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

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DrifePathological overviewFourteen autopsy reports giving the cause of death as pulmonaryembolus were examined and considered in this section:five were excellent, three were adequate and six werepoor. Four of the 14 are considered in other chapters,because the death was primarily the result of another comorbidity;for example sepsis, tumour bulk and Late Coincidentalcauses. Associated predisposing causes were alsooften present in those classified as Direct deaths fromembolus. Significant obesity with a BMI of ‡35 was presentin five women, and one of these also had a family historyof thrombophilia from Protein S deficiency. In one womanthere was preceding significant, though not otherwise lifethreatening,inflammation of the genital tract. These raisethe question of where the dividing line between Direct,Indirect and Coincidental should be drawn for this groupand whether all pulmonary embolic deaths should bereclassified as Indirect.The leg and pelvic veins were not examined/mentionedin any of the six poor reports. One of these was a LateCoincidental death of a woman on antipsychotic drugs.These have been associated with deep vein thrombosis.Given that there is a greater propensity for pregnancy tobe associated with pelvic vein than deep leg vein thrombosis,the site and location of the emboli is useful informationto be derived from the autopsy if not otherwiseknown and in this case may have suggested reclassificationto being from Late Direct causes. In three women, therewas retrospectively a clear preceding clinical history ofdyspnoea, but in only one of these was there any attemptto search for previous embolic episodes; in the other twothere was not even any histology taken. This is particularlysurprising in one woman, who had an enlarged anddilated right heart, but the cause was not investigated.Such examples contrast starkly with, for instance, somedeaths in the first trimester. In one, breathlessness had beenattributed to asthma. As well as identifying the pulmonaryemboli, histology confirmed that several were organisedand quite possibly preceded pregnancy and, furthermore,that the features of asthma were not present. In another,emboli complicated dehydration caused by hyperemesis:the mammillary bodies were macroscopically and microscopicallynormal.Thromboembolism pathology: goodpractice points• Examine and describe the pelvic and deep leg veins.• Identify contributory co-morbid factors.• Correlate the findings and histology with the clinicalhistory.ConclusionsFor many years these Reports have been suggesting thatmost deaths from thromboembolism are preventable. Thereis now evidence to support this. The 1995 RCOG guidelineon thromboprophylaxis after caesarean section 10 was followedby a sharp fall in deaths in this category, and nowthe 2004 RCOG guideline 3 has been followed by a sharpfall in antenatal deaths and deaths following vaginal delivery,and, perhaps unexpectedly, in deaths from cerebralvein thrombosis. The detailed advice in the 2009 revisedguideline 2 should produce further improvement.Guidelines, however, are effective only when there is awidespread awareness of the risks and of the need to applythe advice. The cases reported here demonstrate that mostdeaths from thromboembolism occur in women withknown risk factors. This re-emphasises the need for carefulrisk assessment as early as possible in pregnancy andcontinuing reassessment of risk during and after pregnancy.When an at-risk woman is identified, it is not enoughmerely to give advice or make a referral. Some continuityis needed to check that she has been able to follow theadvice or attend the appointment.Symptoms must be interpreted in the light of thewoman’s background risk factors. This ought to be a statementof the obvious, but several cases show that this doesnot always happen. A distressing feature of this chapter isthe over-representation of vulnerable women. The manypressures on the maternity services are no excuse for providingsubstandard service to women who require care inthe true sense of the word.Disclosure of interestsNone.FundingThis work was undertaken by the Centre for Maternal andChild Enquiries (CMACE) as part of the CEMACH programme.The work was funded by the National PatientSafety Agency; the Department of Health, Social Servicesand Public Safety of Northern Ireland; NHS QualityImprovement Scotland (NHS QIS); and the ChannelIslands and Isle of Man.AcknowledgementsThe pathology overview of this chapter was written by DrH Millward-Sadler, Consultant Histopathologist of SouthamptonUniversity Hospitals NHS Trust. jReferences1 Centre for Maternal and Child Enquires and the Royal College ofObstetricians and Gynaecologists. CMACE/RCOG Joint Guideline:64 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203
Chapter 2: Thrombosis and thromboembolismManagement of Women with Obesity in Pregnancy. London:CMACE/RCOG, 2010.2 Royal College of Obstetricians and Gynaecologists. Thrombosis andEmbolism during Pregnancy and the Puerperium. Reducing the Risk.Guideline no.37. London: RCOG Press, 2009. [www.rcog.org.uk].Accessed 5 October 2010.3 Royal College of Obstetricians and Gynaecologists. ThromboprophylaxisDuring Pregnancy, Labour and After Normal Vaginal Delivery.Guideline no.37. London: RCOG Press, 2004.4 Knight M. Antenatal pulmonary embolism: risk factors, managementand outcomes. BJOG 2008;115:453–61.5 National Collaborating Centre for Women’s and Children’s Health.Antenatal Care: Routine Care for the Healthy Pregnant Woman. London:RCOG Press, 2008.6 National Clinical Guideline Centre—Acute and Chronic Conditions.Venous Thromboembolism: Reducing the Risk of VenousThromboembolism (Deep Vein Thrombosis and PulmonaryEmbolism) in Patients Admitted to Hospital. London: NCGCACCat the Royal College of Physicians, 2009. [www.nice.org.uk/nicemedia/pdf/CG92FullGuideline.pdf]. Accessed 5 October 2010.7 Royal College of Obstetricians and Gynaecologists. ThromboembolicDisease in Pregnancy and the Puerperium: Acute Management.Green-top Guideline no. 28. London: RCOG Press, 2007. [www.rcog.org.uk].Accessed 5 October 2010.8 Lewis G (ed). The Confidential Enquiry into Maternal and ChildHealth (CEMACH). Saving Mothers’ Lives: Reviewing MaternalDeaths to Make Motherhood Safer – 2003–2005. The SeventhReport on Confidential Enquiries into Maternal Deaths in the UnitedKingdom. London: CEMACH, 2007. [www.cmace.org.uk]. Accessed5 October 2010.9 Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M. Pulmonaryembolism in pregnancy. Lancet 2010;375:500–12.10 Royal College of Obstetricians and Gynaecologists. Report of theRCOG Working Party on Prophylaxis Against Thromboembolism inGynaecology and Obstetrics. London: RCOG Press, 1995.ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 65
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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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Page 18 and 19: Oates et al.Back to basicsM Oates 1
Page 20 and 21: Oates et al.BreathlessnessBreathles
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Page 24 and 25: LewisIntroduction: Aims, objectives
Page 26 and 27: LewisAn important limitation of ran
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Page 32 and 33: LewisChapter 1: The women who died
Page 34 and 35: Lewiswho would not have been identi
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Page 58 and 59: Lewis4 Lewis G (ed). The Confidenti
Page 60 and 61: DrifeTable 2.1. Direct deaths from
Page 62 and 63: Drifewomen who died in 2006-08 had
Page 64 and 65: Drifedelivery she became breathless
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Page 74 and 75: NormanBackgroundIn the UK, major ob
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Page 80 and 81: DawsonBox 5.1. The UK amniotic flui
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Page 92 and 93: Harpera major intrapartum haemorrha
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Page 104 and 105: McClure, CooperChapter 8: Anaesthes
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Page 108 and 109: McClure, CooperPostpartum haemorrha
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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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Oates, Cantwell4 Kendel RE, Chalmer
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Lewismaternal mortality rates or ra
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Annex 12.1. Domestic abuseAnnex 12.
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Garrod et al.supportive but challen
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Garrod et al.• Culture and system
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Garrod et al.the second stage and s
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Garrod et al.through the still heal
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ShakespeareChapter 14: General prac
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Shakespeareemergency caesarean sect
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ShakespeareCardiac diseaseDeaths fr
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Shakespearereduce the risks to the
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ShakespeareManaging a maternal deat
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Hulbertin the ED was of a high qual
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HulbertPre-eclampsia/eclampsia: lea
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HulbertTransfersWhen the obstetric
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Clutton-Brocksimply the case that s
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Clutton-BrockDiagnosis of sepsisTak
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Clutton-Brockpulseless electrical a
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Clutton-BrockImprovement Scotland (
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Lucas, Millward-Sadler95 mmHg. This
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Lucas, Millward-Sadleran agreed mai
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Annex 17.1. The main clinico-tholog
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MillerAppendix 1: The method of Enq
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MillerDatanotificationNotificationR
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Knight• investigating different m
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Knightbaseline incidence against wh
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LennoxAppendix 2B: Summary of Scott
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LennoxEvidence of effective managem
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Appendix 3: Contributors to the Mat
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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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