The information presented in this report was obtained from a review of the records of Mills Memorial Hospital and St. Paul's Hospital, interviews with family members and hospital personnel at Terrace, discussions with a certified gynecologist and anaesthetist, and a conversation with Dr. G. Boyd. . The autopsy report, report of examination of the products of conception and a toxicology analysis report were also available.

Myrna George, born on September 21, 1971, was admitted to hospital in Terrace, B.C. on September 10, 1991, and died on September 14, 1991, at St. Paul's Hospital in Vancouver, British Columbia. This 19 year old patient had had two live births, one spontaneous and two therapeutic abortions. A date of the last menstrual period could not be definitely determined for this sixth pregnancy. An ultrasound examination on August 31 indicated a gestation of thirteen weeks. There was a past history of alcohol abuse. Myrna had requested an abortion as she had been abusing alcohol and Tylenol during this pregnancy and also felt she was unable to look after another child.

Dr. G. Boyd after examination on September 9 agreed with therapeutic abortion. Previous therapeutic abortions had been performed in 1986 and 1987. A D&C had been performed following a spontaneous abortion in 1989. Her weight was 105 pounds and height 1.49 metres. Her pre-operative hemoglobin was126.

1225 hours - Operation commenced. During the operation, the blood pressure varied between 100 to 110 systolic and 70 to 80 diastolic. The anaesthetic agent was Enflurane. The bladder was emptied during the procedure. The estimated gestation on examinat ion under anaesthesia was fourteen weeks. The cervix was dilated and then a suction curet, ovum forceps and large sharp curet were used to empty the uterus. A Syntocin drip was commenced. The blood loss was estimated at between 600 and 800 cc and was described as excessive. 1000 cc of Ringer's lactate was commenced.

1330 hours - 'In the recovery room, the patient's blood pressure was approximately 88/50, pulse 84. The patient was described as having cramps.

1400 hours - The patient was moved to a hospital ward. Here the blood pressure was 96/58, pulse 92 and respirations 22. The patient was described as doubled over clutching abdomen, pale but drinking. Demerol and Gravol were administered.

1425 hours - Blood pressure 84/37, pulse 67. Up to void but became dizzy and eyes rolling up. Very pale,

1430 hours - Up at bedside again.

1435 hours - Patient not responding to pain. Dr. Boyd aware.

1445hours - Blood pressure 100/43. Alert, very pale, oxygen started.

1515 hours - Dr. Boyd examined.

1528 hours - Hgb 76.

1620 hours - Blood pressure 85/33, pulse 90, temperature 34.8. Pulse thready. Supervisor aware.

1635 hours - First blood pumped, infusing fast.

1700 hours - Blood pressure 86/35, pulse 72, respiratory rate 40. Dr. Chorn notified. Having abdominal pain.

1710 hours - Blood pressure 90/40, pulse 97. Moderate blood loss. Respirations easy.

1725 hours - Blood pressure 85/38, pulse 117. Pulse irregular, oxygen by mask. First unit of blood absorbed.

1745 hours - Blood pressure 55/35, pulse 148. Pulse irregular, oxygen by mask.

1810 hours - Blood pressure 56/34, pulse 140, temperature 33. Pulse irregular.

1820 hours - Dr. Chorn examined. Dr. Boyd notified by nurse.

1335 hours - Second unit in.

1845 hours - Blood pressure 70/50, pulse 140. Saline running rapidly between blood infusions.

1900 hours - Blood pressure 70/50, pulse 144, respiration rate 36-40. Dr. Boyd to see.

1920 - 1940 hours - Blood pressure 80/40. Dr. Chorn told Dr. Boyd in. Hgb 74. Third unit in. Note written "ICU full''. Catheterized for 10 cc.

2000 hours - Blood pressure 60/-, pulse 152. Dr. Boyd still present. Passing small clots. Restless, very pale.

2030 hours - Blood pressure 80/40, pulse 150. To ICU. Restless. Abdomen firm and distended.

2040 hours - Blood pressure unable to obtain. Pulse 170, respiration rate 34. Confused, restless, pale. Dr. Grant called. Examined and ordered. Dr. Chorn notified. Fourth unit in.

2100 hours - Blood pressure 80/50, pulse 140. Hgb 82.

2130 hours - Blood pressure 82/50, pulse 98. More comfortable. Urine output 20 cc.

2145 hours - Blood pressure unable to obtain. Abdomen firm and appears distended. Drowsy and restless. Dr. Chorn arrived and ordered. Fifth unit in. Dr. Boyd contacted by Dr. Chorn requesting reassessment.

2230 hours - Blood pressure unable to obtain, pulse 160 on monitor, respiration rate 30-40. Pale, severe abdominal pain. Dr. Boyd phoned by nurse.

2240 hours - Blood pressure unable to obtain, pulse 165. Difficult to arouse airway inserted. Respirations 40-50. Supervisor phoned Dr. Chorn phoned. Lab and OR supervisor phoned. Sixth unit in.

2320 hours - Dr. Chorn takes patient to OR.

Operation-#2

Between the completion of the first operation and this second operation, the patient received seven units of packed cells and 5100 cc of crystalloid fluid. The urine output over the ten hours was 270 cc.

At 2340 hours the patient was in the operating room receiving intravenous blood and crystalloid fluids. When the abdomen was opened, Dr. Chorn estimated a discharge of three litres of blood. Dr. Boyd mentions in his operative report a measured quantity of 800 cc of blood. During the first hour of the operation, the patient's blood pressure rose steadily to 120 systolic and the pulse fell to 120 beats per minute. The rent in the uterus was sutured. During this first hour the urine output was between 300 and 400 cc.

At 0055 hours, when the operation was one hour and twenty minutes mature, there was a sudden vascular collapse with the anaesthetist reporting ventricular tachycardia. Dr. Peter Hoy and Dr. Grant, who was called to the operating room at 0120 hours, assisted with resuscitation. The resuscitative measures included defibrillation. At 0240 hours, there is mention of abandoning an attempt at inserting a central venous pressure catheter. The patient left the operating room at 0250 hours. During this operation, the patient received eight units of packed cells and 5500 cc of intravenous fluids. The urine output following the first hour of the operation was 700 cc; that is a total urine output of in excess of 1000 cc during the second operation.

September 12-14, 1991

0250 hours - Returned to ICU from the OR.

For a number of hours folloiwing discharge from the operation room there had been no urine output, the pulse had been over 160 and a blood pressure could not be obtained.

A review of nurses' notes and physicians' progress notes during the next 24 hours indicates that the patient remained comatose with fixed dilated pupils. She was managed on a respirator with large quantities of IV fluids, diuretics and Dopamine in order to maintain a blood pressure and some urine output. There was evidence of the development of a coagulopathy and severe metabolic acidosis. Fresh frozen plasma and platelets had been administered. A chest x-ray showed the changes of pulmonary edema. The hgb had risen to 151.

The following day, Septembear 13, there was some sluggish pupillary reaction and reaction to painful stimuli. After a Swanz-Ganz catheter had been introduced, larger quantities of fluid were administered to attempt to obtain a more reasonable urine output. Blood pressure was maintained over 110 systolic, pulse was over 140 and temperature 38.7. There was marked edema.

On September 14, the condition deteriorated and a blood pressure could not be obtained after 1255 hours. The pulse was over 145. The patient was transferred to St. Paul's Hospital. During transfer the pulse was over 140 and with Dopamine the systolic blood pressure was approximately 95. Forty-five minutes after admission there was a cardiac arrest and the patient was pronounced two hours later.

Summary

The results of autopsy by forensic pathologist Dr. L. H. Gray, of the examination of the products of conception by Dr. G. Taylor and of the toxicological analyses are attached. The cause of death is:

Discussion
Family

Mrs. George does not believe that the danger of the fetus being affected by the alcohol intake of Myrna during the first trimester of this pregnancy was sufficient indication to perform an abortion. She points to Myrna's two children whom she believes have not been born with any affliction due to intrauterine exposure to alcohol.

Mrs. George has requested a copy of the autopsy report and I have indicated that this report could be taken to her physician for an explanation of medical terms.

Myrna's mother is upset by what she believes was a misleading statement by Dr. Boyd immediately following the second operation and it was only after talking with Dr. Chorn that the true serious nature of Myrna's condition was learned. Dr. Boyd states in his operative report that "it was also explained to the family what was happening to the patient in the early morning hours of September 12th and they were present to see her being transferred to the ICU". Dr. Boyd has stated that he does not recall speaking to family members after the second operation but left this to Dr. Chorn.

The Community

Recently a mentally disabled patient died in the Mills Memorial Hospital due to undiagnosed diabetic ketoacidosis. This case had been reviewed to determine if multiple physicians and nurses had demonstrated a lack of responsibility or knowledge in the care of this patients. Now we have a native Indian patient dying following a therapeutic abortion and the community might be concerned that there is a double standard of medical care in Terrace; however, it is my opinion that this investigation can exclude this possibility. The case under investigation does not demonstrate any evidence that there was a lack of responsibility shown by multiple members of the medical team.

The Medical Care

It is my opinion that the most significant factor in the outcome was the delay in the recognition of post-operative hemorrhage due to the uterine rupture. The responsibility for the recognition of hemorrhage in this period rests with the gynecologist performing the operation. In conversation with Dr. Boyd regarding the report of Dr. Chorn tha,t "Dr. Boyd felt we would continue fluid management and that he would reassess the patient in the morning", Dr. Boyd states in his dictated report, "We discussed the case on the phone and selected to watch to see if another two units of blood would improve the situation." One must note that Dr. Boyd has a different recollection of some of the events than those set out in the hospital records.

Excessive vaginal bleeding occurred at the time of the therapeutic abortion on the morning of September 11. This is more likely to occur with a longer gestational period. It has not been the practice in this hospital to employ measures to "ripen" the cervix for therapeutic abortion. Chronic alcoholism by damaging liver function can cause an increased tendency to bleed but it is unlikely this was a factor in the case of Myrna George. An analysis of an antemortem blood specimen collected from this patient prior to her surgery revealed the presence of salicylates. There is information indicating that salicylates taken during pregnancy can be associated with an increased tendency for the mother to bleed (see attached).

It would be important for the medical staff to review this case regarding the monitoring of a patient who is in shock due to hemorrhage and the treatment of acute blood loss. During the first hour of the second operation the urine output was over 300 cc and unless one considered this due to high output renal failure, it would suggest that an adequate circulating blood volume had been restored. Although the prolonged period of ischemia prior to the second operation set the stage for the serious cardiac arrhythmia and ultimately irreversible multi-organ failure, one could also consider that overload was a possible contributory factor to this arrhythmia.

James Lynch
Coroner

Recommendations

1. To:

The College of Physicians and Surgeons
1807West 10th Avenue
Vancouver, BC
V6J 2A9

2. To:

Chief Of the Medical Staff
Mills Memorial Hospital
4720 Haugland Avenue
Terrace, BC
V8G 2W7

3. To:

Hon. Elizabeth Cull
Minister of Health
Parliament Buildings
Victoria, BC
V8V 1X4

James Lynch
Coroner