Case 17: Pregnant Teenager with a Bad Outcome

Abstract

A 17-year-old primigravida (85 kg) is admitted to the hospital at 7p.m. She is 39 weeks pregnant and in labor. Fetal distress is diagnosed and an emergency cesarean section is scheduled. The patient refuses both spinal and epidural anesthesia. She is taken to operating room No. 4 and routine monitors are placed. She is very nervous and does not want the oxygen mask for preoxygenation. You anesthetize her with a rapid-sequence technique consisting of metoclopramide; an antacid, 30 ml per os; etomidate, 18 mg; and succinylcholine, 100 mg, with cricoid pressure. After the endotracheal tube (ETT) is placed in the trachea, anesthesia is maintained with 50 % nitrous oxide in oxygen with isoflurane 0.8 %. Further muscle relaxation is provided by intravenous (IV) injection of vecuronium, 7 mg. At delivery, the child cries immediately and has an Apgar score of 8/8 at 1 min after delivery. After delivery of the infant, the mother receives morphine, 10 mg IV, and the nitrous oxide is increased to 70 % in oxygen. At the end of the surgery, the isoflurane is turned off. The residual effect of the nondepolarizing drug is antagonized with neostigmine, 5 mg, mixed with atropine, 1.2 mg, IV. The patient starts to breathe spontaneously. The nitrous oxide is turned off and 100 % oxygen is given. Three to four minutes later, the oxygen saturation alarms. The saturation is now 88 %, down from 100 %. You check the monitor but it seems to be working as the heart rate per the oximeter and electrocardiogram (ECG) is identical at 100 beats per minute (bpm) up from 82 bpm. You examine your patient and discover that she is cyanosed and, despite all attempts to resuscitate her, she is declared dead 20 min later. You and the whole team are devastated.