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Appendix A: Summary of cases examined in 2019
Summary of 2019 case reviews
Case | Type | Summary | Themes | Recommendations |
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EX-01 | Maternal Executive | The decedent was a 35-year-old woman who had a witnessed arrest 12 days after the delivery of her second child. She had a history of gestational hypertension and obesity. Cause of death was intra-abdominal bleeding from an unknown source during the postpartum period. | n/a | None |
EX-02 | Maternal Executive | The decedent was a 34-year-old woman who had gestational diabetes. She was two months post-partum with her first baby when she developed shortness of breath and a cough. The decedent had a severe presentation of peripartum cardiomyopathy and that she may have had a concurrent pulmonary infection. Cause of death was peripartum cardiomyopathy. | OCP, Transfer OCP, transfer |
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EX-03 | Maternal Executive | The decedent was a 37-year-old G3P1. Emergency Caesarean section was performed after she collapsed and became unresponsive. Cause of death was attributed to amniotic fluid embolus. | n/a | None |
EX-04 | Maternal Executive | The decedent was a 34-year-old woman who had delivered a normal full-term pregnancy approximately seven weeks previously. She had suffered a superficial clot in her right leg about one week post-partum and Doppler testing showed no deep vein thrombosis. Her routine six week post-partum check-up was normal and she was given a requisition to have a follow-up Doppler. The day prior to her death she saw her family physician regarding a possible nipple infection. She was found unresponsive, sitting in a padded chair in the baby's room, with the baby in her lap. It appeared that she was breast-feeding when her death occurred. Cause of death was undetermined. | n/a | The next-of-kin were advised to be assessed in a cardiovascular genetic clinic. |
EX-05 | Maternal Executive | The decedent was a 35-year-old woman. When admitted to hospital for induction of labour, she began to vomit. Emergency Caesarean section was performed due to fetal bradycardia. Cause of death was amniotic fluid embolism. | n/a | None |
EX-06 | Maternal Executive | The decedent was a 33-year-old woman who was in her first trimester of pregnancy. The decedent had a long-standing history of mental health issues which began when she was a teenager. Approximately five years prior, she had been treated for trauma and a substance use disorder. Cause of death was noted as fentanyl toxicity. | n/a | None |
EX-07 | Maternal Executive | The decedent was a 33-year-old G4P2 with a history of asthma for many years and had been experiencing more pronounced dyspnea in the previous month. Cause of death was Intrapartum Hemorrhage due to Caesarean Section/Emergent Hysterectomy for the Management of Placenta Increta. | n/a | None |
EX-08 | Maternal Executive | The decedent was a 24-year-old G1P1 with type 1 myotonic dystrophy. On post-partum day 5, she presented to her family physician with retrosternal chest pain and was diagnosed with acute coronary syndrome. She was transferred to the heart institute where she underwent urgent cardiac catheterization that showed multiple areas of spontaneous coronary artery dissection. Cause of death was multi-organ failure due to left ventricular dysfunction due to healed myocardial infarctions due to healed spontaneous coronary artery dissections in the context of myotonic dystrophy (Type 1) cardiomyopathy. | n/a | None |
EX-09 | Maternal Executive | This case involved the death of a 33-year-old G2P0. Her pregnancy had been unremarkable until the development of elevated blood pressure in the third trimester. She was diagnosed with preeclampsia at 37 weeks. Cause of death to be acute post partum blood loss in a woman with idiopathic pulmonary arterial hypertension. Genetic testing revealed a variant of uncertain significance in GDF2. | n/a | None |
EX-10 | Maternal Executive | The decedent was a 31-year-old woman who was in her first trimester of pregnancy when she was the victim of an assault that resulted in her death. | n/a | None |
EX-11 | Maternal Executive | The decedent was a 32-year-old woman with a long-standing history of intravenous drug use and who was on a methadone program. She had no fixed address and did not have any prenatal care. Cause of death was attributed to Staphylococcal septicemia due to infective endocarditis due to intravenous drug use. | n/a | None |
EX-12 | Maternal Executive | The decedent was a 37-year-old woman who was 44 days postpartum following a delivery that was complicated with shoulder dystocia and lateral vaginal wall tear. Post partum haemorrhage began during repair of the vaginal wall tear. A cardiac arrest occurred during attempts to remove retained products of conception and effect tamponade. Amniotic fluid embolism was the cause of the shock and postpartum bleeding. | n/a | None |
EX-13 | Maternal Executive | The decedent was a 42-year-old G2P1 with a past medical history of metastatic breast cancer. In 2015, bilateral metastases to her lungs was found and she underwent resection. The woman died from tumour lysis syndrome secondary to acute leukemia, with secondary contributing condition of metastatic breast cancer; specific relationship to her pregnancy was not identified. | n/a | None |
M-01 | Maternal | The decedent was a 37-year-old G4P3. History of previous deep vein thrombosis (DVT). She died from a pulmonary embolus and right leg DVT. Thrombo-prophylaxis was indicated, but was not implemented. | OCP, diagnosis and testing OCP, diagnosis and testing |
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M-02 | Maternal | The decedent was a 32-year-old primigravida. Risk factors included: pre-pregnancy BMI 34.4 (height 6'1" and weight 250 lb), polycystic ovary syndrome (PCOS), low lying placenta (1.8 mm, repeat ultrasound in October 2016, clear of cervix), urinary tract infection (at 17 weeks treated with Macrobid), Group B streptococcus positive and it was noted on her anaesthestic questionnaire that she bruised easily. Cause of death was pulmonary arterial hypertension. | OCP, diagnosis and testing Training/ Education, Quality |
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M-03 | Maternal | The decedent was a 33-year-old G3P2. A non-invasive prenatal test (NIPT) was done and was subsequently reported as concerning for Klinefelter syndrome. Amniocentesis was declined. Death was attributed to hemoperitoneum due to placenta percreta invading through the previous Caesarean section scar. | OCP, Diagnosis and testing Diagnosis and testing |
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M-04 | Maternal | The decedent was an obese (pre-pregnancy BMI of 36) 37-year-old G3 TPAL 1011 who had a dichorionic diamniotic twin pregnancy by in vitro fertilization. The cause of death was determined to be “hemorrhagic shock” due to “intrauterine hemorrhage, post Caesarean twin delivery with concurrent myomectomy for uterine leiomyoma (fibroid). | n/a | None |
M-05 | Maternal | The decedent was a 20-year-old G2P0 who died suddenly at 34 weeks and one day gestation. It was subsequently reported by the family that the woman had been experiencing swelling and tingling of her hands and feet in the last 1-2 weeks and a headache for three days prior to her death. Cause of death was sudden unexpected death in pregnancy with findings suggestive of a hypertensive disorder of pregnancy (preeclampsia). | n/a | None. |
M-06 | Maternal | The decedent was a 31-year-old G6P6. Cause of death was noted as complications of endometritis and retained products of conception. She was five days post partum. | n/a | None |
M-07 | Maternal | The mother was a 23-year-old G7 TPAL 2224 First Nations woman. Cause of death was septic and hemorrhagic complications of acute chorioamnionitis due to preterm premature rupture of membranes and ascending infection with Escherichia Coli. It was felt that the fetus had a “rare but distinctive pattern” of severe, fulminant intrauterine E. coli infection due to the ruptured membranes. The infection went from fetus to placental villi without significant infection of the membranes as would be typical of chorioamnionitis. | Other Other Other |
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M-08 | Maternal | The decedent was a 37-year-old G6P4A1 with a history that included multiple trauma’s, chronic pain syndrome, depression, hepatitis B and past hepatitis C and opioid use disorder. Cause of death from gestational Staphylococcus aureus septicemia. The septicemia resulted in the in utero fetal demise through the overall process of multi-organ damage. Although the skin culture grew different organisms, the puncture of the upper left arm showed histologic features of a drug injection site, with evidence of healing, and was likely the original entry point for the bacteria. | OCP, Diagnosis and testing |
|
N-01 | Neonatal | The mother of the deceased infant was a 26-year-old G2P0. Cause of death was multi-organ hypoxic-ischemic complications of perinatal asphyxia of undetermined cause. | n/a | None |
N-02 | Neonatal | The mother of the deceased infant was a 24-year-old G3 TPAL 0110. Newborn exam revealed a morphologically normal, appropriately grown 23 weeks 2 days’ gestational age fetus with fused eyelids. Previable Delivery Occurring at 23 Weeks, (a) Maternal Cervical Incompetence | Transfer OCP, Diagnosis and testing |
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N-03 | Neonatal | The mother of the deceased infant was a 33-year-old G2P1 receiving care from a midwifery practice. Cause of death was Hypoxic-Ischemic Encephalopathy at three days of age. | OCP, Diagnosis and testing OCP, Transfer Quality |
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N-04 | Neonatal | This case involved the death of a four-day-old male infant from hypoxic ischemic encephalopathy due to perinatal asphyxia. Concerns were raised about the obstetrical care provided to the infant’s mother. | OCP, Training/ education OCP, Diagnosis and testing OCP, Diagnosis and testing |
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N-05 | Neonatal | The mother of the deceased female infant was a 19-year-old G2 TPAL 1001. This baby died due to cardiac changes resulting from a narrowing of the aorta known as coarctation. Metabolic and cardiovascular genetic testing indicated variants of undetermined significance. Toxicology was positive for methadone, diphenhydramine and tetrahydrocannabinol (cannabis). | Diagnosis and testing Other |
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N-06 | Neonatal | The deceased infant was born at 38 weeks and five days’ gestational age (GA) to a 26-year-old G1 TPAL 0000. The cause of death was determined to be due to the extensive blood loss and multiorgan failure from a large subgaleal hemorrhage caused by the vacuum used to assist in the vaginal delivery. | OCP, Comm/Doc Training and education OCP, Diagnosis and testing Policy and procedures Comm/Doc Diagnosis and testing |
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N-07 | Neonatal | The mother of the deceased infant was a 36-year-old G1P0. This pregnancy was conceived through in vitro fertilization (IVF). Cause of death was attributed to multiple placental pathologies and subgaleal and intracerebral hemorrhages in the context of arrested second stage of labour and instrumentation. | OCP, Comm/Doc Policy and procedure OCP, Policy and procedure OCP, Diagnosis and testing OCP, Transfer, Diagnosis and testing Quality |
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N-08 | Neonatal | The mother of the deceased was a 33-year-old G6 P4 woman with four previous full-term deliveries. Lab results and post mortem examination revealed the cause of death to be disseminated herpes simplex infection with sepsis syndrome. Herpes simplex Type II was detected in the baby’s blood as well as post-mortem specimens from lung, liver and brain. | Education and training Comm/Doc |
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N-09 | Neonatal | The mother of the deceased infant was a 19-year-old unemployed single woman with financial difficulties. Cause of death was complications of perinatal asphyxia. | Diagnosis and testing Diagnosis and testing Comm/Doc Training and education |
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N-10 | Neonatal | The mother was a 27-year-old G4T3P0A0L2S0N1 0-positive Indigenous woman . Cause of death was determined to be natural recurrent fetal maternal hemorrhages with secondary brain injury, in the context of in utero growth restricting at full term gestation. | n/a | None |
N-11 | Neonatal | The mother was a 29-year-old G1P0. Cause of death was hypoxic-ischemic encephalopathy due to perinatal asphyxia of undetermined cause. | OCP, Diagnosis and testing |
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S-01 | Stillbirth | The mother was a 31-year-old healthy G1 TPAL 0000. The mother wanted to have a vaginal breech delivery and sought out the care of a midwife that would provide the service. However, after the delivery, the mother expressed concerns about the lack of understanding of the risks of vaginal breech delivery. | OCP, Diagnosis and testing OCP, Diagnosis and testing OCP, Diagnosis and testing OCP, Diagnosis and testing |
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S-02 | Stillbirth | The mother of the stillborn was a 41-year-old G11T10P0A0 L10. The mother presented to hospital with a placental abruption. She had sustained significant hemorrhage, having lost an estimated 1L of blood at home. She continued to bleed in hospital. | OCP, Diagnosis and testing OCP, Diagnosis and testing (EFM) Diagnosis and testing, Comm/Doc Quality |
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Full, redacted versions of reports and responses to recommendations are available to the public by contacting: occ.inquiries@ontario.ca.
Updated: January 15, 2024
Published: August 13, 2021