Mortality great presentation

1.  25 Now Para 0+1
 DOA 26/13/23 DOD 30/12/23
 Chronically unwell pTB and Stroke patient diagnosed and
treated in South Africa. HIV neg.
 Had a miscarriage 3 weeks ago at home ?? Self induced.
 Presented in Casualty SMCH with a 2 week history of passing
foul smelling PV discharge associated with abdominal pain
and vomiting.

2.  Normal size non gravid uterus measuring 7.3 x 3x 3.9
 Echogenic material in endometrial cavity measuring 3.3x 1.95
cm
 Increased echogenicity around the uterus suggestive of
infection
 No free fluid in POD
 Cervix long and closed.

3.  Alert, pink BP 117/75 P 89 T 36.7 SpO2 95%
 ABD –soft, generalized tenderness

4.  Initially seen by physicians who made an impression of prev
stroke on prophylaxis, TB on initiation phase and septic
miscarriage.
 Seen by gynecology intern in Casualty who made a plan to
1. Cytotec 800mcg SL stat
2. Amoxyl 500mg po tds
3. Metronidazole 400mg po tds x 2/52
4. CT rest of management as per physicians
5. Review in room 20 in 1/52

5.  Returned to room 20 4 days later with worsening lap and backache.
Reported that she did not expel anything after the cytotec she received 4
days prior.
On examination
Stable, pink, Loc 15/15, Temp 36.2, bp 106/69 p 81
Abd Soft mildly tender , no masses
VE foul smelling discharge
IMP: SEPTIC MISCARRIAGE

6.  Admit A2
 Ceftriaxone 1g IV Bd
 Metronidazole 500mg iv tds
 Clindamycin 500mg iv bd
 1l RL 4 hourly
 Blood culture (no bottles)

7.  RESULTS
◦ FBC:- WCC 5.6 HB 11.3 PLT 313 MCV 87
◦ U&E:- Ur 2.5 Cr 75 Na 148 K3.6
◦

8. DAY PROGRESS RESULTS PLAN
1 LOC 15/15
C/O Lap and back ache
IV antibiotics and
6hrly RL
Fbc and u and e
2 Patient remained stable
Was noted to be bleeding
from cannula site +
epistaxis + hematuria
Na 138 K 3.6 CL 123 Ur 3.0 Cr
292
Stop warfarin
Consult physicians
3 Noted that patient hadn’t
received cytotec
Uterine evacuation
withheld due to warfarin
coagulopathy
Patient collapsed and resus
without success. Certified
Cytotec reordered-
given at 0900
Chase physicians

9.  Septic miscarriage
 Pulmonary tuberculosis

10. FIRST
◦ Delay in seeking health care after noting foul smelling PV discharge
THIRD
◦ 4 day delay in getting inpatient care
◦ Delay in getting cytotec during admission
◦ Delay getting physicians on board during admission

11. ICD-10 code O03. 37 - sepsis following incomplete spontaneous
miscarriage

12. Recommendation Responsible person Timeline
Educate women to identify danger
symptoms post miscarriage
ANC/PNC/A2 SIC as well as
doctors during manning
room 20 and Gynaecology
OPD
Immediate
Equip clinicians in the protocols of
management of sepsis with emphasis
of surviving sepsis campaign
Anaesthesia and critical care 3 months
Swift implementation of orders given
during rounds by nursing staff
SICs Immediate