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

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216 17 Issues for General Practitioners Box 17.2 Key signs and symptoms of possible serious illness in pregnant women or recently delivered mothers. The following signs should alert all health professionals including midwives, GPs, junior doctors and obstetric and other consultants that serious illness is a possibility: • A heart rate greater than 100bpm, • A systolic blood pressure of 160 mm/Hg or above or lower than 90 mm/Hg, and /or a diastolic blood pressure of 90 mm/Hg, or more. • A temperature greater than 38 degrees Centigrade and/or • A respiratory rate more than 21 breaths per minute. The respiratory rate is often overlooked but rates over 30 per minute are indicative of a serious problem. Recognising “red fl ags” when pregnant women need emergency hospital admission This section highlights the key clinical issues that have emerged in reviewing many of the maternal deaths discussed in this Report where there was scope for improvement in GP management, due to of a lack of either knowledge or skills. Further and fuller details are contained within the individual chapters relating specifi cally to each cause of death and these are can also be readily downloaded from www.cemach.org.uk. Breathlessness may be due to pulmonary embolus (PE) The number of women who died from thromboembolism, particularly in early pregnancy, has increased in this triennium despite the continuing decline in those following caesarean section which have continued to fall as thromboprophylaxis becomes routine. Most of the women who died of pulmonary embolus (PE) had the well-known risk factors for PE, especially obesity, and could have been identifi ed as being at higher risk in pregnancy. The risk factors are given in Box 17.3.
Box 17.3 Risk factors for venous thromboembolism a in pregnancy and the puerperium 1 Pre-existing New onset or transient b Previous VTE Thrombophilia Congenital Antithrombin defi ciency Protein C defi ciency Protein S defi ciency Factor V Leiden Prothrombin gene variant Acquired (antiphospholipid syndrome) Lupus anticoagulant Anticardiolipin antibodies Age over 35 years Obesity (BMI >30kg/m2 either pre-pregnancy or in early pregnancy) Parity >4 Gross varicose veins Paraplegia Sickle cell disease Infl ammatory disorders e.g. infl ammatory bowel disease Some medical disorders e.g. nephritic syndrome, certain cardiac diseases Myeloproliferative disorders eg. essential thrombocythaemia, polycythaemia vera. Surgical procedure in pregnancy or puerperium eg. evacuation of retained products of conception, postpartum sterilisation Hyperemesis Dehydration Ovarian hyperstimulation syndrome Severe infection e.g. pyelonephritis Immobility (>4 days’ bed rest) Pre-eclampsia Excessive blood loss Long-haul travel c Prolonged labour c Midcavity instrumental delivery c Immobility after delivery c a Although these are all accepted as thromboembolic risk factors, there are few data to support the degree of increased risk associated with many of them. b These risk factors are potentially reversible and may develop at later stages in gestation than the initial risk assessment or may resolve; an ongoing individual risk assessment is important. c Risk factors specifi c to postpartum VTE only. The following vignette is typical of a death from PE considered in this Report: An obese, parous woman had a home booking carried out by a midwife early in pregnancy. A few weeks later she telephoned her GP because of breathlessness and was told to contact the practice again if it got worse. The next day her husband telephoned the practice requesting a home visit as she had become worse and was told that the doctor would attend after morning surgery. The woman died a few minutes later. 217
Page 1 and 2:
Confidential Enquiry into Maternal
Page 3 and 4:
Saving Mothers’ Lives: Reviewing
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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
Page 33 and 34:
Figure 1.1: Overall maternal mortal
Page 35 and 36:
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
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Table 1.11 Numbers and percentage o
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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
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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
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
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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
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2 Thrombosis and thromboembolism Ja
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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
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
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Sepsis in early pregnancy Six women
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Box 7.3 Learning points: Sepsis in
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Risk factors for, and the identifi
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Box 7.7 Features of septicaemic sho
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8 Anaesthesia Griselda Cooper and J
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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
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What did you learn from this case a
Page 145 and 146:
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
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Liver disease There were four mater
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Diseases of the circulatory system
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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
Page 183 and 184:
cut off point for maternal deaths,
Page 185 and 186:
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,
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 and 224: Box 15.6 Pathology learning points:
Page 225 and 226: References 1 Royal College of Patho
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: Box 17.1 Summary of the key issues
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
Page 283 and 284: The Director of the Maternal Death
Page 285 and 286: Verifi cation of Ascertainment Asce
Page 287 and 288: Scotland A single panel of assessor
Page 289 and 290: CEMACH Regional Managers East of En
Page 291 and 292: Regional Assessors in Pathology Eas
Page 293 and 294: NORTHERN IRELAND Department of Heal
Page 295 and 296:
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Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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