Lymphocytic Myocarditis in the Late Preterm Patientdownload.xuebalib.com/xuebalib.com.46409.pdf · We will discuss her diagnosis, treatment plan, ... with care provided by the ICU

C A S E S T U D I E S

Proceedings of the 2014 AWHONN Convention

Women’sHealth

Pregnancy Saved My Life: A Case of Ovarian Cancerand Pregnancy

Lori H. Smith, BSN, RNC,Christiana Care Health System,Pennsville, NJ

Shelly Drach, RNC, ChristianaCare Health System,Middletown, DE

Keywordsovarian cancerchemotherapy cancer in

pregnancy

Poster Presentation

Background

Ovarian cancer can be a devastating diag-nosis for any woman but is particularly so

for the pregnant woman who must make somedifficult decisions regarding her pregnancy andtreatment plan. The standard treatment for ovar-ian cancer is aggressive chemotherapy, whichattacks the rapidly dividing cells of the cancer.At the same time, the rapidly dividing cells ofthe vulnerable fetus are at risk from the treat-ment. Our patient had multiple surgeries duringpregnancy, including port placement and mul-tiple cycles of chemotherapy (with its associ-ated side effects). The nurses caring for herduring her extended antenatal stay and deliv-

ery learned a great deal about ovarian cancertreatment.

CaseA woman with a history of infertility and en-dometriosis received a diagnosis of ovarian can-cer. We will discuss her diagnosis, treatment plan,effects on maternal and fetal outcome, and deliv-ery and follow-up treatment.

ConclusionEarly detection of ovarian cancer and collabora-tion with a treatment team of obstetricians, oncol-ogists, surgeons, and nurses may lead to positiveoutcomes for mother and infant.

Perplexing Presentation of Pink Breast Milk

Joan E. Crete, DNP,WHNP-BC, Tripler ArmyMedical Center, Honolulu, HI

Jenny Jones, APRN-NP-C,Tripler Army Medical Center,Honolulu, HI

Robin Neumeier, CNM, LTC,AN, Tripler Army MedicalCenter, Honolulu, HI

KeywordspostpartumbreastfeedinginfectionSerratia marcescens

Women’s HealthPoster Presentation

BackgroundSerratia marcescens is an opportunistic pathogenwith strong evidence of a role in nosocomial in-fections. It has been cultured from hospital equip-ment, including breast pumps and inhalation de-vices and can be transmitted from the hands ofhealthcare workers. One outbreak in a newbornintensive care nursery was traced to the contam-ination of healthcare workers’ personal bottles of1% chloroxylenol soap that were left open in workareas.

CaseDuring a routine 6-week postpartum visit, a motherreported a bright pink stain on her beast pads,burp pads, and infant diapers. The same brightpink color was in her bottles and breast pumpwhen they were left out. The review of systemswas negative. Her history was positive for rightbreast mastitis on postpartum day 4, which wastreated appropriately and resolved. Her infant washealthy and thriving. The nurse practitioner car-ing for her was perplexed by this presentation.She consulted with the obstetric–gynecologic staff

and the lactation specialist who were also puz-zled. A breast specialist in general surgery con-sulted with infectious disease and pediatrics. Theworkup included cultures of the mother’s breastpads, milk, and breast pump. Serratia marcescenswas isolated in addition to common gram-negativeand -positive bacteria. The working diagnosis wascolonization of S. marcescens without acute in-fection. The mother was reassured and encour-aged to continue breastfeeding. She and her in-fant were closely monitored and managed withoutantibiotics.

ConclusionThis case provides an example of a uniqueclinical presentation involving unusual bacteria.The workup and management were addressedthrough a multidisciplinary approach. Having in-put from different disciplines provided the work-ing diagnosis. The woman was given guidanceregarding proper care of the breast pump and re-assured that she could continue to breastfeed. Ather final visit, she was breastfeeding 60% of thetime and the infant was thriving.

JOGNNS86 C© 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org

Staib, S., Garibian, R., and Banner, S. C A S E S T U D YProceedings of the 2014 AWHONN Convention

Childbearing

Multidisciplinary Management of Maternal DiaphragmaticHernia

Donna Yukihiro, MN,RNC-OB, CLE, TorranceMemorial Medical Center,Torrance, CA

Sarah Ceja, RNC, TorranceMemorial Medical Center,Torrance, CA

Kadi L. Gonzalez, BSN, RNC,Torrance Memorial MedicalCenter, Torrance, CA

Keywordsmaternal diaphragmatic herniapregnancy

Poster Presentation

Background

Early recognition, diagnosis, and treatment arecritical in the management of the pregnant

woman with a diaphragmatic hernia (DH), whichoccurs when abdominal viscera shift into the tho-racic cavity. Signs and symptoms mimic normalpregnancy and include nausea, vomiting, abdom-inal pain, dyspnea, radiating shoulder pain, andchest pain.

CaseA 30-year-old, gravida 2, para 2, woman at 293/7 weeks gestation presented with nausea, dryheaves, abdominal and back pain, constipation,and an inability to get comfortable. Her medicalhistory included gastric bypass surgery, strangu-lated hernia repair, and a cesarean birth of twins at34 weeks gestation. A CT scan revealed a 7-inchdiameter incarcerated DH. Treatment required twosurgical interventions. The first was an immediateDH repair, and the second an abdominal herniarepair and C/S.

A nurse-coordinated, multidisciplinary team con-vened to discuss the plan of care and identifypotential risks and possible emergency interven-tions. Team members included the general sur-geon and assistant, the operating room (OR) team,an obstetric anesthesiologist, the labor and deliv-ery (L&D) nurse, and the obstetrician. The neona-tal intensive care unit (NICU) team and otherspecialist were on standby. Planned interventionsincluded general and epidural anesthesia, dual-lumen intubation with two ventilators, and intermit-tent fetal monitoring. The woman and her husbandwere involved in the discussions of the plan of

care. The DH repair was completed without inci-dent. The recovery occurred in the intensive careunit (ICU) with care provided by the ICU and L&Dnursing staff to monitor central lines, peripherallyinserted central catheter lines, total parenteral nu-trition, ventilators, sedation, epidural, wound vacu-ums, chest tubes, g-tube, Foley catheter, and fetalheart tones.

Weekly multidisciplinary meetings were held todiscuss maternal and fetal progress, update theplan of care and identify interventions for emer-gency situations, including a cesarean in the ICUfor a prolapsed cord (fetus in transverse lie). Theadjacent ICU room was set up as an NICU, andcesarean and anesthesia equipment were avail-able. The team leads for L&D and ICU created ato do list in case for emergency. The goal was tomonitor the mother and newborn until 34 weeksgestation when the second surgery was planned.

The cesarean and hernia repair were done at34 6/7 weeks gestation in the main OR with thepatient’s husband present. She recovered in thepostanesthesia care unit and was transferred to amedical/surgical unit. The newborn was admittedto the NICU. Detailed postoperative instructionsfor the L&D and medical/surgical team leads wereoutlined. A triage phone list was posted in the pa-tient’s room. The mother and newborn recoveredwithout complications.

ConclusionMultidisciplinary teamwork, communication, andcare coordination resulted in the discharge of ahealthy mother and newborn.

Lymphocytic Myocarditis in the Late Preterm Patient

Stephanie Staib, BSN,RNC-OB, Christiana CareHealth System, Newark, DE

Background

A woman was transferred to us at 35 weeksgestation with gastroenteritis symptoms and

suspected preeclampsia. Further evaluation re-vealed more than a simple case of preeclampsia.Multiple differential diagnoses were considered.

CasePhysical examination was unremarkable on ad-mission. The woman’s blood pressure was nor-mal and viral gastroenteritis was suspected. Shereported headache and nausea, but symptoms

improved after administration of antiemetics andantacids. Subsequently, she became febrile andoliguric and developed epigastric pain. Abdomi-nal magnetic resonance imaging was unremark-able, pancreatitis was ruled out by abdominal ul-trasonography, and the hepatitis panel result wasnegative. She then developed a diffusely tenderabdomen, at which point chorioamnionitis wassuspected, antibiotics were started, and an induc-tion of labor was initiated.

After the initiation of the induction of labor, dysp-nea was noted and a chest X-ray was obtained

JOGNN 2014; Vol. 43, Supplement 1 S87

C A S E S T U D YProceedings of the 2014 AWHONN Convention

to rule out pneumonia. She remained febrile, hy-potensive, tachycardic, and tachypneic through-out labor but had a spontaneous vaginal delivery. Ruth Garibian, BSN, RNC-OB,

RNIII, Christiana Care HealthSystem, Wilmington, DE

Sheryl Banner, BSN, RNC,Christiana Care Health System,Hockessin, DE

Keywordslymphocytic myocarditispregnancy

ChildbearingPoster Presentation

The infant was transferred to the neonatal inten-sive care unit.

No improvement in symptoms occurred after thewoman gave birth. Concerns for worsening pneu-monia and the potential for developing pulmonaryedema led to an electrocardiogram (EKG); repeatchest X-ray, blood, urine, and placental cultures;pregnancy-induced hypertension labs; cardiacenzymes; arterial blood gases; and an echocar-diogram. An arterial line was placed and a diureticwas administered.

Cardiology was consulted and the woman wastransferred to cardiac catheterization lab so thata cardiac catheterization could be completedand endomyocardial biopsies could be obtained.Coronary arteries were patent and the ejectionfraction was less than 10%. She developed ven-tricular fibrillation, was defibrillated twice, stabi-lized, placed on extracorporeal membrane oxy-genation, and had an aortic balloon pump insertedin the operating room.

She was transported to the cardiac intensive careunit for further management. Because the resultsof her myocardial recovery reveal lymphocytic my-

ocarditis, cardiology determined that a biventric-ular assist device (BIVAD) will be required for aprolonged period to allow time for myocardial re-covery. Her aortic balloon pump was removed andshe was transferred out for BIVAD placement andfurther evaluation.

ConclusionAcute lymphocytic myocarditis is rare and difficultto diagnose except by biopsy and is usually an im-mune response to a viral infection. Case reportsin pregnancy are almost nonexistent. Our laborand delivery unit routinely cares for women withpreeclampsia, and this woman’s preliminary labo-ratory results determined routine care. Persistenceof her symptoms indicated the need for furthertesting, which revealed significant abnormalities,prompting additional testing for less common al-ternate diagnoses. Ultimately, her rare diagnosisof acute lymphocytic myocarditis was determinedafter delivery. We learned that pregnancy couldcomplicate and conceal a variety of ailments.Symptoms as common as unresolved persistentnausea and vomiting, tachycardia, and tachyp-nea require further testing, which in turn may leadthe healthcare team to eliminate additional dif-ferential diagnoses. A well-coordinated interdisci-plinary team makes a great impact on the outcomeof patients in the mother–infant unit.

Spinal Muscular Atrophy Type II: Implications in Pregnancyand Cesarean Delivery

Nicole Donahue, BSN, MSN,RNC-OB, Christiana CareHealth System, Middletown,DE

Melissa Jean Jenkins, ADN,RN, Christiana Care HealthSystem, Pedricktown, NJ

Keywordsspinal muscular atrophyneuromuscular degenerationchronic pain


Background

We examined the care provided and thecomplications addressed for an expectant

mother with spinal muscular atrophy type II (SMAII). We will discuss the preoperative testing andeducation provided, inpatient plan of care, andpostoperative outcomes. We will focus on thewoman’s SMA II with chronic pain and neuromus-culoskeletal complications and how it affected thepregnancy and outcome.

CaseA 29-year-old G3P1111woman presented for arepeat cesarean. Her case was significant for ahistory of SMA II that resulted in bilateral lowerextremity contractures, surgical rods in spine,severe scoliosis, and chronic pain. The womanhad no use of her lower extremities and wasconfined to a wheelchair. A multidisciplinary

team consisting of members from anesthesia,maternal–fetal medicine, and neonatology, iden-tified evidence-based interventions based onthe patient’s extensive medical history, prenatalrecords, and phone interview.

ConclusionThe woman had a cesarean and gave birth toa newborn who weighed 4 lbs 6 ounces andhad an Apgar scores were 1/1/3 at 1, 5 and 10minutes. The pediatric team was in attendanceat birth and provided bedside resuscitation andintubation. The newborn was transferred to theneonatal intensive care unit for admission. Thewoman recovered in the perioperative area withan increased need of pain medicines but recov-ered appropriately and was transferred to thepostpartum unit for the remainder of her hospitaladmission.

S88 JOGNN, 43, S86-S97; 2014. DOI: 10.1111/1552-6909.12321 http://jognn.awhonn.org

Schmitt, M. E. and Orndorff, C. W. C A S E S T U D YProceedings of the 2014 AWHONN Convention

Ignoring the Odds: Interprofessional Planning for PositiveOutcomes in Abdominal Pregnancy

Erin Bush, MAIOC, BSN, RN,University of Arkansas forMedical Sciences, Little Rock,AR

Jeni Warrior, APRN,WHNP-BC, UAMS College ofMedicine, Little Rock, AR

Ashita Gehlot, MD, UAMSCollege of Medicine, LittleRock, AR

Keywordsabdominal pregnancyinterdisciplinaryinterprofessional

communicationpatient- and family-centered

care (PFCC)


Background

Abdominal pregnancy is rare and risky. In-terdisciplinary collaboration, comprehensive

clinical management, emotional support, and fam-ily inclusion in planning have a positive effect onoutcomes as was demonstrated in this case.

CaseA 33-year-old gravida 2, para 1 woman presentedat 19 weeks/3 days gestation with an abdomi-nal pregnancy during a routine prenatal anatomyscan. An early transvaginal ultrasound obtained inthe emergency department because of bleedingconfirmed the pregnancy but did not confirm fetallocation. Because of this finding, the woman wastransferred to the high-risk obstetric service at alarge academic medical center.

Her health history included smoking, anxiety, anda cesarean that was performed because of nonre-assuring fetal heart tones. A magnetic resonanceimaging indicated a placenta that enveloped andadhered to the left pelvic sidewall, sigmoid colon,bladder, right ovary, left iliac, and left ureter. Med-ical recommendation to remove the fetus wascounter to the woman’s religious beliefs. Thoughthe medical team and her spouse disagreed withher decision, they accepted it and developed acomprehensive plan of action to preserve the lifeof the mother and the fetus.

Upon admission to the hospital, a special teamdeveloped a woman-centered plan of care. This

team included a core set of registered nurses andrepresentatives from obstetrics, interventional ra-diology, vascular surgery, gynecologic–oncology,neonatology, blood bank, pastoral care, and ob-stetric social work. Multiple family meetings wereheld and limited options were discussed. Obstet-rics coordinated the care team that would bepresent during delivery. The delivery process wasdiscussed with the woman early in her hospital-ization and she verbalized awareness of the stepsneeded to ensure maternal and fetal safety. De-spite a poor prognosis, the pregnancy continued,and the neonate was delivered at 24 weeks ges-tation because of perigestational hemorrhage. Atdelivery, the woman lost 5,500 ml of blood, re-ceived 37 units of blood products, and was trans-ferred intubated to the intensive care unit. Thewoman was discharged home on postoperativeday 8, and the infant was discharged home onroom air after 6 months.

ConclusionThe focus of evidence-based nursing care ispatient-centered and holistic. Though nursing staffagreed that termination of the pregnancy was thebest option for the mother, they respected and ad-vocated for her choices. Facilitating lengthy bedrest, maintaining deep vein thrombosis prophy-laxis, and providing emotional support were pri-orities for the nursing team. Once nursing staffdetected status changes, clear interdisciplinarycommunication and rapid mobilization for deliveryimproved the odds of survival for this woman.

A Multidisciplinary Approach to Delayed Interval Deliveryin Twin Pregnancy

Maureen E. Schmitt, BSN,RNC-OB, WVU Healthcare,Morgantown, WV

Christy W. Orndorff, BSN, RN,CHPPN, WVU Healthcare,Morgantown, WV

Keywordstwinsbereavementperinatal loss


Background

Multiple gestation occurs in approximately32/1,000 births. This number has increased

during the past 30 years primarily because ofassisted reproduction technology and advancedmaternal age. One in eight twins is born before 32weeks gestation. Typically, fetuses of a multiplegestation are born within a short interval of time,however, if membranes rupture, or an intrauterinedemise occurs, there may be benefit in attempt-ing to delay delivery of the second twin to achieveviability. Caring for these patients is challengingand will be best served by a multidisciplinary teamapproach.

Case:1. A 31-year-old woman (gravida 1, para 0)

had an in vitro fertilization-conceived preg-nancy and presented at 19 weeks 5 daysgestation with preterm premature rupture ofmembranes (PPROM) of twin A. She and herhusband chose to attempt to maintain thepregnancy for the benefit of twin B. Twin Awas delivered at 19 weeks 6 days gestation,and twin B was born at 28 weeks 3 days ges-tation and went home from the neonatal in-tensive care unit (NICU) 9 weeks later. Dur-ing the newborn’s hospitalization, the parentsmet with staff from maternal–fetal medicine



(MFM), neonatology, supportive care, andspiritual care. This couple supported eachother well and acknowledged the bittersweetexperience of grieving for one child and be-ing happy for the positive outcome of theother.

2. A 41-year-old woman (P5034) presented at22 weeks 1 day gestation with PPROM oftwin A and gave birth shortly after admission.She desired to continue the pregnancy for thebenefit of twin B and gave birth at 26 weeks 1day gestation. Her newborn died at 16 daysof life in the NICU. Her hospitalization waschallenging for all involved because she hada strong psychiatric and substance depen-dence diagnosis. During her hospitalization,she met with staff from MFM, neonatology,supportive care, and psychiatry. She contin-ues to struggle with her grief.

3. A 29-year-old woman (gravida 1, para 0) hadan intrauterine insemination (IUI)-conceivedpregnancy and was admitted for PPROM oftwin A at 20 weeks 0 day of gestation. Shedelivered twin A 1 day later but desired tomaintain the pregnancy for the benefit oftwin B. She developed chorioamnionitis 24hours later and labor was augmented for twinB. During her hospitalization, she met withstaff from MFM, supportive care, and spiri-tual care.

ConclusionWhen delayed interval delivery is chosen, familiesand caregivers must be educated about the risksof infection and potential poor outcome for the re-maining fetus. Identifying and providing support-ive care is vital for the family and staff.

Necrotizing Fasciitis in an Obstetric Patient

Anita DeWeese, MSN,RNC-NIC, Greenville HospitalSystem, Greenville, SC

Keywordsteamworkpatient advocacyinterdepartmental

communication


Background

Premature rupture of membranes (PROM) ina preterm infant is a serious concern. Ad-

ditional complications, such as chorioamnionitisand a primary herpes outbreak, mean the deliveryteam must be vigilant in the care of such a patient.

CaseA 32-year-old woman was transferred to our facilitywith a singleton pregnancy at 35 weeks gestation.The woman presented with unidentified PROMand had brown watery discharge for the past 3weeks. Additionally, she had a primary herpes out-break, was positive for group B streptococci, andreported flu-like symptoms for the past 3 weeks.The woman was febrile and her abdomen was ten-der to touch. Once stabilized with appropriate an-tibiotic and antiviral treatments, the woman under-went a primary cesarean. During the surgery, theuterus was found to be full of pus. The neonatalintensive care unit (NICU) team was present atthe delivery. The newborn had a low Apgar score,oxygen saturation in the 30 s, no respiratory effort,and required prolonged respiratory support.

The woman’s postpartum course was progress-ing well until bowel sounds and urinary outputdecreased. Reddened areas around her incisionwere shown to her physicians and were attributedto tape burn. With no improvement, the womanwas transferred back to the labor and delivery unitwhere she could receive a higher level of care. The

nurse noticed the reddened area around the sur-gical site and convinced the physicians that thiswas not due to ordinary tape burn. A surgical con-sult was ordered and the woman was taken to theoperating room (OR) to have her wound reopened.In the OR, her wound was cleaned and debridedbut necrotizing fasciitis had set in. The woman wasmoved between the intensive care unit (ICU) andthe OR for serial debridements. Eventually it wasdetermined that her uterus could not be saved,and the woman had a hysterectomy. Soon afterthe surgery, she began to improve.

The clinical nurse specialist was involved withkeeping family and staff from the ICU, NICU, andOB departments up to date on the clinical con-dition of the dyad and provided resources to allareas as needed. The infant remained depressedfor several days but did not contract herpes andwas discharged appearing normal at 25 days oflife.

ConclusionAs this complex patient deteriorated, she wascared for by many specialists, including cliniciansfrom obstetrics, infectious disease, neonatology,nephrology, general surgery, and critical care.Though this case was very medically intensive,nurses had a key role in identifying subtle changesin the patient, communicating and advocating forincreased medical surveillance and treatment.


Arnold, C. S. C A S E S T U D YProceedings of the 2014 AWHONN Convention

An Amniotic Fluid Embolism Survival Story

Suzanne Seaman, RN, BA,Morristown Medical Center,Convent Station, NJ

Keywordsamniotic fluid embolismdisseminated intravascular

coagulationrapid blood transfusion protocol


Background

A full-term woman in labor presented with ahistory of gestational diabetes and no pul-

monary disease. Until the insult, the labor was un-complicated and the fetal monitor tracing was acategory I. The labor and delivery registered nursewas at the bedside charting when the woman (whohad an epidural and was taking Pitocin) first beganto cough.

CaseThe woman suddenly began to cough, and couldnot stop. It appeared as if the woman was chok-ing. A prolonged fetal heart rate deceleration wasnoted, and maternal oxygen saturation and ma-ternal heart rate also dropped. Additional nursesand an anesthesiologist were called to the bed-side stat. The patient’s radial pulse became non-palpable, and the oxygen saturation finger clipconnected to the electronic fetal monitor did notregister a pulse or an oxygen saturation reading;however, an apical pulse via stethoscope was stillheard. The woman was moved quickly to the la-bor and delivery operating room where she wasrapidly intubated by the anesthesiologist. Her res-piratory status stabilized after intubation. A statcesarean was performed, and a live newborn was

delivered and handed to the awaiting neonatal in-tensive care unit staff. Bleeding during surgeryappeared to be slightly increased. The circulat-ing nurse looked under the operating room drapeto check lochia flow and discovered the womanwas bleeding profusely from the vagina. Urine out-put was minimal. An arterial line and a centralline were quickly placed by the anesthesiologistbecause it appeared that the woman had devel-oped disseminated intravascular coagulation. Atthe same time, the circulating nurse called theblood bank to initiate the obstetric rapid bloodtransfusion protocol. The blood transfusion proto-col is similar to an emergency room trauma bloodtransfusion protocol. The blood bank follows theprotocol by cross matching and thawing severalunits of blood products at one time according to anestablished guideline. The woman received mul-tiple units of blood very quickly and never wentinto cardiac arrest. She was transferred to the in-tensive care unit immediately after the cesareanwhere she remained for at least 24 hours.

ConclusionThe woman and newborn were discharged in sta-ble condition on postpartum day 6.

Evidence-Based Quality Improvement MeasuresContributed to Saving a Woman and Experiencing AmnioticFluid Embolism and her Fetus in the Second Stage of Labor

Carolyn S. Arnold, MSN, RN,California,RedlandsCommunity Hospital,Redlands, CA

Keywordscommunicationrapid response teamsTeam STEPPSamniotic fluid embolismanaphylactoid syndrome of

pregnancy


Background

I n 2007, the World Health Organization listed theUnited States as 41st in the world for maternal

mortality. This report triggered a call for action toimprove care for pregnant women. The Institutefor Healthcare Improvement (IHI) advocates forthe development of rapid response teams to im-prove outcomes in critical situations by providingcritical care expertise at the bedside. In 2009, IHIcited a study that reported a 56% reduction in thenumber of deaths from cardiac arrest and a 25%reduction in total number of deaths after the imple-mentation of a rapid response team. At our facilitywe have had similar results. Along with a rapidresponse team, our hospital has established spe-cial codes to bring additional needed personnelto the bedside in situations of suspected sepsis(gold alert), stroke (stroke alert), and hemorrhage(code white). A massive transfusion protocol hasbeen put in place when large blood volume re-

placement is needed. To improve outcomes byimproving communication, our maternal–child unitpiloted implementation of Team STEPPS training.

CaseOur team training was put to the test when a34-year-old multiparous woman was admitted tothe labor and delivery unit in active labor with anuncomplicated pregnancy. The labor progressedrapidly, but shortly after she started to push, thewoman coughed, said “I don’t feel very well,”and then lost consciousness. A code blue wascalled, and the team arrived within 2 minutes.Within 7 minutes the infant was delivered by themidwife and resuscitated by the neonatal inten-sive care unit team. We suspected the womanhad an amniotic fluid embolism (anaphylactoidsyndrome of pregnancy). Over the next 9 hours,the woman went into cardiac arrest four timesand developed a disseminated intravascular



coagulation. A code white (hemorrhage) wascalled, the rapid response team was called forextra help, and the massive transfusion protocolwas implemented. Communication and teamworkwere evident throughout the night, and as a resulta healthy newborn male infant was dischargedhome with his family at 5 days of age; the motherfollowed 11 days later.

ConclusionAfter this dramatic event a debriefing was heldso the team could discuss successes and oppor-tunities for improvement. The word heard repeat-edly to describe the care provided was seamless.Some confusion regarding the massive transfu-sion protocol was identifed, and plans to improvethe process were put in place.

Sim Huddles: A Team STEPPS Approach for EmergencyPreparedness

Karla Olson, MSN, RNC-OB,C-EFM, CBC, CLNC, SarasotaMemorial Hospital, Sarasota,FL

Renee Maietta, MSN,RNC-OB, C-EFM, CBC,Sarasota Memorial Hospital,Sarasota, FL

Keywordsobstetric patientsimulationACLSincreased nursing confidence

and preparednessTeam STEPPS


Background

Obstetric nurses and team members needrapid responses and a coordinated team

effort when emergencies arise. Maintenance ofemergency preparedness skills, including ad-vanced cardiac life support (ACLS), is critical forpatient safety, yet few obstetric nurses feel confi-dent in these high-risk, low-frequency skills.

CaseSim huddles involve melding Team STEPPS prin-ciples and practices with simulation to increasenurse confidence and preparedness for emer-gency skills. Team STEPPS principles are provento enhance teamwork and improve patient safety.Short random in situ simulations of obstetric crit-ical events involve huddling to review key ele-ments, completing a simulated mock code, andthen completing a debriefing experience for thestudents. The debriefing evaluation of the simu-lation is a practical and effective way to providethe perinatal team the opportunity to refresh theirknowledge, perfect their skills, and increase theirconfidence in response to a patient with an ob-stetric emergency. Every sim huddle has uncov-ered at least one latent safety threat, such asequipment or process issue, that is immediatelycorrected to support safety and preparedness.

This process is consistent with current resourcesand the educational culture of hospital obstetricunits across the country, regardless of size or re-sources. Sim huddle scenarios are designed as acollaborative multidisciplinary team response ofobstetric nurses, obstetricians, midwives, anes-thesiologists, nurse anesthetists, neonatologists,respiratory therapists, and scrub technicians whoare present for the educational experience. Byparticipating in a challenging patient simulation,participants develop critical thinking skills, learnteamwork, and increase self-confidence.

ConclusionThrough the implementation of sim huddles, par-ticipants develop a higher level of readiness thatcontributes to optimal outcomes when emergen-cies arise. Improved performance, knowledge,and confidence gained through simulation-basedtraining with the application of modifications forpregnancy will facilitate the prompt initiation basiclife support and ACLS, which are critical for thesurvival of the mother and the fetus during a ma-ternal code. With a foundational knowledge of thechanges and challenges that occur in pregnancy,appropriate treatments can be instituted, and twolives saved.


Stark, M. A., Searing, K. A., and Kershner, W. C A S E S T U D YProceedings of the 2014 AWHONN Convention

Role of the Clinical Nurse Specialist in MultidisciplinaryCare Planning for an Obstetric Patient with CardiacArrhythmia

Dawn Daniels, RN, BSN,Vidant Health, Greenville, NC

Keywordscardiac arrhythmiaCNScase managermultidisciplinaryspheres of influence


Background

Though rare, maternal cardiac arrhythmias canhave significant clinical repercussions for the

mother and fetus. Proper preparation is key to pre-venting adverse outcomes. Collaboration of all po-tential services that may be involved in the careof complex patients can lead to positive patientoutcomes. By remaining an advocate for patient-and family-centered care, the clinical nurse spe-cialist (CNS) plays a crucial role in assisting staff,patients, families, and medical systems to reachthese outcomes.

CaseA woman presented to the Regional PerinatalClinic for high-risk obstetric (OB) care becauseof her history of a cardiac arrhythmia during a pre-vious pregnancy. Care management was compli-cated by the inability of staff to review the chartfrom her previous pregnancy. During her prenatalcourse, the plan of care was flexible and changedseveral times. She was seen as an inpatient forher cardiac arrhythmia and was followed up bycardiology as an outpatient. Care, which includedplanning multidisciplinary meetings and phoneconferences and coordinating delivery plans forthe team, was managed by the maternal–fetalmedicine (MFM) specialists who consulted mul-tiple disciplines during prenatal care.

Interventions included meetings attended by car-diac and perinatal case managers, nurse man-agers, assistant nurse managers, OB patientplacement facilitator, MFM, medical director oflabor and delivery, anesthesiologist, and car-diac intensivist. Close monitoring of maternalcardiac status before, during, and after deliv-ery was maintained. Constant contact with thewoman was available through text messaging tothe CNS and facilitated prompt response to herquestions.

The care coordination that included medical spe-cialists and inpatient and outpatient nursing teamsled to a healthy mother and newborn at discharge,an improved patient and family experience, anddecreased confusion during the delivery of care.Additionally, staff were able to understand the roleof the CNS in direct patient care as a nurse edu-cator and as a change agent in the organizationalsphere of influence.

ConclusionEvidence-based care and multidisciplinary careplanning are central to producing positive patientoutcomes in complex OB cases. The CNS can af-fect three spheres of influence: patient, staff, andorganization.

The Perfect Storm: Severe Penicillin Reaction 3 Weeks AfterIntrapartum Antibiotic Prophylaxis

Mary Ann Stark, PhD, RNC,Western Michigan University,Kalamazoo, MI

Kimberly A. Searing, MS,WHNP, RNC, WesternMichigan University,Kalamazoo, MI

Background

Because of the devastation of early onsetgroup B streptococcal (GBS) infection in the

neonate, intrapartum antibiotic prophylaxis (IAP)has been recommended since 1996 for colo-nized women. Administration of at least two dosesof intravenous penicillin before birth has signifi-cantly reduced the incidence of neonatal GBS dis-ease. Penicillin is a common drug that sometimescauses adverse effects and allergic responses.Risk factors for developing drug allergies includeage, gender, route of administration, frequent ad-ministration of antibiotics, and presence of otherallergies. Women who receive IAP may be at riskof developing penicillin allergy.

CaseA multipara (gravida 4 para 3) woman receivedIAP after testing positive for GBS on routine late-term screening. She also received IAP as recom-mended by the Centers for Disease Control andPrevention (CDC) guidelines during her previousthree labors. She had a normal physiological la-bor and birth for her fourth child, a healthy girl,and initiated breastfeeding immediately after giv-ing birth. Three weeks later, she developed mas-titis and was prescribed oral dicloxacillin. Sheexperienced significant urticaria, pruritus, and an-gioedema 7 days after starting this drug. She hadswelling of the lips and face but did not experi-ence respiratory distress. In the emergency room,she was given a dose of oral prednisone and



discharged. She discontinued the dicloxacillin asinstructed by the emergency care provider. Within18 hours she reported back to the emergency Wendy Kershner, MSN, NP,

Western Michigan University,Kalamazoo, MI

Keywordsallergyantibioticsintrapartum


room with increased severity of symptoms. At thistime, she was started on high doses of steroids,hydroxyzine, and antihistamines and referred toan immunologist.

ConclusionThough IAP has been effective in reducing earlyonset GBS disease in the neonate, infusion of peni-cillin in healthy childbearing women may increasetheir risk of penicillin allergy, especially when peni-cillin or a related drug is administered shortlythereafter. Several consequences of this newly ac-quired allergy have nursing implications. Careful

history is necessary when women report drug al-lergies because most people who state having adrug allergy do not when tested. This underscoresthe importance of a good history and accurate pa-tient records. Nurses were important in providingthe patient with education about allergic reactions,giving comfort measures for her symptoms, andassisting her with pumping because she had todiscard the milk that was laden with drugs. As-sisting the woman to find a formula and nipplethat her completely breastfed infant tolerated andensuring that the woman understood SAFE (Seekhelp, Allergen identification, Follow-up care, andEpinephrine for emergencies) care was importantnursing care.

Gestational Carrier Delivery: What Do I Do Now?

Deborah J. Schafer, MSN,RNC-OB, PinnacleHealthSystem, Harrisburg, PA

Keywordssurrogacygestational carrierrole of advanced practice nursenursing care


Background

Surrogacy is becoming increasingly more com-mon in the United States. Recent publi-

cations and high-profile surrogate births haveopened the discussion for many to consider sur-rogacy. Though surrogacy presents a viable op-tion for childbearing, it can be stressful for allinvolved. Issues surrounding surrogacy includephysical, psychosocial, economic, and legal con-cerns. Clear policies and procedures that outlinethe legal processes coupled with an advancedpractice nurse acting as a care coordinator areintegral for a smooth process of care and to pro-mote satisfaction for the birth mother and intendedparents. Several gestational carrier births (domes-tic and international) will be discussed to demon-strate nursing care related to the birth mother andthe intended parents.

CaseThe clinical nurse specialist collaborated withlawyers, physicians, and all parties involved from

mid second trimester to the postpartum period.Legal processes were determined and explained,and desires of involved parties were incorpo-rated into individualized care plans. Communi-cation with nurses and unit managers occurredthrough detailed checklists and review of casespecifics. Nursing care was directed toward pro-viding maternal and neonatal care to appropriateparties with an emphasis on enhancing the birthexperience for all.

ConclusionBecause of assisted reproduction technology andchanging family dynamics, the rate of surrogatepregnancies will continue to rise. Nurses play akey role in addressing the issues of gestationalcarriers, their families, and intended parents. Op-timal outcomes will occur only through clear pol-icy development, coordinated multidisciplinaryefforts, and fair equitable care with a focus onmeeting physical and psychosocial needs for allinvolved.


Cole, C. C A S E S T U D YProceedings of the 2014 AWHONN Convention

Caring for a Patient with Previously UndiagnosedHyperparathyroidism at 35 Weeks Gestation

Kathleen Cocozzo, BSN, RNC,BC, Hackensack UniversityMedical Center, Hackensack,NJ

Keywordshypercalcemiahyperparathyroidismpregnancy


Background

Primary hyperparathyroidism is an endocrinedisorder rarely diagnosed in pregnancy. Most

cases usually are diagnosed in the first or sec-ond trimester of pregnancy with very few reportedin the third trimester. If untreated, hyperparathy-roidism has the potential for serious maternaland/or neonatal complications, including but notlimited to neonatal tetany and serious electrolyteimbalances.

CaseA 28-year-old Hispanic, gravida 1, para 0, womanat 35 weeks gestation was admitted for man-agement of elevated blood pressures to ruleout preeclampsia. She denied headache, nauseaand/or vomiting, shortness of breath, heart palpi-tations, chest pain, abdominal pain, visual distur-bances, contractions, and vaginal bleeding. Hermedical history was significant for hypothyroidism,which was treated with Synthroid. She denied anyother significant medical issues.

The results of her physical examination werewithin normal limits (WNL): blood pressure re-mained WNLwith one elevation of 143/74, fetal ul-trasonography was normal, and fetal heart ratetracings were Category I. Routine laboratory testsincluded complete blood count, which was WNL;pregnancy-induced hypertension panel, whichwas WNL; and chemistry screen, which revealeda serum calcium of 12.2 ng/dl. Additional labora-tory tests included a 24-hour urine calcium of 370mg/day and 24-hour urine protein of 567 mg/day.Thyroid-stimulating hormone and free thyroxine(T4) were WNL. The diagnosis of hypercalcemia

was made. The woman had an ultrasound of thethyroid and a magnetic resonance imaging of theneck resulting in diagnosis of hyperparathyroidismsecondary to left lower pole adenoma.

Multiple consults were conducted with maternal–fetal medicine, endocrine, ear nose and throatsurgery, and neonatology. The options discussedwith the woman and her partner included conser-vative management, surgical management, andpotential neonatal outcomes. The woman initiallyopted for conservative management that includedtreatment with calcitonin, but it did not decreasecalcium levels. Premature delivery of the fetusalso was discussed but was decided against.The woman opted for surgical removal of theadenoma. Serum parathyroid hormone (PTH) lev-els obtained 30 minutes postoperation decreasedfrom 175 pg/ml before the operation to 35 mg/mlafter. The postoperative calcium levels decreasedfrom 11.3 to 8.0 mg/ml.

The woman was discharged on postoperative day2. She returned at 39 weeks 1 day of gestation forelective primary cesarean for persistent breechpresentation. Her serum calcium was 9.2 mg/mland PTH was 23 mg/dl. The neonate serum cal-cium was 9.7 mg/dl and demonstrated no adversesymptomatology of the maternal hypercalcemia.The woman was discharged with her newborn onpostoperative day 4.

ConclusionThough hyperparathyroidism is uncommon duringpregnancy, it has the potential for serious negativeoutcomes. With surgical treatment, outcomes aremuch improved.

Successful Pregnancy and Delivery with Maple Syrup UrineDisease

Clare Cole, RNC, NP,Massachusetts GeneralHospital, Boston, MA

Background

Maple syrup urine disease (MSUD) is a rareautosomal recessive disorder that affects

branched-chain amino acids. Worldwide, thereare less than a dozen documented cases of suc-cessful pregnancies of women with MSUD. I de-scribe the challenges of caring for a woman witha disease that is rarely seen in obstetrics and theinterdisciplinary care that was required for her tohave a successful pregnancy and delivery. I willprovide education on MSUD and outline a plan

of care intended to prevent metabolic decompen-sation of an obstetric patient with MSUD and toensure her health and the health of her newborn.

CaseThe woman was 27 years old, gravida 1, para0, with MSUD and an expected inpatient stayof 10 to 14 days to closely monitor and adjusther amino acid levels. Multiple interdisciplinarymeetings were conducted to review laboratorytest results and metabolic and nutritional status



before her arrival and daily during her admis-sion. Specialists were involved from nursing, ob- Keywords

maple syrup urine diseasepregnancypostpartum


stetrics, metabolic genetics, nutrition, pharmacy,intravenous therapy, laboratory services, and so-cial services. Amino acid levels were drawn dailyand couriered to another facility; a peripherallyinserted central catheter line was placed beforeadmission; close monitoring of insulin levels andfluids was conducted; weight was checked daily;frequent urinalysis was done for ketones; special-ized total parenteral nutrition (TPN) and daily ad-justed nutrition were monitored; specialized test-ing of the newborn was conducted; and contin-ued close monitoring was maintained. This womandid very well until day 10 when her leucine levelsstarted to increase and she was restarted on TPN.

She was eventually discharged home on her nor-mal diet. Her newborn required admission to thelevel II nursery for hypoglycemia, which resolvedon day 4 of life, and was discharged home withher parents.

ConclusionVery few cases of pregnant women with MSUDare described in the literature. This meant thatproviding care for a woman with MSUD duringlabor, delivery, and postpartum was challenging.An in-depth look at the disease, understandingmetabolic control, and having a multidisciplinaryapproach with clear communication helped ourteam care for this woman and see her through toa safe delivery of a healthy newborn.

Effects of a Massive Transfusion Protocol in Obstetric andGynecologic Populations

Sharon Sabella, MSN, RN,CCRN, Orlando Health,Orlando, FL

Keywordsmassive-transfusion protocolpostpartum hemorrhageblood administration


Background

Large volume blood loss management is vitalto survival, especially in obstetric and gyneco-

logic surgery in women of childbearing age. Forthis reason a protocol was developed to ensureavailability of blood products for transfusion dur-ing acute blood loss in this patient population.

CaseAfter a failed trial of labor, a woman consented toa cesarean delivery, which resulted in the loss of1 L of blood after the birth. In the recovery room,the woman reported increasing abdominal painfrom her right pelvis to her right upper quad-rant. As her blood pressure decreased, the teamquickly attempted to stabilize her, and she wasmoved back to the operating room for exploration.A massive transfusion protocol (MTP) was initiatedbecause of a large hemoperitoneum (blood col-lection in the abdomen) of 3.5 L (total estimatedblood loss of 4.5 L). Surgical repair of a right cervi-covaginal laceration was performed as eight unitsof packed red blood cells (PRBC), two units offresh frozen plasma (FFP), and a pack of plateletswas transfused. The woman remained on mechan-ical ventilation and was admitted to the women’sintensive care unit where she remained intubated

overnight. A review of the laboratory results re-vealed a decrease in hemoglobin from 10.7 mg/dlon admission to 6.5 mg/dl, with a return to 11.6mg/dl the day following these interventions. Thebreathing tube was removed the same day, andthe woman was discharged home on day 6 afterthe MTP was initiated.

ConclusionThe MTP was initiated in 2010 along with a mater-nal urgent surgical team to manage this complexpopulation. Each cooler from the blood bank con-tains six units of PRBC, six units of FFP, and apack of platelets. During the MTP, the blood bankwill release a cooler every 20 minutes until the MTPleader terminates the MTP.

From December 2010 to December 2012, 43 pro-tocols (MTP I: 22; MTP II: 21) were used in ob-stetric and gynecologic patients. The ratio of redblood cells to FFP transfusion ranged from 1:0.54to 1:0.66; the mean patient age was 33.6 years.The average length of stay (LOS) from time ofMTP to patient discharge was 4.3 to 5 days witha mean LOS in the intensive care unit of 2.3 days.Exemplary practice and quality outcomes are a di-rect result of this collaborative effort in patient-firstcare.


Rhodes, C. A. and Bodrock, J. C A S E S T U D YProceedings of the 2014 AWHONN Convention

NewbornCare

Beat to Beat: Antenatal Fetal Arrhythmia to NewbornVentricular Tachycardia Caused by Rhabdomyomas and aSubsequent Diagnosis of Tuberous Sclerosis

Catherine A. Rhodes, MSN,CRNP, WHNP-BC, RNC-OB,SANE-A, The MetroHealthSystem, Cleveland, OH

Judy Bodrock, MHSA, RNC,The MetroHealth System,Cleveland, OH

Keywordsrhabdomyomastuberous sclerosis complex

(TSC)rapamycinfetal arrhythmia

Poster Presentation

Background

The findings of an irregular fetal heart rate an-tenatally and subsequently rhabdomyomas in

the fetus suggest a genetic disease of consider-able importance. Multiple rhabdomyomas triggersuspicion of tuberous sclerosis complex (TSC) be-cause it is present in more than 80% of cases ofrhabdomyomas. Usually, rhabdomyomas regresswithout intervention, but the association with TSCis life changing for the family. Knowledge of theoutcome of affected fetuses and the true inci-dence of TSC in fetal cardiac rhabdomyomas iscritical for accurate prenatal counseling, planningof prenatal treatment, and infant care after deliv-ery.

CaseWe will discuss a woman with an irregular fetalheart rate detected at 34 weeks gestation. Initialultrasonography revealed a slightly irregular fe-tal heart and a somewhat thickened cardiac sep-tum. Ultrasonography at a Level III perinatal cen-ter revealed probable rhabdomyomas of the heartand ruled out tuberous sclerosis (TS). The fetalechocardiogram demonstrated intracardial rhab-domyomas with compromised outflow. Consultswith a geneticist and pediatric cardiologist oc-curred. Weekly nonstress testing along with ultra-sonography for signs of cardiac failure was done.At 38+ weeks gestation, a left ventricular enlarge-ment was identified. At 39 weeks 4 days gesta-

tion, fetal lung maturity was ascertained and la-bor was induced. The infant weighed 3,460 g andhad an Apgar score of 8/9. The infant echocar-diogram showed multiple intracardiac lesions, in-cluding a tumor obstructing aortic outflow nearthe aortic valve, one on the anterior leaflet of themitral valve, a tumor in the left ventricle (2/3 ofthe ventricle size), and multiple nonobstructive le-sions. The infant was admitted to the neonatal in-tensive care unit for monitoring. Family bondingwith the infant was encouraged and facilitated bythe nursing staff. At 26 hours of age, the infant de-veloped supraventricular/ventricular tachycardia.Cardioversion was done and antiarrhythmic drugswere started. The parents were notified, and theoptions and the definitive diagnosis of TS werediscussed. On day 11 of life, the infant had openheart surgery to remove the tumors and did wellpostoperatively.

ConclusionThis family was not expecting a child with a signif-icant health problem. Support from staff was cru-cial. Initially, they focused on the risks of cardiacsurgery and not on the more significant diagno-sis of TSC. However, the diagnosis and its impli-cations were addressed by the multidisciplinaryteam. TSC is an autosomal dominant multisystemdisorder and early diagnosis is critical; recent lit-erature suggests that early rapamycin use mayprevent the development of TSC manifestations.


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