* Now reported as pregnancy‐related sepsis, so now includes urinary tract infections.
Some of these recommendations are directed at non‐obstetricians, and, unfortunately, maternity staff do not always recognise the need for effective control of BP.
Haemorrhage
Over the past 40 years, deaths from haemorrhage have fluctuated (Figure 2.1), which may represent relaxation and tightening of standards. For example, the peak in 1988–1990 included cases where doctors had ignored the recommendation that CS for placenta praevia should be carried out by a consultant.
Figure 2.1 Deaths from haemorrhage reported to the CEMDs, 1976–2018
It is important, however, to see these numbers in context. Haemorrhage is by far the most common life‐threatening complication of childbirth: surveys of severe morbidity show that haemorrhage of >2.5 litres occurs once in about 300 births. Therefore over a 3‐year period with more than 2 million births in the UK, several thousand cases are treated successfully.
In 2016–2018, the total of 14 deaths due to haemorrhage included two cases of uterine atony, three of morbidly adherent placenta, three of abruption, two of uterine inversion and four of genital tract trauma. In 79% of cases there was room for improvements in care, and the main messages focused on:Ensuring a senior clinician takes a ‘helicopter view’ of the management of a woman with major obstetric haemorrhage to coordinate all aspects of care
Early recognition (especially when haemorrhage is concealed) including awareness of the signs of uterine inversion
Ensuring that the response to obstetric haemorrhage is tailored to the proportionate blood loss as a percentage of circulating blood volume based on a woman’s body weight
Early correction of coagulopathy
Progressing to hysterectomy when bleeding is uncontrolled, particularly from a morbidly adherent placenta or uterine rupture
Every triennium, one or more deaths occur in women who refuse blood transfusion and guidelines have been issued about the management of such patients. Placenta praevia associated with a uterine scar is particularly dangerous and all women with a previous CS should have a scan for placental localisation in the second trimester and, if low lying, again at 32 weeks.
Thromboembolism
Thromboembolism has been the leading direct cause of maternal death in the UK since 1985, but while the number of deaths fell dramatically from 41 to 18 between 2003–2005 and 2006–2008, this improvement has not been sustained. In the 1990s, a previous fall occurred after the RCOG published recommendations on thromboprophylaxis at CS. Deaths during pregnancy and after vaginal delivery, however, continued to rise and these were targeted by a further RCOG guideline in 2004. These categories fell sharply in 2006–2008, the first full triennium after the new guideline was published. However deaths from thromboembolism have risen again and in 2016–2018 there were 33 (Figure 2.2).
Figure 2.2 Maternal mortality from venous thromboembolism, 3‐year rolling rates in the UK, 2010 to 2017
The most important risk factor for thromboembolism is obesity and the current guidance includes weight‐specific dosage advice on thromboprophylaxis. Risk assessment early in pregnancy is the key to reducing mortality further; this message needs to be heard in gynaecology wards and early pregnancy assessment units as well as in maternity units. However, a clear message from the 2020 report is that there remains confusion about risk assessment scores, which are done inaccurately in many of the cases reviewed.
The value of individualised care also needs to be emphasised. The 2006–2008 report stresses that vulnerable women, for example those with a learning disability, may not be able to follow instructions about self‐injection and will require particular care.
Chest symptoms (shortness of breath or discomfort/pain), ‘panic attacks’ or leg pains appearing for the first time in pregnancy or the puerperium need careful assessment, particularly in at‐risk women. This lesson needs to get across to other specialties.
Ectopic pregnancy
Deaths from ectopic pregnancies still show no sign of falling. Atypical presentation is common and the CEMD has repeatedly drawn attention to gastrointestinal symptoms that may mimic food poisoning. The 2019 report recommended that all women of reproductive age presenting to an emergency department with collapse, dizziness, abdominal or pelvic pain or gastrointestinal symptoms (including vomiting and diarrhoea) should have a pregnancy test. Women from ethnic minorities are over‐represented among deaths from ectopic pregnancy, possibly because of communication difficulties.
Abortion
The Abortion Act of 1967 eliminated deaths from criminal abortion, which in the 1950s caused about 30 deaths a year. In the 2019 report one woman died from complications associated with a self‐induced termination of pregnancy. Previous deaths from termination have included women who received high doses of uterotonics in the presence of a CS scar and those who have developed sepsis, and hence prophylactic antibiotics are recommended in RCOG guidelines. Haemorrhage after spontaneous miscarriage has accounted for previous deaths, especially in the mid‐trimester, and is associated with a placenta implanted over a CS scar. This again emphasises the importance of placental localisation.
Amniotic fluid embolism
The number of deaths from amniotic fluid embolism has remained constant for 30 years. The condition is not always fatal, and useful information may be gained when the woman survives. All cases, whether fatal or not, should be reported to the UK Obstetric Surveillance System (UKOSS) at the National Perinatal Epidemiology Unit in Oxford.
Most recently the CEMD has highlighted the dangers of hyperstimulation of the uterus as a cause of amniotic fluid embolism and in particular the excessive use of misoprostol for induction with intrauterine deaths. In terms of responding to collapse in the peripartum period (which is how women with this condition present), the take home messages, in addition to rapid response and resuscitation, are of anticipating the massive haemorrhage which will follow and putting out a major obstetric haemorrhage (MOH) call.
Sepsis
In 1982–1984, there were only nine deaths from this cause and none was due to puerperal sepsis. Deaths from sepsis subsequently rose steadily. In 2006–2008 it became the leading direct cause of maternal death with 26 deaths. Thirteen of these were due to the group A beta‐haemolytic Streptococcus (S. pyogenes), compared with four in 2016–2018. Among a total of 10 women who died from genital tract sepsis in 2016–2018, six died after mid‐trimester chorioamnionitis from Escherichia coli; three of these six women had preterm pre‐labour rupture of the membranes. This highlights the high‐risk nature of mid‐trimester rupture of membranes, and the 2020