SU5MR CR- 1/2020

STILLBIRTH & UNDER 5 MORTALITY CONSOLIDATION REPORT

STATE: KELANTAN DISTRICT:

Name: B/O Wan Nafisah binti Wan Mohamad Sex: female DOB: 13/8/2022

Age: Day 4 OL

MyKid: - Race: Malay

MIC: 8509130361063

Others (state):

Date & Time of Death: 16th August 2022 Home Address:

Place of death: HOSPITAL TANAH MERAH

Antenatal History (list antenatal issues, medical problem, social concern)

Mother is a 37 years old , G3P2 at 37 weeks 6 day POG

MBG : A +ve
Infective screening : NR

1) Diabetes Mellitus type II

On T Metformin 1 g BD
S/C Actrapid 26/26/24 u tds
S/C Insulatard 26u ON
HbA1c : 8.06 mmol
Detailed scan at 26 weeks POG : Normal

2) Maternal obesity
BMI : 34kg/m2

3) Voluntary subfertility

Perinatal History (place of delivery, perinatal events, gestation, mode of delivery, BW, resuscitation, Apgar score,
NICU/SCN admission)

She came with complained of contraction pain , Otherwise :

good fetal movement,

no leaking liquor,

no UTI/URTI symptoms.

She was admitted to labour room and ARM was done , noted thin MSL.

CTG post ARM pathological thus decided for EMLSCS. However mother complaining of bearing down and was
complicated with shoulder dystocia

Os fully at 0235h,head out at 0237h, noted turtle neck sign, Mc Robert and suprapubic pressure done , episiotomy
done, however still unable to deliver. Robinz II manouever done.Baby delivered at 0247h after released posterior
arm (time elapsed10 min)

Patient born not vigorous, Apgar score at 1 min of life : 1 (cyanosed, poor breathing effort, poor muscle tone, no
reflex, HR <100).

Given PPV X1 for 30 s

Baby was intubated at 1 min of life

Noted no heart rate post intubation , thus CPR was commenced for 3 minutes.

Adrenaline was given through ETT (0.5ml/kg : 2ml)

Apgar score at 5 min of life :3 (acracyanosis, poor breathing effort, poor muscle tone, no reflex , HR >100)

Apgar score at 10,15,20 min of life : 5 (acyacyanosis, weakly hyperventilated, limping, no reflex, HR > 100)

She was admitted to NICU. Highest Thompson score was 15 and was meet criteria for cooling theraphy, thus
cooling theraphy was started at 13/8/2022@0315h. cooling theraphy was stopped at 64 h of life in view
ofunstable condition.

Neonatal History (comorbidity, postnatal visits, hospital admission, feeding issue, social concern)

1) Severe sepsis with multiorgan involvement

i- Hypoxic liver injury

ii- electrolyte imbalance

Iii- coagulopathy

She acquired new onset of sepsis in which at 41 h of life, she had developed temperature spike and septic
parameters worsening (CRP :0.38—55.8). Chest xray was repeated , noted new pneumonic changes, thus
treated as nosocomial pneumonia

Antiobiotics was escalated to IV Tazosin and IV Amikacin. Her condition deteroriating on D3 of life in which she
developed PPHN and worsening pneumonic changes on chest xray.

At 57h of life, patient developed PPHN in which there is discrepancy pre and post ductal spo2 (pre ductal spo2 :
94- 98%, post ductal spo2 : 87-93%) . Initially, Her oxygen support (conventional mode) was increased up to Fio2
: 0.9 and Pr 22/6. on top of that, blood gaseous show hypoxaemic respiratory failure with worsening metabolic
acidosis. Antibiotics was escalated to IV Meropenem.

• Her condition deteroriating in which her blood pressure become lowish( MAP :32) required of normal
saline bolus 10 ml/kg x2 and human albumin 5% 10ml/kg and started on IV inotropic support titrating
up to 4 maximum inotropes.

• Her blood gaseous show hypoxaemic respiratory failure with worsening metabolic acidosis (Ph :
7.118/pco2 :40.9/ po2 :65.5/hc03 : 13.2/ lactate : 5.6)required of increment ventilator setting up to
 HFOV.

• Initially, trial of HFOV with mean 13, rate 9, Fio2 : 0.99, delta P : 35. Lung recruitment done up till mean
18, rate 8, Fio2 : 1.0. spo2 on manual bagging (with higher pressure) able to get max spo2 , pre (90%),
post (72%). Spo2 on HFOV labile , pre : 74-78% and post : 65-68%.

• Eventually, he was managed for PPHNN and was given loading Mgso4 200mg/kg and IVI Mgso4
30mg/kg/h. IVIG 0.5g/kg was served

2) Severe hypoxic ischaemic encephalopathy secondary to shoulder dystocia with neonatal seizure
She developed fitting at 35 h of life in which characterized by jerky movement of left lower limb with
lateralization (jerky) of the head to the rightside, lasted for 1 minute then aborted spontaneously. She was
load with IV Phenobarbitone 20mg/kg and IV Phenobarbitone maintainance dose (5mg/kg in 2 divided
dose). Then no more fitting episode since then.
U/S Cranium (15/8/2022) :normal study

3) Symptomatic hypoglycaemia secondary to infant of DM type II mother

Patient developed multiple episode of hypoglycaemic required of total fluid concentration D25% (GDR :
26mg/kg/min

Childhood History (main carer, immunization, comorbidity, hospital admission, growth, development, social
concern)

Events leading to death (timeline terminal events, investigation (laboratory/radiological, post mortem)

• Despite on maximal inotropic support and oxygen support, her condition deteroriating.
• She developed bradycardia down to 40bpm and desaturated
• Mother was met and was explained regarding child’s condition. Her mother opted to DIL,DNR
• Noted at 1240 h, cardiac monitor shows asystole, no heart rate, pulse not palpable, pupil fixed dilated
• Pronounced death at 16/8/2022 at 1240h
• COD :
1) Severe sepsis with multiorgan involvement
2) Severe HIE secondary to shoulder dystocia with neonatal seizure

Cause of death:

1) Severe sepsis with multiorgan involvement

2) Severe HIE secondary to shoulder dystocia with neonatal seizure
ICD10 classification:

Death category: Please tick ( / ) one column either A/B/C and choose (a) or (b) or both as appropriate:

A. Preventable / B. Not preventable C. Undetermined

a) Medically treatable / a) Palliative case a) Post-mortem done
b) Public health issue b) Non palliative case b) Pending special Ix

Shortfalls: (as determined during district U5M meeting)

Remedial Actions: (as determined during district U5M meeting)

Medical Officer: (Name, designation) Verified By: (Name, designation)

MUNAWWARAH BINTI MD MOKHTAR

PEGAWAI PERUBATAN UD43

Neutral Assessor: (Name, designation)

Comment:

Recommendation.