Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom

In the triennium 2006-2008, 261 women in the UK died directly or indirectly related to pregnancy. The overall maternal mortality rate was 11.39 per 100,000 maternities. Direct deaths decreased from 6.24 per 100,000 maternities in 2003-2005 to 4.67 per 100,000 maternities in 2006–2008 (p = 0.02). This decline is predominantly due to the reduction in deaths from thromboembolism and, to a lesser extent, haemorrhage. For the first time there has been a reduction in the inequalities gap, with a significant decrease in maternal mortality rates among those living in the most deprived areas and those in the lowest socio-economic group. Despite a decline in the overall UK maternal mortality rate, there has been an increase in deaths related to genital tract sepsis, particularly from community acquired Group A streptococcal disease. The mortality rate related to sepsis increased from 0.85 deaths per 100,000 maternities in 2003-2005 to 1.13 deaths in 2006-2008, and sepsis is now the most common cause of Direct maternal death. Cardiac disease is the most common cause of Indirect death; the Indirect maternal mortality rate has not changed significantly since 2003-2005. This Confidential Enquiry identified substandard care in 70% of Direct deaths and 55% of Indirect deaths. Many of the identified avoidable factors remain the same as those identified in previous Enquiries. Recommendations for improving care have been developed and are highlighted in this report. Implementing the Top ten recommendations should be prioritised in order to ensure the overall UK maternal mortality rate continues to decline.     

Infection control practices reduce nosocomial infections and mortality in preterm infants in Bangladesh.

OBJECTIVE: The skin is a potential source for invasive infections in neonates from developing countries such as Bangladesh, where the level of environmental contamination is exceedingly high. A randomized controlled trial was conducted from 1998 to 2003 in the Special Care Nursery of a tertiary hospital in Bangladesh to test the effectiveness of topical emollient therapy in enhancing the skin barrier of preterm neonates less than 33 weeks of gestational age. In the initial months of the study, the infection and mortality rates were noted to be unacceptably high. Therefore, an infection control program was introduced early in the trial to reduce the rate of nosocomial infections. STUDY DESIGN: After a comprehensive review of neonatal care practices and equipment to identify sources of nosocomial infections, a simple but comprehensive infection control program was introduced that emphasized education of staff and caregivers about measures to decrease risk of contamination, particularly hand-washing, proper disposal of infectious waste, and strict asepsis during procedures, as well as prudent use of antibiotics. RESULTS: Infection control efforts resulted in declines in episodes of suspected sepsis (47%), cases of culture-proven (61%) sepsis, patients with a clinical diagnosis of sepsis (79%), and deaths with clinical (82%) or culture-proven sepsis (50%). CONCLUSION: The infection control program was shown to be a simple, low-cost, low-technology intervention to reduce substantially the incidence of septicemia and mortality in the nursery.     

Perinatal Infection with listeria Monocytogenes

Summary: Listeria monocytogenes has been increasingly recognized as a cause of intrauterine sepsis with associated perinatal wastage. The condition is mostly acquired through dietary intake and appropriate advice should be given to all pregnant women. The most common presentations in pregnancy include premature labour, an influenza-like illness and reduced fetal movements.
In this report, we present a series of 24 cases of perinatal listeria infection presenting to either our obstetric or neonatal units and confirmed by the microbiology department of the hospital. In particular, we wish to highlight 3 cases in which antenatal diagnosis and aggressive therapy was associated with a successful outcome. Amongst the remaining 21 cases in which an antenatal diagnosis was not made, there were 5 perinatal deaths and 1 mid-trimester loss at 18 weeks.
Clinicians must maintain a high index of suspicion for listeria, particularly in gravid patients who present with fever in the setting of a persistent 'flu-like' illness and premature labour. Once suspected, appropriate specimens for listeria culture should include blood, cervical swabs and midstream urine. Empirical antibiotic therapy with amoxicillin should be instituted while waiting for culture results in patients with possible Listeria monocytogenes sepsis.     

Polymicrobial sepsis among intensive care nursery infants

To determine the incidence, characteristics, and course of polymicrobial sepsis among infants in intensive care nurseries, we reviewed all such episodes in our neonatal unit from September 1971 through June 1986. We identified 15 episodes (3.9% of all cases of culture-proven sepsis during the survey period) in which blood or cerebrospinal fluid (CSF) culture yielded multiple organisms felt to represent true pathogens. Mortality associated with late-onset polymicrobial sepsis (7 of 10; 70%) was significantly higher (P less than .001) than in late-onset monomicrobial sepsis (86 of 370; 23%). Six patients were 37 weeks' gestation or greater at birth, and five were younger than 4 days of age when the polymicrobial culture was obtained. Group D streptococci were recovered in eight cases (53%). Gastrointestinal foci appeared to be common among infants with late-onset polymicrobial infection (5 of 10), while prolonged rupture of membranes was frequently associated with early-onset infection (4 of 5). Though recovery of multiple organisms from blood or CSF may not always be significant, one should not immediately assume contamination. A report of more than one organism growing from a normally sterile body fluid in an intensive care nursery infant should be considered significant, and therapy should be adjusted to provide appropriate antimicrobial agents for all reported organisms if the infant has not substantially improved in the interval since the culture was actually obtained.     

Observations on 72 cases of septic abortions

This study examines the effect of liberalizing abortion on the number of septic abortions and complications. 72 women with postabortal sepsis (up to 20 weeks of gestation) admitted at the K.E.M. Hospital in Bombay comprised the study group. A detailed medical history was obtained and a thorough clinical examination conducted. 29.16% of the patients were unmarried and 41.66% were primigavidas. Dilatation and curettage were performed in 36 cases; colpotomy in 8; and laparotomy in 3. Maternal mortality rate was 11.11% and septic shock was the cause of maternal deaths in 75% of the cases. Of the 8 women who died, 6 had a history of criminal interference, suggesting that there are still women who avail of abortion services outside the hospitals and peripheral centers. Medical termination of pregnancy should not be taken lightly as it is not without complications. The incidence of sepsis and its sequelae would be reduced if adequate asepsis and proper selection of cases, and control of vaginal infection before performing abortion, are observed.     

Abortion-related morbidity and mortality in Benin City, Nigeria: 1973-1985

In a 13-year review of maternal deaths at the University of Benin Teaching Hospital, Benin City, abortion was one of the three major causes of death, accounting for 37 (22.4%) out of the 165 deaths. Induced abortion was responsible for 34 (91.9%) of these deaths. The usual victim is the teenage, inexperienced school girl who has no ready access to contraceptive practice. Death was mainly due to sepsis (including tetanus), hemorrhage and trauma to vital organs, complications directly attributable to faulty techniques by unskilled abortion providers, a by-product of the present restrictive abortion laws. Total overhaul of maternal child health services and the family health education system, as well as integration of planned parenthood at primary health care level into the health care delivery system, are suggested. Contraceptive practice should be made available to all categories of women at risk, and the cost subsidised by governmental and institutional bodies. Where unwanted pregnancies occur, the authors advocate termination in appropriate health institutions where lethal and sometimes fatal complications are unlikely to occur. In effect, from the results of this study and a review of studies on abortion deaths in Nigeria and other developing countries, it is obvious that a revision of abortion laws as they operate, notably in the African continent, is overdue.     

Causes of maternal death. A 10-year case analysis]

The causes of maternal deaths in our hospital from 1981 to 1989 were analysed. There were 12,819 live births and 6 maternal deaths during this period, a maternal mortality rate of 46.69/per 100,000. The main cause of maternal deaths was acute fatty liver of pregnancy (50%), and next cardiac disease, acute hemorrhagic necrotic pancreatitis and hemorrhage of subarachnoid space (each 16.67%). There was no death due to obstetric hemorrhage, pregnancy induced hypertension syndrome or ectopic pregnancy. It is suggested that needle biopsy of the liver should be done for pregnant women with jaundice of unknown cause. Pregnant women with cardiac disease should be under the care of both obstetrician and internist in collaboration and cesarean section is indicated when the woman's cardiac function remains at grade 3 or 4.     

Maternal intensive care and near-miss mortality in obstetrics

Objective To determine the level of near-miss maternal mortality and morbidity due to severe obstetrical complications or maternal disease in a tertiary maternity hospital.
Design Retrospective review.
Setting A free-standing maternity hospital delivering 5500 infants per year.
Methods The information coded in the perinatal database concerning women who had required transfer for critical care to a general hospital was reviewed for the 14 year period 1980 to 1993. The complications necessitating transfer and the specialised consultants and services required were noted.
Results Over 14 years there were 76,119 women delivered with two maternal deaths (2.6/100,000). Fifty-five women required transfer for critical care (0.7/1000). The main reasons for transfer were hypertensive disease (25%), haemorrhage (22%) and sepsis (15%). Transfer to an intensive care unit was required by 80%, and the remainder were transferred to specialised medical or surgical units. Twenty different specialist groups were consulted. The 55 patients spent 280 days in critical care and 464 days hospital after-care (mean 13 days, range 3–92).
Conclusion A review of near-miss maternal mortality helps delineate the continuing threats to maternal health and the type of support services most commonly required.     

A study of maternal mortality in Madras city

A 2-year (1974-75) study of maternal deaths occurring in 4 hospitals was undertaken to determine causes of maternal mortality in the city and their prevention. There were 393 maternal deaths from the hospitals for a maternal mortality rate of 4.5 for the hospitals or 2.0 per 1000 births for the city as a whole. 200 or 50.9% of these were due to direct obstetric causes (sepsis 38%; hemorrhages of pregnancy 27%; and prolonged labor 16.5%) and 193 (49%) were due to indirect or associated causes. Avoidable factors were seen in 60.6% of maternal deaths. The patient or her relatives were responsible in almost 1/3 of the cases, while the physician, midwife or in some cases, the institution were responsible in about 20% of the cases. Multiple factors were responsible in 8% of the cases and in 10, the lack of prompt transport facilities. An epidemic of infective hepatitis also contributed to the maternal death rate in 1975. The death rate was higher in the primiparas and grandmultiparas, and in women aged 35 and over. Most of the deaths occurred in unbooked cases and emergency admissions, in contrast to 9% in booked cases. The public should be educated on the benefits of prenatal care and early booking.     

Novel treatment for severe sepsis: recombinant human protein C (RHAPC)

STUDY DESIGN: Review of literature on novel therapy for severe sepsis within recombinant human protein C (rhAPC). DATA SELECTION: MEDLINE and Polska Bibliografia Lekarska (2000-2003) were the main sources of the reviewed articles. DATA SYNTHESIS: Despite advances in critical care the rate of death from severe sepsis ranges from 30 to 50 percent (data related to patients with this complication treated in the intensive care units in the United States). In Poland about one third (27.3%) of all maternal deaths in 1991-2000 were from severe sepsis. Since the introduction of antibiotics, the first significant progress in effective therapy for severe sepsis was achieved due to the novel therapy within rhAPC. In 2001 Bernard et al. reported results of multi-center, placebo-controlled, randomized trial, in which the administration of rhAPC at 24 microgram/kg/h/96 hrs increased the survival in patients with severe sepsis by 6.1% (mortality rate was 24.7% for rhAPC group, while 30.8% for placebo group). There was an insignificant tendency for more bleeding in rhAPC patients (3.5% vs. 2.0% with placebo). In 2003 Dhainaut et al. described the pharmacological effects of rhAPC on severe sepsis. Fifteen biomarkers of inflammation or thrombosis/fibrinolysis were monitored. It was established that rhAPC decreases host response to infection resulting in lowering the levels of all inflammatory cytokines (TNFalfa, IL-1, IL-6 and IL-8), as well as lowering procoagulant markers, mainly D-dimers. CONCLUSION: Sufficient data are available to approve rhAPC for treatment of patients with severe sepsis. Both anticoagulant and antiinflammatory properties of rhAPC, as well as profibrinolytic activity, are the rationale for the use of rhAPC.     

Tuberculosis in association with HIV/AIDS emerges as a major nonobstetric cause of maternal mortality in Sub-Saharan Africa

Every year, approximately 250 000 African women die during pregnancy, delivery, or the puerperium. Maternal mortality rates due to infectious diseases in Sub-Saharan Africa now supersede mortality from obstetric causes. Evidence is accumulating that tuberculosis associated with HIV/AIDS, malaria, sepsis, and other opportunistic infections are the main infectious causes of maternal deaths. Screening for these killer infections within prenatal healthcare programs is essential at this stage to prevent and treat causes of maternal mortality. The combination of proven effective interventions that avert the greatest number of maternal deaths should be prioritized and expanded to cover the greatest number of women at risk, and incorporated into a “prophylaxis and treatment community package of care.” The effectiveness of these “packages of care” will need to be determined subsequently. Maternal deaths from tuberculosis are now on the increase in the UK, and due diligence and watchful surveillance are required in European prenatal services.     

A clinical and microbiological study of puerperal sepsis in a tertiary care hospital in India

Objective: This prospective study was carried out to evaluate the clinical profile and bacterial isolates among women with puerperal sepsis in a tertiary hospital in North India.

Materials and methods: Women with puerperal sepsis (n?=?45) admitted from January 2015 to April 2016 were followed prospectively. Cultures were obtained from cervix, blood, urine, and pyoperitoneum. Initial antibiotics were cefotaxime or piperacillin with tazobactam plus amikacin plus clindamycin or metronidazole and were changed according to sensitivity.

Results: Out of 7887 deliveries during this period, 45 (0.2%) women had puerperal sepsis. 16 (35.5%) delivered in the present hospital, 25 (55.5%) at another health care facility, and 4 (8.9%) at home. Delivery was by cesarean section (CS) in 24/45 (53.3%) and vaginal in 21/45 (46.6%). Grade 1 sepsis occurred in 21, grade 2 in two, and grade 3 in 22 women. Majority (29/45 or 64.5%) had no risk factor for puerperal sepsis. There were two (4.4%) deaths and 13/45 (28.8%) had near-miss morbidity. Pathogenic bacteria were isolated in 33/45 (73.3%) in cervical swab (69%), blood, urine, or pus culture with no significant difference in the bacterial yield or species isolated between cotton or polyester swabs (p?>?.05). Escherichia coli were the commonest isolate and was sensitive to amikacin in all. Five had stillbirths and 4/40 neonates developed sepsis but recovered.

Conclusions: Escherichia coli was the commonest pathogen and was uniformly sensitive to amikacin, which may be included among the initial antibiotics to treat puerperal sepsis in India.     

Sepsis During Pregnancy

The incidence of maternal mortality related to sepsis has decreased during the past 2 decades because of the availability of broad spectrum antibiotics and advances in critical care. However, sepsis continues to account for approximately 7.6% of maternal deaths in the United States. This article focuses on intraamniotic infection as a source of maternal sepsis. Common causative pathogens, typical sources of sepsis, and related pathophysiology are reviewed. Nursing and medical management strategies are included. A case study is presented to illustrate the typical clinical course from infection, to bacteremia, sepsis, and septic shock.     

Pre-eclampsia: maternal risk factors and perinatal outcome

OBJECTIVE: The aim of this study was to throw light on the incidence of pre-eclampsia (PE) in women attending for care and delivery at a hospital in Saudi Arabia, and analyze the maternal risk factors and outcome of mothers and neonates in pregnancies complicated by PE. METHODS: This retrospective study involved almost all women (n = 27,787) who delivered at King Fahad Hospital of the University in a 10-year period (1992-2001). The maternal records were reviewed for age, parity, gestational age, mode of delivery, antenatal care, onset of PE, severity of proteinuria, and the frequency of antenatal and intrapartum complications. The neonatal records were reviewed for perinatal outcome including birth weight, frequency of stillbirths, and neonatal deaths. RESULTS: Among the study cohort of pregnancies, 685 women, i.e. 2.47%, were diagnosed as having PE among whom a high proportion (42.0%) were nulliparous women. Similarly, PE was encountered at a high percentage (40.0%) in women at the extreme of their reproductive age (< 20 and >40 years), and more women with PE delivered prematurely (30.2%) as compared to healthy controls (13.5%). Spontaneous vaginal deliveries were less frequent in women with PE (69.2%) as compared with healthy controls (86.2%). Instrumental deliveries, with spontaneous labor, amounted to 15.9% in women with PE, but they comprised only 2.9% in healthy women. The deliveries were more likely to be induced (22.8%) or be performed by cesarean section (14.9%) in women with PE than in healthy controls (6.8% and 9.6%). Placental abruption was the most common maternal complication (12.6%) in women with PE, followed by oligouria (7.9%), coagulopathy (6.0%), and renal failure (4.1%). The perinatal outcome of pregnancies with PE shows that stillbirths (2.34%) and early neonatal deaths (1.02%) comprised an overall mortality rate of 33.6 per 1,000. More stillbirths and neonatal deaths showed a tendency to be associated with the severe form of PE (diastolic BP > or =120), as compared with the mild form (diastolic BP 90-110). Stillbirths and neonatal deaths appear to be associated with women who had no or irregular antenatal care and whose proteinuria amounted to or exceeded 3 g per 24 h, when delivery occurred at 28th gestational week or less, and when the birth-weight of the neonates was between 500 and 1,000 g. CONCLUSION: We document a hospital-based incidence rate of PE of 2.47%, with a high proportion of PE cases occurring among nulliparous women and those at the extreme ends of the reproductive age. More maternal and neonatal complications were encountered in women with PE when the PE was severe, when the pregnancy had to be terminated early, when there was no regular antenatal care, the birth-weight was low, or the proteinuria was severe.     

Ausgewählte tropische Infektionskrankheiten in der Schwangerschaft

About 500,000 pregnant women and 4 million babies die during the first 4 weeks of life every year, and in the last 3 months of pregnancy 4 million babies are stillborn; 99% of these deaths occur in developing countries, reflecting the poor standard of medical care and hygiene. The high mortality of pregnant women and newborns is due to malnutrition, bleeding, anemia, hypertension, miscarriage, abortion, obstructed labor, and infections. High-risk infections for pregnant women and their unborn children are Plasmodium falciparum malaria, helminthic infections, hemorrhagic fever viruses, hepatitis E, but also toxoplasmosis, tetanus, puerperal sepsis, and HIV. Pregnant women should be discouraged from traveling to tropical areas and countries with poor standards of hygiene and medical care. When undertaking a journey, pregnant travelers should be vaccinated against tetanus, poliomyelitis, diphtheria, measles, mumps, rubella, and varicella. Depending on the destination prophylaxis or vaccinations for malaria, hepatitis A and B, typhoid fever, yellow fever, meningococci, rabies, and Japanese encephalitis are recommended. If possible, all these vaccines should be administered before the pregnancy.     

Non-haemorrhagic obstetric shock.

The causes of non-haemorrhagic obstetric shock (pulmonary thromboembolism, amniotic fluid embolism, acute uterine inversion and sepsis) are uncommon but responsible for the majority of maternal deaths in the developed world. Clinically suspected pulmonary thromboembolism should be treated initially with heparin and objective testing should be performed. If the diagnosis is confirmed, heparin is usually continued until delivery, following which anticoagulation in the puerperium is achieved with either warfarin or heparin. Amniotic fluid embolism is a rare complication of pregnancy, occurring most commonly during labour. The management of amniotic fluid embolism involves maternal oxygenation, the maintenance of cardiac output and blood pressure, and the management of any associated coagulopathy. Acute uterine inversion arises most commonly following mismanagement of the third stage of labour. The shock in uterine inversion is neurogenic in origin, although there may also be profound haemorrhage. The management of this condition includes maternal resuscitation and replacement of the uterus either manually, surgically or by hydrostatic pressure. Genital tract sepsis remains a significant cause of maternal death, the most common predisposing factor being prolonged rupture of the fetal membranes. The management of septic shock in pregnancy includes resuscitation, identification of the source of infection and alteration of the systemic inflammatory response.     

Infections in VLBW infants: studies from the NICHD Neonatal Research Network

Infection is a serious complication among very low birth weight (VLBW) preterm infants hospitalized in neonatal intensive care units. This article reviews studies from the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network including infection data from observational studies and randomized controlled trials. Blood culture-proven early-onset sepsis (< or = 72 hours) was found in less than 2% of VLBW infants, but was associated with substantial morbidity and mortality. A change in pathogens causing early-onset sepsis among Network patients has been observed over the past decade, with a significant reduction in early-onset group B streptococcal infections, but also a significant increase in early-onset Escherichia coli infections. This change is particularly worrisome, because of the high death rate associated with gram-negative infections, including E coli. Late-onset (> 72 hours) sepsis developed in almost a quarter of infants. The vast majority of infections were caused by gram-positive agents, especially coagulase-negative staphylococci. The risk of late-onset sepsis was inversely related to birth weight and gestational age. Infants with late-onset sepsis were at increased risk for a number of neonatal morbidities, for prolonged hospitalization, and for death. The percentage of deaths attributed to infection increased with increasing postnatal age. The increasing survival of extremely immature infants has resulted in a cohort of infants at prolonged risk for acquired infection. Successful strategies to reduce infections among VLBW infants would improve survival, reduce neonatal morbidity, and reduce the high medical and social costs of VLBW infant care.