CASE PRESENTATION
By Dr. Harika.N postgraduate 2nd yr
Department of OBG
21year old Mrs..Sandhya w/o of Raju R/o Nalgonda, home maker by occupation, belonging to socioeconomic class 4 brought to the labour room at 6:30pm on (08‐08‐2015) She is primigravida with 9 months of ammenorhea came with h/o of two episodes of convulsions at home around 5:00pm
H/o of present illnessPatient was apparently asymptomatic before, She suddenly developed headache at 4:00pm and she also developed sudden blurring of vision and which was followed by two episodes of vomitings.
h/o of two episodes of convulsions at home which were generalized tonic clonic seizures, each episode lasted for 2‐3minutes associated with frothing and tongue bite, invlountary micturition, drowsiness.
h/o of one similar episode in the ambulance.And the patient had two episodes after coming to hospital.
No h/o of bleeding per vaginum or leaking per vaginum.No h/o of white discharge and no h/o of burning micturition
Menstrual history
Attained menarche at 14 yrsRegular cycles – 30 days durationNormal flow for 3 to 4 daysNot associated with dysmennorhea or passage of clots.LMP‐ 21‐04‐2014EDD‐ 28‐08‐2015POG‐ 36weeks
Marital history11months of married lifeNon consanguinous marriageNo h/o OCP usage
OBSTETRIC HISTORYConceived after 3months after marriage Spontaneously1st Trimester: uneventful,Pregnancy confirmed by USGDating scan doneNo h/o vomitings, fever, bleeding p/v,
2nd Trimester : Quickening felt at 5 monthsTaken 2 doses of TT at 5th month & 7th monthTaken iron and folic acid supplementation regularlyNo h/o bleeding p/v , no h/o headache/ blurring of vision/ pedal edema/ decreased UO3rd Trimester : she was apparently asymptomatic till she came with the present complaint.
Past historyNo h/o diabetes mellitus, hypertension, Tuberculosis, Asthma, epilepsy, thyroid , heart disease in the pastNo h/o blood transfusion and no h/o of any surgeries in the past.
Personal historyMixed dietSleep , appetite – normalBowel , bladder habits – regularNo addictions
Family historyNo h/o DM, HTN, TB, Asthma, Epilepsy, Thyroid, Heart disease, in the family
no h/o of any drug allergy.
General examinationPatient was drowsy ,irritable, responding to painful stimuli, not well oriented.B/L pupils normal size reacting to light Moderately built & nourished.No pallor/ icterus/ cyanosis/ clubbing/ koilonychia/ pedal edema/ lymphadenopathyThyroid, breast, spine – normal.
VITALS
Temperature: AfebrilePR – 88/min, normal in volume, regular in rythm.BP – 140/100mm of Hg, in right arm, supine positionRR– 24 cycles/min
SYSTEMIC EXAMINATION‐
RS – Bilateral air entry+, normal vesicular breath sounds heard, no added sounds /no basal crepts /no rhochi
CVS ‐ S1 S2 heard, no added sounds and no murmur.
CNS examination : no gross focal neuro deficitDeep tendon reflexes : exagerattedPlantars‐down going.
Obstetric examinationPer abdomen:Inspection : abdomen is uniformly distendedumblicus normal and central, stria gravidarum, linea nigra seen, no sinuses and scars. all hernial sites are normalAll quadrants moving equally with respirationNo visible pulsations.
Palpation : fundal height‐ uterus 32 ‐34wks, corresponding to the gestational age, SFH – 32 cm, AG – 32 inches.Fundal grip – soft broad non ballotable mass felt s/o breechUmblical grip: Rt ‐ knob like structures felt s/o limbs, Lt – continuous resistance felt s/o back
1st Pelvic grip : smooth, hard ballotable structure felt s/o head.2nd pelvic grip : hands are converging over head, s/o head not engaged abdomen is relaxed Liquor less clinically.Auscultation: FHS heard on Lt spino umblical lineFHR‐ 148/min,regular
p/v‐ cervix soft midpostion 30% effaced os admitting 1 finger presenting part vertex ‐high up.
Pelvis‐ sacral promontary‐ not with in reach sacrum well curved Inter spinous diameter‐ average side walls parallel out let adequate
PROVISIONAL DIAGNOSISPrimigravida with 36 weeks of gestational age with severe oligohydrominos with ante partum eclampsia in early labour.
Investigations : BLOOD GROUPING : 0 positiveHb ‐ 13.8 g%TC : 10,000/ cummPlatelet count : 2 lakhs/cummBT CT , PT aPTT : WNLLDH,RFT,LFT: WNLCUE : albumin 4+,6‐8 pus cellsRBS : 82 mg/dlHIV, HbsAg, VDRL – non reactive
Obstetric scan : SLF , cephalic presentation 35 weeks BPD : 7.0cms FL : 6.2cms EFW : 2.1kg placenta : anterior, upper segment, EDD‐ 06‐09‐2015 AFI‐ 4cms. oligohydromnios IMPRESSION: single life intra uterine gestation with 35 weeks with oligohyromnios
IMMEDIATE TREATMENTO2 inhalation.Iv fluids startedPatient was positioned on left lateral positionAirway secured with mouth gauge and suctioning is done.Inj MgSO4 loading dose 14gm (10gms im/4gm iv) given. cap Depin 5mg S/L given Foleys catherization.
High risk consent was taken Pre anesthetic checkup was doneBlood and FFP’s were reserved. patient was taken for emergency lower segment cesarean section at 10:00pm on 08‐08‐2015Indication: primigravida with 36 weeks of gestational age with oligo hydromnios with antepartum eclampsia
Intra op findingsLower segment well formed Bladder normal In positionLiquor thin meconium stained and less Delivered an alive male baby of wt 2.0kg with apgar 8 and 10 at 10:25pm on 08‐08‐2015Placenta expelled intoto and normal morphology. Uterus well retracted /no pph.
At the end of surgeryVitalsPR‐150/MINSPO2‐ dropping to 85%RS‐ creptations + with occasional rhonchi+ more at the basal region.
In v/o pulmonary edema it was decided to put the patient on mechanical ventilator (IPPV with PEEP)
IMMEDIATE POST OP CONDITIONVitals:
PR‐148/min low volumeBP‐80/50mmhgRR:30 cpm.Afebrile
Spo2‐ 85%(FiO2 : 100%)Central venous line is placed for CVP monitoring.
Specific investigationX ray chest: s/o pulmonary edemaEcg‐Sinus tachycardia ventricular ectopics+ occasionally
left axis deviation2dEcho: Acute left ventricular dysfuction
RegionalWallMotionAbnormality + , Global hypokinesia EF‐ less than 30%Hematology/biochemistry and serum electrolytes and coagulation profile was sent
X‐RAY‐
ECG‐
Diagnosis Primigravida with 36 weeks of gestational age with severe oligohydrominos with ante partum eclampsia under went emergency LSCS With peripartum caridomyopathy with LV dysfunction with Pulmonary odema
Treatment Inj dobutamine 5 micgm/kg/min infusionInj furesamide 20 mg iv BDRestriction of IV fluids and were admistered according to CVP and U/O Inj piperacillin and tazobactum 4.5 gms iv bd Inj metronidazole 100ml iv tid Inj pantop 40 mg iv odStrict i/o monitoringVitals monitoring
POD‐1
TIME VITALS ABG
10:00AM PR‐148/MINBP‐80/70SAT‐ 85% UO‐15ML/HR
PH‐7.17PCO2‐36.7PO2‐38.8HCO3‐13.1
4:00PM 130/MIN90/60SAT‐99%UO‐20ML/HR
PH‐7.3433.460.717.6
9:00 PM 118/MIN100/60SAT‐ 100%UO‐20ML/HR
Investigations HB‐13.5gm%Tc‐20,000Platetet‐2.16lakh/cummPT‐18 SecAPTT‐ 34 SecRFT‐ urea‐26mg/dl creatinine‐1.2mg/dl electrolytes‐normalLFT‐ AST‐59iu/l ALT‐104iu/ml
POD‐2 patient was on mechanical ventilatorSpo2 100% PR‐114/minBP‐ 130/90mm hgB/L‐ minimal CREPTS+, X‐ray improved P/A‐ Uterus well retractedP/V‐ no active bleedingTreatment :
Inotropic support (Dobutamine ) was tapper to 2.5 micgm/kg/min
Weaning of patient from mechanical ventilator was startedRest was continued
Investigations HB‐10 gm%Tc‐15,600Platetet‐1.6lakh/cummPT‐16 SecAPTT‐ 34 SecRFT‐ urea‐32mg/dl creatinine‐1.8mg/dl electrolytes‐normalLFT‐ AST‐59iu/l ALT‐104iu/ml
P0D‐3Patient was on mechanical ventilator with minimal inotropic
supportSaturation‐99%BP‐110/90mm hgPR‐88/minP/A‐ Uterus retracted wellp/v‐ no active bleedingTreatment:
Inotropic support was tappered and removed Weaning trials were successful and she was planned for extrubation She was extrubated at 3:00 pm. Rest continued
POST EXTUBATION:Vitals:spo2‐97‐98%PR‐98/MINBP‐130/90mm hgH/L‐ crepts+P/A‐ uterus well retratcedp/v‐ no active bleeding
Post operative day 4,5,6,7 were uneventfulVitals stable Suture removal was done on 7th post operative dayPatient was actively ambulatedEncourgaed for breast feeding patient was stable and hence was discharged on 9th post operative day.
Thank You