Severe Coma and Organ Failure in Postpartum Women

Causes of severe coma or brain death, as well as multiple organ failure in parturients?

Dear Director Liang,
My sister-in-law was seen for prenatal check-ups on June 20, June 27, and July 4, 2003, and was admitted to the hospital for labor on July 4, 2003.
On July 5, 2003, at 1:23 PM, she delivered a mature male infant vaginally at full term.
The hospital informed us that the mother experienced significant hemorrhaging.
Around 3 PM, the hospital notified us that she had poor uterine contractions and urged us to quickly go to the blood bank for an emergency blood transfusion and a hysterectomy.
By around 6 PM, she was taken out of the operating room and transferred to the surgical intensive care unit.
When we saw her, she was in a deep coma and unresponsive.
While we were waiting in the rest area, we noticed the nursing staff frequently going in and out of the ICU to obtain blood, which made us feel that the situation was critical, and we were on the verge of a breakdown.
On July 6, another exploratory laparotomy was performed to remove fluid, and a urinary catheter was placed.
On July 7, she was transferred to the medical intensive care unit for treatment, but her transfusion situation did not improve, and her heart rate remained around 139.
The ICU doctors repeatedly informed us that her pupils were dilated and asked whether we wanted to sign a natural death declaration or opt for resuscitation (the declaration had not yet been signed).
On July 9, another physician performed surgery, and her heart rate improved to 110, along with significant improvement in transfusion needs; however, all her organs remained non-functional, her liver enzymes were extremely high, she required daily dialysis, had a bacterial infection, and was unable to breathe without mechanical ventilation.
To this day, she remains completely unresponsive and has become a vegetative state.
I have several questions for you, Director Liang:
1.
Given the advancements in medical technology, is a 39-year-old woman having her second child (her first daughter is already 17) considered a high-risk pregnancy? I had requested a cesarean section, but the hospital consulted with cardiology and pulmonology and assessed her for vaginal delivery (the mother had experienced respiratory issues due to overload after 30 weeks).
2.
Did the hospital exhibit severe negligence (no cardiology or pulmonology specialists were present during delivery)?
3.
Is there severe negligence if there was no resuscitation within a few minutes (the golden time) during shock, which could lead to hypoxic brain death and multiple organ failure?
4.
After signing the natural death declaration, will it hold up in the event of a future medical dispute?
5.
Can we file a lawsuit against the hospital for severe negligence resulting in the mother becoming a vegetative state (brain death)?
6.
Which specialties and how many physicians are required to certify a vegetative state (brain death)?
7.
How should we proceed in a more appropriate manner?
Sincerely,
Chen Yin-Chuan

Yin, 40~49 year old female. Ask Date: 2003/07/22

Dr. Liang Yinpan reply Obstetrics and Gynecology

Dear Mr.
Chen Yin-Chuan,
Dr.
Yen Kuo-Sen responds as follows: Poor uterine contraction after childbirth can lead to postpartum hemorrhage, which is one of the most serious complications in obstetrics and gynecology.
"One may have a smooth delivery, but complications can arise unexpectedly." Regardless of advancements in medicine, some complications are unpredictable.
It appears that the hospital has made every effort to provide emergency care, and I hope you take good care of yourself.
Dr.
Yen Kuo-Sen, Changhua Hospital, Response dated July 23, 2003.

Reply Date: 2003/07/22

More Info

The case you presented raises several critical issues regarding severe postpartum complications, particularly focusing on the development of severe coma and multiple organ failure in a postpartum woman. The situation described involves a 39-year-old woman who experienced significant complications during and after childbirth, including massive hemorrhage, uterine atony, and subsequent organ failure.
1. Age and Risks: Yes, a 39-year-old woman is considered a high-risk pregnancy, especially for her second child after a significant gap (17 years). Advanced maternal age can lead to increased risks of complications such as gestational diabetes, hypertension, and in this case, potentially more severe postpartum hemorrhage due to uterine atony. The medical team should have closely monitored her throughout the pregnancy and especially during labor, considering her age and previous medical history.

2. Medical Oversight: The question of whether there was severe medical negligence is complex. If the medical team failed to adequately assess and manage the risks associated with her age and previous health issues, this could constitute negligence. The involvement of specialists such as cardiologists and pulmonologists is crucial, especially if there were pre-existing conditions that could complicate the delivery. The decision to proceed with vaginal delivery despite these risks should have been made with thorough consideration and informed consent.

3. Golden Hour and Resuscitation: The "golden hour" refers to the critical time immediately following a traumatic event, where prompt medical intervention can significantly affect outcomes. If the patient went into shock and was not resuscitated within this timeframe, it could lead to irreversible brain damage and multi-organ failure. The medical team’s response during this critical period is vital, and any delays in intervention could be scrutinized in a legal context.

4. Natural Death Declaration: Signing a natural death declaration can complicate future medical disputes. If the family believes that the medical team did not act appropriately, this document could be used against them in a legal context. It is essential to seek legal advice before signing any such documents, especially in cases where there is potential for medical malpractice.

5. Legal Action for Malpractice: If there is sufficient evidence to suggest that the medical team acted negligently, the family may have grounds for a lawsuit. This would require a thorough investigation into the medical records, the decisions made during labor, and the subsequent care provided. Consulting with a medical malpractice attorney would be advisable to explore this option.

6. Determining Brain Death: The determination of brain death typically requires evaluation by a neurologist or a critical care specialist. The criteria for brain death include the absence of brainstem reflexes, unresponsiveness, and the inability to breathe independently. Multiple physicians from different specialties may be involved in confirming brain death to ensure an unbiased assessment.

7. Next Steps: The family should consider consulting with a medical malpractice attorney to discuss the specifics of the case and explore potential legal actions. Additionally, they may want to seek psychological support to cope with the emotional trauma associated with this situation. Engaging with patient advocacy groups may also provide resources and support during this challenging time.

In summary, the case highlights the complexities and risks associated with postpartum complications, particularly in high-risk pregnancies. It underscores the importance of thorough medical evaluation, timely intervention, and the potential for legal recourse in cases of perceived medical negligence.

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