Published
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!
Love these types of mysteries. Sure does sound like a rupture or abruption, but the doc rules that out. Still, I wonder what pathology might find with that placenta. I wish I knew more about AFLP. Pretty rare, thank goodness!(Great slide show on AFLP, SBE!) It does mention severe infection can result with AFLP. That could be the reason for the 7.18 pH, as could anoxia. Was the cord compressed making the FHR drop? Could be, but still there was something going on long before that, as gross meconium staining in a 34 weeker is quite different than in a term infant who merely needs to be born. Something bad had been brewing awhile.
Look forward to hearing more on this!
I figured that you girls would like a brain teaser like that. Unfortunately, I don't know the pt's complete hx; we've had several very sick pts over the last few weeks, so I don't want to tell you something having gotten her confused with someone else. I will try to get a clearer pic tomorrow when I am back on the floor. I know - I swore she was abrupting too (honestly, I never thought about rupture because from what I could see, she was relaxed between contractions.) I think a lot of the screaming was that she was 17 years old, scared and no one could really explain to her what was happening (not that I really think it would have made her more calm); she kept saying, "stop pressing on my stomach! Stop pressing on my stomach!" when I know no one was pressing on her stomach. Does this give you anymore clues? And path will def get somebody results on the placenta, so I'll see about finding out about those.
Also, I know what normal blood gas values are for an adult, but what are they for a neonate? I've been told that 7.15 is normal. Is this correct?
Unfortunately, I really could not find anything more out on this pt except that she came in jaundiced as hell with a temp of 104.8 initially. The nurses said that they thought the docs had decided that it was Hepatitis, even though her tests came back neg. As far as the baby goes, I can tell you that it is now off the vent, which is a good thing. Still not sure what made the baby crash like that if she had not abrupted - maybe he was just so stressed that he finally said "I quit!" Who knows??????
I am still leaning toward fatty liver myself.
You know, SmilingB.......I have really become intrigued about this case.
I now agree that the fatty liver had something to do with this. I know you know that the "out of proportion" pain can be significant in HELLP. Pain definitely in the RUQ. Fatty liver is common in this syndrome as well.
Unfortunately dx is often delayed pending differential, but, to be in the hospital for a month, I just don't know.
The jaundice. Fever? .... Septic. Platelets? WBC? Treated with steroids?
I would vote for hepatic imaging to r/o supcapsular hematoma/rupture ...of course before the actual termination of gestation.
Infant RDS is very common with HELLP syndrome.
Interesting.
sirI, MSN, APRN, NP
17 Articles; 45,876 Posts
Wonder what the admitting dx was?
Yep, more and more like a frank rupture/tear.