MATERNAL

MORTALITY
September 2023
SR PATIENT BOOKIN RESIDENCE PARITY RISK FACTORS CAUSE OF DATE OF
# NAME G DEATH DECLARATION

1 Zero w/o Unbook Sakrand G8P5+2 Multiparity Pulmonary 18-9-23

Somer ed Hypertension edema 12:30pm
Anemia Postpartum
Cardiac disease cardiomyopa
thy
2. Hanifa w/o Unbook Chotyarion G6P5+0 Multiparity Pre 22-9-23
arbab ali ed Hypertension eclampsia 1:15pm
Renal failur

3. Rozina w/o Unbook Moro G5P3+1 Multiparty Anemic 23-9-23

munawar ed Diabetic failure ? 5:25pm
ali anemia
4 Yasmeen Unbook Nawabshah P1+3 Pulmonary 22-9-23
w/o nawab ed embolism 9:15am
Dvt

5. Mehnat Unbook Manik jamali G5P3+1 2-9-23

w/o ed (P3c/sec 4:20am
Ahmed )
 CASE NO 1
• A 35yrs old zero w/o Somerset G8P5+2(p1c/sec) came in ER
through emergency at 4:10am on 16-9-23 with
• H/O =9 months GA
• C/O= Shortness of breath since night
• Pt have history of raise bp from 5 days for that she take tab
Aldomet 250mg 1×od
• According to pt attendant pt was in her usual state of
health 10days back then she develop generalize weakness
for which she went to nearby private hospital ..they advise
her for blood transfusion after transfusion of blood in civil
hospital sakrand pt develope shortness of breath initially it
was mild but from last night it becomes severe..
 Assessment in E.R:
• Young aged female of average built , height and weight,lying on a bed with
anxious look. And taking deep breaths
• Vitals on arrival
• BP 151/110 mmhg
• Pulse 126Bpm
• Temp =100f P/A P/V
• R/R =50 breaths /min HOF Vulva /vagina :
• So2 68% Normal
=36weeks
Lie=Longitudi Os
• Subvitals A++
• O/E: nal =Multiparous
• Chest =B/L crepts P/P = Station= -2
• CNS= anxious cephalic Membrane =
• CVS=S1+S2 audible intact
FM =+ve
FHS= +ve
St = -ve
 Management
Pt directly shifted to HDU
Propup and give oxygen support
Maintain iv line
Send all baseline
Send pih profile
Catheterized the Pt
Arrange 2 pints of blood
Take high risk + death risk consent
Inj hyzonate i/v state give
Antibiotic cover given
Nebulize with atem and clenil
Take ccu opinion
Take physician opinion
In lasix 40mg i/v state give
Inj mgso4 loading given and maintenance start
 EVENT NOTE

Pt manage conservatively in hdu but Pt conditions detoriate

For that lscs done at 10:15pm to 11:00pm on 16-9-23 under GA
Then pt still not maintaining saturation and went on vent support
Pts urine output is not adequate ..and not maintaining saturation and her
labs are dearrange so then pt shift from hdu to sicu at 12:28pm on 16-9-
23
Where her ccu ,nephro and medical call review
Cardiac opinion advice ecg and echo her echo shows
Heart failure, postpartem cardiomyopathy and ejection fraction of 10-15%
Mild mitral regurgitation and mild tricuspid regurgitation
for that they advice restrict iv fluids
Inj lasix 60mg state
Tab dioxin 0.25mg (1×od)
Tab dapti 5mg(1×od)
Tab ascard 75mg (od)
Tab valteral 1+ 1
Tab cardtin 1+0
 EVENT NOTE
Her urine output is only 100ml in 24hrs for that
nephro opinion taken
They advice enhance NG feed 50ml/hr
Continue Inj meropenem
Repeat Urea creatinine and electrolytes
And stop medications like lasix cardtin and other
cardiac medications..and review cardiac opinion
Her medical advice taken for derrange LFTS they
advice syp hepamerz 2+2+2
 Event note
• On 18-9-23 pts condition detoriating
• Attendant counselled
• Her vitals are not maintaining
• 8 cycles of Cpr done + given all life saving
measures
• But pt couldn’t revive
• Having no bp and no pulse
• Ecg leads shows flate
• Pupils dilated
• Pt declare death at 12:30pm on 18-9-23
 LABS
• LABS:
• HB: 12.0g/dl
• PLT: 413000
• TLC : 35700cell/C.mm
• VM = negative
• Uric acid =5.9mg/dl
• Urine dr shows
• Albumin =1+
• Pus cell=9-10 HPF
• ESR=25
• PT,APTT=C
• Total bilirubin=1.4
• Direct bilirubin =0.5
• Indirect bilirubin =0.9
• SGPT=179
• Alk phosphate =456
• Urea and creatinine=normal
 CAUSE OF DEATH ACCORDING TO ICD 2 and 7

Pulmonary edema
Postpartem cardiomyopathy
Mitral and tricuspid regurgitation
Blood reaction
 CASE NO 2

A 35 Years old Hanifa w/o arbab ali G6P5+0(all svds) came

in emergency via referral from Sanghar hospital on date
22-9-23 at 11:30am
With H/O =8months GA
C/O =Epigastric pain+ headache +blurring of vision
since 5 days and SOB and generalize weakness from 7
days
Pt having history of raise bp in previous pregnancy but
taking no any medication.
 Assessment in E.R:
average higt and build dyspnic
.Bp 130/100
• Pulse =91
• Temp = 98f
• RR = 29breaths/min
• Sao2=96%
• Cns =consious
• Cvs s+s2 = audible
• Chest =bilateral crepts‘
• Subvitsl A+and E+
• On examination
• Hof = 28weeks
• Lie= Longitudinal
• P/p = cephalic
• Fm/fhs =-ve
• On p/V
• Os=multiparous
• Station =-1
• Management
Pt shifted to hdu bcz of dyspnoea
• Prop up pt
• Nebulize
• Give O2 support
• Maintain iv line
• Send all baseline
• Catheterize pt
• In hyzonate given
• Antibiotic cover given
• Take high risk consent
• Ccu opinion taken
• Take Chest and medical opinion
• Inj mgso4 loading given and maintenance continue
• Inj lasix 40mg iv state
• After all workup and stabilisation of pt termination of pregnancy start
 Management
Cardio consultant advise tab hydralazine 25mg ×tds
Xray chest shows pleural effusion so medical consultant advise
that pt is preeclapmtic and iud baby so emergency
intervention required..
Then cervical folleys passed with tab prostin E2 in posterior
fornix of vagina at 5:00pm on 22-9-22 ,os=1.5cm cx medium
Cervical foleys out at 8:30pm and Os is 6cm But at 10:30pm
on 22-9-23 pts condition detoriate pt become irritable and
tachypnic her RR is 42breaths/min and pt went on ventilatory
support then at 11:00pm of 22-9-23 her emlscs done o/c was
IUDBG. Then pt shift from ot to hdu..but pt is not maintaining
her vitals then pt shifted to sicu at 1:00pm on 23-9-23
• Pts mgso4 is hold at 9:00pm due to decrease urine output.
 EVENT NOTE
• At 1:15pm on 23-9-23
• Pt condition is not satisfactory same on ventilltory support
• 8 cycles of cpr done and all life saving medication is given but
pt not revive
• Bp =no bp
• Pulse =no pulse
• Temp cold
• injection atropine infusion
• Ecg shows flate line
• Pt declare death at 1:15pm in 23-9-23
 Labs
• HB=9.3
• Wbc=11000
• Plt=271000
• Urine albumin=2+
• Urine pus cell=10-12/hpf
• Hep c=+ve
• Pt and aptt=control
• Blood urea=129mg/dl
• Serum creatinine =1.9mg/dl
• Electrolytes ..potassium =5.9 others are normal
• Total bilirubin=2.0mg/dl
• Indirect bilirubin=0.7
• Direct bilirubin=1.3
• SGPT=451
• ALK PHOSPHATE =865U/L
 CAUSE OF DEATH ACCORDING TO
ICD2 and 7
Pre-eclampsia and renal failure
 CASE NO 3

• A 30years old Rozina w/o munawar Ali G5P3+1

(P3c/sections) resident of Moro come here via
emergency at 3:00pm on 20-9-23 with
• h/O= 9 month GA
• And C/O= LAP
• She is diagnosed case of GDM from 6 month of
pregnancy for that she take tab glucophage
500mg tds...For 1 month only then she stop
taking medication till today...
• Have no any hx of gdm in previous pregnancies.
 Assessment in ER
ViTALS IN E.R: • PER ABDOMEN:
• HOF=38weeks
• BP: 110/80
• Lie longitudinal
• PULSE:72B/m • p/p cephalic
• Fhs +ve
• R: 18 breaths/m
• Fm +ve
• Temp:A/F • St=-ve
• PER vaginal
• Subvitals=A+ examintion
O/E: • V/V =normal
• CVS: S1+S2 • Os = Tip
• Chest: clear
• CNS: GCS 15/15 alert.
 Management
• Admit pt in Er
• Maintaining iv line
• Send all baseline
• Take high risk consent
• Arrange blood
• Sugar profile
• Fmm Charting
• Ultrasound for GA+fetalwellbeing+ AFI.
• After all workup prepare for lscs.
 Management
• Her ultrasound shows
• Fhb=+ve
• Fetal length=40weeks
• B.P.D=40Weeks
• Placenta = anterior low lying completely covering the Os (typeIV)
• AFI=24.2cm
• Placenta looks adherent to previous scar,bladder wall looks separately.
• Her sugar profile continuesly monitor
• Pts lscs done at 12:00pm to 1:30pm on 23-9-23..under GA
• Procedure was Lscs followed by obs hysterectomy + bladder repair.
• Operative findings :
• Presentation =cephalic
• Liquor =increased
• Placenta =accerta completely covering the Os
• Bladder =edematous highehigherup, bladder rupture on anterior wall upto 3cm
• Both ovaries and FT=Normal
• EBL=500ml.
• Then pt shift from ot to hdu for monitoring at 1:55pm on 23-9-23.
• In hdu her vitals are
• BP=112/73
• Pulse=144beats/min
• Resp=42breaths/min
• Uop=600ml (haematuric)
• Sao2=99%
• RBS was high ..glucose shows only high reading >500mg/dl.
• Then medical and ccu and uro call reviews.
• Medical consultant advice: send urine DR for ketone
• Inj N/S 1L i/v
• Inj insulin 10units sc ×state
• Then review call.
• 3 way foley catheter pass and irrigation start.
• Pt in hdu her condition become very serious tachypneic not maintaining saturation spo2=64% on
oxygen. And R/R=42 call anesthetic and they intubate and put her on vent support. At 5:10pm.on
23-9-23.
 Event note
On 23-9-23 at 5:00pm pts condition is not satisfactory, pt become irritable, drop saturation and become tachypneic.
Vitals are:
BP=70/50
Pulse=151
Rep=42b/m
Temp=A/F
Uop=500 on irrigation
Dop=300ml
Sao2=74% on o2 support
RBS=363mg/dl.
Pt condition continously detoriate
Pt was hemodynamically unstable
Bp=70/50
Pulse =165
RR=55
Rbs=330mg/dl
3 cycles of cpr done at 5:15pm but pt couldn’t revive.
Pt expired at 5:25pm
And death declare at 5:40pm on 23-9-23.
 LABS

• HB:12.6G/dl
• PLT: 270000
• TLC : 8300
• Viral marker =–ve
• BG=A+ve
• Pt and aptt=control.
CAUSE OF DEATH ACCORDING TO ICD-
 Case no 4
• A 24 years old pt P1+3 came in Er via emergency
on 20-sep-23 at 8:30pm resident of nawabshah
with
• H/O=Hysterotomy done on 25th August 23 then
pt again admitted on 1st September 23 with burst
abdomen, her laparotomy done on 2nd
September 24 followed by hysterectomy and
bladder repair and foleys for 21 days.
• C/O= fever since 4 days and pedal edema since 3
days.
 Assessment in ER
• On general examination.
Pt well oriented to surrounding but grossly anemic.
Vitals on arrival
Bp=110/80
Pulse=121
Temp=102f
Resp=20
Subvitals
A+, E+
• On examination
• Chest=Clear
• Cvs=S1+S2+0
• Cns=intact
• P/A
– Abdomen distended
– Wound line =dry and cleaned, stitches in situ
• P/V
– v/v=N
– No pusy discharge
• Bilateral pedal edema
• Bilateral calf muscles tender
• And their is swelling on left thigh just above the knee
• And veins dilated on upper side of thigh.
 Management
• Admit pt in Er
• Maintain iv line
• Send all baseline
• Arrange blood after screening and cross matching
• Take high risk consent
• Stocking (compression)
• Inj provas iv state
• Antibiotics cover given
• Stitches remove
• Inj clexin s/c×bd
• Blood culture already send on 18 Sept
• Medical and surgical call send for details.
• Temp +BP Charting
• 2 pints of blood transfused.
 Event note
• On surgical call they advice do Duplex scan to
exclude DVT/Varicose vein and follow up after
investigation.
• Medical call send for malaria they advise inj
Gen M and inj provas
• and on 22-9-23 at 4:00am pt complain of
shortness of breath her respiratory rate at that
time is 29bpm and So2=62% .
• Pt then shift to hdu for further management.
 Event note
• Sick note.
• On 22-9-23 at 6:15am pt not maintaining
vitals..SaO2 was 61% On 7liter o2. respiratory
rate was 55breaths/min.BP not recordable CPR
done for 5 min pt revive. Then intubation done
and put on ventilatory support .and on norpin
support.
• On 22-9-23 at 9:15am pts condition detoriate all
emergency drugs given but pt couldn’t survive.
 Labs
• Hb=5.2g/dl
• Wbc=14700
• Plt=73000
• ICT malaria=+ve
• Thypidot =-ve
• Electorlytes =normal
• Urea =23mg/dl
• S.creatinine=0.7mg/dl
• Urine albumin=1+
• Urine RBCs=20-25.
 Cause of death Accor to ICD

• Primary cause
– Pulmonary embolism
– Sever anemia
• Secondary cause
– Cardiopulmonary arrest.
 Case no 5
• A 34yrs old pt G5P3+1(P3c/sec) admitted
through emergency on 1-9-23 @ 8:00pm
resident of manik jamali with
• H/O= 5months G amenorrhea
• C/O= abdominal pain +abdominal distension
since 3 days and diarrhoea and vomiting since
1 day.
 Assessment in Er
• Pt is Concious alert
• Vitals on arrival
• Bp=88/65
• Pulse=120
• Resp=20
• Temp=100
• SaO2=99%
• Rbs=174mg/dl
• Subvitals.
• A+
• On examination.
• Cns=intact
• Cvs=S1+S2 audible
• Resp = B/L chest clear
• Abdomen =
– Hof=20weeks
– Abdominal grith=37inch distended
– Bowel sound=sluggish.
 Management
• Admit pt in er
• Maintain iv line
• Send baseline
• Inj N/S iv ×12hrly
• Inj septa 1g iv ×12hr
• Inj =proves iv ×8hrly
• Take medical opinion
• Take surgical opinion
• Departmental scan
• Take high risk consent.
• Watch for pv bleed
• Abdominal grith monitor 1hrly
 Event note
• At 11:00pm on 1-9-23 pts condition detoriate pt shift
to hdu and on inj norpin support.
• At 3:30am on 2-9-23 pt continously detoriate irritable
• Bp=169/127
• Pulse=170
• Temp=98
• Resp=55b/m
• Sao2=65%
• Rbs=434mg/dl
• Pt immediately put on vent support ETT passed.
 Event note
• On 2-9-23 at 4:20am pt not maintaining vitals
• Cpr 2 cycles dine
• All life saving measures given but pt couldn’t
survive.
• Attendants are not present since admission.
 Labs
• Hb=9.9
• Wbc=10100
• Plt=115000
• Malaria= positive
• v.m =-ve
• Lft=alk phosphate =680U/l
• All Labs are written on file.
Cause of death according to ICD.
 Case no 6
• A 25 yes old female kali w/o shahdad gul
P2+0(all svds) come in ER via opd at 1:10pm
on 18-9-23 with
• H/O=vaginal delivery 15days back at private
hospital qazi ahmed
• C/O=watery diarrhoea from 5days and high
grade fever and shortness of breath from 1
day.
 Assessment in ER
• Vitals on arrival
• Bp=100/68
• Pulse=155
• Temp=99f
• Resp=33 b/m
• On examination
• Patient look pale and severely dehydrated with sunken eyes
• Cns=semiconsious and irritable
• Cvs=S1+S2+0
• Chest=Clear
• Abdomen =soft +NT
• On bimanuual ex=12week size uterus
• P/V
– v/v=normal
– Cx=Central closed
– Locia healthy hot vagina.
 Management
• Admit pt
• Pt shift to hdu
• Propup and give O2 support
• Maintain iv line
• Send all baseline
• Catheterize pt
• Take High risK+ death risk consent
• Arrange 2 pint of blood
• Take physician opinion
• U/S abdomen +pelvis
• Inj R/L 500ml iv stat
• Inj sefta 1g iv stat
• Inj flagyl 100ml iv state.
 Event note
• Pt recieve in hdu at 1:30pm in serious condition
• Vitals
• Bp =100/60
• Pulse=145
• Resp=35
• Temp=99f
• Spo2=95%

• At 1:30pm on 18-9-23
• Pts condition detoriate and pt in gasping condition
• Bp=90/40
• Sao2=72
• Resp=47bpm
• Temp/100f
• GCS=6/15
• At 1:50pm Pt shift on mechanical ventilator.

• At 3:20pm on 18-9-23
• Pt shift to sicu.pt recieve in sicu at 3:30pm in serious unconscious state
• On arrival her bp =140/87
• Pulse=165
• Resp=13
• Temp=99f
• Sao2=99% on ventilatory support
• Rbs=113mg/dl
• Uop=400ml
 Event note
• U/S done
• Ultrasound shows=Uterus postpartum bulky in appearance.
• endometrial cavity shows mild fluid
• Spleen appear slightly bulky
• Her ECG done
• Ecg show normal
• Medical call done
• Bcz of fever AGE and s creatinine 2.3 and urea=130.
• They advice inj tanzo 2.25gm iv ×bd
• Tab ketocal 1+1+1.
• Further take nephrologist opinion
• Surgical call done
• Bcz of cellulitis on right arm
• They advice manage conservatively
• Inj augmentin 1.2g iv×bd and
• Arm elevation.
 Event note
• Serious note
• Pt is on ventilatory and inotropic support
• Bp =90/50
• Pulse=117
• Resp=13
• Temp=103f
• Uop=100ml
• Sao2=70%
• At 12:30am on 19-9-23
• Bp and pulse unrecordable
• Attendant counselled about pts condition.
• Pt expire at 1:00am on 19-9-23
• Give all life saving drugs but pt couldn’t revive.
 Labs
• Hb=10.4
• Wbc=25000
• Plt=486000
• V.m=-ve
• Ict malaria =-ve
• Blood urea=130
• S.creatinine=2.3
• BUN=64.49
• S.electrolytes=normal
• Urine dr
• Albumin=traces
• Pus cell=8-10
• LFTS alk phosp=215
• Pt and aptt=control.
Cause of death according to icd is