Post-delivery: Active management of third stage (oxytocin 10 IU IM or slow IV to prevent PPH)
• PPH is a major risk: preeclampsia associated with coagulopathy, and MgSO4 causes uterine atony

• Continue MgSO4 for 24-48 hours postpartum
• Monitor for eclampsia (can occur postpartum)
• Emotional/psychological support for fetal loss
• Thromboprophylaxis (high risk - hypertensive disorder, post-delivery)
• Antihypertensives continue postpartum (methyldopa, labetalol, nifedipine - avoid diuretics)
• Neonatal team: not needed (IUFD), but pathology examination of fetus/placenta should be arranged
• Grief counseling and birth certificate/death documentation as per local law

---

QUESTION 3: WHAT ARE THE MISTAKES?

Mistake 1: Failure to Hospitalize When Offered

• The patient refused hospitalization when BP was 150/100 with edema and proteinuria two weeks ago
• The obstetrician/midwife failed their duty of care by allowing her to refuse without:
  • Adequate counseling about risks (imminent eclampsia, IUFD, stroke)
  • Documentation
  • Calling social services or arranging a follow-up visit within 24-48 hours
• Reference: Williams Obstetrics: Any BP ≥140/90 with proteinuria in pregnancy warrants hospitalization for assessment

Mistake 2: Using Hydrochlorothiazide (Thiazide Diuretic) to Treat Preeclampsia at Home

• Hydrochlorothiazide is contraindicated in preeclampsia
• Preeclampsia already has reduced intravascular volume (plasma volume is contracted)
• Diuretics further reduce circulating volume, worsening uteroplacental perfusion and precipitating fetal compromise
• Rosen's Emergency Medicine explicitly states: "Avoid diuretics and hyperosmotic agents" in preeclampsia management
• Correct drugs for home/outpatient management of non-severe hypertension in pregnancy: methyldopa, labetalol, or nifedipine (oral)
• Thiazides are also associated with neonatal thrombocytopenia, electrolyte imbalances, and neonatal jaundice

Mistake 3: Failure to Assess/Monitor Fetal Well-Being

• No mention of:
  • Fetal movement counts
  • Cardiotocography (CTG/NST)
  • Biophysical profile
  • Doppler velocimetry of umbilical artery
• In a hypertensive pregnancy being managed at home, daily fetal movement counting (kick chart) and at least weekly CTG are mandatory
• Failure to monitor led to undetected fetal distress and ultimately IUFD

Mistake 4: Delay in Coming to Hospital / Lack of Follow-Up

• Two full weeks passed between the first hypertensive crisis and hospital admission
• No recorded follow-up visits, no BP checks, no repeat urine tests
• In preeclampsia, BP and proteinuria must be monitored at least twice weekly in a borderline case, and daily if severe features develop
• The patient developed headache and blurred vision (severe preeclampsia features) before seeking care - these symptoms should have been communicated to the patient as emergency warning signs

Mistake 5: Not Recognizing Severe Preeclampsia Early Enough

• BP of 150/100 with proteinuria and edema = moderate preeclampsia at minimum, warranting hospitalization and IV MgSO4 prophylaxis
• The progression to headache + visual symptoms = severe preeclampsia / premonitory eclampsia
• These were predictable and preventable sequelae of inadequate management

Summary Table of Mistakes

---

QUESTION 4: POSSIBLE INDICATIONS FOR CESAREAN SECTION (CS) FROM THIS CASE

From This Specific Case:

1. Obstructed Labor / Cephalopelvic Disproportion (CPD)
   • Head at brim (not engaged) despite fully dilated cervix = most likely CPD
   • This is the primary indication for CS in this case
   • Williams Obstetrics: CS is indicated when the head fails to engage and descend despite full dilatation
2. Severe Preeclampsia with Impending Eclampsia
   • If the hypertensive emergency cannot be controlled and delivery must be expedited
   • CS allows controlled, rapid delivery
   • However, vaginal delivery is preferred if feasible (less blood loss, no surgical risk of wound breakdown in preeclamptic patient on MgSO4)
3. Imminent Eclampsia
   • Seizures or deteriorating neurological status may necessitate emergency CS if vaginal delivery is not imminent
4. Maternal Deterioration / HELLP Syndrome
   • If labs confirm HELLP (hemolysis, elevated liver enzymes, low platelets), delivery must be accomplished rapidly - CS if vaginal delivery cannot be achieved quickly
5. Failed Labor Despite Oxytocin Augmentation
   • Contractions are only 30 seconds duration (suboptimal - should be 45-60 seconds for effective labor)
   • If augmentation fails to produce descent

General Indications for CS (for exam completeness, per Williams Obstetrics & DC Dutta):

• Cephalopelvic disproportion
• Malpresentation: breech (complete/footling), transverse lie, brow presentation
• Cord prolapse
• Fetal distress not responsive to resuscitation
• Placenta previa
• Abruptio placentae with live fetus and fetal distress

• Previous CS (relative, depending on type)
• Failed induction of labor
• Severe preeclampsia/eclampsia not responding to treatment
• Obstructed labor
• Uterine rupture (threatened/actual)
• Active genital herpes
• Cervical cancer

---

QUESTION 5: CONDITIONS AND CONTRAINDICATIONS FOR FORCEPS

Prerequisites / Conditions for Forceps Delivery (DC Dutta & Williams Obstetrics)

• Outlet forceps: Scalp visible at introitus, skull on pelvic floor, sagittal suture in AP diameter or slight oblique, rotation ≤45°
• Low forceps: Leading point at station +2 cm or lower, not on pelvic floor
• Mid-forceps: Station above +2 cm but head engaged (use with extreme caution)

Indications for Forceps Delivery

1. Fetal distress in second stage of labor
2. Cord prolapse in second stage (with head on perineum)
3. After-coming head in breech delivery

1. Maternal exhaustion / inability to push (neuromuscular disease, exhaustion)
2. Prolonged second stage of labor
3. Cardiovascular or respiratory disease (to avoid Valsalva/bearing down straining)
4. Cerebrovascular disease (aneurysm, AVMs)
5. Elective low-pelvic delivery

Contraindications for Forceps Delivery

1. Head not engaged (station above 0) - cannot safely apply blades
2. CPD (cephalopelvic disproportion) - forceps will cause trauma, cannot overcome bony obstruction
3. Incompletely dilated cervix (any rim remaining)
4. Intact membranes (must rupture first)
5. Unknown position of fetal head
6. Anencephalic or hydrocephalic fetus - modified approach, not standard forceps
7. Living fetus with face presentation (mentoposterior position - CS required)
8. Coagulation disorder in fetus (e.g., hemophilia) - vacuum/forceps may cause intracranial hemorrhage

1. Prematurity (<34 weeks) - risk of intracranial hemorrhage
2. Suspected fetal macrosomia with shoulder dystocia risk
3. Operator inexperience with mid-forceps
4. Fetal thrombocytopenia

Why Forceps Are Inappropriate in This Case:

• Risk catastrophic uterine rupture
• Cause severe maternal soft-tissue trauma
• Be physically impossible to deliver the baby
• Constitute gross negligence

---

ADDITIONAL TRICKY AND DETAILED Q&A

---

Q: Why is the head at the brim despite full cervical dilatation?

1. Cephalopelvic disproportion (CPD) - most likely
2. Asynclitism (lateral deflection of head)
3. Deflexion attitude of head
4. Constriction ring (rare)
5. Placenta previa - if placenta is low, head cannot descend (always rule out)

---

Q: What is the significance of meconium-stained amniotic fluid in this case?

---

Q: What drugs are safe for hypertension in pregnancy?

---

Q: What are the signs of MgSO4 toxicity and how is it managed?

---

Q: What is HELLP syndrome and should it be suspected here?

• Hemolysis: abnormal peripheral smear, LDH >600 IU/L, bilirubin >1.2 mg/dL
• Elevated liver enzymes: AST >70 IU/L
• Low platelets: <100,000/mm³

• Abruption (10-20%)
• DIC (20%)
• Acute renal failure (8%)
• Hepatic rupture (rare but fatal)
• Maternal death

---

Q: What is the Parkland protocol for eclampsia?

1. MgSO4 4 g IV loading dose over 15-20 minutes
2. MgSO4 10 g IM (5 g each buttock with 1 mL of 2% lidocaine) - OR 2 g/hr IV maintenance
3. Hydralazine for DBP >110 mmHg
4. Fluid restriction (limit IV fluids)
5. Delivery after stabilization

---

Q: What is the risk of eclampsia developing in this patient?

1. Severe headache ✓
2. Visual disturbances (blurred vision, scotomata, photophobia) ✓
3. Epigastric/right upper quadrant pain (not mentioned but should be asked)
4. BP ≥160/110 ✓
5. Hyperreflexia (should be checked)

---

Q: What is the definition of preeclampsia vs severe preeclampsia?

• SBP ≥160 or DBP ≥110 on two occasions at least 4 hours apart
• Thrombocytopenia <100,000
• Impaired liver function (AST/ALT >2x normal)
• Progressive renal insufficiency (creatinine >1.1 mg/dL)
• Pulmonary edema
• New-onset headache not responsive to analgesia
• Visual disturbances

---

Q: What is the Mendelson syndrome and how is it relevant here?

• She is at risk due to full stomach (pregnancy + emergency)
• Prevention: Sodium citrate (0.3 M, 30 mL) orally before GA to neutralize gastric acid; metoclopramide 10 mg IV to promote gastric emptying; ranitidine 150 mg orally or 50 mg IV
• Rapid sequence induction (RSI) with cricoid pressure (Sellick's maneuver)

---

Q: What is the role of corticosteroids in this case?

• Betamethasone/dexamethasone for fetal lung maturity: NOT applicable - fetus is dead
• Dexamethasone for HELLP syndrome: may be used for platelet recovery to facilitate safe delivery, but remains controversial
• Betamethasone may cause transient worsening of blood glucose and blood pressure

---

Q: What investigations are essential in this case?

1. CBC with platelets
2. Serum urea, creatinine, uric acid
3. LFTs (AST, ALT, bilirubin)
4. Coagulation profile (PT, APTT, fibrinogen, D-dimers) - IUFD can cause DIC
5. Blood group and crossmatch (2 units packed cells)
6. Urinalysis / 24-hour urine protein
7. Bedside ultrasound (confirm IUFD, assess presentation)

---

Q: What is the significance of proteinuria of 0.6 g/L in this case?

• Dipstick: 2+ or greater (300 mg/L)
• Spot urine protein:creatinine ratio: ≥0.3
• 24-hour urine: ≥300 mg/day

---

Q: Why is this a "multipara" and what are the specific risks?

1. Uterine atony after delivery (myometrium less reactive after multiple pregnancies) - leading cause of PPH
2. Placenta previa (higher incidence with previous deliveries/scarring)
3. Placental abruption (previous damage to uterine vasculature)
4. Uterine rupture (especially with oxytocin augmentation in already stressed uterus)
5. Malpresentation more common (pendulous abdomen, lax abdominal muscles)

---

Q: What PPH prophylaxis is needed after delivery?

• Preeclampsia: coagulopathy risk
• MgSO4: uterine atony (antagonizes calcium in myometrium)
• Multiparity: uterine atony
• IUFD: DIC risk

1. Oxytocin 10 IU IM (or slow IV - NOT fast IV bolus which causes hypotension) immediately after delivery of baby
2. Controlled cord traction (Brandt-Andrews maneuver)
3. Uterine massage after placental delivery
4. Examine placenta for completeness
5. Have blood products available

---

Q: Can ergometrine (oxytocin/ergometrine combination - Syntometrine) be used?

---

Q: What is the Bishop score and is it relevant here?

---

Q: What is the significance of contractions every 2-3 minutes for 30 seconds?

• Frequency: 3-5 per 10 minutes
• Duration: 45-60 seconds (adequate)
• Intensity: 40-60 mmHg (measured by IUPC)

---

Q: What is the difference between "head at brim" and "head engaged"?

• At brim (pelvic inlet): The widest diameter of the head is at or above the pelvic inlet. The head has not entered the true pelvis. Clinically: 5/5 palpable abdominally.
• Engaged: The widest diameter (biparietal diameter, ~9.5 cm) has passed through the pelvic inlet. Clinically: 2/5 or less palpable abdominally; vaginally the presenting part is at 0 station (level of ischial spines).

---

Q: What is the Ritgen maneuver and when is it used?

1. Extend the head through the vaginal opening
2. Control the delivery speed to prevent perineal lacerations
3. Method: apply upward pressure on fetal chin through perineum with one hand, while the other hand presses down on the fetal occiput

---

Q: What analgesia is appropriate for labor in this case?

• Epidural analgesia: Preferred if not coagulopathic. Provides excellent pain relief, allows assisted vaginal delivery, and can be extended for CS if needed. Check platelet count first (platelets >80,000 required for epidural, >100,000 preferred).
• Spinal block: Single shot for CS.
• Avoid: General anesthesia as first choice (aspiration risk, airway difficulty in pregnant women).
• Opioids: Morphine/pethidine can be used but cause neonatal respiratory depression (irrelevant here as fetus is dead).
• Entonox (nitrous oxide/oxygen): Useful inhalational analgesia for active labor.

---

Q: What are the criteria for diagnosing IUFD?

1. Absent fetal heart sounds on auscultation (Doppler/Pinard stethoscope)
2. Absent fetal cardiac activity on ultrasound (M-mode and real-time B-mode)
3. Absent fetal movements (the patient had not reported movement - important history gap in this case)

---

Q: What psychological support is needed?

• Immediate: empathetic, private communication to the mother
• Named midwife/nurse for continuity of care
• Bereavement counselor / psychologist
• Allow mother to hold the baby after delivery if she wishes
• Hand/foot prints, photographs (offered, not forced)
• Certificate of stillbirth (≥24 weeks gestation in most countries)
• Perinatal autopsy offered (with consent) to determine cause of IUFD
• Follow-up appointment at 6-8 weeks to discuss results and future pregnancies

---

Q: What causes IUFD in this context?

1. Placental insufficiency secondary to severe preeclampsia - vasospasm and reduced uteroplacental blood flow leading to chronic hypoxia
2. Acute event: placental abruption (partial or complete - not described but possible with severe hypertension)
3. Drug effect: hydrochlorothiazide causing volume depletion and worsening uteroplacental insufficiency
4. Cord accident: unlikely but possible

---

Q: What is the role of misoprostol in this case?

• Cervical ripening and induction of labor in IUFD
• Doses: 25-50 mcg vaginally every 4-6 hours, OR 200-400 mcg sublingual/vaginal for IUFD induction
• Caution: Higher risk of uterine hyperstimulation, uterine rupture in multiparas (use lower doses)
• Since this patient is already in active labor with a fully dilated cervix, misoprostol is NOT needed now

---

Exam Summary Card

---

• Williams Obstetrics, 25th Edition (Cunningham, Leveno, Bloom) - Preeclampsia, Eclampsia, Forceps Delivery
• DC Dutta's Textbook of Obstetrics, 9th Edition - Hypertensive disorders of pregnancy, operative delivery
• Creasy & Resnik's Maternal-Fetal Medicine, 8th Edition - Obstetric Forceps Delivery (pp. 964-966); Meconium-Stained Amniotic Fluid (pp. 1789-1790); ACOG 1988/1991 forceps classification
• Rosen's Emergency Medicine, 9th Edition - Management of Eclampsia and Severe Preeclampsia (Parkland Protocol, Box 173.4)
• Pfenninger and Fowler's Procedures for Primary Care, 3rd Edition - Forceps DeliveryThe full answer is above. Here is a brief orientation to help you navigate it:

---

How This Answer is Organized

---

Q1 - Diagnosis

---

Q2 - Plan for Management of Labor

---

Q3 - Mistakes (5 identified)

---

Q4 - CS Indications from the Case

---

Q5 - Forceps: Conditions and Contraindications

---

Additional Tricky Q&A Covers:

• MgSO4 toxicity levels, monitoring, antidote
• Safe vs. contraindicated antihypertensives in pregnancy
• HELLP syndrome criteria and implications
• Why contractions of 30 seconds are suboptimal
• PPH prevention (oxytocin yes, ergometrine NO in hypertension)
• DIC risk in IUFD and coagulation investigations
• Epidural analgesia platelet thresholds
• Misoprostol role in IUFD
• Psychological care and bereavement support
• Causes of IUFD in this context
• Bishop score interpretation