State blames rare condition for mother's death in childbirth
A state investigation into the death of a Medford woman during childbirth last fall at Beth Israel Deaconess Medical Center found that the medical staff was slow to identify the causes of a disturbing amount of bleeding during her delivery, but that the medical team's actions were not the cause of her death.
A report on the investigation said the state medical examiner's office concluded that the woman - whom relatives have identified as 37-year-old Karen Vasques - died of a rare condition in which amniotic fluid enters the mother's bloodstream, travels to the lungs, and often causes a fatal reaction.
In its report, which was publicly released yesterday, the Massachusetts Department of Public Health found that the patient suffered an unusual degree of bleeding because the placenta prematurely separated from the uterus, known as an abruption, and that her blood was not clotting properly. Doctors ultimately delivered the baby during an emergency caesarean section. State investigators said hospital staff should have recognized the placenta problem earlier, based on the extent of bleeding and blood test results, and that "earlier diagnosis with more prompt and extensive blood product administration would likely have improved her status."
The report goes on to say, however, that the autopsy found that the patient died Oct. 17 of a "pulmonary amniotic fluid embolism," a highly unusual condition that is widely believed by obstetricians to be unpreventable.
Because the condition is so rare, occurring in about 1 in 10,000 deliveries, there is little solid research about its causes, but some obstetricians believe it may be associated with more complex deliveries.
Dr. Kenneth Sands, senior vice president of healthcare quality at Beth Israel, said in an interview yesterday that the hospital is always "looking for opportunities to do better." The report said the hospital has already added more education for its staff on signs of abruption, as well as blood clotting issues. Later, in a released statement, Sands said the patient's death "was the result of a rare and unpredictable complication of pregnancy."
"This was obviously a very sad and distressing event for our staff at Beth Israel Deaconess Medical Center who had not experienced a loss like this for over 10 years."
The baby, Elise, survived and is being cared for by her father, Derek, relatives said.
A spokesman said the family had no comment at this time and will be reviewing the report. 