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PowerPoint slides on maternal mortality.
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- 2. BIODATA Name : Fakhrawife of : M. Jahangeer Age : 25 years MR# 52988 • Address: Rosa , Dak khana khas ,Tehsil Kot Radha Kishan Dist, Qasur • Contact # 03090541951 • CNIC # Patient: N/A CNIC # husband : 35104-0514365-7 • Date of admission: 13-11-2024 at 1:30am Mode of admission: Emergency • Date of death: 21-11-2024 at 3:50am • Receiving status: Patient received in critical condition • Diagnosis : PG at 28 weeks/d Pancytopenia,Acute viral hepatitis ( Hep E IgM +) & Received IUD
- 3. HISTORY • Married for:10 months (non consanguineous) • Parity: PG • Risk factors: Pancytopenia,Acute viral hepatitis • Presenting complain:Absent Fetal movements since 3 hours History of PICA +ve No history of raised blood pressure, Diabetes, IHD ,TB or asthma
- 4. EXAMINATION • Vitals Generalphysical examination Abdominal examination BP. 100/70mmhg Pallor +++. SFH : 28 weeka Pulse: 110/min Jaundice ++. Lie: longitudinal Temp: 98.6 F Pedal edema + Presentation: Cephalic RR: 18/min Liquor: Reduced SpO2:97% at room air Chest: B/L NVB+0 Pelvic examination BSR: 103mg/dl. Os : Close
- 5. INVESTIGATION Labs 13-11- 2024 15-11 7:30am 15-11 7pm 16-11 9am 16-11- 5pm 17-11 18-1119-11 Hb 4.5 8.4 8.1 5.7 7.5 6.1 8.1 5.2 TLC 6.7 4.7 1.6 9.4 17.0 8.6 24.1 4.2 Plat. 18,000 25,000 15000 11,000 15,000 12000 16000 6000 Cr LDH 1.0 1890 2.12 2.3 Bili T 16.2 14.7 11.6 ALT AST 63 124 54 207 109 Na K 140 3.5 130 4.4 139 >10 Trop I 4.29 3.19 S.Fibri- nogen 870 PT APTT 29 38 14 33 Pro- BNP 512.9
- 6. SEQUENCE OF EVENTS •13-11-2024 at 1:30am • Mrs Fakhira w/o Jahangir 25 years old female , unbooked/unscreened , PG at 28 weeks/d presented in emergency with C/O absent fetal movements since 3 hours with following vitals : BP 110/70mmhg , Pulse 110/min ,Temp afebrile, RR 18/min , SpO2 98% at Room air. Workup for Pancytopenia, coagulation profile, Serum Fibrinogen sent , attendants were counselled regarding the poor maternal outcome and informed consent taken. 1 washed RBCs, 5 platlets conc, 1 FFP transfused on 15-11-2024 • 15-11-2024 at 5pm : A dead baby boy of 1.8 kg delivered as cephalic followed by Complete delivery of placenta & membranes, Uterovaginal packing done with 2 roll gauzes with 1 knot due to vaginal bleeding.
- 7. • 16-11-2024 at6:30am Patient became critical , developed shortness of breath, with following vitals BP: 70/40mmhg , Pulse: 140/min ,Temp: 100 F , RR 39/min , SpO2: 84% at room air O/E : Chest – Bilateral fine crepts at bases Abdominal exam:Abdomen was soft , uterus was contracted , Vaginal bleeding was mild Patient immediately shifted to HDU , 8 liters oxygen attached - High risk counselling of attendants done
- 8. • 16-11-2024 at8:30am ( 1st Post natal day). ∆TRALI / Sepsis/ DIC / MOF 1 episode of generalizedTonic clonic fits observed of about 30 second duration. Vitals : BP 60/30mmhf , Pulse 132/min ,Temp Afebrile, RR 38/min , SpO2: 74% at room air, BSR : 120mg/dl , O/E ,Abdomen was soft, vaginal bleeding was mild , chest bilateral fine basal crepts . UOP: 50ml/hr Labs : Hb : 5.9,TLC 9.4 , Platlets: 11,000, Cr : 1.0 , Na: 140, K : 3.5 , BiliT : 16.2 ALT: 63 , AST: 124, LDH : 1890 , CRP : 69.8 Inj Norpine 4mg started at 20 microdrops/min Call to Medicine, Nephrology ,ICU & cardiology sent , High risk counselling of attendants done,
- 9. 1 Megakit and2 FFPs transfused • 16-11-2024 at 4:45pm : Patient developed 2nd episode of GTC fits of about 40seconds , no tongue bite Or frothing from mouth or fecal incontinence noted. Vitals : BP 100/60mmhg (on inj Norpine 4mg at 20microdrops/min) , Pulse 160/min ,Temp 100 F , RR 40/min , BSR 139mg/dl O/E : GCS was 9/15 , abdomen was soft , vaginal bleeding was mild, chest : Bilateral fine crepts UOP : 1800ml/12 hours Patient evaluated by anesthesia team and intubated at 5:15pm • Critical counselling of attendants done regarding poor prognosis.
- 10. • 17-11-2024 at6am (2nd Post natal day) Patient was admitted in HDU in critically ill condition, shifted on vent , sedated and paralyzed with following vitals: BP : 90/60mmhg ( inj Norpine 4mg at 40 microdrops/min) , Pulse: 121/min,Temp 100 F, SpO2: 100% on vent, BSR 83mg/dl • O/E : Abdomen was soft,Vaginal bleeding was mild ,Chest B/L fine crepts, UOP : 1800ml/12hours • Labs : Hb 7.5 g/dl ,TLC 17 , platlets: 15,000 , Cr 2.1 , ALT/AST : 54/201 , Bili T : 12 PT/aPTT : 14/33 • 18-11-2024 at 8:40am: Critical event –Patient collapsed suddenly became BP less , pulseless, Carotids absent, pupils fixed dilated, CPR immediately started According to ACLS protocol and continued for 15 minutes, Patient reverted , Post CPR vitals : BP : 60/30mmhg (on inj Norpine at 34 microdrops/min), pulse 158/min,Temp 101F , SpO2 : 99% on vent , BSR 118mg/dl .
- 11. • Labs :Hb : 8.1g/dl ,TLC : 24.1 , Platlets conc. 16,000 , Cr: 2.3, AST : 109 , BiliT : 11.6 , K : >10 , Na: 139 • 12 lead ECG showed Atrial fibrillation , patient evaluated by Cardiologists at bedside and advised to depotash the patient. Call to ICU sent for shifting, Critical counselling of attendants done. • 18-11-2024 at 12pm : Uterovaginal packing removed, No vaginal bleeding noted . • 19-11-2024 at 12 pm : 1 Megakit transfused.
- 12. • 20-11-2024 at8am : (5th postnatal day) Patient was in critical condition, on vent sedated and paralyzed. On Double ionotropic support. Pupils were Bilateral Pinpoint, non reactive to light. Vitals : BP : 80/60mmhg (on inj Norpine 4mg at 40 microdrops/min , inj dobutamin at 24 microdrops/min) Pulse : 150/min ,Temp : 100 F , SpO2 98% on vent , BSR 148mg/dl , Labs Hb: 5.2 , TLC: 4.2, Platlets: 6000. ECG showed sinus tachycardia & Poor R wave progression.
- 13. • 21-11-2024 at03:40am : Patient collapsed, became BP les, pulseless , Carotids absent, Pupils were B/L fixed dilated, Heart sounds and breath sounds were absent , DNR was already signed by the attendants. Patient declared dead at 03:50am . • ICD Class: M-07 (Non obstetric complications (Maternal death- indirect)
- 14. • Primary causeof death Severe anemia leading to Cardiac failure • Secondary cause of death Pancytopenia,AKI ,TRALI, • Contributory Factors Acute Pulmonary edema , sepsis / DIC , MOF
- 15. RECOMMENDATIONS Adequate antenatal care Earlyassessment of Risk Factors . Anticipation & Recognition of Complications • Early Referral