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new caseFrom: Betsy Hyde (elishyde@connix.com)Wed May 24 21:20:32 2000
35 yo G5P2 @ 34+6 weeks presents to the office c/o decreased FM x 1 day. Comes to office, nurses think they hear a "flurry" of activity when placing her on the external fetal monitor, but can't get an FH. Ultrasound confirms (-) FH and no AF. No history of leaking fluid pv. No pregnancy complications (this time). OB hx significant for sab first trimester, sab 4-5 months, induction for severe PIH @32 weeks, full term NSVD. Admitted yesterday afternoon for misoprostol induction of IUFD. Gets 25mcg miso q4hX2 . Has some painful contractions. At 2am develops asymptomatic tachycardia of 115. At 5am (at time of miso dose) cervix noted by be 4/80/-1, rare UCs, miso is held and she is sent to labor floor. Heart rate now about 130-140. Put on cardiac monitor and pulse oximeter. 7:30 am attempted AROM, no fluid, no membranes felt. Rare UCs. Pitocin started, but contractions seen mild and relatively painless. approx 10:30 am maternal heart rate now >180, has brief period of SOB w/ O2 sats that were briefly in the 80s but which quickly responded to LLP and O2. Pt is somewhat SOB. WBCs which had been 9K on admission are now 27K, 98 neuts, 2 lymphs. Platelets, LFTs and clotting studies are wnl. Temp is 96. Uterus is very tender. 11:30 am nsvd stillborn male, 4 lbs. Head delivers w/o problem, but I cannot complete delivery. Hmmmm. check for shoulders and find that cervix has clamped down around neck and shoulders of fetus, just inside the introitus. I am unable to get inside the tightly clamped cervix to get an arm or axilla. Have never seen this before! (have seen breeches w/ entrapped heads, but not with the cervix at the level of the introitus). After 5-10 minutes we stop the morphine drip, stop the pit and the cervix gradually relaxes enough so that I can get 2 fingers in posteriorly and deliver the posterior arm. Following delivery she persists in sinus tach to 180s (now 12 hours of tachycardia). Not only the uterus but the entire abdomen is tender w/ rebound, esp RUQ, epigastric area. Still somewhat SOB. Hct has dropped from 37 on admission to 32. Have an amazing number of consults and tests: cardiology consult neg carotid artery massage, valsava, adenosine iv 12 lead EKG sinus tach, otherwise neg, no evidence ischemia portable CXR neg flat plate/upright neg, specifically no free air V/Q scan low probability CT scan intraperitoneal fluid esp around liver, spleen and in pelvis hct now 26 w/ minimal vag bleeding coags still neg thrombophilia panel pending (secondary to SAB 4-5 months, severe early PIH, IUFD 35 wks) General surgery now involved, but no trip to the OR yet. If crit drops any more she may get ELAP. Any thoughts? It is puzzling to all of us. PE, AFE, uterine rupture are all near the top of my list.
-- Betsy Hyde CNM Branford, CT
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