79 INTERN

MATERNAL DEATHS. MASTER.

In the Intern Maternity D e p a r t m e n t 5 maternal deaths are recorded, of which only one was " unbooked." The Intern Maternal Mortality incidence was 0.11 per cent. For " b o o k e d " cases the incidence w a s 0.09 per cent. and for " u n b o o k e d " cases 0.34 per cent. (1) C a s e A . C. No. 16525. A g e 43 y e a r s . P a r a l S . " B o o k e d . " T h e d e a t h of t h i s p a t i e n t c o n s t i t u t e s a v e r y m a f o r t u n a t e a n d a v o i d a b l e m a t e r n a l death. She w a s a w o m a n a g e d 43 y e a r s a n d p a r a 15. She h a d a t t e n d e d t h e H o s p i t a l A n t e n a t a 2 Clinic. Of t h e 14 p r e v i o u s p r e g n a n c i e s e i g h t c h i l d r e n w e r e alive. "/?he l a s t c o n f i n e m e n t w a s in 1950. She h a d h a d o n e ectopic p r e g n a n c y a n d in 1952, a F o t h e r g i l l t y p e of o p e r a t i o n w a s p e r f o r m e d for p r o l a p s e . She w a s a d m i t t e d o n a c c o u n t of a p e r s i s t e n t oblique p r e s e n t a t i o n w h e n approach/rig t e r m w i t h a v i e w t o i n d u c t i o n as t h e b a b y w a s large. O n e x a m i n a t i o n t h e c e r v i x w a s f o u n d to be s t e n o s e d a n d n o e x t e r n a l os c o u l d be identified. T h e r e w a s c o n s i d e r a b l e s c a r r i n g in t h e v a g i n a l v a u l t . I n v i e w of t h i s p a t i e n t s age, clinical c o n d i t i o n a n d p r e v i o u s repair o p e r a t i o n , it w a s d e c i d e d t o do a n " e l e c t i v e " C a e s a r e a n section. T h e o p e r a t i o n w a s c a r r i e d o u t in t h e r o u t i n e m a n n e r o n 18]11/'53: A m a t u r e v i g o r o u s i n f a n t w e i g h i n g 8 lb. 4 oz. w a s d e l i v e r e d alive. T h e r i g h t a p p e n d a g e s were a b s e n t , e v i d e n t l y a s a r e s u l t of t h e p r e v i o u s o p e r a t i o n for ectopic p r e g n a n c y . T h e left o v a r y w a s r e p l a c e d b y a c y s t 3" in d i a m e t e r . O n e x p l o r i n g t h e lower s e g m e n t , b o t h b y a finger a n d b y a p r o b e , n o sign of t h e i n t e r n a l o s c o u l d b e located. T h e v a g i n a l v a u l t w a s d e n s e l y scarred. H y s t e r e c t o m y w a s decided u p o n a n d c a r r i e d o u t w i t h o u t difficulty, followed b y r o u t i n e closure. F o r o n e h o u r a f t e r t h e p a t i e n t ' s r e t u r n to t h e w a r d n o a n x i e t y w a s felt c o n c e r n i n g h e r condition, b u t s h o r t l y a f t e r w a r d s s h e did n o t a p p e a r so well a n d h a d a t h r e a d y puIse. She w a s a w a k e a n d c o m p l a i n i n g of pain. O m n o p o u gr. ~ w a s a d m i n i s t e r e d a n d a d e x t r e v a n d r i p / w a s s e t u p , followed b y a slow d e x t r o s e drip. A f t e r t h i s t h e p u l s e i m p r o v e d a n d still n o u n d u e a n x i e t y w a s felt a b o u t h e r condition. A b o u t h a l f a n h o u r l a t e r t h e c o n d i t i o n r a p i d l y d e t e r i o r a t e d a n d blood t r a n s f u s i o n w a s s t a r t e d b u t before it w a s well u n d e r w a y d e a t h occurred. O n p o s t m o r t e m e x a m i n a t i o n t h e a b d o m i n a l c a v i t y w a s f o u n d to c o n t a i n free blood a n d c l o t s w b i c h w a s l o c a t e d a s c o m i n g f r o m a slipped pedicle o n t h e r i g h t side. T h e r e w a s n o d o u b t t h a t t h i s w a s t h e c a u s e of d e a t h . I n t h i s u n f o r t u n a t e o c c u r r e n c e , in a d d i t i o n to m y s y m p a t h y for t h e r e l a t i v e s I also feel s y m p a t h e t i c t o t h e o p e r a t o r . I w a s u n a w a r e t h a t a n y a n x i e t y w a s felt a b o u t t h i s c a s e u n t i l s h o r t l y a f t e r t h e p a t i e n t h a d died. I n c r i t i c i s m I feel, t h a t t h o s e w h o s a w t h i s p a t i e n t a f t e r o p e r a t i o n failed to a r p r e c i a t e t h e i n c r e a s i n g g r a v i t y of h e r condition. T h e r e is n o d o u b t t h a t p r o m p t l a p a r o t o m y s h o u l d h a v e b e e n u n d e r t a k e n . P e r s o n a l l y , I a m v e r y "ligature " m i n d e d , h a v i n g p r e v i o u s l y s e e n t h i s a c c i d e n t o n a n u m b e r of o c c a s i o n s a t t h e h a n d s of s u r g e o n s of u n q u e s t i o n e d skill. (2) Case ]3. ]3. No. 18050. A g e 24 y e a r s . P a r a 1. "]Booked." T h i s p a t i e n t h a d a n u n e v e n t f u l s p o n t a n e o u s d e l i v e r y o n 3013]'54. T h e p u e r p e r i u m was normal and she was discharged on the 8th day. Some days after discharge from hospital this patient disappeared from her home a n d w a s l a t e r f o u n d d e a d , h a v i n g b e e n d r o w n e d in a r i v e r s o m e m i l e s f r o m t h e city. I t m u s t be c o n c l u d e d t h a t t h i s p a t i e n t w a s s u f f e r i n g f r o m a p u e r p e r a l m e n t a l a b b e r a t i o n w h i c h w a s n o t d e t e c t e d while s h e w a s in t h e h o s p i t a l . (3) C a s e H . C. No. 19370. A g e 25 y e a r s . P a r a 2. "]3ooked " T h i s p a t i e n t h a d r e g u l a r l y a t t e n d e d t h e H o s p i t a l for a n t e n a t a l care. She h a d h a d a p r e v i o u s a b o r t i o n . T h e r e w a s a m i l d u r i n a r y i n f e c t i o n p r e s e n t late in p r e g n a n c y , w h i c h r e s p o n d e d to t r e a t m e n t . A t t e r m s h e h a d a s p o n t a n e o u s olxset of labour, w h i c h w a s i n e r t in t y p e a n d l a s t e d 43 h o u r s . N o r m a l d e l i v e r y of a well d e v e l o p e d live i n f a n t . The perineum required 2 sutures. T h e p u e r p e r i u m w a s n o r m a l in e v e r y w a y a n d s h e w a s a c t i v e l y m o v i n g a b o u t a f t e r t h e s e c o n d d a y . She w a s d i s c h a r g e d a f t e r t h e u s u a l s t a y in H o s p i t a l . O n a r r i v a l a t h e r o w n h o m e t h e p a t i e n t c o m p l a i n e d of a s u d d e n p a i n in h e r c h e s t a n d d r o p p e d d e a d i m m e d i a t e l y . She w a s s e e n b y h e r o w n p r a c t i t i o n e r s h o r t l y a f t e r d e a t h . T h e C o r o n e r w a s i n f o r m e d a n d b e w a s satisfied t h a t d e a t h m u s t h a v e b e e n d u e t o m a s s i v e p u l m o n a r y e m b o l i s m , a n d o r d e r e d certification w i t h o n t p o s t m o r t e m e x a m i n a t i o n .

8o (4) Case R. R. No. ]9497. Age 37 y e a r s . P a r a 13. " Booked ". A previous good obstetric h i s t o r y with a large n u m b e r of u n e v e n t f u l deliveries was p r e s e n t in this case. On this occasion t h e p a t i e n t h a d a twin pregnancy. She a t t e n d e d regularly for a n t e n a t a l care a n d was a d m i t t e d a t t h e 38th w e e k of h e r p r e g n a n c y for rest. T h e r e was a trace of a l b u m i n in t h e urine a n d h e r B.P. was 165195. She h a d some oedema of t h e feet. A c a t h e t e r specimen of urine showed no microscopic a b n o r m a l i t y . Haemoglobin was 48 per cent. Five d a y s a f t e r h e r admission to hospital t h e p a t i e n t h a d a well m a r k e d b a e m a t u r i a which continued. L a b o u r s t a r t e d 2 d a y s ' later a n d she was s p o n t a n e o u s l y delivered of live m a t u r e twins. There was no 3rd stage complication. Gross h a e m a t u r i a continued a n d on t h e 2nd puerperal d a y she was given 2 p i n t s of blood. A high t e m p e r a t u r e was now p r e s e n t a n d t h e p a t i e n t was becoming deeply jaundiced. Marked e n l a r g e m e n t of t h e liver was noted. T h e p a t i e n t ' s condition rapidly deteriorated with continuing h a e m a t u r i a a n d deepening jaundice and she died on t h e 6 t h puerperal day. P o s t m o r t e m e x a m i n a t i o n revealed a massive d e s t r u c t i o n of both kidneys due to a c u t e pyelonephritis with multiple abscess formation. T h e following is a copy of t h e p o s t m o r t e m report : Postmortem:

Externally---deep jaundice. B r a i n - - n o t examined. T h o r a x - - l u n g s , right 820 g. L e f t 520 g. No adhesions. Small petecbiae b e n e a t h pleura of b o t h lungs. Section showed s c a t t e r e d h a e m o r r h a g e s t h r o u g h o u t p a r e n c h y m a . No other a b n o r m a l i t y seen. Heart--39,0 g. N o r m a l size. Several subpericardial h a e m o r r h a g e s m o s t l y on t h e right a n d several subendocardial h a e m o r r h a g e s in t h e right ventricle, n o n e in t h e left. No o t h e r abnormality. A b d o m e n - - C l e a r yellow fluid present. L i v e r - - o b v i o u s l y m u c h enlarged (weight 2,200 g.) Cut surface shows regular " n u t m e g " a p p e a r a n c e s as in congestion. No evidence of necrosis nor malignancy. Gall-bladder normal. Spleen--330 g. Cut surface d a r k red. Malpighian bodies n o t prominent. Appearance t h a t of congestion. Pancreas--normal, Suprarenals--normal. K i d n e y s - - L e f t 270 g. R i g h t 9,75 g. B o t h enlarged. I r r e g u l a r i t y of surface with m a n y large h a e m o r r h a g i c areas. Capsule removed with relative ease, disclosing a rough surface due to large projecting areas, yellowish in colour. S t r u c t u r e of c o r t e x m u c h disorganised showing yellowish areas wffh p a t c h e s of h a e m o r r h a g e . Appearance is t h a t of n u m e r o u s , a l m o s t confluent, abscesses in the cortex. M a n y yellowish s t r e a k s t h r o u g h medulla seen. Pelvis contains blood a n d t h e wall a p p e a r s m u c h thickened. B l a d d e r - - c o n t a i n e d bloody urine. Uter~a:~--normal. Histology :

K i d n e y - - T h e r e is a severe s u p p u r a t i v e p y e l o n e p h r i t i s with m a n y cortical abscesses, w i t h infarction a n d s t r e a k s of acute i n f l a m m a t i o n in t h e medulla. T h e pelvis is o e d e m a t o u s , inflamed a n d w i t h m u c h blood u n d e r n e a t h t h e epithelium. There is no v e n o u s t h r o m b o s i s a t t h e hilum. T h e r e is a m i n i m a l degree of cortical scaring a n d t h e r e is no suggestion t h a t renal disability a n t e d a t e d t h e pregnancy. L i v e r - - T h e liver c o l u m n s are c o m p r e s s e d b y t h e dilated sinusoids. These sinusoids contain debris and fibrin b u t n o t fresh red cells. There is no diffuse inflammation, no a b s c e s s e s a n d no reaction a r o u n d p o r t a l tracts. No thrombosis. Myocardium ; p a n c r e a s ; s p l e e n - - n o r m a l . L u n g - - T h e r e is intra-alveolar h a e m o r r h a g e b u t no evidence of consolidation. Postmortem findings :

(1) Acute s u p p u r a t i v e pyelonephritis. (2) Acute congestion of fiver. (5) Case J. D. No. 19813. Age 31 years. P a r a 4. " Unbooked ". This p a t i e n t was " u n b o o k e d ", a n d was s e e n b y t h e writer in consultation in a n n u r s i n g h o m e in t h e c o u n t r y , h a v i n g h a d one eclamptic fit. Following t h e fit she w a s deeply unconscious a n d cyanotic. Admission to hospital w a s arranged. On arrival to t h e hospital t h e general condition h a d deteriorated a n d inequality of t h e pupils h a d develoned. T h e o a t i e n t was xmt in labour a n d t h e F I H could still be heard. She

8I required continuous oxygen, but rapidly became worse and died 3 hours' after admission. It is regretted that Caesarean section was not Lmdertaken earlier as a live baby might have been delivered. Section was done as a terminal procedure without success. The patient had had three previous normal deliveries. She had attended her private doctor for antenatal care on a couple of occasions, when nothing abnormal was noted. On postmortem examination a massive pontine haemorrhage was found which was the evident cause of the rapidity of this patient's death. Other typical eclamptic findings were present in the liver and kidneys. Commentary on Intern Maternal Deaths. Of the 5 deaths during the year in the Intern Department of the Hospital, one only was avoidable. This was the first death described, and was due to an operative misfortune. It is doubtful if the second fatality should be recorded as a maternal death at all. The death from eclampsia illustrates the importance of trying to make both the public and members of the profession more conscious of the necessity of antenatal supervision, even when previous pregnancies have been uneventful.

APPENDIX "A" INCOAGULABLE BLOOD F O L L O W I N G ACCIDENTAL HAEMORRHAGE. THE MASTER A N D H. C. MOORE. In this present year 85 cases of accidental haemorrhage of all types occurred and 6 cases were classified as severe; in 4 of these the clinical condition was such as to warrant tests for incoagulability of the blood. In 3 no defect was found ; the other showed definite evidence of incoagulability. Case E.F. No. 18315, age 34 years, para 5, was admitted about 7 hours after the onset of accidental haemorrhage. She was shocked with a blood pressure of 85/40, her uterus was tense and tender and the foetal heart was not heard. A blood transfusion was set up. A clotting time was performed and only a fragment of clot was obtained ; this clot lysed after 25 minutes at 37 ° C. Repeat investigations over the next 2 hours showed the clot to be increasing in amount although still defective but the lysis disappeared. Caesarean section was decided upon for obstetric reasons. Her general condition was showing no improvement following blood transfusion, and no onset of labour had taken place. Immediately prior to the operation 2g. of fibrinogen was given intravenously. Fifteen minutes later the clot was normally formed and normally stable. Haemostasis at the operation was satisfactory. After delivery of a stillborn foetus and the evacuation of a large quantity of blood clot from the uterus, the latter remained soft and haemorrhagic, a n d s h o w e d practically no contraction to injections of ergometrine administered both intravenously and intrauterine. The uterine incision was, however, rapidly closed in two layers but on completion of this there was no contraction and the uterus was in fact dilating with fresh blood clot. I t was considered most unsafe to leave the uterus in this condition and hysterectomy was immediately decided upon and carried out without difficulty, Convalescence was uneventful,