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