5/16/2022 G1P000 "29 y.o. year old female @ 16+5 weeks gestation who presents for continued OB care. Patient does not feel fetal movements as of yet. + FHT's noted today. Patient denies any cramping/pain, bleeding, or LOF. Patient was having lower abdominal cramping sensation a few weeks ago, but no longer. Patient had an US today that showed normal cervical length. Patient denies having any UTI sx at this time. Patient having no complaints today. Covid and flu done; Recommended booster"  RN MSN WHNP-BC  5/19/2022 3rd Pfizer (1st 12/14/20, 2nd 1/11/21)  6/6/2022 message from patient:  "I?ve noticed the last few days that the skin on my belly appears slightly mottled and there is delayed cap refill. Is this normal? I am growing quite a bit and I am on the paler side. " "Delayed cap refill on your belly? How delayed?" RN "Its about 4-5 seconds, I had my coworker (another RN as well) look at it and confirm the timing. Not sure if im being overly worried but i just  noticed it when I went to the bathroom at work and thought, hm, that's different. " Patient "Would you be able to send a picture of your belly for me to take a look at?" RN photos sent "Overall, this looks normal. This can happen from the quick growth during pregnancy, but nothing to be concerned with" RN  6/7/2022 Message to GI MD "My upper scope last fall looked good after reporting some difficulty with swallowing. This symptom has continued and now over the last month I have noticed that I am having some weird changes with my speech- difficult to explain fully but I feel like my tongue is not articulating the way it used to especially if I am having longer conversations and kind of like it flattens out and sticks to my teeth? Sounds goofy and again I am having a hard time explaining what I am feeling. At the time of my scope we had discussed possibly seeing a SLP for eval? I cannot remember but I feel like we decided against it since the scope was good. Is there something further you recommend for evaluation? I am also 20 weeks pregnant right now so I realize that may hinder some things. " "Congratulations on your pregnancy.  Please try Pepcid 20 mg 2 times daily.  You may buy these pills from over-the-counter.  Please try this for a couple of weeks and kindly contact me if your symptoms do not improve with this.  Thank you." MD  6/17/2022 prenatal visit: "Doing well. No complaints."  6/30/2022 ultrasound 7/1/2022  message :"Is there any concern regarding the last two ultrasounds not being able to visualize the heart? Also is there any concern regarding fetal growth?" patient  "No, it's just suboptimal still. No concerns.  As far as the growth, it's very early to determine if there is cause for concern or not.  I plan to order the follow-up growth ultrasound as recommended after the follow-up cardiac one is completed." DO  7/13/2022 video visit; "Bad tailbone and left hip pain.  Lots of anxiety related to new jobs both for her and for husband and now with home purchase.   History of back surgery; Recommend OB Epidural consultation; Last imaging 2013  Pelvic girdle pain; Start belly binder Referral to Lumen for anxiety" DO   7/20/2022:  "26w0d Called with ABSENT fetal movement all day Drank water, had dinner and still had no fetal movement Affirmed not just decreased but can't feel baby at all. No lof/vb/ctx. However did have SCB 1st trimester Advised to come to now" MD  "26w0d, who presents with absent fetal movement today, she reports there had been more fetal movement than usual the previous 2 days. Today she had been busy at work today and after eating dinner this evening, she laid down and did not feel baby move. Contractions: none. Vaginal bleeding: None. Leakage of fluid: denies."  "Her pregnancy has been complicated by: 1. Subchorionic hemorrhage - @ 7wks resolved 2. Asthma - albuterol inh 3. Covid in early pregnancy"  7/20 9:21 pm "I was called to confirm .   Pt called exchanged with absent fetal movement and unfortunately the midwife and hospitalist did US confirming absent FHTs.   With permission of patient, I also looked with US. Absent FHTs. No blood flow. Placenta observed w/o obvious abruption. No bleeding  No abdominal pain.   Appropriately grieving.   Reviewed induction options today or return at later date. She is reviewing her choices now." MD  7/20/2022: note from MD "Principal and Secondary Diagnosis 1.  29 y.o. G1P0100  2.  IUFD @ 26w 3.  Retained placenta  Principal and Secondary Procedures Induced vaginal delivery Suction D&C under US guidance Pertinent History & Physical See H&P. Hospital Course Patient was admitted. She underwent a vaginal delivery of IUFD @ 26w. Course complicated by maternal fever and retained placenta s/p D&C under US guidance. Concern for continued retained placenta, co-management for postop recommendations. She received IV antibiotics x 24 hrs. Please see delivery and op note for further details.   Postop the patient was voiding spontaneously, tolerating a regular diet, ambulating, and analgesia controlled with oral pain medications. Bleeding remained minimal. She remained afebrile. She was discharged home in a stable condition."  7/20 11pm "Patient transferred safely from OB triage to L&D for MIL for IUFD. She presented for evaluation after not feeling any fetal movement for the past day. BSUS was performed by both OBH, which confirmed no fetal cardiac activity. No obvious placental abruption was noted. She reports some mild cramping pains that have started recently but denies any LOF or bleeding. She is appropriately grieving with her husband and parents. We reviewed the process of induction as well as pain control options and laboratory evaluation. Her questions were answered."  Per record delivery/D and C of fetus with demise was on 7/21/22 - anesthetic epidural  9/14/2022 pt received D and C for retained products of conception for which I was involved with.