A 38-Year-Old Woman With Fetal Loss and Hysterectomy

摘要

Dr Delbanco: Mrs W is a married, self-employed, healthy woman living in a community several hours from Boston. She has private health insurance. At age 38, she was admitted to the hospital for elective delivery of her first child, but the admission ended tragically with fetal loss, hysterectomy, and a prolonged hospitalization.The pregnancy, her first, was wanted and uneventful. When seen initially by her obstetrician, Mrs W's blood pressure was 112/80 mm Hg. She showed no sign of labor at term. At 40 weeks of pregnancy, her blood pressure was 126/78 mm Hg, rising shortly thereafter to 144/85 mm Hg. She had trace proteinuria. Her creatinine level was 0.8 mg/dL (70.7 mumol/L), and her uric acid level was 6.3 mg/dL. At 41 weeks of gestation, her obstetrician, Dr F, decided to admit her for misoprostol induction. Dr F was not on call that night.On admission, the cervix was closed and 50% effaced, and her blood pressure was 124/90 mm Hg. She was given misoprostol (25 mug, vaginally) and sent home that evening at 10 PM. On the way home she noted more contractions, turned around, and was admitted to the hospital at midnight in active labor. She was breathing uncomfortably with contractions, vomiting, and was hypertensive with a blood pressure of 174/104 mm Hg. The cervix was still soft and closed; the fetal heart rate was in the 130s, and no decelerations accompanied the contractions. At 1:30 AM, her membranes ruptured, and contractions were noted every 1 to 2 minutes. At 3:30 AM, her cervix was dilated to 2 cm and 90% effaced. The fetal heart rate was 120/min, with contractions every 1 to 2 minutes. She was given a test dose for epiduralanesthesia (3 mL of l%-5% lidocaine). At that point, her blood pressure dropped to 53/33 mm Hg, but it returned to 107/50 mm Hg with ephedrine. Accompanying the test dose, the fetal heart rate dropped to 80/min for 3.5 minutes, but then returned to the 130s. The epidural anesthesia was then initiated.