AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 22 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 Case 4 A 40-year-old P4G4, unbooked, HIV positive on FDC, CD4 count and viral load unknown, underwent an elective CD for two previous CD at a district hospital. Intra-operative report of multiple adhesions, however no injuries were reported at the time of the CD. She was subsequently discharged on the third day as apparently stable. She presented back to the same hospital on the ninth post-operative 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 then taken to theatre for laparotomy where “dilated small bowel, collapsed remaining 20cm of the terminal ileum, few serosal tears with some areas of necrosis" were found. All was repaired and the patient was taken to the ward apparently stable. Her condition changed six hours later, she was assessed, and sent to ICU, and she died the following day from multi- organ (renal, respiratory, haematological, and metabolic) failure. Post-mortem findings revealed severe peritonitis, unsutured full-thickness bowel tear, acute tubular necrosis, acute respiratory distress syndrome, and septic shock. Case 5 A 35year P2G3 had no previous history of CD, booked early, and attended antenatal clinic as prescribed. Her BMI was 61kg/ m2, she was not anaemic, and had chronic hypertension and diabetes, both controlled on treatment. She was HIV positive with CD4 count of 944 x 106/l on FDC, no viral load. She underwent a CD for foetal distress at a tertiary hospital which was apparently uneventful. She then developed sepsis on day four post CD and was diagnosed and treated as wound sepsis. Wound debridement was done, and she was kept on antibiotics and vacuum dressing in the ward for two weeks. During her hospital stay, she remained tachycardic, hypotensive, tachypnoeic, and febrile, and she also developed pulmonary emboli. On day 20, the diagnosis was reviewed as she was not getting better and developed multiorgan failure. She was then taken to the operating theatre three days later for exploratory laparotomy whereby a total abdominal hysterectomy for uterine sepsis was performed and small bowel resections with secondary anastomosis for multiple perforations were also performed. She was admitted to the intensive care unit, where she continued to deteriorate and died a few days later on day twenty-seven post CD from multi-organ (renal, respiratory, haematological, and metabolic) failure. KEY FINDINGS Risk factors for bowel injury included previous surgery, and being overweight. Most women were HIV positive. Healthcare worker-related avoidable factors Administrative/ system avoidable factors Early recognition i. Missed bowel injury at initial surgery, ii. Inadequate assessment of the patient with poor monitoring (incomplete vital signs at triage). Quick Sequential Organ Failure Assessment (qSOFA) score was only assessed in two women. iii. Wrong diagnosis/ poor problem recognition Delayed and Inadequate treatment following diagnosis Delay to be seen by a specialist Overburdened services (Lack of ICU bed) DISCUSSION In this study we described 14 cases of maternal deaths as a result of bowel injury sustained during caesarean section in the 2020-2022 triennium. Caesarean section is a major surgical procedure that is not without risks. Although bowel injury is a rare complication of CD, the complication can occur even in the hands of experienced surgeons. A history of previous intra-abdominal surgery and associated scarring has been identified as a risk factor for bowel injury. 6 PATHOGENESIS AND CLINICAL PRESENTATION Women with increased BMI and a history of previous caesarean deliveries are at an increased risk for bowel injury. Postoperative monitoring in this group of patients is therefore critical. Bowel injury often presents with vague symptoms, manifesting very late in the postoperative period. Most patients in this review presented to the hospital at least a week post-surgery in a critically ill state, after signs such as persistent tachycardia were missed or not appropriately investigated. NATURAL PROGRESSION AFTER EXPOSURE Women, particularly those who underwent a caesarean delivery at lower levels of care, such as district hospitals, exhibited abnormal parameters early during the postpartum period, with tachycardia observed in at least 90% of cases by the third day. However, these signs were frequently overlooked, and women were discharged three days post- surgery as they were considered to be stable. Notably, by the seventh day upon readmission, the majority (93%) had clinical signs of multiple organ dysfunction syndrome (MODS) with at least two organ failures. HIV positivity further increases the risk of maternal sepsis complications due to bowel injury. MANAGEMENT AND PREVENTION Although bowel injury in pregnancy is rare, it can occur during caesarean deliveries, particularly in cases involving urgent abdominal approaches with intestinal adhesions resulting from previous surgeries. Early identification during surgery followed by prompt repair is crucial. 7 Our findings underscore the necessity for maintaining a high index of suspicion, especially in women with a history of prior surgeries or obesity. Proper patient selection in accordance with available levels of expertise is essential, and remedial measures must be optimised in lower-level care institutions. Best clinical practice dictates that patients at increased risk should be informed pre-operatively of the potential risks. 8 IMMEDIATE MANAGEMENT Compliance with sepsis bundle protocols poses a substantial challenge in our setting, and this issue is similarly reported in other countries outside of South Africa. 9,10 In many cases, the timing of treatment was delayed and often incomplete. The implementation of a national sepsis program has been associated with improved adherence to sepsis protocols for severe sepsis and septic shock, resulting in decreased adjusted in-hospital mortality. 11,12 However, the components of the sepsis bundle were poorly implemented in this study, where only two women had at least 5 out of the 6 components adhered to, yet their disease severity led to poor outcomes. Cases of bowel injury associated with delayed symptomatic presentation and late recognition of MODS, represent a significant mortality risk. SUBSEQUENT MANAGEMENT Inadequate assessment and reporting of parameters necessary to define the quick Sequential Organ Failure