Table 6 The summarised clinical details of index patient 007

A 34-year-old Para 3 Gravida 4 mum presented to a level-2 local hospital in early labour. She had two visits to the clinic during her pregnancy and antenatal assessments did not reveal any abnormalities. Her haemoglobin level was normal in the antenatal records. She was diagnosed HIV positive in this pregnancy and had been started on antiretroviral therapy in the third trimester as per the protocol for prevention of mother to child transmission. Her CD4 count was recorded at 521 cells/mm³. Prolonged first and second stage of labour was noted with early decelerations annotated on the cardiotocograph. Attempts to allow the labour to progress resulted in further decelerations being noted and a late decision was made to proceed with caesarean section under spinal anaesthesia. The obstetrician reported that the operation was difficult (due to adhesions and scarring of the uterus from two prior caesarean sections) requiring extension of incisions and more than 40 min before extraction of the hypotonic male infant. Maternal hypotension was documented during the delivery. The post-operative maternal haemoglobin level was measured at 7.8 g/dL indicating that the mum suffered severe blood loss. The Apgar scores were calculated as 0/10 at 1 min and 1/10 at 5 min with severe metabolic acidosis (Base excess of − 11.8) on cord blood gas. The child required intubation and ventilation. The neonatal blood glucose levels and other electrolytes were normal. Unfortunately, due to the local lack of expertise and imaging services, there was no early neonatal imaging available. MRI was performed at the age of 6 years. See Fig. 2