Indirect deaths

1
Maternal Mortality in the UKThe 2000-2002
confidential enquiry

• Indirect deaths
• Michael de Swiet
• Milan 2005

2
CEMD cases assessed 2000-02

• Direct 106
• Indirect 155
• Direct and Indirect 261
• Coincidental 36
• Late 94
• Total 391

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Maternal Mortality 1954-2002
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Maternal mortality by cause 1975-2002
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Why the increase in maternal mortality?

• CEMACH regional managers and better reporting
• Chance
• Increased deprivation increase in direct deaths
  could be accounted for by increased asylum
  seekers
• Increased substandard care

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Leading causes of indirect deaths reported to the
Enquiries, 2000-02
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(No Transcript)
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Major causes of Maternal Deaths (CEMACH) in UK
2000-2002
Rate per million maternities
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Commonest single cause of maternal mortality

• 44 deaths (22 per million maternities)
• 35 acquired
• 9 congenital
• 13 late cardiac deaths
• 2 other deaths where cardiac disease may have
  contributed
• Substandard care in 18 (40)

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Cardiac causes of death

• Cardiomyopathy (8)
• Myocardial infarction (8)
• Aneurysm / dissection thoracic aorta (7)
• Pulmonary hypertension (4)
• Other (17)

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Cardiac causes of maternal death 1991-2002
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Cardiomyopathy (n8)

• Peripartum cardiomyopathy (PPCM) n4
• All presented post partum (3 within 48 hrs)
• All had risk factors
• Obesity (2)
• Age, multiparity
• Hypertension (3)
• Other dilated (1)
• HOCM (1)
• Late deaths from PPCM (n7 2 presented in
  puerperium)

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Myocardial Infarction (n8)

• 3 ischaemic heart disease
• All antenatal, 2 in 3rd trimester
• All parous with risk factors
• 2 smokers
• 2 ve FH
• 5 coronary artery dissection
• 4 within one month post partum
• 1 mid pregnancy

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Aortic Dissection (n7)

• Chest pain often attributed to PTE
• Severe and interscapular
• Associated hypertension
• One associated undiagnosed coarctation
• Systolic hypertension ignored
• Learning points
• Think of the diagnosis (atypical hypertension
  AR)
• Early CT / MRI / Echo

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Pulmonary hypertension (n4)

• 2 cases where women did not have significant
  pulmonary hypertension at beginning of pregnancy
• Pulmonary hypertension from ASD/VSD may worsen in
  pregnancy and become fatal
• Five other congenital heart disease mainly
  valvular

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Recommendations

• Increased age, obesity and hypertension are risk
  factors for heart disease that should be noted at
  booking
• Isolated systolic hypertension should not be
  ignored and should be treated with
  antihypertensive therapy

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Recommendations

• Termination of pregnancy services should be
  readily available and accessible for women with
  medical conditions precluding safe pregnancy
• Individual obstetric units should develop
  protocols for the management of pregnant women
  who are extremely ill / collapsed for
  non-obstetric reasons

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Leading causes of indirect deaths reported to the
Enquiries, 2000-02
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Psychiatric disease recommendations-1

• Women with current or previous serious mental
  illness should receive advice from their
  psychiatric team when planning pregnancies
• Psychiatric and Maternity Services should
  communicate with each other and the general
  practitioners when both are involved in the care
  of the patient.

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Psychiatric disease recommendations-2

• All women suffering from serious mental illness
  complicating childbirth or who are likely to
  suffer should have access to the care of a
  specialist psychiatric team
• All women who require psychiatric admission
  following childbirth should be admitted to a
  specialist Mother and Baby Unit unless there are
  specific contra indications.

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Other indirect deaths 1
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Other indirect deaths 2
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Diabetes

• All the maternal diabetic deaths were from
  hypoglycaemia or presumed hypoglycaemia.
  Hypoglycaemia has been the principal cause of
  death in diabetics in previous triennial Reports.
• There is no doubt about the benefit of good
  control in diabetic pregnancy. However attempts
  to achieve this at the expense of recurrent
  maternal hypoglycaemia are misguided.

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Other indirect deaths 3
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Lesson 1- think beyond obstetrics

• A woman developed headaches in early pregnancy,
  became unconscious and died the next day.
• Following an autopsy, death was certified due to
  cerebral infarction due to internal carotid
  artery thrombosis.
• Bad Luck?
• The consultant obstetrician reported she was seen
  just after booking and all was well.
• She had had several previous deep vein thromboses
  and an operation for gangrenous bowel.
• In view of her history the assessors consider she
  must have had some form of thrombophilia and
  consideration should have been given to
  thromboprophylaxis

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Recommendation- Be prepared to refer

• Pregnant women with complications must be seen
  early in pregnancy by consultant obstetricians.
  If the complications are outside the experience
  of the local obstetrician they should be referred
  to tertiary centres for a further opinion. This
  would not necessarily entail delivery at the
  tertiary centre.

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Risk factors for maternal mortality(most
interact with late booking and poor attendance)

• Social disadvantage, both partners unemployed
  X20
• Single mother X3
• Poor, economically deprived by post code X45
• Ethnicity other than white X3
• Black, asylum seekers, recent refugees X7
• Obesity, 35 obese (BMIgt30), 50 more than in
  population
• Domestic violence,14
• Substance abuse, 8
• Suboptimal care, 67 of direct deaths
  

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1952 maternal mortality, proportion due to
"medical" causes (VTE, hypertension, cardiac,
other indirect)
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2000 maternal mortality, proportion due to
"medical" causes (VTE, hypertension, cardiac,
other indirect)
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Conclusions- 2

• Maternal mortality now relates to medical
  rather than surgical conditions
• Obstetricians should think beyond conventional
  obstetric conditions
• And be prepared to consult colleagues in
  obstetrics and other disciplines
• Critical care in obstetrics is dependant on team
  work

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Remember

• In the UK 200-02 about 1,100 children lost their
  mothers because of pregnancy
• World maternal mortality 1million /year seven
  jumbo jet loads per day (WHO 2002)

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The international dimension .. Global maternal
mortality by cause

• Haemorrhage 25 150,000/year
• Indirect causes 20 120,000/year
• Sepsis 15 90,000/year
• Abortion 13 78,000/year
• Hypertensive disease 12 72,000/year
• Obstructed labour 8 48,000/year
• Other direct causes 8 48,000/year

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Other cardiac causes (17)

• Valve disease (incl Bacterial endocarditis) (4)
• Other congenital (2)
• SADS (4)
• sudden death for which no cause found
• Eg. long QT
• Myocardial fibrosis (3)
• 2 Sickle cell
• Hypertensive heart failure (2)
• Both obese
• Other acquired (2)

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Maternal deaths by National Statistics
Socio-Economic Classification 2000-02
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Deprivation category for Maternal deaths E and W
2000-02
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Maternal mortality rates by major ethnic group
England only 2000-02