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Chapter 6: Deaths in early pregnancyChapter 6: Deaths in early pregnancyC O’Herlihy (on behalf of the Centre for Maternal and Child Enquiries)University College Dublin School of Medicine and Medical Science, National Maternity Hospital, Dublin, IrelandCorrespondence: Professor Colm O’Herhily, University College Dublin School of Medicine and Medical Science, National Maternity Hospital,Holles Street, Dublin 2, Ireland. Email: colm.oherlihy@ucd.ieKeywords early pregnancy, Confidential Enquiry, maternal, mortality.Death in early pregnancy: specific recommendation• All women of reproductive age presenting to Emergency Departments with gastrointestinal symptoms should have apregnancy test.• Gastrointestinal symptoms, particularly diarrhoea and dizziness, in early gestation are important indicators of ectopicpregnancy. These features need to be emphasised to all clinical staff.• The term ‘pregnancy of unknown location’ based on early pregnancy ultrasound examination should be abandoned.An early pregnancy ultrasound which fails to identify an intrauterine sac should stimulate active exclusion of tubalpregnancy, and even in the presence of a small uterine sac, ectopic pregnancy cannot be excluded.• As emphasised in the Royal College of Obstetricians and Gynaecologists (RCOG) Guideline, The Care of WomenRequesting Induced Abortion, 1 abortion care should include a strategy for minimising the risk of infective morbidity,at a minimum antibiotic prophylaxis. This should be applied whether the abortion is carried out medically or surgically.Death in early pregnancy: learningpointsAbnormal placentation at the site of a previous caesareanscar can lead to haemorrhagic catastrophesin the mid-trimester, as well as in later pregnancy.The possibility of morbid adherence should be consideredwhen evacuation of retained placenta is undertakenfollowing miscarriage in women who have hada previous caesarean section, and this procedureshould be performed by staff of appropriate seniority.Heavy bleeding or bleeding persisting for more than2 weeks following a diagnosis of non-continuingpregnancy needs to be recognised as an indicationfor medical or gynaecological review and considerationof surgical evacuation of retained products of conception.Unless ‘handover’ communication between hospital doctorsis meticulous, truncated shift patterns may result infailure to appreciate a woman’s deteriorating clinicalstatus.Summary of key findings 2006–08Although fewer women died during 2006–08 of causesdirectly resulting from complications arising from earlypregnancy (before 24 completed weeks of gestation) thanin any previous triennium, substandard aspects of carewere identifiable in a majority of the 11 women discussedin this chapter. Six deaths occurred because of rupturedectopic pregnancies and five followed haemorrhagic complicationsof spontaneous miscarriages. Table 6.1 documentsthe trends in early pregnancy deaths since the UKReport began in 1985.In addition, seven other early Direct deaths whichoccurred secondary to sepsis are counted and discussed inChapter 7. Of these, two were associated with spontaneousmiscarriages between 9 and 16 weeks of gestation, two followedpregnancy terminations, one performed medicallyand one surgically induced, and the rest were the result ofinfection following spontaneous premature rupture ofmembranes. Another death, attributed to cocaine interactingwith an anaesthetic for a procedure in early pregnancy,is counted in Chapter 8. Five women died from thromboembolismin early pregnancy and are counted and discussedin Chapter 2. In this triennium, no deaths wereª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 81