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

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116 References 1 Royal College of Anaesthetists. Initial Assessment of Competence. The CCT in Anaesthesia II Competency based Basic level. 2006. 2 National Patient Safety Agency (2007): Patient safety alert 21: Safer practice with epidural injections and infusions. www.npsa.nhs.org.uk 3 Picard J, Meek T, Weinberg G and Hertz P. Lipid emulsion for local anaesthetic toxicity. Anaesthesia 2006; 61: 1116-7. 4 Johnston TD, Chen Y, Reed RL. Functional equivalence of hypothermia to specifi c clotting factor defi ciencies. J Trauma 1994; 37: 413-7. 5 Gubler KD, Gentilello LM, Hassantash SA and Maier RV. The impact of hypothermia on dilutional coagulopathy. J Trauma 1994; 36: 847-51. 6 Bolton TJ, Randall K, Yentis SM. Effect of the Confi dential Enquiries into Maternal Deaths on the use of Syntocinon® at caesarean section in the UK. Anaesthesia 2003; 58: 277-9. 7 Thomas JS, Koh SH, Copper GM. Haemodynamic effects of oxytocin given as i.v. bolus or infusion on women undergoing Caesarean section. British Journal of Anaesthesia, 2007; 98: 116-9. 8 Saravanakumar K, Rao SG, Cooper GM. Obesity and obstetric anaesthesia. Anaesthesia, 2006; 61: 36-48.
9 Cardiac disease Catherine Nelson-Piercy Cardiac disease: Specifi c recommendations As recommended in other Chapters of this Report, pregnant immigrant women require a complete medical examination, including cardiovascular examination, by an appropriately trained doctor at booking. Maternity health care professionals must remember the possibility of rheumatic heart disease in immigrant women and there should be a low threshold for investigation if any symptoms develop. Women at higher risk of developing cardiac disease in pregnancy, i.e. the obese, those who smoke or who have existing hypertension and/or diabetes, a family history of heart disease and those over the age of 35, should be appropriately counselled of these risks pre-conception and particularly prior to receiving assisted reproductive technology (ART) or other infertility treatment. Clinicians should have a low threshold for further investigating pregnant or recently delivered women, especially those with any of the above risk factors, with severe chest pain, chest pain that radiates to the neck, jaw or back, chest pain associated with other features such as agitation, vomiting or breathlessness, tachycardia, tachypnoea or orthopnea. Appropriate investigations include an electrocardiogram (ECG), a chest x-ray (CXR), cardiac enzymes (Troponin), echocardiogram and CT pulmonary angiography. If a clinician is not confi dent or competent to interpret an ECG, he/she should discuss the woman’s case and show her ECG to someone who is. Summary of key fi ndings for 2003-05 In this triennium cardiac disease was the commonest cause of maternal death overall. A total of 48 women who died from heart disease associated with, or aggravated by, pregnancy were reported to the Enquiry in 2003–05. All but one of these cases were fully assessed and these deaths are discussed further in this Chapter. These are classifi ed as Indirect maternal deaths. This compares with 44 deaths in 2000-2002 and 35 deaths in 1997–99, as shown in Table 9.1. This Table shows a clear rise in mortality from cardiac causes since the late 1980s, but no further rise in 2003-05. The maternal mortality rate for cardiac disease was 2.27 per 100,000 maternities in 2003-05. In addition, lessons arising from 34 other women known to the Enquiry who died from cardiac disease later after delivery are discussed and considered here although they are counted as Late deaths in Chapter 14. Future Reports will continue to consider all maternal deaths from cardiac disease which occur during pregnancy or within six weeks of birth, as well as those Late cardiac deaths which arise directly or indirectly from the woman having been pregnant, such as deaths attributed to peripartum cardiomyopathy. Three other maternal deaths to which cardiac disease contributed are counted and considered in other Chapters. One woman died from pulmonary embolus although aortic dissection was a contributing feature, another from liver disease with pulmonary hypertension and the third from amniotic fl uid embolism. 117
Page 1 and 2:
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
Page 23 and 24:
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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Page 69 and 70:
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Most staff reported learning clinic
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exception. The health service has a
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17 Shah A, Sands J, Kenny L. Matern
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Country of birth and migration A fa
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Table A1.4 Direct and Indirect deat
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Body mass index varies with age, be
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2 Thrombosis and thromboembolism Ja
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Pulmonary embolism Of the 33 women
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Family history In two deaths there
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vigilance and take symptoms serious
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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 and 124: A woman who had not been long in th
Page 125 and 126: 7 Genital tract sepsis Ann Harper G
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: What did you learn from this case a
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
Page 175 and 176: her delivery, but her case should h
Page 177 and 178: Severe abdominal and back pain, sci
Page 179 and 180: References 1 Drife, J O. The contri
Page 181 and 182: Psychiatric deaths: Specifi c recom
Page 183 and 184: cut off point for maternal deaths,
Page 185 and 186: Report, 26 deaths from suicide were
Page 187 and 188: Current psychiatric treatment In th
Page 189 and 190: 12 Deaths from psychiatric causes S
Page 191 and 192: caring for the woman. Nonetheless,
Page 193 and 194: 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
Page 295 and 296:
267
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