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

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iv Contents Acknowledgements ................................................................................................................................... vi Foreword ................................................................................................................................................... vii Top ten recommendations ...................................................................................................................... viii Introduction ............................................................................................................................................ xviii Background ......................................................................................................................................... xviii Aims and objectives of the Enquiry .......................................................................................................xxi Defi nitions and methods for calculating maternal mortality rates ........................................................ xxiv Key fi ndings for 2003-05 1. Summary and overall fi ndings Gwyneth Lewis ................................................................................... 1 Key fi ndings for 2003-05 ......................................................................................................................... 3 The clinical reasons why mothers died ................................................................................................... 7 Leading causes of maternal deaths: 2003-05 ......................................................................................... 9 The care the mothers received ................................................................................................................ 9 Underlying health status ........................................................................................................................ 22 Vulnerability ........................................................................................................................................... 29 Discussion and conclusions .................................................................................................................. 43 Acknowledgments ................................................................................................................................. 45 References ............................................................................................................................................ 45 Annex 1:1. The changing face of motherhood in the UK; trends in reproductive epidemiology Alison Macfarlane ....................................................................... 48 Maternal deaths Directly related to pregnancy 2. Thrombosis and thromboembolism James Drife .............................................................................. 55 Annex 2:1. Summary of the RCOG guidelines for thromboprophylaxis during pregnancy, labour and after vaginal delivery and caesarean section. .................................... 67 3. Pre-eclampsia and eclampsia James Neilson ................................................................................... 72 4. Haemorrhage William Liston ................................................................................................................ 78 5. Amniotic fl uid embolism Robin Vlies ................................................................................................. 86 6. Early pregnancy deaths James Neilson ............................................................................................. 92 7. Genital tract sepsis Ann Harper .......................................................................................................... 97 8. Anaesthesia Griselda Cooper and John McClure.............................................................................. 107
Contents Maternal deaths Indirectly related to pregnancy 9. Cardiac disease Catherine Nelson-Piercy .........................................................................................117 10. Other Indirect deaths Michael de Swiet ........................................................................................... 131 11. Deaths from malignancy Gwyneth Lewis ........................................................................................ 145 12. Deaths from psychiatric causes Margaret Oates ........................................................................... 152 Suicide Margaret Oates ...................................................................................................................... 154 Substance misuse Judy Myles ........................................................................................................... 165 13. Domestic abuse Gwyneth Lewis ...................................................................................................... 173 Annex 13:1. National guidelines for England for the identifi cation and management of domestic abuse in pregnancy ............................................................................ 179 Deaths unrelated to pregnancy 14. Coincidental and Late deaths Gwyneth Lewis ................................................................................ 180 Key issues and lessons for specifi c health services and/or health professionals 15. Pathology Harry Millward-Sadler ..................................................................................................... 184 16. Midwifery Grace Edwards ................................................................................................................. 199 17. General Practice Judy Shakespeare ................................................................................................ 213 18. Emergency medicine Diana Hulbert ................................................................................................ 230 19. Critical Care Tom Clutton-Brock ........................................................................................................ 238 Annex 19:1. The Aberdeen Maternity Hospital Modifi ed Early Obstetric Warning Score (MEOWS) chart ............................................................................................ 247 20. Severe Maternal Morbidity - the Scottish experience 2003 to 2005 Gillian Penney et al ............. 248 Appendices Appendix 1: The method of Enquiry ..................................................................................................... 254 Appendix 2: The Enquiry assessors..................................................................................................... 260 v
Page 1 and 2: Confidential Enquiry into Maternal
Page 3: Saving Mothers’ Lives: Reviewing
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
Page 19 and 20: 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
Page 27 and 28: 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:
Page 39 and 40: Table 1.5 Maternal deaths by gestat
Page 41 and 42: Table 1.7 Number of maternal deaths
Page 43 and 44: 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
Page 61 and 62:
double the number of cases in the l
Page 63 and 64:
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
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
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Detailed guidelines for the managem
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acute bleeding situation although i
Page 113 and 114:
References 1 Brace V, Penney G, Hal
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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
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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
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
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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
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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
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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
Page 171 and 172:
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
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
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The mothers affected: 2003-05 Durin
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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
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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
Page 247 and 248:
headaches. The indications for emer
Page 249 and 250:
Box 17.8 GP learning points: Heartb
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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
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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
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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
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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:
267
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