Presented by: Dr. Ayman Bukhari Under supervision of : Prof. Hassan Abdul-Jabbar Dr. Faisal...
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Transcript of Presented by: Dr. Ayman Bukhari Under supervision of : Prof. Hassan Abdul-Jabbar Dr. Faisal...
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