Case Study: An OB Catastrophe

On 9/2/2020 at 9:12 AM, JKL33 said:

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?)

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

Glad you are liking the case. 

GBS is reported to colonize the genital tracts of many pregnant women and vertical transmission to the newborn is a concern which could lead to a host of problems.  Per the CDC data, 1 in 4 pregnant women carry the bacteria in their body (1).  I've read an expert opinion about routine testing for BVI and chlamydia trachomatis in PPROM cases as well but there is no consensus on that.

I  would have to say that in cases where other infections are suspected (like UTI's, endometritis, or chorioamnionitis as  you mentioned that are not just caused by GBS alone), there should be a low threshold to cover those infections with empiric broad spectrum antibiotics until cultures are available. 

Reference

(1) https://www.CDC.gov/groupbstrep/about/fast-facts.html

Hospital Day 3

EJ has received a course of corticosteroids.  Her fetus was found to be in the ideal cephalic presentation.  The OB team decided on labor induction with oxytocin as there were no contraindications identified.  EJ requested an epidural and a CRNA placed the catheter successfully.  Continuous epidural infusion of ropivacaine and fentanyl was started.

Focused Nursing Assessment:

Neuro: alert and oriented, anxious

CV: S1S2 normal, NSR with HR 87, BP 122/80

Pulm: lung sounds CTAB, O2 sat 99% on RA

GI/GU: gravid abdomen, odorless and clear lady partsl discharge

ID: Temp 36.5

Labs:

Delivery Course:

EJ had an uncomplicated labor course thus far and delivered a low birth weight baby girl.  Her newborn was transported to the Neonatal ICU.

Within 30 minutes of manual placental removal, EJ stated "I am not feeling well" and immediately became unresponsive.  Within seconds, she was pulseless and blue.  A Code Blue was called.  Teams from Anesthesiology and Adult Critical Care Medicine arrived to assist the OB team. 

The anesthesiologist was able to secure a #7.5 endotracheal tube and ventilate while the rest of the Code Blue Team did CPR.  Medication administration following ACLS protocol for asystole was carried out.  An arterial line was placed in the left femoral artery emergently.

During the event, she started gushing blood out of her lady parts.  A percutaneous sheath introducer (PSI) was emergently placed by the ICU team on the right femoral vein and Massive Transfusion Protocol (MTP) was activated.  Using a Rapid Infuser, a total of 8 Units of PRBC, 8 Units of FFP, and 4 Units of platelets were rapidly transfused. The OB team placed a Bakri balloon for temporary hemostasis.

Return of Spontaneous Circulation (ROSC) was achieved after 30 minutes. EJ was transferred to the ICU.

Post-Arrest assessment:

Neuro: unresponsive to stimuli, pupils are equal 3 mm, reactive to light

CV: S1S2, Tele: Sinus Tach 110's with some PVC's, Arterial Line BP of 93/50 with MAP of 67, CVP 18.

Pulm: Lung sounds coorifice bilaterally. Os sat 95% (see vent settings)

GI: abdomen soft, ND, hypoactive bowel sounds

GU: Bakri balloon and Foley catheter in place

Extremities:  cool to touch, slow capillary refill

ID: temp 36.2 C

Medications:

Propofol at 30 mcg/kg/min

Epinephrine at 0.03 mcg/kg/min

Norepinephrine at 13 mcg/min

Vent settings and lung mechanics:

Ventilated on Assist Control/Volume Control, set RR 28, VT 350 (calculated as 6 cc/kg of her predicted body weight), FiO2 100%, PEEP 15, peak airway pressure 32, plateau pressure 26.

Imaging:

CXR:

CT brain:

No large vessel ischemia, multiple small vessel supra and infratentorial embolic infacts.

CT abd/pelvis:

hepatic infarcts.

Transthoracic Echocardiogram:

LV dysfunction with EF 35%, regional hypokinesis in the mid and apical segments. RV function and volume were normal. No valvular disease. IVC was full and does not collapse.

Laboratory Data:

ABG:

Questions:

What do you think happened to EJ? Putting all the data together, make some inferences on what the labs and diagnostics mean. What next steps would you anticipate? ICU nurses I expect a system-based response, ie, plan per Neuro...CV...Pulm, etc.

My hunch in my first post.... will let an OB nurse further explain..

@JKL33, it is certainly a DIC picture in the context of a Post-Partum Hemorrhage.  Those are good differentials. 

Just wanted to say that I encourage free discussion here and there should be no judgement on what people give as answers.  Part of practicing the "healing arts" is making inferences based on the data and working through probabilities of what might be happening.  So yes, make guesses and state your thought process.

21 hours ago, klone said:

I'm confident I know what is going on, but I will let someone else chime in first. ?

I think I'm with you. If I'm right, we were just talking about this at work the other day and WAY too few people have ever heard of the acronym that helps both identify the condition and the initial treatment for it.

9 minutes ago, klone said:

Okay, I know labor dude and I are on the same page. I'm going to diagnose this patient with an AFE (amniotic fluid embolism). Even though it's rare, the hallmark sign that that is what is going on is this:

This is typically how an AFE presents: at or around delivery of the placenta, the woman will suddenly feel unwell, nauseated, SOB, or express an impending sense of doom. 

The treatment (as labordude alluded) is immediate administration of the medications known by the acronym A-OK (atropine, ondansetron, and ketoralac). 

AFE will usually quickly develop into DIC, which is why she suddenly hemorrhaged once she became unresponsive. 

Other than A-OK protocol, treatment is supportive - blood products, volume expanders, treatment for cardiac arrest, transfer to ICU. Mortality is around 50-80%. And this is where I tag the ICU nurse. Baby's born, I'm outside my wheelhouse now. I'm happy to assess her  Bakri q2h, but that's about it. ?

There is a FASCINATING book called "37 Seconds" which is a woman's firsthand account of surviving AFE (and KNOWING before she even went into labor that she was going to die in childbirth - she spoke at the 2017 AWHONN annual conference in New Orleans).

This is where I was going. The presentation screams this to me. AFE, especially the rapid cardiorespiratory collapse, neurologic symptoms, moving into DIC and left ventricular dysfunction. The low platelets and low fibrinogen are hallmark and I bet that EJ would high fibrin split products if that lab value was present too. The upside is that AOK is really effective IF AFE is recognized and the meds are given quickly. They are easy to keep available and can be kept together in an AFE kit.