Unexpected poorly done

1. Maternal mortality meeting
3/8/23

2. • TM
• P3G4(3 alive), LNMP 7/9/22, EDD 15/6/23, EGA 39w
• DOA 15/6/23
• DOD 24/6/23
• REFFERAL FROM: RUWA CLINIC
• Booked at Ruwa clinic at 21/40, 4 ANC visits, HIV neg, RPR ND, USS done no
record
• Dx G. HTN at 28/40 commenced on methyldopa 500mg po tds
• NB: Hx hypertension in all prior pregnancies

3. At clinic
• Presented at 3.15 with a hx of fitting about 10 times since 2300
• 3 day hx of headache and blurry vision
• O/E BP 134/94 P 100 depressed LOC
• ABD- HOF 39 long ceph FHNH with pinard VE-not documented
• MgSO4 4g in each buttock
• Catheterized
• Transfer to MNMH (ambulance contacted)
• 54mins later delivered LGI BWT 2750g in thick msl APGAR 9-10 EBL +/-120ml
• Left clinic at 4.35

4. At PGH
• Arrived at 5.30 (1hr)
• BP 234/117 P 89 depressed LOC
• Uterus not well contracted, VE expelled clots
• IMP: eclampsia and PPH
PLAN
• Admit ELW
• Misoprostol 800mcg pr stat
• Ct mgso4 course
• Input-output
• Nifedipine 20mg po bd
• Hydralazine 12.5mg IM stat if bp >/= 160/110
• Oxytocin 40iu/l infusion
• FBC, U&E, LFT, G&R

5. • Seen at handover
• BP 164/102 P116 LOC V1 E4 M5 (10/15) swollen tongue
• Reduced urine output(<100ml in ?time, concentrated)
• Uterus well contracted, moderate pv loss
• Added oral and pressure point care
• Fit chart
• TED stockings

6. Results
• FBC WCC.25 HB.13 PLT.105 MCV.78
• U&E Na144 K4.4 Ur4 Cr92.8 Cl107 eGFR75
• LFT TP68.7 Alb 33.9 AST 826 ALT453 ALP234 GGT25 Tbil 75
Dbil27

7. Problems
• Depressed LOC
• Seizures
• Elevated blood pressures
• Acute kidney injury

8. DAY PROGRESS PLAN
1 BP 159/108 P125 Spo2 100% OFA LOC (V2 E3
M5=10/15)
o10.32: matron concerned about patient’s depressed
LOC and possible need for ICU admission contacted
consultant on cover who advised to reach anasthetist.
11.16: seen by Anasthetics SHO
Dexamethasone 8mg iv tds
Informed senior
No current need of ICU bed
TX feeds 200ml 4hrly
Physiotherapy
R/V in 4hrs
2 01.44: added HCT 12.5mg po od
7:00: LOC M3 V2 E2=7/10, had secretions needing
suctioning to breath
7.47: Ana r/v- ?Mg toxicity,
14.54 LOC E2 V2 M1 5/10 gluc 4.9 BP130/62
U&E Ur12.2 Cr141 K3.6 Na141. FBC WCC14.6 Hb11.5
MCV79 PLT 131 NO MPs
admit ICU (no bed, another patient with LOC 5/15
in ELW being prioritized, mg levels, ct brain
3 14.56 Admitted into ICU- no intubation
Ct scan brain in pvt- no bleed
CT
4 LOC E4 V2 M4 10/15, paucity of mvt of left upper limb
BP 163/92 Gluc 8.7-12.4 Temp 35.8-39.2
Neurosurgeons mild effacement of sulci and gyri in
parietal and occipital regions with open basal cisterns,
no intracranial bleeds or hydrocephalus
Discharged to CCU- no bed so went to ELW
CXR

9. Day 5
• Seen by gyn reg
• Saturating 73% OFA
• LOC E4 M1 V1= 6/15
• Noted U&E Na152 K4.1 Ur12.9 Cr 127
• FBC WCC16.5 Hb10.3 PLT 219 MCV86.7
• ½ N/S 42ml/hr
• Concern for aspiration pneumonia

10. Day 6
• BP 160-170/80-111
• LOC E4 V2 M3 9/10
• Consult ana for readmission into icu
• Physician to review

11. Day 8
• CCU bed now available
• Yet to be r/v by physicians
• 16.13 transferred to CCU
• Unfortunately day 9 at 1.30 patient certified dead

12. Delays
• 1: late booking, symptomatic for 3/7 prior to presentation,
fitted 10 times before presentation
• 2: transport between clinic and hospital
• 3: no ct scan in gvt, no icu bed, rv by physicians, no mannitol or
dexamethasone given, no documented physiotherapist
involvement

13. Cause of death
• Eclampsia
• Group 2
• ICD code O15.1

14. Avoidable/ Unavoidable
• Educate patients on early booking
• Standardize management across all healthcare facilities
• Improve availability of imaging and medication in public
hospitals