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

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Knight• investigating different management techniques; forexample the use of total versus subtotal hysterectomywas examined in the UKOSS study of peripartum hysterectomyfor severe haemorrhage, but no significantdifferences in complication rates between the twotechniques were found 8• describing the outcomes of severe morbidity; forexample UKOSS surveillance of acute fatty liver ofpregnancy showed that both maternal and infant outcomeswere better than suggested by previous hospital-basedhistorical studies 9UKOSS can, in addition, be used to conduct studies rapidlyin response to emerging public health issues; hence, inresponse to the influenza A/H1N1v (‘swine flu’) pandemic,surveillance of women admitted to hospital with confirmedinfection was initiated to inform ongoing clinical guidanceduring the course of the pandemic. 10Surveillance of specific near-missmorbidities—key points fromcompleted UKOSS studiesHaemorrhage and associated conditionsPeripartum hysterectomyThe incidence of peripartum hysterectomy in the UK is 4.1cases per 10 000 maternities (95% CI 3.6–4.5) with a casefatality of 0.6% (95% CI 0–1.5%). Peripartum hysterectomyis strongly associated with previous delivery by caesareansection (adjusted odds ratio [aOR] 3.52, 95% CI2.35–5.26), and the risk rises with increasing number ofprevious caesarean section deliveries (aOR 2.14 with oneprevious delivery, 95% CI 1.37–3.33; 18.6 with two ormore, 95% CI 7.67–45.4)). Maternal age and parity are alsoimportant risk factors. 5The majority of cases occur in association with eitheruterine atony or a morbidly adherent placenta (placenta accreta).The associated haemorrhage is managed in a varietyof ways and not universally according to existing guidelines;some women who have a hysterectomy for haemorrhagecaused solely by uterine atony are not fully treatedwith uterotonic drugs to control the haemorrhage. Veryfew women were reported to have had a hysterectomy followingtreatment with some of the more innovative therapiesfor control of haemorrhage, including uterine arteryembolisation and factor VII. 8 However, this study did notcollect information on women who had a postpartumhaemorrhage successfully controlled using these therapies,and therefore further surveillance was undertaken specificallyto describe all women managed with specific secondlinetherapies to fully describe outcomes following their use(see below).Management with specific second-line therapies forpostpartum haemorrhageInformation was collected on all women in the UK managedwith uterine compression sutures, pelvic vessel embolisationor ligation or factor VII for severe postpartumhaemorrhage between September 2007 and March 2009.An estimated 2.6 women per 10 000 maternities weremanaged with these therapies. 11 Almost a quarter ofwomen subsequently underwent a hysterectomy followingfailure of control of the haemorrhage. Uterine compressionsutures were the most frequently used of these specificsecond-line therapies; the compression sutures failedto control the haemorrhage in 29% of cases (95% CI 26–36%). Treatment with uterine artery embolisation failedto control haemorrhage in 21% of cases (95% CI 6–46%), surgical ligation of pelvic vessels was performed ina very small number of cases and was associated with afailure rate of 68% (95% CI 43–87%) and factor VII,used in 12% of cases, unsuccessfully controlled haemorrhagefor 71% of women (95% CI 52–85%). Womenwhose haemorrhage was not successfully controlled with auterine compression suture were significantly more likelyto have had a later placement of the suture (more than2 hours following delivery) than women whose haemorrhagewas controlled (aOR 3.86, 95% CI 1.65–8.99), highlightingthe importance of early recognition andtreatment of postpartum haemorrhage to improve outcomesfor women.Hypertension and related disordersEclampsiaThe incidence of eclampsia has decreased significantly inthe UK from 4.9 per 10 000 maternities in 1992 12 to 2.7cases per 10 000 maternities (95% CI 2.4–3.1) 3 in 2005.The majority of women in the UK are managed with magnesiumsulphate according to national protocols, and comparisonbetween the 1992 and 2005 data suggest thatmaternal morbidity has been significantly reduced as a consequence.No women in the study died (case fatality 0%,95% CI 0–1.7%). Fifty-four (26%) had recurrent fits.Twenty-two women (10%) were reported to have othersevere morbidity after the eclamptic episode. Outcomeswere known for 222 infants (204 singletons, 18 twins).Eight infants were stillborn, and five died in the neonatalperiod (perinatal mortality 59 per 1000 births, 95% CI32–98). This study showed the practical benefits of theincorporation of research evidence into practice, improvingoutcomes for women through the widespread use ofevidence-based guidelines.192 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203
Appendix 2A: Summary of United Kingdom Obstetric Surveillance System (UKOSS) Report on near-miss studiesAcute fatty liver of pregnancyNationally acute fatty liver of pregnancy is rare, with anestimated incidence of 5.0 cases per 100 000 maternities(95% CI 3.8–6.5/100 000) or 1 in 20 000 maternities. 9 The‘Swansea’ diagnostic criteria previously proposed agree substantiallywith clinical diagnosis. 13 Eighteen percent ofwomen had twin pregnancies, and 20% were underweight(BMI < 20 kg/m 2 ). This suggests that women with twinpregnancies appear to be at higher risk, but further studiesare needed to investigate the risk associated with low BMI.One woman out of 57 received a liver transplant. Onewoman died (case fatality rate 1.8%, 95% CI 0–9.4%).There were seven deaths among 67 infants (perinatal mortalityrate 104 per 1000 births, 95% CI 43–203). The incidenceestimate from this study is lower than documentedby earlier hospital-based studies, but maternal and neonataloutcomes are better than previously reported, possiblyrelated to improved ascertainment.Thrombosis and thromboembolismAntenatal pulmonary embolismA total of 143 women with antenatal pulmonary embolismwere reported, representing an estimated incidence of 1.3per 10 000 maternities (95% CI 1.1–1.5). 6 There were a fewcases where thromboprophylaxis was not provided accordingto national guidelines, and there may be scope for furtherwork on guideline implementation. The main riskfactors for pulmonary embolism were multiparity (aOR4.03, 95% CI 1.60–9.84) and obesity (BMI ‡ 30 kg/m 2 )(aOR 2.65, 95% CI 1.09–6.45); however, without additionalstudies of cost-effectiveness, we are unable to recommendany changes to current guidelines which would aid preventionof this serious condition. Nearly a third of womenwith antenatal pulmonary embolism had no classical riskfactors, and only nine women with classical risk factorswere eligible for prophylaxis under 2007 guidelines. Furtherwork is needed to assess how information about these riskfactors may be used to guide prophylaxis. Two women hadrecurrent pulmonary emboli (1.4%, 95% CI 0.2–5.1%), andfive women died (case fatality 3.5%, 95% CI 1.1–8.0%).Hence, significant severe morbidity from thromboembolicdisease underlies the maternal deaths from antenatal pulmonaryembolism reported in the UK, with approximately30 women diagnosed with the condition for each womanwho died.Amniotic fluid embolismAnalysis of data reported over 4 years to UKOSS shows anestimated incidence of amniotic fluid embolism (AFE) of2.0 cases per 100 000 maternities (95% CI 1.5–2.5/100 000). 14 Occurrence of AFE was significantly associatedwith induction of labour (aOR 3.86, 95% CI 2.04–7.31)and multiple pregnancy (aOR 10.9, 95% CI 2.81–42.7); anincreased risk was also noted in older women from ethnicminorities (aOR 9.85, 95% CI 3.57–27.2). Caesarean deliverywas associated with postnatal amniotic fluid embolism(aOR 8.84, 95% CI 3.70–21.1). Twelve women died (casefatality 20%, 95% CI 11–32%); five of 37 infants of womenwith antenatal AFE died (perinatal mortality 135/1000 totalbirths, 95% CI 45–288). Women who died were significantlymore likely to be from ethnic minority groups (aOR11.8, 95% CI 1.40–99.5). In view of the extreme rarity ofthis condition and the significant associated mortality, surveillancethrough UKOSS is ongoing to further investigaterisk factors and describe outcomes following the use of differentmanagement techniques.Ongoing surveillanceOngoing surveillance of near-miss maternal morbidity isclearly important to complement the comprehensive studiesof maternal death as presented in this report. The followingstudies are ongoing (2010 onwards); additional studies willbe introduced as part of the UK National Maternal NearmissSurveillance Programme funded by the National Institutefor Health Research.Uterine ruptureUterine rupture is associated with significant maternaland fetal morbidity, and a decrease in the number ofwomen attempting vaginal birth after caesarean sectionmay be the result of concerns about the risk of uterinerupture. There are, however, no systematic data availableat a population level to quantify the incidence of uterinerupture and to assess the risks associated with inductionand augmentation of labour in women who have had aprevious caesarean delivery. This study will investigate theincidence, risk factors and outcomes of uterine rupture inthe UK.Placenta accretaPlacenta accreta is thought to be becoming more commonfor a number of reasons, including rising maternal age atdelivery and an increasing proportion of deliveries by caesareansection. There is at the same time a debate aboutthe optimal diagnostic and management techniques. Thisstudy will describe the current management of placenta accretain the UK and associated outcomes for women andtheir infants. In addition, this study will estimate thenational incidence of placenta accreta in the UK and identifythe extent to which previous caesarean section andolder maternal age are risk factors in this population. Thiswill enable appropriate future service planning, provideaccurate information, which can be used when counsellingwomen about the risks associated with caesarean sectionand developing management guidelines, and provide aª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 193
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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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Oates, CantwellChapter 11: Deaths f
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Oates, CantwellTable 11.1. Timing o
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Oates, CantwellTable 11.5. Maternal
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Oates, CantwellChild protection iss
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Oates, CantwellAll women who are su
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Page 152 and 153: Garrod et al.supportive but challen
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Page 156 and 157: Garrod et al.the second stage and s
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Page 160 and 161: ShakespeareChapter 14: General prac
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Page 164 and 165: ShakespeareCardiac diseaseDeaths fr
Page 166 and 167: Shakespearereduce the risks to the
Page 168 and 169: ShakespeareManaging a maternal deat
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Page 172 and 173: HulbertPre-eclampsia/eclampsia: lea
Page 174 and 175: HulbertTransfersWhen the obstetric
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Page 178 and 179: Clutton-BrockDiagnosis of sepsisTak
Page 180 and 181: Clutton-Brockpulseless electrical a
Page 182 and 183: Clutton-BrockImprovement Scotland (
Page 184 and 185: Lucas, Millward-Sadler95 mmHg. This
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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 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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