NEAR MISS CASES IN DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
According to WHO , maternal near miss is defined as “ a woman who nearly died but survived a complication that occurred during pregnancy .childbirth or within 42 days of termination of pregnancy”. The importance of increase in near miss and decrease in maternal mortality is a good indicator of improved health care facilities in community. Here we summarize few near miss cases which were referred to Norvic Hospital and were challenging yet gratifying for our professional development but a huge advantage for patient .
Case 1
A 22 year old married female, primigravidae with history of 2 months amenorrhea with bleeding per vaginum presented in emergency of Norvic International Hospital with referral from different hospital in poor condition with difficulty in breathing, epitaxis, haemtochizia ,abdominal distension, catheter in situ with haematuria she was tachycardic with stable bp =110/80 mm hg with maintaining saturation of 92% with oxygen at 8 l/min.,on examination, she was oriented ,with decreased bilateral breath sounds , with no murmur though tachycardia, with abdomial distension which free fluid, nontender on admission. on further history taking she was a case of H.MOLE – suction and evacuation was done 6 weeks back at the time was 90,445,poc was sent for hpe -no evidence of GTD, was discharged .after 2 weeks of intial Suction and evacuation she complained of bleeding pv ,bhcg done >1.5 lakhs on 2 occasions 48 hrs apart, repeat suction and evacuation done ,poc obtained but was not sent for hpe, was discharged.after 5 days of discharge , she had acute pain in abdomen followed by distension, then she was admitted in icu in view of persistent GTD, She was started with single agent mtx of 4 doses , during her chemotherapy she developed throbocytopenia with haematuria for which she was managed with multiple blood and blood product(prp,ffp) transfusion. Medical oncologist consulted and EMA-CO was planned .On the day of referal, due to haemoperitoneum abdominnal tapping was done.
On admission on our hospital,the team of gynecologist, intensivist and cardiologist collectively monitored the patient, her BHCG on day of admission was >10,000 iu/ml.DIC managed with multiple blood and blood product transfusion. USG done s/o invasive mole with 5 mm myometrium invaded with bilateral theca lutein cyts with mild to moderate ascites likely haemoperitimeum ,bilateral pleural effusion. Echo s/o global hypokinesia of LV with EF-20-25% with Mild MR.RA/RV mild dilated .moderate TR. After stabilizing her DIC, she was started on mtx on day 4 of admission , but following 1st dose she develpoped focal seizures so mtx was stopped, CT scan was normal. On day 6 of admission, she complained of acute pain on lower abdomen with difficulty on breathing , repeat USG and CECT abdomen done suggestive of invasive mole with enlarged uterus with invading myometrium ,with gross ascites s/o haemoperitoneum. with bilateral theca lutein cyst and b/l pleural effusion with cardiomegaly with pericardial effusion..In view of perforating invasive mole with uncontrolled haemorrhage ,TAH done -findings uterus 18 weeks with perforation anteriorly and posteriorly molar tissue visible ,with bilateral theca lutein cyst 10x10 cm each , haemoperitonuem of 2500 ml .Post operative she was managed with team effoft of anasthesist, cardiologist and gyanecologist. bhcg done 1 week after surgery -4499, she received one cycle of single therapy of mtx with folinic acid She was kept on monitoring in opd basis with bhcg checked every 2 weeks , she received seven cycles of MTX till her bhcg was negative and less than 5 IU/ml . After the negative bhcg ,two more cycles of MTX and bhcg was followed monthly for a year which was negative .
Case 2
We present a case of Mrs.GB, referred from peripheral hospital ,31 years old ,G4P2L1A1 at 34 weeks +1 day with uterine rupture in gasping state came to ER on 17th October 2017 .On arrival ,she did not had recordable BP and no peripheral pulses palpable .History taken from guardian suggested ,this is her fourth pregnancy with one living issue by CESAERAN SECTION done at Dhulikhel hospital 6 years back, and one previous uterine rupture at term with IUD gestation two years back after induction of labor use of prostaglandin vaginally and one pregnancy had medcial termination . She had regular pregnancy check up at peripheral hospital where ultrasound was done at regular intervals and latest was at 20 weeks of gestation. There was no history of trauma ,fall injur y or loss of consiuosness. She complained of pain abdomen since 3 to 4 hours early with decrease fetal movements with no vaginal bleeding ,for which she was taken to other hospital where her condition deteriorated and was rushed to emergency
On presentation ,she had no recordable BP and peripheral pulse ,hypoxic with oxygen staturation of 70% in room air , disorientated with GCS 10/15..She was pale and had cold and clamy exterimites .On abdominal examination ,abdomen was distended ,fetal parts were easily palpalble with uterus being palpable separately at right lower abdomen ,no fetal heart sounds were heard .On vaginal exanimation ,os was closed and no presenting part felt. The resuscitation with team of anesthiologist and emergency medicine was done with two large bore 14 gauze cannula obtained blood for full blood count ,coagulation studies ,typing and cross match and IV colloids and cystralliods . 4 units of whole blood and 2 units of FFP were secured . After taking high risk consent from patient guardian. Emergency laparotomy with subtotal hysterectomy under general anesthesia in view of uterine rupture .Her preop Hb was 4gm%.
During surgery ,paramedian insicion was given ,we found that there was haemopertineum estimated at about 4000 ml and the uterus was completely toned at left lateral wall from fundus to supracervical area with active bleeding from margins which was site for previous rupture ,the lower segment caesarean scar was intact .bladder anatomy was intact but it was advanced to lower uterine segment due to previous caesarean section. The fetus was found in peritioneal cavity along with placenta. We carried out Subtotal Hysterectomy and peritoneal toileting .The fetus was female weighing 2500gms.The patient was transfused 2000 ml of whole blood during surgery .She was transferred to intensive care unit where she was extubated the next day 18th October 2018.She received total of 14 pints of blood and blood products from 17 to 20th October (4 whole blood ,3 fresh blood ,4 PACKED CELL AND 3 UNITS OF FFP).She remained in hospital at department of obstetrics and gyanecology for next 15 days ,stitches were removed and on discharge her Hb was 11.2gm%.Patient was discharged with hematinics and vitamins .
Case 3
The patient 26 years old unbooked primigravida presented to emergency department with ? full term pregnancy in 2nd stage of labor. She was unsure of her date but was said to be at 9 months pregnancy at the time of her presentation. She was referred from ? Mugu PHC , airlifted to our hospital in an emergency with complains of spontaneous labor pain since 4 days and leaking per vaginum since 3 days with non-progress of labor (non descent of head) with no fetal heart sound . Due to unavailability of transportation her referral to higher center was delayed.
The patient menstrual cycle was regular. She had her regular ANC check up at the near by PHC and was uneventful. She had no known comorbidities or surgeries in the past.At the time of presentation her general condition was ill- looking,pale ,tachypneoic with RR-36/min, pulse rate - 120/min. BP- 110/80mmhg. Per abdominal examination revealed uterus 36 weeks size , longitudinal lie, cephalic presentation , head engaged ,abdomen was distended with generalized tenderness. FHS could not be heard. Per vaginal examination revealed vulval swelling , cervix was soft edematous, OS was fully dilated, Head station +1, caput present, membrane was absent and liquor was scanty and foul smelling. A self retaining Foley’s catheterization was done which drained blood stained urine. A diagnosis of Primigravida at ? full term pregnancy with prolonged obstructed labor with IUFD with ? ruptured uterus with ? bladder involvement with sepsis was made.
The patient was resuscitated with IV fluids, IV antibiotics and all necessary investigations were sent. Patient was prepared for Emergency Laparotomy under general anesthesia after taking High risk consent. On opening the abdomen intra operatively, two liters of straw colored fluid with urinary smell was drained. Whole anterior wall of uterus was boggy with lower uterine segment distended and boggy, Bandl’s ring was noted. The fetus was delivered via cephalic presentation with caput present. Liqour was foul smelling and scanty in amount. Placenta was fundoposterior and delievered with complete membranes . Bladder dent of 2 X 2 cm was identified at the base of bladder. Left ureter was oedematous and swollen. Urosurgeon was called for bladder repair and done in 2 layers. Total blood loss was approximately 1000ml. Despite persistant uterine massage and maximum dose of uterotonics uterus( oxytocin ,carboprost and misoprost) was flabby and atonic ,so stop further bleeding surgical management was done so Subtotal Hysterectomy carried out. The fetal outcome was 3100 gm still born female with no gross abnormality .Post-operatively patient was managed in SICU for 2 days along with team of anathesiologist and physician with IV antibiotics ,analgesic and iv fluid . She was extubated 2 days later. On 3rd post operative day she developed hypotension so Noradrenaline was started under central venous pressure guidance . Hypoalbuminemia was corrected by transfusing Human albumin 20% along with protein supplement. Anemia was corrected by transfusing 2 pint of whole blood intra operatively and 3 pint post-operatively. She was catheterized with Foley’s catheter which drained clear urine post-operatively and on 22nd post –operative day Cystogram was done which showed post-operative changes with normal findings. Hence, Foley’s was removed under the guidance of urosurgeon. During her follow up she was continent of urine and her wound had healed completely.
Discussion
The near miss case definition was ased on validated specific criteria comprising of five diagnostic feature : hemorrhage, hypertensive disorder of pregnancy , dystocia, sepsis and anemia .For poor resource setting ,near miss are based on near miss management ICU, need for transfusion ,near miss clinical criteria (P.E.T ,PPH) and organ dysfunction .Review of several near miss cases have highlighted the deficiency and as well as positive elements to improve the obstetric care in any health system .Maternal near miss cases are investigated over maternal death as –near miss are more common than maternal death, likely to yield useful information on the same pathway that lead to severe morbidity and death ,investigating the care received .Any near miss is a lesson learned and opportunity to improve the quality of service provision .
Obstetric emergency occur suddenly and unexpectedly endangering the life of mother and represent the quality of obstetric care. We have presented three different types of near miss cases presented at our emergency with classical presentation of hemorrhagic complication in perforating mole ,uterine rupture ,obstructed labor all requiring hysterectomy which avoided maternal death .The management of all the cases require team effort, immediate resuscitative effort ,evaluate the cause of hemorrhage ,transfer to ICU .In all of our patients delay in referral , leading to worsening of condition and surgical intervention resulted in serious morbidity leading to near miss situation.
Near miss review is the tool for maintaining the quality of maternal services in developing countries because persistently high level of maternal mortality has over shadowed the severe obstetric complication from which lesson could be learned .Severe maternal outcome can potentially be reduced by applying the evidence based interventions for life threatening complications, improving referral systems and optimizing the use of critical care.
