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Re: OB: My case list...From: Calvin J. Siegers, MD FACOG (csiegers@hayburn.com)Fri May 29 18:50:56 1998
At Thu, 28 May 1998, Geffrey H. Klein, MD wrote: > >Hi all.. > >Here I am just out of the OR and this is a case for my list. My trip to >Chicago will prove to be an intersting one.. > >28 y/o G3P1A1 at 39 5/7 wks admitted for decreased fetal movement and >contractions. Pt's history of prior LUT CS for failed induction 1987 2800g >infant. Pt had requested trial of labor and was counseled exensively. Pt >had also requested BTL. EFW on admission 3800g. She had been admitted >several times in the past 2 weeks with contractions, labile BPs with DBP in >the 100's and diffuse edema. 24 hr urine had 275mg 2 wks before. She had >gained 10 # in 2 wks. She was requesting augmentation and I started her on >pitocin 2miu/min increasing by 2 miu/min and maximum dosage was 10 miu/min. >SROM occurred and internal monitors were placed. She dilated to 3-4 cm >but, with an adequate mechanism for 4 1/2 hrs and did not dilate beyond 4 >cm or descend below the -2/3 station. The head was molded and she began >to have a sinusoidal pattern and fetal PVCs. Decision was made for repeat >cesarean and BTL. This was performed without difficulty. EBL 400cc. > >Immediately after the procedure was complete, she began to have heavy >vaginal bleeding secondary to uterine atony. She had not left the OR. >Attempted bimanual compression and administration of IM hemabate without >relief. She developed hypotension and tachycardia. Decision was made to >open incision. There was significant atony noted. Hysterectomy was >performed. Time from end of cesarean to initiation of hysterectomy was 17 >minutes. Immediate transfusion was begun. Bleeding was controlled and >her vital signs stablized. Just for peace of mind she was given 5cc of >indigo carmine and cystoscopy was performed. Prompt efflux of blue dye >from each ureteral orifice was noted. She received a total of 4U PRBCs. >preop hgb was 11. Before transfusion it was 6 and after 4 U PRBCs it was 9. >No biochemical or clinical DIC or ARDS was noted and pt was extubated after >surgery alert and conversive. > >I would like to thank some of my faculty mentors, especially Drs. Moise, >Carpenter, Saade, and Belfort for teaching me that the decision to perform >hysterectomy needs to a quick and decisive. That is what resulted in a >good final outcome. Now, I need to go take a sedative... :) > >-- >---------------------------------- >Geffrey H. Klein, MD >---------------------------------- >gklein@bcm.tmc.edu >---------------------------------- >http://members.aol.com/gklein01/geff.html >List-owner OB-GYN-L >co-moderator sci.med.obgyn >Advisory Board Chairman OBGYN.net >http://www.obgyn.net/medical.htm >OBGYN.net Journal Review Editor >http://www.obgyn.net/jr/jr.htm >Office: >2200 Nasa Rd #1 >Houston, Texas 77058 >Tel 713 741 2273 x2628 > Congratulations on the good outcome. Now can we be sure that the treatment was appropriate for the disease: why wasn't atony evident during the tubal? Was it really atony or was there a big wad of placenta still in utero? Path will tell. Cal
-- Calvin J. Siegers, MD FACOG...private practice, 20 yr veteran, Holland, MI
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