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A case of post-partum ‘ascites’
Dr Jeremy CampbellQueen Charlotte’s and Chelsea Hospital
Written informed consent from patient
The case• 46 years old
• Para 1 + 2
• 103 kg BMI 38
• History of migraines• No regular medication
Forceps delivery of 4.4 kg babyTOPMiscarriage ERPC
The pregnancy
Spontaneous pregnancy
17 weeks• Severe headache• No neurology• MRI and MRV normal• Started on aspirin
32 weeks• Recurrent chest infection• Generally unwell• Sputum cultures negative• Three courses of antibiotics
The labour
• SROM at 38 weeks Clear liquor
• Ongoing productive cough
• IOL with PGE2 following evening
• CSE for labour analgesia at 00:20 hrs
• Commenced on syntocinon at 01:20 hrs
The labour
01:20 2 cm 2:10 Comfortable
07:10 4 cm 4:10 CTG reassuring
07:25 CTG: typical variable decelerationsClear liquor with clotsIn pain despite epidural top-ups
The labour
08:30 Anaesthetic review: Epidural unilateralCatheter pulled back 1 cmFurther top-ups
09:55 Fully dilatedOngoing typical variable decelerationsIn pain ++CSE resited
10:40 CTG pathological: deep atypical variable decelerations
The delivery
10:45 Ventouse delivery in roomBack born pale and floppy NICURetroplacental clot seen – presumed abruption
EBL 300 ml40 IU syntocinon infusion commenced
Day of delivery
13:00 Upper abdominal painPale and unwellHR 113 BP 72/50Hemocue 6.9 g/dL (10.8 g/dL pre-delivery)Uterus well contracted but clots in vagina ++EBL now 1.3 L
Ergometrine IMBlood transfusionEpidural top-upTransferred to obstetric HDU
Day of delivery
Ongoing pain throughout rest of the dayRegular epidural top-ups
23:20 Consultant obstetrician review
• Abdomen now distended• Absent bowel sounds• Uterus well contracted• Observations stable• Hb 9.8 g/dL
• USS – uterus empty, small amount of free fluid
Day of delivery
• Commenced on co-amoxiclav and clarithromycin• Likely ileus
Delivery day + 1Obstetric and medical review
• Continuing abdominal pain• Ongoing epidural top-ups• Abdomen distended• Absent bowel sounds• Cardiovascularly stable
Bloods: Hb 9.7 g/dL, WCC 21.0, CRP 213, Albumin 18
CT abdomen: ‘Moderate volume of ascites, no bowel obstruction’
Impression: 1. Infection (likely chest)2. Ileus3. Ascites due to low albumin
Delivery day + 1Surgical review
• No evidence of haemorrhage• Agreed likely ileus
Settled by the evening
Delivery day + 2
Obstetric and medical review
• Increasing abdominal distension• ‘Painful to breathe’• Tachycardic but otherwise stable
• Hb 8.6 , WCC 19.6, CRP 304
• Co-amoxiclav changed to meropenem
Delivery day + 2Anaesthetic review
• Needing morphine for pain• HR 110 – 130• Abdomen massively distended and tender• Hb 6.1 g/dL
• US-guided aspiration of ascites frank bloodHb 11.2
• Immediately prepared for laparotomy
Laparotomy
3 litres blood and clot in abdominal cavity
UTERINE RUPTURE
Posterior tear extending from middle of uterus to upper vagina
Uterus preserved
Admitted intubated to ICU
Post-laparotomy
• Extubated next day
• 2 days in ICU• 7 days in obstetric HDU• Discharged 6 days later
Epidural top-ups post-delivery
Delivery Laparotomy
Day 0 Day 1 Day 2
Fixation error
A form of disordered situation awareness in which one fails to revise one’s mental model
according to the available information, instead distorting the latter so that is ‘fits’
Steve Yentis
Chest infection
Ascites
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