Saving Mothers' Lives. The 2006 - 2008 Report.

This is the title of the 8th. Report of the Confidential Enquiries into Maternal Deaths in the UK.

Published in March 2011.

Covering the years 2006 - 2008.

It was produced by "CEMACE".

You can access it via the BJOG website.

This is CEMACE's last Report: future reports will be produced by mbrrace.

It sound like a device to support a hernia or bad back in pregnancy!

A major change was the emergence of sepsis as the leading direct cause of death.

This was due to the numbers increasing from 18 in 2003 - 2005 to 26.

And the numbers of deaths from VTE falling from 41 to 18.

This is a significant fall and presumably reflects better prophylaxis and management of suspected VTE.

Twenty years ago, when writing about these Reports, I used to say something about VTE and PET vying with each other to be the main direct cause of death.

In recent Reports, PET faded into the "also-rans".

But in this Report, it returns as runner-up, a measure of the size of the fall in VTE deaths.

	2000-2002	2003-2005	2006-2008
Sepsis	13	18	26
PET & eclampsia	14	18	19
Thrombosis	30	41	18
Early pregnancy	15	14	11

Everyone involved in the care of pregnant women can take pride from this achievement.

One thing that caught my eye is in chapter 6: "Deaths in early pregnancy".

We have spoken in the tutorials about the need to become paranoid to be a good obstetrician and gynaecologist.

You walk on a beach and there is no one to be seen.

But, as a POG, paranoid obstetrician / gynaecologist, you sense there are women there.

And that they are all pregnant, some with ectopic pregnancy, some with placenta previa, some about to have cord prolaplse or PPH etc.

But, like a good boy scout or girl guide, you are always prepared and are already considering the possibilities and your actions.

You are constantly looking ahead - always thinking: "what next"?

"OK, she has has had an abruption, but we are on top of it and she will soon have a C. section."

"How will we suture a Couvelaire uterus, manage her PPH, deal with the coagulation problems that arise........"?

The thing I really liked was that the author, Prof. Colm O'Herhily, wrote:

" the term ‘pregnancy of unknown location’ based on early pregnancy ultrasound examination should be abandoned".

We did an EMQ on early pregnancy complications in a recent tutorial.

One scenario was:

• A primigravid woman attends the A&E department with abdominal pain and vaginal bleeding.

• A home pregnancy test was +ve 1 week ago; the date of the LMP is uncertain.

• What will be your management?

K.    Explain diagnosis and refer to the EPU for PUL protocol.

The option list was:

• A.    Admit as an emergency case.

• B.    Counsel and arrange TVS in 1 week.

• C.    Counsel and arrange TV colour Doppler scan.

• D.    Counsel re expectant management.

• E.    Explain diagnosis and counsel re MEUC and SEUC.

• F.    Explain diagnosis and counsel re expectant management and MEUC and SEUC.

• G.    Explain diagnosis and counsel re expectant management, MEUC and SEUC and refer to the EPU.

• H.    Explain diagnosis and counsel re treatment options with accent on the relative merits of SEUC and refer to the EPU.

• I.     Explain diagnosis and counsel re treatment options with accent on the relative merits of MEUC and refer to the EPU.

• J.     Counsel re missed miscarriage and refer to the EPU.

• K.    Explain diagnosis and refer to the EPU for PUL protocol.

• L.    Explain diagnosis and refer to the EPU for PUV protocol.

• M.   Manage as ectopic pregnancy until proven otherwise.

• N.    Arrange progesterone assay.

• O.   Arrange AFC.

• P.    Arrange AMH assay.

• Q.   Arrange serial hCG monitoring for 48 hours.

• R.    Administer anti-D immunoglobulin.

• S.    Administer ergometrine 0.5 mg i.m.

• T.    Prescribe mifepristone.

• U.    Prescribe misoprostol for vaginal use.

• V.    Continue with routine booking.

Many of the students chose "K": Explain diagnosis and refer to the EPU for PUL protocol"."

I didn't like this answer.

Not in any way paranoid enough!

"Pregnancy of unknown location" is not a phrase that will keep you awake at night.

It sounds like a nice little puzzle to keep you amused, like Sudoku or a crossword.

I want something to trigger a Pavlovian response.

Yes, the EPU will have a protocol for the management of this situation.

And most women with PUL will be managed in the EPU.

What we need is the “brown underwear avoidance” approach to O&G, which we have discussed in the tutorials.

In essence, and somewhat crudely, you see a woman.

As a man you might think: "she is really gorgeous".

As a woman you might think: "I like her shoes", or, less kindly: "mutton dressed as lamb".

But as a POG, you think: "she is pregnant - what can she do this second to make me shit my pants in terror"?

And "what can she do to make me shit my pants in half an hour / an hour / when I turn my back / tomorrow / next week / etc."?

A POG can only see one answer: M, with "ECTOPIC PREGNANCY" flashing like a neon danger sign.

A POG will hear alarm bells and feel fear in their soul.

A good POG treats this situation as an ectopic pregnancy from the moment of encounter.

What is her condition?

Is she going to collapse before my very eyes?

Should I site an i.v. line and take bloods immediately in anticipation of her collapse?

Is she fit to be sent to the EPU or should I admit her here?

How far away is the EPU?

(Remember that it could be miles away on a different hospital site.)

Does she need a nurse to accompany her?

What if she collapses on the way?

On a lesser note, I also liked the first sentence of this chapter:

• "all women of reproductive age presenting to Emergency Departments with gastrointestinal symptoms should have a pregnancy test".

This is a good POG response.

We have heard from recent maternal mortality reports that GI symptoms are often the main presenting features of ectopic pregnancy.

The POG thinks:

• "You are female, therefore you are pregnant".

• "You have come to the ED with GI symptoms, therefore you have an ectopic pregnancy".

It is a different way of thinking, but it will surely keep you and your patients out of trouble.

The Report included "Ten Top Recommendations".

I have left the 10 top recommendations from the 2003 - 2005 Report on the website for comparison.

MRCOG candidates should know them - make out a card.

Maternal mortality is covered in the MCQs.

Question 13 in the information booklet.

This has been updated, though not completely.

And the following two, which are being updated.

MCQ paper 5, question 18.

MCQ paper 9, question 1.