GYNECOLOGICALMorbidity & Mortality

Presented by: Dr. Ayman Bukhari

Under supervision of : Prof. Hassan Abdul-Jabbar Dr. Faisal Kashgari

MR NO. 664144

A 24 y.o single Chadian lady was brought to E.R on 28/01/2009 at 08:34 P.M with a complain of:

P-V bleeding confusion for 3 daysgeneralized fatigue

The first assessment :

Case was first referred to ICU department as the patient was vitally unstable

BP=62/41 P=99 RR=24 T= 35.8

O2SAT=100%

ICU DOCTOR ASSESSMENT IN E.R

Hx : moderate PV bleeding ..3 day’s durationLMP: 16 week ago No clots ,Dizziness for 1 dayPalpitationNo nausea ,, vomited once

cont.ICU DOCTOR ASSESSMENT IN E.R

O/E : BP = 50/40 P=100 RR= 24-30conscious , orientedS1+S2+0RESP. : EAE , CLEARABDOMEN : distended but laxSuprapubic mass ?? bladder

cont.ICU DOCTOR ASSESSMENT IN E.R

No neck regidityNo L.L oedema. . No DVT signs

At 09:00 PM : 1 L N.S I.V bolus

At 10:45 PM : BP= 70/55 P=100 O2SAT= 100%

Pregnancy test was sent>>>> PositiveImpression : shock for D.D :

hypovolemic , ?? septic

cont.ICU DOCTOR ASSESSMENT IN E.R

Plan : keep MAP of 65 mmHg UOP >= 0.5 Ml/kg/hr

Give IVF challenges & monitor Pt. Response & tolerance

O.B.GYN consultationCXR, ABG, U&E, Coag. Profile, CBC, serum

lactate levelRecontact ICU after the results are shown

At 01:25 AM :Pt is not responding to IVF wellABG : severe metabolic acidosisPH= 7.1 HCO3= 3.8 PCO2=1.61

PO2=17.99Hb= 7.1WBC= 44PLT= 32Pt= 35.5Ptt=117INR- 3.4

BG: B PositiveNa=133K=3.5Cl=96BUN- 4.3CRTN= 242Ca= 2.04L.A= 17.2

Plan: Dopamine infusion was startedTrace rest of results ,,Sickling test>>> NegativeNAHCO3 50 Ml I.V D-D, Fibrinogen , Perepheral Bl. Film &

hematology referral

At 5:30 AM : Gyne. On-Call review22 YO single , medically ? Aneamia

Amenorrhea 14-16 W

LMP= Not sure

P-V BL. Mild to moderate for 3 days

Hx of fever , chills at home but not documented

Cont. Gyne. On-Call review

Denied any Hx of pregnancy or attempting to abort nor instrumentation

Gave Hx of vaginal infection & took supposatories??

Came to ER in shock, most likely Dx >> Septic shock

Cont. Gyne. On-Call reviewO/E : P/A: soft, distended, No tenderness, No

GuardingAround 12 w GA uterusP/V: only inspection : minimal bleeding

Impression: pt is in sepsis ,,,, to R/O septic abortion

Plan: urgent U/S

At 05:30 AM :U/S result: small RPOC ( hyperechoic

structure ) 3.2 x 2.7 cm ,, No gestational sac ,, no fetal polemoderate ascites

Repeated Labs :Hb= 6.6 WBC= 38.7 HCT= 22.2PLT= 25Pt= 23.5 Ptt= 84.7L.A = 13.1Serology was sent >> negative

At 05:45 am : BP = 100/59 P=125

so the plan was to wean the Dopamine pt is conscious , oriented , no PV bleeding

D/W consultant On-Call: to repeat U/S , QBHCG& discuss with head of department about D&C

At 06:30 am :Pt is deteriorating with Dopamine

BP= 70/55Plan : consultant is on the way for D & CThe pt is admitted to MICUArrangement for ER D&C ..

Anaesthesia .. Will not start untill FFP & blood is ready

At 07:40 am : FFP is ready + 2 U of PRBC in OR fridgeCalling for the patient to be transferred to

OR from MICU

At 08:50 am : pt was transferred to O.R

Procedure: evacuation of RPOC for case of septic abortion, septic shock

Uterus= 14 W , hymen not intact

During O.R :

Under U/S guidance: moderate amount of tissue attached to the uterine wall with offensive smell removed and sent to histopathology>> multiple fragments of tissue composed of blood clots and decidua,, final diagnosis : POC

During O.R :

EBL= 1 L6 U FFP5 U PRBC2 Packs in VaginaPt was shifted back to ICU

At 11:45 am ... Back to ICUPt was received in MICU from OR as a case

of :

Septic shock DICmultiorgan dysfunction

due to septic abortion( post evacuation & curettage)

Upon arrival to MICU

Intubated & ventellated

Sedated on propafol infusion

BP= 121/82 P=132

On Norepenepherin 40 Mg/min

Upon arrival to MICUChest was clearSinus tachycardiaAbdomen: mild distension2 packs in vagina .. Still bleeding

Plan: CBC, PT , PTT Q6hrsLFT , U&E, D-D, Fibrinogen, Peripheral Bl. Film & blood culrue

Cont. Upon arrival to MICUHb = 9.6WBC= 40PLT= 28PT= 20.5 PTT= 62.5Fbrinogen= 193.8D-D = no reagentINR= 1.8L.A = 13.8

Cont. Upon arrival to MICU6 U FFP ,, 6 U Cryoprecipitate

Keep 10 U FFP stand by

4U PRBC stand by

Pt is on : Pip/Taz , Gentamycine , Ranitidine

On 30/01/2009Pt is intubated in ICU ,, FiO2 45%PEEP + 5

BP= 80/70T= 38.5

Intake=200cc/hUOP= 200 cc/h

Hb= 8.3WBC=35.6PLT= 18PT= 17.9 PTT = 51.6

L.A= 6.4 INR= 1.7Plan : cont. Ab

remove vaginal pack>> minimal clots & beeding

On 31/01/2009Pt is on assisted mechanical ventilationMinimal bleedingOn Norepenipherine 14 mcg/hOn Vasopressin 2.4 U/hUOP= 100cc/h ,,, positive balance 2019

MlBP= 115/80Lax abdomenNo incidence of CNS insult

Cont. IN MICU ON 31/01/09Inv : PH = 7.3 PCO2= 45.4 PO2= 83.1

HCO3=23.2

Hb= 6.9WBC= 43.1INR=1.3 PTT= 50.8 PLT= 35Na= 141 K=3.1 CL-105 Mg= 0.9BUN= 6.7 CRTN= 128 Ca= 1.94

PO4=0.88AST= 1078 S. Lactate= 7.1

Plan :

1 U PRBCs I.D referral NGT feeding ECHO

On 01/02/09 MICUDay 3Still sedated ,, on Propofol 1 Mg/Kg/hPt is on vasopressin , Norepenipherin stoppedOn NGTGCS : 8 /15ECHO >> EF = 40 % , severe T.R & Pulm.

HPN

InvestigationsHb =7.8 WBC = 37PLT= 35PT= 13.4PTT= 42.8BUN= 7.8CRTN= 108INR= 1.3

On 02/02/09 MICU

No much change..

Blood culture : + Candidiasis , Diphthroid species & Staph. Epideremedies

Infection team : started Amphotericin B on top of Gentamycine & Pip/Taz

On 03/02/09 MICUPt is still intubated ..rate = 12 BPM , FiO2=

30%Bp= 95/56T= 36.8P=97Hb= 8.4WBC= 34.4PLT= 44INR=1PT= 11.7 (N) PTT= 35.8 (N)

On 04/02/09 MICUEXTUBATED

Agitated ,, Psychiateric episodes

Psychiatry consultation >> Lorazepam , Olanzapin

Was clinically improving ,, minimal PV bleeding

No much change on the day after

On 06/02/09 11:00 pm MICUBP= 100/60P= 112T= 37.8 RR= 37Hb = 9.1WBC= 32.9PLT= 73PT=12.3 PTT=40.9 INR= 1BUN=4.7 CRTN= 74

D-D = 4084 L.A= 1.6 (N)

?? Pelvic ThrombophlebitisHeparin prohylactically was already started

at same day

Switched to Heparin Infusion 1000 u / h

Doppler U/S L.LC-T Pelvic Venography to R/O pelvic

thrombophelibitis Ordered

Spiral C-T

Next Morning 07/02/09Pt is conscious , oriented

T=37 BP=110/70 RR=24

Chest: clear , EAEDoppler >>> DVT both Distal Common Femoral Veins

Hb= 9.5 WBC=21.1 PLT= 101BUN= 4.8 CRTN= 60PT= 11.5 PTT=51.8INR=1

On 09/02/09P=94BP= 108/69RR= 23-30T= 37.6 O2 Sat=100%PV bleeding stoppedChest is clear Abdomen was soft & Lax

Spiral C-T : confirmed the Dx of PE Bilateral segmental pulmonary emboli

PLAN: to continue heparin infusion,to keep INR within therapeutic range

After 2 weeks in MICUPt was progressing well with heparin infusionWas vitally stableOn 12/02/09 : Warfarrin 10Mg po startedOn 13/02/09 :

BP= 106/49 P=89 T=36.5 O2Sat=100%Hb=10.6WBC=8.7PLT=359INR=2PTT= 93 PT=22.6

On 14/02/09 MICUPt has improved a lotBP= 100/64P=79T=36.5Hb=10.7 WBC= 9.5 PLT= 464PT= 25.5INR= 2.3BUN & CRTN >> 4.6 & 68 ( N)

On 15/02/2009Pt is vitally stable , in a good shapeBP=101/70 P=83 RR= 20 T= 36.9Hb=10.7 WBC=9.5PLT=464On warfarin .. INR= 2.3PT=23.2PTT=52.9Blood Culture>>> No Organisms Identified

Plan : to discharge from Gyne site to transfer to F.M.U

Pt is on : Gentamycine , Ranitidine& Warfarrin 10 Mg

D/C Pip/TazD/C Olanzapine & LorazepamD/C Amphoterecin B

After 18 days MICU stay ..Plan to transfer the Pt to Female Medical

Ward in a stable condition

Stayed under observation for 3 days in F.M.W

Gentamycin was stopped in the 2nd day

On 18/02/2009 :BP=122/80P=71 RR=20T= 37.2 O2Sat= 99 %INR=2.8Pt=29.2Ptt= 53.4LFT & U/E >> N

Cont. On 18/02/2009 :discharge day..

After 3 days observation in F.M.WPt looks very wellPlan: Discharge on : Warfarrin 10 Mg P.O O.D O.P.D 1/12 >> Medical & Hematology ECHO as an out patient

Thank You

Case 2 MR NO. 636979A 42 y.o Burmese lady Un bookedG16 P14 + 1 GA= 36 wK/C of chronic hypertension for 12 yrs on

medicationsPrevious 2 C/S due to PET .. First C/S >>outside & the second one was an emergency C/S done

in our hospital on 28/01/2008>>severe PET , Left Parieto-Occipital infarction >> 2 days ICU admission

On 19/01/2009 at 01:08 A.M patient presented to E.R with a chief

complain of CONVULSION one time at home and brought by her relatives

Vitals in triage at 01:15 A.M : BP=121/101 P=98 T=36 C RR=22 O2 sat= 97%

At 1:50 A.M : E.R Gyne doctor assessment: G16 P14 + 1 , 36 w , prev. 2 C/S due to severe

PET cof convulsion one time . Tonic-clonic .

Hx of H/A & blurred vision No other complaints

Cont. E.R Gyne doctor assessment: manual BP= 147/109

urine dip stick +3 protein

P/A: soft , Lax & fundal hieght = date

Doppler F.H = 147

P/V: os = 1-2 cm

Blood taken for PET profile,CBC,U&E ,LFT & cross match

Foley’s catheter

Magnesium sulfate loading dose 4 g

Paediatrics were informed

Pt. was admitted to Labor room at 02:30 A.M

In L & D at 02:35 A.MPt is semi concious

B/P= 147/105

Urine protein +1

Bed-side U/S >> lateral placenta , positive F.H

Pt is on MgSO4 maintenance dose 2 g / hour

CTG>>no uterine contractions ,no decelerations , base line 118 BPM, decreased variability

Plan: to do C-T brain and after the result>> C/S

At 03:30 A.M :Pt was sent for C-T with the MgSO4 infusion

At 04:30 A.M : pt was recieved back from C-T

BP=136/100 P=96 T=36.8RR=23 O2SAT = 98%

C-T result:

Old infarction at the left fronto-parietal and parieto-occipital lobes . No active infarcts nor intracranial bleeding .

Lab results: AT 02:12 A.mPRBC X-Matching : A positiveRBS:5.0PT= 10.6PTT= 27.5FIBRINOGEN=470.5D-D= 260.2INR= 0.9ALBUMIN=24 ALP= 122 ALT=25 AST= 26 GGT= 12

TBIL= 3

Cont.WBC= 8.0 Hb. = 10.1 Hct= 30.6 Platelet =

255Na = 135K= 3.6Chloride = 101 Urea = 2.7Creatinine = 70Calcium= 1.94Mg= 0.77 (N)

At 05:15 A.M: anaesthesiologist reviewed the pt and they refused to start unless if there was a SICU bed available

At 06:00 A.M: pt was pushed to O.R & emergency C/S was done under S . A .. BP= 144/104

A straight forward C/S with a baby girl delivered at 06 :55 am with good APGAR score wt>> 3.1 kg and

EBL= 600 cc

At 09:00 A.M :Post OP : Pt was having heavy PV bleeding in recovery area

Examination : BP= 99/76 P=100T=36

P/A: Lax uterusDiagnosis of uterine atony was made

Pt is on : zenacif , ferrus & caltirate

Plan : prepare blood and to take the pt for O.R

a subtotal hysterectomy was done

EBL = 2.5 L >> received 4 U PRBCs , 6 U FFP & 6 U cryoprecipitate

Surgery finished at 11:15 A.M and pt was intubated

BP=187/119 P=123 T=36.8 RR=28 O2SAT= 90%

Pt was transferred to SICU

Lab results at 09:30 A.mINR= 2.8PT= 29.8 FIBRINOGEN= 80.9D-D = 18749 APTT= > 2 min.WBC= 8.1 Hb.= 5.1 HCT= 13.1 PLT=

122ALB = 7 ALP= 38 AST = 12 ALT= 16

GGT=7 Tbil=4Na= 139 K= 3.6 CL= 111 BUN= 1.8

CRTN= 41

IN SICU :Pt stayed for 4 days.

To continue MgSO4 infusion 24 hr

Propofol infusion .. Centeral line

B/P = 170/100 upon admission to ICU

Hydralazine 5 Mg I.V was given

SICU DAY 1: 19/01/2009Pt. Was intubatedDROWSY

BP = 133/92 – 158/98 T = 36S1+S2=0Clear chest , abdomen :soft and lax , tender to touchLAB works: Hb= 9.1 Wbc=8.2Mg= 1.42 CXR>> N

Medications given :CEFUROXIMEPANTAPRAZOLDEXAMETHAZONEHEPARINAMLORATENOLOLI.S.SASA

SICU DAY 2-4 : 20-22/01/2009:After overnight observation , unable to

extubate due to probable laryngeal oedema ( difficult airway at time of surgery & multiple attempts)

IV steroid was givenDay 3 patient was extubated Fully concious. BP= 160/108P=71 afebrile UOP= 3240 ccPortovac= 410 cc bloody on day 2Otherwise , uneventful ICU stay.

Lab works-day 2 IN SICU :WBC=11.4 Hb.= 9.4 HCT=

28PLT=169Na=136 K= 3.6 CL=101BUN= 1.5 CRTN=63CALCIUM= 1.9 Mg= 1.32 Phosphate= 1.41Albumin= 18

Lab works-day 3 IN SICU :WBC= 10.2 Hb.= 8.5 PLT=

166Hct= 26.8INR= 0.8Na= 138 K= 4 Cl= 101BUN= 2.7 CRTN= 69Calcium= 2.06Mg= 1.01Phosphate= 1.73Albumin= 17

At discharge from SICU-Day 4Condition at discharge: stable

Medications on discharge : Cefuroxime 1.5 g Q8(19/01) x 5 days ,

Pantoprazole 40 mg iv od Atenolol 50mg ODHeparin 5000 U S.C BID Amlodipine 10 mg ODASA 81 mg OD

BP = 116/80

P=74

RR= 18

O2Sat= 98%

Urine : clear

Lab worksHb = 9.1Wbc=10.2PLT= 212PT=10.1 APTT=35.7Na=131 K =131 Mg=1.01 Crtn=69

Urea= 2.7Ca= 2.06 Ph=1.73 Albumin= 17

23/01/09 : in O.B ward :BP=118/81 P=66 RR=18 T =36

O2Sat=98%

Clear chest, s1 + s2 + 0

Portovac = 20cc in 24 h not removed serouse

UOP= 2400cc/24 h

No PV bleeding

On discharge :Pt was discharged on 25/01/2009 in a good

condition

Portovac was 5 cc>> removedBP=120/75 P = 82 afebrileWBC= 8.3 Hb= 10.3PLT= 420 INR= 0.9

ENT OPD 6/52GYN F/U 6/52

Thank You