Interesting night/patient

[lovemyjoblandd]

Okay, here's the situation. I come into work tonight and my patient is a delivered PIH patient with a P C/S due to failure to descend. She had been on mag for the duration of her labor which was approximately 15 hours (she SROM'd the night before) She started bleeding heavily after the c/s and was taken back to the OR to repair what was bleeding (i didn't get a real good explanation of exactly what was repaired, but it was not placental). Just prior to going to the OR a CMP and CBC was drawn. CMP was WNL with the exception of slightly elevated liver enzymes (ast 49, alt 52). H&H 8.5/25 platelets 112, RB 2.68. Patient was transfused with 2 units RBC at shift change. At midnight CMP and CBC was redrawn. H&H 11/32 platelets 107, rbcs 3.44. Now here's the meat of the topic. Chloride 114, CO2 14, Anion gap 9, calcium 6 (not a big concern seeing as how she was on mag before delivery). ast 45, alt 36. Her urine output has been slowly decreasing. started at 50, then 40, then 35, now she's at 28. My first thought is metabolic acidosis. The doc didn't seem concerned. Just told me to watch UO. Any thoughts on what is going on with this patient?

[babyktchr, BSN, RN]

What concerns me more with this patient is why they took her back to the OR. You would expect a boggy uterus because of the long term mag, so what is it that was "repaired"? I assume you mean there was no retained placenta, so was it a bleeder? Was she given cytotec or hemabate? Was the bleed while still in OR or in PACU or post partum?

Platelets concern me more than the other things you mention. Your H&H went up after transfusion (pretty significantly) but platelets remain low. I am sure they were fluid restricting her during labor with mag going, so I would imagine that after a starting out on the dry side as many pregnant patients are, and then having a significant bleed, she is certainly going to be dry intravascularly. She very well may need some hydration. What about BUN and creatinine? Normal? How about PT/PTT. Are you concerned about HELLP?