Intra-operative and post-operative maternal deaths

Cardiac Arrest /AME after CS    Infection after Induction by Foley Balloon      Necrotizing Fasciitis

Date: Fri, 17 Oct 1997 
From: dahmd <>
To: Multiple recipients of list <>
Subject: Re: Cardiac arrest after C-section
Comment: list for discussion of obstetrics and gynecology

Kunto Raharjo wrote:
> 4 hours post op patient become dyspneic, shocked, and then arrested.  CPR revived her, with good BP and SaO2 but she arrested again after 40 minutes, and then started to develop DIC and died.  Any advice on possible cause?

Gail Waldby, MD wrote:
> Just a question.  Wouldn't it be unusual for an amniotic fluid embolus to occur 4 hours after the C-section?

Yes, but AFE has been reported up to 48 hours after delivery (Clark SL. New concepts of amniotic fluid embolism: A review.  Obstet Gynecol Surv 45:360, 1990). 
D. Ashley Hill,M.D.
Orlando, FL

Balloon in lieu of cytotec / maternal death

From: "R. Daniel Braun, M.D." <>
To: Multiple recipients of list <>
Subject: Re: Balloon in lieu of cytotec
Comment: list for discussion of obstetrics and gynecology

I am aware of one case of clostridial  sepsis and death secondary to its use. Dan Braun.M.D.

From: (William J Faulkner)
To: Multiple recipients of list <>

Subject: Re: Balloon in lieu of cytotec

I suspect that we could find a case of Clostridial sepsis and death secondary to "stripping the membranes", or with EASI  as well.  As we all know  "meconium happens". Will


Do we add  "Necrotizing fasciitis" to the list of risks for cesarean section?

Forwarded message:
Subj:    Hospital Faulted for Mother's Death
Date:    1997-10-03 


      A hospital waited too long to diagnose and treat a woman who became infected with so-called ``flesh-eating'' bacteria and died 18 days after giving birth, health regulators said Friday.  Strong Memorial Hospital failed to provide proper care for Susan Dougherty, who fell into a coma in the maternity ward two days after delivering a healthy girl on Feb. 17, said state Health Commissioner Barbara DeBuono.   Her department will waive an $8,000 fine if the hospital makes a series of changes in its medical procedures aimed at preventing such a recurrence. Strong is a teaching institution connected to the University of Rochester.

      While it is not certain that any medical intervention could have saved Mrs. Dougherty's life, ``the hospital failed to recognize the gravity of her condition and did not begin aggressive treatment soon enough,'' DeBuono said.   The hospital also was deficient in its care of one of two other women in the maternity ward who recovered from invasive Group A strep infections, health officials said in a 20-page report.

      Mrs. Dougherty, 39, apparently developed the much more dangerous strain of strep known as necrotizing fasciitis through her Caesarean incision. Her severe postoperative pain wasn't recognized quickly enough as a symptom of the disease that rapidly poisons tissue. She died March 7.  Necrotizing fasciitis, which killed 11 people in England in 1994, responds to antibiotics if treated quickly but is fatal in about 30 percent of cases.  The bacteria produce a toxin that poisons skin, muscle and internal organs. Tissue can be destroyed at the rate of an inch an hour.

      Mrs. Dougherty's attending physician did not visit her the day after her Caesarean delivery, as required by state law, the health department said.
      ``There is no question that I should have visited Susan sooner,'' said Dr. Stephan Sanko, her obstetrician for 10 years who also delivered her two other children. ``I didn't make seeing her the priority it should have been because she seemed to be recovering well.''
      Mrs. Dougherty's family is preparing to sue the hospital for damages.
      In May, the health department said Strong acted promptly in controlling the spread of the bacteria once it was detected in the maternity ward. It is impossible to determine if the three maternity patients were infected by two maternity unit workers later found to be carrying invasive Group A strep, health officials said.

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