Controversy over real cause of Chiamaka’s death after CS

Following the gruesome death of 24-year-old Chiamaka De-Freitas after a Caesarian Section (CS) at Medical Art Centre, Lagos (MART), an autopsy have indicated cause of death to concealed haematoma (collection of blood), which may have presented due to bladder injury sustained during the CS.

The autopsy, signed by Consultant Pathologist at the Lagos State University Teaching Hospital (LASUTH), Dr. Francis Faduyile, stated that Chiamaka died from haemorrhagic shock and concealed haematoma (collection of blood) following a CS). 

The report also stated that Chiamaka had sustained a large bladder injury (4cm) during the CS, which was stitched up with four vicryl sutures. “There is a horizontal laceration on the anterior wall measuring 4.0cm and is held together by four vicryl sutures.

“The urinary wall is covered by haematoma. The urinary bladder contains 50ml of clotted blood,” the repot noted. On how a bladder could get such cut during a pelvic CS remains a puzzle that a medical expert tried to explain.

A Consultant Gynaecologist at the Lagos University Teaching Hospital (LUTH), Dr. Kehinde Okunade, while providing an insight, said the commonest cause of concealed bleeding or blood collection after a CS delivery is broad ligament haematoma, a condition he said usually results due to the inadvertent (accidental) extension of incisions made in the womb to its angles, thus causing a severance of the uterine artery either on one side, or very rarely, to both sides.

“The bleeding may get concealed within the broad ligament space and in most cases, will stop on its own or on rare occasions, may require a secondary surgery, especially if the patient is going into a state of shock,” he said.

According to him, an inexperienced doctor can physically cause the bleeding through surgical errors or through the use of instruments, such as forceps or vacuums.
“Bleeding as a result of lacerations or tears to genital organs can occur from the use of obstetric instruments, such as forceps and ventouse, but this usually occurs in the hands of untrained or inexperienced medical personnel,” he explained.

Okunade, who is also the Secretary, Society of Gynaecology and Obstetrics of Nigeria (SOGON), Lagos chapter, said concealed haematoma is a blood collection within any space in the body that may or may not become clinically obvious.

“There are various reasons why a woman who recently had caesarean delivery can bleed internally. This may be regarded as post-operative haemorrhage. This bleeding can be classified as reactionary or secondary haemorrhage.

“The one that can occur immediately within the first 48 hours of surgery is reactionary haemorrhage, and this usually occurs as a result of the loosening of stitches used to stop bleeding from blood vessels at the initial surgery.

“It may also be because of a sudden increase in the blood pressure of the patient, which may subsequently result in increased blood loss, which may otherwise not be obvious at the time of surgery.

“The other entirely pregnancy-related reason for any form of bleeding after a caesarean delivery is postpartum haemorrhage (PPH), and if this occurs within the first 24 hours after delivery, it is called primary PPH.

“The commonest cause of this is what we called uterine atony, which is the inability of a womb to regain its ability to contract and thus stop bleeding from vessels that open into its inner surface.”He continued: “Another important cause of this, which may even be a commoner reason for internal bleeding after surgery, is laceration or tear in any part of the genital tract that may not be readily obvious or recognised at the time of the initial surgery.

“When such bleeding becomes clinically obvious, the patient may present with features of anaemia or hypovolaemic shock.”It would be recalled that Chiamaka, an indigene of Imo State, died on March 24 after giving birth to a boy through CS after an IVF at the hospital.

Giving their account of the incident, management of MART had published, in a national newspaper, that: “Approximately 36hrs after the baby was born, our doctors found the patient pale, restless and in pain…

“Routine blood test was done and the result showed that her blood levels were low (12.7pcv, according to autopsy).“With the consent of her husband, Chiamaka was immediately transfused with blood (2 pints initially and a further 2 pints of blood with an additional 2 pints of fresh frozen blood).

“Bases on her clinical state, our experienced consultants thought it prudent to do a second surgery to make sure Chiamaka was not bleeding internally… “A concealed haematoma was found behind the bladder.”

While admitting that Chiamaka died from concealed haematoma, the management of MART insisted that the blood loss was not significant, adding: “The blood loss at surgery was not significant, 400ml. Usually, 1000ml is allowed.”But husband of the deceased, Mr. Arlindo De-Freitas, vehemently disagreed with this. He said his wife bled continuously from Friday till Sunday when she finally died.

“The bleeding was so much that the bag connected to the bladder through the catheter, which I believe is about 250ml, got full every two to three hours. I believe this was not normal.

“They allowed my wife to bleed to death, against all my complains and begging to transfer her to Reddington Hospital, where there is a CT scan, and with a CT scan, you can see where the blood is coming from. “They cut the bladder and tried to sow it with four stiches, so ignorant that they don’t know that a mussel can’t be repaired with stiches, but through sealing.

“I have nothing against the medical director, but the doctor in charge of my wife’s case butchered my wife to death. “I have evidence that proved that the said doctor have had similar cases years back in Festac Town (Lagos), where he worked before. Yet, he is still operating.

“They gave a statement online as the true story of my wife’s death, that I was given her Jack Daniels and Coca Cola. They failed, because I don’t drink nor has my wife ever done,” he lamented.

De-Freitas recalled: “After the birth, as my wife was transferred to her room by 7 pm on 24th, I started to complain about the heavy bleeding, but the answer from the assisting doctors was always, ‘don’t worry, it’s normal.”

De-Freitas, a Portuguese, said the case is in the hand of the Lagos State Public Defender, who he also lamented are slow to act.“We have also reported the case to the office of the Inspector General of Police (IGP), National Assembly, Amnesty International (AI), Human Rights Commission and Lagos State Police Commissioner.

“But so far, only AI has given feedback. Right now, I have engaged other lawyers from Intermediation UK, since the office of the Lagos Public Defender are slow.”Regarding the possibility of someone actually going into shock after losing just 400ml of blood, Okunade said: “Yes. It is possible, depending on the person’s reserve prior to the surgery.”

This, he noted, is why the doctor should be aware of the patient’s blood reservoir and risk of bleeding before surgery. He added: “Some women may be at a higher risk of bleeding during and after surgical deliveries and it is imperative that some of these factors are recognised right from the time the woman is presenting for her antenatal care.”

According to experts, bleeding during pregnancy or after birth (obstetric haemorrhage) is the commonest cause of maternal deaths in Nigeria and other developing countries, accounting for a quarter of all maternal deaths, with the majority occurring after delivery.

“Bleeding after birth is regarded as post-partum haemorrhage (PPH) and this can be primary PPH if it occurs within the first 24 hours of birth, or secondary PPH if the bleeding occurs after 24 hours, but within the first six weeks of birth.

“The majority of post-partum bleeding are of the primary category, accounting for about 90 per cent of all cases, and the causes of this include, but not limited to, uterine atony, infection, retained placenta or other products of pregnancy after birth and bleeding disorders that may occur during pregnancy or during a complicated delivery.

“It is, however, pertinent to note that the vast majority of these causes are neither predictable nor preventable, thus emphasising the importance of early recognition and prompt treatment during pregnancy or delivery, so as to avoid the catastrophic and life-threatening complications of post-partum haemorrhage,” Okunade explained.