A Preeclampsia Case Study

[Music] I'm Dr. Stephanie Martin, Maternal Field Medicine Specialist and Medical Directorate Clinical Concepts in Obstetrics. Today's podcast is going to be a pre-eclampsia case study. We're going to go through a case, an actual patient, and talk about different components of her care and opportunities that were either missed or taken. We're also going to be talking about some principles of the pathophysiology involved in the management of pre-eclampsia so that hopefully by the end of the case you'll have a better understanding of how you might take this home to some of the patients you're caring for yourself. This is an actual patient. I'll provide as much detail as is available, but we may not have complete information if the documentation wasn't complete. So this patient is a 31-year-old gravita to Parallel 1. She was admitted at 36 weeks' gestation with preeclampsia and ultimately she ends up getting induced because of worsening disease in her advanced gestational age. The evening of her first of the admission and when the induction was started is around six o'clock in the evening. They start a six-gram bolus of magnesium and then her magnesium is run at two grams per hour. Soon after that they start oxytocin at a high-dose protocol. We're not going to come in on the protocol you said this point. That's for another podcast and she was doing okay for a little while about an hour after starting the oxytocin in the magnesium. She the nurse documents that she was feeling okay and was denying any pain, but about an hour and a half later the patient starts to quote state her breathing is hard and quote. Now at this point we're about an hour and a half into her induction of labor. She's on magnesium. She's on high-dose oxytocin. Remember she's preeclampsic and being induced. So when the patient telling is telling you that she's having difficulty breathing the first thing that should always be on your mind is what? Pulmonary edema. I want you to leave this podcast thinking if my patient has any respiratory problems at all I'm going to assume she has pulmonary edema until proven otherwise. Now sometimes it's very easy to prove otherwise. We just do an evaluation of the patient. We document she's not hypoxemic. She has no respiratory compromise and we're done. That's not what happened in this case unfortunately. A few minutes after she first tells the nurse that her breathing is hard the patient quote states she needs to sit up again breathing becoming more difficult end quote. 15 minutes later the nurse documents that the patient is becoming somewhat anxious and stating she quote just can't catch her breath. The nurse's reaction to this is to encourage the patient to breathe deeply and to stay relaxed. She did perform a long exam stated that the lungs were clear and that the patient was having an occasional cough. She did draw a mag level and documented that the pit was at 16 million. Now I want to stop here and talk about this. Anxiety is a sign of hypoxemia. Of course patients may absolutely have anxiety for other reasons but in a patient who's telling you she's having difficulty breathing and she's becoming anxious. It's likely because she's hypoxemic and especially when she's giving you a major clue that says I can't catch my breath you need to be doing more than just saying deep deep breathe deeply and stay relaxed. This nurse's assessment is incomplete. It should have documented head to toe complete assessment and a full set of vital signs including respiratory rate and pulse-luxymetry. That was not performed. Now about 10 minutes after the nurse documented that the lungs were clear and drew the mag level she reports that the patient positioned herself in the hand knee position stating it helped her breathing. Now why is the patient doing this? So first let's talk about the mag level and then we're going to talk about her positioning. So it's not unreasonable for the nurse to draw a mag level on a patient who's on mag with pre-clampsia. But there are some other ways that I can assess what my patients mag levels may be and whether or not this is this these symptoms are due to mag toxicity and number one is to check reflexes. If the patient has reflexes she is not mag toxic that's the end of the story. If the patient does not have reflexes she may or may not be mag toxic and it's absolutely appropriate to draw a mag level. So in this situation I'm interpreting this mag level as a little bit of a cop out. We've not done a complete evaluation. We've not considered the possibility of pulmonary edema or assuming that everything is due to mag toxicity but we haven't done a complete assessment to even determine if this patient has reflexes or not. Now a few minutes after that she positions herself in hand knee and says that it's helping her breathing. So the patient's on her hands and knees. What's happening here is that we're recruiting the lower posterior airways. So our lungs are bigger at the basis, right? And when we have patients sit up in bed where that's another way of recruiting those lower lung spaces and getting those air spaces open and involved in the breathing process so that there's more possibilities for air exchange. Well the patient's done her done this herself intuitively. So when she gets on hand knees we're opening up those posterior lower air spaces and giving the opportunity for more air exchange to take place. After this the patient does this the nurse documents that the patient is breathing short shallow breaths and encouraging her to breathe deeper and slower. Well the patient is really not capable of doing that at this point, right? She's high-poxemic. She's air hungry. She's not going to be able to breathe deeply and slowly. She's moving herself in this position so that she can have the effect of breathing deeply by opening those air spaces but she's going to be air hungry and and very to kipnic. Although respiratory rate was not documented. 10 minutes after she moves herself into hand knee she moves back over to a self-sitting position at the foot of the bed and is her husband's at the bedside. This patient again is insistent on trying to get air. She cannot cooperate by laying on her side or on her back in bed. 25 minutes later the nurse documents that the patient's still sitting up in bed. Now this patient's feeling heavy in her chest but says she's able to breathe better. Respirations appear less labored and much deeper. I want to comment that there's no respiratory rate here and the patient states she's becoming let anxious but when she relaxes breathing becomes easier. Now for you nurses that are listening to this the patient is just screaming out I'm in pulmonary edema. I have hypoxemia. Please do something to relieve this. The nurse is not taking these cues but she's not even doing the minimum assessment which is to assess vital signs a complete set of vital signs and document them. So we can't really know what this nurse was thinking or not thinking because it was not documented in the chart but from what she does say I can infer a few things. So at this point the nurse documents that the vital signs are stable and the temperature is 97.4. She does not document what the vital signs actually are. She just says vital signs are stable and she increases the oxytocin to 18 million units a minute. So she's desperate to get the baby out but we're not really doing anything to improve this patient's condition. So about a half hour later the mag level comes back. Now what do you think that mag level is? Do you think that mag level is high? Normal or sub therapeutic? In fact the mag level is sub therapeutic at 3.2. That tells you she has very good renal function and this even though she got a mag ballus of six and it's maintained it too she is clearing this mag quite effectively and all of these symptoms she's having have nothing to do with the magnesium that is on board. So an hour after that mag level comes back the nurse documents again vital signs stable but does not provide the specific vital signs. We've had no assessment of oxygenation at this point and she documents that the patient went up to the bathroom then to sitting position at the foot of the bed. Now how do you feel about this patient getting up to the bathroom? We've got a patient on magnesium who's telling you she's having difficulty breathing. I'm not happy about this patient getting up to the bathroom. She's on magnesium she should be in bed. There's no role for ambulating. Finally at last a doctor is called. The first doctor is called an updated on the status and the mag level. Now if you're the physician let's say you're a physician you're listening to this what are you going to be doing? Well if a mag level has been drawn I want to know a little bit more about this patient's status. What is her status? What are her vital signs including her oxygen level and of course what's the progress in labor? The orders were to increase oxytocin to 20 to 22 millionths per minute. About 45 minutes after that the nurse takes to the time to document that the fetus has hiccups which to me this just demonstrates how clearly that this nurse does not understand what's happening to her patient. She thinks it's important to document that the fetus has hiccups. About an hour and a half later the nurse has documented the patient is still sitting up in because it's helping her with her breathing and again vital signs stable without documents of the vitals. We're now middle of the night it's 2.45 in the morning. It's been about an hour and a half since the last documentation and she's still short of breath. Now she reports to the nurse that she has a headache. The nurse's response is to encourage the patient to really relax and breathe. We've got a blood pressure of 160 over 111 documented in the chart. 20 minutes later the nurse documents that she called the doctor, same physician as before. Now when you see a blood pressure that's severe range like this, 160 over 111, what should be the response from the physician? So physicians that are listening to this, I want you to think, what is my response? And I hope your response is I'm going to give an anti-hypertensive and I'm going to come evaluate the patient at the bedside. Nurse is listening to this, I want you to be thinking, what kind of reaction am I expecting from the physician that I'm calling? And it should be for an anti-hypertensive and to have someone come evaluate the patient at the bedside. In fact, what happened is that the orders were given to stop the magnesium for one hour and increase oxytocin to 30 milli units per minute. I cannot explain this order, I don't know what the rationale was or the thought process behind this. 40 minutes later the patient's shortness of breath is worse, no documentation to vital signs, and the patient is now having a feeling of doom. She expresses to the nurse that she is worried she's not going to be able to handle it as she gets farther into labor. Remind you, this patient is not in active labor, we are still in the induction process. 15 minutes later the nurse called the doctor and informed him of the patient's condition and the fact that we have three plus progenuria. No new orders were given. 30 minutes later it's 430 in the morning now, a cervical exam was performed by the physician, the same physician that was on all night long getting these phone calls comes in and examines the patient, ruptures membranes places a scalpelied in an IUPC. 445 now the patient's feeling contractions pretty significantly and she's starting to have some back pain with the peak of the contractions. 630 in the morning about two hours after her bag of water is ruptured, she's up to the bathroom and then back to bed sitting on the edge of the bed, she's saying to the nurse the mag is mating in harder for her to breathe. Is it the mag that's making her harder for her to breathe? It's not. This patient's impulmonary deem it doesn't have anything to do with the magnesium. Now it's shift change. It's 730 in the morning and a new physician has come on and the physician comes into evaluate the patient. Documents that the nurse, the new nurse on for the shift documents that she came in to see the patient found her sitting at the side of the bed with a feet dangling appears to have labored breathing and to kipney. What do we do? We offer an epidural performed a vaginal exam and called the next doctor, the new doctor that's on for the day. Now things are starting to happen. Okay, so the new shift is recognizing that something is happening here. I don't believe that they understand exactly what's going on, but at least some action is starting to happen. So the new doctor is in the room. The patient will not lay flat without severe short of breath and is unable to breathe if she's laying flat. Anesthesiology is in the room to give the patient an epidural. We have our first documentation of O2SATS at 97% the lungs were clear. I don't believe that our O2SATS were actually 97%. I suspect that she had some incomplete readings and they chose the highest temporary SAT that could be obtained because it's the only time we see a SAT of that level. I also want to comment on clear lungs. Now a patient can have pulmonary edema with clear lungs. However, let me expand on how you can have pulmonary edema with clear lungs. First thing that happens is that you end up getting swelling in the tissue that separates the alveolus from the blood vessel. So air comes into the alveolus. It has to cross through this tissue and into the blood vessel. And as that tissue swells, then you have decreased perfusion or diffusion of oxygen across that membrane. Ultimately, the swelling will become enough that fluid starts to ooze from the tissue into the alveolus itself. And it's not until you start getting fluid in the alveolus that you're going to start having changes in your breath sounds. The other point I wanted to make here is that many times we're only listening to the lungs at the apex. Up at the shoulders, the top of the chest, and the place to listen to lungs and patients with pulmonary edema or suspected pulmonary edema is at the bases on the rear because that's where you will have changes in your lungs sounds first. The lungs fill with fluid from the bottom up. It's like filling a gas tank. When you pour in the gas, the bottom fills up first, not the top. So you can have clear lungs on the top or in the front, but not at the posterior bases. So in any event, anesthesiology wants to give this patient an epidural, and they give her a 500cc fluid bolus. What do you think is about to happen here? You and I understand what's going on. The clinicians in this room do not understand what's going on. They do not appreciate that this patient is having is in pulmonary edema. So now they bolus her with fluid. Within 20 minutes, this patient's O2sats are 81%, her breathing appears more labored, and now she's got crackles that they can hear. So this patient is in fluorid pulmonary edema that is finally being recognized here in the room. 30 minutes later, an ABG is drawn. This patient's pH is wait for it, wait for it, 7.08, 7.08. This patient is profoundly acedotic. A pH in a pregnant woman should be 7.4 and above, typically 7.4, 7.4, 2, 7.4, 4 range. This patient's pH is 7.08. Her PCO2 is 86. That is profoundly elevated. She is not clearing CO2 at all. Her PO2 is 62. This is very low. It should be in the 90 to 100 range on room air. If this patient is being given supplemental oxygen, her PO2 should be in the many hundreds. Bicarb is 27 or base excesses, excess is -5 and her SAT is 90% on that ABG. Physicians at the bedside turns the oxytocin off appropriately. Turns the magnesium off. I don't know why we've turned off the magnesium. The patient still has preclampsia. And the last thing you want at this point is a seizure. And we've documented before that this patient is not magtoxic. They put in a catheter. Her SATs are in the low 80s at this point and a chest x-ray is recognized. So this patient is now acutely in acute respiratory decompensation and they're beginning to do things. Now we give her LASIX 30 milligrams. So remember, we gave her 500cc bolus and it's been about one hour since then and we're giving 30 milligrams of LASIX. That is a massive dose of LASIX, but at least we're doing something. Breast sounds are coarse, she has labored breathing and now the patient is unresponsive. So we're taking this patient now for an emergent cesarean section. There are multiple physicians at the bedside. Bagmask and resuscitation is initiated. The patient is intubated 20 minutes later. Now we've got bradycardia on the fetal heart rate and we do a cesarean section. An emergent cesarean section. Eight minutes later, code is called and 12 minutes after the cesarean section was called an infant was delivered by a perimortum cesarean section. The mother and infant survive, shockingly. Now many would say that this patient had quote "flash pulmonary edema." Was this "flash pulmonary edema?" No, in my experience, "flash pulmonary edema" essentially never happens. This patient had pulmonary edema that simply was not recognized until she went into a cute and rapid respiratory failure and acutely decompensated. Now we're rushing to cesarean section for this very unstable patient and performing surgery on her when we could have seen this coming a mile away. So what are the key points with this case? Anticipate complications in preclampsia, especially pulmonary edema. Pulmonary edema is one of the most common complications of preclampsia, expect it to happen, watch for it, look for it, anxiety and refusal to cooperate may be signs of hypoxemia and poor perfusion. The anxiety is a lack of oxygen to the brain. And regular, complete assessments of cardiovascular status are essential in all patients but especially in patients with preclampsia. I hope you've learned something from this case. I hope there's something you can take from this and bring it to the next time you're taking care of a preclampsia patient and avoid some of these complications. Until next time. [Music]