Case Study

29 year old G3 P1 EDD 3/16 with history of cHTN and previous history of
preeclampsia with severe features (delivery at 35 weeks)
-Previously discussed increased risk of developing preeclampsia (30%) and other risks
associated
-Patient did not like side effects of Labetalol, therefore self discontinued
-Continue Atenolol 25mg daily. Previously discussed potential for growth restriction but
will monitor growth q4 weeks. Continue ASA 81mg
-Antenatal testing with weekly NST beginning at 32 weeks gestation
-Delivery in the 39th week of gestation, unless earlier delivery is indicated.
Severe Nausea and Headaches, concerning for migraines
-Uses Fioricet PRN. The patient reports this is what she will continue as this is the only thing
helping
-previously referred to neurology for chronic management of headache.
Obesity- Class 2 BMI 41 (201 lbs, 5ft2in)
-recommend <15lb weight gain this pregnancy
-discussed importance of diet and exercise in pregnancy
Solitary kidney
-s/p laparoscopic left nephrectomy in 2003
-Done for "atrophic kidney" in the setting of labile blood pressures
-Nephrology consult revealed a healthy kidney by both blood tests and US
-Baseline creatinine 0.9 - continue to monitor monthly throughout the pregnancy
Depression/Anxiety:
-Continue Fluoxetine and Diazepam (previously counseled on risks)
-patient referred to women's wellness clinic previously
-continue mood checks
Herpetic Whitlow
-Continue acyclovir 800 mg daily
Palpitations
-EKG and echo Maternal echo WNL with EF 59%, normal LV wall thickness
-Cardiology diagnosed her with exercise intolerance. No clear etiology. Recommend
blood pressure control at this time.
Subclinical hypothyroidism
Prenatal Cares
-Continue daily prenatal vitamin
-Tdap vaccine to be administered between 27-36 weeks gestation, offer at next visit
-Declined influenza vaccine
Baseline studies
24 hour urine protein. 220mg
AST/ALT 17/15
HCT:39 Plt 282
Cr.0.9
EKG sinus tachycardia
Maternal echo WNL with EF 59%, normal LV wall thickness

Weeks Blood pressure Weight

7w1d 142/83 mmHg 91.4 kg
11w1d 147/89 mmHg no weight gain
14w3d 148/91 mmHg 91.8 kg
18w1d 143/91 mmHg 91.3 kg
20w1d 134/80 mmHg 91.9 kg
23w3d 122/67 mmHg, 93 kg , EFW:591gm (50%)
136/74 mmHg,
27w1d 139/98 mmHg 97.3 kg, EFW 959gms(41%)
 Event
Five days prior to admission:
Calls nursing triage with headache from sinus infection
Goes to Quick Care
Has headache
Right upper quadrant pain
SOB
B/P 180/120
Receives z-pack and albuterol inhaler
Arrival to Emergency department
Awake and alert 29 y.o G3 P01,1,1 EDD 3/16/2015 29.6 weeks patient arrives in
emergency department with severe right upper quadrant pain that started 1.5 hours ago.
Patient also has c/o headache and blurry vision. Patient had gone to Quick Care 5 days
prior with right upper quadrant pain and SOB. Per patient BP was 180/120. She was
given an albuterol inhaler and sent home. Patient continued to have symptoms with acute
worsening of the epigastric pain 1.5 hours before arriving to hospital. In the ED patient
was severely hypertensive with SBP >200. Transferred to LDR. Temp 36.5 HR 80 RR 20
B/P 191/118.
Labor and delivery
Late entry due to patient condition. At 1828 patient arrives from ER with severe right upper
quadrant pain, accompanied by____. Patient also complains of headache and blurry vision at this
time. She denies contractions, loss of fluid, or vaginal bleeding and has had positive fetal
movement. Patient is alert and oriented at this time. Patient states that RUQ pain started about
1.5 hours before coming to the hospital. This RN immediately calls for assistance. RN attempts to
find fetal heart tones. Difficulty tracing fetal heart tones due to patient condition. (See doc
flowsheet for heart tones) . Another RN at bedside attempting IV placement. Blood pressure
obtained, see vitals. Both RN's attempt IV placement, this is also difficult due to patient condition.
MD called to bedside for evaluation. At this time patient not in control, thrashing about the bed. 4
RNs and Trevor attempting to calm and reassure patient. IV obtained, labs drawn and
betamethasone given. MD remains at bedside. Multiple attempts made to obtain a blood
pressure. At approximately 1902 patient starts to seize. Patient is rolled to right side, suction
performed, O2 applied via non-re-breather face mask at 10L/min. Staff OB at bedside and
anesthesia paged 911. Magnesium Sulfate started at 4 grams over 30 minutes. Magnesium
Sulfate not scanned into MAR due to emergency. Magnesium administration confirmed with 5 RN's
and MD. Airway and patient safety maintained. Seizure lasts about 40 seconds. Anesthesia at
bedside and is updated on patients condition. Patient combative and unaware of her
surroundings. RNs and _____attempt to calm and reassure patient. Hydralazine 20mg given IVP.
At the same time, another RN attempting to find heart tones. Oxygen remains in place. Once fetal
heart tones obtained, it appears heart tones are in the 60s-70s, ultrasound at bedside to confirm.
Fetal heart tones unclear with ultrasound as well due to patient thrashing and uncooperativeness.
MDs and RNs remain at bedside attempting to monitor fetal heart tones with EFM and bedside
ultrasound. Decision made by MDs to stay in room until fetal heart tones are stable. Clear heart
tones obtained at 1922, fetal heart tones around 135 with minimal variability. At this time patient
is calm and resting comfortably but remains disoriented. At 1925 patient has another seizure that
lasts for 75 seconds. Patient rolled to right side, suction performed and oxygen reapplied due to
patient taking off. After seizure was complete, decision made to go to the OR for a cesarean
section for delivery. This plan discussed and confirmed with_____, he consents verbally for the
patient (prior to first seizure patient had verbally consented to treatment of care). 4 RNs and MDs
wheeled patient to OR where anesthesia and other RNs awaited. See intraop documentation for
further care.

Primary LTCS delivery of 1026 gm male infant Apgars 1,7. Cord gases 6.92 arterial and 6.91
venous. EBL 1000.