A missed opportunity of a preventable maternal death-a case report from Sri Lanka

Abstract

High maternal mortality rate is one of the major public health issues in under-privileged countries. Around 94% of global maternal deaths are reported annually from these countries. Sri Lanka has achieved the lowest maternal mortality rate in the South Asian region in the year 2015. The current National Maternal Mortality Surveillance System in Sri Lanka has been instrumental in achieving this. A forty year old mother of two grown-up children became pregnant after 7 years of her second marriage. She and her husband warmly welcomed the pregnancy. Her two children from the previous marriage were normal vaginal deliveries without any complication and were now aged 23 and 20 years. By 08 weeks of period of amenorrhoea (POA), she attended the local obstetric clinic where the routine examination revealed a cardiac murmur. She was referred to a tertiary care hospital for further management. By 16 weeks of POA she was diagnosed to have critical aortic stenosis, moderate aortic regurgitation with mild mitral stenosis and regurgitation with left ventricular dysfunction. The consultant obstetrician, physician, cardiologist and the anaesthetist had carefully assessed her and decided that continuation of the pregnancy poses a significant risk on her life. They also recommended her pregnancy to be therapeutically terminated which she had adamantly refused. Thereafter she defaulted the local clinic as well as the one at the teaching hospital. Around the 20th week of POA her general health condition started to deteriorate. By the end of the 27th week of POA she was admitted to the same teaching hospital with severe shortness of breath and extreme fatigability. An intrauterine death, pneumonia and sepsis were diagnosed clinically. Despite vigorous treatment she died the next day. The postmortem examination confirmed the clinical diagnosis and rheumatic valvular heart disease was evident at the autopsy. The authors wish to discuss the concepts of preventable maternal death, indirect maternal death and the significance of effective communication with the patients when persuading them to comply with life-saving intimate clinical decisions.