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

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196 15 Pathology In another case a woman admitted acutely ill with epigastric pain and vomiting in mid pregnancy was initially diagnosed as having acalculous cholecystitis. It was later realised that she had serious alcohol dependency and she died soon after. Clinically this was the classic picture of acute alcoholic liver disease described over 40 years ago 21 but her inadequate autopsy gave the cause of death as acute liver failure secondary to disseminated intravascular coagulation and acalculous cholecystitis. No histopathology was performed and so the probable diagnosis of acute severe steatohepatitis was missed. Coincidental deaths The need to assess these deaths, which now mainly comprise those from malignancy and road traffi c accidents, has been questioned. However suicides were previously in this category but because of their unusual characteristics in the fi rst year postpartum, these are now considered to be Indirect. The possibility that other causes may be more closely related to pregnancy than is currently thought cannot be completely discounted and therefore they are kept under review. Although the postmortems have a variety of features and causes of death, the generic theme about the lack of correlation with the clinical circumstances remains pertinent. They also provide additional and valuable information on generic aspects of maternal health such as domestic violence, ethnic discrimination and language diffi culties. These features are discussed in many of the Chapters in this Report. Acknowledgements Earlier drafts of this Chapter were seen and commented on by Dr Robert Nairn, Dr Laurence Brown, Dr Leslie Murray and Dr Grainne McCusker.
References 1 Royal College of Pathologists, 2005, Guidelines on Autopsy Practice- best practice scenarios. At http://www.rcpath.org/publications 2 Lewis G, Drife J (eds) “Why Mothers Die 1997-9 “ The Fifth Report of the United Kingdom Confi dential Enquiry into Maternal Deaths. London RCOG Press 2001. 3 Millward-Sadler GH, 2003, Pathology of maternal deaths. In: Kirkham N, Shepherd N, editors. Progress in Pathology, Vol 6, 163-85. London, Greenwich Medical Media Ltd. 4 Clark SL, Pavlova Z, Greenspoon J, et al. 1986, Squamous cells in the maternal pulmonary circulation. Am J Obstet Gynecol; 154, 104-6. 5 Benson MD, Kobayashi H, Silver RK, et al. 2001, Immunologic studies in presumed amniotic fl uid embolism. Obstet Gynecol 97(4), 510-4. 6 Kobayashi H, Hidekazu O, Hayakawa H, et al. 1997, Histological diagnosis of amniotic fl uid embolus by monoclonal antibody TKH-2 that recognises NeuAc a 2-6GalNAc epitope. Human Pathology, 28, 428-33. 7 Oi H. Kobayashi H., Hirashima Y., et al 1998, Serological and immunohistochemical diagnosis of amniotic fl uid embolism. Semin Thromb Hemost., 24(5), 479-84. 8 Health Protection Agency. 2004, First year of enhanced surveillance of Group A streptococcal infections. Commun. Dis. Rep. Wkly. 14 (16) 9 Smahi A., Courtois G., Rabia SH., et al, 2002, The NF-KappaB signalling pathway in human diseases: from incontinentia pigmenti to ectodermal dysplasias and immune-defi ciency syndromes. Hum Mol Genet 11, 2371-5. 10 Kishkurno S., Ishida A., Takahashi Y., et al, 1997 A case of neonatal choriocarcinoma. American J. of Perinatal 1997, 14, 79-82. 11 Tsukamoto N, Matsumura M, Matsukuma K, et al. 1986 Choriocarcinoma in mother and fetus. Gynaecological Oncology, 24, 113-9. 12 Jarmulowicz M, and Philips WG, 2001, Vascular Ehlers-Danlos syndrome undiagnosed during life. J. Royal Society of Medicine, 94, 28-30. 13 Jouven X, Charles M-A, Desnos M & Duciemetiere. 2001, Circulating nonesterifi ed fatty acid level as a predictive risk factor for sudden death in the population. Circulation, 104, 756-61. 14 Ferns G. Personal communication. 15 Grundy SM, Brewer, HB Jr, Cleeman JI, et al., 2004, Defi nition of Metabolic Syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientifi c Issues Related to Defi nition. Circulation; 109, 433-438. 16 Tan HL, Hofman N, van Langen IM, et al. 2005, Sudden unexplained death: heritability and diagnostic yield of cardiological and genetic examination in surviving relatives. Circulation, 112, 207-13. 197
Page 1 and 2:
Confidential Enquiry into Maternal
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Saving Mothers’ Lives: Reviewing
Page 5 and 6:
Contents Maternal deaths Indirectly
Page 7 and 8:
Foreword Having a baby is a joyous
Page 9 and 10:
The ‘top ten’ key recommendatio
Page 11 and 12:
Migrant women 4. All pregnant mothe
Page 13 and 14:
Clinical skills 7. Maternity servic
Page 15 and 16:
Early warning scoring system 9. The
Page 17 and 18:
References 1 Redshaw M, Rowe R, Hoc
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Working together to save mothers’
Page 21 and 22:
Severe maternal morbidity, “near
Page 23 and 24:
At a national level In every countr
Page 25 and 26:
Table 1 Defi nitions of maternal de
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For the past nine years, ONS have b
Page 29 and 30:
Chapter 1 Which mothers died, and w
Page 31 and 32:
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
Page 37 and 38:
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
Page 45 and 46:
Table 1.11 Numbers and percentage o
Page 47 and 48:
These messages are repeated in many
Page 49 and 50:
Doctors may need specifi c training
Page 51 and 52:
Table 1.13 Total number of Direct a
Page 53 and 54:
Ovarian hyperstimulation syndrome (
Page 55 and 56:
The obese women who died From the n
Page 57 and 58:
Pre-pregnancy counselling and weigh
Page 59 and 60:
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
Page 65 and 66:
Table 1.22 Characteristics of the a
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Most staff reported learning clinic
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exception. The health service has a
Page 75 and 76:
17 Shah A, Sands J, Kenny L. Matern
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Country of birth and migration A fa
Page 79 and 80:
Table A1.4 Direct and Indirect deat
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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
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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
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of over ten litres. Despite a hyste
Page 119 and 120:
References 1 Clark SL, Pavlova Z, G
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The women who died The ages of the
Page 123 and 124:
A woman who had not been long in th
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7 Genital tract sepsis Ann Harper G
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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
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The third case also highlights the
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A woman suffered a concealed haemor
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Sepsis Poor anaesthetic or resuscit
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What did you learn from this case a
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9 Cardiac disease Catherine Nelson-
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Table 9.2 Causes of maternal death
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an estimated incidence of 1.1 per 1
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Quality of care Care was considered
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y a doctor, with a systolic blood p
Page 155 and 156:
Box 9.3 Learning points: peripartum
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Infectious endocarditis Two women d
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10 Other Indirect deaths Michael de
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Table 10.1 Causes of Other Indirect
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Fifty-eight of the eighty-seven wom
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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
Page 195 and 196: It is known that women presenting w
Page 197 and 198: antibiotics nor returned to her gen
Page 199 and 200: It is still evident that there is a
Page 201 and 202: 13 Domestic abuse Gwyneth Lewis Dom
Page 203 and 204: The mothers affected: 2003-05 Durin
Page 205 and 206: Of the women who were murdered: •
Page 207 and 208: Annex 13.1 The recommendations of t
Page 209 and 210: Road traffi c accidents during and
Page 211 and 212: Table 14.2 Late deaths known, or no
Page 213 and 214: Table 15.2 Quality of autopsy repor
Page 215 and 216: Haemorrhage Thirteen of the sevente
Page 217 and 218: association with obesity as eight o
Page 219 and 220: Obesity was present in 55% of these
Page 221 and 222: Toxicology showed non-lethal citalo
Page 223: Box 15.6 Pathology learning points:
Page 227 and 228: 16 Issues for midwives Grace Edward
Page 229 and 230: effective service for women who may
Page 231 and 232: Professional accountability and com
Page 233 and 234: Box 16.1 Key physical signs that ma
Page 235 and 236: Midwives’ responsibility for vuln
Page 237 and 238: Table 16.1 Poor or non attenders fo
Page 239 and 240: Action checklist for midwifery prac
Page 241 and 242: 17 Issues for General Practitioners
Page 243 and 244: Box 17.1 Summary of the key issues
Page 245 and 246: Box 17.3 Risk factors for venous th
Page 247 and 248: headaches. The indications for emer
Page 249 and 250: Box 17.8 GP learning points: Heartb
Page 251 and 252: medication after delivery and been
Page 253 and 254: Women with mitral stenosis may seem
Page 255 and 256: signifi cance in the pregnancy. It
Page 257 and 258: References 1 RCOG. Thromboprophylax
Page 259 and 260: Introduction For the fi rst time in
Page 261 and 262: measures were of a good or excellen
Page 263 and 264: A woman collapsed at home following
Page 265 and 266: never preclude requesting opinion f
Page 267 and 268: admissions represented 0.9% of all
Page 269 and 270: Modifi ed early warning scoring sys
Page 271 and 272: Box 19.3 Critical care learning poi
Page 273 and 274: her initial collapse she was transf
Page 275 and 276:
Chapter 19 Annex A This Annex is av
Page 277 and 278:
Table 20.1 Inclusion criteria used
Page 279 and 280:
Table 20.3 Numbers and rates of sev
Page 281 and 282:
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
Page 291 and 292:
Regional Assessors in Pathology Eas
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NORTHERN IRELAND Department of Heal
Page 295 and 296:
267
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