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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. Cause of Death. Source: Ministry of Health Epidemiology. Cardio/ Cerebrovascular Deaths - 2010.

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Palau Maternal Mortality after 20 years. What Happen?

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  1. Palau Maternal Mortality after 20 years. What Happen? Presented by Dr. D. Ngemaes July 9 – 12, 2013 Apia, Western Samoa

  2. MOH Mortality Statistics - 2010 Cause of Death Source: Ministry of Health Epidemiology

  3. Cardio/Cerebrovascular Deaths - 2010 Source: Ministry of Health Epidemiology (Death Certificate Review)

  4. Indications for Off-islands Referral - 2011

  5. 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.

  6. 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

  7. 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

  8. 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.

  9. 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.

  10. 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

  11. 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.

  12. Pericardial Effusion

  13. 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.

  14. 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.

  15. Maternal Mortality Rates in Palau • Maternal Mortality 1996 • 1996 case had Severe Pre-Eclampsia and developed DIC, unfortunately both mother and baby died.

  16. 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.

  17. Thank You, Mesulang!!!!!! Questions? Comments? Suggestions?

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