Baby’s death causes rethink of clinical advice
The death of a baby girl soon after childbirth has prompted warnings about the use of prostaglandin gel to induce labour in women who have previously suffered a perforation of their uterus.
An inquest into the death of Aurora Sleep, who died just four days after being born, has found that she would have lived if treating doctors at Mount Gambier Hospital had not tried to induce labour using prostaglandin, and had instead elected to deliver the baby by caesarean section.
Delivering the finding, South Australian Deputy State Coroner Anthony Schapel recommended that clinical guidelines be developed to warn of the risk of uterine rupture in women whose uterus has previously been perforated and who are given prostaglandin to induce labour.
“To my mind, the evidence in this case has demonstrated that the use of prostaglandin gels in the induction of labour in respect of a woman who has experienced a previous uterine fundal perforation that has not required surgical intervention poses a material risk of uterine rupture during labour,” Mr Schapel found.
The tragic death occurred when the decision was made to induce baby Aurora at 38 weeks after her mother, Ashlee Brown, 22, developed high and unstable blood pressure during the latter stages of her pregnancy.
But soon after prostaglandin gel to induce labour was applied at 8pm on 17 November, 2011, Ms Brown began to experience frequent and powerful contractions, accompanied by severe abdominal pain.
Little more than two hours later the unborn baby’s heart rate shot shot up above 180 beats per minute before dropping sharply, down to 60 beats a minute at 10.36pm.
By then experienced local GP Dr Lucie Walters, who holds obstetric qualifications, had been called and found Ms Brown “significantly distressed”, while the baby was experiencing “obvious foetal bradychardia”.
Obstetric registrar Dr Kylie Gayford was summoned at 10.52pm, and an emergency caesarean section commenced at 11.30pm. It was then found that Ms Brown’s uterus had ruptured and the baby and placenta had been forced into the abdominal cavity – fatally depriving the infant of oxygen.
The baby was subsequently resuscitated and transferred to Adelaide’s Women’s and Children’s Hospital, but the coroner concluded that by then the hypoxic brain injury was irreversible and the baby died four days later.
During the course of the inquest it became apparent that a crucial factor in the deadly chain of events was an abortion Ms Brown underwent in December 2010.
Following the termination it was found that not all material had been removed from Ms Brown’s uterus, and two months later her treating obstetrician, Dr George Olesnicky, performed a dilation and curettage procedure, during which her uterus was perforated.
Dr Olesnicky inspected the wound, which he estimated to be about eight millimetres, and found there was no significant bleeding or damage to surrounding organs. He concluded it did not requiring suturing and would heal naturally.
He ordered an ultrasound in mid-March which identified a “thinning/scarring” in the inner and middle layers of the uterus wall. In testimony to the Court, Dr Olesnicky said that he expected the uterine wall to return to full thickness, but said the presence of a scar meant the uterus would not be as strong as it was before the perforation.
Unbeknownst to Dr Olesnicky, Ms Brown soon after became pregnant with baby Aurora.
According to the coroner, the scar turned out to be the site of a fatal weakness for Ms Brown’s uterus, giving way under the pressure of the extreme contractions brought on by prostaglandin gel, and expelling baby Aurora and the placenta into the abdominal cavity with deadly consequences.
It became clear during the course of the inquest that there are sharply differing views and clinical advice about the extent of risks posed by perforations of the uterus, particularly in conjunction with the use of prostaglandin.
Dr Olesnicky, who had moved out of the area by the time of baby Aurora’s birth, was firmly of the view that uterine perforations of the kind experienced by Ms Brown precluded the use of prostaglandin gel to induce labour.
But Dr Walters, who knew of the perforation of Ms Borwn’s uterus that had occurred, did not then – and does not now – believe it prohibited the use of prostaglandin, and pose donly a small and indefinable increase in potential risk.
According to clinical advice and protocols including the South Australian Perinatal Practice Guidelines, Australian College of Rural and Remote Medicine guidelines and the Monthly Index of Medical Specialities, previous uterine surgery is among the list of contraindications for the use of prostaglandin.
But exactly what constitutes uterine surgery was not defined (in her evidence, Dr Walters said she did not consider a small perforation that did not require suturing to be surgery), and there was no indication that a uterine scar was a contraindication for the use of prostaglandin (even though, paradoxically, MIMS listed uterine scarring as a contraindication for the use of Syntocinon, another drug used to induce labour).
The coroner said that “no documentation or medical authority” was tendered to the inquest that suggested prostaglandin was contraindicated or prohibited for a women who had suffered a uterine perforation – regardless of whether or not it required surgical correction.
In testimony at the inquest, retired Professor of Obstetrics and Gynaecology Roger Pepperell put the risk that a previously perforated uterus would rupture during labour induced by prostaglandin gels at between 5 and 10 per cent.
But Coroner Schapel found that the estimate was not “directly supported by literature or by other persuasive evidence”.
But he did back Professor Pepperell’s recommendation that patients who have suffered uterine rupture – even if it did not require surgical repair – to have explained to them the risks posed by the rupture and any possible future consequences, particularly where the use of prostaglandin gel is being considered.
Coroner Schapel recommended that clinical guidelines be developed and included in the South Australian Perinatal Practice Guidelines, Australian College of Rural and Remote Medicine Rural Clinical Guidelines “relating to the risk of uterine rupture occasioned by the administration of prostaglandin gel in a woman who has had a previous uterine perforation, whether surgically repaired or not”.
“To my mind it is obvious that for the guidelines to remain as they are…would be misleading,” he said.