Incidents of catastrophic overhydration (maternal and neonatal) identified through medico-legal reviews.

The authors describe two incidents where a mother postpartum and a neonate in the nursery were grossly overhydrated in tertiary care medical centers. In the first case, while receiving intensive care for HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome, involving the participation of eight specialists and subspecialists, the weight of the mother increased by 54% between the 2nd and 8th postpartum days. In the second case, between the time of his birth and his demise 13 days later, the weight of the newborn child increased by 67%. In neither of these cases, was the significance of grossly excessive hydration recognized as a problem either during the management or in retrospect. Only the subsequent medico-legal reviews drew attention to the fact that, in both instances, the participating consultants had ordered the infusion of large quantities of fluids independently of one another without making an attempt to coordinate their activities. The resident and nursing personnel uncritically implemented all of their instructions.