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Clinical Case 136: Maternity Mystery

Another case from the archives this week.  This is a really tough case… things are not what they seem.  Although this is an Obstetric case it does contain a lot of valuable lessons for all critical care practitioners.    I will describe the case and leave it hanging for you all to ponder and comment upon… will be back in a few days to close it out and discuss the diagnosis.

Here we go:-

Kelli is a 27 yo woman who is G2P1.  She is currently 39 weeks and has been having irregular contractions all day but is now in early labour.  It is 9 PM.  As the GP-Anaesthetist you have been called in as she has requested an epidural for her labour analgesia

Her antenatal records are relatively normal and she has had a full set of routine antenatal care with bloods and ultrasounds as per protocol.  Her BP, urinalysis, fetal growth and weight had all been tracking normally and there were no symptoms of pre-eclampsia.

Bloods done in clinic last week including FBC, LFTs and electrolytes are all completely normal.

The only information on past medical history are:

  • Anxiety disorder with panic attacks early in the pregnancy.  She was seen by a local Psychiatrist who felt she was a good candidate for cognitive therapy (not SSRI) given her pregnancy and she had 6 sessions with  clinical psychologist.  She had a good outcome and was coping well with infrequent panic episodes without any interval anxiety.
  • Palpitations 1 year prior.  She had experienced this in the post-partum period with her first child.  She had a Holter monitor which showed brief episodes of sinus tachy.  She was reviewed by the visiting Cardiologist who felt this was benign, possibly anxiety related.  Reassured.
  • A few ED presentations for epistaxis which have required a nasal pack on one occasion – none recently.
  • Headaches ? migraines vs. tension / daily headaches.  Have been infrequent in the last year.  Previously had disabling headaches about once every few months.  Never really diagnosed. Saw a Neurologist 2 years ago – empirical nasal Sumatriptan trialled with some resolution.

OK, so back to the labour ward.  On arrival the midwife informs you (the GP anaesthetist) that Kelli is now 5 cm dilated with good, frequent contractions in spontaneous labour.  She is moderately hypertensive 130/90 but in quite bit of distress with contractions.

She consents to epidural and it is inserted with no complications.  After an initial bolus her BP settles to 120/85 and she gets good pain relief after 20 minutes.  However…

… as you are about to leave you note that she seems “a bit twitchy”.  Something doesn’t seem right.  Despite the epidural wearing in you decide to check her reflexes.  Her knee and ankle jerks are quite brisk.  On testing she has 2 – 3 beats of clonus.  Hmmm…

The BP is now 110/65 and she is looking quite relaxed.  She denies any headache, visual symptoms, or abdominal pain to go along with PET.

The midwife inserts an IDC as part of the epidural protocol and you check the initial CSU on a dipstick – there are 4+ protein and a trace of red cells.  Rechecking the chart shows no prior proteinuria.

Confused by the findings you call your colleague who is covering the labour ward and outline what you have seen.  They agree to come in and review Kelli for possible PET and maybe the need for prophylactic MgSO4 to prevent an eclamptic seizure.  By 10 PM Kelli is “cracking on and a repeat exam shows her to be 8 – 9 cm dilated.  The plan is to push ahead and get this baby out as soon as possible.   You head home.

At midnight you give the midwife a call: “how is Kelli going?”

Good news: “she has just had a little boy and both are well.  Thanks for coming in, that epidural really worked great.  Are you happy if we pull it out now?”

“Sure, pull it,” you reply.  “Goodnight.”

At 1 AM your Obstetric colleague phone you back with a question…

Kelli has developed a headache now.  It is bi-temporal and not really postural.  Do you think you might have caused a dural tap with the epidural?

Her BP is now 145/95 with a pulse of 100.  She has had a small postpartum haemorrhage of 700 mls, however this has stopped with a dose of oxytocin and uterine massage.

The headache doesn’t really sound like a dural tap leak; it is too soon – besides you were very certain that you didn’t trash the dura on insertion.  “Maybe it is part of the evolving PET picture?” you postulate with your mate…  Together you decide that she should probably get loaded with MgSO4.

OK I will leave this case here.  Sorry if you are not Obstetrically inclined.  This is a tough case.

What is going on?

Hit me on the comments if you have any ideas.

If you get it right you may save the day.

Casey

Comments

  1. I think we should perform second neurological examinstion

  2. Wendy hughes says:

    Catecholamines? This is ringing worry bells, but maybe the wrong ones.

  3. Does she have an underlying phaeochromocytoma?

  4. Dean Burns says:

    Hi Casey

    Great case. I’d be somewhat concerned about an evolving HELLP syndrome. It would certainly be on the differential.
    The trace of blood on UA might be an indication of haemolysis.
    Check the LFTs/FBC & get a blood film. Check LDH & platelets. Lower the BP & give some MgSO4. Consider platelets if she’s really low & bleeding (don’t know how isolated you are & how difficult it is to get platelets).
    If she’s really sick, might need to be transferred out.

    You’re doing a phenomenal job. Hats off to you.

    Best wishes

    Dean

  5. Was the cardiac examination normal? Was she experiencing any further palpitations? No arrhythmia?

  6. Which medication did she receive in the epidural? Did she get any meds during delivery that have any serotonin activity?
    My other guess is an undiagnosed pheo- htn, anxiety, intermittent tachycardia, headaches

  7. I guess the other thing to consider would be something like a cerebral sinus thrombosis. I’ve seen a patient present the same way with that odd history (minus the confounding proteinuria of course) who had a weird partial seizure and headache as her presenting feature. But then this is BroomeDocs so it could be absolutely anything.

    Raised ICP on ocular USS? I know you wouldn’t have been able to get a CT.

  8. Aaron Andersen says:

    Post-Partum pre-eclampsia versus central venous sinus thrombosis, higher risk in preganvy and presents as gradually worsening headache and worsening neurological exam. Serial exams, magnesium, and CTOH with worsening symptoms, CTV sometimes required.

  9. Intracranial haemorrhage from a ruptured AVM? Doesn’t explain the proteinuria though.
    Intriguing!

  10. Stephen Dick says:

    Hi Casey, first time poster, long time listener.

    I would be worried about either an intracerebral haemorrhage or amniotic fluid embolism, with the multi-organ involvement perhaps the latter?

    Of course it’s entirely possible that this is PET presenting post partum, as can happen.

    It sounds like she has had a shower of emboli of uncertain type.

  11. Interesting case, sorry i put this in the wrong reply box.

    Pregnancy related atypical haemolytic uremic syndrome?

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