FACILITY BASED MATERNAL DEATH REVIEW FORM

NAME OF THE FACILITY – SAFDARJUNG HOSPITAL DELHI

UNBOOKED

MRD- 46130 Unit-1/ ward 4

REFERRAL FROM ANOTHER CENTRE: yes

NAME: Rukmina W/O: Mubin AGE:26 yrs/F

ADDRESS: Tauru, Haryana, India

PARA:4 ABORTION:0 NO OF LIVING CHILDREN: 3

DATE OF ADMISSION: 05/04/2023 TIME OF ADMISSION: 2:51 AM

DATE OF DEATH:22/05/2023 TIME OF DEATH: 11:15 AM

DURATION OF TIME IN HOSPITAL - 47 days 8 hours 24 mins

DIAGNOSIS AT ADMISSION: P4L3 with PND 14 of preterm vaginal delivery (PTVD) at 6 months
amenorrhea with intrauterine death with POD 3 of exploratory laparotomy i/v/o
pyoperitoneum with cystic mass with septic shock with septicaemia under general Anesthesia
on 1/4/23 with history of physical assault by husband antenatally

CAUSE OF DEATH : Septic shock with disseminated TB

CONDITION ON ADMISSION: poor

ANTENATAL PERIOD: Unbooked

CASE SUMMARY:

Patient Rukmina W/O Mubin underwent preterm vaginal delivery with IUD at 6 months
amenorrhea on 21st March,2023 at Max Hospital, Haryana. She had history of physical assault
by husband before delivery. 3 days following delivery, patient started having complaint of pain
abdomen for which MRI was done which was suggestive of benign cystic lesion of 12X11 cm in
pelvis ? infective collection. She also had complaints of multiple spikes of fever. Following which
exploratory laparotomy was done outside in view of pyoperitoneum with septic shock with
septicemia under general anaesthesia on 1st April 2023. She also received 4 units PRBC, 4 unit
FFP, and 2 units cryoprecipitate. Per operatively, abdominal fluid with internal adhesions with
cystic pus collection of 100-120 cc was found and drained. Peritoneal wash was done and drain
inserted. At post operative day 3 , patient was referred to higher center due to non availability
of vascular surgeon and hematologist. She came to Gynae receiving room in Safdarjung Hospital
on 5th April 2023. Patient when examined in GRR was concious oriented to time , place and
person. Her general condition was poor and she was sick looking and dehydrated, Her
temperature was 101 degree farhennite , pulse rate was 108/min, Blood pressure was 118/78
mm Hg, respiratory rate was 30/min and saturation was 98% at room air. Bilateral chest was
clear, and S1S2 were normal. On per abdomen examination, distension was present with no
soakage of dressing. Left pelvic drain was present with pus discharge from drain site. Bowel
sounds were present. Drain output was 75cc(pus)
. Urine output was 300cc and high coloured. On per vaginal examination – lochia healthy,
uterine size could not be made out. Patient was started on injection piptaz and injection
clindamycin. Surgery call and ortho call was done and shifted to HDU for monitoring.
Ultrasound done showed free fluid with internal echoes in right iliac fossa and right paracolic
gutter. Surgery call done and was advised to keep RT continuous, Nil per oral and no active
surgical intervention required. Ortho call sent in view of restricted movement of leg post
surgery advised Xray left hip and thigh. Patient had bilious fluid in drain and RT tube. And
bilious discharge from stitch line and fever spike of 100 degree Fahrenheit. Repeat surgery call
sent for intraop assistance in view of ? bowel perforation. And patient prepared for re-
exploartory laparotomy in view of bowel perforation. Patient was taken up for re-exploaratory
laparotomy on 6/4/23 at 2am. Re exploratory laparotomy with repair of ileal perforation with
ileostomy with right pelvic drain insertion done under general anesthesia. Per operatively, fecal
metter in cavity of around 1 litre. Serosal tear of 3X3 cm present on proximal ileum and 1X1 cm
perforation ion mid ileum. Multiple mesenteric lymph nodes present. Multiple caseous
tubercles present. Uterus was postpartum , bulky , densely attached to omentum and bowel
with no perforation identified on fundus. Ileostomy done and right pelvic drain placed. 1 unit
PCV. 4 unit FFP and 3 unit PRP transfused. Patient shifted to ICU in post operative period
intubated and started on meropenem and metronidazole. On post day 2 surgery call was done
and as advised RT feeding was allowed. DOTS referral taken and patient started on ATT on high
clinical suspicion of TB as per surgery call.. Colistin was also started. Patient was still having
multiple spikes of fever, Patient self extubated on 9/4/23 at 5 pm. Injection fragmin started on
post operative day 5. Patient was shifted to HDU on 10/4/23 ans surgery call taken on 11/4/23
advised oral sips followed by liquid diet from next day followed by semisolid diet and patient
shifted to ward 4/ unit 1 on 11/4/23 at 1:20 pm. Patient was continued on meropenem,
metronidazole , colistin, ATT and fragmin. Last spike of fever was on 11/4/23. On 14/4/23,
patient started having ? visual hallucination and then started having abnormal movements of
bilateral upper limbs and mouth. Temperature was 100.1 degree. Blood pressure was 108/70
mmHg and pukse rate was 120/min, saturation 95% on room air. A bnormal movements
subsided after 5 mins spontaneously following which patient was following verbal commands.
ABG done – ph =7.543, pO2 = 94.8, Pco2 = 25.1, SpO2 = 97.1%, HCO3-=21.6, lactate = 1.8,
glucose = 74. Neurology call done – not suggestive of seizure activity, psychiatry call to be done.
On 15/4, patient was drowsy and unresponsive, GCS = 5/15 with abnormal clonic movement,
pulse rate 128/min, saturation 89%. Patient started on clindamycin. Psychiatry call done and
was advised tab clonazepam and neuro call. ABG done – pH = 7.537, Pco2 = 28.4, HCO3- = 24.0,
Po2 = 81.9, Lactate = 1.7 and shifted to HDU on oxygen. Chloroquine started on 16/4. Patient
had burst abdomen for which dressing was done two times a day and surgery referral taken.
Patient was intubated following respiratory distress on 19/4 and shifted to ICU on 21/4/23 and
started on targocid and colistin, clindamycin and ATT continued. Patient had colostomy bag leak
following which surgery call taken and colostomy bag changed. Surgery call done for right thigh
swelling and aspiration of pus done from right thigh and ryles tube feeding started. Patient
continued having multiples spikes of fever. Patient continued on antibiotics, daily dressing done
and icu management continued. Blood arranged and transfused on 15/5 in view of low
hemoglobin. Patient had 1 episode of bradycardia after blood transfusion started. Blood
transfusion stopped and injection atropine given 1mg IV stat. Patient started on noradrenaline
on 3/5 in view of low BP at 4ml/hr according to BP. Electrolyte correction given according to
reports. Regular dressing done. Treatment added and modified according to reports. Patient
blood pressure gradually declined and patient was put on noradrenaline 20ml/hr, vasopressin
2.4 ( high inotropic support). Patient put on high ventilatory support and antibiotics. Patient
went to bradycardia on 20/5/23 and injection atropine given. Patient went to asystole on
22/5/23 at 10:45 am , 4 cycles of CPR and injection adrenaline given. Patient couldn’t be revived
and declared dead on 22/5/23 at 11:15 am.

INVESTIGATIONS:

Date 6/4/23 10/04/23 14/4/2 20/4/2 25/4/2 6/5/23 15/5/2 19/5/2

3 3 3 3 3

Hb 11.7 11.2 10.7 8.4 8.9 11.1 6.5 8.2

TLC 16800 14300 9200 12400 8200 7400 24600

Platelet 84000 44000 1.67lak 70000 62000 1.7 lakh 25000 25500
count h

Urea 44 26 19 27 35 62 77 83

Creatinine 0.3 0.2 0.2 0.3 0.5 0.2 0.4 0.6

Na+ /K+ 150/3.5 143/4.2 136/3.4 143/3.5 148/3.2 153/3.4 134/3.1 132/2.7

ALT/AST/ 65/60/10 37/27/77 1.1/26/ 2.4/62/ 4.4/22/ 8.3/45/ 10.1/11 13.1/98

ALP 0 17/119 24/110 17/123 49/216 2/133/ /135/3
251 94
 PRO BNP 2981 2467 2486 5659 2922

Procalcitoni 3.4 11.9 2.2 1.3

n

APTT 60.3 110.1

INR 2.8 2.48

ADA FLUID (6/4/23) 215.51

PERITONEAL FLUID CYTOLOGY Scanty cellular material and comprises of lymphocytes and
(6/4/23) macrophages
PERIPHERAL SMEAR (12/4/23) Dimorphic anemia with neutrophilic leucocytosis

CBNAAT (28/4) MTB not detected

NCCT HEAD (17/4/23) Grossly normal

X-Ray chest (18/4/23)
USG R LL DOPPLER(22/4)
USG RT HIP(23/4)
Grossly rotated towards left
Trachea normal
Cardiac shadow normal
Ill defined reticular opacities noted in lower zone of right
lung field likely infective etiology
Bluntion of right CP angle likely
No e/o DVT
Subcutaneous collection predominantly drainable
displacing muscles of anterior thigh muscles. Max depth
5.1cm , max width 8-10 cm.

CAUSE OF DEATH:
ANTECEDENT CAUSE:
CODE:

Potential avoidable factors/Missed opportunities:

Name designation & Signature of the person filling the form

DR. APRAJITA

FNB TRAINEE OBS &GYNAE UNIT 1

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