Festive cheer

Having just finished some obstetric revision, I have a sneaky suspicion that the new CEMACH 2003-2005 report may feature in next years exam in some form or another. Below is a concise summary, the majority of which relates to anaesthesia:

CEMACH 2003-2005 Summary

Definition
-Confidential Enquiries into Maternal Deaths.
-The longest running "Gold Standard" audit in the world. First Report covered 1952-54
-Triennial report published by DOH looking into all maternal deaths in UK

Causes of death:
-Direct: deaths of women while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not accidental or incidental causes.
-Indirect: deaths resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiological effects of pregnancy.
Late: deaths occurring between 42 days and one year after the end of pregnancy


Changed title from “Why Mothers Die” to “Saving Mothers’ Lives”.

- All maternal deaths: 14 per 100000 maternities (no statistically significant change).

- Direct maternal mortality: slight rise (not statistically significant).

- Lack of decline of maternal mortality: older patient, obesity, comorbidities, migrants, lifestyle.

Commonest direct causes of maternal death
1) Thromboembolism (again)
=2 )pre-eclampsia/sepsis
4) Amniotic fluid embolism
=5) Haemorrhage/early pregnancy

- Increased numbers of: pre-eclampsia, genital tract sepsis/trauma + inexplicable rise in amniotic fluid embolism.
- Decreased haemorrhage/early pregnancy/ectopic.
- Nil of above: statistically significant.

Commonest indirect cause of maternal death
- Cardiac disease (less healthy diets, smoking, alcohol and the growing epidemic of obesity).

Anaesthetics
- 150 cases reviewed: direct or indirect cause of death also having anaesthetic

Direct anaesthetic deaths:
- 6 deaths – (4.5%) 0.28 per 100000 maternities. Same as previous triennium.
- All but one: Caucasian.
- 4/6: obese (2 were morbidly obese: BMI > 35)

Cases
1) Post-op bronchospasm & resp failure: obese asthmatic lady – failed reintubation during recovery post laparascopic surgery for ectopic pregnancy. Irreversible cardiac arrest.

2) Obese lady, early pregnancy, trainee anaesthetist. High-dose opiate given prior to extubation. In recovery developed respiratory difficulties. Inadequate ventilation, bradycardia, cardiac arrest.

3) Morbidly obese asthmatic lady, elective LSCS, spinal anaesthesia. Post-op agitation and SOB. Fatal cardiac arrest on post-op ward with inadequate resuscitation equipment.

4) Low-dose infusion epidural during labour & forceps delivery. PPH + IVI + syntocinon infusions. Grand mal convulsion + VF arrest – unable to resuscitate. Given 150mls 0.1% bupivacaine IV.

5) Lady with pectus excavatum in mid-pregnancy: â foetal movements, fulminant PET, & HELLP. Hypertensive, hyperreflexic, oliguric, & abnormal LFTs – given labetalol, Mg, & hydralazine. For urgent LSCS: RIJ cannulation unsuccessful but subclavian cannulation successful on the second attempt. Cardiac arrest shortly afterwards – large right haemothorax.

6) Obese woman with longstanding renal problems requiring nephrectomy. Had premature labour and delivery. A few weeks later, she was admitted with fever, loin pain, and ileofemoral venous thrombosis. Planned for drainage of septic focus from remaining kidney under U/S guidance. Pt refused LA and suffered an irreversible cardiac arrest during GA.

Indirect Anaesthetic Deaths

-Further 31 cases where poor perioperative anaesthetic management may have contributed to outcome

- Failure to recognise serious illness

- Poor management of haemorrhage (including syntocinon use): Less than optimum anaesthetic management contributed to many of the 17 maternal deaths from haemorrhage (12 died from PPH).

- Sepsis: Poor anaesthetic management/resuscitation was thought to have contributed to 10 maternal deaths from sepsis (usually failure to appreciate seriousness of maternal condition).

- Pre-eclampsia/eclampsia: 4 women died in relation to poor anaesthetic management (usually related to poor control of systolic blood pressure at time of LSCS/post-operatively)

- Management of obese pregnant women

- Quality of in-house hospital Trust enquiries into serious untoward incidents including maternal deaths: some reports of internal hospital enquiries sent to CEMACH were lacking in insight, improperly conducted, did not include clinicians from relevant specialties, or included clinicians involved directly with the maternal death (potential bias).