What on earth could have caused this?

Specialties Ob/Gyn

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Ok, so we have this pt yesterday who has spent at least a month on Antepartum High Risk with elevated liver enzymes. She is really, really sick. They did a PIH workup on her, and determined she was not preeclamptic. They did a liver biopsy and all of her Hepatitis tests came back neg - for some reason, she has a fatty liver, but no one can figure out why. She is 17 years old, 34 weeks, I think. Started contracting yesterday on AP and baby was having rare decel's, so they scheduled a C/S for 1400. We get her over to us at about 1:45, put her on the monitor, and her nurse is helping her breathe with her contractions and she is doing great, though complaining of severe pain. Baby is running 130-140's. Suddenly, I think about 4 of us are at the desk and see her strip plummet into the 40's and not come back up. So we all go tearing in there to help her nurse, flip her back and forth, put on 02, turn up her fluids - the usual stuff - and she's still not coming back up. She is screaming at the top of her lungs and fighting us; we're trying to check her cervix, put in a foley, shave her, and get the bed out the door to the OR, still waiting on the word from the doc. We get it, and she is shreiking down the hall on the way to the OR about her stomach; we get FHT's in the OR and it's still in the 40's. They put her under, get the baby out in about 4 min, and it is gray, floppy, no resp effort, and no heart beat. In our hospital, we have a High Risk team consiting of a RT, ICN nurse, NNP; they get the baby and start NRP. Apgars 0 and 4, 3 min without a spontaneous heart beat. This was the first time I had ever seen a megacode like that. I was watching over the RT's shoulder and he put me to work bagging the baby! I thought I would not be able to handle that situation well when the time came, but I did, and I was fine. I don't know how long it was (you know it always seems like nine years passes and it's only a few minutes), but the heart started beating on its own eventually and they took it to the unit on a vent. Here is the crazy thing: there was thick mec in the fluid (poor baby was completely stained green) and the doc said that SHE DID NOT ABRUPT!!!!!!!! The cord gas came back like 7.18. We were all completely kerflummuxed - what on earth could have caused this??????? Was this baby just majorly stressed and not able to take the contractions anynmore? If she has some kind of virus, would that have done it?

The good thing is, I am starting to feel like I can do this whole nursing thing! I feel more and more confident everyday, and am really getting some hard pts now (severe shoulder dystocia, pp hemorrhage, twins). I love my job!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Acute fatty liver of Pregnancy??? How was her skin? Any jaundice or itching? Her pain, where was it? Anything epigastric?

Well AFLP sounds like a possible diagnosis.... based on what you tell me here.

Here are a couple links to tell you more about AFLP:

http://www.obgyn.net/displayppt.asp?page=/english/pubs/features/presentations/abdalla12/abdalla12-ss

( slideshow presentation)

http://www.emedicine.com/med/topic775.htm

http://www.marchofdimes.com/professionals/14332_14543.asp

hope these help.

just curious, what were the cord gases????

sounds like a real harrowing time for you. Codes always seem to go in "slow mo" for me-----never do I feel good or confident during NRP codes.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

woops I see the cord gas now....reread your post. 7.18. ewwwww

hopefully kid does ok

how are they doing now?

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

no s/s of uterine rupture?

just trying to think this one thru....

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Specializes in Psych, M/S, Ortho, Float..

I'm no L&D nurse, and I don't know what could have caused the decel's, but I was in a situation when I was doing outpost nursing where I had to catch a couple babies. One case, I was just watching, mum was threating to rupture her uterus. The sudden drop that you talk about reminds me of that.

We managed to fly her out before she delivered, but she had us all sweating bullets till the plane took off.

Jacquie

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no s/s of uterine rupture. I had an NRP class today (how appropriate - at least I could apply what I saw yesterday!) and was not on the floor; I work 7a-7p tomorrow and will try to check on mom and baby. I had no idea that there was such a thing as AFLP. I have so much to learn!

Thank you - you are a wonderful resource on this forum!

Rachel

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

we ALL have a lot to learn. But the fatty liver is definately pathologic. I am not sure if it's AFLP or a chronic condition, but it certainly could be contributory to the situation you unfortunately faced in the delivery of that distressed baby. Hopefully, all will be ok. It was scary. I remember my 1st year like yesterday. BOY OH BOY did I see some humdingers. I learned so much that first couple years in my rural hospital setting.......some things that make my hair stand on end, when I look back.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

the whole issue w/screaming at the top of her lungs gets to me...

I have to wonder:

anxiety making pain worse?

or severe pain beyond labor?

or.....

what?

I really wonder WHERE she was hurting as liver problems can cause some severe epigastric pain. The sudden pain gets to me some how. that is the key issue, what the underlying cause was...somehow my instincts tell me that is where the answer will lie...

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7.18 isn't that bad, I've seen a lot worse.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
Ok, so we have this pt yesterday who has spent at least a month on Antepartum High Risk with elevated liver enzymes. She is really, really sick. They did a PIH workup on her, and determined she was not preeclamptic. They did a liver biopsy and all of her Hepatitis tests came back neg - for some reason, she has a fatty liver, but no one can figure out why. She is 17 years old, 34 weeks, I think. Started contracting yesterday on AP and baby was having rare decel's, so they scheduled a C/S for 1400. We get her over to us at about 1:45, put her on the monitor, and her nurse is helping her breathe with her contractions and she is doing great, though complaining of severe pain. Baby is running 130-140's. Suddenly, I think about 4 of us are at the desk and see her strip plummet into the 40's and not come back up. So we all go tearing in there to help her nurse, flip her back and forth, put on 02, turn up her fluids - the usual stuff - and she's still not coming back up. She is screaming at the top of her lungs and fighting us; we're trying to check her cervix, put in a foley, shave her, and get the bed out the door to the OR, still waiting on the word from the doc. We get it, and she is shreiking down the hall on the way to the OR about her stomach; we get FHT's in the OR and it's still in the 40's. They put her under, get the baby out in about 4 min, and it is gray, floppy, no resp effort, and no heart beat. In our hospital, we have a High Risk team consiting of a RT, ICN nurse, NNP; they get the baby and start NRP. Apgars 0 and 4, 3 min without a spontaneous heart beat. This was the first time I had ever seen a megacode like that. I was watching over the RT's shoulder and he put me to work bagging the baby! I thought I would not be able to handle that situation well when the time came, but I did, and I was fine. I don't know how long it was (you know it always seems like nine years passes and it's only a few minutes), but the heart started beating on its own eventually and they took it to the unit on a vent. Here is the crazy thing: there was thick mec in the fluid (poor baby was completely stained green) and the doc said that SHE DID NOT ABRUPT!!!!!!!! The cord gas came back like 7.18. We were all completely kerflummuxed - what on earth could have caused this??????? Was this baby just majorly stressed and not able to take the contractions anynmore? If she has some kind of virus, would that have done it?

The good thing is, I am starting to feel like I can do this whole nursing thing! I feel more and more confident everyday, and am really getting some hard pts now (severe shoulder dystocia, pp hemorrhage, twins). I love my job!

At the time of the section, there was no rupture? Sudden brady like that could be indicative of uterine rupture. Usually have variable decels before hand and alot of nurses and physicians alike will not realize that this is a warning sign of impending rupture. Variables are common, but, not usually early in the labor. And, normally after rupture, you can palpate fetal parts, see a rise in the abdomen, loss of outline of the uterus when palpated, loss of fetal station.

The mec fluid and covered baby indicated stress in utero, for some time. That is why you had such poor cord gases.

As for viral entity.....hmm...maybe, maybe not. Need further eval for that. Enzymes elevate for MANY reasons and sometimes very hard to pinpoint etiology.

Goodness, I am with SmilingBlueyes here, not something I would want to do everyday, but, sounds like you did the best you could do. I am glad you are liking OB. It is great!! But, very harrowing at times.

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Specializes in Education, FP, LNC, Forensics, ED, OB.
the whole issue w/screaming at the top of her lungs gets to me...

I have to wonder:

anxiety making pain worse?

or severe pain beyond labor?

or.....

what?

I really wonder WHERE she was hurting as liver problems can cause some severe epigastric pain. The sudden pain gets to me some how. that is the key issue, what the underlying cause was...somehow my instincts tell me that is where the answer will lie...

I was trying to rack my brain for the same reason. Sounded like something happening so out of proportion to the labor experience. Age? Absolute fear? Combination of both along with undiagnosed pathology?

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Yea I know, Siri, the whole thing stinks of uterine tear/rupture, or abruption. It just does....

the l iver thing, while possibly contributory, should not have been causative.

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