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Re: new caseFrom: H.Fehmi Yazıcıoğlu (hfy@turk.net)Tue May 30 15:17:08 2000
At Wed, 24 May 2000, Betsy Hyde wrote: > >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 > Instead of vaginal delivery,(following the rule of least resistance) a big tear in the posterior uterine wall should normally result in an abdominal delivery.Did you perform a vaginal examination immediately after the delivery and if yes what were your findings? Were intraabdominal viscera visible by the vaginal route? I think an ultrasonographic examination of the abdomen coupled with US-guided tap of any intraperitoneal collections could solve this problem even before the onset of tachycardia.
-- H.Fehmi Yazıcıoğlu, Clinical Chief of Staff, Süleymaniye Maternity Hospital Istanbul,Turkey
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