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

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66 2 Thrombosis and thromboembolism References 1 Knight M, Kurinczuk JJ, Spark P and Brocklehurst P. United Kingdom Obstetric Surveillance System (UKOSS) Annual Report 2007. National Perinatal Epidemiology Unit, Oxford. 2 National Collaborating Centre for Women’s and Children’s Health commissioned by the National Institute for Clinical Excellence. Antenatal care: routine care for the healthy pregnant woman. London: RCOG Press, 2003. Available at www.nice.org.uk 3 Royal College of Obstetricians and Gynaecologists. Thromboprophylaxis during pregnancy, labour and after normal vaginal delivery. Guideline no.37. London: RCOG Press; 2004. Available at www.rcog.org.uk 4 Royal College of Obstetricians and Gynaecologists. Thromboembolic disease in pregnancy and the puerperium: acute management. Guideline no.28. London: RCOG Press; 2001. Available at www.rcog.org.uk 5 Royal College of Obstetricians and Gynaecologists. Report of the RCOG Working Party on prophylaxis against thromboembolism in gynaecology and obstetrics. London: RCOG Press; 1995. 6 Department of Health. Maternity Matters: choice, access and continuity of care in a safe service. London: Department of Health; April 2007. www.dh.gov.uk
Annex 2.1 Summary of the key recommendations of the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for thromboprophylaxis in pregnancy, labour and after vaginal delivery and caesarean section. Thromboprophylaxis during pregnancy, labour and after normal vaginal delivery 3 . Risk factors for venous thromboembolism in pregnancy and the puerperium a Pre-existing New onset or transientb Previous VTE Surgical procedure in pregnancy or puerperium 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. 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. 67
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
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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
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 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: of pregnancy, seven had identifi ab
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 and 144: 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
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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
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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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267
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Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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