Re: new case
From: art fougner, md (evsono@pipeline.com)
Thu May 25 09:36:09 2000
fulminant strep sepsis is a good thought, but strep A would be a better
bet - a few yrs ago in a local tertiary hospital a neonatologist lost
first her baby and then her own life to this disease.
art
At Thu, 25 May 2000, Alexandra Blair wrote:
>
>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
>>
--
art fougner, md
A series of 1000 cases begins with but a single anecdote.
