PRESENTED BY DR. D. NGEMAESJULY 9 – 12, 2013

APIA, WESTERN SAMOA

Palau Maternal Mortality after 20 years. What Happen?

Cause of Death

MOH Mortality Statistics - 2010

Source: Ministry of Health Epidemiology

Cardio/Cere-brovascular

Cancer Injury/accident Respiratory Dx Septicemia Kidney Dx0

5

10

15

20

25

30

35

Proportionate Causes of Death by Year(2006-2010)

2006 2007

2008 2009

2010

Pro

pora

tion o

f death

s (

%)

Cardio/Cerebrovascular Deaths - 2010

Type of Cardio/Cerebrova

scular Disease

Number of Cases (%)

Stroke 19 (37.3)Myocardial Infarction

12 (23.6)

Coronary Artery Disease

7 (13.7)

Aortic Aneurysm 2 (3.9)Rheumatic Heart Disease

2 (3.9)

Other 9 (17.6)Total 48 (100.0)

Source: Ministry of Health Epidemiology (Death Certificate Review)

Indications for Off-islands Referral - 2011

Case

Pt: 33 y/o Palauan female (P1G2)Hx:

Booking Clinic at 9wks gestation Routine ANC Blood Works: All WNL

Total ANC Visits: 8 ( between 9 -32 wks gestation)

B/P: 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: 97-98 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

Lab Results:

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

CBC (AM)

Repeated CBC

Hgb 8.2 6.9

WBC 16.1 17.2

Plts 175 95

Case cont. (Day 3)Gestation: 33 weeks 3 days

Patient ProgressC/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

ManagementContinue IVF (rate

adjusted)1 Unit of blood

transfused.Additional Meds:

Vit. K Terbutaline added for PTL.

O2 started.

CBC

Hgb 7.6

WBC 23.2

Plts 124

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:

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.

CBC

Hgb 7.2

WBC 21

Plts 126

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:

Dengue Titer- negative

Management

Continue IVF with increased rate.

Continue meds. No additional

orders

CBC

Hgb 8.9

WBC 21.2

Plts 107

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/txLab results: CBC - WBC: 23.1 Hgb: 9.6 Plats: 75BUN/Creatinine: urea-25, creatinine-1.2Bleeding time- 4min.15sec

PT-15.3PTT-29.8

EKG: ST elevation on all leads CXR: Enlarged Heart Cardiac U/S: Moderate Pericardial Effusion

LFTs:Sgot (AST): 413 Sgpt (ALP): 632UA-7.0; lyts: not doneNST-Fetal tachycardiaNeeds an emergency C-sectionReferral 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 ventilatedPericardial 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 aboutRecommendations

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?