A WOMAN WHO died hours after giving birth by caesarean section suffered a “catastrophic” internal haemorrhage in which almost half the blood in her body pooled into one area.
An inquest in Tralee into the death of Tatenda Mukwata, who died at University Hospital Kerry on 21 April last year, was told that two litres of blood had gathered in one part of her abdomen, where a body typically holds up to five litres.
Mukwata, 34, had been a resident at the Atlantic Lodge direct provision centre in Kenmare but had been granted permission to stay in Ireland shortly before her death.
She gave birth to her daughter, Eva, at the hospital at 7.48pm on 20 April last year only to die in the early hours of the following day.
Dr John O’Mahony, SC for Mukwata’s family, argued that warning signs were present in the hours prior to her death that would have indicated a huge internal bleed, namely plummeting haemoglobin levels, her pulse rate and an “alarming” drop in her blood pressure levels.
However, the inquest, before Coroner Helen Lucey and an 11-strong jury, was told that Mukwata suffered an arterial venuous malformation (AVM) – a rare occurrence where a vein and an artery running closer to each other can be punctured or torn and results in the blood from one running into the other.
However, the inquest also heard that arterial venous malformations usually go unnoticed until they rupture and one witness, Dr Peter Kelehan, said he believed this was a pre-existing condition in Mukwata, pre-dating not just the delivery of the baby, but the entire pregnancy.
Dr Kelehan – a consultant perinatal pathologist who, alongside Asst State Pathologist, Dr Margot Bolster, reviewed the case – said one possibility was that sutures used to stitch Mukwata following the Caesarean section may have ruptured the pre-existing AVM, causing the bleed.
Mukwata’s mother, Catherine, and her children Munashe, Rutendo, Sherley and Eva, were present for the opening of the inquest, with Rutendo confirming that she had identified her mother to gardai following the death at the hospital.
Next Dr Bolster gave evidence from autopsy, referring to the two litre clot in the abdomen, centred in the pelvic region, with other clots also evident elsewhere in the abdomen. The woman had died from haemorrhage and shock, she said.
Dr Bolster said she found no evidence of sepsis or any other cause of the bleeding, which had taken place on the operative side of the abdomen.
Dr Bolster said she and Dr Kelehan had carried out a histological review of samples taken from Mukwata, indicating the presence of an AVM which had ruptured.
“I knew there was an abnormal area and this is where the clot was centred,” she said. “It is my opinion that caused the bleeding.”
Dr O’Mahony, cross-examining, said the literature did not suggest an AVM causing death in such rapid circumstances and that instead there was evidence they happened weeks or months afterwards.
Dr Bolster said they were rare, describing what occurred as a “massive, catastrophic bleed”. She said she could not cite a precedent where the event had occurred within hours of a c-section as “they are so rare”.
Dr O’Mahony said: “The family is concerned, for example, that at 9.30pm on the day of death of Tatenda Mukwata, the signs were obvious that there was a serious haemorrhage and bleed taking place.”
He said that where a normal blood pressure reading is 120/80, Mukwata’s reading at 9.20pm was 106/52, which he said was “alarmingly low”. By 11.25pm it had fallen to 64/44.
Dr O’Mahony also said haemoglobin levels had fallen from a typical reading of 10 to just 2.8 within hours of the birth, a level “inconsistent with life”.
Dr Kelehan said he had seen a number of AVMs in his professional life, beginning with one on the head of a person who had been hit at an earlier stage with a Hurley. He said AVMs are often only seen when they bleed.
He said his opinion was that in this case it was “the arterial venous malformation that pre-existed this pregnancy that caused haemorrhaging and the patient’s death”.
Dr Kelehan said it was very rare for an AVM to exist in the uterus, adding: “It can be discovered but you have to know to look for it.”
When they are close to the site of an incision, he said sutures – since they have to extend beyond the limits of any wound – could wrap themselves around a vein or artery in an AVM, causing it to rupture in what he described as a “ pseudo aneurysm”.
The inquest was then adjourned and is set to resume at 10.30am on 25 September, with another three days after that set aside for it to be heard.
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