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Obstetrical Case Studies
Patti Heale, RN, DNP
Objectives
• The learner will be able to identify the signs and symptoms of abruption
Case Report
• 29 yo G3P1 GA 27.3 weeks
• Previous SVD @ term
• PMH: Chronic HTN, BP 130‐145, 75‐95
• Type 2 Diabetes times 3 years• Medications: PNV, Tylenol, TUMS • Aldomet 250mg tid, Insulin (Regular, NPH)
2/16 AM
• 1100 Called OB c/o HA• 1145 Arrived OB office BP146/92
– HA, no epi pain, no scotoma, labs drawn– BPP 8/8 reactive NST – Aldomet increased to 500mg tid, – 24 hour urine collection begun, labs drawn– Return next day for BP check
2/17 AM
• 0900 Office Visit‐ BP check 138/88‐ NST – not reported as reactive or non‐reactive –“appropriate for gestational age”
‐ 2/16 labs not reviewed‐ 24‐hour urine sent
2/17 PM
• 1400 Called OB, c/o HA ‐ Tylenol• 1430 Arrived OB office
‐ BP 140/88, HA, no c/o epi pain or scotoma‐ No ctx ‐ ROM – bldg‐ Urine Dip: Protein 2+, labs drawn‐ GFM +, NST reactive, BPP 8/8
• 1530 BP 128/78, HA improved (Tylenol)‐ Patient to home on strict bedrest
2/18 AM
• 0900 Called OB, c/o worsening HA, N+V• 1045 Arrived OB office
‐ BP 144/90 no c/o epigastric pain or scotoma‐ Labs not checked‐ GFM +, BPP 8/8, FHR by Doptone 136
• 1145 BP 132/80, HA improved (Tylenol)‐ Patient to home on strict bedrest
2/18 PM
• 1200 2/16 and 2/17 labs reviewed• 1230 Attempted to contact patient x 3, LMx3• 1300 Patient called into office
• Patient told to go to L&D immediately
• 1600 Arrived at OB office BP 220/118• HA, severe epigastric pain, N+V, ctx q 2 min, • Sm amt dk red bleeding, 3/60/‐1
• 1620 Transferred to hospital by ambulance
Labs 2/16
H+H 13/38 increasedPlatelets 63,000 decreasedAST 76IU/L increasedALT 84 IU/L increasedLDH 653 IU/L increasedBilirubin 4mg/dL increasedUric Acid 6.89 increasedSerum creatinine 1.4 increased
Labs 2/17
H+H 15/43 increasedPlatelets 43,000 decreasedAST 112 IU/L increasedALT 98 IU/L increasedLDH 875IU/L increasedBilirubin 8mg/dL increasedUric Acid 9 increasedSerum creatinine 2.2 increased
Hospital Admission @ 1645
• BP 208/127• HR 128• RR 28 • Temperature 99.8• Urine protein 4+
BP 178/111 1645
Arrived in L&D Labetolol 20mg IVP given
BP 208/108
Labetalol 40mg IVP given, vaginal bleeding increases
1708
BP 190/105
Suddenly c/o severe abdominal pain, board‐like abdomen noted
1716
1725
Prepped for C/S, moved to OR
Outcome
• 1730 PC/S • Complete abruption noted at delivery• Chronic HTN with superimposed preeclampsia• HELLP• DIC
Infant Status
• Apgars 0, 2, 5• Full resuscitation• Infant transferred to NICU• Severe hypovolemia, seizures, low BP• Blood transfusions, dopamine • DIC after 4 days• Passed day of life 5
Abruption
2/18 Labs
H+H 15/42 increasedPlatelets 16,000 decreasedAST 642 IU/L increasedALT 598 IU/L increasedLDH 1025IU/L increasedBilirubin 9mg/dL increasedUric Acid 9.2 increasedSerum creatinine 2.8 increased
Cord Gases
Arterial gas• pH 6.82•pO2 16•pCO2 50•Bicarbonate 2•Base Deficit 18
Venous gas•pH 7.18•pO2 40•pCO2 55•Bicarbonate 12•Base Deficit 8