Case of adverse cardiac

event

29 yrs / f
Primi / followed up elsewhere
Diagnosis cord prolapse/ MCDA twins
Patient presented with c/o
Ruptured membranes for 4 hours
Cord pulsations felt pv
Fetal heart rates 100/110
h/o thyroid disease past 3 years on
regular treatment

 h/o URI past 4 days

No other comorbidities as told by the
patient
Preop TFT
FREE T4 1.39 ng/dl
TSH 1.6 miu/ml

Npo for 10 hours

 Examination findingshydration poor , GC poor , no PICCLE

CVS S 1 , S2 heard , no murmur
RS BAEE , NVBS heard , no added
sounds
CNS NFND
BP 170/110
PR-86/min
Wt 58 kgs , airway adequate

 Patient shifted to ot
Preoxygenated with 100% oxygen for
3 mins
Thiopentone 250 mg iv , suxa 100
mg iv
RSI
Intubated with 7.0 size PVC ETT
Fixed @ 19 cms , inflated with 5 cc
air

 Baby delivered seven minutes after

incision
Baby
details BABY 1
DETAILS
BABY 2
WEIGHT

1.76 kgs

1.6 kgs

APGAR SCORE

8/9

8/9

AFTER BABY DELIVERY UTERUS WAS

FLABBY

 UTEROTONICS ADMINISTERED
Inj. Syntocinon 30 iu
Inj carboprost 250 mic im and 250 mic
intramyometrial
Inj. Methergine 0.2 mg im

Inj .morphine 4.5 mg iv

Inj .midazolam 2 mg iv
Inj . Fentanyl 100 mic iv

 Inj . Hydrocortisone 100 mg iv

Intra operative BP fluctuated between
systolic 150 to 200 mmhg
Diastolic bp fluctuated b/w 90 to 110
mmhg
At 10 mins after intubation vpcs were noted
Followed by ventr.bigeminy on and of
Inj lignocaine 80 mg iv given
Vpcs and bigeminy were terminated

 Arterial line secured

ABG showed
PH 7.40 , PCO2 24.1 , PO2284.5 , Na/K 118/ 2.45 , HCO3
20.1 , BE-4.2

 Surgery lasted for 1. 5 hours

Since uterus was flabby , surgeon
waited till it gets contracted
Hemostasis achieved and abdomen
closed
Total amount of intraoperative fluids
administered 2000 ml
Blood loss 500 ml
Urine output - 500 ml

 EMERGENCE
reversed with 2.5 mg neostigmine
and 400 mics glycopyrolate
Auscultation showed bilateral coarse crepitations /
bilateral rhonchi
patient saturation maintained @ 96 % without
oxygen
Before extubation patient was given inj .
Lignocaine -60 mg iv given
labetolol 5mg iv given

 With oxygen by mask saturation

improved to 100%
Patient had resp. Rate around 27/min
Salbutomol nebulisation given
patient resp rate decreased upto
22/min
Shifted to eclampsia room

 Post operatively salbutomol

nebulisation was continued
Patient resp rate reduced to 18/min
after 1 hour
IBP systolic b/w 110 to 130 and
diastolic b/w 60 to 80 mm hg
12 lead ecg was taken and reference
to cardiologist sent

 POST OP ABG
PH-7.42
PO2-81.2
Na-132
K-3.4
PCO2-32
HC03-21
SAT-96.6%
RBS -111/ Hct-32

 Cardiologist opinion
Echo showed mild AML prolapse, mild
MR, RVSP-34 mm hg
Started on tab metoprolol 25 mg bd ,
tab. Warfarin 2.5 mg od, inj. Heparin
5000 u s/c bd
Patien clinically and hemodynamically
stable hence asked to follow up in opd

THANK YOU