Maternal cardiac arrest secondary to choriosepsis after preterm premature rupture of membranes.

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Date: Sept. 12, 2022
From: CMAJ: Canadian Medical Association Journal(Vol. 194, Issue 35)
Publisher: CMA Impact Inc.
Document Type: Clinical report
Length: 2,597 words
Lexile Measure: 1900L

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A 28-year-old woman with a history of 3 pregnancies and 2 live births presented to the labour and delivery unit of a district general hospital with preterm premature rupture of membranes (PPROM) at 27 + 4 weeks' gestation (Figure 1). Membrane rupture was confirmed on sterile speculum examination; labour had not begun, and bleeding or decreased fetal movement were not observed. Maternal vital signs were normal, as was the fetal nonstress test, which measures fetal heart rate to assess well-being. The patient had no uterine tenderness. The pregnancy was otherwise uncomplicated. The patient's 2 previous births were uncomplicated term vaginal deliveries. She also had mild asthma.

In line with national guidelines for management of PPROM, the patient was admitted and treated with intravenous antibiotics (ampicillin 2 g and erythromycin 500 mg, every 6 h). (1) She was prescribed 2 doses of intramuscular betamethasone (12 mg, 24 h apart) to accelerate fetal lung maturation. The next day, a live fetus and oligohydramnios was confirmed with ultrasonography. After 48 hours, as per national guidelines, the patient's antibiotics were switched to oral amoxicillin (250 mg, every 8 h) and erythromycin (333 mg, every 8 h) for a further 5 days. Amoxicillin was stopped on day 4. (1)

On day 5, while an inpatient, the patient became febrile with painful contractions. Repeat ultrasonography was performed, which showed intrauterine fetal demise. The patient's leukocyte count was 3.3 (normal 4.0-10.0) * [10.sup.9]/L, with neutrophils 2.9 (normal 2.5-7.0) * [10.sup.9]/L. Her labour was augmented with oxytocin, resulting in spontaneous vaginal delivery of a stillborn female, followed by a malodorous placenta, suggestive of chorioamnionitis. She was treated with ampicillin 2 g every 6 hours and gentamicin 340 mg (5 mg/kg) every 24 hours; erythromycin was stopped. The next day, cultures of blood samples grew Escherichia coli that was resistant to ampicillin but sensitive to gentamicin and ceftriaxone. Ampicillin and gentamicin were stopped, and she was treated with ceftriaxone 2 g every 24 hours.

On day 7, the patient developed chest tightness, in the absence of signs of deep vein thrombosis or pulmonary embolism. She deteriorated through the day, developing sepsis and suspected disseminated intravascular coagulation, and was admitted to the intensive care unit (ICU) for management of septic shock. Piperacillin-tazobactam was prescribed to replace the previous antimicrobial regimen.

Within 2 hours of transfer, cardiac arrest occurred, requiring 50 minutes of cardiopulmonary resuscitation. An extensive workup was carried out; imaging showed a subdural hematoma and a very small right-sided peripheral pulmonary arterial thrombus, which was deemed unlikely to be the cause of cardiac arrest, as well as bilateral pleural effusions and left lower lobe consolidation. Bilateral leg Doppler ultrasonography did not show thrombus. The patient's electrocardiogram and echocardiogram were normal, excluding cardiomyopathy.

On day 8, the patient was extubated. She appeared neurocognitively intact. Her hypovolemia and cardiovascular status improved, but there appeared to be an ongoing untreated source of infection, despite treatment with broad-spectrum antibiotics. Pelvic ultrasonography suggested retained products of conception. Suction dilatation and curettage was performed on...

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Gale Document Number: GALE|A716601212