Interesting OB case

[Planktonmd]

This happened a while ago but I think the forum needs it now:

I got called at 3 am by a terrified OB nurse telling me there is a parturient coding in OB.
I take call from home, so I got in the car and flew to the hospital, 7 minutes later I was in the OR, and here is the Data:
37 Y/O, G1 P0, previously healthy,obese, black woman, term pregnant, was in active labor, suddenly became hypotensive and lost consciousness with simultaneous fetal deceleration, now on OR table, unconscious, ER physician ventilating with a mask
BP: 50/25 , Monitor shows SR at 120/ min, SPO2 not getting a signal.
I could feel faint carotid pulse.
OB ready to cut.
She has a patent #18 IV and did not have an Epidural.
Lets talk Intraop management and take it from there.

---

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[rmh149]

OK, in this case I can only go with what I see. I would assume that she is bleeding from somewhere given her hypotension with NSR 120, Spo2 with no signal because there is no perfusion to her finger. Carotid pulse faint...but there is something.

First thing is first...get her intubated and ready to cut. In this situation I would treat her in the same fashion as a trauma patient given that she is unconscious and bleeding from who knows where.

RSI with Etomidate 14-16mg (assuming it was right there ready to go), followed by succynylcholine 140mg….as soon as I can visualize the vocal folds I would tell the surgeon to cut.

After intubation, sevoflurane at maybe .5. Depending on the blood pressure (I assume it is still going to be next to nothing). Titrate according to response….

Vasopressors as needed, ephedrine/phenylepherine, maintain SBP around 85 (if possible)…nothing higher till source of bleeding is stopped.

Secure second 18g IV and proceed with fluid volume resuscitation….call for 4Units of type PRBC STAT and level one infuser.

How long does it take for the surgeon to get the baby out?

How does she respond after induction and intubation?

 

[jetproppilot]

This happened a while ago but I think the forum needs it now:

I got called at 3 am by a terrified OB nurse telling me there is a parturient coding in OB.
I take call from home, so I got in the car and flew to the hospital, 7 minutes later I was in the OR, and here is the Data:
37 Y/O, G1 P0, previously healthy,obese, black woman, term pregnant, was in active labor, suddenly became hypotensive and lost consciousness with simultaneous fetal deceleration, now on OR table, unconscious, ER physician ventilating with a mask
BP: 50/25 , Monitor shows SR at 120/ min, SPO2 not getting a signal.
I could feel faint carotid pulse.
OB ready to cut.
She has a patent #18 IV and did not have an Epidural.
Lets talk Intraop management and take it from there.

WOW.

Awesome case. Thanks for sharing.

Here's my response:




HAHAHHAHAHAHAHAHAHAHAHAHAHA

Nah, thats what an internal medicine dude would do.

She's either bleeding or has thrown an embolus, or she has some weird undiagnosed cardiomyopathy.

Tell the ER dude thanks for his help.

See if theres anyone that can come help you like a CRNA or partner.

Tell the OB's you'll give them the signal in about thirty seconds.

Step up to the mike with micatin and put the Miller 2 in her mouth and intubate her.

If you get a fight, remove the blade and give about 8mg etomidate followed by a stikka sux.

Think about whether or not to buy more WFMI for thirty seconds.

Intubate her, simultaneously telling the OBs to cut as soon as the tube's cuff breaches the cords.

Cycle the BP cuff.

No BP?

Start CPR and ACLS.

BP but still low? Whats the heart rate? Pick whatever agent you think is appropriate...ephedrine, where you'd push a whole stick, phenylephrine, or epi.

Concentrate on the BP with drugs and fluids. Start another IV. When you get a chance, make sure the lady is typed and crossed.

Irf she is not, and you and the OB deduce its a bleeding problem, send for O negative blood pronto.

If its a medical non-bleeding problem, throw in a central line and put your magical inotropes/vasopressors directly into the central circulation for increased efficacy.

If you're really bored, start an A line when everything kinda settles down, which will provide an easy way of drawing the plethora of labs you'll need.

 

[pgg]

LUD. Minus the aortocaval compression, her BP goes back to 120/80. The baby is OK. After delivery, mom goes to ICU to recover from the formerly-in-the-stomach cheeseburger Mr. ER just propelled into her lungs.

Or, if the LUD cureall doesn't work, I'd start with volume resuscitation, stick a tube in her (if she's not really already unconscious, I'd prefer etomidate over ketamine because she sounds very volume down), tell the OBs to cut, then finish resuscitating mom ... better IV access, fluid warmers, blood if needed.

Or maybe she threw a big clot.

 

[jetproppilot]

LUD. Minus the aortocaval compression, her BP goes back to 120/80. The baby is OK. After delivery, mom goes to ICU to recover from the formerly-in-the-stomach cheeseburger Mr. ER just propelled into her lungs.

Or, if the LUD cureall doesn't work, I'd start with volume resuscitation, stick a tube in her (if she's not really already unconscious, I'd prefer etomidate over ketamine because she sounds very volume down), tell the OBs to cut, then finish resuscitating mom ... better IV access, fluid warmers, blood if needed.

Or maybe she threw a big clot.

LUD aint gonna cure this dudette.

Aortocaval compression makes 'em hypotensive and giddy.

Not unconscious and dead.

 

[rmh149]

What does LUD stand for?

 

[zippy2u]

LUD is the nickname of that little devil that sits upon my shoulder sometimes when I'm at work..... What do you call yours? Regards, ----Zip

 

[zippy2u]

The way I see it, this is a classic case of massive pulmonary embolism until proven otherwise. By the way "LUD" stands for left uterine displacement. Regards, ---Zippy

 

[rmh149]

LUD, Left uterine displacement. LOL, I thought you were using some special forum lingo for....she's **cked.

Honestly, If I walked into the OR and the ER doc was mask ventilating her, the last thing I would have thought of was placing a bag of LR under her right side. Doesnt mean I shouldnt....I just know that I wouldnt do that right off.

I can see it now...in court, the attorney asking me..."did you sir perform left uterine displacement....maybe thats why she died". Then I can imagine me jumping over the witness stand and choking him.

 

[indo]

LUD. Minus the aortocaval compression, her BP goes back to 120/80. The baby is OK. After delivery, mom goes to ICU to recover from the formerly-in-the-stomach cheeseburger Mr. ER just propelled into her lungs.

Or, if the LUD cureall doesn't work, I'd start with volume resuscitation, stick a tube in her (if she's not really already unconscious, I'd prefer etomidate over ketamine because she sounds very volume down), tell the OBs to cut, then finish resuscitating mom ... better IV access, fluid warmers, blood if needed.

Or maybe she threw a big clot.

Isn't an LUD something that could've been put into play right away by the ER guy?

 

[Noyac]

Massive PE is my bet but I guess a uterine rupture is possible as well. But she's a P1G0 so unlikely.

I'd most likely give just sux and tube her assuming she really is unresponsive. I'd do this for a few reasons. First, it saves time by not having to draw up others (ie etomidate) and giving them, all while getting to the task at hand, delivery. Secondly, It gives me a good view immediately without dropping pressure and possibly raising her pressure if she has any response. Next. i'd slap a cordis/introducer in her neck and pump it full of fluids. No ephedrine for me, waste of time.

 

[rmh149]

Massive PE is my bet but I guess a uterine rupture is possible as well. But she's a P1G0 so unlikely.

I'd most likely give just sux and tube her assuming she really is unresponsive. I'd do this for a few reasons. First, it saves time by not having to draw up others (ie etomidate) and giving them, all while getting to the task at hand, delivery. Secondly, It gives me a good view immediately without dropping pressure and possibly raising her pressure if she has any response. Next. i'd slap a cordis/introducer in her neck and pump it full of fluids. No ephedrine for me, waste of time.

I still would stick to placing another 18g in the AC first....the amount of time it would take to place a cortis could be too long....being an obese parturient....not the easiest to place a cortis. After seeing some progress I might think about placing a CVL and Arterial line....depending on how she was responding, the progress of the surgery, and the cause for instability....PE or Rupture.

 

[VolatileAgent]

Massive PE is my bet but I guess a uterine rupture is possible as well.

abruptio placentae until proven otherwise. occult ones can happen without blood pouring out of the vag. blood stat, GA, deliver, then uterotonics... all while hoping she (and the baby) don't die.

how'd it turn out?

 

[Planktonmd]

here is part 2:

I gave 50 mg of ephedrine and put the laryngoscope in and just tubed her, she did not move.
told them to cut, put her on the vent and 0.3 sevo in 100% O2.
next BP was sys 40, I put a pressure bag on IV, took the epi stick and gave 100 mcg.
in a few seconds my SPO2 came back to life and was reading 100 %.
BP now 75/30, HR = 150.
Started a # 16 IV and started infusing type specific blood.
No free blood around uterus and uterus was intact, no free intra abdominal blood, no signs of abruption, baby was out in 4 minutes, required intubation but was ok later.
she started wiggling so she got some Roc.
I started a central line, and continued pouring fluids and blood.
After 3 units of blood and 2000 crysatloids her BP was 100/60 and HR 100.
Spo2 100 % all the time, so we decided to close and watch her in the ICU.
Although the oxygenation did not seem to be impaired we still thought this must be an embolus ( clot vs. amniotic).

Over the next few hours she required continous tranfusions, became coagulopathic, metabolic acidosis, and just couldn't maintain her H & H


Any thoughts?

 

[militarymd]

AFE...

just like the 4 cases that I've taken care of.

 

[jwk]

here is part 2:

I gave 50 mg of ephedrine and put the laryngoscope in and just tubed her, she did not move.
told them to cut, put her on the vent and 0.3 sevo in 100% O2.
next BP was sys 40, I put a pressure bag on IV, took the epi stick and gave 100 mcg.
in a few seconds my SPO2 came back to life and was reading 100 %.
BP now 75/30, HR = 150.
Started a # 16 IV and started infusing type specific blood.
No free blood around uterus and uterus was intact, no free intra abdominal blood, no signs of abruption, baby was out in 4 minutes, required intubation but was ok later.
she started wiggling so she got some Roc.
I started a central line, and continued pouring fluids and blood.
After 3 units of blood and 2000 crysatloids her BP was 100/60 and HR 100.
Spo2 100 % all the time, so we decided to close and watch her in the ICU.
Although the oxygenation did not seem to be impaired we still thought this must be an embolus ( clot vs. amniotic).

Over the next few hours she required continous tranfusions, became coagulopathic, metabolic acidosis, and just couldn't maintain her H & H


Any thoughts?

Dang - Mil beat me to it.

AFE was my first thought, only because we've seen it so many times. Not too many things are gonna cause this degree of hypotension - you certainly don't get "coded" for aortocaval compression because someone forgot to tilt the patient. Abruption, previa, AFE, are the biggies, but that "sudden" hypotension would be a big red flag for AFE. Even the rare total abruption takes a few minutes to develop hyptension, but with AFE, you'll see almost total collapse within a few seconds.

We'd have sent coags early and treated in the OR long before heading for the ICU - FFP, platelets, cryo, PRBC's.

 

[Planktonmd]

AFE...

just like the 4 cases that I've taken care of.

No, any other thoughts?

 

[rmh149]

Continue to treat acidosis with bicarb and vent settings.

Transfuse with FFP (1 unit for each 2 units of PRBC) and Platelets.

Acquire a thromboelastography (TEG) to help determine source/cause of coagulopathy and treat accordingly. Probably wouldnt give cryoprecipitate till I received the TEG result....not that its a bad idea, I just wouldnt.

VQ scan.

Does she require any pressors while in ICU? What are her VS's?

 

[jwk]

Continue to treat acidosis with bicarb and vent settings.

Transfuse with FFP (1 unit for each 2 units of PRBC) and Platelets.

Acquire a thromboelastography (TEG) to help determine source/cause of coagulopathy and treat accordingly. Probably wouldnt give cryoprecipitate till I received the TEG result....not that its a bad idea, I just wouldnt.

VQ scan.

Does she require any pressors while in ICU? What are her VS's?

A DIC panel is pretty quick and confirms the AFE diagnosis. Amniotic fluid is a potent complement activator, hence the DIC. Many hospitals don't have TEG. Your patient will be dead before you get a V/Q scan.

You have to make this diagnosis quickly and manage it aggresively. Maternal mortality is greater than 80% - 50% within the first hour.

 

[rmh149]

A DIC panel is pretty quick and confirms the AFE diagnosis. Amniotic fluid is a potent complement activator, hence the DIC. Many hospitals don't have TEG. Your patient will be dead before you get a V/Q scan.

You have to make this diagnosis quickly and manage it aggresively. Maternal mortality is greater than 80% - 50% within the first hour.

OK, but didnt he say she was in the ICU for a few hours...

DIC panel or TEG and continue to support with products.
Consider Heparin 100u/kg SQ, Antithrombin III, and maybe Amicar.

Our hospital does have TEG...but it does have its limitations. It takes an hour from the time it is drawn and they can only run one at a time. I have taken advantage of it many times and have been lucky enough to not have someone in line before me...esspecially When you have that parturient with a PLT level of 85 that wants an epidural or scheduled for a section. Its nice to have the TEG for piece of mind.

 

[Planktonmd]

Ok, she is in the unit, Ventilated, requiring 6 additional units of PRBC to keep Hemoglobin above 8.
DIC profile highly suggestive of DIC.We are correcting coagulation as good as we can.
She still looks like a bleeder but no blood in the abdomen earlier
anything you want to do?

 

[jwk]

Ok, she is in the unit, Ventilated, requiring 6 additional units of PRBC to keep Hemoglobin above 8.
DIC profile highly suggestive of DIC.We correcting Coagulation as good as we can.
She still looks like a bleeder but no blood in the abdomen earlier
anything you want to do?

If this is vaginal/uterine bleeding, the hyster needs to come out. It may simply be too much open area to wait for the clotting mechanisms to kick back in.

 

[rmh149]

Earlier...as in before she was coagulopathic? What about an ultrasound or CT if she is stable enough to help determine the source of the bleeding?

 

[Planktonmd]

We ended doing an abdominal CT with IV contrast and BINGO:
Huge retro-peritoneal hematoma with a ruptured renal artery aneurysm.

We took her to the OR and had to do a nephrectomy but she walked out of the hospital 1 week later and her baby did fine too.

These aneurysms are usually silent although many of them cause secondary HTN.
They could be associated with other aneurysms, especially cerebral and mesenteric.
They do rupture during pregnancy and it's good to keep them in mind.

 

[militarymd]

No, any other thoughts?

so what is it?

Not many things cause sudden severe hypotension and DIC WITHOUT a LOT of bleeding.

Infection?

toxic ingestions?

 

[Planktonmd]

so what is it?

Not many things cause sudden severe hypotension and DIC WITHOUT a LOT of bleeding.

Infection?

toxic ingestions?

See above

 

[militarymd]

See above

damn Zebras

 

[bubalus]

Interesting case. Not what I would have first thought.

 

[Arch Guillotti]

Just a couple of thoughts after reading this very informative thread. I wouldn't induce her with anything other than sux (if that). While I agree a cordis is extremely helpful, I would first place a #14 gauge or two IV first and use a pressure infuser then, depending on the response, put the central line in. Great case.

 

[jwk]

We ended doing an abdominal CT with IV contrast and BINGO:
Huge retro-peritoneal hematoma with a ruptured renal artery aneurysm.

We took her to the OR and had to do a nephrectomy but she walked out of the hospital 1 week later and her baby did fine too.

These aneurysms are usually silent although many of them cause secondary HTN.
They could be associated with other aneurysms, especially cerebral and mesenteric.
They do rupture during pregnancy and it's good to keep them in mind.

Wow - that is pretty bizarre. Was this on anyone's radar?

 

[rmh149]

Wow - that is pretty bizarre. Was this on anyone's radar?

I would have never guessed a ruptured renal artery...I just thought that she had to be bleeding somewhere, and a CT would be helpful. If it wasnt dripping out on the floor of the ICU, then it must be internal.

Plankton, did she ever have any abdominal wall distension?

 

[Planktonmd]

I would have never guessed a ruptured renal artery...I just thought that she had to be bleeding somewhere, and a CT would be helpful. If it wasnt dripping out on the floor of the ICU, then it must be internal.

Plankton, did she ever have any abdominal wall distension?

Slightly, not too impressive.

 

[Trisomy13]

Plankton, did she ever have any abdominal wall distension?

Wouldn't expect much with a retroperitoneal hematoma, would you? I got to this thread too late but I was thinking while reading it "retroperitoneal bleed" ... although I would not have guessed an RA aneurysm..

cool case. thanks Plankton!

 

[rmh149]

Wouldn't expect much with a retroperitoneal hematoma, would you? I got to this thread too late but I was thinking while reading it "retroperitoneal bleed" ... although I would not have guessed an RA aneurysm..

cool case. thanks Plankton!

Good point. Maybe some tenderness on the side of the bleed? Although, she probably was not conscious to assess.

Plankton, how much volume do you think she lost from the bleed? How many products did she require?

 

[dhb]

nice case!

 

[Planktonmd]

Good point. Maybe some tenderness on the side of the bleed? Although, she probably was not conscious to assess.

Plankton, how much volume do you think she lost from the bleed? How many products did she require?

The hematoma was more than 2000 cc with clots.
That was a massive tranfusion type of day, I gave tons of everything especially during the nephrectomy, she looked like a balloon next day but she is alive.

 

[Noyac]

....the amount of time it would take to place a cortis could be too long.....

Not in my experience. Yeah you can get an 18g in faster but not that much faster and then I would be well past you in fluid resucitation within 5 minutes. If you are not sure how hast you can get the cordis in then have someone else putting in the 18 g while they are standing around.

I was out of town during this thread and didn't get a chance to respond again. If I would have been able to I would have said "get a Ct of the abdomen cause she probably has a RA aneurysm". I saw it the whole time.

Allright, now that you know that I am full of ****. Great case. Glad she did fine after all that.

 

[rmh149]

=Noyac;5094790]Not in my experience. Yeah you can get an 18g in faster but not that much faster and then I would be well past you in fluid resucitation within 5 minutes. If you are not sure how hast you can get the cordis in then have someone else putting in the 18 g while they are standing around.

Good point. However, I would be worried of the time/difficulty it would take to place the cortis in an obese patient....assuming that she aslo had a fat neck and huge breasts as many OB patients do. I would probably see what I could do with a second large bore IV....A 16g maybe instead of an 18.

Plankton, did she ever get a CVL....if so, did you place it in the ICU or in the OR prior to the nephrectomy?

 

[Planktonmd]

=Noyac;5094790]Not in my experience. Yeah you can get an 18g in faster but not that much faster and then I would be well past you in fluid resucitation within 5 minutes. If you are not sure how hast you can get the cordis in then have someone else putting in the 18 g while they are standing around.

Good point. However, I would be worried of the time/difficulty it would take to place the cortis in an obese patient....assuming that she aslo had a fat neck and huge breasts as many OB patients do. I would probably see what I could do with a second large bore IV....A 16g maybe instead of an 18.

Plankton, did she ever get a CVL....if so, did you place it in the ICU or in the OR prior to the nephrectomy?

Why do you keep saying "Cortis" ????


I started a 2 lumen central line in the OR during the C section, just after I stbilized her pressure a little.
and started an A line in the unit.

 

[rmh149]

Why do you keep saying "Cortis" ????


I started a 2 lumen central line in the OR during the C section, just after I stbilized her pressure a little.
and started an A line in the unit.

Just to maintain consistency in the thought processes and ideas. I was responding to the suggestion of a placing a cordis/introducer.

Plankton, when in the OR during the C section, what kind of infusers did you have access to....pressure bags, level 1, RIS?

 

[Planktonmd]

Just to maintain consistency in the thought processes and ideas. I was responding to the suggestion of a placing a cordis/introducer.

Plankton, when in the OR during the C section, what kind of infusers did you have access to....pressure bags, level 1, RIS?

Oh ok,
so Cortis = Cordis
Got you.

 

[rmh149]

Oh ok,
so Cortis = Cordis
Got you.

Yup, sometimes I type faster than I think.

 

[Mapleson D]

Cordis = brand name of introducer?

 

[Planktonmd]

Cordis = brand name of introducer?

Yes

 

[VentdependenT]

Freakin awsome case plankton.

How'd you guys come upon finally deciding to do the CT of the abdomen. I could easily have seen how this could have been passed up for another day or so.

You guys scan the CHEST also? Or where the gasses not representative of a big old dead space?

Moving on to AFE...its a diagnosis of EXCLUSION no? Nothing to do but supportive care is what I remember. Including the DIC stuff.

 

[VentdependenT]

Thanks for mentioning ACLS before freaking throwing in A-lines/additional monitors/ whatever.

ALthough you don't need to tube the patient prior to ACLS in this case its necessary to free up your hands to do all the other stuff while people run around in circles finding the paddles/pen to write with/etc.

 

[Planktonmd]

Freakin awsome case plankton.

How'd you guys come upon finally deciding to do the CT of the abdomen. I could easily have seen how this could have been passed up for another day or so.

You guys scan the CHEST also? Or where the gasses not representative of a big old dead space?

Moving on to AFE...its a diagnosis of EXCLUSION no? Nothing to do but supportive care is what I remember. Including the DIC stuff.

We did the abdominal CT because she continued to require blood without signs of external bleeding and no significant hemolysis.

There was never an oxygenation problem or abnormal A/a gradient but if the abdominal CT was normal we would have done a chest CT just to R/O a PE.

You are right, if you are dealing with AFE your treatment is mainly supportive, and if they survive the first few hours they usually make it.

 

[urgewrx]

A DIC panel is pretty quick and confirms the AFE diagnosis.

interesting.

 

[Planktonmd]

interesting.