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

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Lucas, Millward-Sadler95 mmHg. This was not checked over the next few weeks,and there was no testing for proteinuria. She died suddenlyat home: a bitten tongue and subcutaneous oedema were theonly findings at autopsy, but no toxicology or biochemicalanalyses were performed and there was no search for preeclampsiaor eclampsia on histology. The cause of death wasgiven as unascertained.The medico-legal autopsyThe great majority of maternal death autopsies areperformed under the instruction of a coroner (England,Wales and Northern Ireland) or Procurator Fiscal(Scotland). In this triennium, only 10% were consentedautopsies where the only intent is to provide a fullexplanation of the death, rather than satisfy a morelimited medico-legal inquiry.Under current coronial legislation and regulations, adeath is reported to a coroner when it is suspected to beunnatural (which includes iatrogenic factors), occurs incustody or a doctor cannot compose a medical certificateof cause of death ‘to the best of his knowledge and belief’,that is the cause of death is not known. If the cause ofdeath is ‘natural’, as most maternal deaths are, then it isnot a legal requirement of the current coronial system thatthe autopsy cause of death be accurate and true. And it isnot an expectation that such autopsy reports will be scrutinisedin detail by numerous peers, as occurs in theseCMACE triennial reviews.Another factor that militates against universal good practiceis the enhanced coronial control over tissue samplingand other analyses that take place after the gross autopsy.The events of Alder Hey and Bristol at the turn of the millenniumled to the subsequent Human Tissue Act 2004 4 andthe institution of the Human Tissue Authority (in 2006) 5with its compendious regulations on the working of thepost-mortem sector. As a result, there has been documentedincreasing pressure on pathologists not to take tissue samplesfrom dead people. That said, it is gratifying that maternalautopsies defy that trend: the proportion of medicolegalautopsies on Direct and Indirect maternal deaths thathad at least some histopathology performed was 191 of 219(87%)—and in Scotland, the sampling rate was 100%.These are significantly greater than the overall 19% ratedocumented by the National Confidential Enquiry intoPatient Outcome and Death for all coronial autopsies sampledin England and Wales in 2005. 6Another adverse factor that could affect the assessmentis a long delay between death and the autopsy. In sevenof the Direct deaths (9%), there was a delay of 4 days ormore. Autolysis probably adversely affected the assessmentin two deaths clinically attributed to amniotic fluid embolism.In one with a 6-day delay, ‘squames’ were foundnot only in pulmonary vessels but also in glomeruli. Noimmunocytochemistry was performed. Because of the clinicalpresentation, we accept that this death was the resultof amniotic fluid embolus but are concerned that a prolongeddelay leading to misinterpretation of desquamatingendothelium can be a critical issue. In the second example,following a 5-day delay and where the clinical diagnosisalso was amniotic fluid embolus, macroscopicallythere was a mottled liver and kidneys, and no squameswere found on routine microscopy. Unfortunately, therewas no immunocytochemical search for squames and norenal histology. The assessors regard the cause as unascertained.Maternal autopsy quality in the pastThe 5th Confidential Enquiry Report for 1997–99 7 was thefirst of these triennial Enquiries to assess the quality ofautopsies in any great depth. It identified a high proportionof very bad or appalling autopsy reports from the Londonarea, with many seemingly being conducted in publicmortuaries by forensic pathologists and, as such, isolatedfrom clinical information and from ready access to additionalfacilities such as microbiology. Since then, there hasbeen a steady but recently rapid improvement. 8 The mostprobable explanation is that most maternal death autopsiesfrom this area are now conducted in one hospital mortuaryby a team of pathologists, with a noticeable increase in thequality as a consequence. The number of maternal deathsin the UK is small: Direct, Indirect and Coincidentaltogether total around 150 a year, so that experience inmaternal death pathology is difficult to attain. Consequently,having a small cadre of pathologists for eachregion or area in the UK who are prepared to undertakethis work to a high standard would be helpful.The Direct deaths covered all the major groups, but anoticeable feature was the increase in deaths from sepsisand, as noted in Chapter 2, fewer deaths from thromboembolism.The reports in 18 of the 75 deaths (24%) were consideredto be poor or worse, but there was a markedincrease to 61% in the good or excellent reports. Theremaining 14% of autopsies reviewed were considered adequate.Across the spectrum of the different disorders, mostof the poor autopsy reports were in deaths from pulmonaryembolism (six of 14) and pre-eclampsia (six of 12). Inthe deaths from pulmonary embolism, the most commonfailings were a lack of clinico-pathological correlation andno search for the source of the emboli in four cases each.There were usually other deficiencies present: in two therewas no mention of the body habitus in morbidly obeseindividuals, and there was even a totally inaccurate andmisleading clinical history given in one. Although not necessarilya criterion for assessing the quality of the report,182 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203
Chapter 17: Pathology overviewno histology was taken in any of those of poor quality. Forexample:A woman died of a massive pulmonary embolus with a historyof intermittent chest pains over a period of severalweeks and recurrent vomiting that had been diagnosed ashyperemesis. The autopsy report claimed a history of hypertensionalthough her recorded systolic pressure was
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Volume 118, Supplement 1, March 201
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AcknowledgementsSaving Mothers’ L
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AcknowledgementsAcknowledgementsCMA
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Forewordbeen written jointly by a m
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‘Top ten’ recommendationsServic
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‘Top ten’ recommendationscommun
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‘Top ten’ recommendationsof suc
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‘Top ten’ recommendationsMarch
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Oates et al.Back to basicsM Oates 1
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Oates et al.BreathlessnessBreathles
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Oates et al.appropriate pathway of
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LewisIntroduction: Aims, objectives
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LewisAn important limitation of ran
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Lewismaternal and public health-pol
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Lewisresult in a live birth at any
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LewisChapter 1: The women who died
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Lewiswho would not have been identi
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Lewis1098Rate per 100 000 materniti
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LewisTable 1.4. Numbers and rates o
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Lewis2.50Rate per 100 000 materniti
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LewisTable 1.9. Number of maternal
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LewisTable 1.12. Numbers and percen
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LewisThere were cases where a major
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LewisBox 1.5. Classifications of Bo
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LewisTable 1.20. Number and estimat
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LewisNew countries of the European
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LewisTable 1.23. Direct and Indirec
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LewisTable 1.26. Characteristics* o
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Lewis4 Lewis G (ed). The Confidenti
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DrifeTable 2.1. Direct deaths from
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Drifewomen who died in 2006-08 had
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Drifedelivery she became breathless
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DrifePathological overviewFourteen
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NeilsonChapter 3: Pre-eclampsia and
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Neilsontrue, and what might be the
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NeilsonConclusionThe number of deat
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NormanBackgroundIn the UK, major ob
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Normanwhich there was catastrophic
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Normanrecommendations made in succe
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DawsonBox 5.1. The UK amniotic flui
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Dawsontry despite an extensive sear
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O’HerlihyTable 6.1. Numbers of Di
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O’Herlihytoxic shock syndrome aft
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HarperGroup A b-haemolytic streptoc
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Harperthe 6-week postnatal period,
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Harpera major intrapartum haemorrha
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HarperBox 7.1. Signs and symptoms o
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Harperwoman was given several litre
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Harper2 Lamagni TL, Efstratiou A, D
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LucasTable A7.1 Proposed new catego
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Lucasthe same infection scenario as
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McClure, CooperChapter 8: Anaesthes
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McClure, Cooperaddress, but protoco
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McClure, CooperPostpartum haemorrha
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McClure, CooperWorkloadA number of
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Nelson-PiercyTable 9.1. Indirect ma
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Nelson-Piercynary arteries. In view
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Nelson-Piercynormal left ventricle
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LucasAnnex 9.1. Pathological overvi
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Lucasdiac death that is non-ischaem
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de Swiet et al.causes but are aggra
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de Swiet et al.died of SUDEP before
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de Swiet et al.for 6 weeks after de
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de Swiet et al.mised. The obstetric
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de Swiet et al.CancerPregnancy does
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de Swiet et al.a thorough autopsy w
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Page 142 and 143: Oates, CantwellAll women who are su
Page 144 and 145: Oates, Cantwell4 Kendel RE, Chalmer
Page 146 and 147: Lewismaternal mortality rates or ra
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Page 150 and 151: Annex 12.1. Domestic abuseshe could
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Page 156 and 157: Garrod et al.the second stage and s
Page 158 and 159: Garrod et al.through the still heal
Page 160 and 161: ShakespeareChapter 14: General prac
Page 162 and 163: Shakespeareemergency caesarean sect
Page 164 and 165: ShakespeareCardiac diseaseDeaths fr
Page 166 and 167: Shakespearereduce the risks to the
Page 168 and 169: ShakespeareManaging a maternal deat
Page 170 and 171: Hulbertin the ED was of a high qual
Page 172 and 173: HulbertPre-eclampsia/eclampsia: lea
Page 174 and 175: HulbertTransfersWhen the obstetric
Page 176 and 177: Clutton-Brocksimply the case that s
Page 178 and 179: Clutton-BrockDiagnosis of sepsisTak
Page 180 and 181: Clutton-Brockpulseless electrical a
Page 182 and 183: Clutton-BrockImprovement Scotland (
Page 186 and 187: Lucas, Millward-Sadleran agreed mai
Page 188 and 189: Annex 17.1. The main clinico-tholog
Page 190 and 191: MillerAppendix 1: The method of Enq
Page 192 and 193: MillerDatanotificationNotificationR
Page 194 and 195: Knight• investigating different m
Page 196 and 197: Knightbaseline incidence against wh
Page 198 and 199: LennoxAppendix 2B: Summary of Scott
Page 200 and 201: LennoxEvidence of effective managem
Page 202 and 203: Appendix 3: Contributors to the Mat
Page 204 and 205: Appendix 3: Contributors to the Mat
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6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

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