OB Case

[Stank811]

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Come into call shift at 730am to get sign out from the staff who was covering the OB floor during our morning didactics. Told the pt is a 25yo F G1P0, 4cm, otherwise healthy with uncomplicated hx but had limited prenatal care (one visit in Aug) who received an uncomplicated epidural 2 hrs prior but they have been having difficulty getting her level higher to provide adequate pain relief for uterine contractions. After repeated epidural boluses with .25% Bup still unable to get adequate upper level so decision was made to replace epidural. Epidural was again easily placed one level higher without complication and with much improved pain relief. Several hours pass when RN calls and states pt has become febrile 101.2 and baby's FHR has been showing decreased variability and the mother was not progressing in her labor, currently 5cm. Decide to get a CBC (which is not a standard lab on admission) in case of impending C/S. CBC returns showing Plt of 4,000 which was confirmed by lab. Immediately went to access pt and pt is oozing from IV sites, urine has turned red in foley bag, blood is oozing from epidural site and up catheter out of tape onto pt's bed, on aspiration of epidural catheter blood noted. How would you proceed?

 

[imfrankie]

Apprise obstetrician, obtain DIC panel, FFP, Plates, PRBCs, BFI x 2, RSI GETA C/S, postop unit with neuro checks and scan for epidural hematoma.

 

[pgg]

Apprise obstetrician, obtain DIC panel, FFP, Plates, PRBCs, BFI x 2, RSI GETA C/S, postop unit with neuro checks and scan for epidural hematoma.

This and leave the epidural in (with a big 'do not use' label).


Has OB u/s'd her recently? Is she abrupting? It fits the picture.

 

[Stank811]

BMP normal except for an elevated Cr at 1.05 from .75. Repeat CBC Hgb 8.2, Plt 6,0000. US showed no evidence of abruption, baby remains stable. DIC panel with mildly elevated D-Dimer, Plt 5,000, and PT, PTT, Fibrinogen, all normal. Pt continues to ooze. DIC ruled out....what additional labs does anyone want?

 

[pgg]

Peripheral smear?

TTP causes hemolysis, thrombocytopenia, renal dysfunction, fever. You'd see schistos on a smear. PT & PTT are usually normal I think. Then steroids ... exchange transfusion.

 

[bcat85]

BMP normal except for an elevated Cr at 1.05 from .75. Repeat CBC Hgb 8.2, Plt 6,0000. US showed no evidence of abruption, baby remains stable. DIC panel with mildly elevated D-Dimer, Plt 5,000, and PT, PTT, Fibrinogen, all normal. Pt continues to ooze. DIC ruled out....what additional labs does anyone want?

I'd go for some LFT's and a smear (if its available). It does sound like TTP, but it could also be HELLP (though the fever doesn't really fit).

 

[deleted126335]

Fever. You didn't give a white count on the CBC. If elevated, encourage the OB to start big gun Abx.
Blood Pressure? LFTs? Don't know how useful an abdominal u/s looking at Liver and Spleen in a term pregnancy will be. But it should in theory be quickly available on an OB floor.

 

[Stank811]

Our differential became TTP, HUS, ITP, HELLP. Sent many of the labs you asked for but while the labs were pending the pt progressed to complete. How do you want to proceed with this pt's care? Do you want to continue using the epidural even with blood noted on aspiration? Do you transfuse plts? If it is ITP or TTP do we have to worry about the baby's plt's? What if the mom is unable to deliver vaginally do you recommend the OB use Kiwi suction, forceps, or C/S? If it is TTP do you drop in a mahurkar for plasmapheresis or is there another option? PGG mentioned steroids....we gave her 120 methylprednisolone IV.

 

[Stank811]

Pt was given amp and gent. Vitals outside of temp not abnormal. BP 130's/80's during labor.

 

[Planktonmd]

BMP normal except for an elevated Cr at 1.05 from .75. Repeat CBC Hgb 8.2, Plt 6,0000. US showed no evidence of abruption, baby remains stable. DIC panel with mildly elevated D-Dimer, Plt 5,000, and PT, PTT, Fibrinogen, all normal. Pt continues to ooze. DIC ruled out....what additional labs does anyone want?

If that was 60,000 then:
I really think that you have a crappy lab!!!

 

[Planktonmd]

Here is what I would do: NOTHING and would wait for an uneventful vaginal delivery.

 

[jwk]

I'm still trying to figure out why there was no admission CBC. We get one on EVERY patient that comes in in labor, and they don't get an epidural until we know the platelet count.

 

[Planktonmd]

I'm still trying to figure out why there was no admission CBC. We get one on EVERY patient that comes in in labor, and they don't get an epidural until we know the platelet count.

I disagree!
I don't think labs are necessary on EVERY parturient.
But that's my humble personal opinion!

 

[jwk]

I disagree!
I don't think labs are necessary on EVERY parturient.
But that's my humble personal opinion!

The OP's post is a great example of why it should be done routinely. (IMHO of course 😉 )

Our nurses don't even stick them twice - they draw a purple top tube during the IV stick, and if the patient is wanting an epidural, the labs will be back before they're pre-loaded with IV fluid.

 

[Stank811]

At our program we rotate at two sites for OB. At our main academic site every patient does receive a CBC on admission. This case occurred at a separate hospital were we just do an OB rotation and the practice at this particular hospital is to only obtain a lab if you have a level of suspicion for a certain pathology. I have been over this conversation a to many times and I understand both sides of the story and this case obviously supports yours JWK.

Plank that was a typo, was 6,000.

Our initial plan was just let her labor and deliver vaginally and do nothing, but of course that didn't work. Baby ends up being OP and OB is unable to turn baby. FHR monitor shows later. By this time the labs returned and showed schistocytes, haptoglobin was decreased, LDH elevated, retic count elevated, Cr 1.5, Hgb 8, Plt 4,000. Our diagnosis at this time was TTP and we did not give any plts b/c that would have potentially increased thrombotic activity. We decided to use the epidural but first gave a repeat test dose which was negative. Pt was given .5% Bup 10cc for the OB to attempt forceps delivery. OB unable to position forceps and baby continues to have significant lates. OB wants to perform a C/S....now what is your management plan?

 

[imfrankie]

Same as before

 

[Stank811]

Definitely not recommended to give Plts in someone with TTP. We gave steroids like previously mentioned. Since it would incredibly complicated to place a Mahurkar in a labor patient and start her on plasmapheresis(plasma exchange) we did the next best thing which was plasma infusion. Pt recieved three units of FFP prior to taking her to the OR. Two large bore IVs. We again used the epidural with an additional 15cc of 0.5% Bupivicaine. Pt C/S was perfromed and baby's APGARs were 3-5-7 and was taken to NICU intubated. Mom had 2600cc of blood loss and recieved an additional 6 uFFP and 4 pRBCs in the OR with additional transfusion post op. Pt was then admitted to ICU and Heme/Nephrology were consulted for patient. A Mahurkar was placed and plasma exchange was started. Pt Plts increased to 13K the next day and then 18k, 43k, 78k on the subsequent days. The epidural was removed on POD#4. Mom and Baby are doing well.

Pt mortality with out treatment is 90%

http://www.nejm.org/doi/full/10.1056/NEJM199108083250604

 

[sevoflurane]

Peripheral smear?

TTP causes hemolysis, thrombocytopenia, renal dysfunction, fever. You'd see schistos on a smear. PT & PTT are usually normal I think. Then steroids ... exchange transfusion.

Nice. Smart mil dude. Them folks in crakistan are gonna get some good anesthesia over there. 👍

This and leave the epidural in (with a big 'do not use' label).

It's been a while since I've had a real consumptive coagulopathy WITH an indwelling epidural catheter in place. So the thought is to leave it in because pulling it might encourage a hematoma and neurologic compromise. Correct?
So when do you pull it?
When she stops oozing or when the platelet count is above a certain threshold which would be after 3-4 days in this patient (>40K). I'm assuming once she stops oozing is a better method... so closer to 2 days. Splitting hairs here, but just curious with current recommendations as heme is a great agar plate in the spine.

My last TTP was disasterous. Cocaine induced TTP. Complete with vasospasm and huge MI, renal failure, stroke, etc, etc.

Good case.

 

[RT2MD]

Really liked this case, I actually knew enough about the various pathologies to play along a little (albeit a bit late), but still had quite a bit of new knowledge in there... especially with regard to anesthesia. Thanks for sharing!

 

[Dwindlin]

Nice case. Thank you.

 

[pgg]

Nice. Smart mil dude. Them folks in crakistan are gonna get some good anesthesia over there. 👍

Thanks ... hopefully won't be doing any OB there though. 😉

I'll post pics, if I'm allowed, which I probably won't be. 🙂

It's been a while since I've had a real consumptive coagulopathy WITH an indwelling epidural catheter in place. So the thought is to leave it in because pulling it might encourage a hematoma and neurologic compromise. Correct?
So when do you pull it?
When she stops oozing or when the platelet count is above a certain threshold which would be after 3-4 days in this patient (>40K). I'm assuming once she stops oozing is a better method... so closer to 2 days. Splitting hairs here, but just curious with current recommendations as heme is a great agar plate in the spine.

I'd leave it in until she wasn't clinically bleeding any more, and her labs were in line with ASRA's guidelines for placement/removal of an epidural catheter. Obviously religiously do and document frequent neuro checks after removal.

I don't think I would have used that catheter, after aspirating blood from it. I suppose I can't really articulate a great reason not to carefully use it after a test dose ... but I don't know what effect injecting local would have on a locally-brewing epidural hematoma, if one was there. We don't really need the epidural ... GA is fine for a section, and an unpleasant delivery with suboptimal pain control is better than an anesthetic complication.

I'm not concerned about a growth medium around the catheter. No reason to think she's got a local infection or that the catheter was placed in a dirty way, she's getting abx, and the fever she had was probably TTP related not related to a systemic infection. I don't think there's a problem with leaving the catheter in place for a few days or even a week, if it came to it.

 

[soonerfrog]

Agreed. Great case and thanks for sharing!!! I tend to side with JWK about routine CBC's for laboring women. Seems too much to lose by not getting one. Anyone else think Plank's stance is okay? I don't think it's crazy just wouldn't be my choice. Thoughts???

 

[Mr Wizard]

Agreed. Great case and thanks for sharing!!! I tend to side with JWK about routine CBC's for laboring women. Seems too much to lose by not getting one. Anyone else think Plank's stance is okay? I don't think it's crazy just wouldn't be my choice. Thoughts???

I've been at institutions that stand on both sides with regards to admission CBCs as standard procedure on L&D. I like to see the labs prior to epidural placement but I think a thorough history and exam is more than adequate in low-risk parturients. I won't make a laboring woman wait in pain for lab results if I do not have a clinical suspicion to do so.

 

[tennisballs]

Here is what I would do: NOTHING and would wait for an uneventful vaginal delivery.

For those that would do nothing, just order labs, or attempt vaginal delivery, wouldn't suspicion for HELLP and failure to progress be a relative indication for the obstetricians to proceed to C/S? What were the LFTs? What was the patient's blood pressure? Any urine studies?

 

[sevoflurane]

I'd leave it in until she wasn't clinically bleeding any more, and her labs were in line with ASRA's guidelines for placement/removal of an epidural catheter. Obviously religiously do and document frequent neuro checks after removal.

I'm not concerned about a growth medium around the catheter. No reason to think she's got a local infection or that the catheter was placed in a dirty way, she's getting abx, and the fever she had was probably TTP related not related to a systemic infection. I don't think there's a problem with leaving the catheter in place for a few days or even a week, if it came to it.

Well I should have been more clear in my statement. I bet she had a fever and a white count making the waters a little muddy. I'm not sure I'd wait until her platelets were 100k to pull it in light of a white count and fever... which would likely NOT be due to infection, but certainly COULD be do to infection. Just thinking out loud here.

 

[sevoflurane]

When did the OP pull the catheter?

 

[pgg]

For those that would do nothing, just order labs, or attempt vaginal delivery, wouldn't suspicion for HELLP and failure to progress be a relative indication for the obstetricians to proceed to C/S? What were the LFTs? What was the patient's blood pressure? Any urine studies?

I think plank read the OP's typo literally and thought the patient had 60,000 platelets, not 6,000. I don't think anyone would blow off a real 6K count.

 

[Stank811]

Tennis: PIH labs normal and BP were not concerning

Sevo: epidural was pulled once we felt there was a consistent trend up in plt count and pt was not oozing...which happened to be when plts were 78k....but the discussion did occur regarding infection with increased blood in epidural space.....can't say this was a evidence based descision on what parameters we used to decide when to pull the catheter

 

[cincincyreds]

I've been at institutions that stand on both sides with regards to admission CBCs as standard procedure on L&D. I like to see the labs prior to epidural placement but I think a thorough history and exam is more than adequate in low-risk parturients. I won't make a laboring woman wait in pain for lab results if I do not have a clinical suspicion to do so.

We don't get admission CBCs. There is no literature to support getting a routine platelet count before a labor epidural.

 

[pgg]

We don't get admission CBCs. There is no literature to support getting a routine platelet count before a labor epidural.

The OBs get one for everyone at admission.

But for healthy patients who arrive in pain and are otherwise eligible for an epidural, I won't wait for the lab. ASA guidelines support this.

 

[Planktonmd]

I think plank read the OP's typo literally and thought the patient had 60,000 platelets, not 6,000. I don't think anyone would blow off a real 6K count.

Oh, it was 6000?
Sorry... I thought he said the initial lab was 6000 but the second one was 60,000 😳