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Discussion

Case Study: An OB Catastrophe

  • Guides

Case Study Objectives

  1. Present a simulated case as it evolves over time.
  2. Encourage open discussion from nurses that represent a variety of specialties.
  3. Promote learning based on the:
    • details of the case
    • evaluation of the data
    • known interventions in order to provide holistic care
  4. Recognize maternal morbidity and mortality as a serious public health issue facing the world.

Introduction

The initial presentation that will proceed is meant to set the tone for the next set of events that will occur. I would like to preface by saying that this particular part of the case is where I have no actual nursing experience so I encourage colleagues who work in this specialty area to chime in with their responses.

Let's keep this lively, but also make sure we are respectful of each other.  Remember that we work in different hospitals and protocols may be different.  Also, be aware that while the following scenario seems "garden variety", it will get more "exciting" as we move along.

Case Specifics

History / Presentation

EJ is a 32-year old, Gravida 4 Para 2, at 34 weeks and 2 days gestational age. She has no chronic medical problems but admits to current tobacco smoking since age 17.  She says that she has been trying to quit and has cut back her smoking to 2-3 cigarettes a day.  She lives with her husband and two children ages 3 and 5 in a 2-bedroom apartment. 

She receives prenatal care at an urban Federally Qualified Healthcare Center (FQHC).  She previously worked as a server at a restaurant but has become unemployed for a couple of months due to restaurant closures from the coronavirus pandemic.  She has good family support from her parents and her husband, RJ, who is a delivery truck driver.  She is insured through her husband's coverage. 

Today, she called her Women's Health Nurse Practitioner (WHNP) when she experienced a gush of watery fluid from her lady parts while playing with her children.  She was told to come to OB Triage at the nearby Tertiary Medical Center Antepartum Unit.  Upon presentation, she was seen by the OB Triage nurse who found her anxious but well-appearing. 

Vital Signs

  • Temperature: 36.7 degrees C
  • Heart Rate: 84
  • Respiratory Rate: 16
  • Blood Pressure: 112/74
  • O2 Saturation: 96% RA
  • Fetal Heart Rate (FHR): 140

Physical / Pelvic Examination

An OB-Gyn resident saw EJ and performed a physical examination that revealed clear, pale yellow, odorless fluid leaking out of her endocervical canal with pooling in the lady partsl vault.

Diagnostic Studies

The OB-Gyn resident performed ultrasonography which revealed:

  • oligohydramnios
  • a fetus that is small for its age, without birth defects, in no distress
  • a placenta that does not cover the cervix

Recommendation

The OB-Gyn team recommended admission to the Antepartum Unit.

Diagnosis

At this point, EJ's diagnosis seems obvious but you are welcome to state it in your response to the thread.

1 - As EJ's nurse, state some assessment findings that would make you concerned. 

2 - As the nurse in that unit, what laboratory tests and monitoring procedures would you anticipate in this case, and why?

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    • Featured Replies

    1: Fever, localized abdominal pain, elevated WBCs, other signs of sepsis such as change in vital signs, fluid that changes from clear to green, yellow, or bloody. Also concerning would be a category II strip with significant repetitive decels

    2: Continuous fetal monitoring, q4h temp, I would anticipate collecting a GBS swab, an order for betamethasone x 2 doses, and then proceed with induction of labor once she's cleared the steroid window, NICU consult

    Also, maybe I'm jaded from working high risk OB, but I wouldn't call PPROM at 34 weeks to be an "OB catastrophe." ?

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    • Author
    • Guides
    36 minutes ago, klone said:

    Also, maybe I'm jaded from working high risk OB, but I wouldn't call PPROM at 34 weeks to be an "OB catastrophe." ?

    Oh it's not by any means, hence, the statement:

    Also, be aware that while the following scenario seems "garden variety", it will get more "exciting" as we move along.

    thanks for your great responses BTW.

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    • Experts

    You don't want me "birthin' babies"; no OB experience beyond my 2 high risk C sections; tons Respiratory ICU.  My 2 cents:

    Agree with Klone re assessment, meds, labs. G4, P2 --what happened to 2 pregnancies not to term?  Concerned FHR on lower side at 34wks, low amniotic fluid and neonate SGA.

    Add  covid-19 testing, CBC - especially want to see if WBC increased,  Hgb/HCT decreased.  Start IV.   Think I'd check Temp Q 2hrs in "anxious mom".  ? Antibiotic needed. Assess CP status mother - high possibility amniotic fluid embolism/ARDS due to oligohydramnios + placenta not covering cervix.    Prep for C-Section if induction fails or significant change in VS/fetal strip.  Neonate - consider hypoxic resp failure @ birth.

    Await other chiming in...

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    28 minutes ago, NRSKarenRN said:

    Y high possibility amniotic fluid embolism/ARDS due to oligohydramnios + placenta not covering cervix.  

    That's a good thing. And the oligohydramnios is simply because her water broke. 

  • Quote

    Does this patient receive abx at this juncture?

    Also, following because I know nothing. ?

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    This looks fun, I’ve never done a case study here. I’m not an OB nurse...

    VSS. I guess I’d be concerned that’s shes lost one pregnancy in the past. The pooling in the lady parts means amniotic fluid versus urine, so maybe* only acutely low fluid. Don’t babies have to be delivered within 24 hours of rupture because of risk for infection? She seems good for a lady partsl unless Hx of cesareans. Aren’t babies of smokers small for their age normally? How small and how long have they been small? 34 weeks is good to be delivered with steroids to the lungs, yes? For psych/social, does she have any trauma from the previous loss? Are pregnant women allowed to have nicotine patches or anxiety meds? Although her VS may show that she’s compensating well with the anxiety and may not need anything. 

    Looking forward to more posts ?

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    6 hours ago, JKL33 said:

    Does this patient receive abx at this juncture?

    Also, following because I know nothing. ?

    Not typically, unless she starts to show signs of infection or her GBS comes back +. Latency abx for PPROM (preterm premature rupture of membranes) is generally only recommended <34 weeks gestation.

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    17 minutes ago, Mrs.D. said:

     Don’t babies have to be delivered within 24 hours of rupture because of risk for infection? ?

    No - we have women who have PPROMed at 20 weeks hang out in antepartum for months. We watch closely for infection and fetal wellbeing. Assuming both of those things are fine, we try to keep them pregnant until 34 weeks.

    Quote

    For psych/social, does she have any trauma from the previous loss?

    Also, as an OB nurse, the fact that she has had one pregnancy loss would not even blip my radar. Most likely was an early miscarriage or an abortion. If her gravida/para info was provided in GTPAL format, we would have a little more information to go on (such as, was it a miscarriage/abortion, or was it a preterm delivery that didn't survive?).

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    Just have to say woohoo!! I love reading the case studies, and it's finally my time to SHINE! LOL

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    3 hours ago, klone said:

    Not typically, unless she starts to show signs of infection or her GBS comes back +. Latency abx for PPROM (preterm premature rupture of membranes) is generally only recommended <34 weeks gestation.

    Thanks! I was doing some reading after reading the case study and kind of thought this might be your answer. If I understand, it's because less than 34 weeks you are going to try to make it to 34, and that time needed (latency that you wish to lengthen ?) is time for infection (chorioamnionitis, maybe endometritis?) to develop -- and more time is more likelihood that it will?

    Do I have that mostly right?

    ETA--ooh a question: Are other infections (UTIs, STIs, BV, etc.) just found to be not as likely as GBS, or why do we not have to concern ourselves with those (e.g. test for them or cover them?)

    **

    Also, thanks @juan de la cruz for posting the case.

  • Quote
    • Experts
    14 hours ago, klone said:

    Just have to say woohoo!! I love reading the case studies, and it's finally my time to SHINE! LOL

    Woohoo! Let's go...I'm waiting for the promised later excitement too. Initial presentation is pretty much..hey I see this every day ?

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    • Author
    • Guides

    Recap of previous events

    Now that we've all been acquainted with EJ's case, let's summarize what the data revealed to us and start with her diagnosis at this point.  Kudos to @klone for mentioning the diagnosis in her response which is: Preterm Prelabor Rupture of Membranes (PPROM).  Peterm because the event happened before 37 weeks and Prelabor because it occurred before onset of uterine contractions.  PPROM occurs in up to 3% of pregnancies (1) and the etiology is not well understood.  A history of previous PPROM, genital tract infection, and cigarette smoking have been implicated as risk factors (2).

    The classic presentation of PPROM were present in EJ: "gush of clear or pale yellow fluid from the lady parts".  Direct observation of amniotic fluid leaking from the cervical os and pooling in the lady parts vault is pathognomonic of PPROM (3).  The ultrasound finding of oligohydramnios (amniotic fluid volume less than expected for gestational age) supports the diagnosis as @klone stated.  The fetus is small perhaps due to EJ's smoking.  The placenta is not supposed to block or cover the cervix, an abnormal condition called placenta previa.  There are a number of tests used to establish the diagnosis as well but I won't get into that at this point.  These are typically done if there's still a question of alternative causes such as urinary incontinence for example.

    Plan

    Let's recap what was mentioned about EJ's care plan.  Monitoring of vital signs is important just as in other patients who are admitted. As everyone already mentioned, infection is a big concern.  Again, I'm giving this up to our L&D nurses here for giving accurate answers. 

    As per usual, you would expect CBC and maybe electrolytes.  The WBC with differential will be a piece in the puzzle in determining presence of infection as would body temperature, heart rate, and the quality of lady partsl discharge.

    In the absence of other worrisome findings, there are differing camps within Obstetricians on deciding between "expectant management" which is watching and waiting vs delivery.  You are welcome to share what you've seen in practice.   

    Again, hats off to our L&D nurses who are so used to caring for expectant mothers for recognizing fetal health as another concern.  Fetal monitoring and steroids as mentioned are interventions meant to assess and protect fetal well being.  Thanks for participating.

    Tune in on Saturday, Sept 5 for the next update on EJ.

    References:

    (1) Mercer BM, Preterm Premature Rupture of Membranes: Current Approaches to Evaluation and Management, Obstetrics Gynecological Clinics of North America, September 2005.

    (2)(3) Duff P, Preterm Prelabor Rupture of Membranes: Clinical Manifestations and Diagnosis, UpToDate, updated May 29, 2020.

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