Re: new case
From: Alexandra Blair (quelkun@cgocable.ca)
Thu May 25 05:02:37 2000
What about a Strep B sepsis ???
T. Blair md
>----- Original Message -----
From: "Betsy Hyde" <elishyde@connix.com>
To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@forum.obgyn.net>
Sent: Wednesday, May 24, 2000 10:21 PM
Subject: new case
> 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
>
