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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. Cardio/ Cerebrovascular Deaths - 2010.

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palau maternal mortality after 20 years what happen

Palau Maternal Mortality after 20 years. What Happen?

Presented by Dr. D. Ngemaes

July 9 – 12, 2013

Apia, Western Samoa

moh mortality statistics 2010
MOH Mortality Statistics - 2010

Cause of Death

Source: Ministry of Health Epidemiology

cardio cerebrovascular deaths 2010
Cardio/Cerebrovascular Deaths - 2010

Source: Ministry of Health Epidemiology (Death Certificate Review)

slide6
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 wksgestation)
      • B/P: 100/62 – 112/68, P: normal - trace, G: allnormal values
    • Weight Gain: 26lbs
    • Physical Examination: Nothing abnormal detected.
case cont day 1 admission
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
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
case cont day 3 gestation 33 weeks 3 days
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

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
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: 28on 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.

case cont day 5 gestation 33 weeks 5 days
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

case cont day 6 gestation 33 weeks 6 days
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 C-section
  • Referral for Medical and Anesthesia on call for assessment and clearance before surgery.
  • Family Conference Done.
case cont during surgery post op
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
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 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 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
Thank You, Mesulang!!!!!!

Questions? Comments? Suggestions?