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Final clinical long case 49

Created: 23/8/2013
A 28-year-old primipara presents for an emergency laparotomy 7 hours after an emergency lower segment Caesarean section (LSCS) for failure to progress. She was on an oxytocin infusion for 7 hours, and a 4.38 kg foetus was delivered. She had a large post-partum haemorrhage and uterine clots have been evacuated since delivery. At presentation she is pale and very anxious.

Heart rate: 140 bpm
Blood pressure: unrecordable
Pulse oximetry: not picking up trace
Carotid pulse: palpable.

Blood results before LSCS
Haemoglobin: 13 g/dl
Platelets: 235 × 109/L
Other blood results unremarkable

Blood results after LSCS
Haemoglobin: 2.8 g/dl
Platelets: 84 × 109/L
Prothrombin time: 19 s
Activated partial thromboplastin time ratio: 1.8
Fibrinogen 1.7 mg/dl
K+: 5 mEq/L

Chest X-ray
Bilateral infiltrates consistent with acute respiratory distress syndrome (ARDS).

1. How would you resuscitate this patient?
2. Give definitions of massive post-partum haemorrhage.
3. Give the classification of hypovolaemic shock.
4. Discuss the perioperative management of the patient.
5. Would you place an arterial line if you could not feel a radial artery pulse?
6. Which drugs affect uterine tone?
7. Discuss the postoperative management of the patient on the intensive care unit (ITU).
8. Comment on the following on the chest X-ray: the adequacy, positions of lines, position of the endotracheal tube, patchy airspace opacification.
9. Discuss the definition, clinical presentation, causes and ITU management of ARDS.

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