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Challenges on Referrals: A case study of Misdiagnosed Ruptured Uterus

Challenges on Referrals: A case study of Misdiagnosed Ruptured Uterus. PRESENTER: DR MATOVELO Dismas BMC/CUHAS 2016. Case History:. Admission date: 18/1/2016 (19.00 hrs) Name of the Pt: T.B Age : 39 yrs Gravida 3, Para 2, Living 2 LNMP ?/6/15 EDD ?/3/16 GA 32+ wks

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Challenges on Referrals: A case study of Misdiagnosed Ruptured Uterus

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  1. Challenges on Referrals: A case study of Misdiagnosed Ruptured Uterus PRESENTER: DR MATOVELO Dismas BMC/CUHAS 2016

  2. Case History: • Admission date: 18/1/2016 (19.00 hrs) • Name of the Pt: T.B • Age : 39 yrs • Gravida 3, Para 2, Living 2 • LNMP ?/6/15 • EDD ?/3/16 • GA 32+ wks • Two previous c/s scars - due to CPD/Contracted pelvis

  3. Referral from Ukerewe DH • Hx - Pv bleeding and generalized abdominal pain – 3/7 • DDx : • APH – Placenta Praevia • IUFD - 2o APH • DIC • Pre referral Mnx: • FBC : Hb – 6.29 g/dl, Platelets – 74 x 103 • AntiBx – Ceftriaxone + Metronidazole • IV fluids • Pre referral vitals : • BP – 130/60 mmHg,PR 90 bpm ,SPO2 – 98% ( 2 lt of O2) • Reason for referral : No FFP, For further Mnx

  4. HPI • Two episodes of acute onset of pv bleeding for 2 days prior to admission at Ukerewe, that was profuse with clots • changed pads 3xs/day. • Hx of accompanied mild dull LAP that radiated to the flanks • No hx of trauma prior to illness • Hx of feeling weak,dizzy,mild difficulty in breathing and increased awareness of heart beats • Hx of loss of fetal movement following the PV bleeding

  5. ROS – uneventful • ANHx – Never attended the ANC despite the risks she had • the partner wasn’t around (mandatory to book at the ANC with her partner) • POHx: • 1st child – 5yrs, male baby, hospital delivery,term,CS – CPD, 4 kg, no complications • 2nd Child – 3 yrs, female baby, hospital delivery,term,CS – CPD, Bwt -? kg, no complications • All children have different fathers!

  6. GHx: • MHx - ?/28/5, normal flow,2 pads/day • No hx of contraception • PMHx – Uneventful • No hx of bleeding tendencies on trivial injury • FSHx • Single parent, • with multiple partners, • peasant, Ø alcohol, Ø smoking, Ø chronic illness in her family.

  7. At C2LW – BMC O/E: Fully conscious, Pale+++,Ø jaundiced, Ø cyanosed, Ø LND,Ø LL edema BP - 124/72 mmHg,PR - 120 bpm,RR – 30 breaths/Min Urine output – 300mls/ ?hrs.

  8. P/A • SUMI scar, distended ,tense with generalized tenderness, • FH - 38/40 • Longitudinal, breech presentation, easily palpable fetal parts,Ø FHR,presenting part – 5/5 ( No engagement) • Urgent bed side abdominal pelvic USS : Low lying placenta, no fetal cardiac activity, no clear identification of the uterine wall RS : Clear CVS: S1 & S2 heard normal, with tachycardia

  9. DDX: • Ruptured uterus with IUFD • Placenta praevia / Abruptio placenta • ???Consumptive coagulopathy

  10. Mnx • FBC • Hb,grpg + X –match • Bed side clotting time > 15 min • PT,PTT • BT – 3 units whole blood + 1 unit FFP/platelet concetrate • RFT • IV Ceftriaxone 1g od X 5/7 • IV Metronidazole 500mg tds x 5/7 • IV fluids ( RL/NS) – 1.5 lts stat • Medical team on call agreed for Explorative Laparotomy

  11. Pre operative preparations From : 19.30 – 21.30 hrs • Mobilizing blood products & volume expanders as preparations for the operation. • 1 unit of whole blood • 1 unit of FFP • 1 lt of Pentastarch *Hb – 6.4 g/dl, Blood grp O+ • No blood in the BB,No relatives to donate blood • Meanwhile, the team on call – had another emergency op

  12. Laparotomy From 22.00 hrs – 23.00 hrs • Under GA • Extended midline incision • Findings: • A dead fetus within its amniotic sac, floating in the abdominal cavity, weighing 2.1 Kg. • Ruptured anterior wall of the uterus(from the fundus to the Cx,with necrotic foul smelling margins), • Lt broad ligament haematoma that extended to the Lt Adnexa • UB – uninjured, • Haemoperitoneum( old, hemolysed blood, no clots,450 mls)

  13. Done: STAH Lt salpingoophorectomy Peritoneal lavage with warm saline Placing – a rubber drain Abdominal closure in layers + tension sutures Intra op: 1 unit of whole blood 1 unit of FFP 1 lt of Pentastarch

  14. Post op orders • Admit C4/post natal ward • AntiBx ( Ceftriaxone + Metronidazole) • Analgesics (Pethidine then Diclofenac) • Fluids( RL/DNS) • Haematenics( Fefol) • Trace 2 more units of whole blood for BT * Had uneventful recovery from GA,with stable vitals – BP-120/80 mmHg,PR -89 bpm,SPO2- 99%

  15. 1st Day Post OP Cc : - Mild pain at the incision site OE: Clinically improving, Moderately pale, Bp – 120/ 6O mmHg, PR – 100 bpm UOP – 1500 ml/24 hrs P/A :not distended, wound clean and dry, rubber drain in situ – clear odourless fluid, Plan: Off catheter Ambulation Oral sips Ct with AntBx,Analgesics + Haematenics

  16. Challenges: • No antenatal care services received • Single mother • All babies with different partners • no financial & non-financial support • Delay in decision making at home • Delayed in accessing health services: bleeding at home for 2 days • No individual and Community health seeking behavior

  17. Challenges: • Delay in receiving appropriate intervention?? • Diagnosis of Uterine rupture was missed • No blood products available • Questions to the audience: • Time spent to transfer the patient 3-4hours? • Mode of transport? • Was it important for Ukerewe Medical Team to provide initial intervention to the patient and later refer to BMc for advanced care needed?

  18. Challenges: • No Pre-referral communication • Receiving facility be ready in terms of supplies, equipment's and expertise to avoid delays • Will the patient receive care needed • What measure should be attempted before referral is made • Is this referral cost conscious?

  19. Challenges: • For BMC medical Team: • Are were prepared enough to handle such cases? • Blood products: FFP, Platelets concentrates etc • Delay again in receiving appropriate care • Mobilization of blood products was a hustle • Do we have backup plan in case the team on call is overwhelmed? • Cuts across all departments!

  20. Recommendations: • This is a “near-miss” maternal death!!!! • Regular feedback to referring Centre/Medical team involve • Advise on issues pertaining to complication readiness: Blood products • Refresh back our clinical skills • On job training, attend CMEs & sharing updates on obstetric emergencies approaches to management • Case consultations & introduction to e-medicine

  21. Recommendations: • Review our approaches to continuum of care: • Pregnant mother must attend with their partners to ANC • Do we need to be flexible as health workers? • For BMC Medical Team: • Blood products available do not meet the demand • BMC MUST take initiatives to begin its own blood screening lab: any task force formed?

  22. Thanks for Listening Comments?

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