Case
A 29-year-old primigravida at 39+4 weeks pregnancy was admitted to the emergency room (ER), Jigme Dorji Wangchuck National Referral hospital, Thimphu, Bhutan with early labour pain at 4 am on 31st December, 2020. She had uneventful antenatal care. She didn’t have any medical disorders and no known allergy to drugs, foods and insect bite. On admission, her vitals were stable. She was in early labour with cervical dilatation of 2 cm.
While waiting for admission to maternity ward, her pain gradually increased in frequency, duration and intensity. For pain relief, emergency medical officer prescribed intramuscular tramadol 50mg initially. After 30 minutes, her pain score didn’t improve. Immediately upon administration of Intravenous (IV) tramadol at 9:30 am, patient became drowsy with poor respiratory effort with SPO2 of 78% on room air, followed by absent spontaneous respiratory effort and loss of consciousness. There were no skin changes such as generalized hives or urticarial rashes. Bag and mask ventilation was initiated. Her peripheral pulses were palpable. Cardiac auscultation showed regular heart sounds. Injection Naloxone 0.4mg IV was given for two doses 30 seconds apart. Injection adrenaline 0.5mg IM and injection hydrocortisone 200 mg IV were administered.
Since there was no return of spontaneous respiratory effort, respiratory arrest was diagnosed, and endotracheal intubation with 7.00 mm tube was done and connected to ventilator. She was positioned in left lateral position with 15 degree tilt. Cardiopulmonary resuscitation (CPR) with chest compression was not required as her cardiac function was stable. She was sedated with injection propofol 10 mg IV and injection diazepam 10mg IV. Her SPO2 maintained at 100%, blood pressure was 94/76 mmHg, and pulse rate was 85 beats/minute. Fetal heart beat was 126 beats/minute. There is no cardiotocography facility in the ER for fetal heart beat tracing. Injection adrenaline was not repeated as the vitals were stable.
Patient was kept under ventilation as GeneXpert for SARS-COVID 19 report was pending. As soon as negative GeneXpert report was available, she was shifted to Operation Theatre. Emergency caesarean section was performed and a live female baby weighing 3.810 kg was delivered at 10.57 am. There was fresh meconium-stained amniotic fluid. APGAR score of was 8/10 and 10/10 at one and five minutes respectively.
Her vitals were stable during caesarean section. Extubation was done in the post-anesthesia care unit (PACU). She was then shifted to adult intensive care unit (AICU) and monitored closely. As her vitals were stable and SPO2 maintained with nasal oxygen at the flow rate of 2 litres/minute, she was shifted to maternity ward after 24 hours of close observation in AICU. She was weaned off the oxygen on the second day.
In the maternity ward, she made an uneventful recovery. Her anaphylaxis was uniphasic. A healthy mother and baby were discharged home on postoperative day 3. Her postnatal follow up were uneventful at one, three and six weeks.