【高血压精品英文课件】what is the purpose of reviewing maternal deaths and complications

Professor James Drife MD FRCOG FRCPE FRCSE FFSRH FCOGSA CEMACH National Obstetric Assessor 1994-2011,North West Local Supervising Authority Study Day for Supervisors of Midwives and Midwives 8th June 2011,Direct maternal deaths in the UK 2006-2008 Causes and avoidable factors,1952-54,Confidential Enquiries into Maternal Deaths 1952-2008,2000-2002,2003-2005,Aim of Confidential Enquiries to save mothers lives,NOT to blame individuals,Aim of Confidential Enquiries to save mothers lives,HOW? 1. Better management of complications By individual professionals and teams By systems (local, regional, national) 2. Prevention of complications Identify risk factors Identify early warning signs,66 / 100,000,England & Wales 1952-54,UK, 2006-08,Maternal mortality rate, 1952-2008,11.4 / 100,000,Hypertensive disease 246 19 Haemorrhage 188 8 Abortion 153 - Thromboembolism 138 18 Obstructed labour 63 - Anaesthesia 49 7 Sepsis 42 26,Numbers of maternal deaths (E. & W.) (UK) 1952-54 2006-08,UK maternal mortality rates 1952-2008,Direct and Indirect death rates UK 1985-2008,DIRECT,TOTAL,INDIRECT,UK death rates /100 000 maternities,1988-91 1991-3 1994-6 1997-9 2000-2 2003-5 2006-8 Direct 6.1 5.6 6.1 5.0 5.3 6.2 4.7 Indirect 3.9 4.3 6.1 6.4 7.8 7.7 6.7 Total 10.1 9.9 12.1 11.4 13.1 14.0 11.4 (Based on deaths reported to the Enquiry),Based on registered maternal deaths Number 171 150 158 128 136 149 155 Rate 7.2 6.5 7.2 6.0 6.8 7.1 6.7,UK maternal mortality rate 3 year rolling average 2000-08,Leading causes of UK maternal deaths 2006-08,INDIRECT DIRECT,Risk factors Older women,Direct deaths: causes,2003-5 2006-8,Direct deaths: causes,2003-5 2006-8,Direct deaths: UK 1985-2008 Rates per million maternities,1995,RCOG guidelines,Direct deaths: UK 1985-2008 Rates per million maternities,1995,Pulmonary embolism 2003-2005,After miscarriage/ectopic . 3 Antepartum 11 Collapse before delivery (CS) 4 Intrapartum . 0 After caesarean section . 7 After vaginal delivery 8 Total 33,1995,RCOG guidelines,2004,Guideline no 37: “Thromboprophylaxis during pregnancy, labour and after vaginal delivery”,Direct deaths: UK 1985-2008 Rates per million maternities,1995,2004,Thromboprophylaxis vignette,An obese woman with a history of chest pains prior to pregnancy saw her GP early in pregnancy and then consulted several times, in person and by phone, with chest pain or dyspnoea. She developed hyperemesis and was admitted to hospital where tachycardia was noted. Investigation for thromboembolism was started, but she died before treatment was initiated.,Pulmonary thromboembolism Substandard care (56% of cases),Inadequate risk assessment - Risk factors present in 14 of the 16 women - 3 were overweight, 9 were obese Failure to investigate chest symptoms in women at risk - 7 reported symptoms in the weeks before death Inadequate thromboprophylaxis Failure to involve multi-disciplinary care,RCOG Guideline No: 37: ”Reducing the risk of thrombosis and embolism during pregnancy and the puerperium”,RCOG thromboprophylaxis dosage guidelines 2009,Thromboembolism Recommendations,Obesity remains the most important risk factor. New RCOG guideline has weight specific dosage advice Risk assessment in early pregnancy is key: women with BMI 35 are unsuitable for midwifery-only care Women are at risk throughout pregnancy - implications for EPUs and gynaecology wards Vulnerable women (eg learning difficulties) may not be able to self administer injections. Chest symptoms appearing for the first time in pregnancy / puerperium need careful assessment.,Risk factors Obesity,Risk factors Single, unemployed,MMR by deprivation score 2003-05 and 2006-08,Direct deaths: causes,2003-5 2006-8,Pre-eclampsia / eclampsia,Pre-eclampsia vignette,A woman presented to an ED in early third trimester with epigastric pain. Her BP was 150/90 mmHg and she had proteinuria +. She was diagnosed as having “gastritis and discharged home where she collapsed and died shortly afterwards. Autopsy showed a cerebral haemorrhage and the typical histological features of pre-eclampsia.,Pre-eclampsia / eclampsia Recommendations,Pregnant women presenting with headache or epigastric pain should have their BP measured and urine tested for protein Systolic blood pressure should be recorded and discussed Systolic blood pressures 150mmHg should be treated; 180mmHg is an emergency IM syntocinon should be the routine drug for the third stage of labour Team care (including ITU specialists and GPs),Direct deaths: causes,2003-5 2006-8,Postpartum haemorrhage,2,500 cases/year of bleeding 2.5 litres according to severe morbidity surveys 5 deaths from PPH in 2006-2008 50% reduction compared to last triennium In 3 of the 5 deaths, a major contributor was lack of routine observation in the postpartum period or failure to appreciate that bleeding was occurring MEOWs charts should be used,Obstetric haemorrhage Selected recommendations,Protocols and drills required in all areas Early senior multidisciplinary team involvement is essential including elective CS for placenta praevia Placental site identification is required for all with previous caesarean section. Regular observations of pulse and BP for the first 24 hours after CS should be recorded on a MEOWs, and abnormal scores acted upon. Inpatient care required after 34 weeks for women with praevia who have previously bled (RCOG),Direct deaths: causes,2003-5 2006-8,Deaths in early pregnancy,Ectopic 6 (+ 1 anaesthetic death) - Three were from ethnic minorities Miscarriage . 5 (+ 2 from sepsis) - All died from haemorrhage - Three deaths at 16-18 weeks, associated with placenta adherent to previous CS scar - EPUs tend to manage persistent bleeding conservatively Termination . 0 (+ 2 from sepsis),Risk factors Migration and ethnicity,Ectopic pregnancy vignette,A woman was referred to hospital by her GP with diarrhoea, vomiting and abdominal pain. On admission her Hb was 10.9 g/dl with tachycardia but a pregnancy test was not performed. She was seen by several junior hospital doctors and, during the following few hours, received several litres of IV fluids with a urinary output of less than 500 ml and a severe fall in Hb. She died before diagnosis. At autopsy, the abdominal cavity contained about 9 litres of bloody fluid and clot, together with a ruptured tubal pregnancy.,Early pregnancy deaths Recommendations,All women of reproductive age presenting to ED with GI symptoms should have a pregnancy test. Diarrhoea and dizziness in early gestation are important indicators of ectopic pregnancy. This needs to be emphasised to all clinical staff. The term “pregnancy of unknown location” should be abandoned. If an intrauterine sac cannot be identified, ectopic cannot be excluded. Abortion care should include a strategy for minimising the risk of infective morbidity,Direct deaths: UK 1985-2008 Rates per million maternities,Direct deaths: causes,2003-5 2006-8,Sepsis,2000 2003 2006 -02 -05 -08 Sepsis in early pregnancy 2 . 5 . 7 Puerperal sepsis . 5 . 3 . 7 After surgical procedures 3 2 . 4 Before or during labour . 1 . 8 . 8 Total . 13 18 . 26 Group A streptococcus . 3 8 . 13,Sepsis vignette,A woman in mid-pregnancy called an out-of-hours GP. She was feverish, shivery and had a sore throat. Dx “viral infection”. A few hours later, she developed abdominal pain, vomiting, diarrhoea & reduced fetal movements. GP returned. Dx abruption rushed to hospital. On admission, critically ill: tachycardia, breathlessness, cyanosis and confusion. Dx septic shock. Correct multi-disciplinary treatment instituted immediately, including appropriate IV antibiotics and ITU support. Died a few hours after admission to hospital.,Sepsis: recommendations “Be aware of sepsis beware of sepsis”,Education of pregnant and puerperal women Wash hands before and after visiting lavatory Signs and symptoms of infection Identification and monitoring In the community, early signs of infection In hospital, MEOWs charts Immediate antibiotic treatment without waiting for investigation results Guidelines on detection and management Local and, as a priority, national,Sepsis Proposed new classification,1. Unsafe abortion 2. Ruptured membranes (genital tract sepsis) 3. Post-delivery (genital tract sepsis) 4. Community acquired sepsis in pregnancy Severe postpartum sepsis related to the birth process but genital tract not involved eg. spinal anaesthesia, CS wound infection Other, coincidental infection