Date

London Maternal Mortality Learning and

Sharing event

London Maternal Morbidity & Mortality

Working Group

8th September 2016

Date

Session Three Medical risk factors and

complex cases

Dr Renate Wendler, Consultant Anaesthetist

St. George’s UHFT

Mr Richard Howard, Consultant Obstetrician

BHR Hospitals

8th September 2016

3

Medical Risk Factors

18 patients had co-existing medical disease • Not all conditions causative of maternal death • Examples

• Diabetes (4) • Hypertension (1) • Epilepsy (1)

• 9 BMI over 30 (9) with 3 over 40 • 3 patients died of cancer

In 8 cases underlying condition causative for death

4

Causative for Maternal Death

• Cardiomyopathy • Pre-existing pulmonary disease • Sickle Cell Disease • Megarectum • Addison’s Disease • SLE • Scleroderma • Behcets syndrome

5

Connective Tissue Disorders

Variety of chronic multi-system disorders, many with autoimmune origin • Mostly diagnosed in child-bearing age • Difficult diagnosis as multiple unrelated symptoms • Counselling important • MDT care • Knowledge of medication safety crucial • High risk of

• Thromboembolic complications • Pregnancy related disease (PIH, PET) • Adverse fetal outcome

6

Contraindications for Pregnancy

Relative contraindication to pregnancy if • Severe flare or stroke past 6 months • Pulmonary hypertension • Moderate/severe heart failure • Severe restrictive lung disease • Chronic kidney disease stage 4/5 • Uncontrolled hypertension • Previous early onset PET despite preventive therapy

7

SystemicLupusErythematosus (SLE)

Case specifics • 34, G5, P3, delivered at 35 weeks, F&W • Possible cutaneous Lupus signs in retrospect • Admitted after 4 weeks with severe SLE • Treated in hospital 4 weeks • Re-admitted 5 days later with peri-myocarditis • Later malignant hypertension and PRES syndrome • Transferred to tertiary centre, poor response to lupus

treatment and deteriorating cardiac function. Possible sepsis

8

SystemicLupusErythematosus (SLE) General considerations • Chronic inflammatory disease (immune system disorder) • Unclear if pregnancy increases risk of Lupus flares, risk

postnatal • Risk dependent on status 6 months before • Rarely severe flares with major organ involvement can

occur • Difficult to distinguish pregnancy related symptoms from

Lupus features • Risk x 4 for PET and thrombus • Risk x 2-6 for fetal loss

9

Scleroderma (Systemic Sclerosis)

Case specifics

• 32, G1, recent diagnosis of scleroderma

• Due to unstable condition, TOP was advised

• Disease flare up, OC, PET

• Emergency delivery at 31 weeks (maternal

respiratory failure)

• Prolonged ITU stay

• Tracheal-oesophageal fistula with terminal rupture

10

Scleroderma (Systemic Sclerosis)

General considerations • Connective tissue disease (overproduction of collagen) • Increased risk for hypertensive disorders in pregnancy • Gastrointestinal symptoms worsen (reflux) • Assessment of aggressiveness of disease prior to

pregnancy advised • Rare: renal crisis- requires ACE inhibitors (despite

contraindication in pregnancy) • 14 -29 % increased risk of preterm delivery and IUGR,

but steroids for fetal lung maturation not indicated

11

Vasculitis Syndromes (for example Behcet’s disease)

Case specifics • 29, G2 P1, 3 months pp • Now 5 wks pregnant presented to ED with

headache, vomiting and being unwell for 2 days • No localised neurology • On hyperemesis pathway, improved, discharged

after 20 hours • Found dead 7 hours later • PM intracranial haemorrhage, cerebral thrombosis/

Neuro-Behcet’s disease

12

Vasculitis Syndromes (for example Behcet’s disease)

General considerations • Behcet’s characterised by generalised blood vessel

inflammation • Autoimmune disease (genetic disposition?) • Risk low if in remission • Behcet’s patients have high flare rates between 25

and 65%

13

Pregnancy Management

Medication • Some immuno- suppressants need to be changed

before conception • Check for steroids/NSAIDS • Anticoagulation due to high risk for VTE • Consider medication effect on fetus/newborn

(NSAIDs, live vaccine)- risk benefit

14

Pregnancy Management Planning • MDT approach with lead clinician • Tertiary centre assessment • Risk assessment for

• VTE • PIH/PET • GDM

• Low dose aspirin if high risk for PET (SLE and lupus nephritis)

• Calcium and Vit D if on steroids • Fetal surveillance

15

Postpartum Management

High risk of flares in post-partum period • Surveillance for 2 -3 months • VTE prophylaxis pp essential • Counselling for future pregnancies and

contraception

16

SESSION TAKE HOME MESSAGE

• Many patients with connective tissue disease tolerate pregnancy well, but check for contraindications

• Important to risk assess for pregnancy related complications

• These can be difficult to recognise as may look similar to disease flare

• Higher risk for adverse fetal outcome • Requires MDT care and expert involvement that is co-

ordinated by lead clinician

Date

Recommendation 8.5

Continuity of care(r)

Richard Howard Sue Lovell

Consultant Obstetrician Consultant Midwife

8th September 2016

18

Professor Giovanni Galli University of Bolonga 1758 Teaching the science of obstetrics to midwives

19

2015 London maternal deaths

A number of cases identified where continuity of carer was mentioned in SI report

A particular concern in London is women who move between units for care

20

Increasing the number of women who receive continuity of midwife care: A best practice

toolkit

London Strategic Clinical Networks

April 2015

21

National Maternity Review 2016

Better Births

Improving outcomes of maternity services in England

22

Better Births 2016

2 Continuity of carer, to ensure safe care based on relationship of mutual trust and respect in line with the woman’s decisions

1 Every woman should have a midwife, who is part of a small team of 4 to 6 midwives, based in the community who knows the women and family, and can provide continuity throughout the pregnancy, birth and postnatally.

2 Each team of midwives should have an identified obstetrician who can get to know and understand their service and can advise on issues as appropriate.

3 The woman’s midwife should liaise closely with obstetric, neonatal and other services ensuring that she gets the care she needs and that it is joined up with the care she is receiving in the community

23

A best practice toolkit Key messages:

• A woman and her individual needs should be central to model design

• There should be engagement with midwives

• IT and clerical systems should support the aim that majority of care is provided by named midwife

• A back up midwife (or midwives) who the woman has met should be available

• Easy communication with midwife by telephone

• Interdisciplinary collaborative approach means midwifery care continues to be provided, even when complications arise

How are we implementing this…

24

Continuity of carer, to ensure safe care based on relationship of mutual trust and respect in line with a woman's decisions 2.1 Every woman should have a midwife who

is part of a small team of 4-6 midwives based in the community

Providers CCG

Currently small teams 2 midwives to see women antenatal and postnatal Work being developed on continuity of care. Named Midwife for some of the clinics.

Audit of notes

Currently the teams are 5.8-6.4WTE but not all the staff are full time Currently there is a staffing issue – need further teams Name midwife needs addressing Antenatal / postnatal continuity of care

AP/CCG

2.2 Each team of midwives should have an identified obstetrician

Providers Development of a Link Consultant for each Community team

No Link Consultant at present.

Discussion at consultant meeting to look at possibility- also needed for the wards

AP

2.3 Community hubs should enable women to access care in the community

CCG / Providers

Care currently being performed at community clinics

Workshops being performed looking at community models

all teams have a hub and provide antenatal and postnatal care- this needs encouraging this could be developed in Lox ford and Fanshawe clinincs.

AP/CCG

2.4 The midwife should liaise closely with other services to ensure care is correct and joined up

Providers Handover sheet at 10 days Homebirths-transfer of information to the health visitor

Audit of records

Possibility of electronic discharge to HV via E3 – this requires an audit. Fetal medicine team have m-d team meetings. Suggestion that they book women who have had a fetal abnormality.

AP

Number

Recommendation Owner Current service at BHRUT Monitoring Gaps BHR

25

Problems going forward

For BHRUT to achieve full compliance with Better Births and ensure continuity of care for all low risk women we would need large increase in midwifery staffing

Named consultant not in place for each team of midwives – is this necessary for low risk women?

Community only hubs partially in place

There is a lack of joined up working with health visitors (HV). Not enough health visitors. Need to find better way of communication with HV especially for complex women

Date

Recommendation 8.8

Pulmonary Embolism

Richard Howard

Consultant Obstetrician and Gynaecologist

Queen’s Hospital, Romford

8th September 2016

27

Case study 2013

• Aged 34

• IVF pregnancy

• Fetal Hydrops and pleural effusions at 36 weeks

• IUD shortly after diagnosis

• Induction of labour with misoprostol

• Long labour(18 hours) Breech delivery. Atonic uterus. Obstetric haemorrhage 2L and blood transfusion (4 units)

• IV antibiotics for infection. Clexane while on ward

• Discharged on day 3. Clexane not given as TTA

• Sent back to Triage by community midwife (day 5) as “breathless.” Assessed in triage by medical team but no abnormality detected.

• Discharged home same day

• Day 16. Found dead at home. DVT and pulmonary embolism

28

RCOG Green Top Guideline 37a

29

2015 London maternal deaths

• One woman died of confirmed PE two weeks after delivery

• PE occurred in one other woman associated with malignancy

• PE was cause of death in another woman at emergency caesarean section

• VTE assessment mentioned in SI report as learning objective in three other cases (concerns that assessments not done or LMWH injections not given as prescribed)

30

RCOG Green Top Guideline

• Pulmonary embolism is one of the leading direct causes of maternal death in UK

• 70-80% of fatal and non-fatal PE in pregnancy in UK have been shown to have identifiable risk factors

• NICE estimates that LMWH reduces VTE risk by 60-70% in medical and surgical patients

• Incidence of VTE in pregnancy and puerperium is 1-2/1000

• The risk of VTE increases with gestational age reaching a peak just after delivery

• Caesarean section is a risk factor and the relative risk is 5X higher in puerperium compared to antenatal period

31

MBRRACE 2015

32

• More than four fifths of the women who died from VTE between 2009 and 2013 had recognisable risk factors for thromboembolism.

• In many cases, these risk factors were either not recognised, or not acted upon

• In several instances, miscommunication or missing communication at the secondary-primary care interface led to inadequate thromboprophylaxis which may have prevented some women’s deaths

• In the light of the ongoing decrease in direct maternal death rates, deaths from venous thromboembolism remain the major group where a decrease is not currently occurring, highlighting the particular importance of careful assessment of individual women’s risk of thromboembolism in order to aid prevention

33

Prevention and treatment of thrombosis

and thromboembolism (MBRRACE 2015)

All women should undergo a documented assessment of risk factors for venous thromboembolism in early pregnancy or pre-pregnancy. This should be repeated intrapartum or immediately postpartum and if the woman is admitted to hospital or develops other intercurrent problems.

Prescription for the entire postnatal course of low molecular weight heparin (LMWH) should be issued in secondary care.

Predictive tools for pulmonary embolism used outside pregnancy to

determine the need for radiological investigation, such as the Wells score, are not validated for and should not be used in pregnancy.

Pregnant and postnatal women presenting to the Emergency Department

with medical problems should be discussed with a member of the maternity medical team. This should ensure appropriate investigations and treatments for pulmonary embolism are not withheld and prophylaxis is prescribed where appropriate.

34

Risk Stratification

Some form of risk stratification necessary as absolute risk is

low

Threshold for recommending post-natal thromboprophylaxis

is lower than that for antenatal thrombophrophlaxis as the

risk per day is higher and duration of risk is shorter

35

Slide heading

Sub heading

• Bullet point 1

• Bullet point 2

Sub heading 2

• Bullet point 1

• Bullet point 2

36

Auditable standards (RCOG)

37

• Correct risk assessment at booking, on admission to antenatal ward, after delivery and at discharge (100%)

• Correct dose of LMWH (based on weight) prescribed antenatally and postpartum (100%)

• LMWH prescribed and taken for 10 days postpartum in all women with class 3 obesity (BMI greater than or equal to 40) (100%)

• LMWH prescribed and given for 6 weeks postpartum in all women with previous VTE (100%)

Patient information leaflets

38

Monthly audit VTE assessments BHRUT

• VTE assessments dropped from 60% in March

to 50% in April for antenatal clinic visits

40

What am I going to do at Queen’s Hospital?

• Discuss with audit lead to consider using RCOG Audit

• Standards

• Currently doing audit on numbers of women with DVT and

• PE in our population

• Consider introducing information leaflets on DVT/PE for

• Women

41

SESSION TAKE HOME MESSAGE

CONTINUITY OF CARER Better Births National Maternity Review On-going work with commissioners

PULMONARY EMBOLISM A leading cause of direct death Can we do better with VTE assessments and thromboprophylaxis?