26 Year Old Female With Spontaneous Labour Pain | Near-Miss Case 3

During our last two Near-Miss Cases, we shared story about a 22 Year Old Female's Survival and a uphill battle of a 31 Year Old Female's Uterine Ruptured. Prof. Dr. Achala Vaidhya and team helped both of these brave females in their fierce battle against survival.

In this another case which we lable as "Near-Miss Case 3", Prof. Dr.  Achala Vaidhya explains and shares the story of a 26 Year Old Female who gained full-term pregnancy in 2nd Stage of Labour yet was unware of her delivery date.  

Near-Death Miss Case 3 

The patient 26 years old unbooked primigravida presented to the emergency department with? full-term pregnancy in 2^nd stage of labour. She was unsure of her date but was said to be at 9 months pregnant at the time of her presentation. She was referred from? Mugu  PHC was airlifted to our hospital in an emergency with complaints of spontaneous labour pain for 4 days and leaking per vaginum for 3 days with non-progress of labour (non-descent of head) with no fetal heart sound. Due to the unavailability of transportation, her referral to a higher centre was delayed. 

The patient menstrual cycle was regular. She had her regular ANC check-up at the nearby PHC  and was uneventful. She had no known comorbidities or surgeries in the past. At the time of presentation, her general condition was ill-looking, pale, tachypneic with RR-36/min, pulse rate - 120/min. BP- 110/80mmhg. Per abdominal examination revealed uterus 36 weeks size, longitudinal lie, cephalic presentation, head engaged, and the abdomen was distended with generalized tenderness. 

FHS could not be heard. Per vaginal examination revealed vulval swelling, cervix was soft edematous, OS was fully dilated, Head station  +1, caput present, the membrane was absent and liquor was scanty and foul-smelling. A self-retaining Foley catheterization was done which drained blood-stained urine. A diagnosis of Primigravida at? full-term pregnancy with prolonged obstructed labour with IUFD with? ruptured uterus with? bladder involvement with sepsis was made. 

The patient was resuscitated with IV fluids, IV antibiotics and all necessary investigations were sent. The patient was prepared for Emergency Laparotomy under general anaesthesia after taking High-risk consent. On opening the abdomen intraoperatively, two litres of straw-coloured fluid with urinary smell were drained. The whole anterior wall of the uterus was boggy with the lower uterine segment distended and boggy, Bandl’s ring was noted. 

The fetus was delivered via cephalic presentation with caput present. Liquor was foul-smelling and scanty in amount. Placenta was found posterior and delivered with complete membranes. A bladder dent of 2 X 2 cm was identified at the base of the bladder. Left ureter was oedematous and swollen. Uro surgeon was called for bladder repair and done in 2 layers. 

Total blood loss was approximately 1000ml. Despite persistent uterine massage and maximum dose of uterotonics uterus( oxytocin, carboprost and misoprostol)  was flabby and atonic, so to stop further bleeding surgical management was done so  Subtotal Hysterectomy was carried out. The fetal outcome was  3100 gm stillborn female with no gross abnormality. 

Post-operatively patient was managed in SICU for 2 days along with a team of anesthesiologists and physicians with IV antibiotics, analgesics and IV fluid. She was extubated 2 days later. On the 3^rd postoperative day, she developed hypotension so  Noradrenaline was started under central venous pressure guidance. Hypoalbuminemia was corrected by transfusing Human albumin 20% along with a protein supplement. 

Anaemia was corrected by transfusing 2 pints of whole blood intraoperatively and 3 pints post-operatively. She was catheterized with a Foley catheter which drained clear urine post-operatively and on the 22^nd postoperative day Cystogram was done which showed post-operative changes with normal findings. Hence, Foley’s was removed under the guidance of a neurosurgeon. During her follow up she was continent of urine and her wound had healed completely. 

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