MATERNAL MORTALITY

MEETING
CHAIRPERSON: Dr.
PRESENTERS: Dr. walter
DATE: 11th January 2012

2/24/16

INTRODUCTION
NAME: S.A
AGE: 41yrs.
RESIDENCE: Mtongani.
OCCUPATION: HW
DOA; 26.11.2011. at 2047hrs
DOD; 27.11.2011. at 1850hrs
Days of stay at Temeke hospital 1 day.

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GRAVIDITY: Gr5, P4+0, L4, LCB19yrs

LMP; 20.4.2011
EDD: 27.1.2012
GA: 28 weeks

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HISTORY and exam.By Admt

nurse
Admitted in wd 1 at 2047hrs.
Due to labour pain
OE;
General condition good
Temp. 36.5C
BP 110/60 mmHg
No proteinuria
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PA:
FH36/40
Fetalsizemedium
Lielongitudinal
PresentationCephalic
FHR+ve
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PVE:
Cx:dilatationTOF,
LEVEL3/5,

SVDexpected

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ANTENATAL HX.
Booked at 12 weeks,
Attended 3 times.
She was normotensive in 2x
Urinalysis not done,
Hb level 10g/dl 1x
PMTCT ONE
VDRL NR
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Blood group not done

Hematinics not given
SP not given
Mebendazole not given
TT not shown

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On 27th November at 1120hrs pt was

seen by Dr and the following was
noted:
Aminorrhoea 8/12
Fever 3/7
Coughing
Given im quinine at dispensary
PMTCT one on ARV medication
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OE
Look sick,oriented
Not pale, Oral thrush,
Dyspnoeic
Afebrile
Had a BP 70/50 mmHg PR 115bpm
RS BBS, RR not done
PA distended,FH 24/40,lie Long,ceph
presentation, FHR 140 bpm
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PVE vulvae warts,cx-TOF,intact mm,level

4/5
Temp. 37C
Chest -basal fine crackles
PA-FH 28/40
FHR +ve
PVE- Cx closed
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Dx: Mal in pregnancy

Genital warts
Pcp DDX pneumonia

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Plan:
Urgent
RBG
BS for mps,
Hb level,
Nacl 2L,
tabs
co-trimoxazole 960mg tds 1/52

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At 12.30 reviewed finding;

Dyspnoeic,RR34rpm
General body weakness,pink, Afebrile
RBG 2.2mmol/L BP 70/40
Resp. basal fine crakles,
PA FH28/40,FHR +ve,
PVE2/24/16
CX closed,

Dx: Hypoglycaemia,
PCP R/o PTB,
Malaria in pregnancy,
IUGR,
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Oral
candidiasis,

Plan:
10%
dextrose 1L,
tabs
quinine 600mg tds 6/7,
xpen 5IU 6hrly x24,
miconazole
oral gel 8hrly 5/7,
Haematinics,
BS FOR MPS,
RBG,
Septrin 1920mg tds,
sputum for AFB,
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At 1600hrs pt was reviewed finding not

started medicine she cant afford
Plan: inform Overall
Oxygen therapy
Cont Mx above
Nurse in cardiac bed

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At 1745hrs pt vomited once

Still has difficult in breathing
Increased frequency of coughing
Pt deteriorating
PR 125bpm

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Dx -PCP
-severe anaemia in pregnancy
-Malaria in pregnancy
-Hypoglycaemia
-Hypotension

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Plan: -Continue oxygen therapy

- injection hydrocortisone
100mg stat
-Reffer to MNH for blood
transfussion and other
Management

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At 2124hrs pt returned from MNH

already dead without any written
note.

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CAUSE OF DEATH
CARDIORESPIRATORY ARREST
SECONDARY TO AIDS

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Summary
I have been presenting a maternal death
of S.A 41yrs old G5P4+0 L4 who
admitted on 26,11,2011 at TMK hospital
with labor like pain and died a day after
admission with HIV/AIDS related in
pregnancy
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Preventable Death?
Yes
At family level
During ANC
At Temeke
At Muhimbili??
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What was done correctly

Pt attending RCH as erly as 12wks GA

Pt attending hospita as she found
abdominal pain
Frequency review
And same management

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What was inapropriate

At family level conceive
At the RCH
Investigation
Physician (Cardiologist)
ECG. And ECHO
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At Temeke Hospital
The admitting nurse was not keen
enough to realize the pt condition
and seek second opinion.
Dr did not seek advice from experts.

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Thanx

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Preventable Death?
Yes
During ANC
At Temeke

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