Case Pt: 33 y/o Palauan female (P1G2) Hx: Booking Clinic at 9wks gestation Routine ANC Blood Works: All WNL Total ANC Visits: 8 ( between 9 -32 wks gestation) B/P: 100/62 – 112/68, P: normal - trace, G: all normal values Weight Gain: 26lbs Physical Examination: Nothing abnormal detected.
Case cont- Day 1 (Admission) Presented with fever and chills UA showed more than 100phf, ?TX, went home. F/U next day; C/O: severe neck pain, and fever. r/o Dengue Fever Investigaions: CBC: Hgb: 11.2, WBC: 7.5, Plt: 59 Electrolytes Dengue Titer: negative Admitted to MW with Diagnosis of UTI, Anemia and Thrombocytopenia. VS: B/P: 100/60-130/80, T: 103F (39.4°C), p: 120, RR: 20, O2sat: 97- 98 Treatment: IVF, Ampicillin, Tylenol, PNV and Feso4 Patient stable
Case cont. (Day 2) Gestation: 33 weeks 2 days Patient Progress C/O: Fever and Neck pain, SOB lying down. Fetal wellbeing; good. VS: B/P: 90/40-100/62 P: 130 T: wnl Lab Results: UA for R & M: wbc: 10-25, protein: 3+ Management Ob team approached for consultation; care initiated & to continue same management. 1 unit WB ordered. IVF continued (rate adjusted) Additional meds: Gentamicin Solu-medrol Dexamethasone CBC (AM) Repeated CBC Hgb8.26.9 WBC16.117.2 Plts17595
Case cont. (Day 3) Gestation: 33 weeks 3 days Patient Progress C/O: Neck pain, SOB when turning and ambulating Fetal wellbeing; good. VS: B/P: as low as 70/20 P: 109 RR: 28 (+ other readings) Lab ordered: CBC, INR, & PT/PTT Management Continue IVF (rate adjusted) 1 Unit of blood transfused. Additional Meds: Vit. K Terbutaline added for PTL. O 2 started. CBC Hgb7.6 WBC23.2 Plts124
Case cont. (Day 4) Gestation: 33 weeks 4 days Patient Progress C/O: Same as before AND Epistaxis (nurses notes) Fetal wellbeing; good. VS: B/P: 90/50 P: 103 RR: 28 on O 2 Lab Results: Bleeding time: 3.05 (nl: 2-4) PT: 14.9 INR: 1.32 (nl: 1.0-1.4) Management 1 unit of blood transfused Continue IVF (rate adjusted) No changes in management. CBC Hgb7.2 WBC21 Plts126
Case cont. (Day 5) Gestation: 33 weeks 5 days Maternal and Fetal Review C/O: Restless due to shoulder pain Tightness to both flank areas Increasing SOB. Condition unstable (nurses notes) VS: B/P: 100/60 P: 132 RR: 28 T: 100F (37°C) O2: 98% ( on O2) Fetal tachycardia noted on NST with uterine contractions. VE: unfavorable cervix. Lab results: Dengue Titer- negative Management Continue IVF with increased rate. Continue meds. No additional orders CBC Hgb8.9 WBC21.2 Plts107
Case cont. (Day 6) Gestation: 33 weeks 6 days Patient Progress C/O: Severe SOB Generalized pain and bruises on different parts of body. Very Unstable Chart reviewed. Diagnosis: HELLP Syndrome secondary to Severe Pre-Eclampsia developing secondary complications. Labs/Assessment/tx Lab results: CBC - WBC: 23.1 Hgb: 9.6 Plats: 75 BUN/Creatinine: urea-25, creatinine-1.2 Bleeding time- 4min.15sec PT-15.3 PTT-29.8 EKG: ST elevation on all leads CXR: Enlarged Heart Cardiac U/S: Moderate Pericardial Effusion LFTs:Sgot (AST): 413 Sgpt (ALP): 632 UA-7.0; lyts: not done NST-Fetal tachycardia Needs an emergency C- section Referral for Medical and Anesthesia on call for assessment and clearance before surgery. Family Conference Done.
Case cont. During Surgery & Post-op Patient lost about 2.5 liters of blood. Required continuous intra-operative transfusion. Baby delivered- no complications. Mother transferred to SW ICU and placed on Ventilator.
Case cont. Days 7-13 Patient continued to be ventilated Pericardial effusion drained x 2 Dark blood amounting to about 2.5L of blood Continued drainage. Pulmonary Hemorrhage: 2Lmls+ Renal Failure (due to shock/hypoxia): unable to dialyze. Total blood transfused: 15 units. Given almost all the Medications available and Staff support, she unfortunately passed away on day 13. Baby is doing well so far and hopefully will continue to do so.
Maternal Mortality Rates in Palau Maternal Mortality 1996 1996 case had Severe Pre-Eclampsia and developed DIC, unfortunately both mother and baby died.
Issues to think about Recommendations Issues that arose at the time: Suggest to do complete CBC on all ANC Booking for baseline. (Done) Role of FFP and Platelets in our setting. (Getting there) Source of Medical Air @ Hemodialysis Role of Social and Spiritual Health. (Done) Consult with Ob-Gyn for any Obstetric Admissions regardless of the admission. Improve NICU facilities/services to cater for Premature deliveries, specialized nurse, pediatrician specialized in Neonatology.