Last week we returned to the pub for the latest NWRAG journal club. This time we cast our eyes over one of the latest important reports in the form of the MBRRACE-UK report released in December 2014. MBRRACE, standing for the marginally less snappy ‘Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries across the UK’, represents the latest version of the triennial reports looking at maternal deaths in the UK, previously under the acronyms of CMACE and CEMACH. Due to varying (apparently political and funding) issues, necessitating reorganisation, this report actual covers the 4 year period of 2009 to 2012. Similar to the previous incarnations that have been running since 1952, it examines all the maternal deaths that occur in the UK, striving to detect common themes of failure where practice and outcomes can be improved. At 120 pages the report is pretty hefty, but you can check it out at the link below. The aim of this blog was to provide something of a summary of our thoughts from reviewing the report, and which we think are the key points.
MBRRACE Homepage
MBRRACE Homepage
Methods
To aid with an understanding of what the report represents, a quick summary of the methods they employed is probably appropriate. The death of any mother is clearly a tragic event, but is now also fortunately quite an infrequent one. This, along with the long history of the confidential enquiries, means that the majority of such events are now reported directly to the MBRRACE group. There is also reporting through coroners, local midwifery officers, members of the public and cross-checking through death certificate records, hopefully providing full catchment of all these events in the UK. When an event is identified, packs requesting information is sent out to the relevant clinical teams involved in the patient’s care and returned to the MBRRACE teams where it is analysed with any additional information e.g. post mortem results. Each case is analysed by a multidisciplinary teams of 10-15 clinicians (obstetricians, midwives, anaesthetists) and areas where care might have been improved are identified, as is the cause of the death. Cases with common themes (e.g. sepsis) are then summarised as focused chapters and learning points outlined.
Summary
General Points
The main points to take away from the review are as follows:
· Maternal death rates have continued to improve, and are lower than the 2006-08 review.
· This is primarily through a reduction is deaths resulting directly from the pregnancy itself.
· The maternal death rate is now 10 per 100,000 women giving birth
· 1/3rd of deaths resulted from causes directly linked to the pregnancy (e.g. bleeding)
· 2/3rd of deaths resulted from indirect causes (e.g. medical conditions, mental health conditions)
· Indirect deaths remain unchanged in their incidence, with no real change over the past 10 years.
· 29% of women received good care that it seemed could not have been improved upon
· In 52% of cases, improved care would have probably changed the outcome
Sepsis
· 83 women died from sepsis,
· 20 died from genital tract sepsis (considered directly linked to pregnancy), which is a significant decrease compared with the previous report
· 36 women died from influenza which was a major cause of indirect deaths
· Delay in recognition of both the final diagnosis and severity were common themes
· Similarly, delay or incomplete implementation of sepsis care bundles was noted in several cases, particularly relating to delay in antibiotic administration
· Fluid resuscitation was often late and inadequate
· Consideration of influenza as a diagnosis was almost universally delayed, and hence so was treatment
Haemorrhage
· There were 17 deaths due to obstetric haemorrhage
· This represents a relatively unchanged incidence from the previous report
· Atony and genital tract trauma were common causes
· Pathology traditional high risk for haemorrhage were less commonly a cause of death (2 cases from abruption and 1 from placenta percreta)
· Underestimation of blood loss was a common factor, particularly in smaller patients (9 deaths were in women weighing under 60kg)
· The severity was not recognised in 11 cases (61%)
· Inadequate observations were a feature in 7 deaths, and escalation of abnormal observations didn’t occur in 5 cases
· Inadequate resuscitation contributed to many of the deaths, with blood and blood components being given too little and too late.
· A falsely reassuring Hb results from a bedside analyser (taken prior to resuscitative haemodilution) contributed to 3 deaths
· Delay in achieving surgical control of bleeding (turning off the tap) led to several deaths, and progression to hysterectomy was often delayed
· Misuse of uterotonics led to 3 deaths through uterine rupture
Amniotic Fluid Embolism
· 11 women died from AFE
· Induction of labour is an identified risk factor, with induction or augmentation in 6 cases
· Perimortem c-section was delayed in all cases where it was indicated, with none in the 5 minutes after confirmed cardiac arrest that is recommended.
Lessons For Anaesthesia
· Direct deaths from anaesthesia are now fortunately very rare
· However, in the deaths that occur, there are often a multitude of contributing factors in which anaesthetists can be involved
· An awareness of the potential for ‘fixation error’ and appropriate steps to mitigate it should be a high priority
· Human factors, including poor communication, were a factor in many deaths
· Subdural haemorrhage and cerebral venous sinus thrombosis should be included as a differential diagnosis when post-dural puncture headache is considered
Medical Conditions
· Epilepsy is a high risk disease in pregnancy, a fact that is often forgotten.
· Appropriate specialist input, including from epilepsy specialist nurses, is an area that was neglected in many of the deaths from epilepsy.
· Sudden unexplained death in epilepsy (SUDEP) remains the major cause of death in mothers with epilepsy
· Concerns about the potential effects of medication on the foetus was noted as a cause of non-compliance with medication in a number of medical conditions.
· Inadequate consideration of differential diagnoses in pregnant women who presented with unusual symptoms was a common theme.
The main points to take away from the review are as follows:
· Maternal death rates have continued to improve, and are lower than the 2006-08 review.
· This is primarily through a reduction is deaths resulting directly from the pregnancy itself.
· The maternal death rate is now 10 per 100,000 women giving birth
· 1/3rd of deaths resulted from causes directly linked to the pregnancy (e.g. bleeding)
· 2/3rd of deaths resulted from indirect causes (e.g. medical conditions, mental health conditions)
· Indirect deaths remain unchanged in their incidence, with no real change over the past 10 years.
· 29% of women received good care that it seemed could not have been improved upon
· In 52% of cases, improved care would have probably changed the outcome
Sepsis
· 83 women died from sepsis,
· 20 died from genital tract sepsis (considered directly linked to pregnancy), which is a significant decrease compared with the previous report
· 36 women died from influenza which was a major cause of indirect deaths
· Delay in recognition of both the final diagnosis and severity were common themes
· Similarly, delay or incomplete implementation of sepsis care bundles was noted in several cases, particularly relating to delay in antibiotic administration
· Fluid resuscitation was often late and inadequate
· Consideration of influenza as a diagnosis was almost universally delayed, and hence so was treatment
Haemorrhage
· There were 17 deaths due to obstetric haemorrhage
· This represents a relatively unchanged incidence from the previous report
· Atony and genital tract trauma were common causes
· Pathology traditional high risk for haemorrhage were less commonly a cause of death (2 cases from abruption and 1 from placenta percreta)
· Underestimation of blood loss was a common factor, particularly in smaller patients (9 deaths were in women weighing under 60kg)
· The severity was not recognised in 11 cases (61%)
· Inadequate observations were a feature in 7 deaths, and escalation of abnormal observations didn’t occur in 5 cases
· Inadequate resuscitation contributed to many of the deaths, with blood and blood components being given too little and too late.
· A falsely reassuring Hb results from a bedside analyser (taken prior to resuscitative haemodilution) contributed to 3 deaths
· Delay in achieving surgical control of bleeding (turning off the tap) led to several deaths, and progression to hysterectomy was often delayed
· Misuse of uterotonics led to 3 deaths through uterine rupture
Amniotic Fluid Embolism
· 11 women died from AFE
· Induction of labour is an identified risk factor, with induction or augmentation in 6 cases
· Perimortem c-section was delayed in all cases where it was indicated, with none in the 5 minutes after confirmed cardiac arrest that is recommended.
Lessons For Anaesthesia
· Direct deaths from anaesthesia are now fortunately very rare
· However, in the deaths that occur, there are often a multitude of contributing factors in which anaesthetists can be involved
· An awareness of the potential for ‘fixation error’ and appropriate steps to mitigate it should be a high priority
· Human factors, including poor communication, were a factor in many deaths
· Subdural haemorrhage and cerebral venous sinus thrombosis should be included as a differential diagnosis when post-dural puncture headache is considered
Medical Conditions
· Epilepsy is a high risk disease in pregnancy, a fact that is often forgotten.
· Appropriate specialist input, including from epilepsy specialist nurses, is an area that was neglected in many of the deaths from epilepsy.
· Sudden unexplained death in epilepsy (SUDEP) remains the major cause of death in mothers with epilepsy
· Concerns about the potential effects of medication on the foetus was noted as a cause of non-compliance with medication in a number of medical conditions.
· Inadequate consideration of differential diagnoses in pregnant women who presented with unusual symptoms was a common theme.
Final Thoughts
That’s quite a brief summary for a 120 page report, but I think it covers the majority of the important points. After a read through the report there are definitely a few common themes that show through. Top of the list is the number of times that ‘human factors’ played a major role in the poor outcome. Inadequate communication, poor leadership, poor situational awareness and inflexibility of thought were mentioned in multiple chapters and multiple deaths. My impression is that an awareness of these factors is increasingly being recognised as a vital component of medical training, particularly in anaesthesia, but I’m sure we can all think of times when the above failures have occurred own clinical practice, just without the disastrous results.
Secondly, from the numbers in the report it’s clear that the lessons from previous reports have been effective in improving obstetric care. The obstetric pathology as a cause of mortality is now a rare event, as it should be, and they seem to be generally well understood and dealt with effectively. As such, it uncovers the lack of progress with improving mortality from indirect pathology in pregnancy. Nick raised the very interesting question of how we can know what the ‘baseline’ mortality is in these patients, and as such are these indirect deaths something we can do anything about? Despite this, MBRRACE suggests that just being pregnant can distract clinicians, and indeed patients themselves, from delivering appropriate care for medical pathology when it was needed. The fear of potential effects of medication on the foetus was one component, but again factors such as poor communication were identified as an area where these women were failed. Overall then promising results but plenty of areas where care has been far from desirable standards, and plenty of lessons to be found in those pages.
Thanks for reading. Once again I have to massively thank the rest of the journal club who contributed the majority of the above; Philippa Shorrock, Nick Plummer, Matt Leech and Slaman Rzzaki. As always please let us know your thoughts on the topic, especially if there are any key points that you think we've missed.
Tom Heaton
Secondly, from the numbers in the report it’s clear that the lessons from previous reports have been effective in improving obstetric care. The obstetric pathology as a cause of mortality is now a rare event, as it should be, and they seem to be generally well understood and dealt with effectively. As such, it uncovers the lack of progress with improving mortality from indirect pathology in pregnancy. Nick raised the very interesting question of how we can know what the ‘baseline’ mortality is in these patients, and as such are these indirect deaths something we can do anything about? Despite this, MBRRACE suggests that just being pregnant can distract clinicians, and indeed patients themselves, from delivering appropriate care for medical pathology when it was needed. The fear of potential effects of medication on the foetus was one component, but again factors such as poor communication were identified as an area where these women were failed. Overall then promising results but plenty of areas where care has been far from desirable standards, and plenty of lessons to be found in those pages.
Thanks for reading. Once again I have to massively thank the rest of the journal club who contributed the majority of the above; Philippa Shorrock, Nick Plummer, Matt Leech and Slaman Rzzaki. As always please let us know your thoughts on the topic, especially if there are any key points that you think we've missed.
Tom Heaton
Image courtesy of Patrisyu/Freedigitalphotos.net
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