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).