Clinical Case 012: Obstetric challenge

Ok here is my first Obs case.  Ultimately a poor outcome, but one where I think we can all learn some important stuff about pregnancy and the type of medical errors that can occur.  Here is the case:

26 yo, G2P1 – previous straightforward vaginal birth 2 years ago.  Unremarkable antenatal history this pregnancy. Thin, normotensive, all screening NAD. Normal USs at 12/40 and then 20 weeks – normal anatomy scan.  Rhesus +, OGC – negative  Shared antenatal care between GP and local hospital.  PMhx:

  • Recurrent SVTs, eventually treated with AV-node ablation, no ongoing symptoms.
  • Anxiety disorder with panic symptoms, responded to CBT, now well.
  • Appendectomy age 13

Now, skip forwards to labour day – presented mid-afternoon in spontaneous labour 39 + weeks.  Admitted to labour ward, commenced on partogram.  Requested an epidural at 4 cm around sunset.  Gp-Anaesthetist attended – noted high BP, 160/100 and asked for a UA – this showed 4+ protein.                  On examination:  noted to have clonus on ankle jerks.     GP sited an epidural and called the on-call O&G for further assessment

On review the BP had fallen to 140/85, pulse = 100, in active labour, afebrile, no headache / visual disturbance, abdo pain or oedema.  Decision was made to expedite labour and augmentation resulted in an SVB at 20:00 – healthy boy, Apgars 9 + 10.  The family were moved to the ward around 10 pm.

Over the next 8 hours the obs changed dramatically, in a nearly linear fashion…

  • pulse increased from 90 to 130/min
  • BPs were consistently increasing – up to 170/110
  • RR was normal, but climbed in the early hours of the morning to 28/min
  • SpO2 started falling just before sunrise – down to 90% on nasal prongs by morning

The O&G team were called several times and the obs were explained as being due to pain and then a recurrence of the panic episodes the patient had previously suffered…  the patient agreed “it felt just like my previous panic episodes!”   Treated with Panadeine forte and then temazepam 20 mg.

The following morning the team reviewed and made a diagnosis of pre-ecclampsia.  Patient was commenced on MgSO4 infusion as per protocol.

Became increasingly SOB and hypoxic despite being placed on a non-rebreather mask.  Best SpO2 in high 80’s.

Around 11AM a code blue call went out and I attended to the ward bed with the senior RNs and MWs.  The patient looked grey – combination of severe cyanosis and poor peripheral perfusion.  Marked dyspnoea, exam revealed a rapid, barely-palpable radial pulse and bilateral rales up to the shoulders.

Moved to Resus area for a trial of NIV, however became unconscious en route and was intubated on arrival to the Resus room.

Resuscitation with ventilation via ETT and CPR commenced.  Copious pink, frothy sputum coming up the tube with compressions.

Prolonged resuscitation attempts, lots of adrenaline and investigations – no return of circulation.

Fulminant ecclampsia with acute pulmonary oedema was the diagnosis that I wrote in the chart. Any other possibilities?
Large (L) adrenal pheochromocytoma. Widespread hypertensive changes – kidneys, retinae…

(1) The phaeo was not reported on the USs, though it was likely large enough to be visible if you were looking for it (2) The SVTs were investigated by a cardiologist including EPS and eventually the patient had an “empirical ablation” as nothing else was working (3) The panic symptoms were so severe that the patient’s GP had referred her to a Psychiatrist as they represented a clear change from her usual happy demeanor. (4) Never recorded a single high BP in antenatal clinic – likely due to the transient nature of the disease and the vasodilatation of pregnancy.

- Sometimes the hooves are zebras, this is a tough truth when it comes to general practice. You can spend years screening and never come up with a diagnosis like this, but you must keep it in your head, be vigilant and recognise patterns – Don’t be reassured by a specialist’s review and opinion. Go back to first principles and look at the details yourself rather than just assume the specialist has it all covered – I could spend all day on early recognition of clinical deterioration, but that is a whole other topic. Needless to say – don’t explain bad obs away and always be prepared to escalate if you are not getting good results / answers

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