A healthy 39 year old woman has undergone laparotomy and myomectomy because of uterine fibroids. Her pre-operative Hb was 11.3 g/dl and the estimated blood loss was 700 ml. You are asked to see her because she has only passed 40 ml of urine over 4h post-operatively. (a) List the most important causes of oliguria in this woman [2 marks]. (b) Based on these causes, discuss your initial assessment [6 marks]. Two hours later, laboratory results show normal renal function and Hb of 6.8 g/dl and haematocrit of 0.24. Discuss your management [12 marks].
A/ Oligurea in this patient may be due to internal bleeding that reduces the renal blood flow and hence the glumerular filtration rate resulting in oligourea.
Ureteric injury or ligation is an other possible causes specially if there is parasitic fibroid in the broad ligament or if there is distorted anatomy.
bladder injury with leakage of urine intra peritonealy is an other possible cause.
B/I would inquire about abdominal pain radiating to shoulder tip which indicate diaphragmatic irritation by internal bleeding.Also I would ask about loin pain which may point to presence of hydronephrosis.
I would assess the general condition of the patient looking for evidence of hypovoleamia , so would assess her bp, PR,pallor,oxygen saturation
I would examine the abdomen for,distension,tenderness and rebound tenderness which may point to presence of internal bleeding.
also would examine the loins area looking for tenderness.
Then would invistigate the patient ,re test the Hb , RFT , perform U/S of the abdomen looking for free fluid ,as well as u/s for renal system .
c/
It is clearly that this is is internal bleeding so the pateint should informed with the possible cause
consent of re openning and possibility of hysterectomy if bleeding not stop should be discusesed with patient
the senior obstetrician should be called as well as the anasthetist and haematologist
The patent should transfused with cross matched blood and further blood should be prepared for the laprotomy
intra operatively bleeding should be secured, a drain should be inserted
The pt at risk of wound dehesciness so the abdomen should closed in mass suture.
The pt also at risk of infection so should covered with postoperative antibiotic.
Thromboprohylaxsis should be given after the risk of further bleeding subsided
incidence form for risk managment is of paramount important
|
