AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 21 ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | Maternal deaths due to Pregnancy-Related Sepsis arising from bowel injury: A retrospective folder review from the NCCEMD triennium 2020-2022 Failed IOL due to foetal distress 02 14.29 Foetal distress 01 7.14 Severe Pre-eclampsia & foetal distress 01 7.14 Five (35.7%) women were never referred and died at the lower level of care, while eight (57.2%), four (28.6%), four (28.6%), and one (7.1%) died at district, regional, tertiary, and private hospitals respectively. Tachycardia was present in 13 (92.9%) cases at least on the third day post caesarean section delivery before discharge. Nine women (64%) were discharged on day three and readmitted at least on day seven or later. The suspicion of or diagnosis with intraabdominal sepsis was made mainly at or after day seven post CD, with 13 (92.9%) women being unwell as supported by symptoms involving the gastro-intestinal tract such as nausea, vomiting, and absent bowel action. These women also had clinical signs of ≥4 organ systems failure predominantly respiratory, metabolic, haematological, renal, and gastrointestinal tract. None of the bowel injuries were diagnosed intra- operatively at caesarean section. Seven cases (50.0%) were diagnosed during relook laparotomy after readmission and the reaming seven cases (50.0%) at postmortem examination. Injury to both large and small bowel was involved in 6 (42.8%) cases, and in five (35.7%) only small bowel injury was involved. Table 3 is a summary of the management of maternal sepsis in bowel injury cases. The checklist assessing compliance towards the sepsis bundles was used. There was overall poor compliance towards the sepsis bundles’ implementation as evidenced by delayed and inadequate treatment following diagnosis. Only two women (14%) had at least five out of six (83%) components implemented. Table 3: Management (sepsis bundle) of PRS bowel injury cases Bundle component Case no 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1.Resuscitated with 30mL/ kg of IV crystalloids within the 1st 3hours ✕ ✕ ✔ ✕ ✕ ✕ ✕ ✔ ✕ ✕ ✔ ✕ ✕ ✔ 2. Culture samples taken immediately (any possible source) within an hour ✕ ✕ ✔ ✕ ✕ ✕ ✕ ✔ ✕ ✕ ✕ ✕ ✕ ✕ 3. Antibiotics given timeously ✕ ✕ ✔ ✕ ✕ ✕ ✕ ✔ ✕ ✕ ✔ ✕ ✕ ✔ 4. Lactate measured (baseline) at the time of assessment ✕ ✕ ✔ ✕ ✕ ✕ ✕ ✔ ✕ ✕ ✕ ✕ ✕ ✕ Lactate repeated after 3 hours of resuscitation ✕ ✕ ✔ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ 5. Catheterized and urine output measured ✔ ✕ ✔ ✕ ✕ ✔ ✕ ✔ ✔ ✕ ✔ ✔ ✕ ✔ 6. Source of infection timeously Identified and controlled ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ ✕ Total score out of 6 (1point each) 1 0 5 0 0 1 0 5 1 0 3 1 0 3 ✕ =Not done, ✔ = Done Table 4: The excerpts of some of the cases Case 1 A 34-year-old P0G1, BMI 25.2kg/m 2 , HIV positive on FDC, with CD4 count of 102 x 10 6 /l, viral load > 50 copies/ml, had prolonged labour following spontaneous onset of labour and had CD for prolonged second stage at a district hospital. She was subsequently discharged on the third day, apparently stable. She then presented back to the same hospital on the seventh day with a history of nausea and vomiting, abdominal distension, and feeling unwell, duration of symptoms not specified. She was assessed as critical, she was admitted to ICU 90 minutes after triage, and she died the following day from multi-organ (renal, respiratory, haematological, and metabolic) failure. Post-mortem findings revealed small bowel injury and peritonitis. Case 2 A 33-year-old P2G3 had two previous CDs, booked early, and attended antenatal clinic as prescribed. Her BMI was 21.8kg/ m2, she was not anaemic, HIV negative and syphilis test positive, treated as per protocol. She underwent a CD for previous CD x 2 in early labour at a regional hospital. The surgeon stated that she had multiple adhesions, and the patient sustained a bladder injury that was repaired intraoperatively. She was then kept in hospital, for monitoring and a urinary catheter to be kept in for 10 days. The patient was stable during her hospital stay until the eighth day when the patient was assessed as unwell with urinary tract infection/pyelonephritis, and she was managed conservatively. She never improved and got worse until on the eleventh day postoperatively when it was decided that she be taken to theatre for exploratory laparotomy as she was thought to have an incisional hernia with bowel obstruction. Non-viable small bowel with severe intraabdominal hypertension was found at laparotomy. She continued to deteriorate, another relook laparotomy was done on the same day, and she died the following day from multi-organ (renal, respiratory, haematological, and metabolic) failure. Post-mortem findings revealed a 2 cm bladder wall injury that was repaired, a large section of distended, oedematous small bowel with a dark purple-red, and dusky appearance consistent with an Ischemic bowel. The focus of small bowel perforation that was repaired was also identified. Case 3 A 32year old P1G2, previous intrauterine death, BMI 25.2kg/m 2 , HIV positive on FDC, with a CD4 count of 384 x 10 6 /l, undetectable viral load, not anaemic, no previous CD, had a CD for fetal distress at a district hospital. She was subsequently discharged on the third day as apparently stable, even though she had persistent tachycardia postoperatively. She then presented back to the same hospital on the seventh day with a history of nausea and vomiting, abdominal distension, and feeling unwell, duration of symptoms not specified. She was then taken to theatre, “distended small and large bowel with multiple patches of bowel ischemia along with the small bowel and caecum with patches of overt gangrene on 30cm segment of the jejunum…hysterectomy (12week size, dusky and necrotic), bowel resection and debridement was done’’, she was planned to be admitted to ICU however she had to wait for ICU bed to be available and she demised the same day soon after ICU admission from multi-organ (renal, respiratory, haematological and metabolic) failure. Post-mortem findings revealed small bowel injury and peritonitis.