Real-time OB case

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rsgillmd

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There is a 30 some y.o. obese African American female scheduled for repeat C-S w/suspected preeclampsia. All tox labs are negative but OB is suspicious for it b/c BP has not gone down much with their meds.

PMH: DM (on Insulin) and Chronic HTN (on Labetalol) -- did not take these meds for 24 hours

PSgH: C/S x 1

Social: No toxic habits

Allergies: None

She was started on insulin drip, and given labetalol.

I went to see why she was not back in the OR when I thought she would be and found she had developed acute mental status change in her room. This occurred shortly after Magnesium load was started (but not finished).

Initially very difficult to arouse but responsive to pain. HR = 90, resps = 16, BP = 157/98, Sat = 98% on room air (found out later -- had to get the probe into the room). Mag stopped. Insulin drip stopped. O2 applied. Blood sugar = 104, down from 113 40 minutes ago. (starting was 153, so it is not a drastic change). Repeated = 103 (not likely to be instrument error). Reflexes = brisk. Pupils = mid-size -- can't really say they are responsive. Good air exchange. Clear lungs. Strong radial pulses.

CRNA started another IV a little before we got there, and OB placed a foley -- no hematuria, and urine looks clear and of adequate volume -- 50 ml (she voided about an hour earlier). She's a little more responsive now. BP = 167/114, 160/104.

Questions:

1) She was almost behaving like she was post-ictal, but no observed seizure activity (family in the room). No seizure history. All the eclamptic seizures I've seen have been tonic clonic. Has anyone out there seen an abscence type seizure with preeclampsia?

2) Has anyone seen a response to a Magnesium load like this?

She is much more responsive now, but far from her previously alert mental status. I'm almost tempted to sleep her because if I get a high level my only warning signs will be changes in blood pressure and heart rate. I also don't want her mental status to worsen and be trying to intubate her intra-op. Also no way she'd be able to cooperate with positioning at this point.

OB is calling Neuro. Probably will get a CT scan. It gave me a pause to get some dinner and type this. I'll update you when I know more.
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I would blame the mag for the time being. No objection to the ct scan.

Is she on pitocin too? I have heard of pts going 10-4 for a few days from pitocin induced water intoxication/coma.
 
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Hi urge. Good point with the pitocin, but she's not on it. She was sent from clinic with the plan to do a C/S.

Mag level came back as 2.4 (normal). All other labs essentially unchanged and normal, except K = 3.2, but that's not low enough to be a culprit.

Neuro says CT was normal, and by the time she got back from CT her mental status has significantly improved. She still seems drowsy, but more responsive and at least verbalizing her name. Neuro did an exam after she got back from CT and found no deficits.

I forgot to mention before no evidence of tongue bite or incontinence.

We are blaming the Mag for now also. Present plan is restart the Mag but at a maintenance dose to let the level creep up and observe her mental status. If her mental status remains stable, probably do the C-S in the next couple of hours.

She's cooperative enough now that I'll place a CSE, but I'm not going to give her Duramorph as was my initial plan. I figure you have to be somewhat with it to press a PCA button. Instead of PCA I might even use the epidural for post-op pain if I can find a spare pump. Although she'd be in recovery with 1:1 monitoring, if she developed altered mental status again after Duramorph, I'd be afraid of confusing the picture further.
 
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cse early, low dose marcaine, build up the epidural a little more slowly, avoid high spinal, worst case is it takes an extra 15 minutes
 
Idiopathic said:
cse early, low dose marcaine, build up the epidural a little more slowly, avoid high spinal, worst case is it takes an extra 15 minutes
Click to expand...

That's basically what I did. 7.5 mg of Bupivacaine + fentanyl 25 mcg. Didn't need to use the epidural.
 
Idiopathic said:
and its probably the mag
Click to expand...

Yes, that's our conclusion also by process of elimination.

Still very strange -- occurred during the load and Mag level only came back as 2.4.

She was essentially normal by the time we took her back, and she tolerated the basal Mag rate overnight.

Every time I begin to think I can't be surprised, I get proven wrong.
 
Atypical seizure and patient is post-ictal.
The presence of brisk reflexes as the OP mentioned makes it very unlikely that the magnesium was the cause.
In the presence of altered mental status and possible seizures I would have done this case under GETA.
 
Planktonmd said:
Atypical seizure and patient is post-ictal.
The presence of brisk reflexes as the OP mentioned makes it very unlikely that the magnesium was the cause.
In the presence of altered mental status and possible seizures I would have done this case under GETA.
Click to expand...

I'm with plank on this one. I'm suprised that the OBs didn't want to run for the OR in the face of a possible seizure. I'm really suprised they got a consult, CT, etc.
I probably would have pushed for baby out now study and/or fix mom in 30 minutes.
 
IlDestriero said:
I'm with plank on this one. I'm suprised that the OBs didn't want to run for the OR in the face of a possible seizure. I'm really suprised they got a consult, CT, etc.
I probably would have pushed for baby out now study and/or fix mom in 30 minutes.
Click to expand...

Aren't you two going Gung Ho on this one? She doesn't even have criteria for preeclampsia (suspicion does not cut it in my book) and now she has full blown seizures (suspected of course...), so we must hurry an take the baby out before someone strokes out (most likely one of you two)?

Why do you insist in making this business more stressful than it is?
 
urge said:
Aren't you two going Gung Ho on this one? She doesn't even have criteria for preeclampsia (suspicion does not cut it in my book) and now she has full blown seizures (suspected of course...), so we must hurry an take the baby out before someone strokes out (most likely one of you two)?

Why do you insist in making this business more stressful than it is?
Click to expand...

There's nothing stressful about an urgent c/s. Do a couple pregnant GAs and you lose the stress/fear. It's pretty much just like any other obese full stomach.
It does get more stressful after she blows a gasket and the kid sh:ts the bed. I try to head those things off at the pass. It's the OBs decision anyway. If my names on the chart, and I saw the above, something along the lines of "discussed likely seizure and post ictal state with the OB. Immediately available for emergent C/S." If she strokes out waiting for neuro or in the Scanner, they're not hanging any blame on me. "Dr. didn't you recognize the signs of a post ictal state in this previously coherent patient?". Covered. (as much as you can be). I don't trust OBs at all, seen too many Seriously bad ones.
Pregnant, worsening hypertension, new sudden profound MS changes. That gets my
attention. Let's not forget she was admitted, prob from the clinic, for a c/s due to suspected pre eclampsia. Seizure until proven otherwise. No proof disputing that yet. I wouldn't have stopped the mag either, that's the treatment for eclampsia. Pre eclampsia kills mothers, and kids. If you forget that, you're in big trouble. And again, I don't trust OBs, or midwives, at all, unless they're at a high risk OB big baby mill, they're not used to disaster. We have thoughts of averting disaster running around in the back of our heads 24/7.
I bet they were mumbling about how it can't be a seizure and looking up online DDx lists for other possible causes. You already sharpened the knives and put ether in the mask. That's the difference. It's not malpractice to wait, but it's likely putting the kid at significant risk.
 
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Wow, I didn't intend for this to turn into an argument. It was just a strange presentation. I thought I would share and get some thoughts.

Baby's HR was fine the whole time. I stopped the Mag initially, but OB was the one that said keep it stopped. I made my thoughts clear, as well as that I was ready to put the patient to sleep if they wanted to go back for a C/S.

The Mag was restarted after her mental status improved even further after she got back from CT. They just ran the basal infusion, and didn't finish the loading dose. The patient's mental status was basically back to normal by the time we took her back. Whatever happened, both mom and baby did fine.

I like IlDestriero's point about writing something to the extent of willing to go back in the chart. I'll keep it in mind for the future.
 
rsgillmd said:
Wow, I didn't intend for this to turn into an argument. It was just a strange presentation. I thought I would share and get some thoughts.

Baby's HR was fine the whole time. I stopped the Mag initially, but OB was the one that said keep it stopped. I made my thoughts clear, as well as that I was ready to put the patient to sleep if they wanted to go back for a C/S.

The Mag was restarted after her mental status improved even further after she got back from CT. They just ran the basal infusion, and didn't finish the loading dose. The patient's mental status was basically back to normal by the time we took her back. Whatever happened, both mom and baby did fine.

I like IlDestriero's point about writing something to the extent of willing to go back in the chart. I'll keep it in mind for the future.
Click to expand...

No argument, just healthy discussion.:thumbup:
If it all went bad, all the OB will conveniently remember is that you were at dinner when she stroked out, nothing about your discussion, exam and possible need for urgent section. They're shady dude.
Glad it all went well!
 
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urge said:
Aren't you two going Gung Ho on this one? She doesn't even have criteria for preeclampsia (suspicion does not cut it in my book) and now she has full blown seizures (suspected of course...), so we must hurry an take the baby out before someone strokes out (most likely one of you two)?

Why do you insist in making this business more stressful than it is?
Click to expand...

:D
OK Urge, let me try to simplify this for you a little:
A parturient suddenly develops altered mental status while being treated for pre eclampsia with Magnesium, and let's say it is not the Magnesium since her reflexes are "brisk", what do you think happened???
Knowing how smart and intuitive you are I am sure you would say that she probably had a seizure, and you probably would say that this seizure is either fully blown eclampsia or a bleeding in her head.
What is the smart thing to do when a parturient is seizing?
A spinal anesthetic for C section?
 
Planktonmd said:
:D
OK Urge, let me try to simplify this for you a little:
A parturient suddenly develops altered mental status while being treated for pre eclampsia with Magnesium, and let's say it is not the Magnesium since her reflexes are "brisk", what do you think happened???
Knowing how smart and intuitive you are I am sure you would say that she probably had a seizure, and you probably would say that this seizure is either fully blown eclampsia or a bleeding in her head.
What is the smart thing to do when a parturient is seizing?
A spinal anesthetic for C section?
Click to expand...

Kinda harsh IMO.

But personally, I would have pushed for urgent c/s to get the baby out and deal with whatever is happening to mom either in the OR or afterwards. I don't like that they did a CT while she was prego. That's a **** ton of radiation to a new baby. There is a lot of information coming out these days about the use of CT and whether we are doing more harm than good with the amount of radiation.

My plan: GETA for c/s then if things are not more clear, go for CT. Probably what Plank is saying he would do as well.
 
Noyac said:
Kinda harsh IMO.

But personally, I would have pushed for urgent c/s to get the baby out and deal with whatever is happening to mom either in the OR or afterwards. I don't like that they did a CT while she was prego. That's a **** ton of radiation to a new baby. There is a lot of information coming out these days about the use of CT and whether we are doing more harm than good with the amount of radiation.

My plan: GETA for c/s then if things are not more clear, go for CT. Probably what Plank is saying he would do as well.
Click to expand...

Did not mean to sound harsh, certainly nothing against Urge either.
But, he was concerned that one of us (Me and IlDestriero) are too stressed out for suggesting an urgent C section under GA and I was just explaining why it might actually be a good plan of action.
Just a friendly exchange of ideas with a little sarcastic flavor that Urge seems to like.
 
Planktonmd said:
Did not mean to sound harsh, certainly nothing against Urge either.
But, he was concerned that one of us (Me and IlDestriero) are too stressed out for suggesting an urgent C section under GA and I was just explaining why it might actually be a good plan of action.
Just a friendly exchange of ideas with a little sarcastic flavor that Urge seems to like.
Click to expand...

:thumbup:

And as you can tell, I'm in favor of the urgent c/s as well. I think that is the better plan of action for the baby and we are trained to deal with issues like BP, etc. If she had a sz then GA is a good treatment as well if she might have another one. If its from eclampsia then Ga is definitive tx also or at lest it is headed in the right direction.
 
I'm not feeling the eclampsia from the story given 15/9 BP is pretty good for a chronic HTN off meds for 24h. If the patient had any neuro signs compatible with an intracranial bleeding a CT is definitely necessary if not i would push for a c/s.
 
dhb said:
I'm not feeling the eclampsia from the story given 15/9 BP is pretty good for a chronic HTN off meds for 24h. If the patient had any neuro signs compatible with an intracranial bleeding a CT is definitely necessary if not i would push for a c/s.
Click to expand...

BP is not that impressive, I agree. But there is more to eclampsia than just high BP.
 
Posterior reversible encephalopathy syndrome (PRES) could present similarly. It's probably not but something to keep in the back of your head.
 
Noyac said:
What? Never heard of it.
Click to expand...

PRES is out there, perhaps being diagnosed a little more frequently these days than before because people stop to consider it. The only problem is that changes with preeclampsia can mimic changes with PRES. It's a gray diagnosis to make in an OB patient.

I briefly thought about it, but excluded it for two reasons:

1) The cases I have seen/heard about 1st hand from people involved describe PRES seizures as having a tonic clonic component, just like an eclamptic seizure. If this lady had a seizure, it was a very atypical presentation. No direct evidence of a tonic clonic seizure was present.

2) The cases I have seen/heard about 1st hand from people involved/read about have very commonly described a headache as preceding the seizure activity, in addition to HTN. This patient did not have any headache or other symptoms.

Noy, there are a couple of articles about PRES out there. A short and well descriptive one is by Yaakov Beilin in IJOA (I forget the year, but not too long ago). NEJM has one of the original articles on PRES, but it is not easy to find.
 
Noyac said:
Kinda harsh IMO.

But personally, I would have pushed for urgent c/s to get the baby out and deal with whatever is happening to mom either in the OR or afterwards. I don't like that they did a CT while she was prego. That's a **** ton of radiation to a new baby. There is a lot of information coming out these days about the use of CT and whether we are doing more harm than good with the amount of radiation.

My plan: GETA for c/s then if things are not more clear, go for CT. Probably what Plank is saying he would do as well.
Click to expand...

Thank you.

Am i the only one thinking why are they doing a CT on a Pg !! Worse case scenario could have done a MRI.

Either way, I agree.. pt has AMS it seems. Questionable ability to protect the a/w. If by chance the epidural/spinal went higher than expected, you have problems..... RSI...c/s.
 
This was interesting to read. I understand the debate, I think, GA v C/S and all the risks etc. Magnesium, seizure/non-seizure debate etc. So, here's a question:

Has anyone thought, or is it that far-fetched, that this patient, who, for whatever reason is on the OB's radar for drugs despite a neg tox screen, decided to self-medicate when nobody was in the room? So, would it have been worthwhile to repeat a tox screen when the cause wasn't definitive?

Would it, possibly, explain this somewhat transient event, aside from the BP not reacting as normal, which we already know?

(When the current discussion fizzles, I guess here's another question, what happens in this scenario when the patient on the table finally reveals to you she just popped some 3 Vicodin in the women's room, or did a line of coke at home last night, or took 3 ambien bla bla bla?) Do this drug use inherently make the case more risky, thus GA?

D712
 
doctor712 said:
This was interesting to read. I understand the debate, I think, GA v C/S and all the risks etc. Magnesium, seizure/non-seizure debate etc. So, here's a question:

Has anyone thought, or is it that far-fetched, that this patient, who, for whatever reason is on the OB's radar for drugs despite a neg tox screen, decided to self-medicate when nobody was in the room? So, would it have been worthwhile to repeat a tox screen when the cause wasn't definitive?

Would it, possibly, explain this somewhat transient event, aside from the BP not reacting as normal, which we already know?

(When the current discussion fizzles, I guess here's another question, what happens in this scenario when the patient on the table finally reveals to you she just popped some 3 Vicodin in the women's room, or did a line of coke at home last night, or took 3 ambien bla bla bla?) Do this drug use inherently make the case more risky, thus GA?

D712
Click to expand...
I think the tox labs he was referring to were "toxicity of pregnancy" labs which would indicate preeclampsia, not illicit drugs. Having a negative tox screen does not necessarily mean that she does not have preeclampsia though.
If the patient can't cooperate because they are high as a kite, they get a GA. I did many elective intubations for trauma patients, just so they would be still for exams and studies that a sober person would have tolerated fine.
 
Noyac said:
I'm not worried about teratogenesis at this time. I'm worried about the amount of radiation exposure and future problems like cancer.

http://www.time.com/time/health/article/0,8599,1818520,00.html

This one talks about how vulnerable kids are to radiation:
http://www.time.com/time/health/art...i=t0:a16:g2:r1:c0.202705:b18549525&xid=Loomia
Click to expand...
:thumbup::thumbup::thumbup:
Sometimes the surgeons and IR folks use a ridiculous amount of fluoro on kids. I often put the fluoro on pulse, when appropriate. They don't know the difference, and the fluoro times are MUCH lower.:D
 
dhb said:
She's 9 month into it i wouldn't sweat it...
Click to expand...

ok now backto the 'real world".

Do you think that plaintiff's attorney isnt going to try to convince the jury that that cleft palate, hypospadias, ROP, CP, or the like ISNT related to that radiation exposure?

yah right.
 
SleepIsGood said:
ok now backto the 'real world".

Do you think that plaintiff's attorney isnt going to try to convince the jury that that cleft palate, hypospadias, ROP, CP, or the like ISNT related to that radiation exposure?

yah right.
Click to expand...

dhb has the privilege to practice in Europe where they don't worry that much about sleazy attorneys.
 
In a laboring women i think it would be a hard sell.
By the way it's a head scan so you can put some lead around the belly. I'm not minimizing the effects of radiations but if a scan is indicated the benefits outweigh by far the side effects. The problem is people ordering studies left and right with no evidence they are needed (defensive medicine maybe).
 
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