6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

Chapter 10: Other Indirect deathsChapter 10: Other Indirect deathsM de Swiet 1 , C Williamson 2 , G Lewis 3 (on behalf of the Centre for Maternal and Child Enquiries)1 Emeritus Professor of Obstetric Medicine, Imperial College London, London, UK; 2 Institute of Reproductive Developmental Biology,Imperial College London, London, UK; 3 National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UKCorrespondence: Professor Michael de Swiet, Flat 15, Wren View, 75 Hornsey Lane, London N6 5LH, UK. Email: m.deswiet@imperial.ac.ukKeywords risk, Confidential Enquiry, maternal, mortality.Other Indirect deaths: specific recommendations• All women who are planning pregnancies that are likely to be complicated by potentially serious medical conditionsshould have pre-pregnancy counselling.• Women whose pregnancies are complicated by potentially serious medical conditions should be referred to appropriatespecialist centres of expertise where both care for their medical condition and their obstetric care can be optimised.• Lack of consultant involvement remains a problem in the care of women with serious medical problems. Maternityunits should consider developing protocols to specify which medical conditions mandate consultant review.• Health workers who are caring for women in pregnancy with conditions with which they are unfamiliar should consultexperts. If necessary this consultation can be by telephone and most experts are only too pleased to help.• Medical conditions that may be the cause of symptoms that are more commonly seen by obstetricians should not beignored, e.g. seizures can be caused by epilepsy as well as eclampsia.• Multiple admissions or attendances for emergency care demand further investigation and are often an indication forreferral to specialists in other disciplines.• Undiagnosed pain requiring opiates demands immediate consultant involvement and investigation.• The need remains for physicians who do not work directly with pregnant women to know more about the interactionbetween the conditions that they are treating and pregnancy.• Appropriate and professional interpretation services must be made available to women who do not speak English.Other Indirect deaths: learning pointsMost women with epilepsy require an increased lamotriginedose in pregnancy to maintain good seizure control.Clinicians should adjust their managementprotocols accordingly.Women with epilepsy or undiagnosed syncope are stillunaware of the very rare but real risk of drowning whilebathing unattended. A shower is preferable and thebathroom door should remain unlocked.There should be no hesitation in arranging a chest X-ray for women with significant chest symptoms. Similarly,magnetic resonance imaging and computedtomography of the brain can be used to exclude cerebralpathology.Clinicians should be aware that haemoglobin SC diseasecan cause sickle cell crisis and is as dangerous as haemoglobinSS disease.Women should be given advice about sexual intercoursein the postnatal period as fatal air embolism has beenreported as a result of this. The medical assessors to thisEnquiry recommend abstinence for 6 weeks, or gentleintercourse and avoidance of positions where excess aircould be forced into the vagina.IntroductionIndirect maternal deaths are defined as deaths resultingfrom previously existing disease or diseases that developduring pregnancy and which do not have direct obstetricª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 119