MATERNAL DEATH SURVEILLANCE AND RESPONSE REVIEW

Province / City of Zambales

BAYSA, JOAN DONOR

STA. BARBARA, IBA, ZAMBALES

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

CENTRAL LUZON Provincial/City Review Team

Provincial Health Officer as

the team leader

Members:
Technical Secretariat:
• 1 CHD representative
• 1 Private practitioner Head: PHO Technical
Division Chief or Chief
(preferably an OB-Gyn
of Clinics or Chief of OB-
specialist)
GYN Department
• 1 CEmONC doctor
• 1 BEmONC doctor Members: 1
representative from
• Technical Secretariat
each ILHZ

*Recommended Members

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 THE PROVINCIAL / CITY REVIEW TEAM

Provincial/City Health Officer

(Head):
Members:

Technical Secretariat (Head):

Members:

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 PRESENTATION OF CASE PROFILE AND
TIMELINE OF EVENTS

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 CASE PROFILE

AGE: 33 years old

OB SCORE: G7P4 (4024)

CHIEF COMPLAINT: SEIZURE

DATE OF DELIVERY: N/A

PLACE OF DELIVERY: N/A

PREGNANCY
Expired
OUTCOME:

DATE OF DEATH: 01/28/2024

PLACE OF DEATH: President Ramon Magsaysay Memorial Hospital (PRMMH)

ANC (#,
Public
PUBLIC/PRIVATE):

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 HISTORY OF PRESENT ILLNESS

Joan Baysa is a 22-year old patient with OB score of G7P4 (4024). Patient was hypertensive
during her pregnancy. She had prenatal check-ups at Sta. Barbara, Iba RHU and was
advised to have her check up at PRMMH but patient was non-compliant. Most of the
time, patient was also sleep-deprived because of her work as a vegetable vendor.
Patient had headache episodes days prior to admission. Few minutes prior to admission,
patient experienced loss of consciousness and had seizure episode at home.

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 CASE MANAGEMENT / TIMELINE OF EVENTS
(Admission)
January 26, 2024
10:18am
• GCS 14 (E4 V4 M4)
• Initial Vs: BP-200/120, T-36.9, PR-86bpm, RR-20, 02 sat- 99%, FHT-144bpm
• Hooked to oxygen inhalation via nasal cannula
• Started venoclysis- D5LR x KVO
• Inserted IFC
• Meds given:
10:20am- Furosemide 20mg given thru IV
10:25am- Magnesium Sulfate 4grams given thr IV
10:30 am- Hydralazine 10 mg given thru IV

12pm
• GCS 9 (E1 V3 M5)
• Referred to Medicine department

12:24pm
• RBS- 324--- Regular Insulin 10 units given thru SQ
• IVF shifted to PNSS1L x 16hrs

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 CASE MANAGEMENT / TIMELINE OF EVENTS

1:30 pm--- BP-palpatory, 02 sat-60%, GCS-3, repeat RBS- HI

• Patient was intubated and hooked to mechanical ventilator and cardiac monitor
• Regular insulin 12u given thru IV
• NGT-inserted
• Cranial CT scan requested
• For transfer to ICU once available

2:00pm---VS were as follows: BP-110/70 T-36.2, PR-99, 02sat-97%.

2:30pm—RBS-430, Regular Insulin 10 units thru IV and 6 units given thru SQ

3pm---BP- 60/40
• Referred back to Medicine department
• Norepinephrine drip started

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 CASE MANAGEMENT / TIMELINE OF EVENTS

8:45pm- Cranial CT Scan plate referred to OB ROD and MROD

• Meds started: Mannitol 200cc IV q6, Citicoline 1 gm IV q8, Omeprazole 40mg IV OD

Lab results CBC: Hgg-13g/dL, Hct-38.7%, WBC-11.33, Plt-298

Urinalysis: Albumin-Trace, Sugar- Trace, Blood- Negative, Ketone-Negative
Na- 137.1 mEq/L, K-2.04 mEq/L, Crea- 0.67mg/dl, SGPT-27.0 IU/L, SGOT-18.0

10:15pm- Potassium result: 2.04

• KCL drip started

January 27, 2024

• GCS 3
• with intact ET tube connected to mechanical ventilator
• With Norepinephrine drip
• For transfer to ICU once available
Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD
 January 28, 2024
8am- repeat K requested
Result:3.31

1pm- FHT-unappreciated
4:15pm- BP-0, CR-0
CPR and ambubagging done, Epinephrine 1amp given
4:25pm-2nd dose of Epinephrine given
4:50pm-BP- 50/40, CR-104

7:37pm-BP-0 CR-0
-relatives refused resuscitation
9:16pm-pronounced dead
-relatives refused post mortem CS

Cranial CT scan result (released on January 29,2024): Acute Parenchymal hemorrhage, right
parieto- temporal lobes. Acute subarachnoid hemorrhage with minimal intraventricular extension.
Consider rupture aneurysm, Diffuse cerebral edema. Mild midline shift towards the left

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 MEDICAL CAUSE OF DEATH

Hypoxic-Ischemic Encephalopathy secondary to CVA secondary to Uncontrolled

Hypertension; Eclampsia

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 WORKSHOP 1: ANALYSIS OF MATERNAL DEATH CASE

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 CONCLUSION

THE MOTHER DIED BECAUSE OF…

Hypoxic-Ischemic Encephalopathy secondary to CVA secondary to

MEDICAL: Uncontrolled Hypertension; Eclampsia

- Poor Patient Referral Management

NON- - Non compliance to management
MEDICAL: - Limited health care resources

CONCLUSION: THE MOTHER DIED BECAUSE ?

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 NON- MEDICAL CAUSE OF DEATH
Factors that lead to Death
DELAY 1: Poor Patient Referral
Management
DELAY 2:Non compliance/Non Adherence
to treatment or management
DELAY 3: Limited Health care resources
Department of Health, Philippines
Health System Gaps
• Failure to enforced implementation of service
delivery network (SDN) for pregnancy Referral
system
• Poor prenatal check-up
• Poor health education on preventive measures
and activities to prevent maternal
complications
• Lack of necessary and appropriate equipment
when caring for preterm babies
• Limited ICU beds
• Neurologist not available
• Delayed release of results of diagnostic tests
Safe Motherhood Program, Central Luzon CHD
 WORKSHOP 2: ACTION PLAN AND DISSEMINATION PLAN

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 ACTION PLANNING (100 DAYS)
STRATEGIC To reduce the incidence of maternal mortality due to delay in referral and management by
OBJECTIVE: Enforcing Pregnancy tracking and Service Delivery Network (SDN)
RESULT: Intensified pregnancy tracking from prenatal to post-partum and enforced implementation
of service delivery network.

Activities Result or Output Date of Conduct Who’s in charge?

Each activity should lead to Result or Output

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

 DISSEMINATION PLAN

WHO TO INVITE?

WHAT WILL BE PRESENTED?

• What are the recommendations to
address the gaps?

WHAT ARE THE KEY MESSAGES?

Department of Health, Philippines Safe Motherhood Program, Central Luzon CHD

Maraming salamat po!