Case
A 23-year-old G2P0 woman with a body mass index (BMI) of 29 kg/m2 was admitted at 33 3/7 weeks of gestation. She reported a 7-day history of lower limb edema and 3-day history of dizziness. Her initial physical condition was as follows: alert, body temperature (36.5°C), respiratory rate (22b.p.m), heart rate (88 b.p.m), blood pressure (135/97 mmHg), SaO2 was 93%. Bilateral fingers were clubbing fingers, with edema of both lower limbs (+ + +). Peripheral blood tests disclosed with hemoglobin and hematocrit levels of 16.5 g/dL and 57%, respectively, a platelet count of 77×103/μL and white blood cell count 12.2×103/μL. Additionally, laboratory data of serum revealed albumin 22.8 g/L, lactate dehydrogenase 488 IU/L, urea nitrogen, creatinine, blood glucose and electrolytes were normal. Her arterial blood gas analysis showed pH 7.38, PaO293mmHg(FiO2 0.4), PaCO2 32 mmHg, standard bicarbonate 22.5 mmol/L and base deficit of -1.7 mEq/L. Her urine protein (++). Ultrasound showed that the fetal growth retardation, the age of head and femur both were 29 weeks.
The patient was admitted to the obstetric ward and was initially diagnosed as severe preeclampsia, partial hemolytic anemia, elevated liver function and low platelet count (HELLP) syndrome, hypoproteinemia, cardiac insufficiency and intrauterine growth restriction. After 18 hours of admission, due to the deteriorating situation of breath and saturation, she was performed ”cesarean section in the lower uterine segment”. During the operation, 1500ml was put in and 900ml was taken out, bleeding only 150ml, the blood oxygen saturation fluctuated from 80% to 90%.
The patient was admitted into intensive care unit (ICU)after operation with heart rate 98 b.p.m, blood pressure 117/90 mmHg, oxygen saturation 85% and central venous pressure(CVP)12 cmH2O. She accepted invasive ventilation and strengthening heart, diuresis and vasodilation management according the diagnosis of cardiac insufficiency, the initial ventilator parameter setting was respiratory rate 20 b.p.m,pressure support was 16cmH2O, positive end expiratory pressure (PEEP) 10 cmH20,fraction of inspiratory oxygen (FiO2) was 90%. On the day of operation, her fluid balance was -500ml in ICU (13 hours).
In the first day after operation, her heart rate 102 b.p.m, blood pressure 100/70 mmHg, oxygen saturation maintained between 75% and 85% with the same ventilator parameters and CVP 12 cmH2O. A color Doppler echocardiography was done to her, which indicated that the right atrium was 47mm * 45mm, the diameter of the right ventricle and the aorta was separately 38mm and 26mm, the diameter of the left ventricle was smaller, the ventricular septum and the free wall of the left ventricle moved in the same direction. No effusion was found in pericardial cavity. Doppler ultrasound showed that there was a little regurgitation of pulmonary valve and tricuspid valve, and the systolic pressure of pulmonary artery was 70mmHg. Combined with the high hemoglobin(16.5 g/dL in admission)and clubbing fingers, we supplemented the diagnosis of chronic severe pulmonary hypertension and down regulated PEEP to 6 cmH20 as well as strengthen dehydration and the liquid limitation. In the first day after operation, her fluid balance was -2800ml.
In the morning of second day after operation, the patient’s blood pressure began to down slowly, her arterial blood gas analysis showed pH 7.44, PaO2 48 mmHg(FiO2 1.0), PaCO2 36 mmHg, standard bicarbonate 25.8 mmol/L and base deficit of 1.2mEq/L, lactic acid 1.5mmol/L; her peripheral blood tests showed white blood cell count rose to 15.2×103/μL with NE74.4%, hemoglobin and platelet count down to 108 g/dL with hematocrit 36% and 65×103/μL. Considered that the patient’s blood pressure was only about 90 / 70 mmHg and CVP still 12 cmH2O, we reduced the dosage of diuretics to slow down the rate of negative liquid balance. 6 hours later, she died of a sudden cardiac arrest. In the second day after operation, her fluid balance was -600ml (8 hours).