PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIETY (Foundation),
INC
COMMITTEE ON MATERNAL AND PERINATAL WELFARE
MATERNAL MORTALITY CONFERENCE, 2011 / 5:00 pm
August 10, 2011
3rd floor POGS Building
CASE PROTOCOL
General data
This is the case of a 27 year oldG1P0, unemployedfrom Sucat, Paranaque City.
Chief complaint
Watery vaginal discharge for 2 hours
Past Medical History
Patient is diagnosed by a school physician with heart disease at 16 years old due
to palpitations, exertional dyspnea and chest pain. No work up was done. No
medications were taken. Patient was lost to follow up.
Patient was seen last April 1, 2009 at emergency room with a chief complaint of
difficulty of breathing and palpitations. The following diagnostic tests were requested:
(1) chest X-ray which showed cardiomegaly predominantly left sided and (2) 12 Lead
ECG which showed regular sinus rhythm, right axis deviation, nonspecific ST-T wave
changes and biventricular hypertrophy.
Family Medical History
There is no history of hypertension, diabetes mellitus, bronchial asthma, heart
illness and cancer in the family.
Personal, Social and Sexual History
Patient is a high school graduate, unemployed with no vices. Her first coitus was
at 26 years old with a single non- promiscuous sexual partner. She has no history of oral
contraceptive pill and IUD use. There was no history of sexually transmitted infection.
Menstrual History
She had her menarche at 14 years old with subsequent menses coming in at
regular monthly intervals lasting for 3 days using up to 2 pads per day with no
dysmenorrhea. Her last menstrual period was last May 7, 2009 giving her amenorrhea
of35 weeks and 2 days.
Obstetric history
She is a primigravid. This is her first pregnancy.
Prenatal history
Patient was seen 7 times at the High Risk Clinic, first time at 17 weeks and last at
34 weeks age of gestation. Patient was also previously admitted at 30 weeks AOG to
facilitate CVS referral.
The 2D-echocardiography was done November 4, 2009 which showed smallsized left ventricle with good wall motion and contractility and preserved overall systolic
function, right ventricular pressure and volume overload, dilated right atrium and right
ventricle, tricuspid and pulmonic valve sclerosis, severe tricuspid regurgitation and
severe pulmonary hypertension with pulmonic regurgitation.
Available laboratories during prenatal check-up include the following:
 Complete blood count: hemoglobin126, hematocrit 0.379, WBC 10.53, platelets
223;
 Urinalysis: RBC negative, WBC 0-1/hpf
 Blood chemistry: Glucose 3.93, BUN 2.05, creatinine 58, albumin 30, alkaline
phosphatase 137, AST 26, ALT 24, calcium 2.10, magnesium 0.96, K 3.6, Na 138
 BPP/ Biometry (32 2/7 weeks AOG): Single live intrauterine pregnancy, in breech
presentation, 33 weeks by BPD and 32 weeks by FL, with good cardiac and
somatic activities. Placenta is anterior, high lying, grade II. BPP= 10/10 with
adequate amniotic fluid volume (amniotic fluid index 11.7 cm). Sonographic
estimated fetal weight is appropriate for gestational age, estimated fetal
weightHadlock 1630g AGA, Warsof 1803 g AGA.
 BPP/ Biometry (PU 33 4/7 wks AOG): Single live intrauterine pregnancy, in
breech presentation, with good cardiac and somatic activities. BPP= 10/10 with
adequate amniotic fluid volume.
The patient was also being co-managed by CVS, Pulmonology, Perinatology
and Anesthesiology services.
The plan then was to deliver abdominally at 38 weeks age of gestation if still
malpresented, or for assisted vaginal delivery under epidural anesthesia if presentation is
cephalic. She was maintained on the following medications: (1) Sildenafil 25mg/tab, 1
tablet OD; (2) Enoxaparin 0.25 mg SC OD. Patient was advised to restrict physical
activities.
History of present illness
Two hours prior to admission, patient noted regular uterine contractions and
watery vaginal discharge with note of good fetal movement. This prompted patient to
seek consult hence this admission.
Review of systems
(-) Loss of appetite
(-)Weight loss
(-) Blurring of vision
(-) Chest pain
(-) Abdominal pain
(-) Nausea and vomiting
(-) Diarrhea/constipation
(-) Hematuria, dysuria, frequency, urgency
(-) paresthesia
Physical examination
Patient was awake, coherent, in mild cardiorespiratory distress. Patient was ororiented to
time, place and person.
Vital signs were as follows: BP 110/80 HR 90/minRR 22/min T: 37.3 C
Pink palpebral conjunctiva, anicteric sclerae, no cervical lymphadenopathy
Symmetrical chest expansion, clear breath sounds
(+) Right ventricular heave, palpable P2, paradoxically split S2, (+) Grade 3/6 systolic
murmur at 4th ICS left parasternal border, Apex beat at 5th ICS, left midclavicular line,
good S1, loud and split S2,
On abdominal examination, she had fundic height of 28 cm, estimated fetal weight of 1.8
– 2.0 kgs, breech presentation, good fetal heart tones 140s at the right upper quadrant
On internal examination, there was normal external genitalia, nulliparous smooth vagina,
cervix was 3 cm dilated, 80% effaced, station -2, ruptured BOW, thinly stained amniotic
fluid, corpus was enlarged to age of gestation, no adnexal masses or tenderness
Admitting diagnosis
Pregnancy uterine 35 2/7 weeks AOG, breech in preterm labor
G1P0
Gravidocardiac functional class II secondary to right ventricular failure secondary to
primary pulmonary hypertension, severe tricuspid regurgitation, pulmonic regurgitation
Course
On admission, there was note of decrease in BP to __, with note of oxygen saturation of
80% during uterine contractions and on test dose of epidural anesthesia. Otherwise, BP
range was110-130/ 80-90, HR 80s, RR 22-24cpm, T 37.3C, oxygen saturation of 97%.
CVP was inserted with opening pressure of 8cm H2O. The patient then underwent
primary LSCS under general anesthesia. Patient was given ampicillin 2g IV ANST and
gentamicin 80 mg IV as prophylaxis for Infectious endocarditis(IE). A live baby boy was
delivered, 36 weeks by pediatric aging , 2000 g, Apgar score of 5,9. Patient was hooked
to mechanical ventilator due to delayed extubation.
On day 1 post-op (8 am), patient regained consciousnesswith some episodes of agitation. Vital
signs were as follows: BP 110-120/70-80, HR 80’s, assisted respirations via mechanical ventilator,
temp 37.3, central venous pressure 7-9cm H2O, oxygen saturation of 97% which went down to 80%
then 60%. GCS score of E4VxM6. I/O at this time was 1600ml/1200ml. Breath sounds were clear.BP
remained at 120/60 and HR at 90’s. The oxygen desaturation was attributed to a mucus plug. Suction
was done followed by reintubation. Code was called. ACLS was done. Patient was revived after 6
minutes. Patient was sedated with diazepam 5mg IV.
After 10 minutes, patient self- extubated. Code was again called.O2 saturation further
decreased to 40%. There was also note of generalized tonic-clonic seizure which lasted for 30
seconds. GCS of E1VxM1. Patient was assessed to have hypoxic encephalopathy, acute respiratory
failure secondary to right ventricular failure secondary to primary pulmonary hypertension.
Reintubation was done.Diazepam 5mg IV was given. ACLS was done. Patient was revived after 16
minutes.
After another 5 minutes, code was again called. ACLS was done but patient was not revived.
Total code: 30 minutes.
FINAL DIAGNOSIS
Pregnancy uterine delivered by primary low segment cesarean section for malpresentation
breech, preterm, livebirth
Acute respiratory failure secondary to primary pulmonary hypertension
Gravidocardiac functional class II secondary to right ventricular secondary to severe primary
pulmonary hypertension, severe tricuspid regurgitation, pulmonic regurgitation
Appropriate for gestational age
G1P1 (1001)
PROBABLE CAUSE OF DEATH
Acute respiratory failure secondary to primary pulmonary hypertension