Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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96 6 Early pregnancy deaths receive thromboprophylaxis. Autopsy showed fl uid in body cavities and patchy infarction throughout the body, including bowel. Women admitted to hospital with severe ovarian hyperstimulation syndrome should receive thromboprophylaxis. 2 Box 6.1 Learning points: early pregnancy deaths Clinicians in primary care and Emergency Departments, in particular, need to be aware of atypical clinical presentations of ectopic pregnancy and especially of the way in which it may mimic gastrointestinal disease. This needs to be taught to undergraduate medical and nursing students and highlighted in textbooks. Fainting in early pregnancy suggests the possibility of ectopic pregnancy. More conservative approaches to the treatment of ectopic pregnancy should not blind clinicians to the dangers of this condition. Laparoscopy or laparotomy should be undertaken without delay if there are clinical signs suggestive of tubal rupture. Medical treatment of ectopic pregnancy should be based on strict adherence to protocols, with women having immediate access to in-patient facilities if complications occur. Illegal, unsafe abortion is common globally; it can occur in the UK. Acknowledgements This Chapter was seen and discussed with Dr Davor Jurkovic (London). References 1 RCOG Guideline No. 21. The Management of Tubal Pregnancy. London: Royal College of Obstetricians & Gynaecologists; May 2004. www.rcog.org.uk 2 RCOG Green-top Guideline no. 5. The Management of Ovarian Hyperstimulation Syndrome. London: Royal College of Obstetricians & Gynaecologists: September 2006. www.rcog.org.uk
7 Genital tract sepsis Ann Harper Genital tract sepsis: Specifi c recommendations All health professionals must be aware of the symptoms and signs of maternal sepsis and critical illness and of the rapid, potentially lethal course of severe sepsis and septic shock: Maternal tachycardia, constant severe abdominal pain and tenderness are important early features of genital tract sepsis that should prompt urgent medical review. All maternity units should have guidelines for the investigation and management of genital tract sepsis. If sepsis is suspected, regular frequent observations should be made and use of the Modifi ed Early Obstetric Warning core (MEOWS) as recommended by this Report is crucial. High dose broad-spectrum intravenous antibiotic treatment should be started immediately sepsis is suspected, without waiting for microbiology results. Summary of key fi ndings for 2003-05 Twenty-two women died in this triennium from genital tract sepsis. Of these, 18 Direct deaths are counted in this Chapter. A further Direct death from sepsis following an illegal abortion, is counted in Chapter 6 - Early pregnancy deaths. The remaining three were Late deaths which occurred more than six weeks after delivery, outside the international defi nition for maternal deaths. These Late Direct deaths are counted in Chapter 14 but are discussed here. Genital tract infection was also a leading co-factor in a further Late Direct death which was attributed to thromboembolism associated with an infected retained vaginal tampon. Table 7.1 Direct deaths associated with genital tract sepsis and rate per 100,000 maternities; United Kingdom: 1985-2005. Triennium Sepsis in early pregnancy* Puerperal sepsis Sepsis after surgical procedures Sepsis before or during labour All Direct deaths from sepsis counted in this chapter Direct deaths from sepsis counted as early pregnancy deaths Late deaths** from sepsis Number Rate 95 per cent CI Number Number 1985-87 3 2 2 2 9 0.40 0.21 0.75 0 0 1988-90 8 4 5 0 17 0.72 0.45 1.15 0 0 1991-93 4 4 5 2 15 0.65 0.39 1.07 0 0 1994-96 0 11 3 1 16 0.73 0.45 1.18 2 0 1997-99 6 2 1 7 18 0.85 0.54 1.34 0 2 2000-02 2 5 3 1 13 0.65 0.38 1.11 2 0 2003-05 5 3 2 8 18 0.85 0.54 1.35 1 3 * Early pregnancy includes deaths following miscarriage, ectopic pregnancyand other causes. ** Late deaths are not counted in this Chapter or included in the numerator. 97
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Confidential Enquiry into Maternal
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Saving Mothers’ Lives: Reviewing
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Contents Maternal deaths Indirectly
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Foreword Having a baby is a joyous
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The ‘top ten’ key recommendatio
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Migrant women 4. All pregnant mothe
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Clinical skills 7. Maternity servic
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Early warning scoring system 9. The
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References 1 Redshaw M, Rowe R, Hoc
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Working together to save mothers’
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Severe maternal morbidity, “near
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At a national level In every countr
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Table 1 Defi nitions of maternal de
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For the past nine years, ONS have b
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Chapter 1 Which mothers died, and w
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Key fi ndings for 2003-05 Maternal
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Figure 1.1: Overall maternal mortal
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Coincidental deaths The deaths of 5
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Leading causes of maternal deaths:
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Table 1.5 Maternal deaths by gestat
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Table 1.7 Number of maternal deaths
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of note is that every women who die
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Table 1.11 Numbers and percentage o
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These messages are repeated in many
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Doctors may need specifi c training
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Table 1.13 Total number of Direct a
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Ovarian hyperstimulation syndrome (
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The obese women who died From the n
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Pre-pregnancy counselling and weigh
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Table 1.19 Direct and Indirect mate
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double the number of cases in the l
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was ill and he should take her to a
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Table 1.22 Characteristics of the a
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Most staff reported learning clinic
Page 73 and 74: exception. The health service has a
Page 75 and 76: 17 Shah A, Sands J, Kenny L. Matern
Page 77 and 78: Country of birth and migration A fa
Page 79 and 80: Table A1.4 Direct and Indirect deat
Page 81 and 82: Body mass index varies with age, be
Page 83 and 84: 2 Thrombosis and thromboembolism Ja
Page 85 and 86: Pulmonary embolism Of the 33 women
Page 87 and 88: Family history In two deaths there
Page 89 and 90: vigilance and take symptoms serious
Page 91 and 92: Deaths after caesarean section Seve
Page 93 and 94: of pregnancy, seven had identifi ab
Page 95 and 96: Annex 2.1 Summary of the key recomm
Page 97 and 98: The grades of recommendations (B or
Page 99 and 100: High risk patients Patients assesse
Page 101 and 102: Table 3.2 Numbers of deaths from pr
Page 103 and 104: publication from the United States
Page 105 and 106: References 1 Knight M, Kurinczuk JJ
Page 107 and 108: obstetricians and anaesthetists rou
Page 109 and 110: Detailed guidelines for the managem
Page 111 and 112: acute bleeding situation although i
Page 113 and 114: References 1 Brace V, Penney G, Hal
Page 115 and 116: Table 5.1 Direct deaths attributed
Page 117 and 118: of over ten litres. Despite a hyste
Page 119 and 120: References 1 Clark SL, Pavlova Z, G
Page 121 and 122: The women who died The ages of the
Page 123: A woman who had not been long in th
Page 127 and 128: Sepsis in early pregnancy Six women
Page 129 and 130: Box 7.3 Learning points: Sepsis in
Page 131 and 132: Risk factors for, and the identifi
Page 133 and 134: Box 7.7 Features of septicaemic sho
Page 135 and 136: 8 Anaesthesia Griselda Cooper and J
Page 137 and 138: The third case also highlights the
Page 139 and 140: A woman suffered a concealed haemor
Page 141 and 142: Sepsis Poor anaesthetic or resuscit
Page 143 and 144: What did you learn from this case a
Page 145 and 146: 9 Cardiac disease Catherine Nelson-
Page 147 and 148: Table 9.2 Causes of maternal death
Page 149 and 150: an estimated incidence of 1.1 per 1
Page 151 and 152: Quality of care Care was considered
Page 153 and 154: y a doctor, with a systolic blood p
Page 155 and 156: Box 9.3 Learning points: peripartum
Page 157 and 158: Infectious endocarditis Two women d
Page 159 and 160: 10 Other Indirect deaths Michael de
Page 161 and 162: Table 10.1 Causes of Other Indirect
Page 163 and 164: Fifty-eight of the eighty-seven wom
Page 165 and 166: Previous Reports have emphasised th
Page 167 and 168: Aspergillosis usually occurs in imm
Page 169 and 170: Liver disease There were four mater
Page 171 and 172: Diseases of the circulatory system
Page 173 and 174: 11 Cancer and other tumours Gwyneth
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her delivery, but her case should h
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Severe abdominal and back pain, sci
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References 1 Drife, J O. The contri
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Psychiatric deaths: Specifi c recom
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cut off point for maternal deaths,
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Report, 26 deaths from suicide were
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Current psychiatric treatment In th
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12 Deaths from psychiatric causes S
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caring for the woman. Nonetheless,
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Commentary on deaths related to dru
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It is known that women presenting w
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antibiotics nor returned to her gen
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It is still evident that there is a
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13 Domestic abuse Gwyneth Lewis Dom
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The mothers affected: 2003-05 Durin
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Of the women who were murdered: •
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Annex 13.1 The recommendations of t
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Road traffi c accidents during and
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Table 14.2 Late deaths known, or no
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Table 15.2 Quality of autopsy repor
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Haemorrhage Thirteen of the sevente
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association with obesity as eight o
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Obesity was present in 55% of these
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Toxicology showed non-lethal citalo
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Box 15.6 Pathology learning points:
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References 1 Royal College of Patho
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16 Issues for midwives Grace Edward
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effective service for women who may
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Professional accountability and com
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Box 16.1 Key physical signs that ma
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Midwives’ responsibility for vuln
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Table 16.1 Poor or non attenders fo
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Action checklist for midwifery prac
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17 Issues for General Practitioners
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Box 17.1 Summary of the key issues
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Box 17.3 Risk factors for venous th
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headaches. The indications for emer
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Box 17.8 GP learning points: Heartb
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medication after delivery and been
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Women with mitral stenosis may seem
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signifi cance in the pregnancy. It
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References 1 RCOG. Thromboprophylax
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Introduction For the fi rst time in
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measures were of a good or excellen
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A woman collapsed at home following
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never preclude requesting opinion f
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admissions represented 0.9% of all
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Modifi ed early warning scoring sys
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Box 19.3 Critical care learning poi
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her initial collapse she was transf
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Chapter 19 Annex A This Annex is av
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Table 20.1 Inclusion criteria used
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Table 20.3 Numbers and rates of sev
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References 1 Baskett TF,.O’Connel
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The Director of the Maternal Death
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Verifi cation of Ascertainment Asce
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Scotland A single panel of assessor
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CEMACH Regional Managers East of En
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Regional Assessors in Pathology Eas
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NORTHERN IRELAND Department of Heal
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Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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