WebM&M: Case Studies

A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage. After delivery, the patient was transferred to the post-anesthesia care unit (PACU) and monitored for 90 minutes, after which she was deemed stable, despite some abnormal vital signs. All monitor alarm functions were silenced to help the patient rest until a bed became available on the maternity floor. After another 90 minutes, the patient’s nurse discovered her unresponsive and the bedsheets were blood-soaked. A massive transfusion was ordered and uterotonic medications were administered, but vaginal bleeding continued. During an emergency laparotomy, the uterus was noted to be atonic despite uterotonic therapy, requiring an emergency hysterectomy. The commentary discusses the importance and use of early maternal warning systems, checklists and protocols to avoid poor maternal outcomes.

A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed. The perfusionist arrived 30-minutes later and realized that the ECMO machine was introducing room air to the patient’s circulation, leading to air embolism. The patient became severely hypotensive and bradycardic, and despite aggressive attempts at resuscitation, she died.

A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.