PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIETY (Foundation), INC

COMMITTEE ON MATERNAL AND PERINATAL WELFARE

MATERNAL MORTALITY CONFERENCE

September 29, 2010/5:00pm 3rd floor POGS Building CASE PROTOCOL B.B., a 17 year-old G2P1 (1001), in her 32-33 weeks (?) age of gestation, a College Student, Baptist, from Sampaloc, Manila, was admitted in a tertiary care hospital because of loss of consciousness last December 10, 2008. LMP: unrecalled AOG: 32-33 (?) weeks EDD: 3rd week of January, 2009 HISTORY OF PRESENT ILLNESS: Thirty minutes prior to admission, the patient was seen ingesting an unrecalled amount of silver jewelry polisher solution. The patient was then noted to be vomiting and subsequently lost consciousness. The patient was then rushed to the emergency room. PRENATAL CARE: Patient had four prenatal consults at the OPC of a government hospital since 3 months AOG. Laboratory studies included CBC, urinalysis, chest x-ray, early ultrasound, with unrecalled results. REVIEW OF SYSTEMS: Non-contributory PERSONAL AND SOCIAL HISTORY: Non-smoker Not an alcoholic beverages drinker No known illicit drug use Had family problems, according to the partner PAST MEDICAL HISTORY: (+) Bronchial asthma, since childhood Last attack unrecalled, maintained on Terbutaline No allergies, DM, hypertension, thyroid disease No previous blood transfusions FAMILY HISTORY: (+) Hypertension: mother and maternal grandmother (+) Allergy: seafood, mother and maternal grandmother (-) Bronchial Asthma, Diabetes Mellitus, Heart disease, Thyroid disease, PTB (-) Psychiatric disorder, suicide MENSTRUAL HISTORY: Menarche: unrecalled Succeeding menses were occurring monthly, lasted for 4 days, amounting to 1 pad per day, moderately soaked Symptoms: unrecalled SEXUAL HISTORY: First coitus: unrecalled Number of partners: not known Both pregnancies were with the same partner Post-coital bleeding of dyspareunia: not known Family planning methods: none

OB HISTORY: G2P1 (1001) G1 2007, full term, CS due to genital warts, unrecalled birth weight, no complications, government hospital (Manila) PHYSICAL EXAM: Unconscious, GCS 3 BP: 0, PR: 50bpm, CR: 50bpm, RR:0, T: not taken Cold clammy skin: no active dermatoses Pink palpebral conjunctivae, aniteric sclerae, pupils dilated and unreactive to light, no corneal reflex No naso-aural discharge Moist buccal mucosa, no lesions No neck masses, thyroid gland not enlarged, no palpable cervical lymph nodes, no neck vein detention Heart rate: 50s regular; Apex beat not appreciated, (-) murmurs No spontaneous respiration Globular abdomen, no fetal heart tones, LM1 breech, LM2 FB(L), LM3 cephalic Extremities: no cyanosis, edema, nor clubbing Neurologic Exam: Cerebrum: unconscious, GCS 3 Cerebellum: coordination cannot be assessed, no involuntary movements Brainstem: pupils dilated, non-reactive to light; no corneal reflex, no gag reflex, no facial asymmetry Motor: normal muscle tone, MMT cannot assessed No Babinski and nuchal rigidity ADMITTING DIAGNOSIS: Pregnancy 32-33 (?) weeks, cephalic, not in labor Cardiorespiratory arrest secondary to toxic substance ingestion Previous LTCS (1x) secondary to genital warts PLANS: Resuscitate Stabilize cardiovascular and pulmonary status Possible Cesarean Section COURSE: 4:30 PM Patient was being brought to the OB ward by her partner per wheel chair, unconscious, with frothy saliva coming out of her mouth. When met by the OB residents and fellow, the patient was immediately wheeled to the ER. According to the partner, the patient was seen drinking silver jewelry cleansing solution at home about 30 mins before she was brought to the hospital. At the emergency room, the patient was noted to be unconscious, GCS 3, no spontaneous breathing, with pulses, no blood pressure appreciated. Pupils were dilated and non reactive. She had cold and dry skin. Cardiac rate was at 50s, regular. No fetal heart tones noted by stethoscope and Doppler. Assessed to have Acute Respiratory Failure, patient was immediately intubated using a 7.5 L19 endotracheal tube. After a few minutes, there were no appreciable heart sounds, pulses were absent, and no blood pressure was appreciated. Cardio-pulmonary resuscitation was started: chest compressions, Epinephrine 1mg/IV for 3 doses, NaHCO3 50mEqs/ SIVP x 1 dose, Calcium Gluconate/SIVP x1. After 2-3 minutes, 12L ECG showed normal sinus rhythm, heart rate of 80-90bpm, with palpatory blood pressure of 20 mmHg. Patient was started on Dopamine drip 250mg in 200cc PNSS. There was a slight improvement of BP at 100 mmHg, palpatory, dopamine was titrated accordingly. Fetal heart tone (?) noted by Doppler was 80-120 beats per minute. The patient was then brought to the delivery room for emergency Cesarean Section. Informed and written consent from the family was secured. On ultrasound, the fetus was noted to be bradycardic at 80 bpm. The patient, however, went into another cardiorespiratory failure. Cardio-pulmonary resuscitation was rendered, 2

given Epinephrine 1mg/IV x 11 doses, NaHCO3 50mEqs/SIVP x 1 dose, and Calcium Gluconate 10% vial x 1 vial/SIVP. 5:15 PM Delivered to a live but limp baby boy, birthweight: 2.6kg BL: 50cm, APGAR: 0,1,2,2,2 maturity testing: 36 weeks, AGA. 5:28 PM Asystole was noted on 2 limb leads and patient was pronounced dead. Postmortem care was rendered. OPERATIVE FINDINGS: On opening, the lower uterine segment was well-formed. Proceeded with repeat low transverse cesarean section. Amniotic fluid was clear and adequate. LOT, delivered to a live limp baby boy, birthweight: 2.6kg, BL: 50cm, APGAR: 0,1,2,2,2, maturity testing: 36 weeks, AGA. Uterus was well contracted and grossly normal. Both ovaries and fallopian tubes were grossly normal. Estimated blood loss was 1,000cc. POST-OPERATIVE DIAGNOSIS: - Pregnancy 36 weeks, LOT, delivered by peri-mortem LTCS to a live baby boy, BW: 2.6kg, BL: 50cm, AS 0-12-2-2, AGA - Cardiorespiratory arrest secondary to toxic substance ingestion - Previous LTCS (1x) secondary to genital warts PROCEDURE DONE: - Peri-mortem repeat low transverse caesarean section.