Transcript Maternal Mortality 2009 file # 25001 Died July 13, 2009

Palau Maternal Mortality after 20
years. What Happen?
PRESENTED BY DR. D. NGEMAES
JULY 9 – 12, 2013
APIA, WESTERN SAMOA
MOH Mortality Statistics - 2010
Cause of Death
Source: Ministry of Health Epidemiology
Proporation of deaths (%)
Proportionate Causes of Death by Year
(2006-2010)
35
30
2006
2007
2008
2009
25
20
15
10
5
0
2010
Cardio/Cerebrovascular Deaths - 2010
Type of
Cardio/Cerebrova
scular Disease
Stroke
Myocardial
Infarction
Coronary Artery
Disease
Aortic Aneurysm
Rheumatic Heart
Disease
Other
Total
Source: Ministry of Health Epidemiology
(Death Certificate Review)
Number of Cases (%)
19 (37.3)
12 (23.6)
7 (13.7)
2 (3.9)
2 (3.9)
9 (17.6)
48 (100.0)
Indications for Off-islands Referral - 2011
Case
 Pt: 33 y/o Palauan female (P1G2)
 Hx:
 Booking Clinic at 9wks gestation
 Routine

Total ANC Visits: 8 ( between 9 -32 wks gestation)
 B/P:


ANC Blood Works: All WNL
100/62 – 112/68, P: normal - trace, G: all normal values
Weight Gain: 26lbs
Physical Examination: Nothing abnormal detected.
Case cont- Day 1 (Admission)
 Presented with fever and chills

UA showed more than 100phf, ?TX, went home.
 F/U next day;





C/O: severe neck pain, and fever. r/o Dengue Fever
Investigaions:
 CBC: Hgb: 11.2, WBC: 7.5, Plt: 59
 Electrolytes
 Dengue Titer: negative
Admitted to MW with Diagnosis of UTI, Anemia and
Thrombocytopenia.
 VS: B/P: 100/60-130/80, T: 103F (39.4°C), p: 120, RR: 20, O2sat: 9798
Treatment: IVF, Ampicillin, Tylenol, PNV and Feso4
Patient stable
Case cont. (Day 2)
Gestation: 33 weeks 2 days




Patient Progress
C/O: Fever and Neck pain, SOB
lying down.
Fetal wellbeing; good.
VS:
 B/P: 90/40-100/62
 P: 130
 T: wnl
CBC
Repeated
Lab
(AM)
CBC
Results: Hgb
8.2
6.9
WBC
16.1
17.2
Plts
175
95
 UA for R & M: wbc: 10-25,
protein: 3+
Management
Ob team approached for
consultation; care initiated & to
continue same management.
 1 unit WB ordered.
 IVF continued (rate adjusted)
 Additional meds:



Gentamicin
Solu-medrol
Dexamethasone
Case cont. (Day 3)
Gestation: 33 weeks 3 days
Patient Progress
 C/O: Neck pain, SOB when
turning and ambulating
 Fetal wellbeing; good.
 VS:
 B/P: as low as 70/20
 P: 109
 RR: 28
 (+ other readings)
 Lab ordered: CBC, INR, & PT/PTT
CBC
Hgb
7.6
WBC
23.2
Plts
124
Management
 Continue IVF (rate adjusted)
 1 Unit of blood transfused.
 Additional Meds:


Vit. K
Terbutaline added for PTL.
 O2 started.
Case cont. (Day 4)
Gestation: 33 weeks 4 days
Patient Progress
 C/O: Same as before AND
Epistaxis (nurses notes)
 Fetal wellbeing; good.
 VS:



B/P: 90/50
P: 103
RR: 28 on O2
 Lab Results:



CBC
Hgb
7.2
WBC
21
Plts
126
Bleeding time: 3.05 (nl: 2-4)
PT: 14.9
INR: 1.32 (nl: 1.0-1.4)
Management
 1 unit of blood transfused
 Continue IVF (rate adjusted)
 No changes in management.
Case cont. (Day 5)
Gestation: 33 weeks 5 days
Maternal and Fetal Review
 C/O:
 Restless due to shoulder pain
 Tightness to both flank areas
 Increasing SOB.
 Condition unstable (nurses notes)
 VS:
 B/P: 100/60
 P: 132
 RR: 28
 T: 100F (37°C)
 O2: 98% ( on O2)
 Fetal tachycardia noted on NST with
uterine contractions.
 VE: unfavorable cervix.
 Lab results:
CBC

Hgb
8.9
WBC
21.2
Plts
107
Dengue Titer- negative
Management
 Continue IVF with increased
rate.
 Continue meds.
 No additional orders
Case cont. (Day 6)
Gestation: 33 weeks 6 days
Patient Progress
C/O:
 Severe SOB
 Generalized pain and bruises on different parts of body.
 Very Unstable
 Chart reviewed.
 Diagnosis: HELLP Syndrome secondary to Severe
Pre-Eclampsia developing secondary complications.

Labs/Assessment/tx
Lab results:
CBC - WBC: 23.1
Hgb: 9.6
Plats: 75
BUN/Creatinine: urea-25,
creatinine-1.2
Bleeding time- 4min.15sec
PT-15.3
PTT-29.8
EKG: ST elevation on all leads
CXR: Enlarged Heart
Cardiac U/S: Moderate
Pericardial Effusion
LFTs:Sgot (AST): 413
Sgpt (ALP): 632
UA-7.0; lyts: not done
NST-Fetal tachycardia
Needs an emergency Csection
Referral for Medical and
Anesthesia on call for
assessment and clearance
before surgery.
Family Conference Done.
Pericardial Effusion
Case cont.
During Surgery & Post-op
 Patient lost about 2.5 liters of blood.
 Required continuous intra-operative transfusion.
 Baby delivered- no complications.
 Mother transferred to SW ICU and placed on
Ventilator.
Case cont.
Days 7-13
 Patient continued to be ventilated
 Pericardial effusion drained x 2


Dark blood amounting to about 2.5L of blood
Continued drainage.
 Pulmonary Hemorrhage: 2Lmls+
 Renal Failure (due to shock/hypoxia): unable to dialyze.
 Total blood transfused: 15 units.
 Given almost all the Medications available and Staff
support, she unfortunately passed away on day 13.
 Baby is doing well so far and hopefully will continue to do
so.
Maternal Mortality Rates in Palau
 Maternal Mortality 1996
 1996 case had Severe Pre-Eclampsia and developed DIC,
unfortunately both mother and baby died.
Issues to think about
Recommendations
 Issues that arose at the time:
 Suggest to do complete CBC on all ANC Booking for baseline.
(Done)
 Role of FFP and Platelets in our setting. (Getting there)
 Source of Medical Air @ Hemodialysis
 Role of Social and Spiritual Health. (Done)
 Consult with Ob-Gyn for any Obstetric Admissions regardless
of the admission.
 Improve NICU facilities/services to cater for Premature
deliveries, specialized nurse, pediatrician specialized in
Neonatology.
Thank You, Mesulang!!!!!!
 Questions? Comments? Suggestions?