KNH MATERNAL

MORBIDITY AND MORTALITY JULY 2011.

PERIOD 1
st
-31
st
july 2011
PRESENTERS -Dr. BOSIRE / Dr. KURUGA
FACILITATOR -Dr. Kagema
DATE 12
th
August
VENUE DEPT OBS/GYN ( UON)

INTRODUCTION

- 600,000 Women die globally from
pregnancy related conditions

- Most deaths are preventable

- Deaths in developing countries - >2/3rds



DEFINITIONS
Maternal mortality :-
Death of a woman while pregnant or within 42 days of
termination of pregnancy irrespective of the duration or
site of pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not
from accidental or incidental causes (WHO, Geneva
1992).
Death resulting from complications of induced abortion
is considered a maternal death.

Causes of maternal death
Direct
- 75- 80 % 0f maternal deaths
-results from interventions, omissions, incorrect
treatment
-or chain of events resulting from pregnancy or delivery
related conditions
Indirect
- 20-25% of maternal deaths
- From pre- existing disease- DM, cardiac disease, malaria,
TB , HIV etc
or, is unrelated to pregnancy related condition, but is
aggravated by physiologic effects of pregnancy





Maternal mortality ratio
Number of maternal deaths per 100,000 live births in a
given period. Its a measure of obstetric risk i.e. risk of
death once a woman has become pregnant.

Maternal Mortality rate
The number of maternal deaths in a given period of time
per 100,000 women of reproductive age (15-49) during
the same period. This measure reflects proportion of
women who get pregnant in a year and risk of death
among them.
It reflects the frequency with which women are exposed
to risk of death through their fertility
ANC attendance among deliveries


KNH Booked patients.504
Unbooked patients...........449

Total Admissions 953


STATISTICS FOR JULY 2011
Labour ward Admission diagnosis
- Labour. 826
-Previous scars27
-Pre- eclampsia/Eclampsia23
-APH14
-BBA16
-IUFD13
-Prom/PTL13
-PPH.21




Deliveries
-Total deliveries 887






Mode of delivery No. %
SVD 535 60.31%
Emergency C/S 292 32.92%
Elective C/S 51 5.74%
Breech vaginal 9 1.01%
Vacuum 0 0%
Total 887 100
Indications for C/S in L/W
Elective CS
-1 Previous scars31 (60.78%)
-> 1 PS13 (25.49%)
-PMTCT.2(7.5%)
-Breech2(3.9%)
-CPD.2 (3.9%)
-Total.51
Emergency CS
NRFS..48 (16.43%)
1 PS.....68 (23.29%)
>1PS...25 (8.56%)
CPD.30 (10.27%)
Poor Progress..21 (7.19%
Malpresentation10 (3.42%)
PET/Ecclampsia, poor BS..14 (4.79%)
APH6 (2.05%)
Obstructed labour.. 4 (1.36%)
Cord Prolapse..7 (2.39%)
Failed induction.12 (4.10%)
PMTCT..6 (2.05%)
Delayed 2
nd
Stage6(2.05%)
Other.. 8(2.73%)

Total.292
L/W Caesarian section rate

343/887= 38.66%

WHO.15%
Audit 2010..39.6%
May 2011..43%
Juner 2011.36.63%
Ward IC
Deliveries
-Total deliveries76
-Mode of delivery
- SVD34 (44.7%)
- Elective C/S.22 (28.9%)
- Emergency C/S..19 (25%)
- Vacuum1 (1.66%)
- Breech vaginal.0 (1.31%)
C/Section Rate.41/76..53.9%






Outcomes of deliveries
Outcome Number
Live Birth 850
FSB 7
MSB 14
BBA 16
Maternal mortality



Ward Number
L/W 4
GF-A 2
GF-B 0
1A 1
1C 0
1D 0
ICU 4
Renal Unit 3
TOTAL 14
KNH Maternal mortality ratio- JUNE 2011

14/887 x 100,000= 1578 per 100,000 live births

May 2011= 882 per 100,000 live births
June 2011 =1078 per 100,000 live births
March 2011 = 1708 per 100,000 live births
KNH audit 2010=1222 per 100,000 live births
KDHS 2008 =488 per 100,000 live births
KDHS 2003 =414 per 100,000 live births
WHO 2005 =560 per 100,000 live births


Causes of maternal mortality

Cause of death No. %
Eclampsia (CVA, ARF)
Post MVR Cardiac dse
4
1
35.7%
7.14%
Sepsis 5 35.7%
PPH 1 7.14%
Uncontrolled chronic
DM&HTN (ARF)
1 7.14%
Meningitis/Encephalitis 1 7.14%
Anaesthetic Complication 1 7.14%
Diagnosis Number Percentage
Threatened Abortion 42 6.55
Ectopic pregnancy 34 5.3
Peuperal complications 29 4.52
Terminated abortions 119 18.56
Pelvic masses 15 2.34
AUB 74 11.54
Ca cx 37 5.77
GTN 8 1.25
PV DISCHARGE 18 2.81
INFECTION 78 12.17
OTHERS 153 23.87
DVT 7 1.10
DIAGNOSIS NUMBER PERCENT
IUFD 5 0.78
CA OVARY 5 0.78
CA ENDOMETRIUM 4 0.62
INFERTILITY 6 0.94
TOTAL 641 100
STRANGE CASES
DIAGNOSIS NUMBER
MENSES 1
FORNIX LACERATION 1
APPENDICITIS 1
PHYSIOLOGIC PREGNANCY
CHANGES
2
HEPATIC ENCEPHALOPATHY 2
Admission to other units
UNIT DIAGNOSIS NUMBER
ICU INTRACRANIAL BLEED
PET
CA OX DEBULKING
POST MVR
PEUPERAL SEPSIS
1
1
1
1
RENAL UNIT PREECLAMPSIA
VVF
CACX
POSTABORTAL SEPSIS
4
1
2
2
ACUTE ROOM A&E PEUPERAL SEPSIS
IUFD + COMA
HEPATIC
ENCEPHALOPATHY
1
1
1
TOTAL 15
Neonatal morbidity and mortality
Live Birth: Newborn that breathes spontaneously or shows
signs of life such as a heartbeat of definite spontaneous
movement of voluntary muscles
Perinatal period: Period after birth of an infant weighing
more than 500g or 20 weeks gestation and ending at 28
completed days.
Still birth: the absence of signs of life at birth
Neonatal death: Early neonatal death refers to death of a
live born neonate during the first 7 days of life. Late
neonatal death refers to death after 7 days but before 29
days of life.

Still birth rate: Number of stillborn neonates per
1000 neonates born, including live and stillbirths

Neonatal mortality rate: The number of neonatal
deaths per 1000 live births

Perinatal mortality rate: The number of still births
plus neonatal deaths during first 7 days per 1000 total
births

NBU
Total admissions in the month of July = 156
Total mortality in month of July = 77

ADMISSION TO NBU
DIAGNOSIS NUMBER Percentage
Prem + RDS 41 26.28
ASPHYXIA 27 17.31
Prematurity 22 14.10
Neonatal sepsis 12 7.69
RDS 29 18.59
MAS 2 1.28
Congenital anomalies 8 5.13
Mothers condition 9 5.77
Prematurity and NNS 2 1.28
NNJ 1 0.64
RD + Asphyxia 2 1.28
Asphyxia and sepsis 1 0.64
Total 156 100
Admission by weight
Weight No %
<1000 5 3.21
1000 - 1400 22 14.1
1500- 2499 55 35.26
2500 - 3999 70 44.87
>4000 4 2.56
total 156 100
MORTALITY BY GENDER
Number Percentage
Male 43 55.84
Female 34 44.16
Mortality
Number Percentage
Sepsis 17 23.61
RDS 4 5.56
ASPHYXIA 11 15.3
VLBW + RDS + PREM 21 29.17
RDS,NNS & PREM 5 6.94
PREMATURITY 7 9.72
ASPHYXIA + NNS 3 4.17
OTHERS 4 5.56
Total 72 100
Mortality Cases


CASE 1
XY.
36years
Married businesswoman
D.O.A 29/07/2011.. 4.40pm
D.O.D 30/07/2011.14.45am

P2+0 G3 2psc
LMP 4/11/2010 EDD 11/08/2011 GBD ~38/40
Presented with c/o labour pains
Antenatal: attended KNH
Profiles:- Hb 12.1 g/dl
-Blood group A+ve
-HIV/VDRL Non Reactive




Obs/Gyne Hx
2prev scar...2003 c/s .CPD..Lmi 3600gm A/W
2007 c/s.........Lmi 3600gm A/W
O/E: Stable patient, No Pallor, vitals stable
P/A Term, breech presentation, FHHR
V/E: Cervix central, soft 3cm dilated.
Plan: GXM, For emergency C/S
Emergency C/S: at 11.00 pm. Intraop- 11.40..LMI
extracted, Bwght 3200gm in frank breech. A/S , 7/1,
8/5, 9/10. admitted to nursery.
11.50pm:Patient UnresponsiveDuring Uterine repair..
Intubated , Resciscitation AttemptedNo Response.
12.45am Patient Confimed Dead.
Cause of DeathAnaesthetic Complication.

Case 2
Patient Yz;
DOA 22/7/11
DOD 25/7/11
28 yr old P1+0
Reffered From Mary help after Em C/s for severe Pet.
Outcome Lfi 2200gm A/s 6/1, 7/5, 9/10
Post-op; Convulsed twice.
Mgso4 started and patient reffered to Knh with a Bp of
200/150

KNH:
22/7/11... 8.00 am Ward round
Postnatal Ecclampsia; No Convulsion in labor ward.
Invx; U/e/c, Fhg....Urea 10, Cr 1130mmol/l, Hb 5.6g/dl
Wbc ,13.3, Plateletets, 229ooo, Gcs 13/15
Plan; Gxm 3.0, Renal Review.
2.00pm;
Urine Output < 20mls over 12hrs(admn time 2.00am)
Input 4500mls
Plan; Renal Review; Fresh blood.

8.45pm....Ward round
Patient Convulsed... Started on iv Epanutin
Awaiting renal Review and Fresh blood
23/7/11...4.30pm
Renal Review; Ecclampsia/Aki
Issues; Anuria, Raised Creatinine / Urea; Gcs 9/15
Plan; Triple Serology, Repeat U/e/c Renal Lab,
Lasix 40mg, Transfusion; For Hemodyalysis
7.30pm
Bp range 150/80-140/30mmhg; I/o..........?
Awaiting FFPs, Physician Review.
Phenytoin Iv
2.30am;
Input 4500..Output .Nil
Awaiting Results; Triple serology, Repeat U/e/c,
Coagulation Profile, LFTs
24/7/11...6.30am
Patient received 1.0 blood
Repeat Convulsions 10/12hours
Ros ; Gcs 15/15 Bp 120/80
Urine output Nil
9.45am;
Renal Review... U/e/c results dont warrant dialysis;
Recheck catheter; 4hourly U/e/c
12.10pm
Hb 6.9g/dl
Transfuse 3.0 blood
Icu Review
3.45pm;
Icu Review;...Ecclampsia. Aki
Received 2.0 whole blood
O/e Pale++, Edema,Gcs 14/15, OTPP;
R/s Basal Crepitations, No Rhonchi
ICU Plan;
Urgent Dialysis; Add Phenorbabitone,
BGAs, Restrict Fluid intake; Icu Admission When Bed is
Available.
25/7/11;
Followup- Time not indicated;
Icu; Gcs 12/15. Bp 153/95
Repeat U/e/c; Cxr
Urgent ICU admission; Intubation;BGAs
25/7/11; 5.00pm

Patient Unresponsive ; CPR unsuccessful
Patient Confirmed dead 5.00pm
Cause of death;....
Issues.... Delays on investigations; Transfusion; Dialysis;
and Reviews
Pt Ab,
Para 1+ 1
DOA : 20/7/2011
DOD : 27/7/2011
Patient brought in at 10.30pm having delivered twins
MSB at 19 wks. She was not communicating. Had
retained placenta that was subsequently removed in
labor ward.
PMHX;Had been admitted and subsequently
discharged on 17/7/2011 from GFB with hyperemesis
gravidarum. She had been admitted with a month
history of vomiting with inability to retain feeds and
epigastric pain. Headaches,hiccups.
No diarrhea/hob/urinary s/s,No ANC visit
FSHX : Married, lives in huruma,business lady,No
HTN,DM,Alcohol, smoking

O/E At Admission;
Pale + Dehydrated,Jaundiced, T,36 degrees.
RS: Clear
CVS: Tachycardia. Bp 177/54
PA : 20/40 GENERALIZED ABDOMINAL
TENDERNESS, Minimal lochia loss
CNS: Neck soft, Kerning negative. Pupils Berl, 14/15

Imp: Endometritis + psychosis +dehydration
21/7 /2011 : sick looking 6/15, groaning with eyes wide
open.
RS:: CLEAR;
input 2700 output 300: urea 23.6, creatinine 450,Na+
129, k+ 3.0
Imp AKI + Sepsis
Planned for dialysis, rocephin and flagyl prescribed.
11.30PM : GCS 8/15
Diagnosed as hepatic encephalopathy
12noon: Gcs 6/15, developed right sided twitching,
febrile,tachycardia 120bpm
WBC: 16.6,NEUTROPHILS 13.3,HB 4.43, PLTS
132,UREA 20.9,CREAT. 436,K+ 2.4,CL 83, NA+ 127.
Diagnosis of Uremic encephalopathy.

22/7: 14/15, Bs-Mps neg, triple serology neg,
Input 3800,output 100.
Tranfused,CT scan brain requested, daily u/e/c,
dialysis.
1430 patient becomes hydrophobic
encephalopathy.
25/7: to renal unit, urea 27.2,creatinine 555, k+
2.2.abdominal pelvic requested.
27/7 : patient succumbed